Abstract
Poor knowledge, scarce resources, and lack of or misaligned incentives have been widely documented as drivers of the irrational use of medicine (IUM), which significantly challenges the efficiency of health systems across the globe. However, there is limited understanding of the influence of each factor on IUM. We used detailed data on provider treatment of presumptive asthma cases in rural China to assess the contributions of provider knowledge, resource constraints, and provider behavior on IUM. This study enrolled 370 village providers from southwest China. All providers responded to a clinical vignette to test their knowledge of how to treat presumptive asthma. Resource constraints (“capacity”) were defined as the availability of the prescribed medicines in vignette. To measure provider behavior (“performance”), a subset of providers (104 of 370) were randomly selected to receive unannounced visits by standardized patients (SPs) who performed of presumptive asthma symptoms described in the vignette. We found that, 54% (201/370) of providers provided the vignette-based patients with prescriptions. Moreover, 67% (70/104) provided prescriptions for the SPs. For the vignette, only 10% of the providers prescribed the correct medicines; 38% prescribed only unnecessary medicines (and did not provide correct medicine); 65% prescribed antibiotics (although antibiotics were not required); and 55% prescribed polypharmacy prescriptions (that is, they prescribed five or more different types of drugs). For the SP visits, the numbers were 12%, 51%, 63%, and 0%, respectively. The lower number of medicines in the SP visits was due, in part, to the injections’ not being allowed based on ethical considerations (in response to the vignette, however, 65% of providers prescribed injections). The difference between provider knowledge and capacity is insignificant, while a significant large gap exists between provider performance and knowledge/capacity (for 11 of 17 indicators). Our analysis indicated that capacity constraints play a minor role in driving IUM compared to provider performance in the treatment of asthma cases in rural China. If similar findings hold for other disease cases, this suggests that policies to reduce the IUM in rural China have largely been unsuccessful, and alternatives for improving aligning provider incentives with appropriate drug use should be explored.
Highlights
The rational use of medicine requires that “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community” (World Health Organization, 1985)
Medications account for 70–75% of total health expenditures in low- and middle-income countries (LMICs), and WHO has estimated that 50–70% of these medications are not needed and constitute irrational use of medicine (IUM) (World Health Organization, 2008; Ofori-Asenso and Agyeman, 2016)
We found that the total gap for prescribing both correct and unnecessary medicines was due to all three gaps simultaneously
Summary
The rational use of medicine requires that “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community” (World Health Organization, 1985). A World Health Organization (WHO) report noted that less than 40% of primary care patients in public facilities and 30% in the private sector of developing and transitional countries are treated following standard treatment guidelines (Holloway and Van Dijk, 2011). Examples of provider IUM include polypharmacy; inappropriate use of antibiotics for non-bacterial infections; overuse of injections when oral formulations would be more appropriate; and failure to prescribe in accordance with clinical guidelines (De Vries et al, 1994; Hogerzeil et al, 2001; World Health Organization, 2021). Medications account for 70–75% of total health expenditures in low- and middle-income countries (LMICs), and WHO has estimated that 50–70% of these medications are not needed and constitute IUM (World Health Organization, 2008; Ofori-Asenso and Agyeman, 2016)
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