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This study assessed drug use patterns and cost efficiency in Upazilla Health Complexes in Bangladesh. The study aimed to examine inappropriate and irrational drug use, identify factors influencing prescribing behaviors, and assess availability of essential drugs and treatment guidelines. Data was collected through observation of 30 patient encounters at each of 20 randomly selected health facilities. The study indicators included prescribing practices, patient care factors, and availability of drugs and treatment guidelines at the health facilities.
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- 1. Studies on drug use pattern and costStudies on drug use pattern and cost efficiency in Upazilla Healthefficiency in Upazilla Health Complexes in BangladeshComplexes in Bangladesh H. M. AlamgirH. M. Alamgir Department of Clinical Pharmacy and Pharmacology Faculty of Pharmacy University of Dhaka
- 2. Why this study?Why this study? • In the developing countries like Bangladesh,In the developing countries like Bangladesh, inappropriate, ineffective and economicallyinappropriate, ineffective and economically inefficient use of drug is widespread in healthinefficient use of drug is widespread in health care facilities like Upazilla Health Complexes incare facilities like Upazilla Health Complexes in Bangladesh.Bangladesh. • The cost of such irrational use of drugs isThe cost of such irrational use of drugs is enormous in terms of both resources and theenormous in terms of both resources and the adverse clinical consequences of which haveadverse clinical consequences of which have many risks without any objective benefits.many risks without any objective benefits. Studies on Drug Use Pattern and Cost Efficiency 2
- 3. Why this study?Why this study? • This misuse or irrational use of drugs must beThis misuse or irrational use of drugs must be minimized to an affordable limit to save limitedminimized to an affordable limit to save limited resources and the consumers from unnecessaryresources and the consumers from unnecessary sufferings from adverse effects of pharmaceuticalsufferings from adverse effects of pharmaceutical products.products. 3Studies on Drug Use Pattern and Cost Efficiency
- 4. Studies on Drug Use Pattern and Cost Efficiency 4 Research ObjectivesResearch Objectives • To assess the drug use pattern on 6 commonTo assess the drug use pattern on 6 common diseases in Bangladeshdiseases in Bangladesh • To identify magnitude and nature ofTo identify magnitude and nature of inappropriate drug utilizationinappropriate drug utilization • To understand the adverse impacts ofTo understand the adverse impacts of inappropriate use of drugsinappropriate use of drugs • To examine the impact of irrational prescribingTo examine the impact of irrational prescribing on the drug cost for treatment of 6 selectedon the drug cost for treatment of 6 selected common diseasescommon diseases
- 5. Research ObjectivesResearch Objectives • To identify factors that influence the behavior ofTo identify factors that influence the behavior of prescribers and patientsprescribers and patients • To assess the availability of essential drugs inTo assess the availability of essential drugs in health facilitieshealth facilities • To assess the availability of EDL and STG inTo assess the availability of EDL and STG in health facilitieshealth facilities • To identify the role of economic incentives,To identify the role of economic incentives, professional controls and bureaucraticprofessional controls and bureaucratic regulations in the prescribing pattern of theregulations in the prescribing pattern of the health care professionals and providershealth care professionals and providers 5Studies on Drug Use Pattern and Cost Efficiency
- 6. 6 What Is Rational Use of Drugs?What Is Rational Use of Drugs? The rational use of drugs requires that patients receive medicinesThe rational use of drugs requires that patients receive medicines appropriate to their clinical needs, in doses that meet their own individualappropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost torequirements, for an adequate period of time, and at the lowest cost to them and the community.them and the community. (WHO 1988)(WHO 1988) Appropriate indicationAppropriate indication Appropriate drugAppropriate drug Appropriate administration, dosage and durationAppropriate administration, dosage and duration Appropriate patientAppropriate patient Appropriate patient informationAppropriate patient information Appropriate evaluationAppropriate evaluation Studies on Drug Use Pattern and Cost Efficiency
