Oms 2009 - Uso de Medicamentos en Atencion Primaria

ȱ WHO/EMP/MAR/2009.
Medicines use in primary care

in developing and transitional
countries
Fact Book summarizing results from studies

reported between 1990 and 2006
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Thisȱdocumentȱhasȱbeenȱproducedȱandȱtheȱdatabaseȱdevelopedȱwithȱtheȱfinancialȱassistanceȱ
ofȱ theȱ Europeanȱ Communityȱ andȱ theȱ USȱ Agencyȱ forȱ Internationalȱ Developmentȱ (USAID),ȱ
USA.ȱ Theȱ viewsȱ expressedȱ hereinȱ areȱ thoseȱ ofȱ theȱ authorsȱ andȱ canȱ thereforeȱ inȱ noȱ wayȱ beȱ
takenȱ toȱ reflectȱ theȱ officialȱ opinionȱ ofȱ theȱ Europeanȱ Communityȱ andȱ theȱ USȱ Agencyȱ forȱ
InternationalȱDevelopmentȱ(USAID),ȱUSA.ȱȱ
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©ȱWorldȱHealthȱOrganizationȱ2009ȱ
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Preface
PREFACE
MedicinesȱareȱoneȱofȱourȱmostȱcostȬeffectiveȱhealthȱinterventions.ȱBillionsȱofȱpeopleȱ
takeȱthemȱeveryȱyear.ȱHowever,ȱtheyȱareȱonlyȱeffectiveȱifȱusedȱcorrectlyȱandȱthereȱisȱ
evidenceȱ suggestingȱ thatȱ moreȱ thanȱ halfȱ ofȱ allȱ medicinesȱ areȱ notȱ usedȱ inȱ anȱ
appropriateȱ way.ȱ Suchȱ inappropriateȱ useȱ endangersȱ livesȱ andȱ wastesȱ money.ȱ
Unfortunately,ȱmedicinesȱuseȱisȱnotȱroutinelyȱmonitoredȱinȱmanyȱcountriesȱresultingȱ
inȱ aȱ dearthȱ ofȱ information.ȱ ȱ Improvingȱ medicinesȱ useȱ hasȱ notȱ beenȱ aȱ highȱ priorityȱ
globallyȱ orȱ nationally,ȱ andȱ manyȱ countriesȱ areȱ notȱ implementingȱ coreȱ strategiesȱ toȱ
ensureȱappropriateȱuseȱofȱmedicines.ȱ
ȱ
Theȱ firstȱ stepȱ toȱ improvingȱ theȱ currentȱ situationȱ isȱ toȱ measureȱ howȱ medicinesȱ areȱ
usedȱ andȱ thisȱ formsȱ theȱ basisȱ ofȱ advocacyȱ forȱ change.ȱ ThisȱFactȱ Bookȱ describesȱ theȱ
findingsȱfromȱaȱWHOȱdatabaseȱofȱallȱtheȱmedicinesȱuseȱsurveysȱandȱinterventionsȱtoȱ
improveȱ useȱ inȱ developingȱ andȱ transitionalȱ countriesȱ atȱ theȱ primaryȱ careȱ level,ȱ
reportedȱorȱpublishedȱfromȱ1990ȱtoȱ2006.ȱTheȱaimȱisȱtoȱprovideȱaȱpictureȱofȱmedicinesȱ
useȱinȱdevelopingȱandȱtransitionalȱcountries,ȱandȱtheȱimpactȱofȱinterventions,ȱduringȱ
theȱlastȱ20ȱyears.ȱȱ
ȱ
Weȱ hopeȱ thatȱ theȱ informationȱ presentedȱ hereȱ willȱ stimulateȱ actionȱ toȱ increaseȱ theȱ
rationalȱuseȱofȱmedicinesȱandȱthatȱitȱwillȱinformȱandȱfacilitateȱtheȱsettingȱofȱprioritiesȱ
andȱ targets.ȱ Weȱ alsoȱ hopeȱ thatȱ thisȱ Factȱ Bookȱ willȱ beȱ aȱ usefulȱ toolȱ forȱ researchers,ȱ
policyȬmakers,ȱ plannersȱ andȱ othersȱ requiringȱ suchȱ data.ȱ Internationalȱ agenciesȱ andȱ
donorsȱmayȱuseȱtheȱinformationȱinȱthisȱFactȱBookȱasȱbaselineȱdataȱtoȱinferȱtheȱimpactȱ
ofȱfutureȱactivities.ȱProfessionalȱgroupsȱandȱnongovernmentalȱorganizationsȱcanȱuseȱ
theȱresultsȱforȱadvocacy.ȱ
ȱ
WHOȱcreatedȱtheȱdatabaseȱthatȱisȱtheȱbasisȱforȱallȱtheȱinformationȱcontainedȱinȱthisȱ
FactȱBookȱinȱorderȱtoȱfulfilȱitsȱleadershipȱroleȱandȱobligationsȱtoȱmonitorȱmedicinesȱ
use,ȱasȱagreedȱinȱthreeȱWorldȱHealthȱAssemblyȱresolutions.a,b,cȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
a ȱȱ Theȱrationalȱuseȱofȱdrugs;ȱResolutionȱWHA39.27,ȱ1986,ȱGeneva,ȱWHO.ȱ
b ȱȱ WHOȱMedicinesȱStrategy;ȱResolutionȱWHA54.11,ȱ2001,ȱGeneva,ȱWHO.ȱ
c ȱȱ Progressȱinȱtheȱrationalȱuseȱofȱmedicines;ȱResolutionȱWHA60.16,ȱ2007ȱGeneva,ȱWHO.ȱ
– i –
Medicines use in primary care, 1990-2006
– ii –
Acknowledgements
ACKNOWLEDGEMENTS
Theȱ developmentȱ ofȱ theȱ WHOȱ databaseȱ ofȱ reportsȱ onȱ medicinesȱ useȱ andȱ theȱ
publicationȱofȱthisȱFactȱBookȱareȱinitiativesȱofȱtheȱDepartmentȱofȱEssentialȱMedicinesȱ
andȱPharmaceuticalȱPoliciesȱinȱWHOȱGeneva.ȱTheȱFactȱBookȱwasȱproducedȱwithȱtheȱ
assistanceȱ ofȱ theȱ Bostonȱ WHOȱ Collaboratingȱ Centerȱ forȱ Pharmaceuticalȱ Policy,ȱ
jointlyȱ formedȱ byȱ theȱ Departmentȱ ofȱ Ambulatoryȱ Careȱ andȱ Prevention,ȱ Harvardȱ
Medicalȱ Schoolȱ andȱ Harvardȱ Pilgrimȱ Healthȱ Careȱ andȱ theȱ Centerȱ forȱ Internationalȱ
HealthȱandȱDevelopmentȱatȱBostonȱUniversityȱSchoolȱofȱPublicȱHealth.ȱȱ
ȱ
Weȱacknowledgeȱtheȱfollowingȱcontributors:ȱ
ȱ
KathleenȱHollowayȱforȱconceivingȱtheȱideaȱofȱaȱdatabaseȱandȱcreatingȱit,ȱsupervisingȱ
allȱdataȱsearches,ȱextraction,ȱdataȬentry,ȱcleaningȱandȱanalysis,ȱandȱwriteȬup;ȱ
ȱ
VericaȱIvanovskaȱforȱundertakingȱallȱdataȱsearches,ȱextractionȱandȱdataȬentry;ȱ
ȱ
DennisȱRossȬDegnanȱforȱcollaborationȱinȱtheȱcreationȱandȱdesignȱofȱtheȱdatabaseȱandȱ
undertakingȱanalysisȱandȱwriteȬup;ȱ
ȱ
Amyȱ Johnson,ȱ Sarahȱ Lewis,ȱ Catherineȱ VialleȬValentinȱ andȱ Anitaȱ Wagnerȱ forȱ
undertakingȱanalysisȱandȱwriteȬup;ȱ
ȱ
JörgȱHetzkeȱforȱhelpȱinȱdesigningȱtheȱdatabase;ȱȱ
ȱ
ThierryȱLambrechtsȱforȱprovidingȱaccessȱtoȱallȱdocumentationȱinȱtheȱarchivesȱofȱtheȱ
DepartmentȱofȱChildȱandȱAdolescentȱHealth,ȱincludingȱallȱtheȱIMCIȱsurveys;ȱ
ȱ
DaisyȱCarandangȱforȱprovidingȱaccessȱtoȱdataȱfromȱallȱtheȱWHOȱlevelȱIIȱmonitoringȱ
surveysȱ doneȱ duringȱ 2002Ȭ4ȱ inȱ theȱ thenȱ Departmentȱ ofȱ Technicalȱ Cooperationȱ forȱ
Essentialȱ Drugsȱ andȱ Traditionalȱ Medicineȱ andȱ forȱ givingȱ valuableȱ feedbackȱ onȱ anȱ
earlierȱversionȱofȱtheȱFactȱBook;ȱ
ȱ
Alexȱ Roweȱ andȱ Davidȱ Henryȱ forȱ givingȱ forȱ givingȱ valuableȱ feedbackȱ onȱ anȱ earlierȱ
versionȱofȱtheȱFactȱBookȱandȱforȱdetailedȱadviceȱonȱhowȱtoȱanalyseȱtheȱdata;ȱ
ȱ
Samȱ Rowe,ȱ Keesȱ deȱ Joncheere,ȱ Budionoȱ Santoso,ȱ Paulineȱ Norris,ȱ Nataliaȱ
Ceboratenco,ȱTeresaȱAlves,ȱKumariahȱBalasubramaniam,ȱEvaȱOmbaka,ȱJohnȱChalkerȱ
andȱAndyȱGrayȱforȱreviewingȱandȱgivingȱvaluableȱfeedbackȱonȱanȱearlierȱversionȱofȱ
theȱFactȱBook.ȱ
ȱ
Allȱ individualȱ authorsȱ whoseȱ workȱ isȱ includedȱ inȱ theȱ database,ȱ andȱ staffȱ inȱ theȱ
DocumentationȱCentreȱofȱtheȱDepartmentȱofȱEssentialȱMedicinesȱandȱPharmaceuticalȱ
Policies,ȱ WHOȱ andȱ inȱ theȱ Rationalȱ Pharmaceuticalȱ Managementȱ Projectȱ inȱ
ManagementȱSciencesȱforȱHealth,ȱwhoȱprovidedȱreportsȱandȱdetailsȱofȱmedicinesȱuseȱ
surveys.ȱ
– iii –
– iv –
Table of contents
CONTENTS
PREFACE...............................................................................................................................................................i
ACKNOWLEDGEMENTS.............................................................................................................................. iii
CONTENTS .........................................................................................................................................................v
LISTȱOFȱFIGURES........................................................................................................................................... vii
LISTȱOFȱTABLES...............................................................................................................................................ix
ABBREVIATIONS ............................................................................................................................................xi
SUMMARYȱOFȱKEYȱPOINTS...................................................................................................................... xiii
1. INTRODUCTION............................................................................................................................... 1
1.1 Background ............................................................................................................................... 1
1.2 Workingȱtowardsȱrationalȱuseȱofȱmedicines ....................................................................... 1
1.3 Overviewȱofȱthisȱreport ........................................................................................................... 3
2. METHODS........................................................................................................................................... 5
2.1 ObjectivesȱofȱtheȱWHOȱdatabaseȱonȱmedicinesȱuse.......................................................... 5
2.2 Stepsȱtoȱcreateȱtheȱdatabase.................................................................................................... 5
2.3 Databaseȱformatȱandȱdesign................................................................................................... 5
2.4 Searchȱstrategyȱandȱcriteria .................................................................................................... 8
2.5 Dataȱentry .................................................................................................................................. 9
2.6 Dataȱcleaning .......................................................................................................................... 10
2.7 Definitions,ȱvariables,ȱandȱdataȱsources ............................................................................ 10
2.7.1 Dataȱsourcesȱforȱdescriptiveȱanalyses .................................................................................11
2.7.2 Dataȱsourcesȱforȱinterventionȱanalyses...............................................................................11
2.8 Dataȱanalysis ........................................................................................................................... 11
2.8.1 Baselineȱanalysisȱofȱmedicinesȱuseȱindicators....................................................................12
2.8.2 Interventionȱimpactȱanalysis................................................................................................12
2.9 Limitations............................................................................................................................... 13
2.9.1 Limitationsȱofȱtheȱdataȱcollection ........................................................................................14
2.9.2 Limitationsȱofȱtheȱdataȱanalysis:ȱDescriptionȱofȱmedicinesȱuse.......................................15
2.9.3 Limitationsȱofȱtheȱdataȱanalysis:ȱEvaluationȱofȱinterventions .........................................15
3. DESCRIPTIONȱOFȱSTUDIES ........................................................................................................ 17
3.1 Resultsȱofȱsearchȱinȱpublishedȱandȱunpublishedȱliterature........................................... 17
3.2 CrossȬsectionalȱstudiesȱofȱmedicinesȱuseȱandȱpatientȱcare............................................. 17
3.3 Baselineȱmedicinesȱuseȱstudiesȱforȱspecificȱdiseases ...................................................... 23
4. WHO/INRUDȱPRESCRIBINGȱINDICATORS ........................................................................... 25
4.1 Medicinesȱuseȱoverȱtime ....................................................................................................... 25
4.2 Medicinesȱuseȱbyȱregion ....................................................................................................... 26
4.3 Medicinesȱuseȱbyȱtypeȱofȱprescriber................................................................................... 29
4.4 MedicinesȱuseȱbyȱhealthȬcareȱfacilityȱownership............................................................. 30
5. WHO/INRUDȱPATIENTȱCAREȱANDȱHEALTHȱFACILITYȱINDICATORS......................... 33
5.1 Patientȱcareȱindicators ........................................................................................................... 33
5.2 HealthȬcareȱfacilityȱindicators.............................................................................................. 37
– v –
6. TREATMENTȱOFȱACUTEȱRESPIRATORYȱTRACTȱINFECTIONS ....................................... 43
6.1 PatternsȱinȱtreatmentȱofȱARIȱoverȱtime .............................................................................. 43
6.2 PatternsȱinȱtreatmentȱofȱARIȱbyȱregion,ȱfacilityȱownership,ȱandȱprescriberȱtype ...... 45
7. TREATMENTȱOFȱACUTEȱDIARRHOEA .................................................................................... 51
7.1 Patternsȱinȱtreatmentȱofȱacuteȱdiarrhoeaȱoverȱtime.......................................................... 51
7.2 Patternsȱinȱtreatmentȱofȱacuteȱdiarrhoeaȱbyȱregion,ȱfacilityȱownershipȱȱ
andȱprescriberȱtype ................................................................................................................ 53
8. TREATMENTȱOFȱMALARIA......................................................................................................... 59
9. INAPPROPRIATEȱANTIBIOTICȱUSE ......................................................................................... 61
9.1 Inappropriateȱantibioticȱprescribingȱoverȱtime ................................................................ 61
9.2 Inappropriateȱantibioticȱprescribingȱbyȱregion,ȱfacilityȱownershipȱandȱtypeȱofȱ
prescriber ................................................................................................................................. 62
10. INTERVENTIONSȱTOȱIMPROVEȱUSEȱOFȱMEDICINES........................................................ 67
10.1 Overviewȱofȱinterventionsȱtoȱimproveȱmedicinesȱuse .................................................... 67
10.2 ImpactȱofȱwellȬdesignedȱinterventionsȱtoȱimproveȱmedicinesȱuse............................... 75
10.3 ComparisonȱofȱpaediatricȱandȱnonȬpaediatricȱinterventions......................................... 79
10.4 Comparisonȱofȱpaediatricȱinterventionsȱtargetingȱdifferentȱconditions...................... 83
11. DISCUSSIONȱANDȱRECOMMENDATIONS............................................................................ 85
11.1 Majorȱfindings ........................................................................................................................ 85
11.2 Remainingȱgapsȱinȱknowledge ............................................................................................ 86
11.3 Recommendations.................................................................................................................. 87
11.3.1 Maintaining,ȱupdating,ȱandȱdisseminatingȱtheȱdatabase .................................................87
