Transcript Poster presentation

Impact of a cost sharing drug supply
scheme on the quality of care in public
primary health care facilities in rural Nepal
Kathleen Holloway
Bharat Raj Gautam
Britain Nepal Medical Trust (BNMT)
ICIUM 2004
Background
• Revolving drug funds and user fees are often implemented
to improve drug availability and improve quality of care, but:
– access may be reduced
– impact on quality of care and drug use is often not evaluated
• In Nepal, government is able to supply less than half the
drugs needed in public health facilities
• BNMT, an international NGO, operates revolving drug funds
where drug costs are shared between government, BNMT
and the patients (user fees cover about 40% drug costs)
– user fees used by BNMT to purchase more essential drugs at cost
price
– 3 types of user fee
Objectives
• Compare the quality of care provided by facilities
operating a cost sharing drug supply scheme (CSDS) and
those not (non-CSDS)
• Intervention: CSDS - supplementary drugs and 3 types of
user fee, all user fees set so that all patients would pay the
same total amount if treated in accordance with guidelines
– flat fee per prescription (covering all drugs in whatever quantities)
– 1-band fee per drug item (flat fee per drug item covering a full
course of each drug item)
– 2-band fee per drug item (2 rates of fee per drug item, one for
expensive drugs and one for cheaper drugs, each covering a full
course of each drug item)
• Control: non-CSDS - no supplementary drugs and no user
fees
Methods
• Cross-sectional survey in 1996 in E.Nepal
• all 33 CSDS facilities from 3 districts
– 10-12 facilities /district each charging different user fee
• 16 non-CSDS facilities from 7 equivalent districts,
where BNMT was operating other programmes
• Data collection
– 15-30 exiting patient interviews per facility
• for patient knowledge of dosing regimes and socio-eco status
– health facility records
• patient attendance, drug supply, prescribing data (120 Px/HP)
– key drug stock check
– observation of consultation and dispensing
Quality of health services
Health service
Indicator
% key drugs
available
Cotrimoxazole
availability
Prescriber
availability
Patient attendance
over 4 months
Annual patient visits
as % of population
CSDS
Non-CSDS
1-band 2-band Flat fee per
item fee item fee prescription
90%
90%
90%
No user fee
75%
93%
91%
95%
70%
60%
76%
80%
74%
3377
6061
4236
4135
25%
29%
21%
17%
Socio-economic status of patients
Patient characteristics
% < 5 years
CSDS
1-band 2-band Flat fee per
item fee item fee prescription
16
15
17
NonGeneral
CSDS population
No user statistics
fee
18
15
% female
42
49
43
49
50
Average family size
7.1
6.8
6.9
6.9
5.4
% Literacy
49
44
39
43
45
% with no school
leaving certificate
% landowners
86
92
92
93
98
94
98
95
98
82
Av. plot size (ropani)
39
24
30
29
22
% < 30 mins to water
92
84
88
87
-
% using a latrine
61
39
59
49
-
Quality of prescribing
Prescribing
Indicator
Average number of
drugs per patient
% patients prescribed
antibiotics
% patients prescribed
injections
% antibiotic drugs
prescribed full dose
% patients treated as
per guidelines
CSDS
Non-CSDS
1-band 2-band Flat fee per
item fee item fee prescription
1.8
2.0
2.7
No user fee
1.5
50%
46%
66%
28%
14%
15%
20%
10%
84%
85%
67%
45%
51%
55%
24%
31%
Quality of care
Quality of care
Indicator
CSDS
1-band
item fee
Consultation:
- time (minutes)
- % patients not
clinically examined
Dispensing:
- time (minutes)
- % errors
- % drugs dispensed
% patients who knew
their dosing regimes
% facilities that gave
injections safely
Non-CSDS
2-band Flat fee per
item fee prescription
No user fee
4.5
31%
4.7
24%
6.6
21%
4.5
36%
2.5
5%
88%
2.3
7%
82%
3.1
11%
81%
1.7
13%
54%
69%
65%
67%
69%
33%
8%
18%
0%
Cost-effectiveness of prescribing
Cost Indicator
(NRs)
No. health facilities
CSDS
1-band
item fee
10
2-band
item fee
11
Annual drug supply
costs
Annual patient
attendance
Av. cost per patient
902,728 1,215,451
No. (%) cases treated
as per guidelines
Av. cost/case treated
as per guidelines
Non-CSDS
Flat fee per
prescription
12
No user fee
16
1,160,187
1,045,982
10,131
18,183
12,708
12,405
89.11
66.85
91.30
84.32
5,167
(51%)
174.71
10,001
(55%)
121.53
3,050
(24%)
380.39
3,846
(31%)
271.97
Robustness of results
• STG compliance measurements from exiting interview
prescriptions in this study and from same user fee districts
using annual data (published elsewhere) within + 2-7%
• Intra-rater bias for measuring STG compliance + 6%
• Sensitivity analysis to show range of cost / case treated
according to STGs assuming + 5-10% inaccuracy of STG
compliance measurement
1-band item fee 2-band item fee Flat fee per Px No fee
+ 5% 159-194 NRs 111-134 NRs 315-481 NRs 234-324 NRs
+ 10% 146-217 NRs 103-149 NRs 269-652 NRs 206-402 NRs
• Comparison of results showed significant differences
between (1) no fee, (2) fee per drug item, and (3) flat fee per
prescription, p< 0.01
Sensitivity analysis of cost (NRs) per case treated in
accordance with guidelines (STGs)
Av.cost per patient
treated as per STGs
(NRs)
700
600
Flat fee & no fee
500
1-band fee
400
2-band fee
Item fees
300
flat fee
200
no fee
100
0
0
20
40
60
80
% patient treated in accordance with STGs
Conclusions
• Quality of care provided by CSDS was significantly better
than non-CSDS in terms of patient attendance and drug
availability
• The socio-economic status of patients attending facilities
was slightly higher than the general population suggesting
that the CSDS did not improve use by the poorest people
• Quality of prescribing was significantly better in CSDS
areas charging a fee per drug item but not a flat fee per
prescription
• Investment to establish a good drug supply was associated
with lower costs per patient treated in accordance with
guidelines provided an efficient user fee was charged
Key lessons, policy implications and
future research
Key lessons
• A cost-sharing scheme was associated with significantly better quality of
care, drug availability and cost-effective prescribing provided a fee per
drug item and not a flat fee per prescription were charged
Policy implications
• Lack of drug availability or revolving drug funds charging inappropriate
user fees may be associated with less cost effective prescribing. Cost
saving measures resulting in poor drug availability may be associated not
only with poorer quality of care but also with more cost to the health
system for fewer patients treated in accordance with guidelines.
Future research
• Evaluation of the impact of different drug supply and drug financing
systems on the quality and cost-effectiveness of prescribing