The effects of different kinds of user fees on prescribing quality in rural Nepal

This study evaluated the effects of three different kinds of user fee on th e quality of prescribing in rural Nepal. Using data from 33 public health f acilities, we performed a controlled before-and-after study, comparing a fe e per prescription (covering all drugs in whatever amounts) against one-and two-band fees per drug item (covering a full course of treatment for each item). With the one-band item fee, each item incurred the same fee; with th e two-band item fee, more expensive items incurred a higher fee and cheaper ones a lower fee. Thirteen indicators of prescribing quality were evaluate d based on an average of 400 prescribing episodes per facility per year. Th e percentage of prescriptions conforming to standard treatment guidelines w as 12% (95% confidence interval [CI] 3% to 21%) and 15% (95% CI 6% to 24%) greater with the one- and two-band item fees, respectively, than with the f ee per prescription. Prescribing quality improved through a reduction in th e number of unnecessary, but not necessary, drug items prescribed per patie nt. Item-based fees are associated with significantly better prescribing qu ality than a fee per prescription; therefore, item-based fees are preferred over a fee per prescription when considering methods of cost recovery. (C) 2001 Elsevier Science Inc. All rights reserved.