Concentration Paper

Boston University School of Public Health

Department of International Health

 andom.jpg (3611 bytes)

Embaye Andom

Drug Use Studies in Eritrean Health Facilities 

September 1999

BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH

DEPARTMENT OF INTERNATIONAL HEALTH

CONCENTRATION PAPER COVER PAGE

 

NAME: EMBAYE ANDOM

 

Concentration Paper Title: Drug Use Studies in Eritrean Health Facilities

 

Abstract (280 words)

Some drug use studies were conducted in Eritrea since its independence in 1991, with the objectives of determining the prescribing and dispensing habits of health providers, identifying areas that needed improvements, and prioritizing areas of immediate interventions. This paper discusses the outcomes of three drug use studies conducted in 1992, 1995, and 1997 by the Ministry of Health using the WHO/INRUD indicators. More emphasis is made on the 1995 study for two main reasons; firstly it was highly representative and all the prescribing, patient-care and health facility indicators were utilized. Secondly the results of both the primary and disease specific secondary analysis were examined and reviewed. In no other similar study conducted by other developing countries has the disease specific data been reported.

The studies showed that polypharmacy (average 1.8 drugs per prescription), generic prescribing (79%) and availability of key drugs (91%) as well as the availability of (91%) and adherence to (94%) an essential drugs list are not problems in Eritrea and should not be focus of interventions. Areas such as consultation and dispensing times (4.7minutes and 99 seconds respectively) although low to deliver optimum patient care were considered satisfactory when compared to other African countries and may not be considered as current priorities. The main areas that needed immediate interventions were the low level of labeling and the high antibiotic and injection uses with more concern in the irrational use of antibiotics in upper respiratory infection and other infections of non-bacterial origin. Intervention options to decrease the very high antibiotic use in diseases such as URTI and amebic dysentery are discussed. Activities and improvements that followed these studies and areas that still need improvements are also discussed.

 

 

This paper is complete and satisfies the concentration paper requirement for the Master of Public Health Degree with a concentration in International Health. The student may proceed to the oral assessment.

 

 

_________________________________________ ____________________

Signature, Academic Advisor Date

 

 

 

_________________________________________ ____________________

Signature, Writing Specialist Date

 

 OUTLINE

1. INTRODUCTION *

2. BACKGROUND *

a. Country Profile *

b. Healthcare profile *

c. Drug Use in Eritrea *

3. LITERATURE REVIEW *

a. Prescribing Behaviors *

i. Over Prescribing *

ii. Generic Drugs *

iii. Antibiotic Use *

iv. Injection use *

b. Patient Care Processes and Prescribing Environments *

i. Consultation Time and Dispensing Time *

ii. Patient Knowledge of Drugs and Drugs Properly Labeled *

iii. Essential Drug Lists and Drugs Dispensed from the List *

c. Reasons for Irrational Use *

4. SURVEY METHODS *

a. Methods of survey in Eritrea *

b. Data Analysis *

c. Problems During Analysis *

5. RESULTS *

a. Primary Analysis *

b. Secondary Analysis *

i. Morbidity Pattern *

ii. Average Number of Drugs for Specific Diseases *

iii. Percentage of Generics for Specific Diseases *

iv. Percentage of Antibiotics for Specific Diseases *

v. Percentage of Injections for Specific Diseases *

6. DISCUSSION *

7. FOLLOW ON ACTIVITIES *

8. CONCLUSION *

9. REFERENCES: *

10. APPENDIX 1: DETAILED PRIMARY ANALYSIS RESUSLTS *

11. ANNEXES *

12. ADDITIONAL READINGS *

DRUG USE STUDIES IN ERITREAN HEALTH FACILITIES

 

  1. INTRODUCTION

    2. In spite of the progress which has been made over the last 20 years, about one third of the world’s population lacks access to essential drugs, and in developing countries the proportion is much higher.1 Irrational use of drugs has been a persistent global problem.

    Often multiple drugs are prescribed when they are not needed. Other common irrational prescribing practices include incorrect drug choices, overdosing, under-dosing, and use of expensive drugs when less expensive ones would be effective. Expenses on drugs represent a very high proportion of the operating costs of governments in Africa. Any improvement which can be made in the standard of prescribing will result in better health care for the people and possible cost saving for the health care system. In order to deal with such improvements, it is essential to assess the actual situation as regards drug treatment of the common diseases in health facilities. Baseline drug use studies can highlight major problem areas. These studies can measure drug use either as general usage or for use in specific diagnosis.

    In order to encourage a standard approach to measure problems in drug use, the International Network for Rational Use of Drugs (INRUD) and the WHO developed selected drug use indicators to measure drug use in health facilities. These indicators have been used in a number of countries for the primary analysis of facility-specific drug use data. They include core indicators which "are highly standardized as regards definition and sample size and do not require national adaptation" and a set of complementary indicators which are less standardized and need to be defined before use. The core indicators can be used to compare patterns of drug use between countries, facilities or prescribers. Studies in several developing countries using these indicators have identified the average number of drugs prescribed in public sector facilities, the use of generics and the numbers of prescriptions containing antibiotics as well as those containing injections., In none of these published studies were disease-specific indicators reported. Other core indicators like average consultation time, average dispensing time, patient dosing knowledge and availability of core drugs have also been identified.,

    As in most developing countries, prescribing of medicines is an important health issue in Eritrea, and inappropriate prescribing commonplace. In addition to discussing the primary analysis done in other countries, this paper will report some of the findings of the disease-specific secondary analysis of a nationwide drug use survey in the public facilities of Eritrea conducted in 1995., The purpose of the paper is to provide information to health care providers and decision makers at local and national levels that will help them improve drug use practice and promote safe, effective and economical use of drugs. Also, for international readers, the purpose is to show how drug use changes by diagnosis and to suggest diseases which could be the focus for targeted interventions both in Eritrea and internationally.

     

  2. BACKGROUND
    1. Country Profile

      2. Located in the Horn of Africa, Eritrea is the newest nation in Africa, having achieved sovereignty in 1991 after a 30-year war for independence with Ethiopia. Eritrea has a total of 2,234 km coastline alone the Red Sea. It has a total area of 124,320 km2 and an estimated population of 3.9 million (1999 est). About 85% of the Eritrean people live in the rural areas.

      Economically the 30-year war caused decades of loss of development as well as destruction of economic and social infrastructure. The GNP per capita in 1997 was USD 210, which is very low compared to the average of USD 500 for Sub-Saharan Africa.

    2. Healthcare profile

      3. The government has adopted primary health care as the strategy for providing essential health services to its people. Health care services are organized into primary: village health services; secondary: health stations, health centers, mini hospitals; and tertiary: regional and referral hospitals. In total, until 1997, the government health system had about 249 health facilities and this number is increasing rapidly as new facilities become operational. About 50% of the population lives within 5 km of a health facility. The poor health status is apparent from the prevalent high mortality rates reported in 1997, i.e. infant 72/1000, child 136/1000 and maternal mortality 900/100000.

      There are shortages of every category of health workers in the country. In 1995 the physician to population ratio was one of the lowest in the world, i.e. about 1:20,000. Similar low ratio of nurses and health assistants (i.e. about 1:5300 and 1:3700) compared with the increasing number of health facilities means that it will be a long time before adequate numbers of staff are available.

      As for pharmacy personnel the situation is even worse. A shortage of professionally skilled pharmaceutical manpower has compromised the practice of pharmacy in Eritrea. The shortage of personnel has led to pharmaceutical services being provided by non-professionals in the public and in the private sectors. The dispensers in the health station and health centers as well as the persons in charge of rural drug vendors are health assistants or nurses. This could result in poor drug supply management at health center and health station levels.

    3. Drug Use in Eritrea

    The Eritrean National List of Drug, which is based on the WHO model list of essential drugs, was officially published in 1993 and revised in 1996. The list is a legal tool for procurement, prescribing and dispensing for both the public and private sector. There are also standard sub-lists for different levels of use. The government approved the National Drug Policy in 1997. The Eritrean Standard Treatment Guidelines was launched in 1998. Most activities that may improve drug use in Eritrea focused on health providers. Though the Eritrean Pharmaceutical Association provided educational activities during its annual event the ‘Pharmacy Week’ that targeted the community, in general, no drug use work has been done towards the public.

    Drugs are procured centrally through purchase and donations. As there is no local production, all drugs used in the country have to be imported. Though recently, private importers were allowed to import and distribute drugs, until 1998 this activity was done by a sole parastatal agency known as PHARMECOR. The procurement performance of this agency is rated high by some observers. PHARMECOR supplies hospitals, government organizations and the private drug retail outlets. Drugs acquired by donations are conveyed through the Ministry of Health’s Central Medical Store (CMS). Health centers and health stations get most drugs they need from CMS (obtained by donations) and they do not charge customer fees for drugs. Donors can make arrangements only with the central MoH and not with individual health facilities. A large number of drugs consumed in Eritrea are acquired by donations. There is inadequate storage and stock management at health facilities due to lack of a standard operational manual and shortages of trained pharmacy manpower.

    Eritrea depends for all its needs of drugs on imports. Thus, to ensure that drugs entering the country are safe, effective and good quality, a drug law was published in 1993, which contains provision for the control of the logistic cycle including import, manufacture, distribution, supply, storage and sale of drugs. The law also includes provisions covering control of drug labeling, information, and advertisement, as well as drug registration and inspections. The Department of Pharmaceutical Services at the Ministry of Health is the drug regulatory authority, empowered by the drug law. The Department has undertaken a number of drug use studies in Eritrea since independence.

    Table 1: Rational Drug Use Studies in the Eritrea (all OPD)

    Year of Study

    Site of Study

    Sample Size

    1992

    		 2 hospitals (Mekane Hiwot and Keren Hospitals)

    1953

    1995

    		 4 hospitals, 12 health centers and 12 health stations (National Survey)

    3721

    1997

    		 3 hospitals ((Mekane Hiwot, Keren and Massawa Hospitals)

    1161

     

  3. LITERATURE REVIEW
    1. Prescribing Behaviors
      1. Over Prescribing

        2. Drugs have made an important contribution to global reduction in morbidity and mortality. They offer a simple, cost-effective solution to many health problems, provided they are available, affordable, and properly used. Before 1950, drugs were few in number, and doctors or pharmacists were able to answer most questions concerning medicines quickly by referring to pharmacopoeias. But today the pharmaceutical market has grown enormously and become increasingly competitive since the early 1980s., The tension between optimal use of drugs and the pressure of drug companies to expand product sales and maintain their competitive edge is at the same time increasing.