11.3.2 Expandingȱtheȱdatabaseȱcontent..........................................................................................88
ANNEXȱ1:ȱSUMMARYȱOFȱDATAȱINCLUDEDȱINȱFIGURES................................................................. 91
ANNEXȱ2:ȱRESULTSȱBYȱWHOȱREGION .................................................................................................. 111
ANNEXȱ3:ȱWHOȱINDICATORSȱDATABASEȱMANUAL ...................................................................... 115
INTRODUCTION .......................................................................................................................................... 115
SECTIONȱ1........................................................................................................................................................... 119
SECTIONȱ2........................................................................................................................................................... 127ȱ
SECTIONȱ3........................................................................................................................................................... 132ȱ
SECTIONȱ4........................................................................................................................................................... 135ȱ
REFERENCES.................................................................................................................................................. 149
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– vi –
Table of contents
LIST OF FIGURES
Figureȱ3.1:ȱȱ Medicinesȱuseȱstudiesȱbyȱyearȱinȱwhichȱtheȱdataȱwereȱcollected................................ 18ȱ
Figureȱ3.2:ȱȱ MedicinesȱuseȱstudiesȱbyȱWorldȱBankȱregion ............................................................... 19ȱ
Figureȱ3.3:ȱȱ MedicinesȱuseȱstudiesȱbyȱWHOȱregion .......................................................................... 20ȱ
Figureȱ3.4:ȱȱ MedicinesȱuseȱstudiesȱbyȱWorldȱBankȱcountryȱincomeȱlevel...................................... 21ȱ
Figureȱ3.5:ȱȱ Medicinesȱuseȱstudiesȱbyȱprescriberȱtype ...................................................................... 21ȱ
Figureȱ3.6:ȱȱ Medicinesȱuseȱstudiesȱbyȱhealthȱfacilityȱownership ..................................................... 22ȱ
Figureȱ3.7:ȱȱ Medicinesȱuseȱstudiesȱbyȱfacilityȱtype ............................................................................ 22ȱ
Figureȱ4.1:ȱȱ WHO/INRUDȱprescribingȱindicators,ȱbyȱtimeȱperiod.................................................. 26ȱ
Figureȱ4.2:ȱȱ WHO/INRUDȱprescribingȱindicators,ȱbyȱWorldȱBankȱregion .................................... 27ȱ
Figureȱ4.3:ȱȱ WHO/INRUDȱprescribingȱindicators,ȱbyȱWorldȱBankȱincomeȱlevel.......................... 28ȱ
Figureȱ4.4:ȱ Ratesȱofȱadherenceȱtoȱclinicalȱguidelinesȱoverȱtime,ȱbyȱWorldȱBankȱregion ............. 29ȱ
Figureȱ4.5:ȱȱ WHO/INRUDȱprescribingȱindicatorsȱbyȱprescriberȱtype ............................................ 30ȱ
Figureȱ4.6:ȱȱ WHO/INRUDȱprescribingȱindicatorsȱbyȱhealthȱfacilityȱownershipȱ
(prescribingȱbyȱphysicians,ȱnursesȱandȱparamedicsȱonly)........................................... 31ȱ
Figureȱ5.1:ȱȱ WHO/INRUDȱpatientȱcareȱindicators,ȱbyȱtimeȱperiod................................................. 34ȱ
Figureȱ5.2:ȱȱ WHO/INRUDȱpatientȱcareȱindicators,ȱbyȱWorldȱBankȱregion.................................... 35ȱ
Figureȱ5.3:ȱȱ WHO/INRUDȱpatientȱcareȱindicators,ȱbyȱWorldȱBankȱincomeȱlevel ......................... 36ȱ
Figureȱ5.4:ȱȱ WHO/INRUDȱpatientȱcareȱindicators,ȱbyȱhealthȱfacilityȱownership.......................... 37ȱ
Figureȱ5.5:ȱȱ WHO/INRUDȱhealthȱfacilityȱindicators,ȱbyȱtimeȱperiod ............................................. 38ȱ
Figureȱ5.6:ȱȱ WHO/INRUDȱhealthȱfacilityȱindicators,ȱbyȱWorldȱBankȱregion ................................ 39ȱ
Figureȱ5.7:ȱȱ WHO/INRUDȱhealthȱfacilityȱindicators,ȱbyȱWorldȱBankȱincomeȱlevel...................... 40ȱ
Figureȱ5.8:ȱȱ WHO/INRUDȱhealthȱfacilityȱindicators,ȱbyȱfacilityȱownership .................................. 41ȱ
Figureȱ6.1:ȱȱ ARIȱprescribingȱindicatorsȱoverȱtime,ȱincludingȱallȱstudiesȱofȱmedicinesȱuseȱ
inȱARI .................................................................................................................................. 44ȱ
Figureȱ6.2:ȱȱ ARIȱtreatmentȱindicatorsȱoverȱtime,ȱincludingȱonlyȱstudiesȱofȱmedicinesȱ
useȱinȱchildrenȱ<ȱ5ȱyearsȱwithȱARI .................................................................................. 45ȱ
Figureȱ6.3:ȱȱ ARIȱtreatmentȱindicatorsȱincludingȱallȱstudiesȱofȱmedicinesȱuseȱinȱARI,ȱbyȱ
WorldȱBankȱregion ............................................................................................................ 46ȱ
WorldȱBankȱincomeȱlevel ................................................................................................. 47ȱ
typeȱofȱprescriber............................................................................................................... 48ȱ
healthȬcareȱfacilityȱownershipȱ(prescribingȱbyȱphysicians,ȱnurses,ȱandȱ
paramedicsȱonly) ............................................................................................................... 49ȱ
Figureȱ6.7:ȱȱ AvailabilityȱofȱkeyȱmedicinesȱinȱstudiesȱofȱmedicinesȱuseȱinȱARI,ȱbyȱWorldȱ
Bankȱregion......................................................................................................................... 50ȱ
Figureȱ7.1:ȱȱ Diarrhoeaȱtreatmentȱindicatorsȱoverȱtime,ȱincludingȱallȱstudiesȱofȱ
medicinesȱuseȱinȱacuteȱdiarrhoea .................................................................................... 52ȱ
Figureȱ7.2:ȱȱ Diarrhoeaȱtreatmentȱindicatorsȱoverȱtime,ȱincludingȱonlyȱstudiesȱofȱ
medicinesȱuseȱinȱchildrenȱ<5ȱyearsȱwithȱacuteȱdiarrhoea ............................................ 53ȱ
– vii –
Figureȱ7.3:ȱȱ Diarrhoeaȱtreatmentȱindicatorsȱincludingȱallȱstudiesȱofȱmedicinesȱuseȱforȱ
acuteȱdiarrhoea,ȱbyȱWorldȱBankȱregion.......................................................................... 54ȱ
acuteȱdiarrhoea,ȱbyȱWorldȱBankȱincomeȱlevel............................................................... 55ȱ
acuteȱdiarrhoea,ȱbyȱprescriberȱtype................................................................................. 56ȱ
acuteȱdiarrhoea,ȱbyȱhealthȱfacilityȱownershipȱ(prescribingȱbyȱphysicians,ȱ
nurses,ȱandȱparamedicsȱonly) .......................................................................................... 57ȱ
Figureȱ7.7:ȱȱ Availabilityȱofȱkeyȱmedicinesȱinȱstudiesȱofȱmedicinesȱuseȱforȱacuteȱ
diarrhoea,ȱbyȱWorldȱBankȱregion.................................................................................... 58ȱ
Figureȱ8.1:ȱȱ Prescribingȱofȱrecommendedȱantimalarialȱtreatmentȱoverȱtime,ȱincludingȱ
allȱstudiesȱofȱantimalarialȱuse .......................................................................................... 59ȱ
Figureȱ8.2:ȱȱ Prescribingȱofȱrecommendedȱantimalarialȱtreatmentȱoverȱtime,ȱcomparingȱ
studiesȱofȱchildrenȱ<5ȱvs.ȱstudiesȱofȱtheȱgeneralȱpopulation ....................................... 60ȱ
Figureȱ9.1:ȱȱ Inappropriateȱprescribingȱofȱantibioticsȱoverȱtime ....................................................... 61ȱ
Figureȱ9.2:ȱȱ Inappropriateȱprescribingȱofȱantibiotics,ȱbyȱWorldȱBankȱregion ................................ 62ȱ
Figureȱ9.3:ȱȱ Inappropriateȱprescribingȱofȱantibiotics,ȱbyȱWorldȱBankȱincomeȱlevel ..................... 63ȱ
Figureȱ9.4:ȱȱ Inappropriateȱprescribingȱofȱantibiotics,ȱbyȱtypeȱofȱprescriber................................... 64ȱ
Figureȱ9.5:ȱȱ Inappropriateȱprescribingȱofȱantibiotics,ȱbyȱhealthȬcareȱfacilityȱownershipȱ
(prescribingȱbyȱphysicians,ȱnurses,ȱandȱparamedicsȱonly).......................................... 65ȱ
Figureȱ10.1:ȱȱ Typesȱofȱinterventionȱstudiesȱclassifiedȱbyȱdominantȱinterventionȱ
component .......................................................................................................................... 68ȱ
Figureȱ10.2:ȱȱ Typesȱofȱstudyȱdesignsȱinȱstudiesȱtoȱevaluateȱmedicinesȱuseȱinterventions,ȱ
byȱmethodologicalȱquality................................................................................................ 70ȱ
Figureȱ10.3:ȱȱ Methodologicalȱqualityȱofȱinterventionȱstudiesȱbyȱtimeȱperiod ................................. 71ȱ
Figureȱ10.4:ȱȱ Interventionsȱofȱadequateȱmethodologicalȱqualityȱclassifiedȱbyȱdominantȱ
interventionȱcomponent ................................................................................................... 75ȱ
Figureȱ10.5:ȱȱ Largestȱreportedȱpercentageȱchangeȱinȱanyȱstudyȱoutcomeȱforȱallȱ
interventions,ȱbyȱtypeȱofȱintervention ............................................................................ 76ȱ
Figureȱ10.6:ȱȱ Medianȱreportedȱpercentageȱchangeȱacrossȱallȱstudyȱoutcomesȱforȱ
prescribingȱimprovementȱinterventions,ȱbyȱtypeȱofȱintervention .............................. 78ȱ
Figureȱ10.7:ȱȱ QualityȱofȱstudyȱdesignsȱusedȱinȱnonȬpaediatricȱinterventions,ȱbyȱtypeȱofȱ
intervention ........................................................................................................................ 79ȱ
Figureȱ10.8:ȱȱ Qualityȱofȱstudyȱdesignsȱusedȱinȱpaediatricȱinterventions,ȱbyȱtypeȱofȱ
intervention ........................................................................................................................ 80ȱ
Figureȱ10.9:ȱȱ Medianȱreportedȱpercentageȱchangeȱacrossȱallȱprescribingȱoutcomesȱforȱ
wellȬdesignedȱnonȬpaediatricȱprescribingȱimprovementȱinterventions,ȱbyȱ
typeȱofȱintervention ........................................................................................................... 81ȱ
Figureȱ10.10:ȱȱ Medianȱreportedȱpercentageȱchangeȱacrossȱallȱprescribingȱoutcomesȱforȱ
wellȬdesignedȱpaediatricȱprescribingȱimprovementȱinterventions,ȱbyȱtypeȱ
ofȱintervention.................................................................................................................... 82ȱ
Figureȱ10.11:ȱȱ Methodologicalȱqualityȱofȱprescribingȱimprovementȱinterventionsȱtargetingȱ
commonȱpaediatricȱinfections,ȱbyȱproblemȱfocus ......................................................... 83
– viii –
Table of contents
Figureȱ10.12:ȱȱ MedianȱreportedȱpercentageȱchangeȱinȱprescribingȱoutcomesȱinȱwellȬ
designedȱpaediatricȱprescribingȱimprovementȱinterventionsȱtargetingȱ
commonȱinfections,ȱbyȱproblemȱfocus............................................................................ 84
ȱ
AnnexȱFigureȱ2.1:ȱȱWHO/INRUDȱprescribingȱindicatorsȱbyȱWHOȱregion .............................................. 111
AnnexȱFigureȱ2.2:ȱȱWHO/INRUDȱpatientȱcareȱindicatorsȱbyȱWHOȱregion.............................................. 111
AnnexȱFigureȱ2.3:ȱȱWHO/INRUDȱhealthȱfacilityȱindicatorsȱbyȱWHOȱregion .......................................... 112
AnnexȱFigureȱ2.4:ȱȱARIȱtreatmentȱindicatorsȱinȱstudiesȱthatȱincludedȱpatientsȱofȱallȱagesȱbyȱ
WHOȱregion ..................................................................................................................... 112
AnnexȱFigureȱ2.5:ȱȱDiarrhoeaȱtreatmentȱindicatorsȱinȱstudiesȱthatȱincludedȱpatientsȱofȱallȱagesȱ
byȱWHOȱregion................................................................................................................ 113
AnnexȱFigureȱ2.6:ȱȱInappropriateȱantibioticȱprescribingȱbyȱWHOȱregion ................................................ 113
ȱ
LIST OF TABLES
Tableȱ1.1:ȱȱ TwelveȱcoreȱinterventionsȱrecommendedȱbyȱWHOȱtoȱpromoteȱmoreȱ
appropriateȱuseȱofȱmedicines............................................................................................. 2ȱ
Tableȱ2.1:ȱȱ ListȱofȱselectedȱmedicinesȱuseȱindicatorsȱforȱtheȱWHOȱdatabase ................................. 7ȱ
Tableȱ10.1:ȱȱ Individualȱapproachesȱincludedȱinȱdifferentȱtypesȱofȱinterventions.......................... 69ȱ
Tableȱ10.2:ȱȱ DistributionȱofȱinterventionȱstudiesȱbyȱWorldȱBankȱRegion,ȱcountryȱ
income,ȱhealthȱfacilityȱownership,ȱprescriberȱtype....................................................... 72ȱ
Tableȱ10.3:ȱȱ Numbersȱofȱpatientsȱandȱhealthȱfacilitiesȱincludedȱinȱtheȱbasicȱsamplesȱofȱ
interventionȱstudies,ȱbyȱqualityȱofȱresearchȱdesign ...................................................... 73ȱ
Tableȱ10.4:ȱȱ Proportionȱofȱinterventionȱstudiesȱmeasuringȱeachȱmedicinesȱuseȱoutcomeȱ
recordedȱinȱtheȱdatabase,ȱbyȱstudyȱquality.................................................................... 74ȱ
ȱ
– ix –
– x –
Abbreviations
ABBREVIATIONS
AFRO*ȱȱ WHOȱRegionalȱOfficeȱforȱAfricaȱ
AMRO*ȱȱ WHOȱRegionalȱOfficeȱforȱtheȱAmericasȱ
ARIȱȱ Acuteȱrespiratoryȱinfectionȱ
EMLȱ EssentialȱMedicinesȱListȱ
EMPȱ EssentialȱMedicinesȱPolicyȱ
EMRO*ȱ WHOȱRegionalȱOfficeȱforȱtheȱEasternȱMediterraneanȱ
EURO*ȱȱ WHOȱRegionalȱOfficeȱforȱEuropeȱ
ICIUMȱ InternationalȱConferenceȱonȱImprovingȱUseȱofȱMedicinesȱ
IMCIȱ IntegratedȱManagementȱofȱChildhoodȱIllnessȱ
INRUDȱ InternationalȱNetworkȱforȱtheȱRationalȱUseȱofȱDrugsȱ
JRIUMȱ JointȱResearchȱInitiativeȱonȱImprovingȱtheȱUseȱofȱMedicinesȱȱ
MDȱ MedicalȱDoctorȱ
MSHȱ ManagementȱSciencesȱforȱHealthȱȱ
NMPȱ NationalȱMedicinesȱPolicyȱ
NGOȱ Nongovernmentalȱorganizationȱ
ORSȱ Oralȱrehydrationȱsolutionȱ
ORTȱȱ Oralȱrehydrationȱtherapyȱ
PHCȱ Primaryȱcareȱfacilityȱorȱhealthȱcentreȱ
SEARO*ȱȱ WHOȱRegionalȱOfficeȱforȱSouthȬEastȱAsiaȱ
STGȱȱ Standardȱtreatmentȱguidelinesȱ
URTIȱ Upperȱrespiratoryȱtractȱinfectionȱ
USAIDȱ UnitedȱStatesȱAgencyȱforȱInternationalȱDevelopmentȱ
WHOȱȱ WorldȱHealthȱOrganizationȱ
WPRO*ȱȱ WHOȱRegionalȱOfficeȱforȱtheȱWesternȱPacificȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
ȱ
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*ȱ WHOȱ Regionalȱ Officesȱ wereȱ usedȱ toȱ groupȱ countriesȱ forȱ purposesȱ ofȱ regionalȱ dataȱ summaryȱ andȱ
analysis.ȱ
– xi –
– xii –
Summary of key points
SUMMARY OF KEY POINTS

