Professional Documents
Culture Documents
Selection
Procurement
Distribution
Use
27 Managing for rational medicine use
28 Investigating medicine use
29 Promoting rational prescribing
30 Ensuring good dispensing practices
31 Community-based participation and initiatives
32 Drug seller initiatives
33 Encouraging appropriate medicine use by consumers
34 Medicine and therapeutics information
35 Pharmacovigilance
chap ter 27
Managing for rational medicine use
Summary 27.2 illustrations
Figure 27-1 The medicine use process 27.3
27.1 Definition of rational medicine use 27.2
Figure 27-2 Factors influencing prescribing 27.7
27.2 Examples of irrational medicine use 27.3 Figure 27-3 What countries are doing to promote the rational
Polypharmacy • No medicine needed • Wrong use of medicines 27.8
medicines • Ineffective medicines and medicines with Figure 27-4 Framework for improving medicine use 27.10
doubtful efficacy • Unsafe medicines • Underuse of
available effective medicines • Incorrect use of medicines b oxes
27.3 Adverse impact of irrational medicine use 27.5 Box 27-1 Antimicrobial resistance global prevalence
Impact on quality of medicine therapy and medical care • rates 27.6
Impact on antimicrobial resistance • Impact on cost • Box 27-2 Intervention strategies to improve medicine
Psychosocial impact use 27.9
Box 27-3 Useful organizations and websites on rational
27.4 Factors underlying irrational use of medicines at
medicine use and antimicrobial resistance 27.12
various levels of the health system 27.6 Box 27-4 Core strategies to promote rational use of
Health system • Prescriber • Dispenser • Patient and
medicines 27.14
community
27.5 Strategies to improve medicine use 27.9 c ountry studies
27.6 Developing a strategy 27.10 CS 27-1 Overuse of therapeutic injections 27.4
Step 1. Identify the problem and recognize the need CS 27-2 The practices of dispensing prescribers in
for action • Step 2. Identify underlying causes and Zimbabwe 27.8
motivating factors • Step 3. List possible interventions • CS 27-3 Building a national drug policy to improve the
Step 4. Assess resources available for action • Step 5. Choose rational use of medicines: assessing implementation
an intervention or interventions to test • Step 6. Monitor in Lao P.D.R. 27.11
the impact and restructure the intervention CS 27-4 Chile’s efforts to combat the overuse of
antimicrobials 27.11
Glossary 27.14
Assessment guide 27.15
References and further readings 27.15
s u mm a r y
This chapter defines rational medicine use and gives ible sources and communication channels. Personal con-
examples of irrational medicine use and the adverse tact (face-to-face meetings, for example) can sometimes
effects that can result. It considers some of the factors be used to convey a limited number of key messages;
underlying irrational medicine use and possible strate- these can be repeated and clarified using a variety of
gies to address the problem. media.
Rational use of medicines requires that patients receive When implementing an intervention strategy, the logical
medications appropriate to their clinical needs, in doses steps are to—
that meet their individual requirements, for an adequate
• Identify the problem
period of time, and at the lowest cost to them and their
• Understand the underlying causes
community (WHO 1985).
• List possible interventions
Irrational medicine use occurs with polypharmacy • Assess available resources
(when more than one medicine is used unnecessarily), • Choose an intervention
with the use of wrong or ineffective medicines, or with • Monitor and restructure the activity as necessary
underuse or incorrect use of effective medicines. These
Interventions should be based on an understanding of
actions negatively affect the quality of medicine therapy,
the cause of the problem and focus on active strategies
raise health care costs, and may cause adverse reactions
to change behavior. Experience indicates that the most
or negative psychosocial effects.
effective interventions are those that—
Prescriber lack of knowledge and experience is only one
• Identify key influence factors
factor in irrational medicine use. Other underlying fac-
• Target individuals or groups with the worst practices
tors can affect the dispensing process, patient or commu-
• Use credible information sources
nity decisions and use, and the health system itself.
