Bottom-up approach to successful implementation of pharmaceutical policy

Health policy has many dimensions [1]. Growing expenditures on prescription medications represent a major challenge for many health systems [2,3]. Drugs can be important for peoples’ health; however, increased expenditures on drugs in the developed world have also been attributed to inappropriate or unnecessary drug use [101]. As a result, many governments, third-party payers and other insurers feel pressure to ensure better use of drugs and to control costs, but without adverse effects on health [1–3]. A variety of measures to address these issues have been implemented worldwide [4]. However, the success of such policies may not only be dependent on well-designed evidence-based interventions, but also on how the policy is received or even understood by the public.

Public uptake of policy has many challenges; one such barrier may be the tendency of top-down implementation. Many interventions, such as financial incentives to influence patients’ drug use, assume that patients have the ability to prioritize the importance, or ‘actual’ need (as opposed to ‘perceived’ need), of the individual drugs and are informed about the appropriateness of generic substitution [2,3]. This puts burden on patients and demands knowledge about pharmacotherapy, since failure to prioritize their own drug use may, in the worst case scenario, result in negative health outcomes or otherwise undermine the effect and purpose of policies [2,3,5,6]. Patients may not respond to cost-sharing policies as intended, as found in a systematic review on the effects of caps and copayments where reductions were found for both life-sustaining drugs as well as other less essential drugs [2,3].

The emergence of a knowledge society has changed the patient’s ‘ability’ and ‘possibility’ to participate in health decisions [7]. The importance of health literacy has been argued and is often defined as “The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” [8]. Limited health literacy skills have been associated with poorer health outcomes and a barrier to effective participation in health decisions [9]. Furthermore, health illiteracy may also challenge uptake of policy. For example, in a study on generic drugs and beliefs among elderly patients, a low level of health literacy was associated with mistrust of generic drugs [10].

Hence, information available to patients and the patients’ ability to understand such information are vital since their decisions may depend on their knowledge about own health but also their insight into the appropriateness and effectiveness of drugs in question [5,6].

Media influence: health professionals as knowledge brokers

Health professionals are key disseminators of information when implementing and sustaining policy, but the patient–provider relationship has become more complex and the health professional’s role as ‘moderator’ of information is increasingly important [7,11]. For many patients, the most important source of information (second to health professionals) is mass media [102]. Although mass media and, particularly, the internet are important gateways to information for many patients and may provide social support through online communities, the pitfalls are many. The vast amount of information available makes it difficult to navigate and find relevant evidence, and findings from studies indicate that the quality of health information available varies and that the public may be misled by advertising or non-evidence-based information [12–20]. Moreover, the public’s ability to understand health information has been found to be low and many may have difficulties grasping concepts such as risk and causality [17].

Despite this, studies have found that the public have great confidence in the information they find, and that mass media may influence health behavior [21,103]. In a study conducted in the USA comprising 329 participants, half of the respondents believed that direct-to-consumer advertisements were subject to prior approval by the government; moreover, 20% thought that advertising for drugs with serious side-effects was banned and that only “extremely effective” and “completely safe” drugs were advertised directly to consumers [18]. Other findings indicate that direct-to-consumer advertising may create patient demand for drugs without necessarily improving health outcomes [19] and put pressure on insurers to include advertised drugs in their formularies [20]. For example, one reason that patients may prefer one brand versus an identical generic drug have been associated with direct-to-consumer advertising [10,18].

Inaccurate and/or misleading information through mass media are important challenges for modern healthcare and must be considered when informing patients. As the users most important source of health information, health professionals hold a unique position as knowledge brokers.In a study looking at consumer’ attitudes related to switching behavior in multi-tier drug benefit plans, the physician’s opinion about switching was found to be one of the most important factors when patients were asked about what influenced their decision-making [22] Other studies have similar findings and emphasize the importance of health professionals’ communications skills and taking the patients’ inquiries seriously [10,11,23,24]. Furthermore, some patients may be reluctant to ask questions or share concerns such as cost issues or fears about side effects [10,25]. Considering this, the health professional’s role as mediator and moderator of knowledge is crucial. Lessons from studies also argue that reinforcing the understanding of risk, and promoting realistic expectations, are vital [17,26].

Creating awareness: policy literacy?

Moving away from paternalistic thinking about healthcare, consumerism advocated the patient’s right to participation and empowerment based on the libertarian principles of marked-mechanism [27]. However, one short-coming of consumerism is that it encouraged patient demand but failed to emphasize shared responsibilities [27]. Although the concept of consumerism have been replaced by more commonly used terminologies such as partnership and shared decision-making to describe the patient–health professional relationship, healthcare is still challenged by ‘patient-pull’ of services [19,28].

A tendency can also be seen internationally that the public may not have confidence in public policy, believes that information is withheld or thinks that implementation of a drug policy is solely driven by cost concerns without careful consideration of safety and efficacy [22,29,102]. Educating patients about policy may help to create awareness, improve trust and more effective implementation and sustainability of interventions. The broader definition of health literacy also includes insight into the social and economic determinants of health and the policy dimension [30]. Thus, health literacy is not only associated with empowerment and improving health outcomes but may also be a facilitator to successful policy.

An example of patients not necessarily having insight into the mechanisms of policy is exemplified in a study conducted in Norway that looked at patients’ attitudes towards generic substitution [23]. When questioned regarding to what extent cost would influence their switching behavior, 41% of the respondents reported that they would not switch unless it meant direct savings for themselves [23]. Estimated threshold of direct savings before being willing to switch was US$7.5–14.5 (Converted from Norwegian Kroner; rates as of 17 March 2009), whereas savings on behalf of the public health system would have to be doubled to that of own savings [23]. Considering that all citizens in Norway are covered by public (tax-funded) health insurance coverage, increased drug expenditures would have to be paid for through taxes or potentially be taken from other budgets meaning less money for hospitals, health personnel and other health services.

The importance of public involvement and accountability has been argued in order to manage cost but also in meeting the public’s raised expectations [5,26]. This illustrates a shift from top-down to bottom-up strategy in policy, in that patient involvement is not only about empowerment and protecting the patients’ interests, but is also seen as a more sustainable approach through shared information, responsibility and accountability [10,26,28,31]. When tailoring drug policies, modifying factors that may compromise the success of the intervention should be carefully addressed. Policies should include also bottom-up strategies where emphasis is made on educating the patient about own health and decision alternatives, but also creating awareness about the rational of the policy itself. Health professionals are key actors in this context, supporting and educating patients when implementing sustainable policies.

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.