Background
Inappropriateȱ useȱ ofȱ prescriptionȱ medicinesȱ isȱ aȱ globalȱ problemȱ withȱ seriousȱ
consequencesȱforȱpatientsȱinȱtermsȱofȱpoorȱhealthȱoutcomes,ȱincreasedȱadverseȱdrugȱ
events,ȱacceleratingȱratesȱofȱantimicrobialȱresistance,ȱspreadȱofȱbloodȬborneȱinfectionsȱ
dueȱtoȱnonȬsterileȱinjections,ȱandȱwasteȱofȱscarceȱhealthȱresources.ȱȱ
ȱ
Manyȱ countriesȱ haveȱ adoptedȱ Nationalȱ Medicinesȱ Policiesȱ andȱ Essentialȱ Medicinesȱ
Programmesȱ thatȱ includeȱ componentsȱ toȱ promoteȱ moreȱ appropriateȱ useȱ ofȱ
medicines.ȱHowever,ȱtheseȱeffortsȱareȱoftenȱhaphazardȱandȱtheirȱimpactsȱhaveȱrarelyȱ
beenȱthoroughlyȱevaluated.ȱOneȱreasonȱforȱthisȱmayȱbeȱaȱlackȱofȱevidenceȱaboutȱtheȱ
seriousnessȱ ofȱ theȱ problemȱ ofȱ inappropriateȱ useȱ ofȱ medicinesȱ andȱ aboutȱ theȱ
effectivenessȱ ofȱ variousȱ smallȬscaleȱ interventionsȱ thatȱ haveȱ beenȱ testedȱ toȱ improveȱ
medicinesȱuse.ȱ
Objective
Theȱ objectiveȱ wasȱ toȱ undertakeȱ aȱ systematic,ȱ quantitativeȱ reviewȱ ofȱ studiesȱ
publishedȱbetweenȱ1990ȱandȱ2007ȱaboutȱmedicinesȱuseȱinȱdevelopingȱandȱtransitionalȱ
countries,ȱandȱtoȱassessȱtheȱimpactȱofȱinterventionsȱundertakenȱtoȱimproveȱuse.ȱ
Methods
WHOȱ createdȱ aȱ databaseȱ ofȱ studiesȱ onȱ theȱ useȱ ofȱ medicinesȱ inȱ primaryȱ careȱ inȱ
developingȱandȱtransitionalȱcountries.ȱTheȱdatabaseȱincludesȱsystematicallyȱextractedȱ
quantitativeȱinformationȱonȱcommonlyȱusedȱindicatorsȱofȱmedicinesȱuseȱmeasuredȱinȱ
theseȱ studiesȱ asȱ wellȱ asȱ detailsȱ onȱ studyȱ settingȱ andȱ methodologyȱ extractedȱ fromȱ
publishedȱ andȱ unpublishedȱ articlesȱ andȱ reports.ȱ Inȱ addition,ȱ theȱ databaseȱ alsoȱ
containsȱinformationȱonȱanyȱinterventionȱimplementedȱtoȱimproveȱuseȱofȱmedicinesȱ
reportedȱinȱtheseȱstudies.ȱȱ
ȱ
Allȱstudiesȱpublishedȱduringȱ1990Ȭ2006ȱreportingȱquantitativeȱdataȱonȱmedicinesȱuseȱ
atȱ theȱ primaryȱ careȱ levelȱ wereȱ eligibleȱ toȱ beȱ includedȱ inȱ theȱ database.ȱ Toȱ identifyȱ
studies,ȱ weȱ searchedȱ variousȱ sourcesȱ likelyȱ toȱ containȱ studiesȱ ofȱ interest,ȱ includingȱ
theȱ Internationalȱ Networkȱ forȱ theȱ Rationalȱ Useȱ ofȱ Drugsȱ (INRUD)ȱ Bibliographyȱ onȱ
medicinesȱuse,1ȱEmbase,ȱPubMed,ȱandȱtheȱarchivesȱofȱWHOȱdepartmentsȱconcernedȱ
withȱ medicinesȱ andȱ childȱ health;ȱ weȱ alsoȱ contactedȱ otherȱ agenciesȱ involvedȱ inȱ
primaryȱcareȱandȱmedicinesȱprogrammesȱforȱreportsȱofȱmedicinesȱuseȱstudies.ȱȱToȱbeȱ
includedȱ inȱ theȱ database,ȱ studiesȱ hadȱ toȱ reportȱ quantitativeȱ dataȱ usingȱ commonȱ
medicinesȱ useȱ indicators,ȱ includingȱ theȱ WHO/INRUDȱ indicators2ȱ andȱ theȱ WHOȱ
IMCIȱ indicators.3ȱ Allȱ articlesȱ identifiedȱ forȱ possibleȱ entryȱ intoȱ theȱ databaseȱ wereȱ
reviewedȱ byȱ twoȱ authorsȱ (KH,ȱ VI).ȱ Oneȱ authorȱ extractedȱ andȱ enteredȱ informationȱ
aboutȱ theȱ studyȱ andȱ theȱ reportedȱ dataȱ onȱ medicinesȱ useȱ intoȱ theȱ databaseȱ andȱ theȱ
otherȱcheckedȱallȱentries.ȱȱ
ȱ
– xiii –
Aȱ Microsoftȱ Access©ȱ databaseȱ wasȱ createdȱ toȱ recordȱ theȱ extractedȱ data.ȱ ȱ Asȱ farȱ asȱ
possible,ȱ theȱ databaseȱ containsȱ oneȱ recordȱ perȱ studyȱ groupȱ (i.e.,ȱ aȱ specificȱ typeȱ ofȱ
healthȱproviderȱpracticingȱinȱaȱspecificȱsectorȱorȱsetting);ȱinterventionȱstudiesȱcontainȱ
dataȱ onȱ theȱ characteristicsȱ ofȱ eachȱ ofȱ theȱ individualȱ studyȱ groupsȱ identifiedȱ byȱ theȱ
interventionȱ design.ȱ Dataȱ fromȱ theȱ sameȱ studyȱ reportedȱ inȱ multipleȱ articlesȱ wereȱ
onlyȱenteredȱonce.ȱArticlesȱthatȱreportedȱdataȱseparatelyȱfromȱmultipleȱcountriesȱorȱ
resultsȱ forȱ differentȱ typesȱ ofȱ healthȱ facilityȱ orȱ prescriberȱ wereȱ enteredȱ intoȱ theȱ
databaseȱ asȱ separateȱ records.ȱ Studyȱ patientȱ populationsȱ wereȱ characterizedȱ byȱ age,ȱ
treatmentȱlocationȱandȱdisease.ȱ
ȱ
Thisȱreviewȱcontainsȱresultsȱfromȱallȱstudiesȱinȱtheȱdatabaseȱpublishedȱupȱtoȱtheȱendȱ
ofȱ 2006,ȱ withȱ someȱ additionalȱ studiesȱ onȱ theȱ Integratedȱ Managementȱ ofȱ Sickȱ
Childrenȱ(IMCI)ȱfromȱ2007.ȱȱWeȱconvertedȱtheȱAccessȱdatabaseȱintoȱSAS©ȱtoȱassessȱ
dataȱqualityȱandȱtoȱconductȱstatisticalȱanalyses.ȱȱWeȱcalculatedȱtheȱmedianȱvalueȱofȱ
eachȱ indicatorȱ ofȱ interestȱ acrossȱ allȱ studiesȱ reportingȱ theȱ indicator,ȱ byȱ yearȱ ofȱ dataȱ
collection,ȱregion,ȱcountryȱincome,ȱfacilityȱownership,ȱandȱprescriberȱtype.ȱȱTheȱfinalȱ
dataȱsetȱwasȱconvertedȱtoȱMicrosoftȱExcel©ȱtoȱcreateȱgraphsȱandȱtables.ȱȱȱ
ȱ
Studiesȱ thatȱ reportedȱ theȱ impactsȱ ofȱ interventionsȱ orȱ policiesȱ intendedȱ toȱ improveȱ
useȱ ofȱ medicinesȱ wereȱ categorizedȱ byȱ typeȱ ofȱ intervention.ȱ Weȱ assessedȱ theȱ
methodologicalȱqualityȱofȱtheȱresearchȱdesignsȱofȱtheseȱstudiesȱandȱlimitedȱanalysisȱ
ofȱ interventionȱ impactsȱ toȱ studiesȱ thatȱ metȱ commonlyȱ acceptedȱ standardsȱ ofȱ
adequateȱ studyȱ designȱ (randomizedȱ controlledȱ trials,ȱ timeȱ seriesȱ withȱ orȱ withoutȱ
comparisonȱ series,ȱ andȱ preȬpostȱ withȱ control).ȱ Twoȱ methodsȱ wereȱ usedȱ toȱ
summarizeȱtheȱeffectsȱacrossȱstudies.ȱTheȱfirstȱmethodȱcomparedȱtheȱlargestȱreportedȱ
improvementȱ inȱ aȱ keyȱ medicinesȱ useȱ outcomeȱ thatȱ wasȱ targetedȱ byȱ theȱ individualȱ
authors.ȱ Theȱ secondȱ methodȱ calculatedȱ aȱ compositeȱ indicatorȱ ofȱ improvementȱ forȱ
eachȱstudyȱbyȱcalculatingȱtheȱmedianȱeffectȱacrossȱallȱoutcomeȱmeasuresȱreportedȱinȱ
theȱ mainȱ categoryȱ ofȱ outcomesȱ targetedȱ byȱ theȱ authors;ȱ prescribingȱ practicesȱ wereȱ
theȱ majorȱ outcomesȱ targetedȱ inȱ overȱ 90%ȱ ofȱ studies,ȱ althoughȱ someȱ alsoȱ targetedȱ
measuresȱofȱpatientȱcareȱorȱmortality.ȱȱ
Results
Weȱidentifiedȱandȱenteredȱdataȱfromȱ679ȱstudiesȱconductedȱinȱ97ȱcountriesȱintoȱ856ȱ
recordsȱ inȱ theȱ database.ȱ Forȱ theȱ 711ȱ databaseȱ recordsȱ (representingȱ 559ȱ studies)ȱ
whereȱ theȱ institutionalȱ settingȱ couldȱ beȱ determined,ȱ aȱ largeȱ majorityȱ (71%)ȱ wereȱ
undertakenȱinȱtheȱpublicȱsector,ȱwithȱ29%ȱconductedȱinȱtheȱprivateȱsectorȱ(26%ȱinȱtheȱ
privateȱ forȬprofitȱ settingsȱ andȱ 3%ȱ inȱ privateȱ notȬforȬprofitȱ settings).ȱ Onlyȱ 13%ȱ ofȱ
studiesȱlookedȱatȱmedicinesȱuseȱinȱpharmacyȱshopsȱandȱonlyȱ2%ȱatȱmedicinesȱuseȱinȱ
nonȬlicensedȱ shopsȱ evenȱ thoughȱ privateȱ medicineȱ retailersȱ accountȱ forȱ theȱ majorityȱ
ofȱmedicineȱtransactionsȱinȱprimaryȱcareȱinȱmanyȱdevelopingȱcountries.ȱȱ
ȱ
Changesȱinȱmedicinesȱuseȱoverȱtheȱpastȱ25ȱyearsȱhaveȱbeenȱvariable.ȱȱInȱallȱregions,ȱ
lessȱthanȱhalfȱofȱallȱpatientsȱwereȱtreatedȱaccordingȱtoȱclinicalȱguidelinesȱforȱcommonȱ
diseasesȱ inȱ primaryȱ care.ȱ Theȱ treatmentsȱ ofȱ acuteȱ respiratoryȱ tractȱ infectionȱ andȱ
malariaȱ haveȱ notȱ improvedȱ considerablyȱ overȱ time;ȱ treatmentȱ ofȱ diarrhoea,ȱ whileȱ
stillȱ deficient,ȱ showsȱ someȱ improvement.ȱ Lessȱ thanȱ 60%ȱ ofȱ pneumoniaȱ casesȱ wereȱ
– xiv –
Summary of key points
treatedȱ withȱ anȱ appropriateȱ antibiotic,ȱ andȱ moreȱ thanȱ halfȱ ofȱ allȱ casesȱ ofȱ upperȱ
respiratoryȱtractȱinfectionȱreceivedȱantibiotics,ȱmostȱofȱthemȱunnecessarily.ȱLessȱthanȱ
60%ȱ ofȱ childrenȱ withȱ diarrhoeaȱ receivedȱ oralȱ rehydrationȱ therapy,ȱ andȱ moreȱ thanȱ
40%ȱreceivedȱantibiotics,ȱagainȱmostlyȱunnecessarily.ȱOnlyȱaboutȱhalfȱofȱallȱmalariaȱ
casesȱreceivedȱanȱappropriateȱantimalarial.ȱAnȱencouragingȱsignȱisȱtheȱincreaseȱinȱtheȱ
useȱofȱgenericȱandȱessentialȱmedicinesȱinȱtheȱpublicȱsector.ȱȱ
ȱ
Theȱuseȱofȱmedicinesȱinȱtheȱpublicȱsectorȱwasȱsubstantiallyȱbetterȱthanȱinȱtheȱprivateȱ
sectorȱ forȱ WHO/INRUDȱ prescribingȱ indicatorsȱ andȱ alsoȱ forȱ theȱ treatmentȱ ofȱ ARI,ȱ
diarrhoeaȱ andȱ malaria.ȱ Byȱ contrast,ȱ inȱ theȱ privateȱ sector,ȱ thereȱ wereȱ longerȱ
consultationȱ times,ȱ betterȱ labelling,ȱ andȱ betterȱ patientȱ knowledgeȱ ofȱ dosing.ȱ
Prescribingȱbyȱparamedicalȱandȱnursingȱstaffȱwasȱasȱgoodȱasȱthatȱofȱdoctorsȱforȱtheȱ
practicesȱmeasuredȱbyȱtheȱWHO/INRUDȱindicatorsȱandȱwithȱregardȱtoȱtheȱtreatmentȱ
ofȱȱacuteȱrespiratoryȱtractȱinfection,ȱdiarrhoeaȱandȱappropriateȱuseȱofȱantibiotics.ȱ
ȱ
Althoughȱ386ȱseparateȱinterventionsȱwereȱevaluatedȱinȱ313ȱstudies,ȱonlyȱ121ȱofȱthemȱ
wereȱ adequatelyȱ evaluatedȱ inȱ 81ȱ studies.ȱ Theȱ evidenceȱ baseȱ aboutȱ interventionȱ
effectsȱ hasȱ grownȱ slowlyȱ andȱ theȱ proportionȱ ofȱ studiesȱ usingȱ acceptableȱ researchȱ
designsȱ hasȱ notȱ improvedȱ overȱ time.ȱ Theȱ situationȱ isȱ particularlyȱ criticalȱ forȱ
interventionsȱ toȱ improveȱ useȱ ofȱ medicinesȱ amongȱ children,ȱ whereȱ aȱ veryȱ smallȱ
proportionȱofȱstudiesȱcontributeȱtoȱknowledgeȱaboutȱinterventionȱeffectiveness.ȱ
ȱ
Theȱ mostȱ frequentȱ typesȱ ofȱ interventionsȱ evaluatedȱ haveȱ beenȱ educationalȱ
programmesȱ forȱ healthȱ providers,ȱ halfȱ ofȱ whichȱ wereȱ implementedȱ inȱ conjunctionȱ
withȱ educationalȱ programmesȱ forȱ patientsȱ orȱ consumers.ȱ Anȱ increasingȱ numberȱ ofȱ
studiesȱhaveȱevaluatedȱtheȱimpactȱofȱenhancedȱsupervision,ȱfrequentlyȱaccompaniedȱ
byȱ routineȱ monitoringȱ ofȱ prescribingȱ practice.ȱ Manyȱ surveysȱ haveȱ beenȱ conductedȱ
duringȱ theȱ implementationȱ ofȱ Nationalȱ Medicinesȱ Policies,ȱ Essentialȱ Medicinesȱ
Programmes,ȱ orȱ otherȱ nationalȱ policies,ȱ butȱ theirȱ uncontrolled,ȱ crossȬsectionalȱ
designsȱprovideȱvirtuallyȱnoȱevidenceȱtoȱsupportȱtheȱpositiveȱeffectsȱofȱtheseȱpoliciesȱ
onȱappropriateȱuseȱofȱmedicines.ȱ
ȱ
Theȱmostȱeffectiveȱinterventionsȱinȱtermsȱofȱlargestȱpositiveȱeffectsȱonȱmedicinesȱuseȱ
outcomesȱ haveȱ combinedȱ multipleȱ interventionȱ components,ȱ especiallyȱ thoseȱ
characterizedȱ byȱ enhancedȱ healthȱ workerȱ supervisionȱ combinedȱ withȱ providerȱ andȱ
consumerȱ education.ȱ ȱ Interventionsȱ thatȱ involveȱ aȱ groupȱ educationalȱ processȱ forȱ
healthȱ workersȱ haveȱ alsoȱ hadȱ consistentlyȱ positiveȱ effects.ȱ ȱ Communityȱ caseȱ
managementȱisȱanotherȱexampleȱofȱaȱsuccessfulȱmultiȬcomponentȱstrategyȱtargetingȱ
paediatricȱ mortality.ȱ Nationalȱ medicinesȱ policies,ȱ regulationȱ andȱ printedȱ materialsȱ
areȱexamplesȱofȱinterventionsȱwithȱlimitedȱevidenceȱofȱimpact.ȱ
Conclusions
Inappropriateȱuseȱofȱmedicinesȱcontinuesȱtoȱbeȱaȱwidespreadȱproblemȱinȱdevelopingȱ
andȱ transitionalȱ countries.ȱ ȱ Basedȱ onȱ reportsȱ publishedȱ betweenȱ 1990ȱ andȱ 2006,ȱ
prescribingȱandȱpatientȱcareȱpracticesȱdidȱnotȱexhibitȱmuchȱimprovement.ȱSinceȱmostȱ
studiesȱ includedȱ inȱ thisȱ reviewȱ wereȱ conductedȱ inȱ theȱ publicȱ sectorȱ whereȱ useȱ ofȱ
medicinesȱisȱgenerallyȱthoughtȱtoȱbeȱbetterȱthanȱinȱtheȱprivateȱsector,ȱitȱisȱlikelyȱthatȱ
– xv –
theȱ overallȱ situationȱ isȱ worseȱ thanȱ reported.ȱ Sinceȱ theȱ majorityȱ ofȱ healthȱ careȱ isȱ
undertakenȱ byȱ theȱ privateȱ sectorȱ inȱ manyȱ countries,ȱ includingȱ bothȱ forȱ profitȱ andȱ
nonȬprofitȱ providersȱ ofȱ care,ȱ thereȱ isȱ anȱ urgentȱ needȱ toȱ conductȱ moreȱ studiesȱ toȱ
measureȱqualityȱofȱmedicinesȱuseȱinȱthisȱsector.ȱȱ
ȱ
Weȱ foundȱ thatȱ onlyȱ 121ȱ ofȱ 386ȱ interventionsȱ wereȱ evaluatedȱ usingȱ validȱ studyȱ
designs,ȱindicatingȱtheȱpaucityȱofȱbothȱreportedȱexperienceȱwithȱinterventionsȱasȱwellȱ
asȱ limitedȱ evidenceȱ aboutȱ theirȱ effectiveness.ȱ However,ȱ theȱ limitedȱ resultsȱ areȱ
generallyȱsimilarȱtoȱthoseȱfromȱindustrializedȱcountries.ȱMultiȬfacetedȱ interventionsȱ
involvingȱbothȱeducationȱandȱmanagerialȱsystemsȱhaveȱtendedȱtoȱbeȱmoreȱeffectiveȱ
thanȱ thoseȱ thatȱ employȱ oneȱ strategyȱ only.ȱ Countriesȱ needȱ toȱ extendȱ theȱ rangeȱ ofȱ
interventionsȱ tested,ȱ especiallyȱ inȱ theȱ privateȱ sector,ȱ asȱ wellȱ asȱ toȱ examineȱ theȱ
impactsȱ ofȱ scalingȱ upȱ interventionsȱ shownȱ toȱ beȱ effectiveȱ inȱ smallȬscaleȱ studies.ȱ
Promisingȱ approachesȱ includeȱ interventionsȱ thatȱ haveȱ multipleȱ components,ȱ
especiallyȱ thoseȱ thatȱ includeȱ someȱ typeȱ ofȱ enhancedȱ supervisionȱ orȱ groupȱ processȱ
strategies.ȱȱ
ȱ
Theȱ creationȱ ofȱ theȱ medicinesȱ useȱ databaseȱ hasȱ allowedȱ theȱ firstȱ systematicȱ
quantitativeȱreviewȱofȱstudiesȱmeasuringȱmedicinesȱuseȱindicatorsȱinȱdevelopingȱandȱ
transitionalȱ countries.ȱ Nevertheless,ȱ theȱ databaseȱ andȱ ourȱ analysesȱ haveȱ severalȱ
limitations.ȱ ȱ Theȱ databaseȱ isȱ limitedȱ toȱ reportsȱ ofȱ medicinesȱ useȱ practicesȱ thoughtȱ
importantȱ enoughȱ toȱ beȱ assessed;ȱ itȱ isȱ probablyȱ notȱ representativeȱ ofȱ allȱ medicinesȱ
useȱ problemsȱ inȱ developingȱ countriesȱ andȱ itȱ excludesȱ allȱ dataȱ fromȱ industrializedȱ
countriesȱ whereȱ moreȱ isȱ knownȱ aboutȱ useȱ ofȱ medicinesȱ andȱ interventionȱ
effectiveness.ȱ ȱ Whileȱ weȱ stratifiedȱ studiesȱ ofȱ medicinesȱ useȱ practicesȱ byȱ importantȱ
categoriesȱ (geographicȱ region,ȱ countryȱ income,ȱ healthȱ facilityȱ ownership,ȱ typeȱ ofȱ
prescriber),ȱ theȱ dataȱ wereȱ tooȱ sparseȱ toȱ conductȱ moreȱ elaborateȱ statisticalȱ analyses.ȱ
Weȱusedȱtheȱmedianȱresultȱwithinȱaȱgroupȱasȱtheȱmostȱrepresentativeȱexpressionȱofȱ
practiceȱ andȱ weȱ didȱ notȱ weightȱ studies,ȱ adjustȱ resultsȱ forȱ factorsȱ thatȱ influenceȱ
medicinesȱuseȱoverȱtime,ȱorȱadjustȱforȱclusteringȱofȱstudiesȱinȱaȱparticularȱregionȱorȱ
population.ȱForȱsomeȱindicators,ȱtimeȱpoints,ȱandȱsubgroups,ȱtheȱnumberȱofȱstudiesȱ
isȱsmallȱandȱtheȱdataȱmoreȱuncertain.ȱ
ȱ
Theseȱ limitationsȱ notwithstanding,ȱ theȱ evidenceȱ presentedȱ inȱ thisȱ reportȱ aboutȱ
continuingȱ problemsȱ inȱ useȱ ofȱ medicinesȱ isȱ compellingȱ andȱ shouldȱ beȱ usedȱ toȱ
advocateȱforȱgreaterȱinvestmentȱbyȱallȱstakeholdersȱinȱpromotingȱappropriateȱuseȱofȱ
medicines.ȱ
– xvi –
Introduction
1. INTRODUCTION
1.1 Background
Rationalȱ useȱ ofȱ medicinesȱ requiresȱ thatȱ patientsȱ receiveȱ medicationsȱ appropriateȱ toȱ
theirȱclinicalȱneeds,ȱinȱdosesȱthatȱmeetȱtheirȱrequirements,ȱforȱanȱadequateȱperiodȱofȱ
time,ȱandȱatȱtheȱlowestȱcostȱtoȱthemȱandȱtheirȱcommunity.4ȱȱUnfortunately,ȱmoreȱthanȱ
50%ȱ ofȱ allȱ medicinesȱ areȱ prescribed,ȱ dispensed,ȱ orȱ soldȱ inappropriatelyȱ onȱ aȱ globalȱ
basisȱandȱ50%ȱofȱpatientsȱfailȱtoȱtakeȱtheirȱmedicinesȱcorrectlyȱaccordingȱtoȱestimatesȱ
basedȱ onȱ variousȱ adȱ hocȱ reviews.5ȱ Commonȱ typesȱ ofȱ inappropriateȱ medicinesȱ useȱ
includeȱ polypharmacyȱ (theȱ useȱ ofȱ tooȱ manyȱ medicinesȱ perȱ patient),ȱ overuseȱ ofȱ
injections,ȱinappropriateȱuseȱofȱantimicrobials,ȱfailureȱtoȱprescribeȱinȱaccordanceȱwithȱ
clinicalȱ guidelines,ȱ andȱ inappropriateȱ selfȬmedication,ȱ oftenȱ withȱ prescriptionȬonlyȱ
medicines.ȱȱȱ
ȱ
Inappropriateȱ useȱ ofȱ medicinesȱ isȱ harmfulȱ forȱ patientsȱ inȱ termsȱ ofȱ poorȱ patientȱ
clinicalȱ outcomesȱ andȱ avoidableȱ adverseȱ drugȱ reactions.ȱ Overuseȱ ofȱ antimicrobialsȱ
exertsȱ pressureȱ toȱ increaseȱ ratesȱ ofȱ antimicrobialȱ resistance.ȱ NonȬsterileȱ injectionsȱ
contributeȱ toȱ theȱ transmissionȱ ofȱ hepatitis,ȱ HIV/AIDSȱ andȱ otherȱ bloodȬborneȱ
diseases.6,7,8ȱ ȱ Inappropriateȱ medicinesȱ useȱ wastesȱ scarceȱ economicȱ resourcesȱ thatȱ
couldȱ beȱ usedȱ forȱ foodȱ orȱ otherȱ necessities.ȱ Unnecessaryȱ overuseȱ ofȱ medicinesȱ canȱ
stimulateȱinappropriateȱpatientȱdemand5ȱandȱleadȱtoȱmedicineȱstockȬoutsȱandȱlossȱofȱ
patientȱconfidenceȱinȱtheȱhealthȱsystem.ȱ
1.2 Working towards rational use of medicines

