Essential drugs and rational drug use

With limited resources at the disposal of health care facilities, it is important to improve the management of existing resources, says Guru Prasad Mohanta

India is a country with significant drug use problems where more than 50,000 drug formulations are licensed for sale and substandard and counterfeit drugs find their way into the market. The non-availability of quality essential drugs, excessive availability of unnecessary drugs is common in health facilities. About 30-35 per cent of the health budget at the centre and in the states is spent on medicines. The number having access to allopathic medicines in rural areas is only around 35 per cent. Accessible health services, qualified staff and availability of quality drugs are essential components of any health care system but drugs have special importance for various reasons.

With the limited resources at the disposal of health care facilities, it is important to improve the management of existing resources. Many more persons requiring medicines could be provided with good quality medicines with the same resource if drug management system improves. Drug management system consists of four components; Selection, Procurement, Distribution and Use. Through the use of these components the availability of quality medicines can be improved.

WHO in 1975, defined essential drugs as “Those considered to be of utmost importance and hence basic, indispensable and necessary for the health needs of the population. They should be available at all times, in the proper dosage forms, to all segments of society”. The WHO model list of Essential Medicines prepared first time in 1977, and is updated every two years since then. In Alma Ata in 1978, the WHO/UNICEF conference on primary health care adopted the essential drugs concept as one of the basic tools to improve health care.

Essential medicines are those satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost effectiveness.

Numerous studies have indicated the impact of concept of essential medicines on the availability and proper use of medicines within health care systems. The concept is more important and relevant in country like India.

Implementation of the concept of essential drugs by Government of Tamil Nadu and Delhi as early as in 1994 showed significant improvement in drug availability in government health care facilities under their jurisdiction. Exactly which medicines are regarded as essential remains a national, regional or local responsibility.

The selection process for inclusion in EDL is critical. Though EDL of WHO may be used in the first instances, it requires to be best developed for different levels of care.

The wastage of drugs by prescribers and users is common. The notion that if one drug is good, two are better and three ideal are perceived by general public. The quantities of drugs prescribed for a given illness are often far more than what is reasonably needed. Drugs are often prescribed when no drug is needed at all, because patients expect or demand a pill or injection or because prescribers are anxious to be seen as doing something. Worldwide more than 50 per cent of all medicines are prescribed, dispensed or sold inappropriately, while 50 per cent of the patients fail to take them correctly.

Rational Use of Drugs is defined as “Patients receiving medication appropriate to their clinical needs, in doses that meet their own individual requirement, for an adequate period of time and at the lowest cost to them and their community”.

Common types of irrational medicine use are :

• The use of too many medicines per patient (Polypharmacy)
• Inappropriate use of antimicrobials, often in inadequate doses, for non bacterial infections.
• Over use of injections where oral formulations would be more appropriate.
• Failure to prescribe in accordance with STG.
• Inappropriate self medication, often of prescription medicines only.

The prescriber’s lack of knowledge and experience; inappropriate dispensing process; non-compliance by the patient and their attitude; and the non-availability of appropriate drugs are important reasons for irrational drugs use.

The following six steps are advocated to promote RDU:

Step - I : Identifying the drug use problems and recognising the need for action

WHO’s Drugs Use Indicators - How to Study Drug use in Health Facilities?

Prescribing Indicators

• Average number of medicines prescribed per patient encounter.
• Percentage of medicines prescribed by generic name.
• Percentage encounters with an injection prescribed.
• Percentage medicines prescribed from essential medicines list / Hospital
• Patient Care Industors
• Average consultation time.
• Average dispensing time.
• Per centage of medicines actually dispensed.
• Per centage of medicines adequately labelled.
• Per centage of patients with knowledge of correct doses.

Facility Indicators

• Availability of EDL or Formulary to prescribers.
• Per centage of prescriptions in accordance with STG.

An effective response can be planned once all the involved parties, including prescribers,patients and health care managers, recognise that there is a problem.

Step II : Identifying Underlying Causes and Motivating Fractures :

Step III : Planning Possible Interventions

Step IV : Assess Resources Available for action

Step V : Monitor the Impact and Restructure the intervention

Global Effect and RDU in India

The formulation of EDL in 1977 by WHO was the first step towards RDU. The first conference in 1985 at Nairoti (Kenya) adopted the definition for RDU. Subsequently in 1989, the International Network for Rational Use of Drugs (INRUD) was formed to conduct multidisciplinary intervention research projects to promote more rational use of drugs. WHO/INRUD indicators were widely accepted as tool to investigate drug use patterns. The first International Conference is due again in Thai and in early 2004.

The WHO globally arranges several International training programmes like Promoting Rational Drug Use, Promoting Rational Drug Use in Community, Drugs and Therapeutics Committee, Problem based Pharmacotherapeutic teaching, Pharmacoeconomics, Drugs Policy issues for developing countries, Anatomical Therapeutic Classification (ATC)/Defined Daily Dose (DDD) for developing human resources who would lead work for promoting RDU activities.

Very little research on rational drug use is reported in India. Many of the studies are not reported because of their inadequacy on quality of work. Most of the indicator study reported on the availability of drug. The intervention studies in Delhi showed the availability at 95.1 per cent in 2000 against the base line data of 59.7 per cent in the year 1995. Another study at Delhi showed a decrease use of antibiotics in Acute Respiratory Infection in the study group (from 66 per cent to 51 per cent) as compared to the control group (from 61 per cent to 60 per cent). Another study at Delhi hospitals showed that patient’s knowledge on drug dosage is extremely low - 34 per cent. A randomised control trial on the effect of patient counselling at the dispensing point showed two - three fold increase in patient’s knowledge indicator compared to control group.

Delhi Society for Promotion of Rational Use of Drugs (DSPRUD), Delhi - based NGO is promoting the concept of essential drugs and rational drug use in the country. Delhi and Tamil Nadu have INRUD India chapter. The success stories at Delhi and also of TN have made many states follow suit to improve drug use situation in their states.

Role of Hospital Pharmacists / Clinical Pharmacists

• As a member of Drugs and Therapeutic Committee, probably as member secretary, participates in decision making process of drug use.
• Involves in on going staff education.
• Involves monitoring and taking action to prevent ADR and medication error.
• Patient counselling to help improve patient’s understanding of drug dosage and improving compliance.
• Providing independent drug information services in the health care set up.
• Conducting Drug Utilisation Review and reporting for managerial intervention.
• Ensures drug management processes like procurement, distribution of drugs and availability of quality medicines.

The writer is Professor, Division of Pharmacy Practice,Department of Pharmacy, Annamalai University