        While 30% of the world’s population does not have access to essential drugs, drugs continue to be used inappropriately and irrationally both in the developed and developing countries. Irrational drug use is manifested in many ways including the use of a drug that is unsafe or obsolete; taking a drug in the wrong dose, at the wrong time or for the wrong diagnosis; taking a drug when no drug is needed or not taking a drug when one should be taken. Depending on the personnel and material resources what seems rational in one country may become irrational in another. Consequently there should be agreement in defining what is rational and irrational use of drugs for each country.

        A study in the US suggested that adverse drug reactions (ADRs) have been the fourth to sixth leading cause of about 2.2 million serious events and 106,000 fatalities each year for the last few decades. Though most of these ADRs were due to the uses of drug with unavoidably high toxicity, the role of ‘a pill for every ill’ could not be overlooked.

        The cost of inappropriate use of drugs is very high. Studies in the US have shown that the costs associated with ADRs to be an additional $1.5 billion to 4 billion per year. Many benefits, like withdrawal from market of drugs that are not safe, have stemmed from ADR monitoring in developed countries. Unfortunately, ADR monitoring programs are not as readily available in developing countries. Using multiple drugs per prescription in less developed countries with poor capabilities of monitoring of therapies and doses may yield devastating results. The higher the number of drugs per prescription, the higher would be the risk of unwanted effects. Studies in several developing countries using the WHO/INRUD indicators showed that the average number of drugs prescribed in public sectors in most countries ranges from 1.3-2 drugs, though higher scores were observed by Nigeria with 3.8, Indonesia 3.3 and Pakistan 3.5., ,

        In Eritrea similar studies in 1992 in two hospitals showed the average number of drugs per prescription to be 2.2. The larger nationwide survey in 1995 showed an overall figure of 1.8. Another study in 1997 in three hospitals remained at an average of 1.8.

      2. Generic Drugs

        3. The existence of a number of brand products for a single medicine can significantly confuse health providers. A simple drug like paracetamol (acetaminophen USP) is presented in the Martindale – Extra Pharmacopoeia by 283 brand names. In Karachi, Pakistan, over the past two years there were seven documented deaths and several toxic reactions due to confusion of brand names. As health providers know generic names from their training and as it is difficult to remember hundreds of brand names for each medicine, it is more appropriate and safe to use generic products.

        In addition to safety, the appeal of generic drugs is their low cost, compared to brand-named products. Although generic drugs are sold at the cost of reduced funding for research of new pharmaceutical agents, their cost benefit overshadow this concern for most health providers and patients both in developed and developing countries. Over the past few decades the trend towards replacing brand with generic drugs has spread in both the developed and developing world.,, As generic drugs cost less than their equivalent brand names, in the US they have played an important role in holding down national spending on prescription drugs from what it would otherwise have been. According to the Congressional Budget Office (CBO), purchasers in the US saved about $8 billion to $10 billion in 1994 at retail prices by substituting generic for brand name drugs., USA is the largest generic market among developed countries and studies showed that the percentage of generic drugs in relation to all drugs sold increased steadily from 19% in 1984 to 43% in 1996., Similar studies by the UK Department of Health showed that 60% of all prescriptions in England in 1997 were written generically which was an increase of 2% over 1996.

        Though generic drugs could be counterfeited, field examples concluded that brand drugs are the most frequently counterfeited because of their high cost.,, Generic drugs from reliable suppliers are as safe and effective as drugs bought by well-known brand names. This has been confirmed by the US Food and Drug Administration.,, The WHO has been making increasing efforts to improve drug use practices in developing countries by encouraging the use of generic drugs so that they can use their limited resources appropriately.

        The WHO/INRUD indicators showed that the use of generic among countries varies from 37 to 94%., The 1992 two hospital study in Eritrea showed an average of 74.5% generic drug use. The 1995 national survey showed overall rate of 79% generics while the 1997 hospital survey showed a lower rate of 61%.,

      3. Antibiotic Use

        4. Antibiotics have been highly effective in the treatment of infectious diseases, but the emergence of resistant bacteria is now becoming a great global concern. Patients in major hospitals staffed by highly competent personnel are dying as a result of infections by resistant bacteria in developed and developing countries. Resistance is costing a great deal of money and human lives. Resistant infections are also associated with increased morbidity, prolonged hospital stays, greater direct and indirect costs and spread of infection to others. Developing new antibiotics is a long and costly process, and even after their development resistance will inevitably emerge to the new drugs as long as irrational use of antibiotic occurs. A study to assess antibiotic prescribing by office US-based physicians from 1980-1992 revealed that antibiotics were the second leading therapeutic category of drugs prescribed. Studies in 17 European countries showed that between 60-100% of patients were prescribed antibiotics; in over 40% of the cases prescription was without laboratory confirmation., In Canada, as many as half of the 26 million antibiotic prescriptions dispensed annually have been estimated to be unnecessary. Twelve million antibiotic prescriptions to adults in the US in 1992 were for upper respiratory tract infections (URTI) and bronchitis, on which antibiotics have little or no effect. Such overpresciption for URTI and bronchitis results from patients’ expectations and physicians’ habits.

        Antibiotics are the largest single group of drugs by value purchased in the developing countries. In many developing countries, the availability and use of antibiotics are poorly controlled, which has resulted in a high rate of resistance, particularly to older antibiotics. The high cost of the few remaining second-line antibiotics makes them unavailable where they are most needed. Prescribing indicator studies in many developing countries showed that the percentage of prescriptions containing antibiotics ranged from 25—40%., The 1992 Eritrean survey showed 43.4% prescriptions with antibiotics. The 1995 national survey scored the overall average of 44% and in the 1997 three hospital survey the rate was reduced to 35.1%.,

      4. Injection use

      Where an immediate physiological action is needed the best route of administration of drugs is injection. However, use of injection is accompanied with a variety of disadvantages including the requirement of asepsis at administration, the risk of tissue toxicity from local irritation, the real or psychological pain factor and the difficulty in correcting an error. To attain accuracy, injection should be administered by a professionally trained person. The overall cost of injections is very high because of additional cost of syringes, power for sterilization, skilled manpower etc. There is a danger of transmitting infections like HIV/AIDS. On the other hand, most orally administered drugs including antibiotics have been proven equally effective, safer and much cheaper.,,, For these reasons, the use of injections should be restricted for diseases where oral medications could not be used. Indiscriminate use of injections especially in the developing countries is therefore irrational.

      However, injections continue to be high on the list of causes of treatment errors. Injection use is another simple indicator of therapeutic practices. In Germany there is a traditional attitude of preference for injections over the oral route. In many developing countries there is a tendency to believe that injections are better and more potent in treating disease than oral medication.

      The reasons for the overuse of injections are complex. Prescribers tend to believe that patients expect and are satisfied by receiving injections. Some patients do ask for injections. However, many dislike injections but accept them because the doctor who "knows best" prescribes them. There appears to be great variation in attitudes toward injections across different societies. Misuse of injectable products in Indonesia has been implicated in an incidence of shock. Studies in Indonesia showed that almost half of the under five and more than 70% of over-five received at least one injection. In 1990 in Uganda rates as high as 48% were registered, which were too high in the HIV/AIDS era.

      Results of studies on the use of injection in developing countries vary greatly and the 1992 Eritrean study revealed that an average of 17.8% of patients received at least one injection per prescription. Similar results of 17% were obtained by the 1995 study, and the 1997 study in three hospitals showed a lower rate of 10.7%.

    2. Patient Care Processes and Prescribing Environments

      3. The ability of prescribers in the public sectors to use drugs rationally is influenced by many features of the environment in which they practice. These features include access to relevant, impartial pharmaceutical information and adequate supply of products needed to treat common health problems.

      1. Consultation Time and Dispensing Time

        2. Recently efforts have been made to quantify the consulting and dispensing process, though dispensing has been observed in a limited number of countries. Studies in the United Kingdom have shown that longer consultation time (more than 15 minutes) increased patients’ satisfaction and more effective resource use due to reduced prescribing of drugs.,,, According to Howie et al., consultation times were described as ‘short’ (five minutes or less), ‘medium’ (6-9 minutes), ‘long’ (10 minutes or more) and the ratio of long to short consultation length might become a simple proxy measure of quality of care. Though consultation length has increased in the UK, Wilson considers the UK consultation time (2 to 20min) to be short as compared to international standards., The duration of dispensing time or more accurately the patient/pharmacist communication time has similar effect on patient satisfaction and enablement, i.e. patients are better able to deal with their health, illness and medication as a result of good understanding.,,,

        The consultation time in most studies in developing countries varies from 2.3 to 3.5 minutes, which is very low compared to developed countries.,, Similarly the average dispensing time in these studies varied from 12 seconds to 86 seconds, which is very short to convey the necessary information about the prescribed drugs to the patient. The 1995 Eritrean study showed a consultation time of 4.7 minutes and a dispensing time of 99 seconds.

      2. Patient Knowledge of Drugs and Drugs Properly Labeled

        3. At some point during the examination or dispensing process, medications prescribed for a patient should be explained. Ideally, this explanation would include the reasons why each particular medication is being given, how each drug should be taken, and any precautions or possible side effects explained. Increasing patient knowledge of drug therapy is said to improve compliance and may reduce adverse drug reactions., Crichton et al. studied the effect of pharmacists’ explanation about medications on improving the level of recall. A prior 16.6% level of recall increased to 82.2% after pharmacists’ intervention. Studies found that 50% of Canadians believed that antibiotics were active against viral infections such as colds and influenza, whereas a survey in Australia revealed that 70% of the population considered it inappropriate to take antibiotics for colds, influenza or a sore throat. This difference could be attributed to the wide use of Antibiotic Guidelines coupled with drug audits involving health providers and consumers in Australia.

        A recent study in Burkina Faso revealed that patients recalled prescribed dosage and duration of treatment for 68% of the drugs. According to the WHO/INRUD indicator studies in 12 developing countries, when patients were assessed as to their knowledge of how they should take drugs, between 27% and 83% knew how and when to take their drugs. The 1995 nationwide survey in Eritrea showed that on average 80% of patients had adequate knowledge.

      3. Essential Drug Lists and Drugs Dispensed from the List

      Accessibility and availability of drugs have been a matter of great concern for health services all over the world, especially for the less developed countries. Factors contributing to lack of access include weak healthcare structure, inadequate financial resources, lack of effective drug policy and ineffective drug utilization.

