USE OF DRUGS IN SIND PROVINCE PAKISTAN PRIMARY HEALTH CARE FACILITIES

BY

KHALIL MEMON

CONCENTRATION PAPER FOR MPH AT
BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH

DEPARTMENT OF INTERNATIONAL HEALTH

Name: Khalil Memon

Concentration Paper Title: Use of Drugs in Primary Health Care (PHC) Province of Sindh Pakistan

ABSTRACT(150-300 words)

In addition to being unethical, irrational drug use often leads to problems such as drug resistance and wastage of resources and overall decreases the quality care of population. Studies have been carried out in several developing and developed countries to assess the extent and severity of the problem. The present study, designed according to WHO methods, was carried out in thirty public sector primary health care facilities in three randomly selected districts of Pakistan’s southern province of Sindh during the fall of 1998. During the study 1320 patient records were studied and reviewed retrospectively and 900 patients were observed and interviewed prospectively, to assess what was prescribed, dispensed and what information and knowledge was communicated to the patient during each visit to health facility. The study collected data of prescribing and patient care indicators such as number of drugs prescribed, percentage of injections, antibiotics and generic drugs prescribed, average consulting time and average dispensing time and drug adequately labeled and knowledge of patient regarding drug use. Results show that the indicators in Sindh are quite dismal, not comparing favorably even with other developing countries in Asia and Africa, and underscore the need for a great deal of effort and improvement in this area. An earlier intervention under a foreign-aided project was also found to be ineffective.

As we stand poised to enter the 21st century, it is a matter of great concern that the misuse and irrational use of drugs is still common in most countries. Although the problem is no doubt more acute in the developing world, which also has to contend with fast shrinking health budgets, developed countries are not immune to unscientific prescribing and dispensing habits and practices. Significantly the rapid advances in technology and the use of modern education methods in health have failed to remedy the situation. In the developing countries, where the resources for the health sector are scarce, this inappropriate use of drugs makes the situation even worse as squandering of the slim provisions invariably affects the overall quality of care adversely, leading to grave consequences for the general population.¹ Since 1981, the WHO, through the Action Program of Essential Drugs (DAP), the Nairobi Conference of Experts and the International Network for Rational Use of Drugs has been supporting and assisting developing countries in addressing this problem. Their technical assistance is mainly in the field of research, development of intervention strategies and promoting the rational use of drugs while also providing forums and tools of expertise.^{2, 3,4}

Several factors are generally known to contribute in varying degrees to inappropriate drug use. These factors greatly influence the behavior of the prescribing physicians, and include their training (or lack of it) in prescribing drugs, influence of sales representative of pharmaceutical companies, peer pressure, social and cultural pressure, emulating prescribing habits of senior doctors, availability of drugs, procurement and selection irregularities and demands of patients for certain medications.^{5, 2}

In Pakistan, irrational drug prescribing and dispensing practices are prevalent at all levels in the government health facilities as well as by the private practitioners, in all the four provinces and its three other territories. But in the public sector, the problem is particularly serious in the primary health care (PHC) facilities of the province of Sindh, where 60 % of population lives in rural areas that are provided with primary health care facilities alone. These irrational drug use practices cause wastage of scare resources, produce resistance to various commonly used antibiotics, and go against the ethics of the medical profession. So far neither the Government nor the private sector has made any significant effort to alter the existing state of affairs although some scattered interventions are in place. In Pakistan, the problem is all the more acute in view of the peculiar problems routinely encountered in the country. These include spurious drugs in the market, certification of pharmaceutical companies with doubtful credentials, poor quality control mechanisms, drug smuggling across the borders, widespread use of antibiotics for self- limiting conditions and minor ailments, over- the- counter dispensing of practically all type of drugs, and unaffordable prices of good quality medicines.^{6, 7} All these factors, individually or in combination with each other, contribute to the misuse of drugs and lower the natural defense mechanisms to infections in most Pakistani citizens, the majority of whom live below the poverty line.

The National Health Policy that was introduced in Pakistan in 1997 has been striving to promote the rational use of drugs at every level of care.⁸ However, despite the fact that policies are in place to promote the appropriate use of drugs in both the public and private health sectors, no scientific study has been carried out to assess the effectiveness of such policies and correlate them to the actual prescribing practices.

In Sindh, the Department of Health (DoH) and its World Bank funded Family Health Project is aiming to improving the health status of the population within the province with a special emphasis on increasing the accessibility and quality of maternal health services. The project’s primary objective is to improve the quality and integration of primary health care services, particularly for communicable disease control, and also to enhance the effectiveness of the existing health care network.⁹ To achieve the objective of health services development, the project has developed an area focus approach concept. The basic methodology of this approach is to identify a rural health center (RHC) in each district with four or five surrounding basic health units (BHUs) and to develop them as prototype models for that district. ¹⁰

In this paper I will present the findings of a survey conducted during the Fall of 1998, regarding drug prescribing and dispensing practices in the out- patient department of the primary health care facilities in the province of Sindh. In this paper I also want to characterize the prescribing physicians behavior with regard to their drug use practices related to the level of care (RHCs & BHUs). In addition, an attempt will be made to assess the impact of the intervention in area focus facilities and also to characterize drug use by diagnosis and age category. This paper will also draw the attention of the government and concerned citizens towards the problem of irrational drug use, provide certain baseline data and assist policy makers at DoH to design future interventions.