• Use credible communication channels
Strategies to address irrational medicine use can be • Use personal contact whenever possible
characterized as educational, managerial, economic, or • Limit the number of messages
regulatory. Whichever method is selected, a successful • Repeat key messages using a variety of methods
intervention is likely to include a focus on key factors, • Provide better medicine use alternatives to existing
target facilities with the poorest practices, and use cred- practices
27.1 Definition of rational medicine use • Appropriate indication—that is, prescribing is based
on sound medical considerations
The aim of any pharmaceutical management system is to • Appropriate medicine, considering efficacy, safety,
deliver the correct medicine to the patient who needs that suitability for the patient, and cost
medicine. The steps of appropriate selection, procurement, • Appropriate dosage, administration, and duration of
and distribution are necessary precursors to the rational use treatment
of medicines. • Appropriate patient—that is, no contraindications
The Conference of Experts on the Rational Use of exist, and the likelihood of adverse reactions is mini-
Drugs, convened by WHO in Nairobi in 1985, defined mal
rational use as follows: “The rational use of drugs requires • Correct dispensing, including appropriate information
that patients receive medications appropriate to their clini- for patients about the prescribed medicines
cal needs, in doses that meet their own individual require- • Patient adherence to treatment
ments, for an adequate period of time, and at the lowest
cost to them and their community.” Depending on the To conform to these criteria, prescribers should follow a
context, however, many factors influence what is consid- standard process of prescribing, which starts with a diag-
ered rational. It may be rational, for example, for a drug nosis to define the problem that requires treatment. Next,
seller to sell antibiotics without a prescription to earn the therapeutic goal should be defined. The prescriber must
enough income to survive. decide which treatment is required, based on up-to-date
This book uses the term rational medicine use in a bio- information on medicines and therapeutics, to achieve the
medical context that includes the following criteria— desired goal for an individual patient. When the decision
27 / Managing for rational medicine use 27.3
is made to treat the patient with medicines, the best drug Polypharmacy
for the patient is selected based on efficacy, safety, suitabil-
ity, and cost. Then dose, route of administration, and dura- Polypharmacy occurs when patients use more medicines
tion of treatment are determined, taking into account the than are necessary; for example, a patient with an upper
condition of the patient. When prescribing a medicine, the respiratory infection receiving prescriptions for antibiotics,
prescriber should provide proper information to the patient cough remedies, analgesics, and multivitamins. Use of too
about both the medicine and the patient’s condition. Finally, many medicines may be a particular problem with prescrib-
the prescriber should decide how to monitor the treatment, ers who also dispense medicines, especially when they have
after considering the probable therapeutic and adverse a financial incentive; for example, dispensing prescribers in
effects of treatment. Zimbabwe tended to prescribe a medicine for every symp-
Next, the medicine should be dispensed to the patient in tom reported by the patient, resulting in their dispensing
a safe and hygienic manner, making sure that the patient more antibiotics, cough syrups, mixtures, and analgesics per
understands the dosage and course of therapy; then the patient than nondispensing prescribers (Trap and Hansen
patient takes the medicine. Adherence occurs if the patient 2003). Polypharmacy is usually judged by measuring the
(and the community) understands and appreciates the value average number of medicines per prescription.
of using specific medicines for specific indications (see
Figure 27-1 on the medicine use process). No medicine needed
Diagnosis
Follow-up
Adherence Prescribing
Dispensing
27.4 U SE
Poor injection practices, especially in developing coun- breaks in infection control procedure. Even with the high
tries, include the prescription of unnecessary injec- rate of injections, 90 percent of the prescribers and 49
tions and the reuse of equipment without sterilization. percent of the population were aware of the potential risk
Unsafe injections increase the risk of transmitting of HIV transmission through unsafe injections (Logez et
hepatitis B and C, HIV, and a number of other blood- al. 2004).
borne pathogens. Although usage studies have shown
Pakistan. A study of 198 adult patients in Karachi col-
a gradual trend toward lessened use of injections,
lected information on injection practices using a ques-
progress still remains to be made in certain geographic
tionnaire about respondents’ last interaction with a health
areas—especially countries in the Middle East and
care provider. It revealed that nearly one-half (49 percent)
Southeast Asia.
of respondents had been given an injection during their
Egypt. In a household survey of 4,197 people in two last visit; 91percent of respondents reported that the doc-
regions of Egypt, more than 26 percent reported hav- tor always recommended an injection; and 83 percent
ing received an injection in the previous three months. of respondents believed injections to be more powerful
Overall, respondents reported receiving an average of 4.2 than alternatives. When treatments were equally effec-
injections per year. Of those who had recently received tive, 83 percent of respondents preferred alternatives
an injection, 8 percent reported that the providers did (pills or advice) to injections. Respondents reported that
not take the syringe from a sealed packet. Respondents the nature of their complaint did not affect the likelihood
reported receiving injections from public- and private- of injection, and 30 percent had received ten or more
sector physicians, pharmacists, barbers, doctor’s assis- injections in the previous year (Raglow, et al. 2008).
tants, housekeepers, relatives, and friends (Talaat et al.
Interventions to decrease the number of unnecessary
2003).
injections and improve injection practices have shown
Mongolia. The Ministry of Health in Mongolia collected that—
information on injection practices through interviews
• Better communication between patients and provid-
and observations of a sample of prescribers, injection
ers can reduce injection overuse
providers, and members of the population. The sixty-
• Increased access to single-use injection devices
five members of the population reported receiving an
improves injection safety
average of thirteen injections per year. All twenty health
• Managerial approaches (that is, restricting access
care facilities surveyed used single-use injection devices,
to selected unnecessary and dangerous injectable
but almost 30 percent of the providers admitted reusing
medicines) can improve injection practices
infusion bottles. Observations of practices showed other
27 / Managing for rational medicine use 27.5
than one-third of low- and middle-income countries have complicate prescribing decisions. In India, doctors often
either national AMR strategies or national AMR task forces prescribe ineffective tonics because many patients believe in
(WHO/TCM 2006). In addition, health systems that fail to them and will not return to a doctor who will not prescribe
implement policies on standard treatment guidelines, essen- them, which impinges on the doctor’s livelihood. Finally,
tial medicines lists, and medicine formularies are missing profit may affect a prescriber’s choice if the prescriber’s
out on well-proven methods to increase the rational use of income is dependent on medicine sales. Country Study 27-2
medicines. describes the prescribing practices of doctors who also dis-
pense medicines.
