Economic costs associated with inadequate drug prescribing: an exploratory study in Chiapas, Mexico
Introduction
Irrational prescribing of drugs has been much investigated, as it is a large-scale problem worldwide. Many initiatives have been made to improve drug use and distribution (López and Kroeger, 1994, López et al., 1995, HAI, 1998, Laing et al., 2001). However, few studies have investigated the economic cost of poor prescribing.2 Drugs make up a large portion of health budgets (Sterky et al., 1991, Management Sciences for Health, 1997) and a large proportion of a family's out-of-pocket expenditure on health care is on drugs, estimated up to 50% for some poor households in Mexico (INEGI, 1996). Therefore, improved drug prescribing can imply huge savings for families and governments. It has been estimated that improved drug prescribing can produce savings of up to 70% on national drug expenditures (Le Grand et al., 1999). However, very little is known about the economic costs of poor prescribing practices on health-care users.
The auditing of medical records has been used as a method for estimating the cost and adequacy of drug prescribing in several developing country settings (Zhan et al., 1998, Krause et al., 1999). Zhan et al. (1998) also used data from household surveys to assess prescribing behaviour of different providers, including drug vendors and patients themselves. These types of studies are usually complicated to implement and their results are hard to interpret, partly because health-care systems are highly fragmented in most developing countries. How much money do users spend on unnecessary drugs? Who are the major sources of inadequate prescribing for health-care users? What do such economic losses represent in terms of daily wages for the poor? These are the questions that animated the present study. It had four objectives: (1) to identify the socioeconomic characteristics of pharmacy customers, (2) to compare the cost of drug prescription by four different prescribers, (3) to assess the adequacy of drugs bought by pharmacy customers and (4) to estimate the economic losses experienced by health-care users due to previous inadequate prescribing.
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Study setting
The study was carried out in two cities in Chiapas State, Mexico: San Cristóbal de las Casas and Tuxtla Gutierrez. The study was undertaken in 1998/1999, over 18 months. Chiapas State is one of the poorest in the country: of a total of 3.21 million inhabitants, 2.9 million (90.3%) are poor (Boltvinik, 2001). Population and poverty data for the two cities under study are as follows: San Cristóbal de las Casas has 132,317 inhabitants (INEGI, 2000) with 50–60% in poverty (Boltvinik, 2001). The
Methods
Two research methods were used to achieve the study objectives: (a) an exit survey with pharmacy users and (b) in-depth individual interviews. For comparative purposes, three tracer conditions were selected and used for both methods of data collection: acute respiratory infection (ARI), diarrhoeal disease (DD) and hypertension. However, only a small number of hypertension cases were collected from a sampling of the exit survey. So, analysis presented in this report only includes ARI and DD for
General characteristics of pharmacy customers (from study A)
Of the 1190 customers surveyed, 49.5% were female and 50.5% were male. In terms of ethnicity, 15.4% belonged to the indigenous population. 11% of all customers had no schooling and 32% had completed primary school. 38% had either secondary or a technical education and 19% had university level education. 69% of all customers were not part of any social security scheme. 73% of all customers bought drugs without any prescription.
Comparing the cost of drugs as advised by four types of prescribers (from study A)
Only 27% of the customers had a prescription when they bought drugs.
Improving rational drug use: who should be trained?
Our research has shown that medical doctors and other health staff play a major role in inadequate prescribing and in adding economic costs for users. However, drug vendors in pharmacies are also a major source of inadequate prescribing. The most revealing data from our research are the fact that health-care users impose unnecessary costs on themselves by exercising a high level of inadequate self-prescribing. Almost three-quarter of all pharmacy customers in our study bought self-prescribed
Conclusions
Doctors, drug vendors at pharmacies, traditional healers, users of health-care services themselves (through self-prescription) and other health staff are sources of inadequate prescribing which places a substantial economic burden of unnecessary costs on users. In general, treatment costs were high compared with standard treatments and prescriptions included a high proportion of non-essential drugs, particularly when treatments were based on medical prescriptions or a drug-seller's advice. Data
Acknowledgements
This study was supported by the British government (DFID-HP ACCORD Contract No. R7174). The authors are indebted to the assistance of their enthusiastic field staff Z. Barrios, E. Lopez Perez, M. Lopez, A. Flores, B. Villatoro, J.H. Ruiz, P. Camacho, G. Vargas, R. Perez and W. Bonifaz as well as the Director of the Regional Hospital of San Cristóbal de las Casas, Dr. Francisco Millan Velasco and his staff.
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Previously of Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK.