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Rational use of drugs: an overview


Rational use of drugs: an overview Kathleen Holloway Technical Briefing Seminar November 2008 Department of Essential Medicines and Pharmaceutical Policy TBS 2008 – PowerPoint PPT presentation

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Title: Rational use of drugs: an overview

Rational use of drugsan overview
  • Kathleen Holloway
  • Technical Briefing Seminar November 2008

Department of Essential Medicines and
Pharmaceutical Policy TBS 2008
  • Define rational use of medicines and identify the
    magnitude of the problem
  • Understand the reasons underlying irrational use
  • Discuss strategies and interventions to promote
    rational use of medicines
  • Discuss the role of government, NGOs, donors and
    WHO in solving drug use problems

The rational use of drugs requires that patients
receive medications appropriate to their clinical
needs, in doses that meet their own individual
requirements for an adequate period of time, and
at the lowest cost to them and their
community. WHO conference of experts
Nairobi 1985
  • correct drug
  • appropriate indication
  • appropriate drug considering efficacy, safety,
    suitability for the patient, and cost
  • appropriate dosage, administration, duration
  • no contraindications
  • correct dispensing, including appropriate
    information for patients
  • patient adherence to treatment

Adequacy of diagnostic processSource Thaver et
al SSM 1998, Guyon et al WHO Bull 1994, Krause et
al TMIH 1998, Bitran HPP 1995, Bjork et al HPP
1992, Kanji et al HPP 1995.
5-55 of PHC patients receive injections - 90
may be medically unnecessary
Source Quick et al, 1997, Managing Drug Supply
  • 15 billion injections per year globally
  • half are with unsterilized needle/syringe
  • 2.3-4.7 million infections of hepatitis B/C and
    up to 160,000 infections of HIV per year
    associated with injections

of primary care patients receiving injections
Variation in outpatient antibiotic use in 26
European countries in 2002
Source Goosens et al, Lancet, 2005 365
579-587 ESAC project.
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Overuse and misuse of antimicrobials contributes
to antimicrobial resistance
Source WHO country data 2000-3
  • Malaria
  • choroquine resistance in 81/92 countries
  • Tuberculosis
  • 0-17 primary multi-drug resistance
  • 0-25 primary resistance to at least one
  • Gonorrhoea
  • 5-98 penicillin resistance in N. gonorrhoeae
  • Pneumonia and bacterial meningitis
  • 0-70 penicillin resistance in S. pneumoniae
  • Diarrhoea shigellosis
  • 10-90 ampicillin resistance, 5-95
    cotrimoxazole resistance
  • Hospital infections
  • 0-70 S. Aureus resistance to all penicillins

Adverse drug events
Source Review by White et al,
Pharmacoeconomics, 1999, 15(5)445-458
  • 4-6th leading cause of death in the USA
  • estimated costs from drug-related morbidity
    mortality 30 million-130 billion US in the USA
  • 4-6 of hospitalisations in the USA Australia
  • commonest, costliest events include bleeding,
    cardiac arrhythmia, confusion, diarrhoea, fever,
    hypotension, itching, vomiting, rash, renal

Changing a Drug Use ProblemAn Overview of the
Many Factors Influence Use of Medicines
Strategies to Improve Use of Drugs
Educational StrategiesGoal to inform or persuade
  • Training for Providers
  • Undergraduate education
  • Continuing in-service medical education
    (seminars, workshops)
  • Face-to-face persuasive outreach e.g. academic
  • Clinical supervision or consultation
  • Printed Materials
  • Clinical literature and newsletters
  • Formularies or therapeutics manuals
  • Persuasive print materials
  • Media-Based Approaches
  • Posters
  • Audio tapes, plays
  • Radio, television

Impact of Patient-Provider Discussion Groups on
Injection Use in Indonesian PHC Facilities
Source Hadiyono et al, SSM, 1996, 421185
Prescribing Injections
Training for prescribersThe Guide to Good
  • WHO has produced a Guide for Good Prescribing - a
    problem-based method
  • Developed by Groningen University in
    collaboration with 15 WHO offices and
    professionals from 30 countries
  • Field tested in 7 sites
  • Suitable for medical students, post grads, and
  • widely translated and available on the WHO
    medicines website

Managerial strategies Goal to structure or
guide decisions
  • Changes in selection, procurement, distribution
    to ensure availability of essential drugs
  • Essential Drug Lists, morbidity-based
    quantification, kit systems
  • Strategies aimed at prescribers
  • targeted face-to-face supervision with audit,
    peer group monitoring, structured order forms,
    evidence-based standard treatment guidelines
  • Dispensing strategies
  • course of treatment packaging, labelling, generic

RCT in Uganda of the effects of STGs, training
and supervision on of Px conforming to
Source Kafuko et al, UNICEF, 1996.
Economic strategiesGoal to offer incentives to
providers an consumers
  • Avoid perverse financial incentives
  • prescribers salaries from drug sales
  • insurance policies that reimburse non-essential
    drugs or incorrect doses
  • flat prescription fees that encourage
    polypharmacy by charging the same amount
    irrespective of number of drug items or quantity
    of each item

