IMPROVING ACCESS TO ROUTINE MEDICATION FROM A REVOLVING DRUG FUND FOR CHRONIC PATIENTS IN RURAL CAMBODIA MAO Ngeav, Maurits VAN PELT
Abstract Problem statement: A structured 1,023-chronic-patient-membership community, consisting of diabetic mellitus (DM) and high blood pressure (HBP) patients, has formal arrangements with the public hospital services to prescribe the medicines for these chronic conditions and with the private sector to dispense the prescription medicines in their districts. The patient network facilitates access to prescription medication through a revolving drug fund (RDF) having contracted with one private pharmacy. In the first 6 months of 2010, this private pharmacy underperformed, leaving uncertainties about adherence and medicine use by the members. Besides, inconsistent health education messages from different sources reaching HBP patients compromised access and their adherence to the continuum of care. Objectives: To document how both access and adherence to routine prescription medicines from an RDF were improved using a comprehensive set of specific measures. These measures include expanded roles of chronic patients and peer educators (PE) and also supply-side measures, notably increasing the number of pharmacies and agreeing with service providers on harmonization of specific health education messages. Design: Before-and-after study of intervention effects Setting: In a rural Cambodian district of 133,000 people, mostly served by private and to lesser extent by public health services, a community-based peer educator network (PEN) operates. The 9 PEs is all diabetic themselves and some of them also have HBP. The network facilitates access to health services for DM and HBP patients registered as members of the network and access to an RDF by dispensing from contracted private pharmacies. Study population: 1,023 chronic patients 448 DM and 575 HBP Intervention: During the second half of 2010, three more pharmacies were contracted: one was located near the existing central one, one was in the eastern part of the district, and one was in the southern part. Specific measures were introduced throughout the whole operational district such as reinforcing Health education messages and increasing the number of specialised consultation sessions and the level and type of PE incentives for follow-up and for monitoring the RDF. Outcome measure(s): (1) Comparing the RDF sales during first half of 2010 to and by the one pharmacy to the RDF sales to and by the four pharmacies in the first half of 2011, detailing RDF revenue and costs, including PEN incentive costs; (2) number of dispensing to members by gender and age group compared with their prescriptions in periods before and after the introduction of the measures; and (3) health expenditures, monthly prescription costs, and the numbers of molecules prescribed. Results: Among 1,023 registered members, 65% are women, and 29% are DM patients older than 60 years indicating relatively good access to the organisation's membership status by these groups. After introducing the special measures, out of 448 DM members the proportion of those with prescription for using the RDF increased from 58% (260 DM) to 67% (302 DM) (p<0.001). The proportions of men and women having used medical consultation remained unchanged and relatively proportionate: 73% women and 27% men. Among the DM patients older than 60 years, the proportion with prescriptions remained unchanged: 29%. The average monthly prescription cost increased from USD 4.36 to USD 5.44 (median from 3.66 to 4.94). The number of dispensing invoices by contracted pharmacies tripled from 345 invoices in first half of 2010 to 1,059 invoices in the first half of 2011. The average number of invoices per DM patient with prescription increased from 1.30 in the first half of 2010 to 3.51 in the first half of 2011. In the first half of 2010, only 11 of the 575 registered HBP members had a prescription, but this increased to 63 HBP patients in the same group in the first half of 2011. Invoice-based dispensing for them rose from 2 (0.18 times per patient) to 250 (3.97 times per patient) in the first half of 2011. The RDF gross revenue from drug sales to pharmacies rose from USD 2,817 in the first half of 2010 to USD 6,156 in the first half of 2011. The intervention s main costs in first half 2010 and first half 2011 were USD 1,087 and USD 2,401 respectively for the RDF, and USD 1,117 and USD 1,359 respectively for the PEN suggesting increased activity. Both the costs of organising medical consultation and local supervision remained unchanged at USD 936 and USD 708 respectively. Costs and revenue related to the laboratory service provision are excluded from these financial figures to show the dynamics related to the RDF in particular. Conclusions: The utilisation figures suggest that an intervention combining low-cost measures and pulling together demand and service supply sides can significantly improve access to routine medication for a structured rural membership community of chronic DM patients and has potential to serve an even larger group of HBP patients in the same area, simultaneously improving financial sustainability of the RDF.
