Elsevier

Social Science & Medicine

Volume 57, Issue 5, September 2003, Pages 937-948
Social Science & Medicine

Public and private sector responses to essential drugs policies:: a multilevel analysis of drug prescription and selling practices in Mali

https://doi.org/10.1016/S0277-9536(02)00462-8Get rights and content

Abstract

Many African countries have introduced cost recovery mechanisms based on the sale of drugs and measures aimed at improving drug supply. This study compares prescribing and selling practices in Mali, in 3 cities where the public sector contributes differentially to the supply of drugs on the market. Multilevel models are used to analyse the content and cost of 700 medication transactions observed in 14 private and public legal points of sale.

Results show that the objective of improving access to drugs seems to have been achieved in the sites studied. Costs of prescriptions were lower where public health services had been revitalized. Affordable generic drugs were accessible and widely used, even in the private sector. However, measures intended to rationalize the prescription and delivery of drugs did not always have the desired effect. While agents in the public sector tended to prescribe fewer antibiotics, injectables, or brand-name drugs, the data confirm the virtual absence of advice concerning the use or the side effects of the drugs in both public and private sectors. In addition, data supported the notion that the public and private sectors are closely intertwined. Notably, availability of drugs in the public sector contributed to diminishing the prices charged in the private sector. Similarly, the use that agents in the public sector made of the opportunities afforded by the presence of the private pharmaceutical sector provided another illustration of interrelatedness. Finally, the data showed that the presence of a private sector, which has not been affected by measures aimed at rationalizing prescription and sales practices, limits the effects of measures implemented in the public sector. More assertive policies, based on strategies encompassing actors in the private sector, are needed to increase the safety and effectiveness of prescription and sales practices.

Introduction

Health authorities in developing countries have recently been engaged in a re-examination of their health policies and service development strategies. As a result, the majority of these countries have implemented processes of health care reform which vary from one country to another, but are driven by a number of common principles. In particular, many African countries have introduced either national or regional programs that incorporate cost recovery mechanisms based on the sale of drugs. The goal of these strategies, frequently referred to as the “Bamako Initiative Model” (BI), which is strongly linked to National Drug Policies (NDPs), is to direct generated income toward ensuring a reliable supply of essential drugs, and thereby guarantee the maintenance of minimal standards of quality of health services (Lancet, 1988). They are more or less explicitly based on the following premises: (1) communities are willing to pay for services offered by the public system to the extent that these are high quality services; (2) increasing resources for health facilities and providing complementary measures such as improvement of district management, renovation of health facilities, and promotion of prescription issuing and rational use of medications, will allow for the provision of essential medications and high-quality health care; and (3) the availability of quality medications sold at reasonable prices and provided through appropriate prescription will limit the negative impacts on access of cost recovery schemes (Haddad, Fournier, Diakite, Maiga, & Dicko, 1997).

Cost Recovery Policies and National Drug Policies (also called Essential Drug Policies) are closely related. Cost recovery schemes are most often based on the sale of low-cost generic drugs that are promoted and implemented through NDPs. In addition, they are usually supported by a variety of complementary measures such as improvement of district management, renovation of health facilities, and promotion of prescription issuing and rational use of medications (which generally combine the development of a list of essential drugs with personnel training to rationalize prescriptions), and limits on the quantity and nature of drugs that can be prescribed. NDPs are mostly oriented towards the public sector whereas the private sector, with support from pharmaceutical companies, promotes a market approach with few public regulation measures (Hardon, 1992; World Health Organisation, 1987).

Medication is thus a central component of strategies to revitalize public services derived from the BI model. In this regard, two aspects are particularly salient. First, the lack of availability of drugs results in public health services being under utilised; a better supply of drugs is a precondition to improving utilization (Gilson, 1997; Haddad & Fournier, 1995; McPake, Hanson, & Mills, 1993). Second, one of the main concerns of leaders in the public sector is to eliminate prescription, sales, and consumption practices that are viewed as inappropriate. These practices, which have been extensively described in developing countries, are fuelled by both the popularity of modern drugs and by the dynamism of market forces. Modern drugs are in fact a commodity that is so commonly available on the markets that some people have compared them to Coca Cola (Bledsoe & Goubaud, 1985). Drugs mean business and, in the majority of African cities and villages, they can be purchased from a variety of legal and illegal, private, or public sources. Quite often, however, the sales practices of these pharmaceutical suppliers are driven more by a logic of commercial exchange than that of the delivery of professional services (Ferguson, 1981; Logan, 1973; Sterky, Tomson, Diwan, & Sachs, 1991; Van der Geest, 1983), a logic that is illustrated by the widely observed presence of inappropriate, and even dangerous, practices in the legal sector as well as in the illegal market. These practices include the sale of loose medication (i.e. a few tablets at a time), the sale of prescription medication without requiring the buyer to provide a prescription, the inadequate substitution of prescriptions, the lack of advice and information on the use of the products, employment of unqualified staff, as shown by Bledsoe and Goubaud (1985), Dua, Kunin, and White (1994), Haak (1988), Kamat and Nichter (1998), Krause et al. (1999), Lansang et al. (1990), LeGrand, Hogerzeil, and Haaijer-Ruskamp (1999), Wolffers (1987). These practices contribute to reinforcing the inappropriate use of medication among the general public, especially inadequate therapeutic use, over-consumption of drugs, excessive use of antibiotics and injectables, or premature discontinuation of treatment (Bledsoe & Goubaud, 1985; Bush & Hardon, 1990; Homedes & Ugalde, 1993; Reeler, 2000; Sachs & Tomson, 1992; Van der Geest & Hardon, 1988).