Pre-post with control study of an economic
intervention (user fees) on prescribing quality
in Nepal
Source Holloway, Gautam Reeves, HPP, 2001
PHC prescribing with and without Bamako
initiative in Nigeria
Source Scuzochukwu et al, HPP, 2002
Regulatory strategiesGoal to restrict or limit
  • Drug registration
  • Banning unsafe drugs - but beware unexpected
  • substitution of a second inappropriate drug after
    banning a first inappropriate or unsafe drug
  • Regulating the use of different drugs to
    different levels of the health sector e.g.
  • licensing prescribers and drug outlets
  • scheduling drugs into prescription-only
  • Regulating pharmaceutical promotional activities
  • Only work if the regulations are enforced

Impact of multiple interventions on injection use
in Indonesia
Source Long-term impact of small group
interventions, Santoso et al., 1996
Varying intervention impact in developing
countriesSource WHO database 2007
Intervention type No.studies Median impact Range
Printed materials 5 6 1 to 8
Community education 3 13 0 to 26
Provider education 24 10 -2 to 31
ProviderComm.educ 14 11 -4 to 32
Provider supervision 23 14 1 to 39
Community case mgt 6 19 3 to 29
Provider group process 9 20 4 to 41
Essential drug program 2 21 16 to 25
Provider Community education supervision 7 21 11 to 49
What are countries doing to promote the rational
use of medicines? national policies
Source EMP pharmaceutical policy database
Basic training and obligatory continuing medical
education (CME) available for health professionals
Source EMP pharmaceutical policy database
Why does irrational use continue?
  • Very few countries regularly monitor drug use
    and implement effective nation-wide interventions
    - because
  • they have insufficient funds or personnel?
  • they lack of awareness about the funds wasted
    through irrational use?
  • there is insufficient knowledge of concerning the
    cost-effectiveness of interventions?

What are we spending to promote rational use of
medicines ?
  • Global sales of medicines 2002-3 (IMS) US 867
  • Drug promotion costs in USA 2002-3 US gt30
  • Global WHO expenditure in 2002-3 US
    2.3 billion
  • Essential Medicines expenditure 2 (of 2.3
  • Essential Medicines expenditure on
  • promoting rational use of medicines 10 (of
  • WHO expenditure on promoting
  • rational use of medicines 0.2 (of 2.3

2nd International Conference for Improving Use of
Medicines, Chiang Mai, Thailand, 2004472
participants from 70 countries
  • Recommendations for countries to
  • Implement national medicines programmes to
    improve medicines use
  • Scale up successful interventions
  • Implement interventions to address community
    medicines use

WHO priorities
  • Resolution WHA60.16
  • Urges Member States " to consider establishing
    and/or strengtheninga full national programme
    and/or multidisciplinary national body, involving
    civil society and professional bodies, to monitor
    and promote the rational use of medicines "
  • WHO to support countries to implement resolution
  • Continue to give technical advice to countries
  • Model EML and formulary
  • Training on promoting RUM in community, PHC,
  • Research to identify cost-effective interventions
  • Advocacy

  • Health systems with no national programs
  • No coordinated action
  • No monitoring of use of medicines

Situational analysis
WHO facilitating multi-stakeholder action in
Develop national plans of action
Modifying action plans
Implement evaluate national action plans
  • Health systems with national programs
  • Coordinated action
  • Regular monitoring of use of medicine

WHO Goal to support establishment of national
programs coordinated by mandated, resourced,
multi-disciplinary, national bodies
  • Specific Objectives
  • Develop and pilot a standardised tool to
    undertake situational analysis and then undertake
    it in selected countries
  • Support establishment of national programs in
    selected countries using a multi-stakeholder
    approach, involving civil society professional
    bodies and based on situational analysis
  • Establish global mechanism for sharing info
    lessons learnt
  • Global steering committee to guide global program
  • Meetings for stakeholders from participating
  • External evaluation of strategy after 5 years to
    review progress with recommendations next 6 years

Creating the WHO Essential Drugs Libraryto
facilitate the work of national committees
Evidence-based clinical guideline
Summary of clinical guideline
WHO Model Formulary
Reasons for inclusion Systematic reviews Key
WHO Model List
Cost - per unit - per treatment - per month -
per case prevented
Quality information - Basic quality tests -
Internat. Pharmacopoea - Reference standards
WHO-sponsored training programmes
  • INRUD/MSH/WHO Promoting the rational use of
  • MSH/WHO Drug and therapeutic committees
  • Groningen University, The Netherlands / WHO
    Problem-based pharmacotherapy
  • Amsterdam University, The Netherlands / WHO
    Promoting rational use of drugs in the community
  • Newcastle, Australia / WHO Pharmaco-economics
  • Boston University, USA / WHO Drug Policy Issues

Identifying effective strategies to promote more
rational use of drugs
  • Joint research initiative between WHO/PSM, MSH,
    Harvard and Boston Universities, and ARCH
  • over 20 intervention research projects in
    developing countries
  • WHO/EMP databases on drug use and policy
  • quantitative data on drug use and interventions
    to improve drug use over the last decade
  • data from MOHs on pharmaceutical policies

  • Irrational use of medicines is a very serious
    global public health problem.
  • Much is known about how to improve rational use
    of medicines but much more needs to be done
  • policy implementation at the national level
  • implementation and evaluation of more
    interventions, particularly managerial, economic
    and regulatory interventions
  • Rational use of medicines could be greatly
    improved if a fraction of the resources spent on
    medicines were spent on improving use.

ActivityDiscuss in groups the following questions
  • What should be the roles of
  • government,
  • NGOs and donors,
  • WHO,
  • in promoting the rational use of medicines?
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