Cost Burden to Patients, Drug Stockouts, and Impact on Nonadherence
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Within poor communities, the economic burden of healthcare influences patients’ adherence to prescriptions across the 3 countries and locations studied.In Ghana, the national insurance scheme covers the costs of some medicines from health facilities for those in the scheme. In Burkina Faso, free healthcare is provided to pregnant women and children <5 years old; in theory, providing cheap drugs at healthcare facilities and support schemes should alleviate the economic burden of purchasing medication in these population groups. In Uganda, free care, including a few tests and essential drugs, are provided to all patients by the government. However, in practice, this does not appear to be the case. Due to drug and test stockouts, many patients miss these free services, and cost burdens impact patients’ adherence to prescriptions.While national schemes exist, they are, by their nature, limited. In Ghana, the national insurance scheme does not cover all medicines in health facility pharmacies, nor most medicines obtained at private pharmacies/drug shops. In Burkina Faso, the scheme is limited to medications received from the health facility pharmacy and for pregnant women and children aged <5 years. Whether these schemes cover a patient or not, medicines may not be available at the health facility pharmacy because the prescribed medications are not routinely stocked there or because drug stockouts mean the drugs are unavailable when needed.Prescribed medicines not available at the health facility must be purchased elsewhere. Drugs purchased at private drug shops are costly and more expensive than drugs that can be bought at public health facilities. In addition, especially in rural settings, patients must pay for transport, such as motorcycle taxis, to reach the alternative drug shops. Additional costs put further pressure on already stretched household finances, and families must choose between competing healthcare needs.Patients use a variety of strategies to try and overcome unaffordability problems. They may find the money needed to buy the prescribed medicine in full—by selling cereals, poultry, or other assets or borrowing money (Burkina Faso). The time required to raise funds has the effect of starting a dose later than intended (Burkina Faso, Uganda). Patients may act to change the prescribed medicine so that it is cheaper by asking the HCW for help—generally reducing the number of prescribed drugs, prescribing more affordable drugs (Burkina Faso), or acting to reduce the cost of the medicines by delaying the start of doses, suspending or stopping treatment early (Uganda), buying alternative drugs or herbal medicines that are cheaper (Burkina Faso), or simply not buying the prescribed medication (Ghana).Once patients visit private drug shops, further factors impact prescription adherence. Patients can be persuaded to buy less medicine than prescribed or to buy something else. Moreover, there is a sense (from HCWs) that while pharmacies in health facilities will generally provide prescription instructions, there is little control over the prescription instructions provided by private drug shops.While drug stockouts are highlighted as a significant factor in increasing the cost to patients and contributing to a lack of adherence, unaffordability is also reportedly driven by late presentation at health facilities, leading to more expensive treatment such as intravenous injections (Burkina Faso), and wrong and multiple diagnoses, resulting in the need to purchase numerous medicines (Burkina Faso).While financial constraints are reported in isolation from other factors, it is anticipated that issues of finance interact with the beliefs of the patient and household decision-maker about the duration of medicine needed for the patient to recover. For example, household heads report that they would not purchase a full course of treatment if the patient showed signs of improvement following a small initial dose of the prescribed medicines (Uganda).