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Objective: To evaluate a community education program about treatment of acute respiratory infection (ARI)., Methods: First, community case definitions for severe and mild ARI were developed. The intervention was then evaluated using a controlled before-and-after design. Household surveys collected data about ARI treatment in 20 clusters, each based around a school and health facility. Treatment indicators included percentages of cases attending health facilities and receiving antibiotics. The intervention consisted of an education program in schools culminating in street theater performances, discussions with mothers after performances and training for community leaders and drug retailers by paramedics. The intervention was conducted in mid-2003. Indicators were measured before the intervention in Nov/Dec 2002 and again in Dec 2003/Jan 2004., Results: Two thousand and seven hundred and nineteen households were surveyed and 3654 under-fives were identified, of whom 377 had severe ARI. After implementing the intervention, health post (HP) attendance rose by 13% in under-fives with severe ARI and fell by 9% in under-fives with mild ARI (test of interaction, P = 0.01). Use of prescribed antibiotics increased in under-fives with severe ARI by 21% but only by 1% in under-fives with mild ARI (test of interaction, P = 0.38). Irrespective of ARI severity, the use of non-prescribed antibiotics dropped by 5% (P = 0.002), and consultation with female community health volunteers (FCHVs)and use of safe home remedies increased by 6.7% (P not estimated) and 5.7% (P = 0.008) respectively., Conclusion: The intervention was implemented using local structures and in difficult circumstances, yet had a moderate impact. Thus it has the potential to effect large scale changes in behaviour and merits replication elsewhere.

Objective: To compare prescribing quality with a fee per drug unit vs. a fee per drug item., Methods: Prescribing data were collected prospectively over 10 years from 21 health facilities in two districts of rural eastern Nepal. In 1995, both districts charged a fee per drug item. By 2000, one district was charging a fee per drug unit, and the second district continued to charge a fee per drug item (control group). By 2002, the second district was also charging a fee per drug unit. These fee changes allowed two pre-post 'cohort' with control analyses to compare INRUD/WHO drug use indicators for a fee per drug unit vs. a fee per drug item., Results: Charging a fee per drug unit increased the percentage of antibiotics prescribed in under-dosage by 11-12% (P = 0.02 and 0.02), decreased the percentage of patients prescribed injections by 4-6% (P = 0.002 and 0.02), reduced the units per drug item prescribed by 1.7 (P = 0.02 and 0.03), and decreased compliance with standard treatment guidelines by 11-15% (P = 0.02 and 0.06)., Conclusion: A fee per unit was associated with prescription of fewer units of drugs and fewer expensive drugs (such as injections), resulting in significantly poorer compliance with standard treatment guidelines. This finding is of great concern for public health in countries where patients are charged a fee per unit of drug.

Objectives: (1) To estimate the cost of irrational prescribing, and (2) to compare the effect of three different kinds of user fee on prescribing costs, in rural Nepal., Methods: A controlled before-after study was conducted in 33 government primary health care facilities in rural eastern Nepal during 1992-95. A fee per prescription (covering all drugs in whatever amounts) was regarded as the control against which two types of fee per drug item (covering a full course of treatment for each item) were compared. The average total cost to the patient for two drug items was the same in all fee systems. Total cost, expected cost (according to standard treatment guidelines) and wastage costs (total minus expected cost) per prescription were calculated from an average of 400 prescribing episodes per facility per year. The proportion of prescriptions conforming to standard treatment guidelines was calculated from 30 prescriptions per facility per year., Results: 20-52% of total drug costs were due to inappropriate drug prescription. A fee per drug item, as compared with a fee per prescription, was associated with (1) significantly fewer drug items prescribed per patient, (2) significantly lower drug costs per prescription, (3) significantly lower wastage due to inappropriate drug prescription, and (4) a significantly greater proportion of prescriptions conforming to standard treatment guidelines. Average drug cost per prescription (which was 24-33 Nepali rupees [NRs] across districts and time) was 5.7 NRs (95% confidence interval 1.0 to 10.4) and 9.3 NRs (95% confidence interval 4.8 to 13.8) less with the two different item fees, respectively, than with the fee per prescription., Conclusion: The economic consequences of irrational prescribing are severe, particularly in association with charging a fee per prescription. Item fees in the public sector reduce irrational prescribing and associated costs.

This study evaluated the effects of three different kinds of user fee on the quality of prescribing in rural Nepal. Using data from 33 public health facilities, we performed a controlled before-and-after study, comparing a fee 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 the two-band item fee, more expensive items incurred a higher fee and cheaper ones a lower fee. Thirteen indicators of prescribing quality were evaluated based on an average of 400 prescribing episodes per facility per year. The percentage of prescriptions conforming to standard treatment guidelines was 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 fee per prescription. Prescribing quality improved through a reduction in the number of unnecessary, but not necessary, drug items prescribed per patient. Item-based fees are associated with significantly better prescribing quality than a fee per prescription; therefore, item-based fees are preferred over a fee per prescription when considering methods of cost recovery.