Pakistan, which is situated in the northwestern part of the South Asian subcontinent, obtained independence from the British in 1947 following the sub division of the Indian subcontinent. It is comprised of four provinces, namely Sindh, Punjab, Balochistan, North West Frontier (NWFP), and three territories. With the density of population around 50-199/sq km and a population of 129 million persons, 97% of whom are Muslims, ¹¹ is the ninth most populous country in the world.¹¹

Pakistan is predominantly agricultural country with just over 50 % of the work force employed in agriculture-related occupations. A sizable majority of the population lives in rural areas, with about 30% of the population in Pakistan living below the poverty line.¹¹

Pakistan has one of the lowest literacy rates (31 %) in the world, ¹¹ with a wide gap between the male (43%) and female (18 percent) literacy rates. The sex ratio of population is estimated to be 111 males per 100 females.¹¹ The population has increased at an average growth rate of about 2.6% per annum since the time of the last census conducted in 1981 till the present one in 1998, with rapid urbanization¹²

3. BACKGROUND.

The study to investigate the drug use practices in the primary health care facilities was conducted in the province of Sindh which is the second largest province of the Pakistan in terms of population and the third largest in terms of area.

The population of Sindh according to the 1998 census is about 30 million¹², of which 40% live in urban areas while 60% live in the rural areas.¹³ Health is generally considered as a provincial responsibility, although the Federal Government coordinates with all the provinces and suggests the policies to be adopted.

The area of Sindh is about 141,537 sq. km and the density of population around 135 per sq. km. The percentage of male population is 53% while that of females is 47%. The province is administratively divided into 5 divisions, 21 districts, 38 tehsils or talukas and 640 union councils.¹³

The network of primary public health facilities is comprised of 90 Rural Health Centers (RHC), 659 Basic Health Units (BHU), 36 Maternal and Child Health (MCH) Centers, 18 Maternity Homes, 5 Urban Health Centers (UHC), 12 Urban Health Units, 11 sub health centers, 43 centers where traditional medicine is practiced and 134 dispensaries. At the secondary level of health care there are 11 District Headquarter hospitals, 22 major hospitals and 45 Taluka Headquarter hospital. At the tertiary level there are five teaching hospitals and an equal number of specialized hospitals for persons with psychiatric, dermatological or chest diseases.¹⁴

The Basic Health Unit (BHU) with two labour beds and outdoor dispensing facilities is the health care facility provided at the level of the Union Council, which is the smallest administrative unit. The Department of Health has made efforts to see that all the union councils are covered with at least one basic health unit. It provides the basic curative, preventive and supportive services. The population of each union council ranges from 4000 to 8000, while on an average the patient attendance in the basic health units is between 20-40 per day. The BHU is staffed with a doctor, male health technician, female health technician, lady health visitor and other support staff. Every BHU also supervises the activities of 20 outreach lady health workers (LHW).

The rural health center is a more upgraded facility and has 20-30 beds at the level of town committee in the districts. It mainly provides inpatient and outpatient curative and preventive health services, and serves a population of 20000-40000. The RHC is staffed with 4-6 male doctors and 1-2-lady doctors with technical and supportive staff, both male and female.

The Sindh Family Health Project is a World Bank-assisted project which started in 1993, at cost of 33.776(million) US $, with the main objectives increasing the availability and quality of maternal health services, integrating primary health care services and building the institutional capacity. These objectives are being realized by strengthening health services; staff development by providing in-service training to doctors and paramedical staff in different disciplines such as management, nutrition, family planing, health education, communicable disease control; and enhancing institutional capacity to address public health issues.¹⁵

Through the network of primary health care facilities, free treatment is provided to patients, but owing to inadequate laboratory equipment and medical staff, these government -owned health facilities and hospitals fail to provide adequate health care. Furthermore, most health practitioners are employed in public health facilities during the morning and practice privately in the evening. Most physicians in the basic health units are fresh graduates from the medical schools.¹⁶

Since 1981, the Action Program on Essential Drugs (DAP) of the World Health Organization has been working to ensure the development of national essential drug lists along with the availability of these essential drugs in developing countries ^{24, 25,2} The reliable supply and availability of drugs were also considered to be indicator of high quality care in most of developing countries, but availability of drugs alone is not a definite criteria for high quality care unless the appropriate use of drugs is ensured.

The terms "appropriate" and "rational" use of drugs were more recognized after the Conference of Experts on Rational Use of Drugs, convened by the World Health Organization (WHO) in Nairobi in 1985²¹ in which it was stipulated that, "the rational use of drugs requires that patients receive medication appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, at the lowest cost to them and their community."^23,3 This definition implies that the rational use of drugs in the biomedical context in terms of rational prescribing practices should meet certain criteria, which are listed below:

• Appropriate indication in terms of the rationale of drug use practices based entirely on medical considerations.

• Appropriate drug in terms of selection of drugs based on efficacy; safety, suitability and taking into account cost considerations.

• Appropriate patient, to avoid the existence of contraindication and minimizing the chances of reactions.