Prescriber
Dispenser
The prescriber can be affected by internal and external fac-
tors. He or she may have received inadequate training either The dispenser plays a crucial role in the therapeutic pro-
preservice or in-service, or his or her prescribing practices cess. Dispensing quality may be affected by the training
may have become outdated because of a lack of continu- and supervision the dispenser has received and the medi-
ing education and a poor supervisory system. Prescribing cine information available to the dispenser. A shortage of
role models who are imitated may not prescribe rationally. dispensing materials and short dispensing time caused by a
Objective information on medicines may be lacking, and heavy patient load may also have an adverse impact on dis-
the information provided by supplier representatives may pensing. As with prescribers, dispensers, especially private
be unreliable. Temptation can be strong to generalize inap- drug sellers, may have a financial incentive to dispense irra-
propriately about the effectiveness or side effects of medi- tionally. In addition, drug sellers in retail outlets are rarely
cines on the basis of limited personal experience. Externally, trained and there is little to no structure for monitoring or
a heavy patient load and pressure to prescribe from peers, supervision. Finally, the low status of dispensers affects the
patients, and pharmaceutical company representatives all quality of dispensing.
Wrong s Lack
o
ine trainin f
medic g
,
ed d,
pir ar Po
Ex tand rfeit m or r
bs te s od ol
su coun icine els e
r
o me d
or ine
es
TE M
sh edic
tag
YS PR
YS ES
M
Inad rmatio
PL C
info
P
RI
equ n
SU
BE
R
LTH
ate
ble
HE A
supply
Unrelia
Financial
interest
Cultural
beliefs
PAT
IE
ing
train or
NT
Po
ER
Ava nds
AN
NS
CO E
D
fu
ilab
M SP
MU DI
le
NIT
Y
n o
pe o
isi
Sh sult e
co tim
su N
rv
or ing
n
Pre e
ag
att scribe Lack of h ort erials
itud r S at
printed m
es
informa Patient of
tion load
Figure 27-3 What countries are doing to promote the rational use of medicines
0 10 20 30 40 50 60 70 80 90 100
Percentage of countries implementing policies to promote rational use
AMR = antimicrobial resistance; CME = continuing medical education; DTCs = drug and therapeutics committees; EML = essential medicines list; STGs = standard
treatment guidelines
Source: Holloway 2005.
27.5 Strategies to improve medicine use neglected or delegated to an untrained person. Chapter 30
describes ways to ensure good dispensing. The final stage of
Before attempting to change medicine use, the scale of the medicine use is when the patient takes the medicine. The
problem should be assessed and quantified. The underlying patient is more likely to take medicines as advised if he or
reasons for the problem behavior then need to be investi- she understands how to take the medicine and if there is
gated. Quantitative and qualitative methods for assessing general community awareness of rational medicine use.
medicine use are described in Chapter 28. It is a mistake Developing informational materials for patients and plan-
to intervene before understanding the reasons for a problem ning public education campaigns requires an understand-
behavior. ing of cultural norms, values, and practices. These issues as
Several choices exist for interventions to change medi- well as those surrounding patient adherence are covered in
cine use practices. These approaches can be characterized as Chapter 33.
educational, managerial, economic, or regulatory (see Box Whatever problem is being addressed, health care pro-
27-2). Whichever approach is used, interventions should viders and consumers need impartial drug and therapeu-
focus on specific problem behaviors and should target pre- tics information. Such information can serve as the basis
scribers, dispensers, facilities, or the public, depending on for standard treatment guidelines or therapeutic standards.
where the assessment shows the problems lie. A single inter- Information can be made available actively through drug
vention rarely results in sustainable changes, so a combined bulletins or in a largely passive manner through drug
strategy is preferred. Figure 27-4 shows a framework for information centers. However, in a 2003 survey, less than
imporving uses. half of all countries—no matter what income level—had
Possible interventions for prescribers, such as training, independent national drug information services for pre-
accessing unbiased information, and using opinion lead- scribers, dispensers, or consumers (WHO/TCM 2006).
ers, are described in Chapter 29. After prescribing has been Medicine information is covered in Chapter 34.
addressed, the next stage of medicine use is dispensing. This No matter which point in the medicine use process
crucial aspect of the provider-patient relationship is often becomes the focus of an intervention strategy, there are
Box 27-2
Intervention strategies to improve medicine use
common characteristics of effective interventions. These Step 1. Identify the problem and recognize the need
interventions— for action
Identify key influence factors. Use qualitative methods to Within the facility, district, or country, a consensus must
understand why a person behaves in a certain way, and exist about the most important problems in medicine use.
identify influences that can promote and prevent change. Recognition of the primary problems may come as a result
Target individuals or groups with the worst practices. For the of an indicator survey or drug use review, a disaster in which
greatest impact, focus on these individuals or facilities. patients have been adversely affected, or an economic analy-
Use credible information sources. Involve influential, sis of medicine expenditures. An effective response can be
respected authorities and ensure that resource materials planned only after all the involved parties, including pre-
are well referenced and authoritative. scribers, patients, and health service managers, recognize
Use credible communication channels. Enhance the mes- that a problem exists. If an influential prescriber or politi-
sage and acceptability of its content by communicating cian refuses to accept that a specific problem exists, it will
through existing, credible channels. be very difficult to intervene effectively. Thus, compiling
Use personal contact whenever possible. Communicate key the evidence that clearly details the scope of the problem,
messages most effectively with face-to-face individual or establishing a consensus that action is needed, and secur-
small group meetings. ing support from all interested parties are important tasks.