Muchȱ hasȱ beenȱ doneȱ inȱ theȱ pastȱ 20ȱ yearsȱ toȱ improveȱ theȱ useȱ ofȱ medicines.ȱ ȱ Theȱ
presentȱ definitionȱ ofȱ rationalȱ useȱ ofȱ medicinesȱ wasȱ agreedȱ atȱ theȱ internationalȱ
conferenceȱ ofȱ expertsȱ inȱ Kenyaȱ inȱ 1985ȱ andȱ endorsedȱ byȱ aȱ Worldȱ Healthȱ Assemblyȱ
Resolutionȱinȱtheȱfollowingȱyear.4ȱȱTheȱInternationalȱNetworkȱforȱtheȱRationalȱUseȱofȱ
Drugsȱ (INRUD)ȱ wasȱ formedȱ inȱ 1989ȱ withȱ theȱ objectiveȱ ofȱ undertakingȱ
multidisciplinaryȱ interventionȱ researchȱ toȱ promoteȱ appropriateȱ useȱ ofȱ medicinesȱ inȱ
developingȱ countries.9,10ȱ ȱ INRUDȱ coreȱ groupsȱ fromȱ manyȱ countriesȱ inȱ Africaȱ andȱ
Asiaȱ participatedȱ inȱ theȱ developmentȱ ofȱ theȱ WHO/INRUDȱ indicatorsȱ toȱ investigateȱ
medicinesȱ useȱ inȱ primaryȱ careȱ facilities,ȱ whichȱ haveȱ formedȱ theȱ basisȱ forȱ
measurementȱ inȱ manyȱ studiesȱ conductedȱ sinceȱ thatȱ time.2ȱ INRUDȱ groupsȱ alsoȱ
spearheadedȱ theȱ testingȱ ofȱ manyȱ innovativeȱ interventionȱ studiesȱ toȱ improveȱ useȱ ofȱ
medicines.ȱȱȱ
ȱ
Inȱ 1997,ȱ theȱ firstȱ Internationalȱ Conferenceȱ onȱ Improvingȱ Useȱ ofȱ Medicinesȱ (ICIUM)ȱ
wasȱ heldȱ inȱ Chiangȱ Mai,ȱ Thailand,ȱ toȱ reviewȱ globalȱ experienceȱ inȱ thisȱ fieldȱ andȱ toȱ
defineȱ futureȱ directionsȱ inȱ developingȱ countries.11ȱ ȱ Aȱ reviewȱ presentedȱ atȱ theȱ
conferenceȱ ofȱ allȱ publishedȱ studiesȱ ofȱ outpatientȱ useȱ ofȱ medicinesȱ withȱ adequateȱ
studyȱ designȱ revealedȱ thatȱ interventionsȱ toȱ improveȱ useȱ ofȱ medicinesȱ couldȱ beȱ
successfulȱ andȱ thatȱ impactsȱ variedȱ byȱ interventionȱ type.12ȱ Printedȱ materialsȱ aloneȱ
hadȱ littleȱ impactȱ onȱ improvingȱ practice.ȱ Greaterȱ effectsȱ onȱ medicinesȱ useȱ wereȱ
associatedȱwithȱimprovedȱsupervision,ȱauditȱandȱfeedbackȱofȱpractice,ȱgroupȱprocess,ȱ
– 1 –
andȱcommunityȱcaseȱmanagement.ȱTheȱeffectsȱofȱtraining,ȱtheȱmostȱcommonȱtypeȱofȱ
intervention,ȱ wereȱ variableȱ andȱ oftenȱ unsustained,ȱ probablyȱ dueȱ toȱ differencesȱ inȱ
trainingȱ qualityȱ andȱ theȱ absenceȱ ofȱ followȬupȱ afterȱ aȱ timeȬlimitedȱ educationalȱ
process.ȱ
ȱ
Basedȱonȱtheȱevidenceȱaboutȱproblemsȱinȱmedicinesȱuseȱandȱeffectiveȱinterventionsȱ
presentedȱ atȱ ICIUMȱ 1997,ȱ WHOȱ developedȱ recommendationsȱ forȱ twelveȱ coreȱ
nationalȱ policiesȱ andȱ structuresȱ thatȱ areȱ neededȱ toȱ promoteȱ appropriateȱ useȱ ofȱ
medicinesȱ(Tableȱ1.1).5ȱ
Table 1.1: Twelve core interventions recommended by WHO to promote more

