1. WHO, Dept. Essential Drugs and Medicines Policy Measuring use of medicines: progress in the last decade Kathleen Holloway and Verica Ivanovska Dept. Essential Drugs and Medicines Policy WHO Geneva ICIUM, March 30 – April 2, 2004

2. WHO, Dept. Essential Drugs and Medicines Policy2 WHO database of all drug use surveys done in developing countries 1993-2003 Objectives To provide an overview of drug use –existing drug use patterns in primary health care settings in developing and transitional countries over time To identify effective interventions and trends –impact of different types of interventions on improving the use of drugs To provide evidence for advocacy, planning –tool for routine monitoring nationally & internationally

3. WHO, Dept. Essential Drugs and Medicines Policy3 Criteria for inclusion of study in database Quantitative data on drug use Descriptive and intervention studies Developing and transitional countries Primary health care patients –primary health care clinics –hospital general & paeds non-specialist outpatients –pharmacies, drug sellers and households Articles in English, French, Spanish, Russian Reported/published during 1993-2003

4. WHO, Dept. Essential Drugs and Medicines Policy4 Methods Search strategy –INRUD bibliography & WHO archives 1993-2003 Retrieval strategy –WHO library resources Database format –Access, compatible with other WHO databases Data entry –one record per published survey divided again by country, health facility type/level, prescriber type Data analysis –Time series & comparisons between sectors, regions, etc –Export into excel and later into statistical packages

5. WHO, Dept. Essential Drugs and Medicines Policy5 Design of the database 1st section on demographic detail –country, year of survey, publication reference, healthcare setting, prescriber/dispenser type, patient/disease type 2nd section on types of interventions –provider education, printed materials, supervision & audit, economic strategies, regulation, essential drug programs 3rd section on methodological details –study design, sample sizes (prescriptions, facilities, patients), data collection 4th section on drug use indicators –WHO/INRUD indicators, IMCI and specific disease indicators, mortality rates, additional indicators

6. WHO, Dept. Essential Drugs and Medicines Policy6 Current status INRUD bibliography –3080 articles screened 1993-2003 –207 (7%) articles met the inclusion criteria WHO/Essential Drugs & Medicines archives –67 unpublished articles/reports 1993-2003 entered WHO/Child Adolescent Health archives –71 unpublished articles/reports 1993-2003 entered 441 data records entered in the database –about half surveys done to evaluate an intervention

7. WHO, Dept. Essential Drugs and Medicines Policy7 Reliability of search strategy Comparing retrieval of intervention studies of good study design 1993-6 between ICIUM1997 review and WHO database WHO database contained 11 out of 17 articles used for 1997 ICIUM review i.e. 6 articles missing –3 articles with non-relevant outcomes –3 articles with relevant outcomes Unpublished study identified in INRUD bibliography but not retrievable (1 study) Not in INRUD bibliography (1 study) – subsequently retrieved and entered Missed article (1 study) – subsequently retrieved and entered

8. WHO, Dept. Essential Drugs and Medicines Policy8 Methodological challenges Some surveys published in more than one article, sometimes with inconsistent results Standard indicators often not used Missing data –survey year, facility type, facility level, prescriber type Data sometimes difficult to classify –indicators sometimes poorly described –drug use reported for a mix of facility / prescriber type –description of study design in article descriptions not consistent with database definitions time series stated but 4 data points not described “retrospective” interviews/observation described

9. WHO, Dept. Essential Drugs and Medicines Policy9 Problems of classifying data Surveys may be divided on the basis of facility or prescriber, but... –If the prescribers include MDs, nurses and paramedics, what is the prescriber type? –If there are 20 PHC facilities and 2 hospitals, what is the facility level? Standard indicators used in database but outcomes maybe poorly described, so... –Does “% antibiotic use” mean “% patients treated with antibiotics” or the “% drugs used that were antibiotics”?