Limit the number of messages. Improve understanding by Country Study 27-3 shows how the Lao People’s Democratic
confining the intervention to a few key messages. Republic approached the implementation of a national
Repeat key messages using a variety of media. People learn in medicine policy to improve rational use.
different ways—some learn visually from text or graph-
ics, some learn through spoken messages, and some learn Step 2. Identify underlying causes and motivating
through a combination of media. Help reinforce key mes- factors
sages by repeating them using a variety of approaches.
Provide better alternatives. Whenever possible, give a posi- As described in Section 27.4, many factors contribute to the
tive message that encourages people to do something. irrational use of medicines. These factors must be investi-
Negative messages tend to alienate people. With an gated and understood before intervening. If this step has not
emphasis on the positive, the negative behavior can be been taken, the intervention is likely to fail. For example, a
excluded. For example, a positive message: DO treat diar- campaign to promote the use of generic medicines by hang-
rhea with ORT. Antidiarrheals are not necessary. ing up posters in a health clinic will fail if the underlying
reason for the lack of use is that the doctors do not know the
generic names of the medicines. Also, a prescriber who is
27.6 Developing a strategy allowed to dispense and earn money from medication sales
is going to be motivated to prescribe (and sell) more medi-
Six steps to follow in developing a strategy to promote ratio- cines and more expensive medicines, including brand-name
nal medicine use are described below. products.
27 / Managing for rational medicine use 27.11
Box 27-3
Core strategies to promote rational use of medicines
Evidence suggests that the following core policies, strate- significantly influence future prescribing habits. Training
gies, and interventions promote more rational use of is most successful when it is problem based, concentrates
medicines. on common conditions, takes into account students’ level
of knowledge, and is targeted to their future prescrib-
Establishing a mandated multidisciplinary national
ing requirements. In most settings, rather than focus-
body to coordinate medicine use policies. Ensuring
ing on basic science, problem-solving skills should be
rational medicine use requires many activities that need
promoted and interdisciplinary problem-based learning
coordination among many stakeholders. Therefore, a
encouraged. If the existing focus is not on problem-based
national body is necessary to coordinate strategies and
training in pharmacotherapeutics, national consultative
policy at the national level, in both the public and private
workshops may help build awareness of the value of the
sectors. This body should involve government, health
approach.
professions, academia, pharmaceutical industry, con-
sumer groups, and the national regulatory authority. Continuing in-service medical education as a licen-
sure requirement and targeted educational programs
Implementing procedures for developing, using, and
by professional societies, universities, and the govern-
revising standard treatment guidelines. Standard
ment. Unlike in developed countries, opportunities for
treatment guidelines (STGs) (or clinical guidelines or
continuing medical education in less developed countries
prescribing policies) are systematically developed state-
are limited because continuing education is not required
ments to help prescribers make decisions about appro-
for licensure. Governments should support efforts by
priate treatments for specific clinical conditions. STGs
university departments and national professional asso-
are made more credible through the use of evidence-
ciations to offer independent, unbiased continuing medi-
based recommendations. They vary in complexity from
cal education courses to health professionals, including
simple algorithms to detailed protocols on diagnostic
medicine dispensers. The most effective in-service train-
criteria, patient advice, and costs.
ing is likely to be problem based, repeated on multiple
Implementing procedures for developing and revis- occasions, focused on practical skills, and linked to STGs.
ing an essential medicines list (or hospital formulary)
Developing a strategic approach to improve prescrib-
based on treatments of choice. An essential medicines
ing in the private sector through regulation and col-
list makes pharmaceutical management easier at all
laborations with professional associations. Most efforts
levels: procurement, storage, and distribution are easier
in improving use of medicines have focused on the
with fewer items, and prescribing and dispensing are
public sector, but the private sector often provides greater
easier for professionals. A national essential medicines
access to pharmaceuticals. Changing practices in the
list should be based on national STGs, and both should
private sector requires an understanding of the motiva-
be revised regularly.
tions of private prescribers. A range of strategies should
Establishing a ttommittee in districts and hospitals, be considered to improve rational medicine use, includ-
with defined responsibilities for monitoring and ing licensing regulations with appropriate enforcement,
promoting rational use of medicines. This commit- accreditation and continuing education through profes-
tee, also called a pharmacy and therapeutics committee, sional associations, and financial incentives.