• Appropriate dose in terms of administration and duration of treatment.
• Appropriate information and appropriate monitoring²³

The terms "inappropriate" and "irrational" use of drugs were often used in association to the use of drugs when no therapy is indicated, the use of wrong drugs for specific conditions requiring drug therapy, the use of drugs with doubtful efficacy, the use of drugs for uncertain safety status, use of correct drugs with incorrect route of administration, dosage, or duration.²³

In the Conference of Experts in Nairobi in 1985, for the first time health planners, academicians, representatives of the pharmaceutical industry, and consumer activists from developing countries sat together and agreed on the importance of rational use of drugs, and emphasized investigating drug use practices to determine the factors which influence prescribers.²

In 1989, the International Network for Rational Use of Drugs (INRUD) was established. ^2,3,4 The main objective of INRUD was to provide a forum and tools for the promotion of well -designed research into drug utilization problems and help identify interventions that are most appropriate in promoting the rational drug use.²

In order to promote the rational use of drugs, and encourage a standard approach to measuring problems in drug use, the first step was to initiate drug use research, which describes the current drug use situation in the country, region, or individual health facility. INRUD developed drug use indicators, which were tested in developing countries with the collaboration of WHO. The tested drug use indicators were again revised and refined, and thereafter the methodology for collection of data on indicators was developed. ²⁴

A standardized set of drug use indicators was used to quantify the impact of essential drug programs in Yemen and Uganda, and the studies conducted revealed that antibiotics were used in 46% and 56% of the patients, respectively in the two countries while the average number of drugs per prescription was 1.5 in Yemen and 1.9 in Uganda. ^22,23 Similar studies using these indicators and basic methodology were carried out to assess drug use practices in primary health care facilities in a total of 21 developing countries. ²³

The studies conducted in the African region showed that in Ghana the average number of drugs was 4.3, which is not only the highest in the region but also exceeds the figure for Asia, Latin America and the Caribbean countries, indicating inappropriate use of drugs on a massive scale. In Asia, the average use of drugs per prescription was 3.3 in Indonesia and 1.4 in Bangladesh. A study conducted in Sudan estimated the antibiotics use at 63% and the use of injections at 36 percent. In the same region another study conducted in Zimbabwe showed that the use of antibiotics was 29% while that of injections was 19%only.^22,23

TABLE 1 Field test for rational drug use in twelve developing countries

Results of field tests for rational drug use in twelve developing countries are reflected below in (Table- 1) below, which indicate the prescribing practices and identify areas which require to be prioritized for future promotion of rational drug use. The table also suggests the type of intervention will be more effective keeping in view the prevailing cultural, social and economic factors in these countries.^22,3

In developed countries also the inappropriate use of antibiotics has been observed in the case of a teaching hospital in USA in 1978 where 41% of antibiotics were used in all inpatients and in Australia in 1983 when the inappropriate use of antibiotics was 48% in all departments.¹⁷

In Pakistan, a community-based study was conducted in 1997 to test the hypothesis that over- the-counter availability of antimicrobial leads to self-medication and misuse of drugs. The study showed, however, that over-the-counter availability of antimicrobial agents does not result in self-medication by default. Moreover, it was seen that the vast majority (91%) of antimicrobials used in the city of Karachi were taken on the advice of physicians or surgeons.²⁹

Another Pakistani study was conducted to compare the drug prescribing practices among general practitioners and pediatricians for childhood diarrhea, where the results showed that 66.1% of general practitioners (GPs) were prescribing antibacterial as compared to 50% by pediatrician. Similarly it was seen that 32.1% of general practitioners (GPs) used injections as compared to 19.9% of pediatricians. The above two categories of prescribers used injections in 15% and 8%, respectively, of their encounters to treat the childhood diarrhea.¹⁶

Yet another recent Pakistan study was conducted in the province of Sindh to test the utilization of primary health services in the public sector. The results of this study showed that both male and female patients who went to public health facilities were nine times more likely to receive medicines as compared to those who went to private practitioners. Moreover, the use of injections and antibiotics was ten times more in public health facilities as compare to private practitioner clinics³⁰. With all the known problems in drug used in Pakistan there was need for a standard WHO indicators study to be conducted to document the situation in Pakistan.

The main objective of the study presented in this paper was to assess the current drug use practices in terms of number of drug per prescription and percentage of patients prescribed antibiotics or injections and generics. Efforts were also made to evaluate patient care in terms of the time given to each patient during the consulting and dispensing process and the knowledge of the patients regarding drug use. More importantly, this study characterized the behavior of the physician regarding the use of drugs after arriving at a diagnosis and considering the age of patients. Also studied the impact of the interventions carried out by the World Bank-assisted Family Health Project Sindh under the area focus approach that targeted selected health facilities in various areas was also studied. The study was focused on primary health care (PHC) facilities in the Sindh province.

Studies in various developing countries have been used to assess certain standard drug use indicators required to assess and quantify the magnitude of the problem of inappropriate drug use.^{20, 21,25,26} In Pakistan, however, there is a dearth of such studies, though a few have taken place.^{6, 7,16,29,30} Most of these studies were based on the single disease treatment protocol or intervention and regulatory impact assessment focused on the secondary and tertiary health care^{16, 29,34.} No study has been conducted to date in the setting of primary health care; this area needed to be investigated regarding the drug use practices. In the province of Sindh more than 60% of the population resides in rural and far-flung areas where only primary health care facilities are present. It is, therefore, important to study drug use practices and quantify the magnitude and severity of the practices. Under the Family Health Project Sindh certain minor studies were done to assess the impact of certain project-based interventions¹⁰. The current study is one of them, and it aims to assess the current use of the drugs, correlate it with specific variables and provide the baseline data for further investigations or qualitative research in order to determine the main factors which contribute to inappropriate prescribing behavior. These studies would serve as the basis for follow up intervention.

