Paul Kutyabami

MPHP439

 “Rational Drug Use” as a Public Health Concept

(In developing world)

Table of Contents

1) Overview

2) Poverty as a Factor in Disease Prevalence

3) Drugs Use in Public Health

·        Access to Drugs in Developing Countries

·        Reasons for Concern about Drug Use and Consequences of Inappropriate Use

4) Defining appropriate or Rational Use of Drugs

·        Examples of irrational Use of Drugs

·        Causes of Irrational Drug Use

o       International Level

o       National Level

o       Health Systems Level

o       Prescribers Level

o       Dispensers Level

o       Patients and Community Level

·        Strategies for Improving and Promoting Rational Use of Drugs

·        Challenges to Rational Drug Use in Developing countries

5) Suggested Further Readings

6) Reference

Overview

The World Health Organization (WHO) indicates that most leading causes of death and disability particularly in developing countries can be prevented, treated or alleviated with appropriate use of drugs and vaccines (Essential Drug Monitor, No. 23 1997). However, a third of the world’s population living mostly in developing countries lacks access to drugs resulting in preventable serious disability, morbidity and mortality. It is estimated that two out of every three deaths in developing countries is caused by infections that could be prevented with the use of drugs (WHO, 1999). Table: 1 and 2 below show the 7 major causes of death and their impact on the population expressed in Disability Adjusted Life Years (DALYs) respectively, for both African and American region. Disability Adjusted Life Years (DALYs) is a measure of disability and death caused by a disease. It is obtained by assessing the burden caused by disease and death on the population through measuring the gap between current and ideal health condition (Quality of life and Mortality). Higher percentages indicate greater deleterious effect on the population.

 

 

Table: 1 leading causes of deaths in WHO regions

Rank

African Region

% total deaths

Rank

American Region

% total deaths

1

 

HIV/AIDS

 

22.6%

 

1

 

Ischemic heart disease

15.6%

 

2

 

Lower respiratory infections

10.1%

 

2

 

Cerebrovascular disease

7.7%

 

3

Malaria

9.1%

3

 

Lower respiratory infections

4.4%

 

4

 

Diarrhoeal diseases

6.7%

 

4

 

Trachea, bronchus, lung cancers

3.9%

 

5

 

Perinatal conditions

5.5%

 

5

 

Diabetes mellitus

 

3.7%

 

6

 

Measles

 

4.3%

 

6

 

COPD

 

3.5%

 

7

 

Tuberculosis

 

3.6%

 

7

 

Violence

 

2.7%

 

COPD in full is Chronic Obstruction Lung Disease

Table: 2 leading causes of Disability Measured in DALYs

Rank

African Region

% total DALYs

Rank

American Region

% total DALYs

1

 

 

HIV/AIDS

 

 

20.6

 

 

1

 

 

Unipolar Disorders

depressive

 

8.1%

 

 

2

 

 

 

Malaria

 

 

 

10.1

 

 

 

2

 

 

 

Alcohol use disorders

 

 

4.4%

 

 

 

3

 

Lower respiratory infections

8.6%

 

3

 

Ischemic heart disease

4.4%

 

4

 

Perinatal conditions

6.3%

 

4

 

Perinatal conditions

3.9%

 

5

 

Diarrhoeal diseases

 

6.1%

 

5

 

Violence

 

3.8%

 

6

 

Measles

 

4.5%

 

6

 

Cerebrovascular disease

3.3%

 

7

 

Tuberculosis

 

2.8%

 

7

 

Road traffic accidents

3.2%

 

This data was adopted from the Global Burden of Disease: Cambridge: Harvard University Press (1996)

 

Comparing the ranking between Mortality and DALYs in the African and the American regions, the major causes of deaths, are also the major causes of disability in the African region whereas in the American region there is a greater proportional burden of less fetal conditions.

Table 3 below shows how the seven leading causes of disease in the African region can be prevented, treated or alleviated.

Table: 3 Gives various ways available to ameliorate the seven leading causes of death in African region.

