WHO, Dept. Essential Drugs and Medicines Policy Measuring use of medicines: progress in the last...

WHO, Dept. Essential Drugs and Medicines Policy

Measuring use of medicines:progress in the last decade

Kathleen Holloway and Verica Ivanovska

Dept. Essential Drugs and Medicines PolicyWHO Geneva

ICIUM, March 30 – April 2, 2004

WHO, Dept. Essential Drugs and Medicines Policy 2

WHO database of all drug use surveys done in developing countries 1993-2003

Objectives• To provide an overview of drug use

– existing drug use patterns in primary health care settings in developing and transitional countries over time

• To identify effective interventions and trends– impact of different types of interventions on improving the use of

drugs

• To provide evidence for advocacy, planning– tool for routine monitoring nationally & internationally


Criteria for inclusion of study in database

• Quantitative data on drug use• Descriptive and intervention studies• Developing and transitional countries• Primary health care patients

– primary health care clinics– hospital general & paeds non-specialist outpatients– pharmacies, drug sellers and households

• Articles in English, French, Spanish, Russian• Reported/published during 1993-2003


Methods• Search strategy

– INRUD bibliography & WHO archives 1993-2003• Retrieval strategy

– WHO library resources• Database format

– Access, compatible with other WHO databases• Data entry

– one record per published survey divided again by country, health facility type/level, prescriber type

• Data analysis – Time series & comparisons between sectors, regions, etc– Export into excel and later into statistical packages


Design of the database• 1st section on demographic detail

– country, year of survey, publication reference, healthcare setting, prescriber/dispenser type, patient/disease type

• 2nd section on types of interventions – provider education, printed materials, supervision & audit,

economic strategies, regulation, essential drug programs

• 3rd section on methodological details– study design, sample sizes (prescriptions, facilities,

patients), data collection

• 4th section on drug use indicators – WHO/INRUD indicators, IMCI and specific disease

indicators, mortality rates, additional indicators


Current status• INRUD bibliography

– 3080 articles screened 1993-2003– 207 (7%) articles met the inclusion criteria

• WHO/Essential Drugs & Medicines archives– 67 unpublished articles/reports 1993-2003 entered

• WHO/Child Adolescent Health archives– 71 unpublished articles/reports 1993-2003 entered

• 441 data records entered in the database– about half surveys done to evaluate an intervention


Methodological challenges• Some surveys published in more than one

article, sometimes with inconsistent results• Standard indicators often not used• Missing data

– survey year, facility type, facility level, prescriber type• Data sometimes difficult to classify

– indicators sometimes poorly described– drug use reported for a mix of facility / prescriber type– description of study design in article descriptions not

consistent with database definitions• time series stated but 4 data points not described• “retrospective” interviews/observation described


Facility types16%

2%

19%

63%

Don't know

Private-no profit

Private-profit

Public


Facility level

32%

50%

13%

5%

Hospital OPD / PHC

Primary health care

Pharmacy / drug seller

Household


Prescriber types

24%

24%25%

6%

11%

1%9%

MDs

MDs/paramedic/nurse

paramedics/nurses

pharmacists/assts

CHWs

laypersons/self

Don't know


Intervention types844 interventions in 204 study sites

38.3%

10.5%25.1%

7.6%

2.2%1.1%

7.2%

7.6% 0.4% Provider education

Consumer education

Printed materials

Supervision & audit

Community case mgt

Group process

Economic strategies

Essential drug prog

Regulation


WHO/INRUD Prescribing Indicators

0

10

20

30

40

50

60

70

80

90

100

<1992 1992-5 1996-9 2000-3

% p

atie

nts

/ % d

rugs

0

1

2

3

4

5

Av.

no.d

rugs

/ pa

tient

% patients pres antibiotic(n=24,63,56,29)

% patients pres injections(n=15,48,56,14)

% pres drugs on the EDL(n=3,33,41,12)