The study was designed using the methods contained in the WHO manual, "How to investigate drug use in health facilities: selected drug use indicators (WHO/DAP1993) .²⁴ Core indicators were used in order to achieve the objectives. (Annex 1) The study was designed to mainly focus on the specific behavior of the health care provider regarding drug use practice at different levels of care such as BHUs and RHCs. At the first contact primary health care facilities or BHUs, the medical officers posted are newly graduated with less training and exposure to different diseases, while the average patient attendance at 20-40 per day was quite low. In the case of upgraded primary health facilities such as RHCs, four or five different types of physicians with training in various specialties are present, with the average daily patient attendance usually more than 100 who are suffering from different kinds of illnesses.

The overall approach was to assess the current drug use practices and correlate them with the impact of interventions made in area focus approach facilities and comparison of the results with non- area focus approach facilities, detecting potential problems in current drug use practices with regard to the location of health facilities, social and cultural norms, training and education of physicians.

In order to achieve the objectives of the study, its scope was limited to three randomly selected districts of Sindh, which were considered adequate. The study was generally comparative, cross-sectional with patients record review, observation of consulting and dispensing processes and exit interviews of patient.

The health sector in Sindh is comprised of public and private sector hospitals and health facilities. The pubic sector facilities are divided in primary, secondary and tertiary health care facilities. The study population was, however, limited to the public sector primary health care facilities in the province of Sindh. The primary unit of study was rural health centers (RHCs) and basic health units (BHUs), the study unit for analysis was the health facilities and secondary analysis was prescribing encounters by diagnosis.

The independent variables included the type of health facilities, type of districts, area focus approach health facilities, non-area focus approach facilities, age group of patients and most common ten diseases by diagnosis. In order to produce representative and comparative statistics of drug use practices at different levels, we used the core drug indicators as dependent variables. These were prescribing indicators average number of drugs per encounter, percentage of antibiotics and injections used, percentage of drugs prescribed by generic name and percentage of drugs used from the essential drugs list. The patient care indicators were also used as dependent variables. These were: average consulting time, average dispensing time and percentage of drugs actually dispensed and adequately labeled; percentage of patient who knew the dosage and use of drug; availability of essential drugs and presence of essential drug list.

The first step was to sample districts from the whole province. In Sindh there are five divisions i.e. Sukkur, Larkana, Karachi, Hyderabad, and Mirpurkhas. Each division has 3-5 districts, with a total of 21 districts. The three districts randomly selected were Sukkur, Larkana and Thar. Sukkur is also a divisional headquarter and the third largest city in the province with a sizable population, 70% of whom live in rural areas. Larkana district is also a divisional headquarters with a more rural touch but having a medical school and teaching hospital. Most of the doctors working in these two districts graduated from the same medical school at Larkana and received the same type of pre-service training. District Thar is located in Mirpurkhas division in the lower part of the province. It is an essentially rural district with 90% of the population living in a desert area. In the Thar district most of the doctors working had graduated from another medical school in Hyderabad.

The second step was to select the health facilities from these three districts. The pre-existing prototype models of the area focus approach (i.e.1 rural health center and 4 basic health units) were included in the study in each district, while the same type of rural health center and basic health units of comparable staffing and patient load were randomly selected from the remaining of RHCs and BHUs in the non-area focus approach areas of the districts.(Annexes 11)

In the third step, sampling of prescribing encounters, we used the WHO sampling method.²⁴ In the BHUs 30 encounters were selected retrospectively from the record of outpatient register over a one-year period starting from the survey day. In RHCs the same method was used only the number of prescribing encounters were 100. The patient care indicators were sampled prospectively on the day of survey on those who attended the health facility RHC and BHU between 10 AM to 1.0 PM, with the first 30 patients considered as sample of patient care indicators, as shown in Table-2 below.

Selection of appropriate candidates is an important task in data collection as the quality of the entire survey and validation of data depend on collection of data by researchers. In this regard the medical officer incharge of the district health development center was appointed as supervisor of the survey team. He in turn selected five eligible candidates for data collection with background knowledge of drugs. Most of them happened to be health technicians with practical experience of working in different BHUs and RHCs. A one-day training program was scheduled in each district to train data collectors and supervisors of the team regarding data collection methods and certain basic knowledge regarding antibiotics and other drugs.

Before the start of data collection, I as principal investigator pre-tested the data collection methods, prescribing indicator forms and patient indicator forms. One BHU and one RHC with the same level and type of staff and almost the same patient attendance were selected in district Thatta. The incharges of district health development center Sukkur, Larkana, and Thar were involved in the pre-test. Manual data analysis was made during the pre-test and corrected the weakness of data collection instruments and data analysis tools.

