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Kathleen Holloway Bharat Raj Gautam Britain Nepal Medical Trust (BNMT) ICIUM 2004

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.

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Kathleen Holloway Bharat Raj Gautam Britain Nepal Medical Trust (BNMT) ICIUM 2004

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  1. 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

  2. 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

  3. 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

  4. Methods • Cross-sectional survey in 1996 in E.Nepal • all 33 CSDS facilitiesfrom 3 districts • 10-12 facilities /district each charging different user fee • 16 non-CSDS facilitiesfrom 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

  5. Quality of health services

  6. Socio-economic status of patients

  7. Quality of prescribing

  8. Quality of care

  9. Cost-effectiveness of prescribing

  10. 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 fee2-band item feeFlat fee per PxNo fee + 5% 159-194 NRs111-134 NRs315-481 NRs234-324 NRs + 10% 146-217 NRs103-149 NRs269-652 NRs206-402 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

  11. Flat fee & no fee Item fees

  12. 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

  13. 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

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