Ezekiel Taiwo ADEBAYO, Nurudeen Ayoola HUSSAIN, Victor Segun AJANAKU

Akılcı ilaç kullanımı üzerine sağlık sigortasının etkisi

AMAÇ : Nijerya 2005’te Ulusal Sağlık Sigortası Projesi’nin Kamu Sektörü Sosyal Sağlık Sigortası bileşeni ile tanıştı. Kamu çalışanlarına katkı payı içeren bir sağlık güvence paketi sağlandı. Ordu için tüm katkı devlet tarafından ödenmektedir. Sağlık sigortasından önce Nijerya askeri hastanesinde reçeteleme örüntüsü yüksek muayene başına ilaç sayısı, düşük jenerik ilaç kullanımı ve yüksek enjeksiyon kullanımından dolayı akılcı değildi. Bu çalışmanın amacı, Dünya Sağlık Örgütü (DSÖ)’nün kriterlerini kullanarak aynı tesiste sağlık sigprtasının akılcı ilaç kullanımını nasıl etkilediğini incelemektir. YÖNTEM: Ikoyi, Lagos Nijerya’daki Askeri Hastanenin polikliniğinde 2008 - 2011 arasında kabul edilen hastaların kayıtları üzerinden yürütülen retrospektif kesitsel bir çalışmadır. Veriler tabakalı örnekleme ile rasgele seçilen yıl başına 45 hasta olmak üzere 180 hastanın kayıtlarından toplanmış ve DSÖ’nün istediği reçeteleme indikatörleri hesaplanmıştır. BULGULAR: Toplam 180 hastaların yaşı 1 hafta ile 66 yıl (mean 24,09±17,02) arasındaydı. En fazla hasta büyük gruplar 10 yaş altı (%28,3) ve 30-39 yaş (%27,8) gruplarındaydı. Erkek kadın oranı 1,15’e 1 idi. 180 muayenede 160 hastaya 466 ilaç reçete edilmişti. Muayene başına ilaç sayısı 2,6, jenerik reçeteleme hızı %56,4 ve antibiyotik yazma hızı %35 iken enjeksiyon reçetesi hızı %8,9 idi. Kalitatif çalışmadaki 50 soru formundan 29’u doktorlar 16’sı eczacılar tarafından dolduruldu. Doctorların %82,8’i ve eczacıların %75,0’ı reçete edilmiş ilaçların hasta tarafından ödenme sayısı ile ilgiliydi. Cepten ödeyen hastalar için doktorlar piyasa ismini %44,8 ve jenerik ismi %37,9 önerirken, eczacılar piyasa ismini %81,3 ve jenerik ismi %19,7 önerdiler. Aradaki fark istatistiksel olarak anlamlıydı (p=0.04). SONUÇ: Cepten ödemeden sağlık sigortasına geçişte ödeme şekli değişikliği muayene başına ilaç sayısını azalttı ve jenerik reçetelemeyi arttırdı. Muhtemelen sağlık sigortası altında artmış ödeme gücünden kaynaklanan antibiyotik reçeteleme hızında hafif artış oldu. Nijerya’da sağlık sigortası ajansları paydaşlarını akılcı ilaç kullanımı konusunda aydınlatma ihtiyacı duyarken hükümet sigorta yararlanımlarını optimize ederek kapsanan toplumu genişletmelidir.

Influence of health insurance on rational use of drugs

AIM: In 2005, Nigeria introduced the Formal Sector Social Health Insurance component of National Health Insurance Scheme. This provides public sector workers with a package of health interventions in return for employee and or employers contributions to the scheme. For the military, the entire contribution is paid by the government. Before health insurance was introduced, the prescription pattern at a Nigerian military hospital was reported as irrational with high drugs per encounter, low use of generic prescriptions and high level of injection use. The aim of this study is to evaluate how health insurance affects the rational use of drugs in the same facility using World Health Organisation criteria. METHOD: Retrospective cross-sectional study of case notes of patients seen at the general out- patients clinics of Military Hospital, Ikoyi, Lagos Nigeria between 2008 and 2011. Data collection from 180 case notes sampled through stratified sampling technique to retrieve 45 case notes per year. Materials were collected to calculate prescribing indicators as stipulated by the WHO. RESULTS: From analysis of 180 case notes, patients were aged from 1 week to 66years (mean 24.09±17.02). More patients were below 10years (28.3%) and 30-39 years (27.8%). The overall male to female ratio was 1.15:1. There were 446 drugs prescribed for 160 patients. The average drug encounter rate was 2.6, the generic prescription rate was 56.4%, antibiotic encounter rate was 35.0% while the injection prescription rate was 8.9%. Out of 50 questionnaires in the qualitative study, 29 doctors, 16 pharmacists returned theirs. Doctors (82.8%) and pharmacists (75.0%) were interested in mode of patient payment for prescription medicines. For patients who pay out-of- pocket, while doctors favoured using generic and branded drugs (44.8%), generics (37.9%); pharmacists favoured generic and branded drugs (81.3%) and generics (19.7%) with slight statistical difference (p=0.04) between both professionals. CONCLUSION: The change in payment pattern from out-of-pocket to health insurance has actually reduced average drug prescribed per encounter, increased prescription of generics possibly because hospital reimbursement is at the rate of generics and based on capitation for these group of patients. There was scant moral hazard in the slight increase in antibiotic prescription possibly due to improved affordability under health insurance. Nigerian health insurance agencies need to pursue enlightenment of stake holders on rational drugs use, while government needs to increase the covered population to optimize benefits accruable from health insurance.

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