Tropical Doctor, July 1990
Philippines", Ghana", and Bangladesh 10. What is
Rational drug use:
an unsolved problem
R 0 Laing MB ChB MD
International Network/or the Rational Use 0/ Drugs (INRUD),
Management Sciences/or Health, 165 Allandale Road, Boston,
MA 02130, USA
TROPICAL DOCTOR, 1990, 20, 101-103
INTRODUCTION
Many developing countries have essential drugs
programmes. These programmes have usually
improved the availability of a limited list of
'essential' drugs. However, the quality of care
delivered to patients depends on giving the right
drugs, for correct indications, in a way that
encourages the patient to take the medication.
Irrational use of drugs occurs in all health systems
and in advanced countries has been addressed to
a limited extent. However, in developing countries
the emphasis on providing a minimum of services
has meant that very little attention has been paid
to rational use issues until recently.
THE ESSENTIAL DRUGS PROGRAMME
The Essential Drugs Programme was established by
WHO in 1972. The programme has addressed the
issue of drug selection with a series of Technical
Reports and model lists. The latest list (the fifth)
was released in 19891• These lists have served as the
basis for the development of national drug lists in
over 110 countries-.
The procurement of these essential drugs has also
improved during the 1980s, with pooled procure-
ment, international tendering, and the involvement
of non-profit organizations who procure and
distribute drugs, such as UNIPAC, IDA, and
ECHO reducing the price by between 40 and 60%.
Kit systems have been developed in countries which
have difficulties in distributing their drugs",
With support from the WHO Drug Action Pro-
grammeand from donors, many developingcountries
have implemented essential drug programmes which
include elements of selection, procurement, and
distribution of drugs. Promotion of rational use has
often been neglected in such programmes".
DRUG USE IN DEVELOPING COUNTRIES
Reports exist on drug prescription from many
countries, including India", Sri Lanka", Ethiopia",
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101
fascinating about these reports from different
cultures, countries, and health systems is how
similar the situation is in each country. The
general pattern is of polypharmacy due to both
combination drugs and multiple prescriptions,
frequent injections, use of coloured preparations,
vitamins, and incorrect medications. Examples of
inappropriate treatment abound: the use of tetra-
cycline for children, chloramphenicol for minor
infections, dypyrone as an analgesic, antidiarrhoeal
medications instead of oral rehydration solutions.
There are very few papers that address the reasons
for this irrational use. Frequently, suggestions are
made that further education should be given, but
there is little evidence that knowledge among
qualified prescribers is deficient. The prescribing
behaviour may be affected by factors other than
knowledge. The influence of drug representatives
is widely reported. The pressure from the patient
to prescribe an injection or certain specific 'strong
or hot' medicines is recognized. The widespread
faith that there should be a pill for every ill is a
product of our scientific/medical heritage. How
often is the act of writing a prescription the signal
that the consultation is over?
Many drugs in developing countries are sold by
untrained drug sellers who treat drugs as consumer
items. The initiative in Nepal to provide training
for these drug sellers is interesting and worthy of
further study (K K Kafle, personal communication).
Rational use of drugs was the focus of a
conference of experts held in Nairobi in 1985. This
conference brought together academics, health
planners, representatives of the pharmaceutical
industry, and consumer activists. With such varied
participation, the report produced reflects a wide
range of interests. The importance of rational
prescribing was agreed upon by all; however,
specific proposals for how this should be achieved
are difficult to find. Suggestions were made for
better information, proper training, and continuing
education, but evidence to demonstrate that these
strategies would significantly improve prescribing
is lacking.
Since that conference each report and country
evaluation by WHO's Drug Action Programme has
highlighted the need for action to promote rational
drug use. But reports of successful activities in
developing countries are few, and very few show
success in well-controlled interventions. Hogerzeil
et al. (1989) report on a project in Democratic
Yemenwherea combination of training and provision
102
of a limited list of drugs reduced the proportion of
patients who received injectables, and the total
number of drugs prescribed at each attendance".
Laing and Ruredzo (1989) reported on an
innovative extensive training programme in
Zimbabwe aimed at improving the use of drugs-'.
However, clear impact indicators of success are not
provided in this article.
A report by Lindtjorn (1987) from Ethiopia
reports on the effect of introducing an essential drug
list into a small (55 bed) rural hospital 13• The time
series study showed a significant decrease in non-
essential and placebo prescriptions and vitamin
injections. Multidrug use was also reduced.
However, the staff at the hospital were different
during the two periods studied. Also, no inform-
ation is given on drug availability. Thus, while the
authors ascribe the changes to the introduction of
an essential drug list, other factors may have been
responsible.