appropriate use of medicines
1. A mandated multi-disciplinary national body – to coordinate medicines use policies.

2. Evidence-based clinical guidelines – to aid prescribers on how to treat patients.
3. Essential medicines lists based on treatment of choice – to be followed in
procurement and distribution of medicines.
4. Medicines and therapeutic committees – to monitor quality of care in the districts
and hospitals under their jurisdiction.
5. Problem-based pharmacology training in undergraduate curricula – to better equip
future doctors in how to prescribe.
6. Continuing in-service medical education as a licensure requirement – in order to
ensure that prescribers remain up-to-date with new treatments.
7. Supervision of health-care workers, audit of prescribing and feedback to prescribers
– in order to help prescribers use medicines more appropriately.
8. Provision of independent information (such as clinical guidelines, drug bulletins) on
medicines – in order to make sure that prescribers have sufficient unbiased
information on medicines.
9. Public education about medicines to try and reduce inappropriate self-medication
and demand for medicines and also to increase awareness about the importance of
adherence.
10. Avoidance of perverse financial incentives such as prescribers earning money from
the sales of medicines which encourages over-prescription of medicines.
11. Appropriate and enforced regulation, particularly concerning medicine promotional
activities by the pharmaceutical industry, licensing of medicine outlets and health-
care workers, and the availability of prescription-only medicines without
prescription.
12. Sufficient government expenditure to ensure availability of medicines and staff.
ȱ
Inȱ 2004,ȱ theȱ secondȱ ICIUMȱ Conferenceȱ wasȱ held,ȱ againȱ inȱ Chiangȱ Mai,ȱ Thailand.13ȱȱ
Reviewȱ ofȱ theȱ evidenceȱ presentedȱ highlightedȱ thatȱ inappropriateȱ useȱ ofȱ medicinesȱ
continuedȱ toȱ beȱ widespread,ȱ withȱ seriousȱ healthȱ andȱ economicȱ implications,ȱ
especiallyȱinȱresourceȬpoorȱsettings.ȱWhileȱexamplesȱofȱmanyȱeffectiveȱinterventionsȱ
wereȱpresentedȱatȱICIUM,ȱglobalȱprogressȱhadȱbeenȱconfinedȱprimarilyȱtoȱsmallȬscaleȱ
demonstrationȱprojects.ȱExpertsȱatȱICIUMȱ2004ȱemphasizedȱanȱurgentȱneedȱtoȱmoveȱ
fromȱsmallȱscaleȱresearchȱprojectsȱtoȱlargeȬscaleȱsustainableȱprogrammesȱthatȱachieveȱ
publicȱ healthȱ goalsȱ throughȱ appropriateȱ medicinesȱ use.ȱ Conferenceȱ participantsȱ
madeȱ threeȱ majorȱ recommendationsȱ supportingȱ effectiveȱ nationalȱ effortsȱ thatȱ
improveȱtheȱuseȱofȱmedicinesȱonȱaȱlargeȱscaleȱandȱinȱaȱsustainableȱmanner.ȱȱ
– 2 –
Introduction
x CountriesȱshouldȱimplementȱNationalȱMedicinesȱProgrammesȱtoȱimproveȱ
medicinesȱuse,ȱcoveringȱbothȱtheȱpublicȱandȱprivateȱsectorsȱandȱincludingȱinȬ
builtȱmonitoringȱsystems;ȱ
x Successfulȱpilotȱlevelȱinterventionsȱshouldȱbeȱscaledȱupȱandȱtheirȱimpactsȱ
regularlyȱmonitored;ȱ
x Moreȱinterventionsȱshouldȱtargetȱmedicinesȱuseȱatȱtheȱcommunityȱlevel,ȱ
particularlyȱwithȱregardȱtoȱschoolȱprogrammes,ȱmedicineȱsellers,ȱtreatmentȱofȱ
chronicȱdiseasesȱandȱtheȱregulationȱofȱpromotionalȱactivities.ȱ
FollowingȱICIUMȱ2004,ȱthereȱwasȱmuchȱconcernȱaboutȱtheȱcontinuedȱinappropriateȱ
useȱofȱmedicinesȱandȱtheȱfailureȱtoȱtakeȱactionȱatȱtheȱglobalȱlevel.ȱTheseȱdiscussionsȱ
culminatedȱinȱtheȱadoptionȱofȱresolutionȱWHA60.16ȱentitledȱProgressȱinȱtheȱresolutionȱ
onȱ rationalȱ useȱ ofȱ medicinesȱ atȱ theȱ Worldȱ Healthȱ Assemblyȱ inȱ Mayȱ 2007.14ȱ Theȱ
resolutionȱcallsȱforȱaȱcrossȬcutting,ȱsectorȬwideȱpolicyȱapproachȱtoȱhealthȱsystemsȱtoȱ
promoteȱrationalȱuseȱofȱmedicines.ȱȱ
ȱ
Toȱpromoteȱmoreȱappropriateȱuseȱofȱmedicines,ȱitȱisȱusefulȱtoȱsummarizeȱcurrentȱandȱ
historicalȱ patternsȱ ofȱ medicinesȱ useȱ reportedȱ inȱ theȱ literature.ȱ ȱ Suchȱ dataȱ canȱ beȱ
usefulȱ inȱ advocacy,ȱ programmeȱ planning,ȱ andȱ evaluatingȱ medicinesȱ policyȱ andȱ
programmeȱ changes.ȱ Theseȱ dataȱ canȱ alsoȱ provideȱ insightȱ intoȱ howȱ medicinesȱ useȱ
patternsȱ compareȱ acrossȱ countriesȱ andȱ regions,ȱ whetherȱ medicinesȱ useȱ improvesȱ
overȱ time,ȱ andȱ whichȱ strategiesȱ areȱ successfulȱ inȱ improvingȱ use.ȱ Basedȱ onȱ suchȱ
information,ȱcountriesȱcanȱsetȱprioritiesȱandȱdevelopȱaȱcoherentȱstrategyȱtoȱimproveȱ
useȱofȱmedicines.ȱTheȱneedȱforȱmonitoringȱdataȱonȱuseȱpromptedȱtheȱcreationȱofȱtheȱ
WHOȱdatabaseȱonȱmedicinesȱuseȱstudies.ȱȱFindingsȱfromȱstudiesȱinȱtheȱdatabaseȱthatȱ
areȱ summarizedȱ inȱ thisȱ documentȱ providedȱ muchȱ ofȱ theȱ evidenceȱ presentedȱ toȱ theȱ
WorldȱHealthȱAssemblyȱpriorȱtoȱadoptionȱofȱresolutionȱWHA60.16.ȱȱȱ
1.3 Overview of this report