      Many developing countries have prepared essential drugs list based on the model list of WHO. The purpose of an essential drug list is to itemize the minimum number of essential drugs that suffice the health care needs of the majority of the people. Availability of essential drugs is a quality indicator of integrated, cost-effective basic health services. Their unavailability in health facilities may decrease public interest. To complete the drug use process (ie diagnosis, prescribing, dispensing and adherence cycle) the drugs prescribed should be available to the patient.

      Drug treatment may vary according to the availability of drugs. The availability of both such a list and the key drugs as well as the proportion of drugs actually dispensed to the patients are important facility indicators. Surveys in developing countries showed that the availability of 10-15 key drugs per country was between 60% and 90%. In the 1995 survey the availability of key drugs in Eritrea was 91%, the availability of essential list was 83% and the key drug stock was 91%.

    3. Reasons for Irrational Use

    There are many different factors that cause the irrational use of drugs. Irrational use may occur in any of the complex and interrelated components of the drug use system comprised of drug supply process, the provider and consumer behavior, and illness patterns. It is important to identify which factors are most important in causing the problem before trying to correct any problem in drug use.

    According to Laing, 1998, the factors that influence drug use can be categorized into five. The first are causes which are related to health providers, these include lack of adequate knowledge, their acquired habits, their beliefs about illness and drugs, or just their personal economic motivations for using particular drugs. The second are causes related to the interaction between patients and providers, including the sociocultural attitudes and beliefs, quality of communication, and patient demand. Third come causes related to the social structure in which providers practice, including the authority and power relationships, peer interaction and consultation and peer practice norms. The fourth factors are related to the aspects of the work environment, including the availability of drugs and diagnostic services, unsuitable physical environment like lack of privacy during consultation, the workload and institutional economic motivations. The fifth factors are related to the availability of neutral and unbiased drug information, or the presence of biased information and "education incentives" from drug companies. Thus the WHO/INRUD drug use study addresses all these factors.

  4. SURVEY METHODS

    5. To clarify the drug use situation in a country quantitative and qualitative surveys are needed., Drug use surveys may have different objectives: to describe current treatment practices; to compare the performance of individual facilities or prescribers; to monitor or supervise specific drug use behaviors; or to assess the impact of an intervention. Most of the WHO/INRUD drug use indicators studies conducted in many developing countries including Eritrea are noninterventional cross-sectional descriptive studies.,,,,

    1. Methods of survey in Eritrea

      2. In November, 1995 the Ministry of Health undertook a national survey to study the drug use practices in six out of ten provinces that represented the different ecological, economic and ethnic environments of Eritrea. They include Asmara (urban), Hamasien (semi-urban), Seraye (highland), Senhit (semi-lowland with different ethnic group), Gash-Setit (lowland), and Semhar (Coastal). (See map at the annex 1) The drug use practices in one hospital, two health centers and two health stations were studied in each province utilizing the INRUD/WHO indicators. Data were collected from 30 facilities: in 4 hospitals, 14 health centers, and 12 health stations.

      A total of 3721 prescribing episodes were reviewed, comprising 2784 retrospective data from patient registers and 937 prospective episodes (a census of all patients attending that day) including consulting & dispensing encounters and interviews. An external consultant, Dr Richard Laing, who helped in the design and the analysis of the survey, confirmed the validity of the study.

      There were six data collection teams composed of a team leader (a pharmacist, or experienced pharmacy technician) and four research assistants (pharmacy technicians). To ensure quality, data collectors were trained and a pilot test was conducted in Asmara province. The training included the purpose of the study, responsibilities, sampling procedures, data handling, preliminary data analysis and some agreements that helped in uniformity. There was agreement not to include metronidazole and anti-tuberculosis drugs as antibiotics and to consider aspirin as a generic drug. As the WHO manual recommends, a few combination drugs — specifically cotrimoxazole, anti-hemorrhoidal preparations, antacid combinations, vitamin B complex, multivitamins, oral contraceptives, infusions and sufadoxine/pyrimethamine — were defined as single drugs.

      Data were collected using detailed forms and filled onto the summary sheet later. Overall, the methods used by the six survey teams were confirmed to be consistent and reliable.

    2. Data Analysis

      3. The original data were used for both primary and secondary analysis. Each team prepared the preliminary analysis and the detailed reports of the facilities they surveyed. The data were then analyzed by Dr. Laing using Excel spreadsheet, by level of care (hospital, health center and health station), province, and overall. All of the 3721 prescription data were then entered into Excel spreadsheet for the secondary analysis, cleaned, sorted by diagnosis and analyzed by level of care, province, age (adult or child) and whether retrospective or prospective data. Key differences were seen when analyzed by health care whereas very few differences were seen when analyzed by provinces. The secondary analysis showed very interesting results in identifying the diseases where most irrational use of drugs occurred.

    3. Problems During Analysis

    There were some problems in the classification of some products or diseases. For example preparations that include vitamins and iron were sometimes termed as supportive which is not a name of a drug. The study teams then decided to record supportives as generic names. In some facilities food supplements were prescribed by the name ‘protein’, which was not recorded as a drug. Rarely some information was missing from the register, for example the route of administration of drugs that could be given as either a tablet or as an injection. In a few facilities, the observational data collected prospectively was affected by small sample sizes.

     

  5. RESULTS

    6. Table 2: Overall Result of Primary analysis

    No of drugs % Generic % Antibiotics % Injection % ENLD Av. consultation time minute Av. dispensing time seconds % Actually dispensed % adequately labeled % patient knowledge % Availability of ENLD % Availability of key drugs
    Level of Care
    Hospitals

    2.1

    70

    48

    15

    94

    4.6

    89

    82

    76

    81

    100

    94
    Health Centers

    1.7

    79

    49

    17

    94

    4.5

    99

    89

    43

    82

    93

    92
    Health Stations

    1.7

    82

    37

    14

    94

    4.9

    110

    96

    44

    76

    67

    88

    Province
    Gash Setit

    1.8

    86

    47

    19

    94

    4.3

    131

    90

    55

    82

    100

    95
    Hamasien

    1.7

    65

    49

    21

    91

    5.7

    86

    92

    0

    94

    60

    91
    Asmara

    1.6

    86

    47

    15

    91

    4.0

    77

    85

    73

    72

    80

    86
    Semhar

    1.8

    81

    36

    15

    99

    4.2

    87

    95

    63

    81

    100

    98
    Senhit

    2.0

    78

    47

    15

    96

    5.4

    87

    91

    49

    75

    80

    82
    Seraye

    1.6

    81

    40

    16

    93

    4.6

    127

    92

    48

    74

    80

    92

    Overall

    		                        
    Average

    1.8

    79

    44

    17

    94

    4.7

    99

    91

    48

    80

    83

    91
    Maximum

    2.5

    93

    67

    31

    100

    9.1

    168

    100

    100

    100

    100

    100
    Minimum

    1.2

    49

    28

    4

    86

    2.3

    48

    74

    0

    33

    0

    69
    International Range

    1.3-3.8

    37-94

    25-63

    5-48

    		  

    1-6.3

    13-86

    		    

    27-83

    		  

    38-90

     

    1. Primary Analysis

 

The details of the primary analysis results are found in the appendix. The highlights of the primary analyses are as follows

bulletThe overall results of the primary analysis are as follows:
bulletThe overall average number of drugs per prescription was 1.8.
bulletThe overall average percentage generic was 79%. Retrospective data were generally lower at all levels which implies that health workers are aware of the need to prescribe generically.
bulletThe overall percentage of encounters with antibiotics prescribed was 44%.
bulletThe overall percentage of prescriptions with an injection prescribed was 17%. Retrospective value of 18% was slightly higher than the prospective 15%. This indicates that the health providers’ are aware of the need to restrict injection use.
bulletA high adherence to the to the Eritrean National List of drugs (ENLD) of 94% was scored for all levels without variation by health care levels, by provinces or by data type or between retrospective and prospective data.
bulletThe overall average consulting time was 4.7 minutes. There was no significant difference in the average consultation time between levels of care but there was considerable variation between the different provinces for this indicator that ranged from 4.0 minutes in Asmara to 5.7 minutes in Hamasien.
bulletThe overall average dispensing time was 99 seconds.
bulletThe percentage of drugs actually dispensed was 89%, considered as very creditable considering the logistic challenges faced in distributing drugs.
bulletThe overall percentage of drugs adequately labeled was 50% meaning that half of the prescriptions were not labeled correctly.
bulletThe overall percentage adequate knowledge of the dispensed drugs was 80%. In contrast to the poor labeling reported above, the figure shows that good explanations were being given to the patients.
bulletThe availability of impartial information was measured by the availability of the Eritrean National List of Drugs (ENLD) and prescription paper. The ENLD was widely available at an average of 83% facilities, in contrast prescription paper was only available at 17% of facilities.
bulletThe overall percentage availability of drugs in stock value was 91%.
    1. Secondary Analysis

      2. The disease-specific (secondary analysis) analyzed the percentage frequency of diseases, average number of drugs per specific disease, percentage of generic per specific disease, percentage of antibiotics per specific disease, percentage of injections per specific disease and the percentage of drugs prescribed from the Eritrean National List of Drugs per disease.

      Secondary analyses were done by age, by province, and overall; the results showed how drug use changed by diagnosis. Table 3 shows disease-specific analysis for the top 30 diseases, which accounted for 82% of the diagnoses. The tables for the top 10 diagnoses by age, province and data type are found in the annex.

      Table 3: Secondary Analysis All Cases 3713 Cases

      Diagnosis

      		 Count

      % Diag

      Av# drug

      % Generic

      AB's

      Inj

      %ENLD
      Multiple

      367

      9.88%

      2.47

      75%

      53%

      18%

      94%
      Malaria

      354

      9.53%

      2.04

      89%

      5%

      7%

      98%
      Common Cold

      303

      8.16%

      1.65

      89%

      17%

      3%

      94%
      U.R.T.I.

      194

      5.22%

      1.78

      77%

      74%

      14%

      93%
      Wound

      162

      4.36%

      1.12

      91%

      72%

      51%

      96%
      Bronchitis

      159

      4.28%

      1.77

      76%

      93%

      19%

      91%
      Gastritis

      131

      3.53%

      1.65

      75%

      2%

      3%

      88%
      Diarrhea

      127

      3.42%

      1.88

      80%

      35%

      5%

      97%
      Pneumonia

      127

      3.42%

      1.69

      87%

      97%

      60%

      95%
      Tonsillitis

      117

      3.15%

      1.88

      85%

      92%

      59%

      97%
      A. Dysentery

      81

      2.18%

      2.17

      65%

      30%

      0%

      97%
      Scabies

      76

      2.05%

      1.27

      86%

      34%

      21%

      96%
      Blank

      69

      1.86%

      0.99

      73%

      26%

      13%

      88%
      Conjunctivitis

      69

      1.86%

      1.48

      79%

      90%

      6%

      96%
      Anemia

      68

      1.83%

      1.82

      87%

      4%

      9%

      91%
      U.T.I.

