Patient fees drive antibiotic resistance

Medication hand with pills
Copyright: Lianne Milton/Panos

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  • Big bills push patients to shorten expensive drug treatments
  • This can lead to microbes becoming resistant
  • The more that patients pay, the more resistance rises

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Making people pay for medicines out of their own pockets encourages the spread of drug-resistant microbes in developing countries, research suggests.

Steep medical bills may force patients to shorten expensive antibiotic treatments or switch to poor-quality drugs often found in private pharmacies, according to a paper published in The Lancet Infectious Diseases earlier this month (8 July).

“We have to understand that policies that might dampen demand in some places might just shift demand to a poorly regulated private sector in others.”

Marcella Alsan, Stanford University in the United States

“We have to understand that policies that might dampen demand in some places might just shift demand to a poorly regulated private sector in others,” says lead author Marcella Alsan, an infectious disease researcher at Stanford University in the United States.

Alsan says her findings challenge the conventional wisdom that making patients pay restricts drugs’ use to those patients who really need them, slowing the steady march of resistant microbes.

Shortening drug treatment or using antimicrobial drugs unnecessarily, for instance to fight a viral infection, can lead to microbes becoming resistant to the medicines that are meant to destroy them, turning common bacteria such as E. coli into killers. If left unchecked, this phenomenon could leave the world without effective antibiotics before the end of this century, the World Health Organization (WHO) warned in a 2014 report.

Alsan and her team used this WHO report to chart the prevalence of drug resistance for nine pathogens across 47 countries, including 23 in Africa. They then examined various social and environmental factors to see which ones might play a role in increasing resistance. These included poverty levels, sanitation facilities, the number of hospital beds and patients’ out-of-pocket medical expenses, which account for more than 60 per cent of total healthcare spending in some African countries, according to the WHO.

The study found that the only factor to significantly affect resistance was personal medical spending. Countries in the bottom fifth for out-of-pocket health expenses had half the resistance rates of those in the top fifth.

The results suggest high prices may fail to discourage patients from taking unnecessary antibiotics. Instead, many people look for cheaper or easier ways to buy them, says Alsan. They often find these in private facilities that may overprescribe medicines and where they may also be of poorer quality, the paper says.

Therefore policymakers must focus their efforts on making these alternative routes safer, Alsan says, for instance by controlling drug supply more strictly.

But regulating private providers is only part of the solution, says Vemu Lakshmi, head of microbiology at Nizam’s Institute of Medical Sciences in India. Governments must also work to make drugs more affordable, for example by encouraging the use of cheaper generic medicines, she adds.

Only when people can afford to buy a full course of antibiotics, and not reduce their doses to keep costs low, will resistance be kept in check, she says.