Many studies have dealt with the analysis of the effects of interventions aimed at ensuring the availability and sale of essential drugs in public health facilities and/or rationalising drug use. The bulk of the literature shows that the coordinated implementation of cost recovery and essential drug policies leads to an improvement of the availability of medications at low cost in peripheral health care centres. However, the literature is quite ambiguous regarding the impact of these policies on appropriate prescription practices and rational use of drugs. Moreover, as recent reviews highlight, these studies have focused almost exclusively on the public sector (LeGrand et al., 1999) and often due to their poor designs, results are generally open to various interpretations (Ratanawijitrasin, Soumerai, & Weerasuriya, 2001). In fact, we know very little about the possible effects of these interventions on the prescription, sale, or purchase of drugs in the private sector. Moreover, we do not have any specific indications about the existence of distinct effects in the public sector when it is facing a competitive supply of drugs and services. In our view, this constitutes an important gap in the literature. The private sector is a significant actor, playing a dominant role in the modern drug market; the prosperity of the private dispensaries and of the informal sector shows that it remains competitive and attractive, even in the presence of a revitalized public sector. It is thus advisable to analyse the practices observed in public health facilities in light of those adopted by private suppliers or prescribers. Private actors are not usually concerned by measures to rationalize drug utilization and therefore may continue to promote forms of utilization that contradict medication use promoted by revitalization measures. As a result, the outcome of these interventions in the pubic sector can be limited in scope or modified in some undesirable way. Several studies have shown that, in private dispensaries, antibiotics are sold routinely without prescription (Dua, et al., 1994; Hossain, Glass, & Khan, 1982; Kamat & Nichter, 1998; Lansang et al., 1990; Wolffers, 1987), and antibiotic treatment is frequently abused (Goel, Ross-Degnan, Berman, & Soumarei, 1996; Igun, 1994; Organization Mondiale de la Santé, 1990). In pharmacies, antibiotics as well as other drugs are sold loose (Haak, 1988; Hossain et al., 1982; Wolffers, 1987), and consumers are very rarely given any information on the indications, contraindications, and side effects of the drugs purchased (Dua et al., 1994; Kamat & Nichter, 1998; Lansang et al., 1990; Wolffers, 1987). Another example of a practice that runs counter to those promoted in the public sector pertains to generic drugs: pharmacies and the majority of health professionals in the private sector are reluctant to promote their use because they prefer brand-name drugs, which are better marketed and more profitable (Foster, 1991; Kloos, Chama, Abemo, Tsadik, & Belay, 1986).

Mali is an example of a country that, by the early 1990s, had introduced a large-scale national drug policy designed to promote generic, low-cost medication use. In the same period, a variety of cost recovery schemes had been implemented in selected regions in the country. As is often the case, these schemes were complemented by interventions aimed at improving prescription practices and utilization of drugs in facilities of the public sector. This led to a significant increase in the availability of low-cost generic drugs in private facilities and also, to some extent, in private pharmacies who decided to sell generic drugs in order to maintain their competitiveness. However, improvement of the availability of drugs is not necessarily equivalent to an improvement in the quality of care, which is a function of proper prescription practices, appropriate sales practices, and correct utilization. While it is possible to surmise that interventions have had a positive influence on practices adopted in the private sector as well, the absence of empirical data on these practices precludes any strong conclusions in this direction.

As a result, Mali was and is confronted, as have been several other countries, with two core policy issues: (1) whether or not implementation of complementary measures in selected regions has led to a more rational use of medication and (2) whether or not patterns of prescription and utilization in public facilities targeted by these policies differ from those observed in the private sector and to what extent they are more or less costly.