Background 1 A Revolving Drug Fund (RDF) is managed by Cambodian NGO MoPoTsyo in cooperation with the Ministry of Health and local health authorities in urban and in rural areas. The RDF aims to secure regular access to good quality, efficacy and affordable prescription medication for members (=chronic patients with Diabetes and High Blood Pressure) of Peer Educator Networks. Registered members by sex and age: - Total 1,023 chronic patients - 448 DM and 575 HBP - 65% of DM are women - 29% of DM are >60 years old In 2008, MoPoTsyo contracted one rural private pharmacy to sell to MoPoTsyo s local members against fixed prices per unit the prescribed RDF medication, which the NGO supplies and sells monthly to this pharmacy.
Background 2 In 2009, the contracted pharmacy was found not to meet the reporting requirements making it among other things difficult to track adherence to routine medication by patient-members. INTERVENTION Description: 3 additional private pharmacies (total 4) were contracted in Ang Roka (OD): Pharmacy 1 (in front of hospital) Pharmacy 2 (next to existing one) Pharmacy 3 (10 km to the South) Pharmacy 4 (10 km to the East) As specific measures in the whole OD: Reinforce Health Education Increase frequency of medical consultation sessions Raise level of and create a new type of PE incentives for member follow-up and for monitoring the RDF.
Objective / Study Questions OBJECTIVE To document how both access and adherence to routine prescription medicines from an RDF changed after a comprehensive set of specific measures. These measures included expanded roles of chronic patients and peer educators (PE) and also supply-side measures, notably increasing the number of pharmacies and agreeing with service providers on harmonization of specific health education messages. QUESTIONS 1. How can suboptimal access to affordable routine medication from an RDF for chronic patients be improved? 2. How can the role of an RDF itself be enhanced as part of a continuum-of-care for chronic patients? 3. Is it effective to increase the number of dispensing pharmacies?
Methods 1 Compare adherence to routine medication before and after intervention without control group. Secondary Data analysis. Source of data: copies of preprinted pharmacy invoices used for dispensing to member-patients, sent from rural pharmacies to the NGO for entry into database; copies of prescriptions made during the medical consultations; Method: Pharmacy invoices and prescriptions can be linked through patient ID providing information on adherence to routine prescription medication from the RDF. The proportion of members using alternative sources to procure prescription medication is unknown. We used as a baseline the routine reporting data in first half of 2010, comparing these with the first half of 2011 to measure changes.
Outcome measures 1) The proportion and number of prescriptions for DM and HBP made by medical doctors by gender and age group. 2) The average and median cost of prescription per month for DM and HBP. 3) The numbers of copies of pre printed invoices collected from pharmacies by PEN. 4) The number of times pharmacies dispensed to members by gender and age group in the period of 6 months. 5) Financial details from RDF sales to contracted pharmacies. 6) Details of revenue and intervention costs, including PEN costs, consultation cost and local cost of supervision by the NGO. 7) Proportion of members who bought RDF medicines from contracted pharmacies.
Results 1 1. Members having a prescription from a Medical Doctor for to buy RDF medicines: Out of 448 DM members the proportion of those with prescription for using the RDF increased from 58% (260 DM) to 67% (302 DM) (p<0.001) Proportions of men and women were 27% and 73% suggesting slightly better access by women. 68% 66% 64% 62% 60% 58% DM with RDF prescription 58% = 260 DM 67% = 302 DM Male=27% Female=73% 56% 54% Male=27% Female=73% 52% First half of 2010 First half of 2011 Among the DM patients older than 60 years, the proportion with prescriptions remained unchanged at 29%.