Rank

Disease

Treatment

Prevention

Alleviation 

1

HIV/ AIDS

No Cure Yet but Treatment for opportunistic infections is available 

Behavioral Change

Anti Retro Viral Drugs & various Drugs for opportunistic infections

2

Lower Respiratory Infections

Antibiotics

 

Proper diagnosis & adherence to treatment

3

Malaria

Antimalarial drugs e.g. Chloroquine, Quinine

Mosquito nets & eradication of mosquito breeding grounds

Proper diagnosis, early treatment & adherence to treatment

4

Diarrhoeal Diseases

Oral Rehydartion Salts

Good hygiene

Oral Rehydartion Salts

5

Perinatal Conditions

Vitamins

Vaccination & antenatal care

Regular antenatal check ups

6

Measles

No cure but treatment for opportunistic infection is available

Vaccination

Treatment of opportunistic infections

7

Tuberculosis (TB)

Various drugs are available that can cure TB

Vaccination

Early Diagnosis  treatment and adherence to treatment

 

Poverty as a Factor in Disease Prevalence

Underlying virtually all major causes of death in developing countries is the significant role played by poverty and its associated problems (Merson et al, 2001). Poverty has three main effects: it is a cause of disease; it is a reason for inappropriate drug use and access to drugs; and it is an impediment to successful implementation of interventions in rational drug use. The last two issues are discussed in detail later in the chapter.   The effects of disease will lead to further promotion of poverty among the population. Prevention of morbidity and mortality from specific infections in developing countries has been the focus of many governments and organizations. Access to drugs and ensuring their appropriate use has been key in these efforts.

Drug Use in Public Health

     Drugs are among the most salient and cost-effective elements of health care and often a key factor for the success of health sector reforms (Falkenberg et al, 2000). Because drugs make health care delivery credible by relieving symptoms and curing diseases, there are compelling arguments in favour of ensuring their steady supply.

Table 4 below gives the summary of issues that surround drug use in developing countries.

 

 

 

Table: 4 Drug Use in Developing Countries

 

Effects of IDU

Examples of IDU

Causes of IDU

Strategies for Improvement

Challenges

International Level

Lack of Access

Substandard drugs, unreliable Med-info. High prices

Drug marketing & profiteering, Patents and Trade agreements

Provide Tec-Assis.  & funding

 

National Level

Poor health indices

Substandard drugs

Budgetary constraints, weak laws & regulations, poor

infrastructure

NDP & A

Budgetary constraints, poor infrastructure

Health System Level

Loss of confidence & wastage of resources

Drug shortages, expired drugs

Lack of MIS

Unreliable supplies, bad procurement practices, poor infrastructure

Drug Committees Essential Drugs list

Lack of trained manpower, Budgetary constraints

Prescriber Level

Drug wastage, drug resistance

Poly pharmacy, wrong drugs, over prescribing

Lack of knowledge, patient over load

Training,

S.T.G

Lack of training

Dispenser Level

Drug wastage, drug resistance

Inadequate patient counseling 

Lack of Knowledge, Patient overload

Training

Lack of training

Patient & Community Level

Drug resistance, drug dependence   Increased costs of treatment, Death

High cost of drugs, sharing of drugs, self medication,

Poverty, illiteracy, culture, self medication

Community outreach, Advertising, posters, Leaflets

Illiteracy, traditional medicines, Poverty

IDU. refers to irrational drug use

Med-info. Refers to medical information

Tec-Assis. Refers to technical assistance

NDP & A refers to National Drug Authority and Policy

S.T.G refers to Standard Treatment Guidelines

MIS refers to Management Information Systems

 

 

 

Access to Drugs in Developing Countries

     It is estimated that one-third of the world’s population lacks regular access to essential drugs, with this figure rising to over 50% in the poorest parts of Africa and Asia (Vazquez, 2003). Drug access is a combination of three factors: availability, affordability and rational use. In developing countries, drugs of standard quality are not available; the majority of the population cannot afford the high cost of the available drug therapies; and drugs are not rationally used.

Although there has been an improvement in access to drugs world wide from one third in 1975 to two thirds presently (W.H.O. Report on the Progress in Essential Drugs and Medicine policy 1998-1999), this has not been reflected significantly in developing countries. The international community through international agencies such as W.H.O. and World Bank has instituted a variety of approaches to mitigate this problem. W.H.O for example introduced the Essential Management Program in 1975 to increase access to drugs that treat the most prevalent diseases. This program had an objective of making available essential drugs that satisfy the health care needs of the majority of the population at all times, in adequate amounts and in the appropriate dosage forms (W.H.O, 1987). This has been done through helping countries set priorities in drug procurements following a model list of essential drugs established by experts at W.H.O. On the other hand, the World Bank committed more funding to developing countries towards the procurement of the seriously needed drugs and medical equipment (Falkenberg et al, 2000). To a great extent, these interventions have resulted into improvement in accessibility to drugs in developing countries. However, such improvement should be evaluated along side with the appropriate or rational use of the drugs. The rest of the chapter is focused on appropriate or rational use of drugs as a measure for improving public health in developing countries

