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Table 1 An example of a plausible reason for anticipating differences in relative effectiveness

From: SUPPORT Tools for evidence-informed health Policymaking (STP) 10: Taking equity into consideration when assessing the findings of a systematic review

User fees were widely introduced in sub-Saharan Africa as part of the Bamako Initiative adopted by Health Ministers of the WHO African Region in 1988 [27]. The Initiative advocated selling drugs to users at a profit: the intention was to use the profit, in addition to user consultations payments, to improve access to care and quality of service. Opinion remains divided on the impact of introducing user fees for accessibility to services, particularly on the very poor. This initiative has been the subject of much debate for more than 15 years but there can be no doubt that user fees are a financial barrier for poor people needing drugs or other health services [28, 29].

In other instances where a third party pays all drug costs, patients may potentially have inappropriately high utilisation rates [30]. Direct cost-share policies shift part of the financial burden from insurers to patients and therefore increase patient financial responsibility for prescription drugs. These policies are intended to be an incentive to reduce the following: the overall overuse of drugs; the use of drugs of limited efficacy or those used for conditions where other, more cost-effective treatments are available; and third party payer expenditures. Patients are expected to respond to direct payments by decreasing drug use, by shifting to cheaper drugs, or by paying more costs out-of-pocket. By reducing the financial burden for third party payers and facilitating rational drug use, overall health levels may be improved by saving resources and reallocating them to other healthcare services.

However, a too-restrictive drug insurance policy may have unintended consequences. For example, a shift of cost from insurer to consumer may lead to the discontinuation of necessary drugs by patients. In turn, this may cause a deterioration of health and an increase in healthcare utilisation and expenditures for both patients and insurers. This is an unintended effect that is likely to have a larger impact amongst low-income or other vulnerable populations because such costs are likely to represent a more substantial proportion of total income. Schemes involving direct payment for drugs by patients are therefore controversial because increased cost sharing for drugs may present a financial barrier to the poor and other disadvantaged groups. Placing a cap on reimbursement for prescriptions has been shown to be linked to a reduction in the use of essential drugs in vulnerable subgroups of both elderly patients and severely disabled patients, and increases in hospitalisations and nursing home admissions [30].