1. Impact of a NGO-supported supervisory programme on the quality of care in private shops in rural E.Nepal Kathleen Holloway Bharat Raj Gautam Britain Nepal Medical Trust (BNMT) ICIUM 2004

2. Background In Nepal, < 20% of the population use public primary health care facilities and in many rural communities the population has no access to essential drugs Private drug shops are a primary source of health care for many people in Nepal and other poor countries, yet the quality of care is often poor, unsupported and unsupervised BNMT, an international NGO, operated a “Hill Drug Scheme” (HDS) to improve access to essential drugs and the quality of care offered by private drug shops: –contract between BNMT and drug shops chosen by the communities where there were no existing drug shops –BNMT supplied essential drugs, training and supervision

3. Objectives Compare the quality of care provided by private drug shops within the Hill Drug Scheme (HDS) and those not (non-HDS) Intervention:(HDS) –contract between BNMT and private shops in communities, where there were no other existing drug shops –communities identified a community member with an existing shop (not already selling drugs) and school leaving certificate to serve the community and enter into a contract with BNMT –BNMT supplied (1) essential (EDL) drugs to shops at cost price, (2) training and supervision, and (3) sponsorship for govt. retailer training –Shop retailers bought drugs only from BNMT and sold them for a 12.5% mark-up, i.e. drugs were available at cost price plus 22.5% –Retailers undertook to abide by the 12.5% mark-up rule and good dispensing practices to stay within the HDS

4. Methods Cross-sectional survey in 1996 in E.Nepal all 16 HDS drug shops from 7 districts 21 non-HDS drug shops from the same areas as far as possible as the HDS shops Data collection –15-30 exiting patient interviews per drug shop (211 patients in HDS shops, 383 patients in non-HDS shops) –retailer interviews –observation of the consultation and dispensing processes

5. Drug costs and fees paid

6. Socio-economic status of patients

7. Quality of Prescribing *antibiotics

8. Patient quality of care

9. Prescriptions (Px) and quality of care

10. Quality of drug retailer service

11. Retailer views on the HDS When an HDS shop starts, there is no competition: –easy to sell only EDL drugs and not sell Px-only drugs without Px Often within one year of an HDS shop starting, another shop starts up nearby in competition: –lose money if they do not sell non-EDL drugs and Px-only drugs –cater to patients’ desire to buy more expensive non-EDL drugs, branded products and drugs in incomplete courses Local health workers and wealthier community members often cease to support the HDS shop: –may start their own shops in competition with the HDS shops –often a financial partnership between the retailer and health worker –deliberately prescribe and sell drugs not available in HDS shops

12. Conclusions Quality of care provided by HDS versus non-HDS was: –significantly better with regard to cost to the patient and provision of purchase receipt, use of essential drugs and retailer qualification –marginally better with regard to fewer dispensing errors, fewer antibiotics sold in under-dose –no different in terms of socio-economic status of their customers –worse with regard to reported drug availability Though HDS shops were only started in areas with no drug shops, competing drug shops soon followed, causing: –profit loss for HDS shops if they followed the principals of good retailing in terms of selling only EDL and generic drugs, Px-only drugs only with a Px, and antibiotics only in full course.

13. Key lessons, policy implications and future research Key lessons An NGO-supported supervisory programme was able to improve the quality of care with regard to use of essential drugs and reduced drug prices in private shops, but not in areas that reduced competitiveness with other shops e.g. OTC prescribing of Px-only drugs Policy implications Schemes to improve quality of care in the private sector must take into account the need of private systems to be competitive and profitable Future research Further schemes to improve quality of care in private shops using financial incentives should be implemented and evaluated