% generic drugs pres(n=11,43,40,12)

% treatments STGcompliant (n=6,11,7,6)

Av.no.drugs/patient(n=24,69,60,19)


10-year trends in antibiotic & injection use

010203040506070

88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

% patients pres AB % patients pres inj.N= 9 per year (on average)


WHO/INRUD patient care indicators

0102030405060708090

100

<1992 1992-51996-92000-3

% d

rugs

/ %

pat

ient

s

012345678910

time

(min

s)

% pres drugsdispensed (n=3,17,27,7)

% drugs adeq labelled(n=0,12,23,6)

% patients knowingdosing (n=4,16,20,10)

Av.consultation time(n=4,19,16,2)

Av.dispensing time(n=3,15,16,2)


WHO/INRUD facility indicators

020406080

100

<1992 1992-5 1996-9 2000-3

% key drug availability (n=9,20,25,10)% facilities with EDL (n=1,11,11,4)% facilities with STGs (n=0,3,5,2)


Public/private prescribing for all years

020406080

100

Av.no.drugsper patient x

10

% patientsprescribedantibiotics

% patientsprescribedinjections

% presdrugs on

EDL

% genericdrugs

prescribed

Public (n=55-118) Private-no-profit (n=3-7)Private for profit (n=19-34)


Public / private patient care for all years

020406080

100120

Av.consult(minsx10)

Av.dispensing

(secs)

% presdrugs

dispensed

% drugsadeq

labelled

% patientsknowingdosing

Public (n=25-38) Private-no-profit (n=2-3)Private for profit (n=3-7)


Prescribing by prescriber type for all years

0 20 40 60 80 100

Av.no.drugs/Px x 10

% patients pres AB

% patients pres inj.

% pres EDL drugs

% pres generics

% STG compliance

Doctor (n=6-58) Paramedic (n=20-96)


ARI treatment in last decade

0102030405060708090

<1992 1992-5 1996-9 2000-3

% A

RI c

ases

trea

ted

AB for viral URTI(n=7,21,13,8)

AB for pneumonia(n=3,19,7,27)

Cough syrup(n=3,6,4,2)

STG compliance(n=2,14,5,21)


ARI treatment by region for all years

0

20

40

60

80

100

% AB use inviral URTI(n=8-25)

% AB use inpneumonia(n=11-26)

% Coughsyrup use(n=1-11)

% STGcompliance

(n=9-17)

% Key drugavailability

(n=4-15)

Africa Asia Latin America


Diarrhoea treatment in last decade

0

10

20

30

40

50

60

70

<1992 1992-5 1996-9 2000-3

% d

iarr

hoea

cas

es tr

eate

d

ORS(n=12,24,13,25)

Antibiotics(n=10,23,12,8)

Antidiarrhoeals(n=7,19,12,7)

STG compliance(n=3,27,9,17)


Public/private diarrhoea treatment for all years

0

10

20

3040

50

60

70

ORS Antibiotics Antidiarrhoeals STGcompliance

% d

iarr

hoea

cas

es tr

eate

d

Public (n=24-50) Private for profit (n=5-23)


ConclusionsUses of WHO database of drug use surveys• track drug use over time and between countries

– plan future strategy & evaluate past strategy– identify effective interventions and policies– routine monitoring and evidence-based advocacy

Initial findings over the last decade• Few surveys and even fewer interventions done,

mostly in the public sector• Irrational drug use remains a very serious problem• Increased antibiotic use and decreased injection use• Prescribing often better in public than private sectors


Thank you• Prof. Dennis Ross-Degnan

– For constant support and advice throughout with regard to database design and analysis

• Jorge Hetzke– For help designing and maintaining the database

• Richard Laing and Hans Hogerzeil– Advice and support

• All authors around the world– For clarifying their studies for us

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WHO, Dept. Essential Drugs and Medicines Policy Measuring use of medicines: progress in the last...

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