In the data collection process, three teams were formed; each comprised of one physician-supervisor and three other data collectors. The principal investigator supervised the data collection process on an overall basis and was present in each district during data collection. The data collection team visited each health facility on an appointed date and randomly collected 30 records at BHU and 100 records at RHC of prescribing indicators by retrospective method from the patient record register. The records were checked from October 1997 to October 1998. Thirty patients were observed and interviewed at RHC and BHU for patient care indicators through prospective sampling, in which the consulting time and dispensing time were collected by observation, and adequate knowledge and labeling of drugs were collected by the exit interview of patient on the day of survey. To ensure the quality of data, the principal investigator closely checked for any missing information after the closing of the health facility, and sat with team members at the end of the day, and the completed forms were checked and reviewed by team members for any missing or doubtful entry. These scrutinized forms were then passed to the principal investigator for final checking.

The raw data was brought back to Boston, and after consulting and detailed discussions with the academic advisor the data processing started. Initially the manual method was used to check and edit data forms and the average calculations in respect to each indicator were made manually on the data sheet. The edited forms were then entered as a spreadsheet in the Microsoft Excel computer application.³⁸ In order to avoid any errors the print out of the entered data was rechecked and matched with original data sheets. During this processing of data, sorting method was used to sort the data by districts, type of health facility, area focus approach and non-area focus approach, age group and diagnosis.

During the analysis of data all dependent variables were calculated by using the sub total in the Excel program. Averages, percentages, frequency tables, t-test and bar chart were made.

8.1. Average Number of Drugs per encounter.(Table.8.1)

8.2. Percentage of Drugs Used by Generics. (Table. 8.2)

The overall average percentage of drugs used by generic name was 35, while it ranged from a minimum of 17% at BHU Arore (a NAFA facility) and a maximum of 58% at BHU Dubar (also a NAFA facility). There was no significant difference found at the level of care p= <632 i.e. Rural Health Center was 38%, while Basic Health Unit was 33%. Generally at every level in Area focus Approach health facilities there was a percentage of 39 while in the Non Area Focus Approach the percentage was 30 for the use of drugs by generic names. The percent of generics varied from33% in age group 0-1 Year and 37% in 45+Years.

(Table. 8.2)

PERCENTAGE OF GENERICS DRUGS USED
Level of Care	Percentage of Drugs By Generics
Rural Health Center	38%
Basic Health Center	33%
Intervention/Control
Area Focus Approach	39%
Non Area Focus Approach	30%
Districts
Larkana	34%
Thar	37%
Sukkur	35%
By Age Group
0-1Years	33%
1-4Years	34%
5-14Years	37%
15-45Years	35%
45+Years	37%
Over All
Average	35%
Maximum	58%
Minimum	17%

8.3 percentage of antibiotics prescribed.(Table. 8.3)

8.4 Percentage of Injections Prescribed. (Table. 8.4)

8.5 Percentage of drugs used from EDL(Table. 8.5)

8. 6 Average Consulting Time. (Table. 8.6)

8.7 Average Dispensing Time. (Table. 8.7)

Drugs prescribed by Diagnosis

The practices of drug use in different illnesses can be viewed in Table. 8.11, which shows that average number of drugs used in the ten most common diseases ranged from 2.7 drugs per encounter in case of boils and 4.0 drugs in asthma or bronchitis. Ninety-nine percent use of antibiotics was witnessed in acute respiratory infections, 61 % in diarrhea, 63 % in malaria, and an interesting 7 % for general weakness. The range of injections used varied from 21 % in diarrhea to 96 percent in general weakness, while in malaria cases injection were used in 83% of the cases. The drugs used by generics ranged from 30 % in skin infections to 40 percent in bronchitis. The drugs prescribed from the essential drug list was 86 % in boils, 71% in diarrhea, 69 % in fever & asthma, 68 % in bronchitis and general weakness. The overall average number of drugs was 3.5, with average antibiotic and injections use at 76% and 74 %, respectively.

Table-8.11 PRESCRIBING INDICATORS BY DIAGNOSIS

During the past decade efforts have been made to research the drug use practices in developed and developing countries. In most developing countries with the help of WHO and INRUD a standard set of drug indicators were used and tested to measure the drug use practices, at the country level and also in various regions and individual facilities. The standard methodology and technique were used to collect data in thirty developing countries, ^22,23,26,28 and efforts have been made to develop and test intervention strategies to improve the use of medicine in these countries. The experience and results not only indicated the problematic areas but also the degree of severity in the misuse of drugs, forcing policy makers and health planers to set the priorities and plan strategies for interventions according to the situation prevalent in each country.

The main objective of the present study based in a Pakistani province using standard methodology was to find out the current drug use practices in terms of what was prescribed, dispensed and what information and knowledge was communicated to the patient during each visit to a health facility²⁸. We analyzed the results of the study in relation to the types of health facilities manned by doctors of varying experience and skills. Another purpose of the study was to assess the impact of interventions in area focus approach health facilities, and to compare the results there with non-area focus approach health facilities to determine its efficacy. We also analyzed the results by districts to find any variation or influence of urban or rural districts on the prescribing and dispensing process and also to correlate the drug use practices with the age of patient and diagnosis.

The average number of drugs per prescription was 3.5, which is the highest in the regions of Asia, Latin American, Caribbean and Africa except Ghana, which has an average of 4.1.²² Incidentally Bangladesh, which was a part of Pakistan until 1971, shows the lowest average of 1.5 in the Asian region.²² The average number of drugs used in rural health center was 3.2 and drug used in basic health units was 3.7, also indicating that the level of care is not affecting the drug prescribing pattern. Moreover, no significant improvement was visible in the area focus approach health facilities. The use of drugs in the various districts was also found to be non-significant (p< 0.435).