- 7. 7 Irrational Use of DrugsIrrational Use of Drugs • The use of drugs when no drug therapy is indicatedThe use of drugs when no drug therapy is indicated • The use of wrong drugs for a specific conditionThe use of wrong drugs for a specific condition requiring drug therapyrequiring drug therapy • The use of drugs with doubtful or unproven efficacyThe use of drugs with doubtful or unproven efficacy • The use of drugs of uncertain safety statusThe use of drugs of uncertain safety status • Failure to prescribe available, safe & effective drugsFailure to prescribe available, safe & effective drugs • Incorrect administration, dosages or durationIncorrect administration, dosages or durationStudies on Drug Use Pattern and Cost Efficiency
- 8. 8 Examples of Common InappropriateExamples of Common Inappropriate Prescribing PracticesPrescribing Practices • Overuse of antibiotics and antidiarrheals forOveruse of antibiotics and antidiarrheals for nonspecific childhood diarrheanonspecific childhood diarrhea • Indiscriminate use of injections for malariaIndiscriminate use of injections for malaria • Multiple or overprescriptionMultiple or overprescription • Use of antibiotics for mild, nonbacterialUse of antibiotics for mild, nonbacterial infection, e.g., ARIinfection, e.g., ARI • Tonics and multivitamins for malnutritionTonics and multivitamins for malnutrition Studies on Drug Use Pattern and Cost Efficiency
- 9. 9 Components of the Drug UseComponents of the Drug Use SystemSystem Drug ImportsDrug Imports LocalLocal ManufactureManufacture HospitalHospital oror HealthHealth CenteCenterr Private Physician orPrivate Physician or Other PractitionerOther Practitioner Pharmacist orPharmacist or Drug TraderDrug Trader The DrugThe Drug SupplySupply ProcessProcess Provider andProvider and Consumer BehaviorConsumer Behavior Illness PatternsIllness Patterns ++ PublicPublic Studies on Drug Use Pattern and Cost Efficiency
- 10. 10 Factors Underlying Irrational UseFactors Underlying Irrational Use of Drugsof Drugs • inefficientinefficient managementmanagement • nonavailabilitynonavailability of requiredof required drugsdrugs Drug SupplyDrug SupplyDrug SupplyDrug Supply • availability ofavailability of non-essentialnon-essential drugsdrugs • informalinformal prescribersprescribers Drug RegulationDrug RegulationDrug RegulationDrug Regulation • promotionpromotion • misleadingmisleading claimsclaims IndustryIndustryIndustryIndustry • lack of educationlack of education and trainingand training • lack of druglack of drug informationinformation • heavy patient loadheavy patient load • pressure topressure to prescribeprescribe • generalization ofgeneralization of limited beliefslimited beliefs • misleading beliefsmisleading beliefs about efficacyabout efficacy PrescribersPrescribersPrescribersPrescribers • drugdrug misinformationmisinformation • misleadingmisleading beliefsbeliefs • inability toinability to communicatecommunicate problemsproblems PatientsPatientsPatientsPatients Studies on Drug Use Pattern and Cost Efficiency
- 11. 11 Impact of InappropriateImpact of Inappropriate Use of DrugsUse of Drugs ReducedReduced quality ofquality of therapytherapy •morbiditymorbidity •mortalitymortality Waste ofWaste of resourcesresources Risk ofRisk of unwantedunwanted effectseffects •patients rely onpatients rely on unnecessary drugsunnecessary drugs PsychosocialPsychosocial impactsimpacts •reduced availabilityreduced availability •increased costincreased cost •adverse reactionsadverse reactions •bacterial resistancebacterial resistance Studies on Drug Use Pattern and Cost Efficiency
- 12. Study SettingStudy Setting Area Dhaka Division Facilities Included 20 (Out of 119 UHCs) Facility Selection Procedure Systemic Random Sampling Time Frame of Study 1 Year Prescribing or Patient Care Encounters Per Facility 30 Type of Prescribing or Patient Care Data Prospective 12Studies on Drug Use Pattern and Cost Efficiency
- 13. Selection of Health FacilitiesSelection of Health Facilities 13Studies on Drug Use Pattern and Cost Efficiency
- 14. Selected Health FacilitiesSelected Health Facilities Serial No. UHC Serial No. UHC 1 Goshaipur 11 Kaliakair 2 Sibehar 12 Sakhipur 3 Gopalganj 13 Sarisabari 4 Faridpur 14 Bakshiganj 5 Pangsha 15 Nalitabari 6 Ghior 16 Mymensingh 7 Keraniganj 17 Nandail 8 Tongibari 18 Bhairab 9 Araihazar 19 Tarail 10 Shibpur 20 Mohonganj 14Studies on Drug Use Pattern and Cost Efficiency
- 15. Study IndicatorsStudy Indicators Prescribing IndicatorsPrescribing Indicators • Average number of drugs per encounterAverage number of drugs per encounter • % of drugs prescribed by generic name% of drugs prescribed by generic name • % of encounters with antibiotic prescribed% of encounters with antibiotic prescribed • % of encounters with injection prescribed% of encounters with injection prescribed • % of drugs prescribed from essential drug list% of drugs prescribed from essential drug list • Providers knowledge about standard treatmentProviders knowledge about standard treatment practices and prescribing drugspractices and prescribing drugs • Use and application of regulatory measuresUse and application of regulatory measures necessary to implement rational drug usenecessary to implement rational drug use 15Studies on Drug Use Pattern and Cost Efficiency