      66

      1.78%

      1.71

      71%

      92%

      11%

      96%
      Gastroenteritis

      62

      1.67%

      1.92

      75%

      56%

      6%

      94%
      Otitis Media

      60

      1.62%

      1.42

      82%

      93%

      23%

      94%
      Skin Infection

      55

      1.48%

      1.29

      80%

      55%

      40%

      97%
      Arthritis

      43

      1.16%

      2.00

      77%

      12%

      19%

      93%
      Dysentery

      41

      1.10%

      1.80

      64%

      54%

      0%

      100%
      Dental Caries

      39

      1.05%

      1.59

      71%

      64%

      15%

      97%
      Fever

      39

      1.05%

      1.92

      92%

      31%

      8%

      99%
      Giardiasis

      38

      1.02%

      1.95

      78%

      24%

      0%

      99%
      Fungal Infection

      33

      0.89%

      1.15

      81%

      18%

      12%

      95%
      Asthma

      32

      0.86%

      1.72

      80%

      13%

      13%

      87%
      Abdominal Cramps

      30

      0.81%

      1.53

      83%

      30%

      7%

      100%
      Allergy

      29

      0.78%

      1.24

      72%

      21%

      7%

      89%
      Head Ache

      28

      0.75%

      1.29

      86%

      0%

      0%

      100%
      Rheumatism

      28

      0.75%

      1.64

      91%

      4%

      11%

      91%

      Grand Total

      3713

      82%

      1.76

      80%

      45%

      17%

      94%

       

      1. Morbidity Pattern

        2. Multiple diagnoses was the most common of the diagnoses which accounted for 9.9% followed by malaria (9.5%), common cold (8.2%), upper respiratory tract infection (5.2%), wounds (4.4%), bronchitis (4.3%), gastritis (3.5%), diarrhea (3.4%), pneumonia (3.4%), and tonsillitis (3.2%) etc (table 3). In general most of the encounters were either for self limiting diseases such as common cold that may not need medications, or minor diseases like URTI, uncomplicated malaria, gastritis and diarrhea that could have been treated by over-the-counter (OTC) medications. Eighteen of the 30 top diseases diagnosed were infectious diseases of viral, bacterial, fungal or protozoan origins. In contrast, almost no chronic non-communicable diseases appeared within the top 30 diagnoses. The only chronic disease that appeared in the list of the top 30 diagnoses was asthma and which ranked 26th accounting for only 0.86% of the diagnoses. Cardiovascular diseases, neoplastic diseases and other chronic diseases were either not diagnosed properly or they were not major public health problems during the study. Generally the results show that Eritrea is still at the early stage of epidemiological transition where most diseases are still predominantly infectious with very low prevalence of chronic non-communicable diseases.

        By provinces disease-specific analysis revealed ‘multiple’ cases to be the highest diagnoses in Hamassien, Seraye, and Senhit (annex 4-9). However, in Gash-Setit a malarious area, 23.5% of the cases were malaria followed by 9.6% ‘multiple’. Similarly in Semhar malaria was the highest with 11.4% followed by common cold with 7.8% and ‘multiple’ was third with only 6.4% of the total cases. In Asmara province common cold was the highest with 14.6% and ‘multiple’ was not among the top ten.

        Secondary analysis by age showed that the pattern of disease frequency for adults and children was slightly different (annex 1-2). The most diagnosed condition in adults i.e. 15 years and above was malaria with 11.1% of the total cases followed by multiple (10.3%), for gastritis (5.7%) and common cold (5.3%). While in children i.e. under 15 years the highest was common cold with 12.4% followed by 9.2% multiple, 8.6% URTI and 7.3% malaria.

      2. Average Number of Drugs for Specific Diseases

        3. The average number of drugs for the most common diagnosis —multiple— was 2.4. Though this number is higher than the average i.e. 1.8, it is acceptable because multiple diagnosis could include treatment of two or more different diseases. For the second most common disease —malaria— the average of 2.04 is acceptable, as it could be associated with fever, vomiting and/or joint pain, which may necessitate more than one drugs. Several diseases that do not need any drug or which could be treated with only one drug were treated by more than one. These include 1.7 for common cold, 1.8 for upper respiratory tract infection (URTI), 1.7 for gastritis, 1.9 for diarrhea, 2.2 for amebic dysentery, 1.5 for conjunctivitis, 1.6 for dental caries, 1.9 for fever, 1.9 for giardiasis and 1.3 for headache. The findings were similar for the secondary analysis by age and provinces (annex 2-9).

      3. Percentage of Generics for Specific Diseases

        4. Diseases treated with low percentage of generic drugs include 64% for dysentery (not specific), 65% for amebic dysentery, dental caries (71%), for anemia (71%), allergy (72%), gastritis (75%), bronchitis (76%) etc. In most of these cases the brand used was either Mezilä (a brand of metronidazole) or Bactrimâ . Even when ‘antacid’ was considered as a generic name the percentage of generic drugs for the treatment of gastritis was still as low at 75%. There was no variation of result between the overall analysis and analyses by age, by province or by type of study.

      4. Percentage of Antibiotics for Specific Diseases

        5. The analysis of antibiotics used for specific diseases revealed that irrational antibiotic use occurred in the treatment of many diseases. The high use of antibiotic in pneumonia (97%), bronchitis (93%), otitis media (93%), tonsillitis (92%), urinary tract infection (90%), conjunctivitis (90%) and wound (72%) are acceptable as the diseases should usually be treated with antibiotics (annex 12). But in many diseases, antibiotics were used irrationally; these include 74% for URTI, 56% for gastroenteritis, 35% for diarrhea, 30% for amebic dysentery, 24% for giardiasis, 21% for allergy, 18% for fungal infection, 17% for common cold and 12% for arthritis (annex 12). There was high antibiotic use for infections like colds, URTI, gastroenteritis, and fungal infections that have viral or fungal etiology where antibiotics have no clinical impact. The remaining diseases like amebic dysentery, giardiasis, diarrhea, arthritis etc were also treated needlessly by antibiotics.

        The most irrational antibiotic use was observed in the treatment of upper respiratory tract infection (URTI). Seventy two percent of the prescription for URTI in adults (annex 2) and 79% for children (annex 3) contained at least one antibiotic with an extremely high overall figure of 74% for this specific disease (table 3). This is of great concern and should be a focus for interventions. Secondary analysis by province showed that the percentage of prescriptions containing at least one antibiotic for the treatment of URTI was the highest (95%) in Senhit province, followed by 89% in Gash-Setit, 82% in Hamassien, 73% in Seraye, 60% in Semhar and the lowest (52%) in Asmara (annex 4-9). Provinces where very high antibiotic use has been observed need to be considered for further interventional studies.

        There was no significant difference in average for URTI and common cold by type of study (annex 10-11), but there was some difference in the treatment of malaria and diarrhea. The retrospective study showed that 7% of the treatment for malaria contained antibiotics whereas in the prospective study the average dropped to only 1%. Similarly the retrospective mean for diarrhea was 40% whereas the prospective mean was 23%. This reflects that prescribers may have known that they should not use antibiotics for these conditions.

      5. Percentage of Injections for Specific Diseases

 

High injection use including 60% for pneumonia, 59% for tonsillitis, 51% for wound, 19% for bronchitis, is acceptable because most of these values are attributed to penicillin injections (annex 13). Unnecessarily high percentage of injection use took place in many diseases including 19% for arthritis, 14% for URTI, 12% for fungal infection, 11% for rheumatism, 9% for anemia, 7% for malaria, 7% for abdominal cramps, 6% for conjunctivitis and 6% for gastroenteritis. On the other hand there was an example of under-prescribing where only 51% of wound patients received injection when all (100%) wound patient should receive an injection of anti-tetanus toxoid. There was also a creditable percentage of 0% injection use in some disease like amebic dysentery, unspecified dysentery and giardiasis. There was no significant difference between the overall results and the results by age, province or type of study.

Most of these unnecessary injections given to patients were vitamin B complex and neurobionä injections used mainly for their placebo effects. Both these drugs are outside the ENLD.

  1. DISCUSSION

 

A number of studies have been undertaken to describe or to improve the pattern of use in a range of health settings including hospitals, health centers, private practitioners, and pharmacies., Most of such studies were undertaken in developed countries and the efforts of different organizations who have been promoting rational drug use were coordinated in 1989 to establish the INRUD.

The INRUD developed simple indicators and methods for measuring drug use in health facilities, which were then published by WHO. These indicator studies have been conducted in more than 30 developing countries and they have become the basis for targeting different intervention studies.,,,,, The ideal values for some indicators could be obviously high e.g. availability of essential drugs list, whereas it could be difficult to define the optimum values for other indicators e.g. consultation time, where high values do not give much information but low values may indicate problems. The 1995 drug use indicator study in Eritrea is one of the studies that strictly followed the INRUD/WHO manual.

bulletThe average number of drugs per prescription was 1.8. Though this value is slightly higher than the average by 12 developing countries, it is still within acceptable range. The hospital value of 2.1, though slightly higher is still acceptable considering the morbidity patterns in hospitals. Some improvements were seen in three major hospitals during the 1997 study, where the value for the hospitals improved from 2.06 to 1.81. Thus polypharmacy is not a problem in Eritrea and should not be a focus for interventions.
bulletThe percentage of drugs prescribed by generics was 79%. Lower retrospective data implies that health workers are aware of the need to prescribe generically. Unexpected decline was found in the 1997 study in the three hospitals from 73% to 61%. Prescribing by brand name may be caused by previous prescribing habit, promotional activities of drug companies and peer influence. Some of the prescriptions for drugs such as libraxä were not only brand names but were also outside the ENLD. Others include mezilä (a brand of metronidazole unknown in other countries). As the drug law does not permit drug promotion, prescribing by brand name may not be a big threat. However, some intervention may be needed to improve the generic prescribing habit especially in the big hospitals where senior prescribers’ behaviors may influence other prescribers in lower level facilities.
bulletThe percentage of prescriptions with antibiotics prescribed was 44%. Antibiotics are costly and their misuse may lead to drug resistance and dangerous drug reactions. Such high overall value is a serious concern as antibiotics while life saving are clearly being misused.