The overall use of drugs by generic names was 35%, which is the lowest for most parts of the developing world and doesn’t compare favorably at all with Zimbabwe (94%)^22,23 or even Asian countries such as Bangladesh^22,23 and Indonesia^22,23, which stand at 78% & 59%, respectively. This is despite the declared policy of the Government to promote generics drugs in all prescriptions, selection and procurement. The single most important factor dissuading people from using generic drugs is their poor quality and efficacy. In Pakistan about 12000 to 20000 pharmaceutical products are registered and available in the market while around 300 pharmaceutical manufactures are functioning in the absence of any effective drug control authority, which would exert a deterrent force on the defaulters³⁰. This has led to an overall impression that generic drugs are of an inferior quality and generally unreliable.

Overall average antibiotics used were 76 %, which is also the highest percentage in Asia, Africa, and other developing countries. In Bangladesh^22,23 and Sudan^22,23 the averages stand at 25% and 63%, respectively. There was no correlation either to the level of care (RHCs & BHUs) or to the area focus approach facilities. The high use of antibiotics (72%) in age group of 0-1 year was alarming as this can have devastating consequences by affecting the immune system of newborns and decreasing the body defense mechanism by producing resistance. This high use of antibiotics reflects poorly on the behavior of physicians as a whole. Incidentally, it was observed that the estimated cost of antibiotics consumed in 1990 in Pakistan was US$ 120 million, which constituted 46% of total drug sales for that year.¹⁶

The results of the study show that overall average injections used were 74% which is perhaps the highest in the world, as it is 48% in Uganda²² which leads most developing countries and it is as low as 1-2% in Bangladesh.^22,23 The high percentage of injection use was also witnessed at all facility types and also in area focus approach facilities in the same percentage as the control group of the non-area focus approach facilities. The high use of injections not only cause the wastage of scarce resources but also adversely affects the quality of care by exposing population to hazards such as hepatitis and HIV/AIDS and drug reactions. Furthermore, an erroneous route of administration of injections also takes its toll of human lives. A few months ago in Karachi, 6 patients died due to wrong administration of injection in the emergency room of a tertiary hospital.³² This level of malpractice is both distressing and alarming as one shudders to think what must be the position in lesser hospitals where the patients are illiterate and not aware of the negligence of the health personnel.

The overall average drugs prescribed from EDL were 70%, which, although generally not so bad, does not compare favorably with Bangladesh^22,23 (85%), Nepal^22,23 (86%) or Tanzania^22,23 (88%). In Pakistan, the first essential drug list was issued in 1994, was comprised of about 400 generics drugs³¹, and WHO has categorized us as a medium coverage country, where only 30-60% of the population has regular access to essential drugs.³³

The overall average consulting time was found to be 2.8 minutes, as compared to 1 minute in Bangladesh,^22,23 3 minutes in Indonesia^22,23, 2.3 minutes in Malawi^22,23 and 6.3 minutes in Nigeria.^22,23 In the rural heath centers the average consulting time was 2.7 minutes while in the basic heath units it was 2.8, indicating virtually the same behavior. Another study conducted in Pakistan has shown that the average consulting time in a tertiary care hospital in Karachi was 1.2 minutes.³⁶ The consulting time in districts varied sharply from 1.8 minutes in the urbanized town of Sukkur as compared to 3.2 minutes in the rural district of Thar, indicating that in urban areas the physician are giving less time to their patients in public sector facilities.

The average dispensing time was found to be 106 seconds, and a trifle better than the averages in Bangladesh^22,23 (85 seconds) or Tanzania^22,23 (88 seconds). Generally the dispensing time was higher in basic heath units as compare to rural heath centers although the technical and support staff is much less at the BHU level. This indicates that the better availability of staff does not per se improve the dispensing process but it is the motivation and proper supervision that in reality makes the difference. What was intriguing was that the dispensing time was higher in non-area focus approach facilities at 123 seconds, as compared to 90 seconds in the area focus approach facilities, indicating that the interventions have yielded virtually nothing positive.

The study shows that the average percentage of drugs, which were adequately labeled, was only 20%, indicating that 80% of drugs received by patients were not labeled. This in turn means that most patients do not know which drug they are taking for their illness. But the knowledge of patients regarding correct dosage, time period or duration for taking the medicines was, found to be 60%, as compared to 27% and 82% in Indonesia^22,23 and Bangladesh,^22,23 respectively.

The results also indicate that low percentage of adequate labeling of drugs does not correlate with knowledge of patients regarding dosage and duration of taking the drugs. In basic health units where the percentage of drug adequate labeled was 19%, 63% of the patients knew the correct dose and duration for taking the medicines. During the survey it was observed that although the patients’ education level was low and drugs were not adequately labeled, the patients recalled their medicines by the size and color of the tablets or capsules. The knowledge of patients about the correct dosage and duration was surprisingly higher in facilities of non-area focus approach as compared to the area focus approach. The percentage of adequately labeled drugs was, however, lower in non-area focus approach health facilities. Moreover, the percentage of patients with adequate knowledge of correct dosage and duration was found to be lower in district Sukkur as compared to districts Thar and Larkana.