is responsible for ensuring the safe and effective use
Monitoring, supervision, and using group processes
of medicines in the facility or area under its jurisdic-
to promote rational medicine use. Supervision that is
tion. The committee should operate independently, and
supportive, educational, and face-to-face will be more
members should represent all the major medical special-
effective with prescribers than inspection and punish-
ties and the administration. The primary tasks of the
ment. Effective forms of supervision include prescription
committee are to develop and revise institutional STGs
audit and feedback, peer review, and group processes of
(based on national guidelines) and to maintain an insti-
self-identifying medicine use problems and solutions
tutional essential medicines list or formulary.
in a group of prescribing professionals. Group process
Using problem-based training in pharmacotherapy interventions with practitioners and patients to improve
based on national STGs in undergraduate curricula. prescribing practices have been effectively used to change
The quality of basic pharmacotherapy training for prescribing behavior.
undergraduate medical and paramedical students can
27 / Managing for rational medicine use 27.13
Training pharmacists and drug sellers to offer useful companies, as well as public education activities led by
advice to consumers, and supplying independent med- consumer organizations, may influence medicine use by
icine information. In many countries with shortages of the public.
trained health professionals, pharmacies and medicine
Avoiding perverse financial incentives. Financial
shops are a major source of information for consumers.
incentives may strongly promote rational or irratio-
Interventions have shown that the skills of untrained
nal use of medicines. Examples include the ability of
prescribers and dispensers can be upgraded. In addition,
prescribers to earn money from medicine sales; flat
the only information about medicines that prescribers
prescription fees that lead to overprescription; and dis-
receive is from the pharmaceutical industry, which may
pensing fees that are calculated as a percentage of the
be biased. Pharmaceutical information centers and drug
cost of medicines, which encourages the sale of expen-
bulletins are two useful ways to disseminate indepen-
sive medicines.
dent, unbiased information. They may be administered
by the government, a university teaching hospital, or a Ensuring sufficient government expenditure and
nongovernmental organization, under the supervision of enforced regulation. Appropriate regulation of the
a health professional. activities of all those involved in the use of medicines is
critical to ensure rational medicine use. For regulations
Encouraging involvement of consumer organizations,
to be effective, they must be enforced, and the regulatory
and devoting government resources to public educa-
authority must be sufficiently funded and backed by the
tion about medicines. Governments have a responsibil-
government’s judiciary. Without sufficient competent
ity to ensure the quality of information about medicines
personnel and finances, none of the core components of
available to consumers. Without sufficient knowledge
a national program to promote rational use of medicines
about the risks and benefits of medicine use, people will
can be carried out.
often fail to achieve their expected clinical outcomes
and may even suffer adverse effects. Regulation of con- Sources: WHO 2002 and Laing et al. 2001.
sumer advertising and promotion by pharmaceutical
Educational, managerial, economic, and regulatory inter- Factors to consider when choosing an intervention include
ventions can be used to address the problem of irrational the effectiveness with which it addresses the underlying
use (see Chapter 29 for details). Whenever possible, a com- causes of the problem; its previous success rate in similar
bination or sequence of interventions should be used, and situations, areas, or countries; its cost; and whether it can be
there should be evidence that the interventions are effective sustained with available resources. Whichever intervention
in similar settings. As seen in Country Study 27-4, the gov- is chosen, it must be tested before widespread implemen-
ernment of Chile changed its regulations to restrict sales of tation. Again, if feasible, a strategy that combines a mix of
antimicrobials to prescription only in the private sector, and interventions will be more effective and sustainable.
supported the legal measure with a public and professional
education and media campaign. Step 6. Monitor the impact and restructure the
intervention
Step 4. Assess resources available for action
During testing of the intervention, it is important to mon-
When deciding which intervention or combination of itor related medicine use in order to evaluate the inter-
interventions to test, it is important to take stock of what vention’s efficacy or unexpected and negative effect; for
resources are available. The most important limiting example, an intervention aimed at banning antidiarrheals
resource is usually human. Ask the following questions: may lead to an increased use of antibiotics. On comple-
Who will implement the intervention? Will that per- tion of the intervention, evaluate the results to decide
son have enough time to work on the intervention? Try whether it should be expanded to involve a larger popula-
to identify groups or individuals who would support the tion. An intervention’s effectiveness in a small area with a
intervention. For example, manufacturers of generic medi- limited number of people does not guarantee widespread
cines would support an intervention to popularize gener- success.
ics. Financial, transport, and material resources also need Box 27-3 has a list of core strategies to promote the ratio-
to be assessed. nal use of medicines.
27.14 U SE
The remaining chapters in this section address the task ized training in the uses, side effects, contraindications, and dos-
of improving medicine use. All these chapters should be ages of medications for human use.
reviewed before planning an intervention. In addition, Box Clinical pharmacologist: A physician who has had specialized
training in the uses, side effects, contraindications, and dosages
27-4 lists useful organizations and their websites, which pro-
of medications for human use.
vide further information on specific related topics. n Course-of-therapy prepackaging: Prepackaging of medicines
in sealed plastic bags, each bag containing a complete course of
treatment, as established by standard treatment guidelines. The
Glossary package usually contains a complete label with instructions for
use.
Adherence to treatment (also compliance): The degree to which Dispense: To prepare and distribute to a patient a course of therapy
patients adhere to medical advice and take medicines as directed. on the basis of a prescription.