This article presents a portion of the results of a study aimed at addressing these two core policy issues. The overall study focuses on comparing prescription practices, sales, purchase, and consumption of modern drugs in three regions in Mali having distinct cost recovery schemes and degrees of implementation of NDPs. The current paper excludes the informed sector and focuses on drug transactions observed in legal points of sale in three cities—Koutiala, Niono and Gao—which differ significantly in implementation of NDPs.

Even though examining drug transaction does not fully represent final consumption of medication, data pertaining to legal drug transactions is a useful and widely used indicator of both the characteristics of prescriptions and the use of drugs by patients. This study thus focuses on analysing the extent to which purchased medications and prescriptions provided by patients were more or less costly and corresponded to appropriate prescription and utilization practices as a function of: (1) whether or not the transaction occurred in cities where interventions were more vigorous, and likely more effective, in terms of regularity of drug supplies to the public sector points of purchase; (2) whether or not the transaction occurred in a public sector point of purchase wherein agents are encouraged to promote the sale of lower-cost, generic drugs to reduce overall costs and to limit over consumption of antibiotics and injections; and (3) whether or not the prescriptions had been provided by an agent in the public sector wherein sensitization to the need to promote appropriate prescription practices had been implemented.

Given that the goal of the BI model is to promote the use of less costly generic drugs and a more rational utilization (World Health Organisation, 1994) of drugs in public settings, the study focuses on the following characteristics of the transaction: the number of drugs acquired per transaction, the purchase of antibiotics, injectable products, generic drugs or brand-name drugs, and the total cost of the transaction.

Section snippets

Background

Koutiala and Niono are two medium-sized, relatively prosperous and growing cities, located at the centre of large agricultural production zones—cotton plants in Koutiala and rice-growing in Niono. Gao, which is located in the North of the country, was severely affected by political problems in the early 1990s and by a reduction in trade with Algeria; it is no longer the commercial hub that it once was. The purposive sampling of these three specific cities was conducted because they also differ

Methods

The survey is based on the observation of a sample of transactions in each of the 14 authorized points of sale—pharmacies and public health centre sales outlets—in the three cities. The sample was constructed as follows: the observations began with the first customer of the day and continued until the required number of observations was reached. Approximately 50 consecutive transactions were observed in each of the points of sale. A first observation period allowed for an appreciation of the

Results

Examination of descriptive data showed that transactions observed in Koutiala did not include a public sector point of sale, since the health centre did not have any drugs for its patients when the survey was conducted. Three-quarters of the transactions were observed in private pharmacies (Table 2). The buyers were most often male, average age of 35 years, and the purchase was generally made for someone else. One out of five of the beneficiaries was a child. An employee with no professional

Use of drugs

Poisson multilevel models showed that the variance between points of sale in the number of different drugs acquired was not statistically significant (χ2=18.3; p=0.15) and neither the study site nor the supplier's sector (public or private) were significantly associated with the number of drugs acquired. The analysis of the effects of individual factors showed, however, that the existence of a prescription significantly limits the quantity of different drugs purchased and suggests that a visit

Cost of drugs

Over 20% of the variance in the log of the cost comes from the variance between points of sale. The regressions on the first block of variables (Table 7) show that, all things being equal, and after deriving percentages by transforming the estimate in the following manner ((eβx–1.00)×100), a transaction costs significantly more when it includes several drugs (+24% per additional drug), at least one antibiotic (+49%), one injectable (+97%) or one brand-name drug (+98%). Our expectations were

Discussion

At first glance, compared to many other developing countries, drug utilization in our study looks quite “rational”: the number of drugs acquired is limited, a large proportion of the drugs purchased follow a prescription from a health professional (up to 95% of drugs purchased without professional advice in Vietnam, (Chuc & Tomson, 1999)), and the utilization of generic drugs is widespread.

We draw three generalizations from the findings. The first concerns prescriptions, which appear to be a

Conclusion

When it was launched in 1986, the Bamako Initiative raised as many hopes as it did fears. Its goal was to make essential drugs more available while improving appropriate use via more rational prescription and utilization. This constituted a strategy to revitalise public health services which were faltering and whose effectiveness was being called into serious question. Moreover, by focusing the strategies on essential drugs and on their profit margins, which did constitute a financial

Acknowledgements

The authors extend sincere thanks to their many collaborators from the following partner institutions: the Malian Ministry of Health, the local UNICEF Office, the Institut National de Recherche en Santé Publique and the Health Authorities of Segou, Niono, Koutiala, and Niono. They would also like to thank Dr Mohamed Dicko, Dr Soumayla Laye Diakite, and their local collaborators for their contributions to this study and the analysis of the findings, and Helene Kaufman for translation of original

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