Reasons for the Concern about Drug Use and Consequences of Inappropriate Drug Use 

Governments in developing countries spend 20-50% of their national budgets on drugs and medical sundries, making the economic impact of pharmaceuticals on these economies substantial (World Bank, 1994). In most developing countries pharmaceuticals are the largest public expenditure on health after personnel costs and the largest household health expenditure (World Bank, 1994). The substantial expense put on drugs provides reason for countries all over the world to be concerned about them.

     Studies done in Cameroon and Nigeria also indicate that drugs are a valuable resource in developing countries and their availability is considered an indicator of the quality of care. For example, Uzochukwu and associates indicate in their study about access to drugs in Nigeria that patients’ visits dropped by 50%-75% when the most commonly used drugs ran out. When drugs running out of stock, the entire drug use process is affected.

Many societies consider drugs as key health technologies involving both public health and safety and when they run out of stock; the credibility of the health system is lost leading to escalation of irrational use of drugs and its related effects. As result governments are concerned about the availability, handling and the effective and safe use of drugs (Ratanawijitrasin et al, 2001). However, the W.H.O. Policy Perspective on Medicine (2002) indicates that even when drugs are made available, more than 50% are prescribed, dispensed or sold inappropriately while 50% of the patients fail to take the medicines correctly leading to harmful consequences.

According to figures gathered by surveys presented to the World Health Organization, in 2000, about 60% of antibiotics in Nigeria were prescribed unnecessarily. In Nepal, over 50% of antibiotics prescribed in 1996 were not needed and 40% of medicines expenditure in the same year was wasted due to inappropriate prescriptions. Globally, the figure for unwarranted antibiotics prescriptions stands at roughly 50%. A survey done in Nigeria to look at drug use and antibiotic prescribing in 2002 reveals that the percentage of antibiotics per prescription was more than 50% for out-patients and 97% for in-patients as compared to the WHO recommendations of 20% to 26% (Chukwuani et al 2002). Such inappropriate prescribing habits will result into terrible consequences to the patients and the community.

  Inappropriate use of drugs may lead to drug resistance and tolerance particularly if it involves anti infective agents on top of wasting of resources. For example; misuse of antibiotics is contributing to the worldwide increase in antimicrobial resistance that is now being observed for most common pathogens. Chloroquine resistance has been reported from 81 countries, and up to 98% of Neisseria gonorrhoea is resistant to penicillin (W.H.O. Reports). The costs associated with antimicrobial resistance are very high. For example second-line treatment for resistant meningitis or malaria may be 50-90 times as expensive as the original drugs, while one year’s treatment of multi-drug resistant tuberculosis costs US$ 8,000-12,000, compared with about US$ 40 for first-line treatment (W.H.O Reports). Drug resistance and tolerance may also lead to mortality as patients fail to respond to available treatment.

     Because of these and other reasons that we shall see later, there is great concern about how drugs are handled and finally used by the patients.

Defining Appropriate or Rational Use of Drugs

According to the World Health Organization conference that took place in Nairobi, Kenya in 1985, rational use of medicines requires that patients receive quality efficacious medicines appropriate to their needs, in doses that meet their individual requirements, for the adequate period of time and at the lowest cost to them and to the community. However, consumers’ perspective of what is rational may differ from this definition as their thinking is influenced by a number of factors such as culture and economic situation (Amanda Le Grand et al, 1999).            In biomedical context the following criteria may be used to qualify an act a rational use of drugs;

·        Correct drug

·        Appropriate indication (the reason for prescribing is based on sound medical consideration)

·        Appropriate drug (the drug should be of the required quality, efficacy at the time the patient uses it and at the right cost)

·        Appropriate dosage (administration of right quantities and duration of treatment)

·        Appropriate patient (no contra indications exist and the likelihood of adverse drug reactions is minimal)

·        Correct dispensing (including appropriate information to the patient about the drugs)

·        Patient adherence to the treatment

(This criteria has been adopted from Managing Drug supply, 2nd edition, Authored by WHO/ Management Science for Health)

