COMMUNITY FINANCING OF DRUG SUPPLIES IN RURAL NEPAL - EVALUATING A FEE PER ITEM DRUG SCHEME

A new programme in rural Nepal was evaluated in which users partly fun d the supply of additional drugs needed at health posts. Patients are charged a fee per item prescribed (FPI scheme). The scheme is administ ered by the District Public Health Office (DPHO). This scheme is compa red with two established schemes: one charges patients a fee per presc ription ('fee-per-script' or FPS scheme) and is administered by indepe ndently paid NGO (non-governmental organization) staff; the other uses local shops as a means of supplying drugs. The new scheme was associa ted with a rise in average daily attendance from nine to thirty-two pa tients a day (a 240% increase) when compared to a similar period the p revious year. Fewer drugs were prescribed in the FPI scheme (average p er patient 1.8 vs. 2.4, Chi square P <0.001). The average cost of a dr ug from the user's perspective was approximately 12% lower in the FPI scheme. These factors combined to make the average cost to the patient of a prescription haff that of one in the FPS scheme. The new scheme was 24% cheaper to run on a 'cost per patient' basis when compared wit h the FPS scheme. However, the overall subsidy needed for the scheme t o operate was higher because of the big increase in attendance. One-of f stocktakes of ten essential drugs were used to assess the availabili ty of drugs for patient use. The proportion of these drugs that were i n low supply or absent was 24% in the FPI scheme. This was similar in the other two schemes. The government DPHO did not perform all the adm inistrative tasks required. These tasks need to be simplified and diff erent methods for involving DPHO staff in drug scheme management need to be explored. The rapid turnover of senior staff, however, will rema in a major impediment. This preliminary evaluation shows that an FPI s cheme promotes a more rational use of resources, compared to an FPS sc heme. Administration of the scheme may, however, prove to be more diff icult. A simple field-based comparative assessment of drug supply sche mes can give a valuable insight into the strengths and weaknesses of a new programme.