Medicines use in primary care in developing and transitional countries Results from studies reported between Kathleen Holloway, Verica Ivanovska, Dennis Ross-Degnan Progress in standard indicators of medicines use over 20 years

Background Irrational medicines use is a worldwide problem that is receiving insufficient attention –Little routine monitoring, few large scale interventions and poor policy framework to improve use (ICIUM 2004) Objectives To do a systematic quantitative review of studies published between 1990 and 2009 on medicine use in primary care in developing & transitional countries and to assess the impact of interventions done to improve use… –in order to provide the evidence of the seriousness of the problem and what interventions are effective –in line with recommendations from ICIUM 2004 and the request from WHA60.16 to undertake monitoring and advocacy

Methods Database (MS Access) created of studies on the use of medicines in primary care in developing and transitional countries All studies published during 1990 – 2009 reporting quantitative data eligible for inclusion Data on commonly used medicine use indicators measured in these studies plus details of study setting and methodology extracted from the reports/articles & entered into the database Studies identified from INRUD bibliography, PubMed, WHO archives (EMP, CAH), MSH archives As far as possible, extracted data from one study was entered as one database record All data-entry checked by 2 persons (KAH, VI) Analysis done using excel To estimate trends and patterns of use, medians of medicine use indicators (limited to baseline data for intervention studies) estimated by study year, region, facility ownership, and prescriber type were calculated

Results 1033 surveys conducted in 104 countries – identified 87% surveys included > 2 health facilities &/or > 599 patient encounters Facility type –% of surveys done in the public sector 70%, private-for-profit sector 28% and private not-for-profit sector 2% –% of surveys done in pharmacy shops 15%, non-licensed shops 2%, households 3%, hospitals 13%, PHCs 46% and hospitals+PHCs 21% Prescriber type –% surveys examining prescribing by doctors 35%, nurses or paramedics 52%, CHW 6%, pharmacist/assts 4%, layperson 3% Patient type –32% studies investigated medicines use in children < 5 years

Medicine use over time

Guideline adherence over time by region

Public vs private medicines use: doctors, nurses & paramedics only % No.drugs/Px

Intervention impact 405 surveys (226 in children) were associated with an intervention to improve medicines use –110 interventions (45 in children) were adequately evaluated, using RCT, pre-post with control or time series study design Effect size of interventions –Pre-post change (intervention group) – pre-post change (control) calculated for each outcome measured in each study –2 measures of effect for each intervention study: largest % change in any outcome measured median % change across all outcomes measured –Median of the above 2 measures calculated across all studies by intervention type

Intervention impact: largest % change in any medicines use outcome measured in each study Intervention typeNo. studiesMedian impact25,75 th centiles Printed materials6 8% 4%, 10% National policy617% 4%, 23% Economic strategies813% 8%, 19% Provider education2917% 9%, 22% Consumer education326%13%, 27% Provider+consumer ed1621%11%, 24% Provider supervision2618%14%, 31% Provider group process936%19%, 59% Essential drug program427%22%, 40% Community case mgt1033%28%, 39% Provider+consumer educ & supervision 740%18%, 54%

Intervention impact: median % change over all medicines use outcomes measured in each study (av.4/study) Intervention typeNo. studiesMedian impact25,75 th centiles Printed materials6 1%-3%, 6% National policy6 10%-2%, 18% Economic strategies8 -1%-7%, 6% Provider education29 7% 4%, 15% Consumer education3 2% 1%, 14% Provider+consumer ed16 15% 4%, 22% Provider supervision26 7% 2%, 15% Provider group process911%11%, 28% Essential drug program414% 0%, 40% Community case mgt1032%24%, 39% Provider+consumer educ & supervision 727%18%, 34%

Conclusions Key Lessons Learnt –Medicines use remains poor in all regions over the past 25 years and is worse in the private compared to the public sector –Effective interventions are those with multiple components e.g. education for providers and consumers with provider supervision or group process –Medicines use database can be used to monitor drug use and intervention impact in developing & transitional countries, where there is little data and methodological limitations Policy implications: –Implement more multi-faceted interventions to medicines use & evaluate the impact using adequate study design –Database can provide evidence to inform policy (as for WHA60.16) Future research agenda: –Identify how to build effective interventions & monitoring into the health care systems in a sustainable way –How to expand/maintain the drug use database and put it in the public domain (requires funds) –Validation of analytical methods used in order to do more comparisons & benchmarking of countries with regard to drug use