In many diseases including URTI, gastroenteritis, diarrhea, amebic dysentery, giardiasis, allergy, fungal infection, common cold and arthritis, antibiotics were used irrationally. Treating infections of viral or fungal origin like common colds, URTI, gastroenteritis, and fungal infections result in the introduction of bacterial resistance towards antibiotics with more harm to the patient and the community in terms of both pharmaceutical benefit and cost. Similarly diseases such as amebiasis, giardiasis, diarrhea, arthritis etc were also treated needlessly by antibiotics when other very effective medications were available. Improving antibiotic use should be considered as the first priority of any interventions to be conducted in Eritrea to improve rational drug use.

The most irrational antibiotic use occurred in the treatment of URTI with an extremely high value of 74%. Although the primary analysis identified Hamasien as the province with the highest general antibiotic use, the secondary analysis identified Senhit province followed by Gash-Setit as the highest in terms of irrational antibiotic use for URTI. These provinces that share comparable ethnic, cultural or geographic characteristics and health infrastructure could be used for pilot interventional studies prior to national intervention.

bulletAn overall average of 17% of prescriptions containing injection was high. Unnecessary use of injection in arthritis, URTI, fungal infection, rheumatism, anemia, malaria, abdominal cramps, conjunctivitis and gastroenteritis should be corrected by some interventions. Comparison of retrospective and prospective data revealed prescribers’ awareness of the need to restrict injection use. This could be augmented by some educational activities. At the same time tetanus antitoxin injections should be given to wound patients to prevent the possible infection by Clostridum tetani from the site of injury.

More strict regulatory actions are needed to stop the use of illegal medications such as vitamin B complex and neurobionä injections, which contributed to irrational use of injection.

bulletAs adherence to the to the Eritrean National List of Drugs (ENLD), the availability of drugs in stock and the availability ENLD itself were high, they should not be areas for interventions. Such high adherence and availability could be due to the centralized drug procurement and the regulation that prohibits the procurement of drugs outside the list. However, care should be taken to maintain this situation which may be affected by private procurement and distribution.
bulletThe average consulting time of 4.7 minutes, average dispensing time of 99 seconds, the percentage of drugs actually dispensed (89%) and the percentage adequate knowledge of the dispensed drugs (80%), are satisfactory when compared to other African countries and should not be the focus of intervention for the time being. However, these times may be inadequate for optimum health care provision.

Another area for intervention identified during the 1995 study was percentage of drugs adequately labeled where more than half of the prescriptions were not labeled correctly. There should be adequate and stable supply of dispensing bags. Dispensing more than one medication in one bag can cause drug interactions and/or confusion exposing the patient to dangerous but avoidable drug toxicity.

  1. FOLLOW ON ACTIVITIES

    2. Some rational drug use activities were in place before the drug use studies while others followed and utilized the outcomes of the studies. The Ministry of Health through its Department of Pharmaceutical Services has been working to improve the situation regarding drug use.

    The Eritrean National List of Drugs (ENLD) which was first published 1993 is one of the important tools for the rational use of drugs. Limiting the number of drugs circulating in a country and further limiting the available drugs by level of facility is one of the managerial strategies to improve drug use. This is augmented by a regulatory approach, which says that no drug could be procured, manufactured, prescribed or dispensed outside the list in Eritrea. To make these strategies applicable careful selection of drugs is necessary. The list is subject to revision every two years and the drug use studies have helped a great deal in its subsequent improvements.

    The surveys identified areas that should be considered for interventions. The need for a comprehensive national drug policy (NDP) which will be an official guide for action in integrating all drug use activities to promote the rational use of drugs was clearly established.

    The surveys identified the need for standard treatment guidelines (STG) in order to standardize and harmonize consistency among prescribers. The preparation of the Eritrean Standard Treatment Guidelines started immediately after the 1995 nationwide survey, which has strongly recommended the need for STG. It was completed and distributed in 1999.

    Another area that needed intervention was in improving the very low availability of prescribing paper. The problem was solved using managerial approaches, first securing decent paper in each facility for writing prescriptions. Then structured prescription forms, enough for at least one year, were printed and distributed to all facilities. Apart from standardizing prescriptions, the pads have added advantages in that they can be easily traced by their colors, and the copy that remains at the facility has a separate area for writing the diagnosis, making supervisors’ and researchers’ work easier.

    Another activity that followed the 1995 survey was improving labeling and dispensing practice. Since the main cause of the low level of labeling was the unavailability of dispensing bags and that some facilities dispensed two or three medications in one bag, purchasing and distributing bags instantly solved this problem. The adequate supply of dispensing materials was a managerial approach but the educational component, which includes the preparation of dispensing guidelines and short seminars, is yet to be implemented.

    Availability and accessibility of drugs alone may not contribute towards rational use of drugs if the safety and effectiveness of the drugs entering (or manufactured) in a country is not properly controlled. A new quality control laboratory has recently been established but it is at the stage of strengthening its human and financial resources. The registration of drugs, similarly, has not started, though preparations are under way. These two areas are still important components of rational drug use that needed to be addressed.

    The secondary analysis identified specific areas where there is inappropriate drug use including the high antibiotic use in URTI, amoebae as well as the high utilization of health facilities for minor ailments like common cold, malaria, URTI, gastritis diarrhea that could have easily been treated by OTC medications. For example the two provinces — Anseba and Gash-Barka — which share comparable characteristics such as ethnic, cultural, geographic situation and health infrastructure showed the worst outcome in terms of very high antibiotic use in URTI and amoebiasis. These provinces could be considered for further combined interventional studies, where a face-to-face educational strategy followed by an audit-and-feedback approach could be tested by randomly assigning one province as intervention and the other as control. Studies in other countries show that single-shot interventions have limited impact over time; while temporary improvement may occur, prescribers may revert to their previous behaviors if the intervention is not followed up. To achieve better results it is assumed that audit-and-feedback, which is a managerial type of intervention, would augment the effect of face-to-face intervention. Such a targeted strategy that focuses on the correct treatment of URTI and amebic dysentery is more likely to reduce irrational antibiotic use in the specific diseases and may probably have a spillover effect in reducing the overall antibiotic use.

    In addition to providing STG and ENLD, training and supervision are still essential for all health providers involved in prescribing, dispensing, or other aspects of drug management. The acute shortage of qualified pharmacists and pharmacy technicians is still an area that should be improved through undergraduate education.

    All the drug use surveys conducted in Eritrea show that very few activities have been done towards improving the knowledge of the community concerning drugs. Although the Eritrean Pharmaceutical Association (ERIPA) provides rational drug use campaigns to improve drug use by patients and consumers during its annual event the ‘Pharmacy Week’, more educational activities need to focus on including patients as partners in therapy.

  2. CONCLUSION

    3. As in many other developing countries, irrational use of drugs including overuse, under use and inappropriate use were observed in Eritrea. The overall results of drugs use studies in the public health facilities showed that there is a good availability of essential drugs and a high adherence to the Eritrean National List of Drugs. The inappropriate use of antibiotics was common with special concern being the high rate of antibiotic use in URTI, amoebiasis and other diseases of non-bacterial origin. Another area of concern is the high injection use, which may result in dangerous drug toxicities. As one of the poorest countries in the world, Eritrea cannot afford the high human and financial costs of irrational drug use and rationalizing drug use may enable the country to give appropriate health service to the majority of the people. Being a small nation with a population ready for change, if more effort is exerted, I believe that Eritrea has a good chance of improvement towards rational drug use.