We did the secondary analysis regarding use of drugs by diagnosis. See Table 8.11. We chose the 10 most common illnesses which were seen by physicians and analyzed the average number of drugs, percentage of injections, antibiotics and drugs prescribed by generics for that illness. The results shows that in cases of fever the average number of drugs prescribed was 3.6, while 85% of antibiotics and 76% of injections were used on an average, indicating an unhealthy trend in the prescribers' behavior. In case of malaria the average number of drugs used was 3.6, percentage of injections used was 83% and percentage of antibiotics used was 63%, although antibiotics and injections have no proven role in the treatment of this disease. The average number of drugs used in diarrhea cases was 3.0, while surprisingly the percentage of antibiotics used was 61%, while injections were used in 21% of the cases indicating gross misuse of drugs and degree of irrationality in this condition, where only oral rehydration salts are indicated. Furthermore, 96% of injections were used in-patients complaining of general weakness.

We do not claim this study to be representative for the whole country of Pakistan but the standard sampling methods which were used to select districts and health facilities, and the standard methodology to collect data makes the study representative of Sindh province government health facilities. The methodology has been tested and approved in 30 developing countries.²⁸ It is hoped that the lessons learnt from this study shall pave the way for more studies under the domain of health systems research in the PHC sector to further evaluate the factors involved in irrational drug use, especially qualitative aspects of prescribing and dispensing behavior.

On the basis of the findings of our study, we recommend as a first step a detailed investigation into the specific causes of the documented irrational drug use practices in province of Sindh Pakistan. Qualitative research should be designed in such a to determine the precise factors that influence the physicians’ and patients’ behavior in the context of drug use. Based on the study results, my personal experience and informal discussions with my physician colleagues, I also recommend the following:

Training is a vital intervention to change the behavior of prescribers and improve drug use practices, as evidenced by the intervention studies conducted in developed and developing countries^18,26,, which have clearly shown that educational intervention strategies are successful for improving drug use practices.^26,28

In-service training should accordingly be planned for all type of perscribers advising them how to prescribe rationally and dispense drugs. This could be followed up with some continuing medical education or community-oriented medical education program designed according to our local needs, keeping in view our particular social and cultural factors.

The very high rate of injections and antibiotics use for even minor ailments reflects the absence of any standardized protocol or set of guidelines for the treatment of common illness. It is therefore important to develop Standard Treatment Guidelines, which indicate the number and type of drugs, their route of administration and duration of treatment.

3. Health education

It is important to educate the community about rational use of drugs through involvement of its leaders in the heath education process. Preferably, the physicians and community leaders should sit together in a health committee and develop heath education intervention strategies and disseminate health educational material regarding the correct use, side effects and indication of drugs.

The selection, procurement and supply should be from essential the drug list and all drugs should be supplied by generic names. People also need to be educated to use the generic drugs instead of brand name drugs. The National Health Formulary and Essential Drugs Lists for various categories of hospitals and health facilities usually mention drugs by generic names alone. The introduction of strict laws in this regard and their effective implementation may help lead to desired change in attitudes, behaviors and practices. The Government also needs to ensure that the generics drugs manufactured by firms in Pakistan meet all the standard quality requirements.

Both the policy makers and managers in the health sector should exhibit a firm commitment to improving drug use. The results of this and other similar studies can provide base line information about the drug use practices in Sindh and also indicate the possible target areas for intervention. It is, however, important to develop a supervisory plan indicating how to monitor and implement the interventions, and subsequently follow them. The health management information system may be used to collect information regarding use of drugs, the conformity with the standard treatment guidelines, use of generic drugs, route of administration, dose and duration of treatment.

The results of this study also acknowledge and affirm the other studies conducted in developing countries to describe current drug practices. Our study shows that the average number of drugs, antibiotics and injections used was not only high in the region of Asia but also in comparison to Africa, Latin America and Caribbean. This means those policy makers, health planners, health managers, prescribers and community members must plan intervention strategies to improve drug use practices.

The study has shown the magnitude of problem regarding drug use practices and has also identified the areas which need the immediate attention of the DoH to plan for a need based intervention to improve drug use practices. It is also clear from the results of study that the intervention in the World Bank-funded area focus approach has not changed the behavior of physicians regarding drug use practices and has also not shown any significant impact on prescribing and dispensing practices. The results also indicate the high use of antibiotics and injections, which is not only a serious problem but also reaches the level of irrationality, at great cost to the health system.