  Examples of Irrational Drug Use

The availability of substandard or counterfeit drugs in a country is an example of irrational drug use that affects the entire country. Many developing countries do not manufacture drugs locally, so they rely on importation and drug donations from the developed countries. Health workers and the community rely on government to ensure quality of drugs. Substandard or counterfeit drugs are a growing problem. W.H.O data base of counterfeit drugs for example reported 771 cases in 1999, 77% of which were from developing. Counterfeit drugs are a waste of money because they are illegal copies of particular brands of drugs and patients are lured to by them expensively as though they were buying the brand and if substandard, they prolong treatment periods, exacerbate the conditions being treated and help create drug resistance with its associated problems. Counterfeit and substandard drugs are mainly the result of failure to comply with good manufacturing practices (GMP) (W.H.O. Report on the Progress in Essential Drugs and Medicine policy 1998-1999).

     Drug shortages, presence of large quantities of expired drugs and presence of drugs that are not required by a setting are manifestations of inappropriate use of drugs at the health systems level.

  Examples of inappropriate use of drugs at the Prescribers level are usually noted by how prescriptions are written. Use of drugs when no drug is needed, use of wrong drug and poor prescribing habit are some of the examples noted. Poor prescribing habits may include prescribing too many drugs for a patient referred to as Polypharmacy or over prescribing at particular drug or dosage form. Prescribers tend to embark on poly pharmacy in their attempt to treat a number of possible diseases simultaneously (Uzochukwu et al, 2002).

  At the dispenser level, drug shortages, poor drug records, poor storage facilities and lack of appropriate dispensing equipment and materials are common examples.

     All the examples noted above will have manifestations at the consumer or community level either through unavailability, wrong use or over use of drugs. Drugs commonly used incorrectly include; antibiotics, anti-diarrhoeals, pain killers, Cough and cold preparations, vitamins, injections and anti malarial drugs is seen in many communities (Le Grand et al, 1999). However at the consumer level, the following are significant examples of inappropriate use of drugs: Sharing of drugs and self medication.

     Sharing of drugs occur when patients stop taking drugs as soon as symptoms recede and keeping whatever remains for others with similar symptoms or for future episodes of the disease. For example, in cases of epidemics such as malaria one member of the family would seek treatment and will share out the drugs with other sick family members or friends. Either way the patients will not have received the correct amount of treatment for the recommended period of time.

Self medication will involve patients, recommending to himself or by a peer with no medical knowledge without visiting a health setting. Self-medication occurs in both industrialized and developing countries, as the most common reaction to perceived symptoms (Fresle, 1997). During a disease episode, the patient has the option of going to a prescriber or to buy the drugs from a drug store normally located with in the community. Choice depends on a number of factors but most importantly the perceived severity of the disease. In the Loa study, 84% of all drugs bought from private pharmacies were self medication. The study also indicated that 40% of drugs bought from private were decided by the patients themselves and 19% by friends and the drugs were being brought for themselves, family members and friends. Household survey and other community based studies in Africa, Asia and Latin America conducted by WHO have found that up to 80% of illness episodes are self-treated with modern pharmaceuticals. The most common drugs were analgesics for treating pain, common cold and fever, followed by antibiotics for treating coughs, common colds and general sickness, vaginal infections, abdominal pains and wounds and then vitamins for fortifying the body (Syhakhang et al 2001). The significance of Self medication as   a way of seeking health care required that the public is knowledgeable about diagnosis and treatment of the most common illnesses.

Causes of Irrational Drug Use

A multitude of factors have been found to lead to irrational use of drugs and these affect at various levels at which drugs are handled. Research studies conducted by international Health organizations such as W.H.O, reveal that factors such as knowledge, attitudes and practices within the community, economic incentives and promotional practices contribute towards irrational drug use (The essential Drug Monitor, No. 23, 1997).

International Level

At the international level, drug promotion and marketing by the multinational pharmaceutical companies plays a big role in providing information to both health workers and patients through direct advertising. Such information is often misleading, biased, scientifically inaccurate and always persuasive to encourage over use of particular drugs or brands. Studies indicate that in the French speaking countries, over half of the information provided by Drug companies did not match the official drug monographs (Lexchin, 1992).