  3. REFERENCES:

    1. Hodgkin C. Drug Issues Discussion Paper: Written for the WHO Roundtable Discussion with Consumer and other Health-Related NGOs Involved in Pharmaceutical Issues, Use and Supply, HAI-Europe, Geneva, Switzerland, 9 Oct 1998 http://www.haiweb.org/news/issuespaper.html 5/10/99
    2. Hogerziel HV, Promoting rational prescribing: an international perspective. Br.J Clin Pharmac 1995; 39 1-6.
    3. World Health Organization Regional Office for Africa, Afro Essential Drugs, Price Indicator, Harare, Zimbabwe: WHO; July 1998 vii.
    4. Ford V. A survey of prescribing in out patient clinics in Asmara, Eritrea. Unpublished Report, Australia, 1996.
    5. Laing RO. Session Guides IH820, Promotion of Rational Use of Pharmaceutical, Problems of irrational use of drugs.1998 http://dcc2.bumc.bu.edu/richard/ih820/schedule.htm 1/19/99.
    6. WHO Manual, How to Investigate Drug Use in Health Facilities, 1993 WHO/DAP 93.1 1993.
    7. Hogerzeil HV, Bimo Ross-Degnan D, Laing RO, Ofori-Adjei D, Sanstoso B, Azad Chowdhury AK, Kafle KK, Mabadeje AFB, Massele AY. Field tests for rational drug use in twelve developing countries. The Lancet 1993; 342: 1408-1410.
    8. Laing RO. Report on Consultancy Visit. Unpublished report, Asmara, Eritrea: January1996
    9. CIA. Country Listing, Eritrea. CIA Factbook 1998, http://www.odci.gov/cia/publications/factbook/er.html 1/19/99
    10. Europa World Year Book; International Travel and Healths; Yearbook of Labor statistics. Facts and Figures. Document 3 of 5, Country: Eritrea 1999. ABC-CLIO, Inc. http://web.lexis-nexis.com/univers...5=76a6688d198ae30b4ef2205baeb45919 7/23//99
    11. National Statitiscs office [Eritrea]. Department of Macro and International Economic Cooperation Office of the President, Demographic and Health Surveys 1995 Cavelverton, Maryland, Macro International Inc; 1995.
    12. World Health Organization. Eritrea Annual Report. Asmara, 1997.
    13. World Bank, World Development Indicators, http://www.worldbank.org/data/countrydata/adi/adi.html. 5/12/99
    14. Proclamation No 36: 1993, To Control Drugs Medical Supplies Cosmetics and Sanitary Items. Asmara. Provisional Government of Eritrea. 1993.
    15. Woldeysus K. The Drug Situation in Eritrea: A Drug Regulators Perspective, Fragile Economies, Flooded Markets: Networking for Rational Drug Use in Eastern Africa. Nairobi: Health Action International 1997.
    16. WHO. Making a Difference: The World Health Report. France: WHO 1999; 2
    17. Howson CP, Fineberg HV, Bloom BR. The Pursuit of Global Health: the relevance of engagement for developed countries. The Lancet 1998; 350 (9102): 586-590.
    18. Congressional Budget Office. How increased competition from generic drugs has affected prices and returns in the pharmaceutical industry, summary, July 98 http://www.cbo.gov/showdoc.cfm?index=655&sequence=1 5/20/99
    19. Mintzes B. Blurring the boundaries. New Trends in drug Promotion. HAI-Europe.1998. http://www.haiweb.org/pubs/blurring/blurring.Intro.html 5/10/99
    20. WHO. The World Drug Situation, Geneva: WHO, 1988; 53.
    21. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalize patients: a meta-analysis of prospective studies. JAMA 1998; 279 (15):1200-1205.
    22. Thomas M. Spontaneous Adverse drug reaction monitoring program: a springboard to better physician education in developing countries. Clinical Pharmacology & Therapeutics 1991; 49(4):347-9.
    23. Memon K. Use of Drugs in Primary Health Care Province of Sindh Pakistan. Unpublished Concentration Paper for Boston University, School of Public Health, 1999.
    24. Andom E, Mehari M, Orobaton N. Prescribing Practice of Physicians in Eritrea: Evidence from Three Hospitals. Unpublished Report. Ministry of Health Eritrea. 1997.
    25. Martindale: The Extra Pharmacopoeia, 32nd ed. Taunton, MA: The Pharmaceutical Press, World Color Services; 1999.
    26. Monteiro N. Deaths by wrong injections: Conspiracy of Silence. DAWN the Internet Edition Feb 16 1999 http://www.dawn.com/daily.19990216/local1.htm 2/17/99
    27. Banahan BF, Kolassa EM. A physician survey on generic drug and substitution of critical dose medications. Archives of Internal Medicine 1997; 157(18):2080-8.
    28. Sogoo K, Bala K. Health Action International, No 104, December 1998, http://www.haiweb.org/pubs/hainews/Dec1998.html 5/10/99
    29. Pecoul B, Chicac P, Trouiller P, Pinel J. Access to essential drugs in poor countries: a lost battle? JAMA 1999; 281(4):361-7.
    30. Csillag C. SAO PAOLO Epidemic of counterfeit drugs causes concern in Brazil. Lancet 1998; 352(9127):553.
    31. Taylor RB, Shakoor O, Behrens RS. Drug quality, a contributor to drug resistance. Lancet 1995: 346(8967):122.
    32. Food and Drug Administration. FDA position on product selection for ‘narrow therapeutic index’ drugs. American Journal of Health-System Pharmacy 1997; 54(14):1630-2.
    33. Lantell JP. Projecting future drug expenditures-1996. American Journal of Health-System Pharmacy 1997; 53(2):139-50.
    34. WHO. The rational use of drugs. Report of the Conference of Experts, Nairobi, Nov 25-29, 1985. Geneva: World Health Organization, 1987.
    35. Nikaido H. Prevention of Drug Access to Bacterial Targets: Permeability Barriers and Active Efflux. Science 1994; 264(5157):382-388.
    36. Williams R, Heymann DL. Containment of antibiotic resistance. Science 1998; 279(535):1153-1154
    37. McCaig LF, Hughes JM. Trends in Antimicrobial Prescribing Among Office-Based Physicians In the United States. JAMA 1995; 273(3):214-219.
    38. Touw-Otten FW, Johansen KS. Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO Regional Office for Europe study in 17 European countries. Family Practice 1992: 9(3):255-62.
    39. Avis K, Levchuk J, Parenteral Preparations. IN: Remington: The Science and Practice of Pharmacy 19th ed. Easton, PA: Mack Publishers, 1995: 1524-27.
    40. MacGregor RR, Graziani AL. Oral administration of antibiotics: a rational alternative to the parenteral route. Clinical Infectious Diseases 1997; 24(3):457-67.
    41. Craig WA, Andes DR. Parenteral versus oral antibiotic therapy. Med Clin North Am 1995; 79:497-508.
    42. Hoppe JE, Rational prescribing of antibacterial in hospitalized children. Pharmacoeconomics 1996; 10(6):575-93.
    43. Garrelts JC, Herrington AM. Cost-effective treatment of lower respiratory tract infections. Pharmacoeconomics 1996; 10(1):36-58.
    44. Sohn W. Benefits and risks of intramascular injection. Are expectations of physicians and patients irrational? Fortschritte der Medizin 1996; 114(17):217-20.
    45. Howie JG, Porter AM, Heaney DJ, Hopton JL. Long to short consultation ratio: a proxy measure of quality of care for general practice. British Journal of General Practice 1991; 41:48-54.
    46. Howie JG, Heaney DJ, Maxwell M. Care of patients with selected health problems in fundholding practices in Scotland in 1990 and 1992: needs, process and outcome. British Journal of General Practice 1995; 45: 121-126.
    47. Morrell DC, Evans ME, Moris RW, Roland MO. The "five minute" consultation: effect of time constraint on clinical content and patient satisfaction. BMJ 1986; 292: 870-873.
    48. Martin CM, Attewel RG, Nisa M, McCallum J, Raymond CJ. Characteristics of longer consultation in Australian general practice. Med J Aust 1997; 167:67-79.
    49. Wilson A. Consultation length in general practice: a review. British Journal of General Practice 1991; 41: 119-122.
    50. McCormack PM, Lawlor R, Donegan C, O’Neill D, Smith S, Moroney C, McGrath A, Walsh JB, Coakley D, Feely J. Knowledge and attitudes to prescribed drugs in young and elderly patients. Irish Medical Journal 1997; 90(1):29-30
    51. Holloway A. Patient knowledge and information concerning dedication on discharge from hospital. Journal of Advanced Nursing 1996; 24(6):1169-74.
    52. Crichton EF, Smith DL, Demanuele F. Patient recall of medication information. Drug Intelligence & Clinical Pharmacy 1978; 12(10): 591-9.
    53. Hemming M, Harvey K. International strategies on antibiotics. HAI News Feb 1999: 105 http://www.haiweb.org/pubs/hainews/Feb1999.html 5/10/99
    54. Krause G, Benzler R, Heinmuller R, Borchert M, Koob E, Ouattara K, Diesfeld J. Performance of village pharmacies and patient compliance after implementation of essential drug programme in rural Burkina Faso. Health Policy and Planning 1998; 13(2): 159-166.
    55. Howard NJ, Laing RO. Changes in the World Health Organization essential drug list. Lancet 1991; 338(8769):743-5
    56. Quick JD, Rankin JR, Laing RO, O’Conner RW, Hogerzeil HV, Dukes MNC, Garnett A. Managing Drug SupplyDrug Management Program, Management Sciences for Health: in collaboration with WHO Action Programme on Essential Drugs, West Hartford, Connecticut: Kumarian Press, 1997
    57. Brownlee A, Gonzales LD, Gonzales G, Nuyens Y, Pathmanathan I, Stark A, Twumasi P, Varkeviseer CM. Proposal Development and Fieldwork: Designing and Conducting Health System Research Projects. Health Systems Research Training Series, Ottawa, Ontario: International Development Research Center 1991: Vol 2 part 1, 118-136
    58. Ross-Degnan D, Laing R. Quick J. Ali HM, Ofori-Adjei D, Salako L. & Santoso B. A Strategy for Promoting Improved Pharmaceutical Use: The International Network for Rational Use of Drugs. Soc Sci Med 1992; 35(11) 1329-1341.
    59. Ross-Degnan D., Laing R. Santoso B. Ofori-Adjei D, Diwan V, Lamoureux C, and Hogerzeil H. Improving Pharmaceutical Use in Primary Care in developing Countries: A Critical Review of Experience and Lack of Experience. Paper prepared for the International Conference on Improving the Use of Medicines, Chang Mai, Thailand. April 1997.
    60. Christian Medical Commission & World Council of Churces. Rational use of drugs. Contact No 139. Geneva 1994.
    61. Soumerai, SB. Factors influencing prescribing. Aust J. Hosp Pharm 1988; 18(3): 9-16.

  4. APPENDIX 1: DETAILED PRIMARY ANALYSIS RESUSLTS

    5. Average Numbers of drugs

    The overall average number of drugs per prescription was 1.8. For both health centers and health stations the average was 1.7. Hospitals showed higher value ranging from maximum 2.3 in Tessenei hospital to minimum 2.0 in Keren with an average of 2.1 drugs per prescription. Within the provinces the average number varied from 1.6 in Seraye and Asmara to 2.0 in Senhit. The overall range was minimum 1.17 in Hycota and maximum of 2.49 in Begu Mission health stations. There was no significant difference between retrospective and prospective results which ranged from 1.7 to 1.9 respectively.

    Percentage Generic

    The overall average percentage generic was 79%. It was 70% in hospitals, 79% in health centers and 82% in health stations. Generally most health stations prescribed using generic names. The same is true to health centers except for a very low result of 49% in Mai-Nefhi health center. The range of values varied from a minimum of 49% in Mai-Nefhi health center to as high as 93% in Omhajer health center. The provinces ranged from 65% in Hamasien to 86% in Gash-Setit and Asmara. Retrospective data were generally lower at all levels. These imply that health workers are aware of the need to prescribe generically.

    Percentage Antibiotics

    The overall percentage of encounters with antibiotics prescribed was 44%. The hospitals and health centers both had similar rates of 48% and 49%, while the health stations were 37%. There was very little difference between retrospective and prospective results. The range between the provinces was from 49% in Hamasien to 36% in Semhar. The individual facility range varied from a minimum of 28% in Adi Beza-hans to a maximum 67% in Mekerka.

    Percentage Injections

    The overall percentage of prescriptions with an injection prescribed was 17%. The hospital value was 15% while health centers were 17% and health stations were 14%. There was little variation between provinces, with lowest value of 15% obtained in Asmara, Semhar, and Senhit and the highest value of 21% obtained in Hamasien. Retrospective value of 18% was slightly higher than the prospective 15%. This indicates that the health providers’ are aware of the need to restrict injection use. As is common in such surveys percentage of encounters with injections is the indicator with considerable variation. The range in this study was quite considerable ranging from 4% at Wokiro Health Station to a hih at Massawa Hospital of 31% .

    Percentage on Eritrean National List of Drugs (ENLD)

    A high adherence to the to the Eritrean National List of drugs (ENLD) of 94% was scored for all levels without variation by health care levels, by provinces or by data type or between retrospective and prospective data. The range in provinces was from 86% in Hamasien to 100% in Semhar. Adherence to essential drugs list is clearly not a problem in Eritrea.

