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Copayments linked to antibiotic resistance in low-, middle-income countries
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In low- and middle-income countries, copayments in the public sector were associated with the development of antibiotic resistance, researchers reported.
Out-of-pocket health expenses drive patients to purchase antimicrobials from the private sector where there is great incentive to overprescribe and quality assurance is less well-regulated, they added.
“The control of the spread of resistant bacterial pathogens is an urgent global public health priority,” Marcella Alsan, MD, MPH, PhD, assistant professor of medicine at Stanford University School of Medicine, and colleagues wrote in The Lancet Infectious Diseases. “Our results highlight an underappreciated policy lever to address this problem — the rolling back of cost-sharing arrangements for drugs in the public sector.”
Alsan and colleagues analyzed data from WHO’s 2014 antibacterial resistance global surveillance report. After adjusting for environmental factors that also can predict resistance — including sanitation, animal husbandry and poverty — the researchers assessed the effect of out-of-pocket spending and copayments in the public sector on the level of antimicrobial resistance in low- and middle-income countries. Most importantly, the researchers were interested in the proportion of tested bacterial isolates that were resistant to a class of antibiotics.
In a sample of 47 countries, only copayments were significantly associated with antibiotic resistance, the researchers wrote. A 10-point increase in the percentage of out-of-pocket health costs was correlated with a 3.2 percentage point increase in resistant isolates (95% CI, 1.17-5.15), according to the study.
In countries that required copayments, “moving from the 20th to the 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% (95% CI, 31.16-41.38),” the researchers wrote.
Out-of-pocket expenses were the single-most important predictor of antibiotic resistance in low- and middle-income countries, according to Alsan and colleagues. This correlation was driven by countries that require a copayment in the public sector, they said.
“The key insight of our analysis is that cost-sharing on drugs in the public sector might shift individuals into a less well-regulated, often informal private sector,” Alsan and colleagues wrote. – by Colleen Owens
Disclosure: The researchers report no relevant financial disclosures.
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