- 16. Study IndicatorsStudy Indicators Patient care indicatorsPatient care indicators • Average consultation timeAverage consultation time • Average dispensing timeAverage dispensing time • % of drug actually dispensed% of drug actually dispensed • Patients knowledge of correct dosePatients knowledge of correct dose 16Studies on Drug Use Pattern and Cost Efficiency
- 17. Study IndicatorsStudy Indicators Health Facility IndicatorsHealth Facility Indicators • Availability of copy of essential drug list orAvailability of copy of essential drug list or formularyformulary • Availability of key drugsAvailability of key drugs • Total drug costs of the UHC per dayTotal drug costs of the UHC per day • Average drug cost per encounterAverage drug cost per encounter • Total cost and average cost of antibiotics perTotal cost and average cost of antibiotics per encounterencounter • Cost of ARI treatment etcCost of ARI treatment etc 17Studies on Drug Use Pattern and Cost Efficiency
- 18. 6 Common Diseases to be6 Common Diseases to be ConsideredConsidered • DiarrheaDiarrhea • DysenteryDysentery • Acute Respiratory tract InfectionAcute Respiratory tract Infection • ScabiesScabies • Worm InfectionsWorm Infections • Fungal Skin InfectionsFungal Skin Infections 18Studies on Drug Use Pattern and Cost Efficiency
- 19. Drug Use IndicatorDrug Use Indicator Consolidation FormConsolidation Form 19 Click Here Studies on Drug Use Pattern and Cost Efficiency
- 20. 20 Average Number of Drugs perAverage Number of Drugs per EncounterEncounter Studies on Drug Use Pattern and Cost Efficiency
- 21. 21 Percent of Drugs Prescribed asPercent of Drugs Prescribed as GenericsGenerics Studies on Drug Use Pattern and Cost Efficiency
- 22. 22 Percent of Encounters withPercent of Encounters with AntibioticsAntibiotics Studies on Drug Use Pattern and Cost Efficiency
- 23. Percent of Encounters withPercent of Encounters with InjectionsInjections • Not a single encounter with injectionNot a single encounter with injection was observed in any health complexwas observed in any health complex under investigation. This trend is veryunder investigation. This trend is very appreciable and encouraging.appreciable and encouraging. 23Studies on Drug Use Pattern and Cost Efficiency
- 24. Percent of Drugs PrescribedPercent of Drugs Prescribed from EDLfrom EDL 24Studies on Drug Use Pattern and Cost Efficiency
- 25. 25 Average Consultation TimeAverage Consultation Time Studies on Drug Use Pattern and Cost Efficiency
- 26. 26 Average Dispensing TimeAverage Dispensing Time Studies on Drug Use Pattern and Cost Efficiency
- 27. Percent of Drugs ActuallyPercent of Drugs Actually DispensedDispensed 27Studies on Drug Use Pattern and Cost Efficiency
- 28. 28 Percent of Patients withPercent of Patients with Adequate Dosing KnowledgeAdequate Dosing Knowledge Studies on Drug Use Pattern and Cost Efficiency
- 29. 29 Percent of Key Drugs in StockPercent of Key Drugs in Stock Studies on Drug Use Pattern and Cost Efficiency
- 30. Disease PrevalenceDisease Prevalence 30Studies on Drug Use Pattern and Cost Efficiency
- 31. Health Care ExpenditureHealth Care Expenditure 31Studies on Drug Use Pattern and Cost Efficiency
- 32. Cost of Antibiotics for ARICost of Antibiotics for ARI 32Studies on Drug Use Pattern and Cost Efficiency
- 33. Drug Cost for Each SelectedDrug Cost for Each Selected Category DiseaseCategory Disease 33Studies on Drug Use Pattern and Cost Efficiency
- 34. Percent Drug Cost for EachPercent Drug Cost for Each Selected Category DiseaseSelected Category Disease 34Studies on Drug Use Pattern and Cost Efficiency
- 35. ConclusionConclusion • High number of drugs (3 per encounter)High number of drugs (3 per encounter) prescribed to patients tends to increaseprescribed to patients tends to increase the risk of drugs interactions, affectsthe risk of drugs interactions, affects patient compliance, encouragespatient compliance, encourages polypharmacy and causes serious patientpolypharmacy and causes serious patient harmharm • Generic prescription of drugs wasGeneric prescription of drugs was considerably low (49%)considerably low (49%) 35Studies on Drug Use Pattern and Cost Efficiency
- 36. ConclusionConclusion • Not a single encounter with injection wasNot a single encounter with injection was observed in any health facility underobserved in any health facility under investigation which is very appreciableinvestigation which is very appreciable and encouraging (0%)and encouraging (0%) • Prescribing of antibiotics in the healthPrescribing of antibiotics in the health facilities was very high (44%)facilities was very high (44%) 36Studies on Drug Use Pattern and Cost Efficiency
- 37. ConclusionConclusion • Mean duration for consultation (2 min) andMean duration for consultation (2 min) and for dispensing (22 sec), both consideredfor dispensing (22 sec), both considered as insufficient for effective patient careas insufficient for effective patient care • Average percent availability of drugs in theAverage percent availability of drugs in the health facilities was very poor (51%)health facilities was very poor (51%) 37Studies on Drug Use Pattern and Cost Efficiency