    Average Consultation Time

    The overall average consulting time was 4.7 minutes. There was no significant difference in the average consultation time between levels of care but there was considerable variation between the different provinces for this indicator that ranged from 4.0 minutes in Asmara to 5.7 minutes in Hamasien. The shortest time of 2.3 minutes was registered at Felege Hiwot Health Center, while the highest time of 9.1 minutes was registered at Begu Mission Health Station.

    Average Dispensing Time

    The overall average dispensing time was 99 seconds. The mean time by level of care was 89 seconds in hospitals, 99 seconds in health centers and 110 seconds in health stations. The average dispensing times varied similarly for the different provinces ranging from 77 seconds in Asmara to 131 seconds in Gash-Setit. The overall time ranged from a minimum of 48 second in Edaga Hamus Health Center to a maximum of 168 seconds in Wokiro Health Station.

    Percentage Drugs Dispensed

    The Percentage of drugs actually dispensed was 89%. This percentage varied from 82% in hospitals, to 89% in health centers, and 96% in health stations. The percentage of drugs actually being dispensed varied by provinces from 85% in Asmara to 95% in Semhar. The overall percentage ranged from a minimum of 74% in Semenawi Asmara to a maximum of 100% in seven health stations and three health centers. These figures were considered as very creditable considering the logistic challenges faced in distributing drugs.

    Drugs Adequately Labeled

    The overall percentage of drugs adequately labeled was 50% meaning that half of the prescriptions were not labeled correctly. These figures contain wide variations because some facilities had none of the prescriptions adequately labeled and a few facilities scored 100%. By facility level the average percentage was 76% in hospitals, 43% in health centers and 44% health stations. The cause of such low percentage of labeling was that in some facilities two or three medications were dispensed in one bag because of the shortage of dispensing bags. For this reason four health centers and four health stations had no satisfactory labeling! Similarly considerable variation occurred between provinces that ranged from 0% correct labeling in Hamasien to 73% in Asmara.

    Percentage Adequate Knowledge of the Dispensed Drugs

    The overall percentage adequate knowledge of the dispensed drugs was 80%. In contrast to the poor labeling reported above, the figure shows that good explanations were being given to the patients. There was no significant difference in the average adequate knowledge between facilities. The hospitals had 81% of patients with adequate knowledge, while the percentage for health centers and health stations were 82% and 76% respectively. The value by provinces varied from 74% in Seraye to 94% in Hamasien where the population is better educated. The facility value ranged from a minimum of 33% in Mai Nefhi to 100% in Adi Sheka Health Center.

    Availability of Impartial Information

    The availability of impartial information was measured by the availability of the Eritrean National List of Drugs (ENLD) and prescription paper. ENLD was widely available at an average of 83% facilities. Its availability was 100% in hospitals, 93% in health centers and 67% in health stations. In contrast prescription paper was only available at 17% of facilities and this was another area needing intervention.

    Percentage Availability of Drugs in Stock

    The overall percentage availability of drugs in stock value was 91%. The 15 marker drugs were available in 94% of hospitals, 92% of health centers, and 88% of health stations. By facility the range of availability was from 69% at Sembel and Hadish Adi Health Stations to 100% at two health stations and four health centers, and at two hospitals.

     

  5. ANNEXES

Annex 1 Map of Eritrea

The shaded shows provinces included in the 1995 survey

Annex 2: Secondary Analysis Adults 15 Years and Above 2205cases

Diagnosis

Count

%Diagnosis

Av # Drugs

%Generic

%AB's

%Inj

%ENLD
Malaria

244

11.07%

2.10

86%

6%

8%

98%
Multiple

228

10.34%

2.57

74%

44%

17%

94%
Gastritis

125

5.67%

1.64

75%

2%

3%

87%
Common cold

116

5.26%

1.68

88%

16%

5%

94%
Wound

92

4.17%

1.20

93%

77%

53%

96%
Bronchitis

83

3.76%

1.78

72%

94%

19%

86%
URTI

65

2.95%

2.00

72%

65%

14%

92%
Anemia

63

2.86%

1.87

88%

5%

10%

92%
U.T.I

62

2.81%

1.77

71%

94%

11%

96%
A. Dysentery

52

2.36%

2.31

63%

37%

0%

98%
Total

1130

51.25%

1.89

78%

44%

14%

93%

 

Annex 3: Secondary Analysis Children Under 15 Years 1508 Cases

Diagnosis

Count

%Diagnosis

# Drugs

%Generic

AB's

Inj

%ENLD
Common cold

187

12.40%

1.64

89%

17%

2%

94%
Multiple

139

9.22%

2.32

76%

68%

19%

96%
URTI

129

8.55%

1.67

80%

79%

14%

93%
Malaria

110

7.29%

1.89

95%

4%

4%

99%
Diarrhea

96

6.37%

1.83

80%

31%

5%

98%
Tonsillitis

86

5.70%

1.90

85%

95%

56%

96%
Pneumonia

77

5.11%

1.65

86%

99%

54%

97%
Bronchitis

76

5.04%

1.75

80%

92%

20%

98%
Wound

70

4.64%

1.01

89%

66%

47%

97%
Gastroenteritis

49

3.25%

1.92

78%

61%

6%

94%
Total

1019

66.91%

1.76

84%

61%

23%

96%

 

Annex 4: Secondary Analysis Gash-Setit Top Ten Cases Total 595 cases

Diagnosis

Count

% diagnosis

# drugs

%generic

Ab's

Inj

%ENLD
Malaria

140

23.53%

1.89

91%

6%

7%

98%
Multiple

57

9.58%

2.42

85%

54%

21%

96%
Pneumonia

41

6.89%

1.29

96%

95%

59%

97%
Common cold

34

5.71%

1.44

98%

35%

6%

99%
URTI

27

4.54%

1.48

86%

89%

15%

93%
Bronchitis

21

3.53%

1.81

88%

100%

29%

84%
A. Dysentery

19

3.19%

2.05

95%

21%

0%

97%
Gastritis

19

3.19%

1.42

96%

5%

0%

96%
Scabies

17

2.86%

1.18

85%

18%

12%

95%
Dysentery

16

2.69%

1.69

79%

50%

0%

103%
Total

391

66%

1.67

90%

47%

15%

96%

 

Annex 5: Secondary Analysis Hamasein Top Ten Cases Total 588 Cases

Diagnosis

Count

%Diagnosis

# Drugs

% Generic

AB's

Inj

%ENLD
Multiple

103

17.52%

2.36

65%

53%

27%

90%
Wound

42

7.14%

1.19

82%

76%

55%

96%
URTI

33

5.61%

2.00

68%

82%

27%

89%
Common cold

31

5.27%

2.03

67%

26%

3%

83%
Malaria

31

5.27%

2.42

73%

3%

10%

93%
Blank

29

4.93%

0.57

81%

18%

14%

81%
Gastritis

24

4.08%

1.38

76%

0%

13%

85%
Pneumonia

23

3.91%

1.91

82%

100%

52%

95%
Conjunctivitis

18

3.06%

1.44

38%

83%

6%

96%
Tonsillitis

18

3.06%

1.83

64%

78%

56%

100%
Total

352

60%

1.71

70%

52%

26%

91%

 

Annex 6: Secondary Analysis Asmara Top Ten Cases Total 620 Cases

Diagnosis

Count

% Diagnosis

Av # Drugs

%Generic

% AB's

% Inj

% ENLD
Common cold

95

14.62%

1.61

89%

20%

7%

92%
Tonsillitis

57

8.77%

2.04

90%

98%

67%

95%
URTI

46

7.08%

1.93

82%

52%

13%

97%
Diarrhea

41

6.31%

1.80

86%

49%

12%

96%
Bronchitis

30

4.62%

1.90

81%

90%

23%

86%
Gastritis

25

3.85%

1.68

79%

4%

0%

88%
Wound

24

3.69%

1.13

96%

58%

33%

96%
Skin infection

23

3.54%

1.39

91%

61%

52%

97%
Blank

22

3.38%

1.00

73%

14%

9%

86%
Anemia

18

2.77%

1.44

85%

6%

11%

92%
Total

381

59%

1.59

85%

45%

23%

93%

 

Annex 7: Secondary Analysis Semhar Top Ten Cases Total 652 Cases

Diagnosis

 Count %Diagnosis

# Drugs

%Generic

% AB's

% Inj

%ENLD
Malaria

74

11.35%

1.99

86%

5%

3%

100%
Common cold

51

7.82%

1.65

99%

8%

0%

100%
Multiple

42

6.44%

2.81

77%

69%

10%

99%
Diarrhea

33

5.06%

2.09

74%

27%

3%

100%
Bronchitis

29

4.45%

1.31

74%

100%

24%

100%
URTI

25

3.83%

1.72

84%

60%

4%

98%
Fever

23

3.53%

1.96

91%

30%

9%

100%
Gastritis

22

3.37%

1.82

90%

0%

0%

100%
Cough

17

2.61%

2.18

89%

47%

12%

100%
Pneumonia

15

2.30%

1.73

77%

100%

47%

100%
Grand

331

51%

1.93

84%

45%

11%

100%

 

Annex 8: Secondary Analysis Senhit Top Ten Cases Total 576 Cases

Diagnosis

Count

%Diagnosis

# Drugs

%Generic

% AB's

% Inj

%ENLD
Multiple

82

14.24%

2.55

76%

55%

12%

97%
Common cold

47

8.16%

1.72

90%

9%

0%

96%
Malaria

37

6.42%

2.43

87%

5%

3%

98%
U.r.t.i.

