Co-payments tied to drug resistance

Photo: A dollar note showing from a jeans pocket

Do out-of-pocket payments contribute to the growing antimicrobial resistance?; © Photoman

The high out-of-pocket costs for antimicrobial drugs in many developing countries are leading to an increase in drug-resistant pathogens, according to a study by Stanford University researchers.

Many government-run public health systems in developing countries have instituted copayments for visits to clinics and prescription drugs. However, the study's authors found evidence to suggest that such policies are associated with increased antimicrobial resistance, likely because high out-of-pocket costs have prompted low-income patients to turn to the black market or informal clinics for antibiotic and antiparasitic drugs.

The quality of drugs on the black market and at informal clinics is often poor. In addition, caregivers at such clinics may prescribe antimicrobials excessively and inappropriately, as well as provide inaccurate course and dose instructions, the researchers said. If patients do not take the proper dose of a drug, or take one that has been improperly manufactured, microbes can more easily evolve resistance to it.

Some four-dozen countries - from the Central African Republic to Sri Lanka to Russia - are particularly vulnerable to antimicrobial resistance, given their high burden of infectious disease and the high cost of treating resistant microbes. What is unfolding in these countries could undo decades of progress in declining morbidity and mortality from infectious diseases around the world, the researchers said.

"Understanding the drivers of antibiotic resistance in low- to middle-income countries is important for wealthier nations because antibiotic-resistant pathogens, similar to other communicable diseases, do not respect national boundaries," said Marcella Alsan, MD, the lead author of the study, which will be published in The Lancet Infectious Disease.

"Out-of-pocket health expenditures are a major source of health-care financing in the developing world," said Jay Bhattacharya, MD, senior author of the study and a professor of medicine, a senior fellow at the Freeman Spogli Institute for International Studies and another core faculty member at CHP/PCOR.

Purchases of drugs, including antimicrobial agents, constitute an estimated 70 percent of out-of-pocket health expenditures in India and 43 percent in Pakistan. In the sample of low- and middle-income countries used in the study, 49 percent of health expenditures are, on average, private. And the majority of those private health expenditures - some 76 percent - are out-of-pocket.

The study included 47 countries: 23 in Africa, eight in the Americas, three in Europe, eight in the Middle East, three in Southeast Asia, and two in the Western Pacific.

The data set for the main analysis is from the first global report by the World Health Organization on antibiotic resistance. The report, which came out last year, indicates that antimicrobial resistance is a "serious, worldwide threat to public health."
And the Stanford researchers believe this is, in part, due to high out-of-pocket costs. "To our knowledge, we are the first to emphasize the idea that copayments imposed in the public sector of a health-care system lead to overuse of a medication or product in the private sector," the authors wrote. "Conventional teaching in health economics - which focuses on their effect on the demand for care within a single insurance system - is that copayments tend to discourage use."

The most prominent and convincing evidence for this, the authors wrote, was the 15-year RAND health insurance experiment conducted in six U.S. cities on 2,000 households. That study found that the increase in copayments led to a significant decline in the use of antibiotics, "providing evidence that the demand for health care is not completely inelastic."

However, when the regulated public sector and unregulated private sector are selling the same or similar products, a price increase in one does not necessarily reduce the overall demand, the authors found. In fact, it may increase demand because higher dosages of drugs will be required to fight more resistant microbes, which are the result of poorly made and prescribed drugs in the private sector

"Even if total consumption of antibiotics were unchanged, the shift of more patients to less-regulated providers could lead to more antibiotic resistance," the authors wrote.; Source: Stanford University Medical Center

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