The huge investment in Research and Development by pharmaceutical companies, the role of patent laws and other international trade agreements under The World Trade Organization together with costs of promotion and marketing lead to drug prices to be out of reach by the majority of people in developing countries. At the same time, many pharmaceutical companies are not willing to invest in developing countries because these provide a low market potential due to the poor economy and low purchasing power hence limiting accessibility and affordability of drugs to the people who need them.

     The National Level

     Weak laws and regulations in a country encourage dubious individuals with selfish interest to get involved in drug handling and supplies. Examples such as counterfeit or substandard drugs highlighted earlier on are effects of such. Good laws and regulations provide a frame work under which issues concerning drug use are to be handled and monitored and when these are missing result are always chaotic.  At the same time such laws and regulations require personnel and equipment to enforce them both of which are significantly lacking in developing countries.  

     The weak economic conditions in developing countries that has resulted in general poor infrastructure and other economic indices are a cause of the lack of access to drugs by many in these countries.

Health Systems Level

The Health System inefficiencies disable health workers from performing efficiently to ensure rational use of drugs. Causes of irrational drug use at the Health system level include the following;

·        Unreliable suppliers of drugs; whose quality and cost of supplies may be questionable

·        Poor planning of the drug needs of the unit

·        Poor infrastructure for storage

·        Poor information management systems

·        Lack of monitoring and supervision

Prescribers Level

Irrational drug use has often been thought to be entirely due to health workers lacking information and training; thereby it could be solved by providing such information and training. Although lack of information and training are indeed major factors, out dated prescribing practices, heavy patient load, pressure from peers and patients together with those factors at international such as drug promotion, National such as economic factors and health system level such as lack of diagnostic equipment too affect the effectiveness of Prescribers in ensuring the rational use of drugs.

Sometimes, there is a conflict of interest particularly with Prescribers practicing privately that motivate them to make choices of drugs that will maximize profit.

Dispenser Level

     Dispensers are usually the last health professionals in the drug use process to interact with the patient. This gives them a crucial role in the therapeutic process and in ensuring adherence to the standards of rational drug use. Just as under Prescriber level, lack of information and training, patient overload and the factors at the other levels including Prescribers affect the quality of services among dispensers. Studies done in Loa People’s Democratic Republic to look at practice in both public and private pharmacies indicate that 54% of the staff in public pharmacies where medical assistant or nurses and more than 60% low level nurses in the private pharmacies. Although almost all the staff in private pharmacies where knowledgeable about regulations none was in the public pharmacies. These can not provide credible information the patients ensure rational drug use (Syhakhang et al, 2001). They are very few pharmacists and qualified dispensers to fill the job market and as such many setting particularly in the private sector a filled by non trained staffs.

     At the same time, the perception of patients that dispensers as mere keepers of drug with no significant value to add to the quality of health, makes patients not take the information provided by dispensers seriously.

Patients and Community Level

Patients are the ultimate users of drugs. They make the final decision about whether or not to seek health care, where to seek it, and what medicines to actually take and at what intervals or duration. Correct prescribing does not guarantee that drugs will be properly used. Non adherence to prescription is very common (Le Grand et al 1999). Decisions by the patient are influenced by many factors, including cultural beliefs, the communication skills and attitudes of health workers, accessibility to and nature health service delivery point, community belief about the efficacy of certain drugs, routes of administration and the patient’s assessment of a particular disease. For example some diseases are regarded as simple and may not necessitate visiting a physician so a patient may decide to medicate him or herself.

Patients’ perception of disease symptoms as minor or their thinking that they are sufficiently familiar with the disease and how to treatment it makes them believe they do not need to visit a health facility and therefore able to avoid the inconvenience and cost of doing that. Patients may also avoid reporting some diseases because of the fear of being stigmatized. Diseases such as sexually transmitted diseases are associated with social stigma; patients would prefer to treatment themselves or at worst consult with peers. 

In some instances, patients’ lack the knowledge to make appropriate judgement of their drugs they require and the fear of the illness lead them to the demand for inappropriate treatment. This together with the concept that, there is a pill for every ill has resulted into patients’ over reliance on drugs, becoming accustomed to using particular drugs or dosage forms. For example, using injectables in conditions where oral dosage forms would be more appropriate or using of antibiotics in the treatment of the common cold. 