Adherence depends not only on the patient’s acceptance of infor- Dispenser: A general term for anyone who dispenses medicines.
mation about the health threat but also on the practitioner’s abil- Also specifically used to mean an individual who is not a gradu-
ity to persuade the patient that the treatment is worthwhile and ate pharmacist but who is trained to dispense medications, main-
on the patient’s perception of the practitioner’s credibility, empa- tain stock records, and assist in procurement activities.
thy, interest, and concern. Generic substitution: Dispensing of a product that is generically
Antimicrobial resistance: A biological phenomenon where, equivalent to the prescribed product, with the same active ingre-
as part of the natural selection process, microbes mutate and dients in the same dosage form, and identical in strength, con-
develop drug-resistant genes that can be passed on. Antimicrobial centration, and route of administration.
resistance can be amplified or accelerated by human behaviors Irrational prescribing: Prescribing that does not conform to good
including the irrational use of medicines. standards of treatment—for example, extravagant prescribing,
Clinical pharmacist: An individual trained in pharmacy, usually overprescribing, incorrect prescribing, multiple prescribing, or
with the minimum of a bachelor’s degree, who has had special- underprescribing of medications.
Box 27-4
Useful organizations and websites on rational medicine use and antimicrobial resistance
APUA (Alliance for the Prudent Use of Antibiotics) Promoting Rational Drug Use: A CD-ROM Training
http://www.tufts.edu/med/apua Program
http://dcc2.bumc.bu.edu/prdu/default.html
BUBL Catalogue of Internet Resources—Infectious
Diseases Réseau Médicaments et Développement
http://bubl.ac.uk/link/i/infectiousdiseases.htm (Network of Medicines and Development)
http://www.remed.org
Centers for Disease Control and Prevention
(“Drug Resistance”) Therapeutics Initiative
http://www.cdc.gov/drugresistance http://www.ti.ubc.ca
EARSS (European Antimicrobial Resistance United Kingdom Health Protection Agency
Surveillance System) (“Infectious Diseases”)
http://www.rivm.nl/earss http://www.hpa.org.uk/Topics/InfectiousDiseases
Essentialdrugs.org United Nations Children’s Fund–United Nations
http://www.essentialdrugs.org Development Fund–World Bank–World Health
Organization Special Programme for Research and
Infectious Disease News
Training in Tropical Diseases
http://www.infectiousdiseasenews.com
http://www.who.int/tdr
International Conference on Improving Use of Medicine
World Health Organization (“Drug Resistance”)
(ICIUM 2011, ICIUM 2004, and ICIUM 1997)
http://www.who.int/topics/drug_resistance/en
http://www.icium.org
World Health Organization (“Essential Medicines and
International Network for the Rational Use of Drugs
Pharmaceutical Policies”)
http://www.inrud.org
http://www.who.int/medicines/en
International Society for Infectious Diseases
http://www.isid.org World Health Organization (“Infectious Diseases”)
http://www.who.int/topics/infectious_diseases/en
27 / Managing for rational medicine use 27.15
a s s e s s me n t g u ide
• Have studies been done to identify possible prob- • Do prescribers follow a standard process of prescrib-
lems with rational medicines use? In the country? In ing and monitoring treatment?
the province? In the facility? • What unbiased resources are available to prescribers
• If problems have been identified, what might be regarding information on pharmaceuticals?
some of the underlying causes in the health system? • At each level of the health care system, who is
With prescribers? With dispensers? With the public? responsible for dispensing medicines? Are prescrib-
• Does the country have a national medicine policy or ers allowed to dispense medicines?
policies in place to promote rational medicine use, • Are injections a preferable way to deliver medicines
such as national standard treatment guidelines or an with prescribers? With the public?
essential medicines list? Are there any regulations • Has an assessment been done to evaluate the level of
that seek to control medicine use? For example, antimicrobial resistance in the country?
restricting the sales of antibiotics to prescription • Have any interventions been designed and carried
only? out to improve rational medicine use? What were
• Does the government have any campaigns to pro- the results? Were the results shared with other stake-
mote rational use in the public? holders?
Labeling: Placing written or symbolic instructions on the con- Control Priorities in Developing Countries. 2nd ed. D.T. Jamison, J.
tainer in which medicines dispensed to the patient. G. Breman, A. R. Measham, and G. Alleyne, eds. Washington, D.C.:
Medicine use: The process of diagnosis, prescribing, labeling, Disease Control Priorities Project.<http://files.dcp2.org/pdf/DCP/
packaging, and dispensing and of adherence to medicine treat- DCPFM.pdf >
CPM/MSH (Center for Pharmaceutical Management/Management
ment by patients.
Sciences for Health). 2011. Center for Pharmaceutical Management:
Pharmacology: The study of medicines and their actions.
