Alsan Marcella, Schoemaker Lena, Eggleston Karen, Kammili Nagamani, Kolli Prasanthi, Bhattacharya Jay
Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA; National Bureau of Economic Research, Cambridge, MA, USA.
Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA.
Lancet Infect Dis. 2015 Oct;15(10):1203-1210. doi: 10.1016/S1473-3099(15)00149-8. Epub 2015 Jul 9.
The decreasing effectiveness of antimicrobial agents is a growing global public health concern. Low-income and middle-income countries are vulnerable to the loss of antimicrobial efficacy because of their high burden of infectious disease and the cost of treating resistant organisms. We aimed to assess if copayments in the public sector promoted the development of antibiotic resistance by inducing patients to purchase treatment from less well regulated private providers.
We analysed data from the WHO 2014 Antibacterial Resistance Global Surveillance report. We assessed the importance of out-of-pocket spending and copayment requirements for public sector drugs on the level of bacterial resistance in low-income and middle-income countries, using linear regression to adjust for environmental factors purported to be predictors of resistance, such as sanitation, animal husbandry, and poverty, and other structural components of the health sector. Our outcome variable of interest was the proportion of bacterial isolates tested that showed resistance to a class of antimicrobial agents. In particular, we computed the average proportion of isolates that showed antibiotic resistance for a given bacteria-antibacterial combination in a given country.
Our sample included 47 countries (23 in Africa, eight in the Americas, three in Europe, eight in the Middle East, three in southeast Asia, and two in the western Pacific). Out-of-pocket health expenditures were the only factor significantly associated with antimicrobial resistance. A ten point increase in the percentage of health expenditures that were out-of-pocket was associated with a 3·2 percentage point increase in resistant isolates (95% CI 1·17-5·15; p=0·002). This association was driven by countries requiring copayments for drugs in the public health sector. Of these countries, moving from the 20th to 80th percentile of out-of-pocket health expenditures was associated with an increase in resistant bacterial isolates from 17·76% (95% CI 12·54-22·97) to 36·27% (31·16-41·38).
Out-of-pocket health expenditures were strongly correlated with antimicrobial resistance in low-income and middle-income countries. This relation was driven by countries that require copayments on drugs in the public sector. Our data suggest cost-sharing of antimicrobials in the public sector might drive demand to the private sector in which supply-side incentives to overprescribe are probably heightened and quality assurance less standardised.
National Institutes of Health.
抗菌药物疗效的下降是一个日益严重的全球公共卫生问题。低收入和中等收入国家由于传染病负担沉重以及治疗耐药微生物的成本，容易受到抗菌药物疗效丧失的影响。我们旨在评估公共部门的自付费用是否会通过促使患者从不太规范的私人供应商处购买治疗药物而促进抗生素耐药性的发展。
我们分析了世界卫生组织2014年抗菌药物耐药性全球监测报告中的数据。我们评估了低收入和中等收入国家自付费用和公共部门药品共付要求对细菌耐药水平的重要性，使用线性回归来调整据称是耐药性预测因素的环境因素，如卫生设施、畜牧业和贫困，以及卫生部门的其他结构组成部分。我们感兴趣的结果变量是测试的细菌分离株中对一类抗菌药物显示耐药性的比例。特别是，我们计算了给定国家中给定细菌-抗菌药物组合中显示抗生素耐药性的分离株的平均比例。
我们的样本包括47个国家（非洲23个、美洲8个、欧洲3个、中东8个、东南亚3个、西太平洋2个）。自付医疗费用是与抗菌药物耐药性显著相关的唯一因素。自付医疗费用百分比增加10个百分点与耐药分离株增加3.2个百分点相关（95%置信区间1.17-5.15；p=0.002）。这种关联是由要求公共卫生部门药品共付的国家推动的。在这些国家中，自付医疗费用从第20百分位数升至第80百分位数与耐药细菌分离株从17.76%（95%置信区间12.54-22.97）增加到36.27%（31.16-41.38）相关。
低收入和中等收入国家的自付医疗费用与抗菌药物耐药性密切相关。这种关系是由要求公共部门药品共付的国家推动的。我们的数据表明，公共部门抗菌药物的费用分担可能会将需求推向私营部门；在私营部门，过度开药的供应方激励可能会增强，质量保证也不太规范。
美国国立卫生研究院。
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