- 38. ConclusionConclusion • Many of the health facilities visited did notMany of the health facilities visited did not have copies of EDL; however, 59% drugshave copies of EDL; however, 59% drugs prescribed were listed on the EDLprescribed were listed on the EDL • Only four out of twenty health complexesOnly four out of twenty health complexes were found to possess the nationalwere found to possess the national essential drug list (18%)essential drug list (18%) 38Studies on Drug Use Pattern and Cost Efficiency
- 39. ConclusionConclusion • Almost all health facilities lacked STGs forAlmost all health facilities lacked STGs for common diseases except diarrheacommon diseases except diarrhea • Marketing and product promotionMarketing and product promotion strategies may lead to unnecessary drugsstrategies may lead to unnecessary drugs useuse • Doctors in most cases prescribeDoctors in most cases prescribe helplessly inappropriate drugs for thehelplessly inappropriate drugs for the patients due to inadequate supply of keypatients due to inadequate supply of key essential drugsessential drugs 39Studies on Drug Use Pattern and Cost Efficiency
- 40. ConclusionConclusion • Not a single dispensed drug wasNot a single dispensed drug was adequately labeled (0%)adequately labeled (0%) • Poor adequate knowledge of patients onPoor adequate knowledge of patients on correct dose (36% only)correct dose (36% only) • Cost of drugs per encounter was very highCost of drugs per encounter was very high (Tk.236)(Tk.236) 40Studies on Drug Use Pattern and Cost Efficiency
- 41. ConclusionConclusion • Majority of the dispensers interviewed didMajority of the dispensers interviewed did not have any formal trainingnot have any formal training • Many of the dispensaries visited lackedMany of the dispensaries visited lacked the necessary dispensing toolsthe necessary dispensing tools 41Studies on Drug Use Pattern and Cost Efficiency
- 42. 42 RecommendationsRecommendations Interventions toInterventions to improve drug use canimprove drug use can reduce unnecessary drug expenditure andreduce unnecessary drug expenditure and lead to improvement in the quality of healthlead to improvement in the quality of health and medical care.and medical care. 33 major approaches are----major approaches are---- Educational :Educational : Seek to inform or persuadeSeek to inform or persuade prescriber, dispenser and patients to useprescriber, dispenser and patients to use drug in rational waydrug in rational way Studies on Drug Use Pattern and Cost Efficiency
- 43. RecommendationsRecommendations Managerial :Managerial : Guide decision through theGuide decision through the use of specific process, packages oruse of specific process, packages or monetary incentivesmonetary incentives Regulatory :Regulatory : Seek to restrict decisionSeek to restrict decision 43Studies on Drug Use Pattern and Cost Efficiency
- 44. RecommendationsRecommendations For policy implications, findings suggestFor policy implications, findings suggest the below courses of actions:the below courses of actions: Continuous monitoring and supervision ofContinuous monitoring and supervision of the drugs management systemthe drugs management system Continuous development for healthContinuous development for health providers to reduce indiscriminateproviders to reduce indiscriminate prescribing and dispensingprescribing and dispensing 44Studies on Drug Use Pattern and Cost Efficiency
- 45. RecommendationsRecommendations Availability of the STGs, EDL andAvailability of the STGs, EDL and appropriate dispensing tools in all healthappropriate dispensing tools in all health facilities and prescribers be mandated tofacilities and prescribers be mandated to adhere to the use of these documents inadhere to the use of these documents in prescribing drugsprescribing drugs 45Studies on Drug Use Pattern and Cost Efficiency
Editor's Notes
- #7: Emphasize that this is medical model.
- #8: Request an example of each practice from participants.
- #9: Elicit 2-3 others from participants.
- #10: Key points: relationship of demand and supply multiple outlets for drugs many decision-makers effect system
- #11: Emphasize interrelationship of factors and that problems rarely have single cause.
- #14: rounded upward
- #21: Possible discussion for all indicator slides: 1.) Why are countries different? 2.) What is gold standard value?
- #26: Discuss reasons for short consultation times when the workload is low.
- #27: Point out that times are measured in seconds not minutes and that training of dispensers can have good effects. Begin to discuss that dispensing time includes both preparation of drugs to dispense and dispensing communication.
- #29: Possible discussion: What should patients know about their drugs?