Technical Frameworks, Approaches, and Results. Arlington, Va.:
Polypharmacy: The practice of using too many medicines per CPM.
patient. Demyttenaere, K., R. Bruffaerts, J. Posada-Villa, I. Gasquet, V. Kovess,
Prescribing: The act of determining which medication the patient J. P. Lepine, M. C. Angermeyer, et al. 2004. Prevalence, Severity, and
should have and writing the dosage, frequency, and duration of Unmet Need for Treatment of Mental Disorders in the World Health
treatment on a form. Organization World Mental Health Surveys. Journal of the American
Self-medication: The selection and use of medicines by individu- Medical Association 291(21):2581–90.
als to treat self-recognized symptoms. Finer, D., and G. Tomson, eds. 1992. Essential Drug Information: The
Standard treatment guidelines: Agreed-upon treatment practices Story of a Workshop. Stockholm: Karolinska Institutet.
Goossens, H., M. Ferech, R. Vander Stichele, and M. Elseviers for the
for a diagnosed illness; may include more than details of medi-
ESAC Project Group. 2005. Outpatient Antibiotic Use in Europe
cine treatment.
and Association with Resistance: A Cross-National Database Study.
Symbolic labeling: A system of providing written instructions for The Lancet 365:579–87.
patients using sketches or other graphic representations. Hogerzeil, H., V. Bimo, D. Ross-Degnan, R. O. Laing, D. Ofori-
Therapeutic substitution: Interchange of one drug product with Adjei, B. Santoso, A. K. Azad Chowdhury, et al. 1993. Field Tests
another that differs in composition but is considered to have sim- for Rational Drug Use in Twelve Developing Countries. Lancet
ilar pharmacologic and therapeutic activities, in accordance with 342:1408–10.
written protocols previously established and approve Holloway, K. A. 2005. “Rational Use of Drugs: An Overview.” Paper
presented at the WHO/UNICEF Technical Briefing Seminar on
Essential Medicines Policies, September 18–22, Geneva. <http://
archives.who.int/tbs/tbs2005/holloway.ppt>
References and further readings Holloway, K. A., B. R. Gautam, and B. C. Reeves. 2001. The Effects of
Different Kinds of User Fee on Prescribing Costs in Rural Nepal.
H = Key readings. Health Policy and Planning 16:421–7.
Hutin Y. J. F., A M. Hauri, and G. L. Armstrong. 2003. Use of Injections
Arrow, K. J., C. B. Panosian, and H. Gellband, eds. 2004. Saving Lives, in Healthcare Settings Worldwide, 2000: Literature Review and
Buying Time: Economics of Malaria Drugs in an Age of Resistance. Regional Estimates. BMJ 37(7423):1075–8.
Washington, D.C.: National Academy Press for Institute of H INRUD (International Network for Rational Use of Drugs)
Medicine. Bibliography. Undated. <http://www.inrud.org/Bibliographies/
Bavestrello, L., and A. Cabello. 2000. How Chile Tackled Overuse of INRUD-Bibliography.cfm>>
Antimicrobials. Essential Drugs Monitor 28/29:13–4. <http://apps. A searchable annotated database of published and unpublished
who.int/medicinedocs/pdf/s2248e/s2248e.pdf> articles, books reports, and other documents focusing on rational
Breman, J. G., A. Mills, R. W. Snow, J. Mulligan, C. Lengeler, K. use of medicines, mainly in developing countries. Updated every six
Mendis, B. Sharp, et al. 2006. Conquering Malaria. In Disease months.
27.16 U SE
Institute of Medicine. 2003. The Resistance Phenomenon in Microbes Talaat, M., S. el-Oun, A. Kandeel, W. Abu-Rabei, C. Bodenschatz, A. L.
and Infectious Disease Vectors: Implications for Human Health Lohiniva, Z. Hallaj, and F. J. Mahoney. 2003. Overview of Injection
and Strategies for Containment: Workshop Summary. Washington, Practices in Two Governorates in Egypt. Tropical Medicine and
D C.: National Academies Press. <http://www.nap.edu/openbook. International Health 8(3):234–41.
php?record_id=10651&page=1> Trap, B., and E. H. Hansen. 2003. Dispensing Prescribers—A Threat to
Kadyrova, N., B. Waning, and C. Cashin. 2004. “Kyrgyzstan Outpatient Appropriate Medicines Use? Essential Drugs Monitor 32:9.
Drug (OPD) Benefit Program: Use of Automated Claims Data to H Whyte, S. R., S. van der Geest, and A. Hardon. 2003. Social Lives of
Evaluate the Impact of the OPD Benefit Program on Rational Drug Medicines. Cambridge: Cambridge University Press.
Prescribing by Physicians and Generic Drug Use by Patients.” Paper H WHO (World Health Organization). 2010. Medicines: Rational Use
presented at ICIUM 2004 Conference, March 30–April 2, Chiang of Medicines. Fact Sheet No. 338. Geneva: WHO. <http://www.who.
