Impact on prescribing patterns of a fee per drug unit versus a fee per drug item Kathleen Holloway 1, Karkee SB 2, Tamang AL 2, Gurung YB 2, Pradhan R 2, Reeves BC 3 ICIUM Dept. Essential Drugs and Medicines Policy, WHO Geneva 2. Britain Nepal Medical Trust (BNMT), Kathmandu, Nepal 3. London School of Hygiene and Tropical Medicine, London

Background User fees are commonly charged to improve drug availability or modify patient demand, but their effect on prescribing is rarely evaluated In Nepal, BNMT (an international NGO) operates community revolving drug funds to supplement essential drugs in government health facilities Drug costs are shared between government, BNMT and patients; user fees (about 40% of drug costs) are used to purchase more drugs Fee per prescription, 1-band fee per drug item and 2-band fee per drug item were charged in 1995 in different districts, each fee type covering a full course of treatment; previous research in this setting showed the benefits of a fee per drug item compared to a fee per prescription, and no difference between 1-band and 2-band fees per drug item All fee types were changed during to a fee per unit (tab, cap) to conform to government policy

Objectives To compare the effects of a fee per drug unit vs. a fee per drug item (at similar below cost-price levels) on prescribing quality and cost in government primary health care facilities: –Is charging per drug unit (40% of drug costs) associated with the prescription of more incomplete courses of drugs, compared with a fee per drug item covering full courses of treatment?

Study design Non-randomised pre-post studies with controls Comparisons in (1) and (2)

Fee details

Data Collection Prescribing indicators 1995, 2000 and 2002 –carbon copy prescriptions Drug availability –Routine monitoring at health facilities –>90% of key drugs available in all districts in all years Sample sizes facilities per fee type (one fee type / district) average 200 prescriptions per facility per year –systematic random selection –>30 prescriptions per facility per year for all indicators

: fee per drug unit vs. fee per item

: fee per drug unit vs. fee per item

Estimates of effect of changing from fee per drug item to fee per drug unit * PxIndicator2000 = a + b1(Pxindicator1995) +b2(fee per unit) + error † PxIndicator2000 = a + b1(Pxindicator2002) –b2(fee per item) + error

Conclusions Fees per unit as compared with fees per item covering a full course of treatment were associated with: –the prescription of fewer injections –the prescription of slightly lower number of units per drug prescribed –the prescription of more antibiotics in under-dose –similar prescribing patterns with regard to the number of drugs per patient, the drug costs per patient and the % of patients receiving antibiotics and vitamins An EDL change and decentralisation of purchasing authority to health facilities during the study may account for decreased use of essential drugs and increased cost per prescription, so masking prescribing and cost changes due to the fee systems.

Key lessons, policy implications and future research Key lessons Fee per unit, as compared to fee per drug item (covering a full course), is associated with the prescription of fewer units per drug item and less use of expensive items such as injections Policy implications Revolving drug funds and insurance systems often charge per unit and should beware adverse effects on prescribing quality particularly if the fee level is unaffordable to patients Future research Impact on prescribing quality of different fee types, set at different levels, to ascertain (1) whether similar effects to this study are seen, and (2) at what level of fee the positive effects of a fee per unit and a fee per drug item are maximised (and the negative effects minimised)