37

6.42%

1.92

72%

95%

8%

93%
Bronchitis

30

5.21%

2.20

85%

97%

17%

97%
Gastritis

25

4.34%

2.12

58%

4%

4%

79%
Wound

22

3.82%

1.23

85%

95%

68%

93%
A. Dysentery

13

2.26%

2.38

65%

15%

0%

100%
Anemia

13

2.26%

2.77

94%

0%

0%

97%
Pneumonia

13

2.26%

2.08

93%

100%

92%

96%
Total

319

55%

2.14

81%

48%

20%

95%

 

 Annex 9: Secondary Analysis Seraye Top Ten Cases Total 682 Cases

Diagnosis

Facility

% Diagnosis

# Drugs

%Generic

% AB's

% Inj

%ENLD
Multiple

82

12.02%

2.41

77%

44%

13%

93%
Malaria

68

9.97%

2.00

96%

4%

10%

100%
Common cold

45

6.60%

1.58

87%

7%

0%

94%
Wound

45

6.60%

0.87

100%

64%

51%

97%
Pneumonia

33

4.84%

1.82

83%

94%

59%

88%
Bronchitis

32

4.69%

1.63

63%

97%

16%

85%
Diarrhoea

31

4.55%

1.71

79%

16%

0%

96%
URTI

26

3.81%

1.42

73%

73%

15%

84%
Scabies

18

2.64%

1.22

91%

17%

6%

95%
Gastritis

16

2.35%

1.31

57%

0%

0%

76%
Total

396

58%

1.60

81%

42%

17%

91%

 

Annex 10: Prospective Secondary Analysis Top Ten Cases

Diagnosis

Count

% Diagnosis

# Drugs

%Generic

% AB's

% Inj

%ENLD
Multiple

119

12%

2.7

78%

50%

16%

93%
Common cold

106

11%

1.6

93%

15%

2%

96%
Malaria

95

10%

2.1

93%

1%

5%

99%
U.R.T.I.

48

5%

2.0

74%

69%

10%

96%
Wound

46

5%

1.3

88%

78%

48%

97%
Bronchitis

39

4%

1.8

74%

100%

15%

88%
Diarrhoea

39

4%

1.9

76%

235

3%

96%
Pneumonia

32

3%

1.8

88%

100%

59%

92%
Conjunctivitis

24

2%

1.3

93%

96%

0%

97%
Tonsillitis

23

2%

1.7

88%

96%

75%

98%
Total

571

58%

1.72

85%

64%

24%

95%

 

Annex 11: Retrospective Secondary analysis

Diagnosis

Count

% Diagnosis

# Drugs

%Generic

% AB's

% Inj

%ENLD
Malaria

259

9.4%

2.0

87%

7%

7%

98%
Multiple

248

9.0%

2.4

73%

55%

19%

95%
Common cold

197

4.2%

1.7

86%

17%

4%

93%
U.R.T.I.

146

5.3%

1.7

78%

76%

15%

92%
Bronchitis

120

4.4%

1.7

77%

91%

21%

93%
Wound

116

4.2%

1.0

93%

70%

52%

96%
Gastritis

108

3.9%

1.7

76%

2%

4%

88%
Pneumonia

95

3.5%

1.6

86%

96%

61%

96%
Tonsillitis

93

3.4%

1.9

84%

91%

55%

97%
Diarrhoea

88

3.2%

1.9

82%

40%

6%

98%
Total

1470

53.6%

1.8

75%

50%

22%

94.6%

 

Annex 12: Seconday Analysis Sorted by Antibiotics for the Top 30 Diseases

No

Diagnosis

Count

% Diag

Av# drug

% Generic

AB's

Inj

%ENLD
  1. 1
 Pneumonia

127

3.42%

1.69

87%

97%

60%

95%
bullet2
 Bronchitis

159

4.28%

1.77

76%

93%

19%

91%
Otitis media

60

1.62%

1.42

82%

93%

23%

94%
Tonsillitis

117

3.15%

1.88

85%

92%

59%

97%
U.T.I.

66

1.78%

1.71

71%

92%

11%

96%
Conjunctivitis

69

1.86%

1.48

79%

90%

6%

96%
U.R.T.I.

194

5.22%

1.78

77%

74%

14%

93%
Wound

162

4.36%

1.12

91%

72%

51%

96%
Dental caries

39

1.05%

1.59

71%

64%

15%

97%
Gastroenteritis

62

1.67%

1.92

75%

56%

6%

94%
Skin infection

55

1.48%

1.29

80%

55%

40%

97%
Dysentery

41

1.10%

1.8

64%

54%

0%

101%
Multiple

367

9.88%

2.47

75%

53%

18%

94%
Diarrhoea

127

3.42%

1.88

80%

35%

5%

97%
Scabies

76

2.05%

1.27

86%

34%

21%

96%
Fever

39

1.05%

1.92

92%

31%

8%

99%
A. Dysentery

81

2.18%

2.17

65%

30%

0%

97%
Abd. Cramps

30

0.81%

1.53

83%

30%

7%

100%
Blank

69

1.86%

0.99

73%

26%

13%

88%
Giardiasis

38

1.02%

1.95

78%

24%

0%

99%
Allergy

29

0.78%

1.24

72%

21%

7%

89%
Fungal infection

33

0.89%

1.15

81%

18%

12%

95%
Common cold

303

8.16%

1.65

89%

17%

3%

94%
Asthma

32

0.86%

1.72

80%

13%

13%

87%
Arthritis

43

1.16%

2

77%

12%

19%

93%
Malaria

354

9.53%

2.04

89%

5%

7%

98%
Anemia

68

1.83%

1.82

87%

4%

9%

91%
Rheumatism

28

0.75%

1.64

91%

4%

11%

91%
Gastritis

131

3.53%

1.65

75%

2%

3%

88%
Head ache

28

0.75%

1.29

86%

0%

0%

100%

Total

3027

82%

1.66

80%

43%

15%

95%

 

Annex 13: Seconday Analysis sorted by injection for the top 30 diseases

No

Diagnosis

Count

% Diag

Av# drug

% Generic

AB's

Inj

%ENLD
bullet1
 Pneumonia

127

3.42%

1.69

87%

97%

60%

95%
Tonsillitis

117

3.15%

1.88

85%

92%

59%

97%
Wound

162

4.36%

1.12

91%

72%

51%

96%
Skin infection

55

1.48%

1.29

80%

55%

40%

97%
Otitis media

60

1.62%

1.42

82%

93%

23%

94%
Scabies

76

2.05%

1.27

86%

34%

21%

96%
bullet2
 Bronchitis

159

4.28%

1.77

76%

93%

19%

91%
Arthritis

43

1.16%

2

77%

12%

19%

93%
Multiple

367

9.88%

2.47

75%

53%

18%

94%
Dental caries

39

1.05%

1.59

71%

64%

15%

97%
U.R.T.I.

194

5.22%

1.78

77%

74%

14%

93%
Blank

69

1.86%

0.99

73%

26%

13%

88%
Asthma

32

0.86%

1.72

80%

13%

13%

87%
Fungal infection

33

0.89%

1.15

81%

18%

12%

95%
U.T.I.

66

1.78%

1.71

71%

92%

11%

96%
Rheumatism

28

0.75%

1.64

91%

4%

11%

91%
Anemia

68

1.83%

1.82

87%

4%

9%

91%
Fever

39

1.05%

1.92

92%

31%

8%

99%
Abd. Cramps

30

0.81%

1.53

83%

30%

7%

100%
Allergy

29

0.78%

1.24

72%

21%

7%

89%
Malaria

354

9.53%

2.04

89%

5%

7%

98%
Conjunctivitis

69

1.86%

1.48

79%

90%

6%

96%
Gastroenteritis

62

1.67%

1.92

75%

56%

6%

94%
Diarrhoea

127

3.42%

1.88

80%

35%

5%

97%
Common cold

303

8.16%

1.65

89%

17%

3%

94%
Gastritis

131

3.53%

1.65

75%

2%

3%

88%
Dysentery

41

1.10%

1.8

64%

54%

0%

101%
A. Dysentery

81

2.18%

2.17

65%

30%

0%

97%
Giardiasis

38

1.02%

1.95

78%

24%

0%

99%
Head ache

28

0.75%

1.29

86%

0%

0%

100%

Total

3027

82%

1.66

80%

43%

15%

95%

Abosede OA. "Self-medication: an important aspect of primary health care" Social Science Medicine Vol. 19 No. 7, pp. 699-703, 1984.

Action Prograrnme on Essential Drugs: Estimating Drug Requirements: A Practical Manual. Geneva: World Health Organization, 1988.

Avorn J, Soumerai SB. Improving drug therapy decisions through educational outreach. a randomized controlled trial of academically based detailing New England Journal of Medicine 1983; (308):1457-1463.

Ethics and the Use of Formularies McCarthy, RL; MA College of Pharm, Boston; 1994, pp 1-7

Hogerzeil H, Walker GJ, Sallam AO, Fernando G. Impact of an Essential Drug Program on Availability and Rational Use of Drugs Lancet 1989; 141-142.

Kafle, KK, Gartoulla R.P., Pradhan YM, Shrestha AD, Karkie SB, Quick JD. "Drug Retailer Training: Experiences from Nepal. Social Science Medicine 35 (8) 1015-1025 1992.

Laing RO. Ruredzo R. The Essential Drugs Programme in Zimbabwe: New Approaches to Training. Health Policy and Planning 1989; 4 (3): 229-234.

Laing RO. Hogerzeil HV, Ross Degnan D Ten Recommendations to promote improved use of medicines in developing countries Draft paper submitted for publication 1999

Montagne, M. Basara, L., "Consumer Behavior regarding the choice of prescription and non-prescription medication use," Smith N.C., Wertheimier A.I. (eds) Social and Behavioral Aspects of Pharmaceutical Care, Binghampton, NY, Haworth Press 1996

Montagne, M., "Drug Education," Gennaro, A.R. (ed) Remington: The Science and Practice of Pharmacy. 19th edition, Easton, PA, Mack Publishers pp. 1786-95, 1995

National Statitiscs office [Eritrea]. Department of Macro and International Economic Cooperation Office of the

Sachs L. and Tomson G. Medicines and Culture - A Double Perspective on Drug Utilization in a Developing Country. Social Science Medicine Vol. 34 No. 3 pp. 307-3 1 5, 1 992.

Soumerai SB, Avom J. Principles of Educational Outreach ('academic detailing) to Improve Clinical Decision Making JAMA 1990; 263 (4): 549 - 556.

Soumerai SB, McLaughlin TJ, Avorn J. "Improving Drug Prescribing in Primary Care: A Critical Analysis of the Experimental Literature" Milban_Ouarterly 1 989; 67 (2): 268-3 1 7.

Soumerai, SB, Ross-Degnan D, Gortmaker S. Avorn J. "Withdrawing Payment for Non-Scientific Drug Therapy" JAMA 1990; 263: 831-839.

Van der Geest S., Hardon A., Whyte, S.R. "Planning for Essential drugs: Are We Missing the Cultural Dimention?" Health Policy and Planning; 1990: 5:(2): 182-185.

Van Der Geest. "Pharmaceuticals in the Third World: The Local Perspective" S. Social Science and Medicine 1987; 25 (3) 273-276.

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