Mai, Thailand. int/mediacentre/factsheets/fs338/en/>
Kardas, P. 2002. Patient Compliance with Antibiotic Treatment for H ————. 2009. Community-Based Surveillance of Antimicrobial
Respiratory Tract Infections. Journal of Antimicrobial Chemotherapy Use and Resistance in Resource-Constrained Settings: Report on Five
49(6):897–903. Pilot Projects. Geneva: WHO. <http://whqlibdoc.who.int/hq/2009/
H Laing, R., H. V. Hogerzeil, and D. Ross-Degnan. 2001. Ten WHO_EMP_MAR_2009.2_eng.pdf>
Recommendations to Improve the Use of Medicines in Developing H ————. 2007. Progress in the Rational Use of Medicines. Geneva:
Countries. Health Policy and Planning 16(1):13–20. WHO. <http://apps.who.int/gb/ebwha/pdf_files/WHA60/
Logez, S., G. Soyolgerel, R. Fields, S. Luby, and Y. Hutin. 2004. Rapid A60_24-en.pdf>
Assessment of Injection Practices in Mongolia. American Journal of ————. 2005. Containing Antimicrobial Resistance. Geneva: WHO.
Infection Control 32(1):31–7. <http://www.who.int/medicines/publications/policyperspectives/
Paphassarang, C., R. Wahlström, B. Phoummalaysith, B. Boupha, and ppm_10_en.pdf>
G. Tomson. 2004. “Building the National Drug Policy on Evidence: ————. 2004. Safety of Injections: Global Facts and Figures. Geneva:
Assessing Implementation in Lao P.D.R.” Presented at ICIUM 2004 WHO. <http://www.who.int/injection_safety/about/resources/en/
Conference, March 30–April 2, Chiang Mai, Thailand. <http://www. FactAndFiguresInjectionSafety.pdf>
icium.org/icium2004/resources/ppt/AC092.ppt> H ————. 2002. Promoting Rational Use of Medicines: Core
Patel, V., R. Vaidya, D. Naik, and P. Borker. 2005. Irrational Drug Use Components. Geneva: WHO. <http://www.who.int/medicines/pub
in India: A Prescription Survey from Goa. Journal of Postgraduate lications/policyperspectives/ppm05en.pdf>
Medicine 51(1):9–12. ————. 2001. WHO Global Strategy for Containment of Antimicrobial
Quick, J. D., R. O. Laing, and D. Ross-Degnan. 1991. Intervention Resistance. Geneva: WHO. <http://apps.who.int/medicinedocs/
Research to Promote Clinically Effective and Economically Efficient index/assoc/s16343e/s16343e.pdf>
Use of Pharmaceuticals: The International Network for Rational Use ————. 1985. The Rational Use of Drugs: A Review of the Major Issues.
of Drugs. Journal of Clinical Epidemiology 44(Suppl. 2):57–65. Report of the Conference of Experts, November 22–29, Nairobi,
Radyowijati, A., and H. Haak. 2003. Improving Antibiotic Use in Low- Kenya. <http://whqlibdoc.who.int/hq/1985-86/WHO_CONRAD_
Income Countries: An Overview of Evidence on Determinants. WP_RI.pdf>
Social Science and Medicine 57(4):733–44. H WHO and FIP (World Health Organization and International
Raglow, G. J., S. P. Luby, and N. Nabi. 2008. Therapeutic Injections Pharmaceutical Federation). 2006. Developing Pharmacy Practice: A
in Pakistan: From the Patients’ Perspective. Tropical Medicine and Focus on Patient Care. Geneva: WHO and FIP. <http://www.who.
International Health 6(1):69–75. <http://www3.interscience.wiley. int/medicines/publications/WHO_PSM_PAR_2006.5.pdf>
com/cgi-bin/fulltext/118999307/PDFSTART> WHO/TCM (World Health Organization/Technical Cooperation for
H Ross-Degnan, D., R. O. Laing, J. D. Quick, H. M. Ali, D. Ofori- Essential Drugs and Traditional Medicine). 2006. Using Indicators
Adjei, L. Salako, and B. Santoso. 1992. A Strategy for Improved to Measure Country Pharmaceutical Situations: Fact Book on WHO
Pharmaceutical Use: The International Network for Rational Use of Level I and Level II Monitoring Indicators. Geneva: WHO. <http://
Drugs. Social Science and Medicine 35:1329–41. apps.who.int/medicinedocs/documents/s14101e/s14101e.pdf>
SCORE (Strategic Council on Resistance in Europe). 2004. Resistance: ————. 2009. Medicines Use in Primary Care in Developing and
A Sensitive Issue. Utrecht: SCORE. Transitional Countries: Fact Book Summarizing Results from Studies
Soumerai, S. B., S. Majumdar, and H. L. Lipton. 2005. “Evaluating and Reported Between 1990 and 2006. Geneva: WHO. <http://whqlibdoc.
Improving Physician Prescribing.” In Pharmacoepidemiology, 4th who.int/hq/2009/WHO_EMP_MAR_2009.3_eng.pdf>
ed. B. Strom, ed. Chichester, England: John Wiley & Sons. WHO/UNICEF (World Health Organization/United Nations
Stevenson, F. A., N. Britten, C. A. Barry, C. P. Bradley, and N. Barber. Children’s Fund). 2009. Diarrhoea: Why Children Are Still Dying and
2002. Perceptions of Legitimacy: The Influence on Medicine Taking What Can Be Done. Geneva: WHO/UNICEF. <http://whqlibdoc.
and Prescribing. Health 6(1):85–104. who.int/publications/2009/9789241598415_eng.pdf>