Make health care affordable for all

If we are really serious about achieving the national goal of making quality health care affordable and accessible to all, there is no better place to start than reining in unnecessary tests and costly medicines that increase costs without improving patient outcomes.

I recently took a patient to a Nairobi hospital and the cost for laboratory tests alone, even before admission, came to Sh15,520. From my analysis, none of these tests the doctor requested — urea, electrolytes and creatinine, liver profile, full blood count, random blood sugar, erythrocyte sedimentation rate, malaria antigen, and C-reactive protein — were necessary and the results returned normal.

I was left wondering if tests are sometimes requested solely to generate revenue for hospitals. Do some doctors and hospitals have a financial incentive to prescribe more expensive medicines even when cheaper alternatives might be as effective?

When I asked the doctor why she had requested these tests, her response was: “We order these tests routinely for all patients just in case.”

Imagine if I were a casual worker on a minimum wage. I would have spent my entire month’s salary on tests alone even before a diagnosis is determined and treatment given.

Now, I am not saying that all doctors have this habit of requesting unnecessary tests or that tests should not be requested. In medicine, disease symptoms overlap and making a diagnosis on a clinical basis alone may be no better than guesswork.

However, laboratory tests and investigations must be targeted, informed by science, and relate to the patient’s complaints and findings on examination. In other words, order tests only to confirm or rule out what you think the patient may be suffering from.

If you do not think I have malaria symptoms — fever, headache, joint pains, nausea, vomiting, and possibly a history of travel — do not make me pay for a malaria test.

Because kidney function is measured in terms of how efficiently they filter waste from blood, only request blood creatinine if you suspect a problem there or if the drug you want to prescribe is filtered through that route.

When a patient presents with chest pain, she/he may be having a heart attack or something else.

One cardiologist that I spoke to told me that in addition to or instead of chest pain, about a third of people with a heart attack will have non-specific symptoms that include abdominal pain, heavy sweating, back pain, neck pain, nausea, and vomiting.

Therefore, to determine if these non-specific symptoms (other than chest pain) are actually from a heart attack, it is important to find out if the symptoms came on suddenly or worsened over a period of hours or days. If so, the doctor can assume they are caused by a heart attack and order tests to confirm or rule out this.

Another bad practice I have come across is where patients got prescriptions for expensive “branded” drugs when there were cheaper generic options that work equally well.

In one instance, I had an epileptic patient who was taking a branded drug that retails at Sh180,000 a year and yet there is a cheaper generic version that works equally well and whose annual cost is Sh30,000.

Now, being epileptic is a serious problem and a patient is required to take medication daily for the rest of their life to alleviate the seizures

To reduce the cost of drugs, some countries use a system called reference pricing where all drugs with identical or similar therapeutic effects are grouped together. That means that all painkillers with the same active ingredients would be in the same class and the insurer, or patient, pays only one amount, called reference price, for any drug falling in that class.

The reference price can be set at the lowest priced drug in the group or the average of all the drugs in the group. That way, even though a doctor prescribes a more expensive drug, unless the patient wants to pay more, the reference price applies.

This puts pressure on drug companies to lower prices for drugs with good substitutes and for doctors to prescribe what is reasonable and affordable.

For heaven’s sake, this is the 21st century and we are long past the era where doctors simply prescribe what they feel is best for people. There is a moral issue here as well: an individual’s income should not influence the quantity and quality of medical care one receives.

Dr Obwogo works for an international NGO. [email protected].