12. References

1. Word Health Organization. The World Drug Situation. Geneva; World Health Organization,1988.
2. Ross-Degnan D, Laing RO, Quick J, et al. A strategy for promoting improved pharmaceutical use: the International Network for Rational Use of Drugs.Soc.Sci.Med.1992;35:1329-41
3. The rational use of drugs. Report of the Conference of Experts, Nairobi, and Nov 25-29, 1985. Geneva: World Health Organization, 1987.
4. Laing R. International networks for the rational use of drugs (INRUD). Trop. Doct 1990; 20. 133,
5. Soumerai S. Factors influencing prescribing. Aust J Hosp Pharm 1988;18 (suppl): 9-16
6. Akhtar M. A. Misuse of Drugs. A clinical study. Pakistan Armed Forces Med. J. 30, 40, 1979.
7. Ahmed R. and Bhutta Z.A. A survey of prescribing and dispensing in Karachi. J. Pak. Med. Asso.1990; 40. 126.
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9. The World Bank Group. Staff Appraisal Report, Pakistan Family Health Project, Islamabad, April 12,1991.
10. Concept of Area focus approach, Family Health Project Sindh .1996.
11. Pakistan Demographic and Health Survey 1990-91, National Institute of Population Studies. Islamabad July 1992.
12. National Census Report 1998 Islamabad. Dawan- Local http://www.dawan.com 11th Oct 1998.
13. Situation Analysis of Children and Women in Sindh, Government of Sindh and UNICEF Karachi .1993
14. Brief for the press conference of the Hon’ble Minister for Health and Primary Health 10^th June 1996 Health Department, Government of Sindh.
15. PC-1 Proforma (Planning Commission form No. 1) Family Health Project Sindh 1998
16. Nizami S.Q., Khan I. A. and Bhutta Z. A. Drug prescribing practices of general practitioners and pediatricians for childhood diarrhea in Karachi, Pakistan. Soc. Sci. Med. 1996;42: 1133
17. Hogerzeil HV. Promoting rational prescribing: an international perspective. Br. J. Clin. Pharmac; 1995;39: 1-6
18. Soumerai S.B. McLaughlin T.J. and Avorn J. Improving drug prescribing in primary care: a critical analysis of the experimental literature. Milbank Q.67, 268-317,1989.
19. Van der Geest S. Anthropology and pharmaceuticals in developing countries. Med. Anthropol.Q.1, 1980;5: 59-90.
20. Hardon A. P. The use of modern pharmaceuticals in a Filipino village: doctors’ prescription and self medication .Soc. Sci. Med. 1987; 25: 277-292
21. Greenhalgh T. Drug prescription and self- medication in India: an exploratory survey. Soc. Sci. Med. 1987; 25: 307-318
22. Hogerzeil HV, Bimo, Ross-Degnan D, Laing R.O., Oforri-Adjei D., Santoso B., Chowdhury A. K. A., Das A. M., Kafle K. K., Mabadeje A. F. B. and Massele A. Y. Field-tests for rational drugs use in twelve developing countries. Lancet 1993;342: 1408-1410
23. Quick JD, Rankin JR, Laing RO, O’ Connor RW, Hogerzeil HV, Dukes MNG and Garnett A, eds. Managing Drug Supply. Boston 1997;
24. How to investigate drug use in health facilities: selected drug use indicators. Geneva: World Health Organization,1993.WHO/DAP/93.1:1-87
25. Christer, R. A Strategy for improvement of prescribing and drug use in rural health facilities in Uganda. Report of an assignment carried out under the auspices of the Uganda Essential Drugs Management Program, 2 September – 11 October.
26. Ross-Degnan, D., Laing, R., Santoso, B. Ofori-Adjei, D., Diwan, V. Lamoureaux, C., Hogerzeil, H. Improving Pharmaceutical use in primary care in developing countries: acritical review of experience and lack of experience. Unpublished report for the International Conference on Improving Use of Medicines, Chiang Mai, Thailand, April 1-4, 1997.
27. Laing RO, Ruredzo R. The essential drugs program in Zimbabwe: new approaches to training. Health Pol Plan 1989;4 :229-234
28. Laing RO, Hogerzeil HV, Ross-Degnan D, Ten recommendation to promote improved use of medicines in developing countries Unpublished draft 1999.
29. A. W. Sturm, R. van der Pol, A. J. Smits. Over the counter availability of antimicrobial agents, self-medication and patterns of resistance in Karachi, Pakistan. Journal of Antimicrobial Chemotherapy,1997; 39: 543- 547
30. Akhound, Utilization of primary health care facilities in province of Sindh, Study conducted for the requirement of MPH in Agha Khan University 1998 (Un published)
31. Inayat, K. What action for rational drug use? World Health Forum. Volume 18. 1997
32. Death by wrong injections: Dawan-local http://www.dawan.com 16 Feb 1999.
33. Hogerzeil HV,Walker GJA,Sallami AO,Fernando G. Impact of an essential drugs program on availability and rational use of drugs. Lancet1989;I: 141-42.
34. Laing R. Rational drug use: an unsolved problem. Trop. Doct. 1990;20:101
35. Butta T.I and Balchin C. Assessing the impact of a regulatory intervention in Pakistan. Soc. Sci. Med. 1995;42: 1195
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37. Excel Program. Microsoft Corporation Seattle 1997.

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13. Glossary of Abbreviation.

WHO World Health Organization

DAP Drug Action Program

PHC Primary Health Care

DoH Department Of Health

BHU Basic Health Unit

RHC Rural Health Center

MCH Maternal and Child Health

UHC Urban Health Center

LHW Lady Health Worker

INRUD International Network For

Rational Use of Drug

GP General Practitioner

AFA Area Focus Approach

NAFA Non Area Focus Approach

EDL Essential Drug List

1. Average number of drugs per encounter
2. Percentage of drugs prescribed by generics name
3. Percentage of encounters with an antibiotics
4. Percentage of encounters with an injection prescribed.
5. Percentage of drugs prescribed from essential drug list or formulary

 

Patient care indicators.

6. Average consultation time
7. Average dispensing time
8. Percentage of drugs actually dispensed
9. Percentage of drugs adequately labeled
10. Patients’ knowledge of correct dosage

 

Facility Indicators.

11. Availability of copy of essential drug list or formulary
12. Availability of key drugs

Annexes 11) Sampling Frame