The influence of user fees and patient demand on prescribers in rural Nepal☆
Introduction
Irrational prescribing of drugs has been reported all over the world, particularly in developing countries, where polypharmacy and the abuse of injections and antibiotics are common (Laing, 1990; Hogerzeil, 1995). Inappropriate prescribing is not only wasteful, but also potentially very harmful, and seems to encourage inappropriate self-medication (Greenhalgh, 1987; Hardon, 1987).
Physicians and prescribers of all kinds are greatly influenced by the demands of the patients. Many traditional practitioners are now prescribing allopathic medicines instead of herbal or other kinds of medicines because this is what patients desire (Waxler-Morrison, 1988). In Tanzania 60% of health workers admitted to prescribing inappropriate drugs demanded by socially influential patients to avoid being labeled “difficult” (Mnyika & Killewo, 1991). Many people in India believe in ‘tonics’ and will not return to a doctor unless he prescribes according to their wishes. Even though the doctor may know that ‘tonics’ are ineffective, he prescribes them because he is dependent on the patient returning for his livelihood (Nichter, 1989). Encouragement of irrational prescription and polypharmacy has also been described in China where health workers supplement their salaries by selling drugs (Shao-Kang, Shen-Ian, You-de, & Bloom, 1998).
Prescribers citing patient demand as a cause of irrational prescribing has been reported in China (Shao-Kang, 1998), Peru (Paredes, de la Pena, Flores-Guerra, Diaz, & Trostte, 1996), USA (Schwartz, Soumerai, & Avorn, 1989), and Africa (Michel, 1985). Patient demand for specific drugs has been observed by researchers in China (Shao-Kang et al., 1998), Tanzania (Gumodoka et al., 1996) and Indonesia (Hadiyono, Suryawati, Danu, Sunartono, & Santoso, 1996). However, the degree to which prescribers are influenced by their patients is unknown (Britten, 1995) and probably varies according to the skills and confidence of the prescriber.
User fees, as a way to raise revenue (often inefficiently) and to contain consumer demand (often at the cost of equity), are charged in many countries, both developing and developed (Creese, 1997). It has been suggested that, unlike charging per prescription which tends to encourage over-prescription, charging per drug item may discourage over-prescribing possibly by reducing consumer demand (WHO, 1988; Abel-Smith, 1991). However, very few studies have made direct comparisons between what patients demand and what they receive and examined whether demand significantly influences prescribing.
Two studies that attempted to measure the influence of patient demand on prescribers, one in Peru (Paredes et al., 1996) and the other in the UK (Cockburn & Pit, 1997), found that patient demand did not influence prescribing at the individual level. Another study in the UK showed that doctors’ perceptions of patients’ expectations were the strongest predictor of their decisions to prescribe (Britten & Ukoumunne, 1997), a finding also supported by the Peru study (Paredes et al., 1996) where it was found that physicians treating diarrhoea cases were aware of patient demand based upon past experience although this demand was not verbally expressed during the consultation. With so few studies, the question about the degree to which patient demand influences prescribers, particularly paramedical workers in developing countries, remains open.
Section snippets
Context
Nepal is extremely poor with a GNP in 1991 of US$180 (World Bank, 1993). About 90% of the population is engaged in agriculture and much of the country is without roads, electricity, sanitation and reasonable access to safe drinking water. The health status of the population is poor, life expectancy being 53 years and infant mortality rate 101 per 1000 live births in 1991 (World Bank, 1993). Lack of human resources and drugs undermine primary health care in the public sector (Tamang & Dixit, 1992
Objectives
To investigate the attitudes and behaviour of patients and health workers towards drugs in rural Nepal in order to:
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determine the degree of influence patient demand has upon prescribers;
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investigate whether different kinds of user fees affect the prescribing process through consumer demand or prescriber behaviour.
Methods
There were two parts to the study design. The first part consisted of focus group discussions conducted with patients attending health facilities, and the second part consisted of patient and health worker interviews.
Focus group discussions
Sixteen focus group discussions with 218 participants were conducted in 1995 using recommended guidelines (Krueger, 1994). Two BNMT Nepali staff acted as moderator and note-taker. A tape-recorder was not used because it was thought that this would inhibit the participants. Detailed notes were taken and these were translated into English by the moderator in consultation with the note-taker within two months of the discussion. The notes were always supplemented by an immediate feedback discussion
Patient and health worker interviews
The interviews took place over five months during 1995–6 at:
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all 33 health facilities (including three hospitals) supported by BNMT drug schemes in three districts, and
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a convenience sample of 16 health facilities (including two hospitals) spread over five similar districts (but treated as one area for analysis) not supported by BNMT drug schemes.
An average of 22 patients per health post (HP) and 100 patients per hospital were interviewed. At least one health worker per HP and three health
Data collection
Data from the focus group discussions were qualitative and used to complement and qualify the quantitative interview data. The interview data was entered into a data-base using Epi-Info 6.03 software and the author checked a random sample of the data entered finding mistakes in 0.5–5.0% of all the data. The data collected concerned:
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patient demand in terms of (1) patient expectation about the number and type of drugs that they needed pre-consultation, and (2) whether patient perception of drug
Analysis
Analysis consisted, firstly, of simple descriptive comparisons across districts, and secondly, of simple linear regression investigating the associations between:
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the number of drug items patients felt they needed (patient expectation or “demand”) and number of drug items patients were actually prescribed, and
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the number of drug items per patient health workers stated they usually prescribed (prescribing habit) and the average number of drug items patients were actually prescribed.
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the fee type
Patients’ main reasons for coming to the government health facility
In all the groups many participants mentioned that usually they would first attend the “dhami jankri” (local traditional healers using herbs, spiritualism or shamanism) and only later attend the HP, having waited some days for improvement. Only if the problem was severe would they attend the HP without first seeing the “dhami” or waiting for improvement. A few people mentioned that they would always consult the “dhami” first before attending the HP even for a serious problem and also before
Discussion
Patient demand has usually been studied by health economists who have measured willingness to pay, price elasticities and utilisation. However, in this study demand was defined in terms of patient expectations about the actual drugs themselves. The few studies in the literature examining patient demand in a non-economic context have used slightly different methods though comparison is still useful. In this study 16–22% of patients knew the name of the drug they wanted as compared to China where
Acknowledgements
For advice concerning the analysis and writing up of this research: Barnaby Reeves, Clinical Effectiveness Unit Director, Royal College of Surgeons, London. For supervising the interviewing of patients: Yam Bahadur Gurung, Sitaram Thapa and Gokul Mishra. For doing data-entry: Ramesh Pradhan, Minu Bhattarai, Gokul Thapa and Narayan Yakso. For looking after the authors, including the carrying of baggage on field trips: Mongol Singh Limbu and Vishnu Limbu. For giving support that was instrumental
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Sources of support: (1) Inter-Church Organisation for Cooperation (ICCO), Amsterdam, The Netherlands. (2) John Snow Incorporated, Kathmandu, Nepal.