So the unanswered question remains: What
interventions are effective in promoting rational
drug use?
EXPERIENCE IN DEVELOPED COUNTRIES
Within developed countries considerable experience
has been reported which generally shows how
difficult it is to promote rational use. Drug
utilization studies have been reported from
Europe" and the United States. However, these
studies have examined the pattern of drug use in
a comparative fashion. Various interesting inter-
vention studies have been reported. In Northern
Ireland McGavock has reported on a 13-year
programme to improve the rationality and economy
of family doctor (GP) prescribing by means of
feedback interviews'>, The programme revolves
around a computer-based analysis of prescribing
patterns for individual doctors who were then
visited by a doctor who would discuss with them
any deviations from the norm. The rate of increase
in number and cost of prescriptions has been slower
in Northern Ireland than in the remainder of the
United Kingdom, and this is ascribed to the
programme.
In Victoria, Australia an antibiotic project in
which 'Antibiotic Guidelines' have been developed
has been effective in promoting rational antibiotic
use for prophylaxis!". A controlled intervention
study to improve antibiotic prophylaxis was carried
out through an educational campaign. The campaign
included promotional materials, academic detailing,
lecturing, and other such educational activities.
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Tropical Doctor, July 1990
What is special about the Victoria Antibiotic
Project is the active involvement of a number of
doctors and the frequent revision of the Guidelines.
Also, the Guidelines have been actively marketed.
Within the United States, a recent review by
Soumerai, McLaughlin, and Avorn (1990) describes
the various interventions that have been attempted
to improve drug prescribing!", In summary, they
report that there is considerable consistency between
well-controlled trials which show that distribution
of educational materials may change prescribers'
knowledge, but will not have an effect on prescribing
practices. Distributing printouts of prescribing
information is ineffective. What has been found to
be most effective is face-to-face educational out-
reaches where a well-informed, credible individual
discusses a limited number of issueswith prescribers.
Various reports have suggested that such inter-
ventions, though expensive, are cost effective.
Where regulatory methods, such as limiting the
number of drugs that can be prescribed or
reimbursed, have been used to restrict prescriptions,
unexpected effects have occurred which may cost
more than the intended or expected savings'".
In Britain, considerable reductions in drug
expenditures have been achieved in a Health District
where a limited list and a district drugs guide were
developed by consensus through a process of
continuous consultation 19.
What are the lessons from developed countries?
Some interventions are usually effective. These are:
• Face-to-face education focused on a few
prescribing problems
• Structured drug order forms
• Prescription audit/procurement review with
active feedback.
Other interventions may be effective. These are:
• Essential drug lists plus education and
participation in developing the list
• Standard treatment schedules plus education.
The longest list is those interventions which have
been shown to be ineffective. These include:
• Printed materials alone
• Arbitrary limits on number or quantity of
drugs per prescription
• Unfocused education
• Essential drug lists alone
• Standard treatment schedules.
What needs to be done in developing countries?
There is an urgent need to develop and test inter-
ventions to identify effective methods to improve
Tropical Doctor, July 1990
rational use. These interventions should have
control groups and adequate sample sizes to ensure
that the results obtained are valid and could be
extended to the national situation. The interventions
should test educational, managerial, and regulatory
methods to promote rational drug use. Once this
information is available, it will be possible to
develop policy initiatives to address the problem of
irrational use.
The International Network for the Rational Use
of Drugs (INRUD) has been established to promote
the study of such interventions and is described in
more detail on page 133 of this issue. However,
before we have the results of these intervention
studies, countries with essential drugs programmes
may require advice. On the basis of present
knowledge and experience, which is limited in
developing countries, we can make the following
suggestions:
(1) Basic and post-basic training should cover not
only pharmacology and therapeutics but also
prescribing.
(2) Essential drug lists and standard treatment
schedules should be developed in a consultative
fashion with broad representation and, when
introduced, should be accompanied by intensive
education.
(3) Before introducing limitations on prescribers,
a careful study should be made, as unexpected
effects may occur.
(4) Face-to-face education of prescribers is very
likely to be effective but may be expensive.
(5) Printed materials, such as drug information
bulletins, may change knowledge but not
prescribing behaviour. While it is important to
have such unbiased information available,
the material should be incorporated into
educational programmes.
CONCLUSION
The problem of irrational drug use is a challenge
to us all. Within this challenge exists an opportunity
to identify effective means of promoting rational
drug use. The impact of such effective drug use may
be far greater than the discovery of new wonder
drugs.
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103
If we made better use of what we have now,
would we need anything more?
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