The availability of drugs with in the community has allowed unlimited access to patient of all classes of drugs. Reports from WHO indicate that prescription drugs are widely available from a variety of sources which include street peddlers, traditional healers and unlicensed stores in most of the developing countries (WHO, 1997). Prescription-only drugs are also routinely available direct to consumers even from licensed pharmacies due to lack of state regulatory enforcement capacity. Drugs sellers and consumers do not differentiate between the Over the counter (OTC) and the prescription only medicines.

Lack of access to health facilities lead to patients to resort to any form of health care available in the community, including self medication as a result, irrational drug use is more prevalent in areas that are less covered by public health unit than those that are covered.

Strategies for Improving and Promoting Rational Use of Drugs

Effective treatment exists for most of the leading causes of mortality and morbidity as has been noted earlier. The challenge that remains is to ensure that people can access these drugs and be able to translate the drugs into vital technologies to improve health. It is through the appropriate use of drugs that health and quality of life can be improved. Intervention in situations where inappropriate drug use is reported is plausible and indeed many governments and organizations have undertaken strategic steps to ameliorate problems related to drug use. Table 4 shows some of the strategies and steps undertaken to improve Rational Drug Use.

Effectiveness of these interventions has been noted in many of countries at various levels. Already W.H.O and World Bank interventions in improving access to drugs have been discussed and these organizations continue to provide technical assistance to countries involved in rational drug use.

Through such technical assistance, many developing countries have developed laws and regulations enshrined in their National Drug Policies and established secretariats to monitor and evaluate drug use problems in these respective countries. Uganda for example established the National Drug Authority established in 1993 following the enactment parliament the National Drug Authority and Policy statute and the country has since registered improvement in drug use indices.

There are various examples of successful interventions at health systems level such as establishing drug committees, setting up priority list for drug procurement and improving drug information management systems.

At the same time health workers; Prescribers nurses and dispensers have undergone various forms of training to improve their knowledge in rational drug use.

Other interventions at both health workers’ and community levels have been undertaken in many counties.

Table 5, Educational, Managerial and regulatory Strategies for intervention in Rational Drug Use

Strategies

Interventions

Targeted category of persons

International

Technical assistance

Drug Donations

Funding

W.H.O, World Bank and Various international organizations

Regulatory

-Drug registration

-Essential drug list

-Laws and regulations restricting dispensing, prescribing & the entire pharmaceutical industry

-Ministry of Health

-Ministry of Health

-Ministry of Health & other relevant ministries and agencies.

Managerial

-Establishing a priority list for drug procurement

 

-Establishing Drug committees

-Establishing price indicators

-Establishing a drug utilization information system for monitoring and evaluation

-establishing procedures for selection, procurement and distribution

-Standard operating procedures for dispensing and drug storage

-Standard diagnostic & treatment guidelines

-Storekeepers, Administrators, purchasers & Health workers

-All health Units

-Accounts & Purchasers

-Drug Use supervisors

 

 

-Administrators, purchaser & unit Heads

 

-Store keepers & Dispensers

 

 

-Prescribers

Educational

-Formal training(curriculum review)

-Continued Medical Education

 

-Increased supervision and support

-Medical Journals, Newsletter, Treatment Guidelines

-Flyers, Posters, Billboards & Radio spots

-Community outreaches and use of Folk media

-Drug Budgeting

 

 

-Medical & Nursing Schools

 

-In service training for all Health workers

-All Health workers

 

-All health workers

 

-Patients and community

 

-Patients and community

 

-Administrators, Units Heads & Purchasers

 

For example in Mexico after finding evidence of overuse of drugs, a Non governmental organization embarked on a short but intense educational campaign that involved development of posters, leaflets, press articles, radio and television programs for health workers and the community. Feed back from the campaign were positive (W.H.O, 1996).

Challenges to Rational Drug Use in Developing Countries

  • Socio-economic and political environment of the country

The state of health and general well being in developing countries is generally poor with a high disease burden that encourages the use of drugs. The social and cultural perceptions of disease and drugs that view these differently from the west make the task of intervention enormous. Successful intervention requires the political goodwill to be registered with subsequent enactment of laws and regulations that focus on drug handling. In some states reports of political patronage have been sighted as the reasons for the presence of counterfeit drugs on the market.