Thisȱ documentȱ summarizesȱ availableȱ historicalȱ dataȱ onȱ patternsȱ ofȱ medicinesȱ useȱ
fromȱallȱrelevantȱstudiesȱconductedȱpriorȱtoȱtheȱendȱofȱ2006ȱthatȱwereȱreportedȱupȱtoȱ
theȱ endȱ ofȱ dataȱ collectionȱ inȱ 2006ȱ (withȱ allȱ studiesȱ onȱ integratedȱ managementȱ ofȱ
childhoodȱ illnessesȱ thatȱ wereȱ reportedȱ inȱ 2007).ȱ Inȱ Chapterȱ 2,ȱ weȱ describeȱ theȱ
structureȱ ofȱ theȱ WHOȱ medicinesȱ databaseȱ andȱ theȱ methodsȱ usedȱ toȱ summarizeȱ theȱ
informationȱincludedȱinȱthisȱreport.ȱChaptersȱ3ȱtoȱ5ȱprovideȱsummariesȱofȱstudiesȱonȱ
generalȱ medicinesȱ useȱ indicators,ȱ whileȱ Chaptersȱ 6ȱ toȱ 9ȱ provideȱ summariesȱ ofȱ
indicatorsȱ forȱ studiesȱ ofȱ specificȱ diseasesȱ (acuteȱ respiratoryȱ infection,ȱ diarrhoea,ȱ
malaria)ȱandȱmedicinesȱuseȱproblemsȱ(antimicrobialȱuse).ȱChapterȱ10ȱsummarizesȱtheȱ
typesȱ ofȱ interventionsȱ thatȱ haveȱ beenȱ conductedȱ toȱ improveȱ medicinesȱ use,ȱ andȱ
assessesȱtheȱrelativeȱimpactȱofȱdifferentȱtypesȱofȱinterventions.ȱChapterȱ11ȱdiscussesȱ
theȱfindingsȱinȱtheȱlightȱofȱtheȱimportantȱlimitationsȱinȱcollectingȱandȱanalysingȱtheȱ
dataȱandȱrecommendsȱnextȱsteps.ȱȱȱ
ȱ
Annexȱ 1ȱ containsȱ tablesȱ withȱ detailedȱ dataȱ correspondingȱ toȱ allȱ ofȱ theȱ figuresȱ
presentedȱinȱChaptersȱ3ȱtoȱ9,ȱwhileȱAnnexȱ2ȱpresentsȱkeyȱdescriptiveȱindicatorsȱwithȱ
countriesȱclassifiedȱbyȱWHOȱregionȱratherȱthanȱbyȱWorldȱBankȱregionȱwhichȱisȱusedȱ
inȱ theȱ bodyȱ ofȱ theȱ report.ȱ Annexȱ 3ȱ containsȱ theȱ manualȱ describingȱ detailsȱ ofȱ theȱ
– 3 –
constructionȱofȱtheȱWHOȱdatabase,ȱextractionȱofȱdataȱfromȱpublicationsȱandȱreports,ȱ
andȱcodingȱofȱallȱvariablesȱinȱtheȱdatabase.ȱ
ȱ
WeȱhopeȱthatȱthisȱsummaryȱofȱdataȱfromȱtheȱWHOȱmedicinesȱuseȱdatabaseȱwillȱbeȱ
usefulȱ inȱ providingȱ informationȱ toȱ buildȱ futureȱ globalȱ andȱ nationalȱ strategiesȱ toȱ
promoteȱappropriateȱuseȱofȱmedicines.ȱȱStakeholdersȱareȱencouragedȱtoȱuseȱtheȱdataȱ
presentedȱinȱthisȱreportȱandȱitsȱAnnexesȱtoȱsummarizeȱdataȱrelevantȱtoȱtheirȱinterests.ȱȱ
ToȱensureȱtheȱavailabilityȱofȱupȬtoȬdateȱinformationȱonȱmedicinesȱuseȱandȱtheȱeffectsȱ
ofȱinterventions,ȱtheȱWHOȱdatabaseȱwillȱrequireȱregularȱupdatingȱandȱmaintenance.ȱȱȱ
ȱ
ȱ
– 4 –
Methods
2. METHODS
2.1 Objectives of the WHO database on medicines use

Theȱ WHOȱ databaseȱ ofȱ reportsȱ onȱ medicinesȱ useȱ inȱ developingȱ andȱ transitionalȱ
countriesȱwasȱcreatedȱwithȱtheȱfollowingȱoverallȱobjectives:ȱ
x Toȱprovideȱaȱgeneralȱoverviewȱofȱpatternsȱandȱtrendsȱinȱmedicinesȱuseȱinȱ
primaryȱcareȱsinceȱ1990,ȱandȱ
x Toȱsummarizeȱexperienceȱwithȱtestingȱinterventionsȱandȱassessȱtheȱimpactȱofȱ
differentȱtypesȱofȱinterventionsȱonȱuseȱofȱmedicines.ȱȱȱ
Aȱ developmentalȱ versionȱ ofȱ theȱ WHOȱ databaseȱ wasȱ presentedȱ atȱ ICIUMȱ inȱ 2004.15ȱ
Followingȱ ICIUMȱ 2004,ȱ theȱ databaseȱ wasȱ completedȱ withȱ studiesȱ thatȱ wereȱ
conductedȱ upȱ toȱ theȱ endȱ ofȱ Decemberȱ 2006.ȱ Becauseȱ ofȱ continuingȱ interestȱ inȱ
assessingȱ theȱ impactȱ ofȱ variousȱ strategiesȱ forȱ integratedȱ managementȱ ofȱ childhoodȱ
illnessesȱ(IMCI),ȱweȱaddedȱrecentȱIMCIȱstudiesȱpublishedȱinȱ2007ȱtoȱtheȱdatabase.ȱȱȱ
2.2 Steps to create the database

WeȱundertookȱtheȱfollowingȱstepsȱtoȱdevelopȱtheȱWHOȱdatabaseȱonȱmedicinesȱuse:ȱȱȱ
x DesignedȱaȱdatabaseȱofȱkeyȱvariablesȱinȱMicrosoftȱAccess;ȱ
x Developedȱcriteriaȱforȱinclusionȱandȱaȱsearchȱandȱretrievalȱstrategyȱforȱarticles;ȱ
x Developedȱrulesȱforȱdataȱextractionȱandȱentry,ȱallȱofȱwhichȱareȱdescribedȱinȱtheȱ
databaseȱmanualȱinȱAnnexȱ3;ȱ
x Extractedȱtheȱdata,ȱenteredȱthemȱintoȱtheȱdatabase,ȱdoubleȱcheckedȱeachȱrecord,ȱ
andȱresolvedȱdiscrepanciesȱforȱeachȱreportȱthatȱmetȱtheȱinclusionȱcriteria.ȱ
2.3 Database format and design

TheȱdatabaseȱusesȱMicrosoftȱOfficeȱAccessȱ2003ȱ(MicrosoftȱCorporation,ȱRedmond,ȱ
WA).ȱToȱconstructȱaȱdatabaseȱcomparableȱtoȱotherȱWHOȱdatabases,ȱweȱusedȱWHOȱ
standardizedȱcodesȱforȱcountries,ȱregionsȱandȱyears.ȱScannedȱimagesȱofȱtheȱdatabaseȱ
sectionsȱandȱdescriptionsȱofȱallȱdatabaseȱfieldsȱareȱincludedȱinȱAnnexȱ3.ȱTheȱdatabaseȱ
consistsȱofȱfourȱsections:ȱ
x Sectionȱ1ȱcontainsȱfieldsȱforȱdemographicȱandȱpublicationȱdetailsȱofȱeachȱstudy,ȱ
includingȱtheȱcountryȱandȱyearȱofȱsurvey;ȱtheȱhealthȬcareȱsetting;ȱtheȱtypeȱofȱ
prescriber,ȱdispenser,ȱpatientȱandȱdiseases;ȱandȱwhetherȱanyȱinterventionȱtoȱ
improveȱmedicinesȱuseȱwasȱundertakenȱasȱpartȱofȱtheȱstudy.ȱȱDetailedȱ
instructionsȱaboutȱhowȱtoȱcodeȱtheseȱfieldsȱusingȱdropȬdownȱmenusȱareȱgivenȱ
inȱtheȱdatabaseȱmanual.ȱȱThisȱsectionȱalsoȱincludesȱfullȱcitationsȱforȱupȱtoȱthreeȱ
reportsȱorȱpublishedȱarticlesȱfromȱwhichȱtheȱdataȱforȱtheȱstudyȱwereȱextracted.ȱ
x Sectionȱ2ȱcontainsȱfieldsȱcollectingȱinformationȱaboutȱanyȱinterventionsȱ
conductedȱinȱconjunctionȱwithȱtheȱstudy.ȱȱInterventionsȱhaveȱbeenȱgroupedȱintoȱ
nineȱmajorȱtypes:ȱproviderȱeducation;ȱconsumerȱeducation;ȱadministrativeȱorȱ
– 5 –
managerialȱstrategies;ȱcommunityȱcaseȱmanagement;ȱprintedȱmaterials;ȱgroupȱ
processȱstrategies;ȱregulatoryȱinterventions;ȱeconomicȱstrategies;ȱandȱEssentialȱ
MedicinesȱProgrammes,ȱincludingȱmedicineȱsupplyȱstrategies.ȱInterventionȱ
fieldsȱuseȱyes/noȱresponsesȱtoȱindicateȱwhetherȱspecificȱfeaturesȱwereȱpartȱofȱanȱ
intervention.ȱȱInȱaddition,ȱthereȱareȱthreeȱopenȬendedȱfieldsȱinȱwhichȱupȱtoȱ
threeȱdifferentȱinterventionsȱconductedȱasȱpartȱofȱtheȱstudyȱcanȱbeȱdescribedȱinȱ
moreȱdetail.ȱȱ
x Sectionȱ3ȱcontainsȱfieldsȱforȱmethodologicalȱdetailsȱofȱdataȱcollection.ȱȱThisȱ
sectionȱcollectsȱinformationȱaboutȱtheȱqualityȱofȱtheȱdataȱreportedȱinȱtheȱstudyȱ
andȱwhetherȱtheȱstudyȱdesignȱwasȱsufficientlyȱrobustȱtoȱdrawȱinferenceȱaboutȱ
interventionȱimpacts.ȱRelevantȱinformationȱincludesȱstudyȱdesign,ȱdataȱ
collectionȱmethods,ȱandȱsampleȱsizesȱforȱpatients,ȱprovidersȱandȱhealthȱ
facilities.ȱDetailedȱinstructionsȱaboutȱhowȱtoȱsummarizeȱsampleȱsizeȱ
informationȱareȱgivenȱinȱtheȱdatabaseȱmanual.ȱ
x Sectionȱ4ȱcontainsȱfieldsȱforȱquantitativeȱdataȱonȱindicatorsȱofȱmedicinesȱuse.ȱ
Thisȱsectionȱincludesȱaboutȱ50ȱcommonlyȱreportedȱindicatorsȱfromȱwhichȱtoȱ
choose,ȱincludingȱtheȱstandardȱWHO/INRUDȱcoreȱandȱcomplementaryȱ
indicatorsȱonȱmedicinesȱuse;16ȱmedicinesȱuseȱindicatorsȱassociatedȱwithȱspecificȱ
diseasesȱsuchȱasȱARI,ȱmalariaȱandȱdiarrhoea;16,17,18,19ȱtheȱstandardȱIMCIȱ
indicators;17ȱandȱmortalityȱratesȱforȱallȱcausesȱorȱinȱassociationȱwithȱspecificȱ
diseasesȱthatȱareȱoftenȱreportedȱinȱcommunityȱcaseȱmanagementȱstudies.ȱTheȱ
mostȱfrequentlyȱreportedȱȱindicatorsȱareȱshownȱinȱTableȱ2.1.ȱForȱeachȱindicator,ȱ
dataȱwereȱenteredȱonȱtheȱobservedȱindicatorȱvalue,ȱtheȱdateȱtheȱindicatorȱwasȱ
measured,ȱandȱforȱinterventionȱstudies,ȱwhenȱtheȱvalueȱwasȱmeasuredȱinȱ
relationȱtoȱtheȱinterventionȱ(atȱbaseline,ȱduringȱtheȱintervention,ȱorȱatȱupȱtoȱ3ȱ
followȬupȱassessments)ȱandȱtheȱstudyȱgroupȱtoȱwhichȱitȱreferredȱ(i.e.,ȱtheȱ
controlȱgroupȱorȱaȱspecificȱinterventionȱgroup).ȱ
Theȱ databaseȱ manualȱ inȱ Annexȱ 3ȱ detailsȱ theȱ definitionsȱ (includingȱ theȱ numeratorsȱ
andȱ denominators)ȱ ofȱ eachȱ indicatorȱ capturedȱ inȱ theȱ database.ȱ Itȱ alsoȱ givesȱ
instructionsȱ onȱ howȱ toȱ calculateȱ outcomeȱ valuesȱ forȱ someȱ indicatorsȱ inȱ situationsȱ
whereȱanȱarticleȱdoesȱnotȱpresentȱdataȱinȱaȱformatȱthatȱtheȱdatabaseȱcanȱaccept,ȱbutȱ
whereȱ thereȱ areȱ sufficientȱ dataȱ toȱ enableȱ calculationȱ ofȱ theȱ indicatorsȱ usedȱ inȱ theȱ
database.ȱ Aȱ frequentlyȱ occurringȱ exampleȱ ofȱ thisȱ isȱ whereȱ dataȱ areȱ presentedȱ forȱ
individualȱhealthȱfacilitiesȱbutȱnotȱaveragedȱacrossȱfacilities.ȱ
– 6 –
Methods
Table 2.1: List of selected medicines use indicators for the WHO database
16
WHO/INRUD medicines use indicators for primary care facilities
Prescribing indicators
1. Average number of medicines prescribed per patient encounter
2. Percentage of medicines prescribed by generic name
3. Percentage of encounters with an antibiotic prescribed *
4. Percentage of encounters with an injection prescribed
5. Percentage of medicines prescribed from an EML or formulary
Patient care indicators
6. Average consultation time
7. Average dispensing time
8. Percentage of medicines actually dispensed
9. Percentage of medicines adequately labelled
10. Percentage of patients with knowledge of correct dose
Facility indicators
11. Availability of EML or formulary to practitioners
12. Availability of clinical guidelines
13. Percentage of key medicines available in a facility
Complementary medicines use indicators
14. Average medicine cost per encounter
15. Percentage of prescriptions in accordance with clinical guidelines
Disease-specific medicines use indicators

ARI treatment indicators
16. Percentage of pneumonia cases treated with recommended antibiotics
17. Percentage of cases of upper respiratory tract infections treated with antibiotics
18. Percentage of cases of acute respiratory infections treated with cough syrups
Diarrhoea treatment indicators
19. Percentage of cases of diarrhoea treated with antibiotics
20. Percentage of cases of diarrhoea treated with antidiarrhoeals
21. Percentage of cases of diarrhoea treated with oral rehydration therapy (ORT)
Malaria treatment indicator
22. Percentage of cases of malaria treated with recommended antimalarials
Additional indicators
23. Percentage of patients receiving medicines without prescription
24. Percentage of cases prescribed multivitamins/tonics
25. Percentage of injections prescribed inappropriately
26. Percentage of patients prescribed antibiotics inappropriately
27. Percentage of antibiotics prescribed in too low dose
28. Percentage of cases of pregnant woman treated with iron and/or folic acid
ȱ
*ȱAsȱdefinedȱbyȱindividualȱauthors;ȱtheȱwidelyȱusedȱWHO/INRUDȱindicatorȱmethodologyȱexcludesȱ
antiȬprotozoalȱagentsȱandȱantimicrobialsȱprimarilyȱusedȱtoȱtreatȱtuberculosisȱorȱmalaria.ȱȱȱ
ȱ
Italicized indicators are reported in the present fact book.
– 7 –
2.4 Search strategy and criteria