Results 2 - In the first half of 2010, only 11 of the 575 registered HBP members had a prescription, but this increased to 63 HBP members in the same group in the first half of 2011. 70 60 50 40 30 20 10 0 HBP with RDF prescription 63 HBP 11 HBP First half of 2010 First half of 2011 $6.00 $5.00 $4.00 $3.00 $2.00 $1.00 $- DM & HBP Average Monthly Prescription Cost $4.36 Median = $3.66 $5.44 Median = $4.94 First half of 2010 First half of 2011 The average monthly prescription cost increased from USD 4.36 to USD 5.44 (median 3.66 to 4.94)
1200 1000 800 600 400 200 Results 3 3. RDF monthly dispensing to members: RDF invoice-based dispensing Number of Invoice-based dispensing to DM patients Number of Invoice-based dispensing to HBP patients 0 first half of 2010 first half of 2011 345 1059 2 250 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Average times of dispensing (out of 6) Average number of Invoice per DM Average number of Invoice per HBP 1.3 0.18 3.51 3.97 first half of 2010 first half of 2011 Out of 6, in the first half of 2010, DM bought medicines 1.3 times and HBP bought medicines 0.18 times and then increased to 3.51 and 3.97 times, respectively, in the first half of 2011.
Results 4 4. RDF Gross revenue from medicines sales: RDF Gross Revenue $7,000.00 $6,000.00 $6,156 $5,000.00 $4,000.00 $3,000.00 $2,817 $2,000.00 $1,000.00 $- first half of 2010 first half of 2011 The increases across the board observed in the first half of 2011 show that it is possible to positively influence access to routine medication from RDF and improve chances of financial sustainability at the same time. RDF sales can cover the whole cost of medicines, medical consultation and incentive for PEN within the district but only if pharmacies pay on time.
Results 5 5. RDF Intervention s main cost: $3,000 Intervention's main cost over 6 months $2,500 $2,000 $1,500 $1,000 $500 $- RDF Cost PEN Cost Consultation Cost Local Supervision Cost first half of 2010 $1,087 $1,117 $936 $708 first half of 2011 $2,401 $1,359 $936 $708 The intervention s main costs in first half of 2010 and first half of 2011 were USD 1,087 and USD 2,401 respectively for the RDF cost, and USD 1,117 and USD 1,359 respectively for the PEN cost suggesting increased activity. Both the costs of organising medical consultation and local supervision remained unchanged at USD 936 and USD 708 respectively.
Results 6 6. Proportion of members bought medicines from each pharmacy: Pharmacy Location First half of 2010 First half of 2011 Pharmacy 1 In front of hospital 98% 44% Pharmacy 2 next existing one not open yet 7% Pharmacy 3 10 km to the South 34% not open yet Pharmacy 4 10 km to the East 15% not open yet 1) Adding 2 pharmacies far away from existing one has helped to improve access to routine medication for more than of half members being able to buy medicines closer to home. 2) Adding 1 pharmacy next door to the existing one created supply side competition which helped to improve attitudes of the original pharmacy and improve its compliance with the contractual requirements. In its first year the next door pharmacy (Nr 2) appears unable to compete with the original pharmacy once it (Nr 1) started to improve its attitude.
Conclusion and Recommendations The utilisation figures suggest that an intervention combining low-cost measures and pulling together demand and service supply sides can significantly improve access to routine medication for a structured rural membership community of chronic DM patients and has potential to serve an even larger group of HBP patients in the same area, simultaneously improving financial sustainability of the RDF. The use by women and by patients older than 60 years was already proportionate and improved therefore in absolute terms but not in relative terms. A profit margin of 15% is sufficient to satisfy a contracted pharmacy provided with monthly supplies on credit and served with community-based monitoring. RDF medicines can be administered and dispensed through a separate circuit with community support. Adding a pharmacy within the district is associated with improved attitude of the existing one and improved access for members.