  • Poor infrastructure and lack of technology

Rational drug use relies on the availability of the necessary infrastructure for easy communication and transportation, disease diagnosis, drug storage and a quick information processing mechanism. The low technology exhibited and lack of infrastructure may make implementation of some of the intervention strategies impossible. For example laboratory testing is only possible with the necessary equipment, the lack volumes of information relating to drug utilizations may be difficult to hand without computers and the long distances patients have to walk to the nearest health units and the lack of proper roads may prevent patients from seeking services from trained health workers.

  • Lack of trained personnel to implement and sustain the interventions

Success in implementing any intervention requires human resources to perform the task. One of the problem sighted as a cause for irrational drug use is lack of trained health worker. It is apparent that interventions that will successfully address irrational drug use need to focus at this as a long term strategy. However in the short term lack of man power to perform the different tasks in many countries is the major impeding factor in successful implementation.

 

 

 

  • Illiteracy

Many of the interventions employed to address the problem of irrational drug use in the community, require one’s ability to read and understand the message. With the high rates of illiteracy in developing countries, there is a need to design messages in ways that can ensure comprehension of the community. This will mean that messages are put in audio form in local languages which in the end may be costly to disseminate. The high levels of poverty on top of being a cause of irrational use of drugs may also impede strategy implementation. Patients even after knowing the value of taking a complete dose of drugs may be unable to buy it end up either not taking the drugs at all or taking a fraction of the dose.

  • Traditional Medicine

Traditional medicine includes diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness (W.H.O. Policy Perspective on Medicine No.2 May 2002). There is a growing population using traditional medicine world wide. Populations throughout the world including Africa, Asia and Latin America use traditional medicine to help meet their primary health care needs. As well as being accessible and affordable, traditional medicine is also often part of a wider belief system, and considered integral to everyday life and well-being. Table 4 indicates the populations using traditional medicine for primary health care in some of the developing countries.

Table 6, Percentage population of Selected Countries Using Traditional medicine for Primary Health Care

Country

Ethiopia

Benin

India

Rwanda

Tanzania

Uganda

% of the population

90

70

70

70

60

60

 

Sources: (W.H.O. Policy Perspective on Medicine No.2 May 2002)

 

The wide spread and growing use of traditional medicine provides a challenge to public health in terms of safety, quality, efficacy, access and rational use. Governments and organizations dealing with rational drug use and access to medicine need to incorporate traditional medicine in their strategic plan in order to ensure balanced success.

 

 

 

 

 

 

 

Suggested Further Readings

1.              Management Science for Health/WHO/DAP. Managing drug supply, 2nd edition. Hartford, CT: Kumarian Press; 1997. Management Sciences for Health in collaboration with World Health Organization, Action Program on Essential Drugs. Edited by Quick JD, Rankin J, Laing RO, O'Connor R, Hogerzeil HV, Dukes MNG, and Garnet A

2.                Essential Drug s monitor produced and distributed by The W.H.O department of essential Drugs and Medicines Policy (EDM)

Accessible at: http://www.who.int/medicines/default.shtml

Reference

1.              Le Grand A. et al. Interventional Research in Rational Use of Drugs: A Review. Health Policy and Planning, 1999 14 (2) pp 89-102

2.              Bennett S. et al, PUBLIC-PRIVATE ROLES IN THE PHARMACEUTICAL SECTOR: Implications for equitable access and rational drug use, (1997) WHO/DAP/97.12

3.              Bexel P. et al. Improving Drug Use through Continuing Education, A Randomized Controlled trial in Zambia. Journal of clinical Epidemiology 1996 49(3) pp 355-357

4.              Brudon P. et al. Indicators for Monitoring National Drug Policies: A Practical Manual. 2nd edition, World Health Organization. Geneva 1999

5.              Chukwuani C. M. et al. Survey of drug use practices and antibiotic prescribing pattern at a general hospital in Nigeria. Pharmacy World and science. 2002 25(5) pp 188-195

6.              Egger, G (1980): Psycho-Social Aspects of Increasing Drug Abuse. A Postulated Economic Cause in Social Science and Medicine

7.              Essential Drugs Monitor Number 23 (1997) WHO publication. Geneva

8.              Falkenberg T. and Tomson G. The World Bank and Pharmaceuticals. Health Policy and Planning, 2000 15(1) pp 52-58

9.              Fresle DA, Wolfheim C. (1997) Public Education in Rational Drug Use: a Global Survey W.H.O Geneva 1997

10.         Stimsom G. V. Promoting Rational Drug Policy. International Journal of drug policy, 2001

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