Allȱrelevantȱstudiesȱonȱuseȱofȱmedicinesȱwereȱidentifiedȱusingȱbothȱpublishedȱarticlesȱ
andȱunpublishedȱreportsȱforȱtheȱperiodȱ1990Ȭ2006,ȱwithȱtheȱadditionȱofȱIMCIȱstudiesȱ
publishedȱinȱ2007.ȱȱȱ
Theȱsearchȱstrategyȱincluded:ȱ
x AȱsearchȱforȱpublishedȱstudiesȱreferencedȱinȱtheȱINRUDȱbibliographyȱonȱ
medicinesȱuse.20ȱȱTheȱINRUDȱbibliographyȱisȱupdatedȱeveryȱ6ȱmonthsȱbyȱ
searchingȱPubMed21ȱandȱoverȱ50ȱjournalȱtablesȱofȱcontentsȱforȱpublicationsȱ
relevantȱtoȱmedicinesȱissues.ȱȱWeȱȱreviewedȱeveryȱabstractȱlistedȱinȱtheȱINRUDȱ
bibliographyȱreportingȱonȱworkȱinȱaȱdevelopingȱorȱtransitionalȱcountryȱ
retrievedȱusingȱtheȱkeywordsȱȈdrugȱuseȈ,ȱȈdrugȱutilizationȈ,ȱȈdrugȱtherapiesȈ,ȱ
ȈprescriptionsȈ,ȱȈantibioticsȈ,ȱȈdiarrhoeaȈ,ȱȈacuteȱrespiratoryȱinfectionsȈ,ȱ
ȈmalariaȈ,ȱȈinterventionsȈ,ȱȈevaluationȱstudiesȈ,ȱȈeducationȈȱandȱȈdevelopingȱ
countriesȈ.ȱ
x AdditionalȱPubMedȱandȱEmbaseȱsearches,ȱusingȱtheȱkeywordsȱ“drugȱ
use/utilization“,ȱ“medicinesȱuse/utilization”,ȱ“prescribing”,ȱ“integratedȱ
managementȱofȱchildhoodȱillness”,ȱ“developingȱcountries”,ȱ“Africa”,ȱ“Asia”,ȱ
“CentralȱAmerica”ȱandȱ“South/LatinȱAmerica”.ȱ
x StudiesȱconductedȱbyȱtheȱRationalȱPharmaceuticalȱManagementȱProjectȱofȱ
ManagementȱSciencesȱforȱHealthȱandȱotherȱUSAIDȱdevelopmentȱpartners,ȱandȱ
foundȱinȱtheirȱarchives.ȱ
x StudiesȱfromȱtheȱarchivesȱofȱtheȱWHOȱDepartmentȱofȱChildȱandȱAdolescentȱ
Healthȱonȱcontrolȱofȱdiarrhoealȱdiseases,ȱrespiratoryȱinfections,ȱandȱintegratedȱ
managementȱforȱchildhoodȱillnessȱ(IMCI).ȱ
x CountryȱreportsȱfromȱtheȱWHOȱEssentialȱMedicinesȱDocumentationȱCentreȱ,ȱ
suchȱasȱWHOȱconsultants’ȱreports,ȱdocumentsȱfromȱtheȱministriesȱofȱhealth,ȱ
masterȱandȱdoctoralȱthesesȱfromȱuniversityȱstudents,ȱstudiesȱonȱinjectionȱ
practices,ȱNGOȱreports,ȱprojectȱproposals,ȱandȱothers.ȱ
x ReportsȱfromȱWHOȱLevelȱIIȱIndicatorȱPharmaceuticalȱSurveysȱimplementedȱbyȱ
theȱWHOȱDepartmentȱofȱTechnicalȱCooperationȱforȱEssentialȱDrugsȱandȱ
TraditionalȱMedicine.18ȱ
x StudiesȱfromȱtheȱJointȱResearchȱInitiativeȱonȱImprovingȱUseȱofȱMedicinesȱ
(JRIIUM)ȱofȱWHO,ȱHarvardȱMedicalȱSchool,ȱBostonȱUniversityȱandȱ
ManagementȱSciencesȱforȱHealth.ȱ
x HandȱsearchesȱofȱkeyȱjournalsȱincludingȱCahiersȱSanté,ȱHealthȱPolicyȱandȱ
Planning,ȱandȱTropicalȱMedicineȱandȱInternationalȱHealth.ȱ
Inȱ addition,ȱ weȱ reviewedȱ allȱ studiesȱ presentedȱ atȱ theȱ 1stȱ andȱ 2ndȱ Internationalȱ
ConferencesȱforȱImprovingȱtheȱUseȱofȱMedicinesȱinȱ1997ȱandȱ2004,ȱrespectively,ȱandȱ
soughtȱ publicationsȱ orȱ reportsȱ ofȱ theseȱ studiesȱ fromȱ theȱ authors.ȱ However,ȱ studiesȱ
thatȱ wereȱ onlyȱ reportedȱ inȱ abstractȱ formȱ atȱ theȱ conferencesȱ withȱ noȱ supportingȱ
documentationȱwereȱnotȱincluded.ȱ
– 8 –
Methods
Aȱ studyȱ wasȱ includedȱ inȱ theȱ databaseȱ ifȱ itȱ wasȱ fromȱ aȱ developingȱ orȱ transitionalȱ
countryȱandȱifȱitȱcontainedȱquantitativeȱdataȱdescribingȱmedicinesȱuseȱinȱaȱprimaryȱ
careȱ settingȱ usingȱ standardizedȱ indicators.ȱ Developing/transitionalȱ countriesȱ wereȱ
definedȱ asȱ allȱ countriesȱ excludingȱ thoseȱ fromȱ Westernȱ Europe,ȱ theȱ USA,ȱ Canada,ȱ
Japan,ȱ Australia,ȱ andȱ Newȱ Zealand.ȱ Primaryȱ careȱ settingsȱ includedȱ primaryȱ careȱ
clinics,ȱhospitalȱgeneralȱandȱpaediatricȱnonȬspecialistȱoutpatientȱsettings,ȱpharmacies,ȱ
medicineȱ shopsȱ andȱ households.ȱ Studiesȱ wereȱ consideredȱ ifȱ theyȱ wereȱ publishedȱ
duringȱ 1990Ȭ2006ȱ (asȱ foundȱ inȱ searchesȱ conductedȱ untilȱ Decemberȱ 2006)ȱ orȱ IMCIȱ
studiesȱ publishedȱ inȱ 2007,ȱ writtenȱ inȱ English,ȱ French,ȱ Spanish,ȱ Portugueseȱ andȱ
Russian,ȱandȱhadȱfullȬtextȱreportsȱ(ratherȱthanȱabstractsȱonly)ȱavailableȱforȱreview.ȱ
ȱ
RelevantȱarticlesȱandȱreportsȱwereȱobtainedȱusingȱtheȱWHOȱlibrary,ȱonȬlineȱjournals,ȱ
andȱ otherȱ externalȱ libraryȱ resources.ȱ Inȱ additionȱ reportsȱ wereȱ retrievedȱ fromȱ theȱ
WHOȱ Essentialȱ Medicinesȱ Documentationȱ Centre,ȱ theȱ Departmentsȱ ofȱ Childȱ andȱ
Adolescentȱ Healthȱ andȱ Technicalȱ Cooperationȱ forȱ Essentialȱ Drugsȱ andȱ Traditionalȱ
Medicineȱ inȱ WHO,ȱ theȱ MSHȱ Rationalȱ Pharmaceuticalȱ Managementȱ Project,ȱ
individualȱauthors,ȱandȱtheirȱrespectiveȱorganizations.ȱȱ
ȱ
Theȱ searchȱ andȱ retrievalȱ strategyȱ wasȱ testedȱ byȱ comparingȱ theȱ articlesȱ foundȱ usingȱ
theȱ databaseȱ searchȱ strategyȱ withȱ selectedȱ referenceȱ listsȱ providedȱ byȱ theȱ Childȱ
Adolescentȱ Healthȱ Departmentȱ ofȱ WHO,ȱ theȱ Harvardȱ Medicalȱ Schoolȱ Drugȱ Policyȱ
ResearchȱGroup,ȱandȱtheȱU.S.ȱCentersȱforȱDiseaseȱControlȱinȱAtlanta.ȱ
2.5 Data entry

Aȱmainȱprincipleȱforȱdesignȱofȱtheȱdatabaseȱandȱdataȱentryȱwasȱtoȱenterȱindividuallyȱ
identifiableȱ dataȱ forȱ eachȱ predefinedȱ studyȱ population,ȱ asȱ definedȱ byȱ (1)ȱ healthȱ
facilityȱ ownershipȱ [public,ȱ privateȱ forȬprofit,ȱ privateȱ notȬforȬprofit];ȱ (2)ȱ settingȱ
[primaryȱ careȱ centre,ȱ hospital,ȱ chemist,ȱ household];ȱ (3)ȱ prescriberȱ typeȱ [doctor,ȱ
paramedic,ȱ other],ȱ (4)ȱ andȱ dispenserȱ typeȱ [pharmacist,ȱ pharmacyȱ assistant,ȱ other];ȱ
(5)ȱpatientȱtypeȱ[outpatient,ȱconsumer],ȱandȱ(6)ȱyearȱofȱdataȱcollection.ȱȱTheȱdatabaseȱ
manualȱinȱAnnexȱ3ȱcontainsȱdefinitionsȱofȱtheȱstudyȱpopulationȱcategories.ȱȱȱȱ
ȱ
Weȱdefinedȱeachȱrecordȱinȱtheȱdatabaseȱasȱ“quantitativeȱdataȱonȱmedicinesȱuseȱbyȱaȱ
specificȱmedicinesȱuserȱinȱaȱspecificȱcountryȱinȱaȱspecificȱtimeȱperiod.”ȱȱEachȱdatabaseȱ
recordȱ relatesȱ toȱ justȱ oneȱ country;ȱ studiesȱ reportingȱ dataȱ fromȱ multipleȱ countriesȱ
haveȱbeenȱenteredȱasȱseparateȱrecordsȱforȱeachȱcountry.ȱȱDataȱreportedȱinȱindividualȱ
articles/reportsȱ wereȱ enteredȱ intoȱ theȱ databaseȱ asȱ separateȱ recordsȱ accordingȱ toȱ theȱ
numberȱ ofȱ groupsȱ studied,ȱ asȱ characterizedȱ byȱ uniqueȱ combinationsȱ ofȱ medicineȱ
outletȱ ownership;ȱ medicineȱ outletȱ type;ȱ prescriberȱ type;ȱ patientȱ typeȱ (outpatient,ȱ
consumer)ȱandȱtimeȱperiod.ȱDataȱfromȱmultipleȱarticlesȱrelatedȱtoȱtheȱsameȱstudyȱorȱ
involvingȱ populationsȱ fromȱ theȱ sameȱ settingȱ wereȱ assignedȱ aȱ commonȱ studyȱ
identificationȱ numberȱ andȱ onlyȱ oneȱ databaseȱ recordȱ wasȱ createdȱ perȱ countryȱ andȱ
setting.ȱ
ȱ
Articlesȱwereȱnotȱdividedȱintoȱdifferentȱrecordsȱonȱtheȱbasisȱofȱpatientȱageȱorȱdiseaseȱ
type.ȱIfȱanȱarticleȱreportedȱmedicinesȱuseȱbyȱmoreȱthanȱoneȱcriterionȱusedȱtoȱdefineȱ
settingȱ (e.g.ȱ healthȱ facilityȱ typeȱ andȱ prescriberȱ type)ȱ theȱ researchersȱ selectedȱ oneȱ
– 9 –
categoryȱforȱaȱrecordȱinȱtheȱdatabase.ȱTheȱchoiceȱofȱcategoryȱdependedȱonȱtheȱqualityȱ
ofȱtheȱdataȱreportedȱandȱtheȱobjectivesȱofȱtheȱstudy.ȱNoȱdataȱpointȱwasȱenteredȱtwiceȱ
intoȱtheȱdatabase.ȱInȱaddition,ȱsomeȱstudiesȱareȱdescribedȱinȱmoreȱthanȱoneȱarticleȱorȱ
report,ȱinȱwhichȱcaseȱupȱtoȱthreeȱreferencesȱhaveȱbeenȱenteredȱinȱtheȱdatabaseȱtoȱciteȱ
theȱparticularȱstudyȱbutȱwereȱnotȱcountedȱasȱdifferentȱstudies.ȱ
2.6 Data cleaning

Abstractsȱ ofȱ allȱ identifiedȱ reportsȱ wereȱ screenedȱ byȱ oneȱ researcher,ȱ theȱ secondȱ
researcherȱ reviewedȱ aȱ randomȱ selectionȱ ofȱ abstractsȱ toȱ ensureȱ agreementȱ aboutȱ
whetherȱtheȱfullȱarticleȱshouldȱbeȱretrieved.ȱAllȱarticlesȱretrievedȱwereȱreviewedȱbyȱ
twoȱresearchers,ȱwhetherȱorȱnotȱenteredȱintoȱtheȱdatabase.ȱOfȱtheȱretrievedȱarticles,ȱ
onlyȱ thoseȱ foundȱ toȱ haveȱ noȱ quantitativeȱ medicinesȱ useȱ dataȱ wereȱ notȱenteredȱ intoȱ
theȱ database.ȱ Oneȱ researcherȱ enteredȱ theȱ dataȱ andȱ eachȱ entryȱ wasȱ reviewedȱ byȱ theȱ
otherȱ researcherȱ forȱ accuracy.ȱ Inȱ addition,ȱ weȱ exportedȱ theȱ dataȱ intoȱ Excelȱ
(MicrosoftȱOffice®ȱExcelȱ2003,ȱMicrosoftȱCorporation,ȱRedmond,ȱWA)ȱandȱcreatedȱ
frequencyȱdistributionsȱofȱkeyȱvariablesȱtoȱassessȱdataȱentryȱaccuracy.ȱȱ
2.7 Definitions, variables, and data sources

