1. Medicines use in children under 5 years primary care in developing and transitional countries Results from studies reported between 1990-2009 Kathleen Holloway, Verica Ivanovska, Dennis Ross-Degnan Medicines use in children under 5: Twenty years of practice patterns and intervention effects

2. Background Common childhood infections still a major avoidable cause of under 5 mortality Many efforts made to improve the treatment of common childhood infections –ARI/Diarrhoea control, Integrated Management of Childhood Illness Little evidence of progress Objectives To undertake a systematic quantitative review of studies published between 1990 and 2009 about medicine use in children < 5 years in primary care in developing and transitional countries in order to assess progress and the impact of interventions undertaken to improve use

3. Methods Database (MS Access) created of studies on use of medicines in primary care in developing and transitional countries All studies published during 1990 – 2009 reporting quantitative data eligible for inclusion This study uses a subset of studies in children <5 years 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

4. Results 394 surveys conducted in 78 countries – identified 82% surveys included > 2 health facilities &/or > 599 patient encounters Facility type –% surveys done in the public sector 74.5%, private-for-profit sector 25% and private not-for-profit sector 0.5% –% of surveys done in pharmacy shops 13%, non-licensed shops 3%, households 7%, hospitals 7%, PHC 41%, hospitals+PHC 29% Prescriber type –% surveys examining prescribing by doctors 26%, nurses or paramedics 56%, CHW 10%, pharmacist/assts 3%, layperson 5% Disease type –% surveys examining treatment of diarrhoea 60%, ARI 58%, malaria 32%

5. Treatment of childhood infections over time

6. Treatment of childhood infections by region

7. Public vs Private treatment of childhood infections doctors, nurses & paramedics only

8. Intervention impact 226 surveys were associated with an intervention to improve medicines use –45 interventions 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

9. Intervention impact: largest % change in any medicines use outcome measured in each study Intervention typeNo. studiesMedian impact25,75 th centiles Printed materials 2 -5% -12%, 2% National policy 1 19% Economic strategies 1 15% Provider education10 15% 11%, 22% Consumer education 2 13% 7%, 20% Provider+consumer ed 8 21% 17%, 24% Provider group process 2 21% 13%, 28% Provider supervision 6 31% 22%, 36% Provider+consumer educ & supervision 4 18% 16%, 25% Community case mgt 8 30% 23%, 39% IMCI -mix of interv type 7 16% 15%, 27%

10. Intervention impact: median % change over all medicines use outcomes measured in each study (av.4/study) Intervention typeNo. studiesMedian impact25,75 th centiles Printed materials 2 -2%-7%, 2% National policy 1 19% Economic strategies 1 6% Provider education10 9% 5%, 16% Consumer education 2 13% 6%, 19% Provider+consumer ed 8 19% 4%, 21% Provider group process 2 16%11%, 22% Provider supervision 6 13%10%, 26% Provider+consumer educ & supervision 4 18%16%, 22% Community case mgt 8 28%19%, 39% IMCI -mix of interv type 7 16%15%, 25%

11. Conclusions Key Lessons Learnt –Treatment of childhood infections 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. provider & consumer education with supervision, community case management, IMCI –Medicines use database can be used to monitor treatment of childhood infections in developing & transitional countries, where there is little data and methodological limitations Policy implications –Implement more multi-faceted interventions to improve treatment of childhood infections & evaluate the impact using adequate study design 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)