THE ROLE OF FREE PROVISION ON HOUSEHOLD EXPENDITURES FOR MEDICINES IN BRAZIL

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THE ROLE OF FREE

PROVISION ON HOUSEHOLD

EXPENDITURES FOR

MEDICINES IN BRAZIL

Andréa D Bertoldi

1

; Aluísio J D Barros

1

;

Aline Lins Camargo

2

; Pedro C Hallal

1

;

Sotiris Vandoros

3

; Anita Wagner

4

;

Dennis Ross-Degnan

4

1Universidade Federal de Pelotas, Brazil; 2Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil;

3The London School of Economics and Political Sciences,

UK; 4Harvard Medical School and Harvard Pilgrim Health

Care, USA

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THE ROLE OF FREE PROVISION ON HOUSEHOLD EXPENDITURES FOR MEDICINES IN BRAZIL

Andréa D Bertoldi1; Aluísio J D Barros1; Aline Lins Camargo2; Pedro C Hallal1;

Sotiris Vandoros3; Anita Wagner4; Dennis Ross-Degnan4

1Universidade Federal de Pelotas, Brazil; 2Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil; 3The London School of Economics and Political Sciences, UK; 4Harvard Medical School and Harvard Pilgrim Health Care, USA

Problem Statement: Medicine expenses contribute significantly to health care expenditures worldwide. In Brazil, among all health care expenses, medicines account for the largest share (41% in 2002/2003). The Brazilian national health system (SUS, Sistema Único de Saúde) is committed to supporting free access to medicines. To date, information is lacking about household spending on health care and medicines, particularly on who is getting free medicines supplied by SUS and how much households are saving because SUS is providing medicines for free.

Objectives: To investigate across different socioeconomic groups how much households spent on medicines and how much the Brazilian national health system supplied free of charge. Design: Cross-sectional study. Setting: This study was carried out in Porto Alegre, Brazil, from July to September 2003 and included 56 units of the Family Health Program (PSF, Programa Saúde da Família) from the Brazilian Public Health System. A two-stage sampling strategy was employed, with areas covered by the PSF constituting the primary sampling units. From the 56 units, 45 were selected with probability proportional to size and 20 households from each area were sampled. Study population: All individuals living in the selected households were included in the study. Individuals older than 13 years were interviewed face-to-face and mothers of younger subjects responded on their behalf. Using a pre-coded questionnaire, we asked individuals about the use of medicines during the past 2 weeks and requested to see the medicines’ packaging and prescriptions. For each reported medicine, we asked how the medicine was obtained and when and the amount bought or obtained free of charge. A total of 869 households were visited and 2,988 individuals were interviewed. Outcome Measure(s): We defined two expenditure variables: “out-of-pocket medicines value” (sum of retail prices of all medicines used by family members within the previous 15 days and paid for out-of-pocket) and “free medicines value” (similar definition for medicines obtained without charge).

Results: The Brazilian national health system provided free of charge 78% of the monetary value of medicines reported (79% in the bottom wealth quintile and 32% in the top ones); 73% of the medicines for continuous use were provided free of charge, whereas the equivalent proportion for medicines for acute use was 58%. Of the products listed on the essential medicines list, 86% were provided free of charge. The mean out-of-pocket expense for medicines was 6 times greater among the top wealth quintiles as compared to the worse-off (P < 0.001), but free medicines constituted a 3-fold greater proportion of potential medicines expenditures among the bottom quintile than among the better-off. Conclusions:

In Brazil, free provision of medicines, along with other economic incentives, may improve access and avoid high medicines expenditures for poor people.

Key words: Household expenditures; medicines; out-of-pocket spent; medicines access

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Problem Statement

• Medicine expenses contribute significantly to health care expenditures worldwide.

• In Brazil, among all health care expenses, medicines account for the largest share,

particularly among the poorest members of the population.

• According to national household surveys in Brazil, medicines represented 37% of health care

expenses in 1995 to 1996 and 41% in 2002 to 2003.

• The Brazilian national health system (SUS –

Sistema Único de Saúde) is committed to

supporting free access to medicines.

