Thursday, 12 March 2009

Health care adherence and responsibility

A recent study published in PLoS Medicine confirms what has previously been thought by those working in African health field. Adherence to antiretroviral (Anti-HIV) medication in Africa is high (> 90%) and higher than the West. After several hundred interviews the reasons were documented. Summarising the responses,
[Medication] adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.
I am not certain how robust this study was, nor whether other factors (age, religion, sex, income, etc.) were adequately addressed, but it is interesting that the high adherence was due to perceived responsibility of action.
Relationships confer responsibility in addition to providing resources. Recipients of help must recognize what they receive and reciprocate. To ignore these responsibilities is to risk resentment on the part of helpers.
It is their sense of duty within the domain of immediate family, supporters and community. There is no disconnect created by involving the government as an intermediary. When others help directly there is a sense of reciprocality. Not necessarily that one has to do the exactly the same as others, rather that one should do his duty in response to others.

I believe that when antiretrovirals have been scarce or expensive, the choice to medicate one patient funded by other patients who were not receiving treatment meant that the survivor would likely care for the non-survivors' kin. So an expectation is on the treated person to comply so that he will indeed survive.

Interestingly another article in the same edition compared health outcomes in children for user pays medicine and free health care. There was no difference in rate of illness. The authors wrote,
This lack of any effect of being randomised to free health care on health outcomes is unexpected, since there has always been an assumption that increased access as a result of free health care improves health.
Though the free care group used significantly more services!

People are capable of caring for themselves (if they have the resources). They are able to be responsible for their care and respond to reasonable community expectations.

Government intervention is mostly unnecessary—at least in illness; however it is likely the attribute of self care and responsibility extends beyond health behaviour.

(Not to mention the government cash savings by leaving the funding private. And, as usual, private investment is more efficient: in this case same outcome for probable lower cost—I am using attendance as a proxy for cost.)

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