10. WHO, Dept. Essential Drugs and Medicines Policy10 Rules: survey description Surveys not divided on basis of disease Judging a prescriber as “self” can only be done from a household survey Facility level refers to the source of drug use data (not intervention target group or place) Prescriber type refers to the main prescriber in the study irrespective of whether an intervention is aimed at the prescriber or there are any prescribing indicators reported

11. WHO, Dept. Essential Drugs and Medicines Policy11 Rules: survey methodology Interviews or observation can only be done prospectively Time series study design has more than 4 data points No. health facilities or no. patients per health facility are based on the lowest number during any one measurement or for any time period for any outcome variable Total no. patients is based on all patients in the study for all time periods of measurement

12. WHO, Dept. Essential Drugs and Medicines Policy12 Rules: outcome variables If an outcome is reported by individual facilities and patients, calculating an overall result should be done by averaging across facilities not patients. Prescription-only-medicines (POM) –POM are either defined as such in the article or are otherwise considered to be injections and antibiotics. –Availability of POM over the counter has a numerator that is the number of patients that got POM without a prescription, and a denominator that is the total number of patients given POM; this cannot be judged from a simulated patient survey

13. WHO, Dept. Essential Drugs and Medicines Policy13 Facility types

14. WHO, Dept. Essential Drugs and Medicines Policy14 Facility level

15. WHO, Dept. Essential Drugs and Medicines Policy15 Prescriber types

16. WHO, Dept. Essential Drugs and Medicines Policy16 Intervention types 844 interventions in 204 study sites

17. WHO, Dept. Essential Drugs and Medicines Policy17 WHO/INRUD Prescribing Indicators

18. WHO, Dept. Essential Drugs and Medicines Policy18 10-year trends in antibiotic & injection use N= 9 per year (on average)

19. WHO, Dept. Essential Drugs and Medicines Policy19 WHO/INRUD patient care indicators

20. WHO, Dept. Essential Drugs and Medicines Policy20 WHO/INRUD facility indicators

21. WHO, Dept. Essential Drugs and Medicines Policy21 Public/private prescribing for all years

22. WHO, Dept. Essential Drugs and Medicines Policy22 Public / private patient care for all years

23. WHO, Dept. Essential Drugs and Medicines Policy23 Prescribing by prescriber type for all years

24. WHO, Dept. Essential Drugs and Medicines Policy24 ARI treatment in last decade

25. WHO, Dept. Essential Drugs and Medicines Policy25 ARI treatment by prescriber %

26. WHO, Dept. Essential Drugs and Medicines Policy26 ARI treatment by region for all years

27. WHO, Dept. Essential Drugs and Medicines Policy27 Diarrhoea treatment in last decade

28. WHO, Dept. Essential Drugs and Medicines Policy28 Public/private diarrhoea treatment for all years

29. WHO, Dept. Essential Drugs and Medicines Policy29 Diarrhoea treatment by region for all years %

30. WHO, Dept. Essential Drugs and Medicines Policy30 Future areas of work Inclusion of hospital inpatient and specialist studies, self medication, patients’ compliance, diagnostic accuracy Link with other WHO databases –National Drug Policy, Burden of Diseases, Safe Injection Global Network Internet availability Integrate into routine monitoring and use the data for evidence-based planning & advocacy

31. WHO, Dept. Essential Drugs and Medicines Policy31 Conclusions Uses of WHO database of drug use surveys track drug use over time and between countries –plan future strategy & evaluate past strategy –identify effective interventions and policies –routine monitoring and evidence-based advocacy Initial findings over the last decade Few surveys and even fewer interventions done, mostly in the public sector Irrational drug use remains a very serious problem Increased antibiotic use and decreased injection use Prescribing often better in public than private sectors

32. WHO, Dept. Essential Drugs and Medicines Policy32 Thank you Prof. Dennis Ross-Degnan –For constant support and advice throughout with regard to database design and analysis Jorge Hetzke –For help designing and maintaining the database Richard Laing and Hans Hogerzeil –Advice and support All authors around the world –For clarifying their studies for us