• The Brazilian Ministry of Health spent US$618 million on medicines in 2003, and this

expenditure increased to US$2.9 billion in 2006.

• Half of all medicines used by the population are obtained free of charge from the SUS.

• To date, information is lacking about household spending on health care and medicines,

particularly on who is getting free medicines supplied by the SUS and how much households are saving due to SUS provision of medicines for

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Objectives

• To investigate, across different socioeconomic groups, how much households spent on

medicines and how much the Brazilian national health system supplied free of charge to families.

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Methods

Design: Cross-sectional study.

Setting: This study was carried out in Porto Alegre, Brazil, from July to September, 2003 and included 56 units of the Family Health Program (PSF – Programa Saúde da Família) from the Brazilian Public Health System. A two-stage sampling strategy was employed, with areas covered by the PSF constituting the primary sampling units. From the 56 units, 45 were selected with probability proportional to size, and 20 households from each area were sampled.

Study population: All individuals living in the selected households were included in the study. Individuals older than 13 years were interviewed face-to-face and mothers of younger subjects responded on their behalf. Using a pre-coded questionnaire, we asked individuals about the use of medicines during the past two weeks and requested to see the medicine’s package and prescription. For each reported medicine, we asked how the medicine was obtained and when, the amount bought or obtained free of charge. A total of 869 households were visited and 2,988 individuals were interviewed. 5

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Methods

Ethical Aspects: The study protocol was approved by the Federal University of Pelotas Medical School Ethics and Research Committee and by the Porto Alegre Municipal Health Secretariat. Written informed consent was obtained before each interview. For respondents younger than age 18 years, one of the parents signed on their behalf.

Outcome Measures: We defined two

expenditure variables: “out-of-pocket medicines value” (sum of retail prices of all medicines used by family members within the previous 15 days and paid for out-of-pocket) and “free medicines value” (similar definition for medicines obtained without charge).

Data Analysis: We carried out double data entry and consistency checks by using Epi Info version 6.04 (Centers for Disease Control and Prevention, Atlanta, GA, 2001). We used Stata version 10.0 (StataCorp, College Station, TX, 2005) for data cleaning and analyses. The main unit of analysis was the household (n=869), although the total number of medicines mentioned by respondents (n=3492) was used as the denominator in some

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Results

As shown in Table1, the mean overall value of out-of-pocket medicines was R$15.75; this value was more than 6 times greater for families in the top 2 wealth quintiles than for those in the bottom quintile (P<.001).

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Results

Table 2 shows the proportion of the values of

out-of-pocket medicines and free medicines in relation to monthly family income and monthly overall health care expenditures.

As shown by comparing the data in Table 1, the SUS provided free of charge 78% of the total monetary value of medicines used by this population.

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Results

In Table 3, our data show that:

• 73% of the medicines for continuous use were provided free of charge, whereas the equivalent proportion of medicines for acute use was 58%.

• 70% of those medicines prescribed were provided free of charge, whereas only 30% of the medicines used for self-medication were provided free of charge.

• Of the products listed on the SUS list of essential medicines, 86% were provided free of charge.

• The pharmacologic groups most often provided free of charge were medicines targeting the blood and bloodforming organs (88%) and anti-infectives for systemic use (85%), whereas medicines for the respiratory system (37%) and dermatological products (39%) were less frequently subsidized by SUS.

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Results

The mean out-of-pocket expense for medicines was six times greater among the top wealth quintiles as compared to the worse-off (P<0.001), but free medicines constituted a three times greater proportion of potential medicines expenditures among the bottom quintile than among the better-off. 10

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Results

Figure 1 shows the relative proportions of values of

out-of-pocket and free medicines, stratified by quintiles of socioeconomic status. The higher the socioeconomic status, the lower is the contribution of medicines provided free of charge.

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Conclusions

• In our study, we gave emphasis to the out-of

pocket expenses on medicines and the savings to families resulting from the free provision of

medicines by the Brazilian health system.

• Although absolute values of free medicines were not markedly different across socioeconomic

groups, the proportions that these values

represent in relation to total family income were much higher among poor families.

• Along with other economic incentives, free provision of medicines in Brazil may improve

access and avoid high expenditures for medicines for poor people

Figure

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