Croatian pharmaceutical sector reform project: rational drug use

The Croatian Pharmaceutical Sector Reform Project was one component of a larger Health Reform Project financed by the World Bank. The Croatian government was concerned that Croatia appeared to spend more money on medicinal drugs than most other countries in the region; that the price of drugs purchased in Croatia was higher than in some other countries, and that the prescribing habits of some Croatian physicians were perceived to be unnecessarily expensive. In addition, the Croatian Institute for Health Insurance (CIHI), which pays for most health care, had come under considerable financial pressure due to increasing health expenditure and a decreasing proportion of the population contributing to insurance. The Australian Health Insurance Commission won the contract for the pharmaceutical reform project. Australian experts were matched with Croatian experts in order to share knowledge, learn from each other, and provide the best advice. The project had two main components. The first addressed supply side issues and provided advice about savings that could be made by incorporating pharmacoeconomic principles into the selection and purchase of drugs on the Croatian positive list. The second component addressed demand side issues and provided advice aimed at evaluating and improving the quality and effectiveness of drug prescribing by Croatian physicians. This paper describes the second project component. We quantitatively and qualitatively evaluated the prescribing practice of Croatian physicians and ascertain how these might be improved. Croatian general practitioners are required to enter an International Classification of Diseases, 10th Revision (ICD10) diagnostic code on their prescription in order to indicate the clinical problem being treated. Quantitative research involved sorting CIHI prescription data for 2002 into ICD10 diagnostic categories and comparing the drugs prescribed for particular conditions with the recommendations in local and international best-practice guidelines. The results showed a number of areas where the prescribing of Croatian general practitioners and specialists could be improved, such as the use of antibiotics in upper respiratory tract infections and the treatment of hypertension. Qualitative research involved a series of workshops with local pharmacological experts and general practitioners during which the collected prescribing data was discussed, local factors which influenced prescribing were explored, and suggestions for improvement were collated. Many general practitioners felt pressured by increasingly assertive consumers, relentless pharmaceutical promotion, and strident government (CIHI) demands to restrain escalating health care costs. In addition, there was a lack of information about what constituted cost-effective treatment appropriate to the Croatian economic situation. There was support for the production of concise Croatian therapeutic guidelines that provided a limited number of best-practice treatment options for common conditions. A pilot set of such guidelines was devised and incorporated into a clinical software trialed in a Primary Health Care Information Technology Project in Koprivnica. This initiative received support from the general practitioners involved. It was recommended that a unit for the quality use of medicines should be set up to sustain the production of therapeutic guidelines and coordinate this activity with related initiatives. In addition, a quality assurance system (including performance indicators linked to financial incentives) was recommended that would encourage general practitioners to practice in accord with guidelines. We understand that the Croatian government has accepted a number of these recommendations and, in particular, performance indicators (and financial incentives) are written into new contracts for Croatian general practitioners in 2004.