Bitter Pills:Medicines & The Third World Poor | Page 135

been very hard to find retailers with both the necessary capital and the motivation
to participate in the scheme. A recent project report explains: "Ideally the retailer
is someone with an interest in medicine, an interest in community service and the
ability to manage finances (ie pay in advance for drugs on the shelf). However,
this community-minded capital wallah is an endangered species." (23) Almost
invariably the retailers have to be given their stock on credit. Recovering money
from them has proved a time-consuming and expensive process.
On balance the Hill Drug Scheme strategy of trying to improve drug availa bility
through the private sector has not been as successful as hoped. In the words of
Dr. Cassels, Medical Director of the Britain Nepal Medical Trust, "... all too
often the retailers' need to make a profit has been incompatible with the patients'
need to obtain medicines cheaply." (24'

BHOJPUR DRUG SCHEME
In 1980 a new model was tried, this time to increase drug supply within the health
services. Dr. Cassels stresses that the Nepalese Government is in no position to
provide more free medicines. "With costs rising and more and more new health
posts being opened every year the effective medicine budget per health post is
in fact going down." <25) The new scheme pioneered in the Bhojpur district of
eastern Nepal is modelled on the fixed prescription charge that patients in Britain
are asked to pay for National Health Service prescriptions. Hospital and health
post patients in Bhojpur who had previously received medicines free must now
pay a prescription fee of Rupees 2 (8p).
Exemptions were made for TB, leprosy and antimalarial drugs, and for patients
suffering from "chronic diseases" who would not be expected to pay more than
once every three months. The Health Post Committees were made responsible
for collecting the prescription fees which go into a central fund to buy more
medicines from an agreed list. The advantage for patients is that, whereas before
they were forced to pay high prices in the bazaars when stocks of free government
drugs ran out, now there should be regular drug supplies at the health posts.
The scheme is intended to be self-financing. In its first year, income from
prescription fees only covered about one third of the cost of drugs bought by the
Britain Nepal Medical Trust which had to make up the deficit. But subsequent
analysis of why the scheme ran at a loss has been valuable in highlighting specific
problems in drug use in the health service. Amongst these, over-prescribing was
a major problem, with health post patients receiving an average of 3.7 items on
the one prescription fee. Some expensive items, particularly antibiotics, were overused, as were costly proprietary preparations like cough mixtures. About 20%
of patients complaining of the same symptom as on their last visit were given
prescriptions without a charge, because the "chronic illness" exemption had not
been clearly defined. The standard fee was also unrealistically low to cover the
cost of drugs for in- patients, averaging Rupees 27.68. (26'
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