Forȱ theȱ analysesȱ reportedȱ here,ȱ weȱ adoptedȱ theȱ followingȱ conventionsȱ andȱ
definitions:ȱȱ
x Aȱpublicationȱ(n=726)ȱisȱanyȱpublishedȱorȱgreyȱliteratureȱsourceȱofȱdataȱinȱtheȱ
WHOȱmedicinesȱuseȱdatabase.ȱ
x Aȱdatabaseȱrecordȱ(n=856)ȱcontainsȱanȱarrayȱofȱdescriptiveȱinformationȱandȱ
quantitativeȱdataȱonȱmedicinesȱuseȱpertainingȱtoȱaȱspecificȱcountry;ȱhealthȱ
setting;ȱprescriber,ȱdispenser,ȱorȱpatientȱgroup;ȱandȱtimeȱperiod.ȱ
x Aȱstudyȱ(n=679)ȱconsistsȱofȱtheȱtotalȱsetȱofȱdataȱpertainingȱtoȱaȱspecificȱcountry,ȱ
setting,ȱstudyȱgroup,ȱandȱtimeȱperiod.ȱȱAȱstudyȱcanȱcontainȱdataȱextractedȱfromȱ
moreȱthanȱoneȱpublicationȱorȱreport,ȱandȱenteredȱinȱmoreȱthanȱoneȱdatabaseȱ
record.ȱForȱinterventionȱstudies,ȱaȱstudyȱmayȱalsoȱconsistȱofȱdataȱforȱdifferentȱ
timeȱperiodsȱbefore,ȱduring,ȱorȱafterȱtheȱsameȱintervention.ȱȱȱ
x Aȱdataȱpointȱ(n=5958)ȱisȱdefinedȱasȱaȱmeasurementȱofȱaȱspecificȱmedicinesȱuseȱ
indicatorȱatȱaȱspecificȱpointȱinȱtime.ȱȱDataȱpointsȱareȱmeasuresȱofȱoneȱindicatorȱ
atȱaȱparticularȱpointȱinȱtimeȱforȱaȱspecificȱproviderȱinȱaȱspecificȱsetting.ȱȱȱ
x Aȱstudyȱgroupȱinȱdescriptiveȱanalysesȱisȱaȱcategoryȱbasedȱonȱaȱuniqueȱ
combinationȱofȱhealthȱfacilityȱownershipȱ[public;ȱprivateȱforȬprofit;ȱprivateȱnotȬ
forȬprofit;ȱnotȱidentified]ȱandȱsettingȱofȱcareȱ[hospital/primaryȱcare;ȱ
pharmacy/drugȱshop;ȱhousehold;ȱnotȱidentified].ȱInȱanalysesȱofȱdifferencesȱinȱ
medicinesȱuseȱbyȱprescriberȱtypeȱ[doctor,ȱparamedic/nurse,ȱother],ȱthisȱvariableȱ
isȱalsoȱusedȱtoȱdifferentiateȱstudyȱgroups.ȱȱȱ
Whenȱ severalȱ dataȱ pointsȱ wereȱ reportedȱ fromȱ theȱ sameȱ studyȱ forȱ theȱ sameȱ studyȱ
groupȱ inȱ aȱ givenȱ timeȱ period,ȱ onlyȱ theirȱ meanȱ valueȱ wasȱ usedȱ inȱ descriptiveȱ
analyses.ȱȱForȱexample,ȱifȱanȱinterventionȱstudyȱreportedȱdifferentȱbaselineȱvaluesȱofȱ
anȱ indicatorȱ forȱ aȱ controlȱ groupȱ andȱ twoȱ interventionȱ groups,ȱ allȱ ofȱ whichȱ
– 10 –
Methods
representedȱprescribingȱinȱtheȱpublicȱsector,ȱtheseȱvaluesȱwereȱaveragedȱintoȱaȱsingleȱ
dataȱpointȱpriorȱtoȱtheȱdescriptiveȱanalysis.ȱȱThisȱprocedureȱavoidedȱgivingȱtooȱmuchȱ
emphasisȱtoȱaȱlargeȱamountȱofȱdataȱpointsȱforȱtheȱsameȱindicatorȱfromȱinterventionsȱ
thatȱ haveȱ severalȱ similarlyȱ definedȱ groupsȱ orȱ studiesȱ inȱ settingsȱ thatȱ haveȱ beenȱ
evaluatedȱintensively.ȱȱȱȱ
ȱ
Furthermore,ȱ inȱ studiesȱ thatȱ presentȱ trendsȱ inȱ medicinesȱ useȱ overȱ time,ȱ noȱ studyȱ
groupȱ wasȱ allowedȱ toȱ contributeȱ moreȱ thanȱ oneȱ dataȱ pointȱ inȱ aȱ givenȱ timeȱ period.ȱȱ
Forȱ example,ȱ whenȱ multipleȱ measuresȱ wereȱ reportedȱ forȱ theȱ sameȱ studyȱ groupȱ
withinȱaȱtimeȱperiodȱ(e.g.,ȱforȱbaselineȱandȱfollowȬupȱmeasuresȱofȱtheȱsameȱindicatorȱ
thatȱbothȱoccurredȱinȱtheȱsameȱperiod),ȱtheseȱwereȱaveragedȱintoȱaȱsingleȱdataȱpointȱ
forȱdescriptiveȱanalyses.ȱ
ȱ
Aȱ studyȱ couldȱ contributeȱ multipleȱ dataȱ pointsȱ forȱ aȱ specificȱ timeȱ periodȱ forȱ studyȱ
groupsȱthatȱwereȱnotȱidentical,ȱforȱexample,ȱpublicȱandȱprivateȱsectorȱfacilitiesȱor,ȱinȱ
analysesȱ ofȱ differencesȱ byȱ prescriberȱ type,ȱ forȱ physicianȱ andȱ nonȬphysicianȱ
prescribers.ȱ Weȱ justifyȱ usingȱ multipleȱ dataȱ pointsȱ inȱ aȱ timeȱ periodȱ fromȱ studiesȱ
reportingȱ dataȱ inȱ differentlyȱ definedȱ studyȱ groupsȱ byȱ theȱ factȱ thatȱ patternsȱ ofȱ
medicinesȱuseȱtendȱtoȱdifferȱgreatlyȱbyȱhealthȱfacilityȱownershipȱandȱsettingȱofȱcare.ȱ
2.7.1 Data sources for descriptive analyses
Weȱ usedȱ theȱ followingȱ dataȱ sourcesȱ toȱ generateȱ dataȱ pointsȱ forȱ theȱ descriptiveȱ
analyses:ȱdataȱfromȱanyȱstudyȱthatȱdidȱnotȱreportȱonȱanȱintervention;ȱdataȱfromȱtheȱ
baselineȱ periodȱ ofȱ interventionȱ studies;ȱ dataȱ fromȱ controlȱ groupsȱ ofȱ interventionȱ
studiesȱ inȱ allȱ followȬupȱ periods;ȱ andȱ dataȱ fromȱ crossȬsectionalȱ surveysȱ thatȱ wereȱ
codedȱ asȱ postȬonlyȱ crossȬsectionalȱ interventionsȱ becauseȱ theyȱ followedȱ
implementationȱofȱdiseaseȱmanagementȱorȱIMCIȱprogrammes.ȱ
2.7.2 Data sources for intervention analyses
Allȱ studiesȱ describingȱ anȱ interventionȱ wereȱ includedȱ inȱ theȱ overallȱ descriptionȱ ofȱ
interventionȱstudies.ȱȱOnlyȱdataȱfromȱinterventionȱstudiesȱwithȱvalidȱstudyȱdesignsȱ
(randomizedȱ controlledȱ trials;ȱ interruptedȱ timeȱ seriesȱ studiesȱ withȱ orȱ withoutȱ
comparisonȱgroups;ȱandȱpreȬpostȱstudiesȱwithȱaȱcontrolȱgroup)ȱwereȱincludedȱinȱtheȱ
statisticalȱanalysisȱofȱinterventionȱeffects.ȱȱȱ
ȱ
WhenȱinterventionȱstudiesȱreportedȱmultipleȱpostȬinterventionȱassessments,ȱweȱusedȱ
theȱlastȱpostȬinterventionȱdataȱpointȱreported,ȱforȱcalculatingȱstudyȱeffects.ȱȱȱ
2.8 Data analysis

Weȱ exportedȱ theȱ Accessȱ databaseȱ intoȱ anȱ analyticȱ relationalȱ databaseȱ inȱ SASȱ (SASȱ
Institute,ȱ Inc,ȱ Cary,ȱ NC).ȱ ȱ Weȱ conductedȱ descriptiveȱ analysesȱ ofȱ keyȱ descriptiveȱ
studyȱ variables.ȱ ȱ Valuesȱ ofȱ eachȱ medicinesȱ useȱ indicatorȱ fromȱ eachȱ studyȱ wereȱ
summarizedȱbyȱcalculatingȱmediansȱandȱ25thȱandȱ75thȱpercentilesȱacrossȱstudiesȱthatȱ
reportedȱ thatȱ indicator,ȱ overallȱ andȱ forȱ studiesȱ thatȱ reportedȱ onȱ medicinesȱ useȱ inȱ
specificȱprovider,ȱfacilityȱandȱpatientȱgroups.ȱȱ
ȱ
– 11 –
Weȱconductedȱsensitivityȱanalysesȱtoȱdetermineȱtheȱimpactȱofȱexcludingȱdataȱpointsȱ
fromȱ theȱ analysesȱ ofȱ descriptiveȱ studiesȱ ofȱ crossȬsectionalȱ studiesȱ ofȱ diseaseȱ
managementȱ andȱ IMCIȱ programmes,ȱ asȱ someȱ mightȱ argueȱ thatȱ theseȱ describeȱ
patternsȱ ofȱ medicinesȱ useȱ afterȱ anȱ interventionȱ hasȱ occurredȱ (althoughȱ inȱ theseȱ
studies,ȱ theȱ interventionsȱ cannotȱ beȱ clearlyȱ defined).ȱ ȱ Exclusionȱ ofȱ crossȬsectionalȱ
studiesȱ ofȱ diseaseȱ managementȱ andȱ IMCIȱ programmesȱ (n=89)ȱ didȱ notȱ materiallyȱ
changeȱ theȱ resultsȱ andȱ theȱ analysesȱ presentedȱ inȱ thisȱ Factȱ Bookȱ includesȱ theseȱ
studies.ȱȱȱ
2.8.1 Baseline analysis of medicines use indicators
Theȱfollowingȱdescriptiveȱanalysesȱwereȱcarriedȱoutȱforȱeachȱindicator:ȱ
x Trendsȱinȱmedicinesȱuseȱoverȱtime.ȱ
x TrendsȱinȱmedicinesȱuseȱbyȱWorldȱBankȱandȱWHOȱregions.ȱ
x TrendsȱinȱmedicinesȱuseȱbyȱWorldȱBankȱcountryȱincomeȱcategory.ȱ
x Medicinesȱuseȱinȱtheȱpublicȱversusȱprivateȱsectors.ȱ
x Medicinesȱuseȱbyȱdoctorsȱversusȱparamedicalȱstaffȱandȱnurses.ȱ
Theȱresultsȱinȱthisȱreportȱareȱpresentedȱasȱlineȱcharts,ȱbarȱchartsȱandȱpieȱcharts.ȱȱWeȱ
oftenȱpresentȱaȱgroupȱofȱrelevantȱindicatorsȱinȱaȱgraphȱtoȱenableȱreadersȱtoȱcompareȱ
changesȱ orȱ differencesȱ inȱ indicatorsȱ ofȱ desiredȱ andȱ undesiredȱ medicinesȱ useȱ
practices.ȱȱOnlyȱsummaryȱdataȱpointsȱwithȱaȱsufficientȱnumberȱofȱstudiesȱonȱwhichȱtoȱ
baseȱaȱmedianȱvalueȱ(definedȱasȱaȱminimumȱofȱatȱleastȱ4ȱstudies)ȱareȱincludedȱinȱtheȱ
figuresȱpresentedȱinȱtheȱtextȱofȱtheȱFactȱBook.ȱȱAnnexȱ1ȱcontainsȱtheȱmedianȱvaluesȱofȱ
theȱ indicatorsȱ depictedȱ inȱ theȱ graphs,ȱ andȱ additionalȱ dataȱ elementsȱ (theȱ numberȱ ofȱ
studiesȱusedȱinȱcalculatingȱtheȱmedian,ȱasȱwellȱasȱtheȱ25thȱandȱ75thȱpercentilesȱofȱtheȱ
distribution).ȱ
2.8.2 Intervention impact analysis
Additionalȱ analysesȱ wereȱ conductedȱ toȱ evaluateȱ theȱ impactȱ ofȱ interventions.ȱ Forȱ
theseȱanalysesȱonlyȱstudiesȱusingȱadequateȱmethodologyȱwereȱincluded.ȱAcceptableȱ
studyȱdesignsȱconsistedȱofȱrandomizedȱcontrolledȱtrials,ȱinterruptedȱtimeȱseriesȱwithȱ
orȱ withoutȱ comparisonȱ group(s),ȱ andȱ preȬpostȱ studiesȱ withȱ oneȱ orȱ moreȱ controlȱ
groups.ȱForȱtheȱtimeȱseriesȱdesign,ȱaȱminimumȱofȱfourȱtimeȱpointsȱwereȱrequired,ȱoneȱ
toȱ summarizeȱ theȱ preȬinterventionȱ valueȱ andȱ threeȱ toȱ captureȱ postȬinterventionȱ
values.ȱ ȱ Studiesȱ usingȱ aȱ postȬonlyȱ withȱ controlȱ designȱ orȱ preȬpostȱ withȱ noȱ controlȱ
studyȱdesignȱwereȱexcludedȱfromȱtheȱinterventionȱimpactȱanalyses.ȱ
ȱ
Theȱ ratesȱ ofȱ prescribingȱ practicesȱ wereȱ theȱ primaryȱ outcomesȱ ofȱ interest.ȱ Mortalityȱ
ratesȱ areȱ alsoȱ usedȱ asȱ theȱ primaryȱ outcomesȱ ofȱ interestȱ forȱ communityȱ caseȱ
managementȱ interventions.ȱ ȱ Aȱ majorȱ aimȱ ofȱ theȱ analysisȱ wasȱ toȱ drawȱ basicȱ
conclusionsȱaboutȱbothȱtheȱqualityȱofȱresearchȱevidenceȱandȱtheȱrelativeȱeffectivenessȱ
ofȱ differentȱ interventionȱ strategiesȱ inȱ improvingȱ prescribing.ȱ Weȱ followedȱ theȱ
methodȱdevelopedȱbyȱRossȬDegnanȱandȱcolleaguesȱinȱtheirȱreviewȱofȱimprovingȱuseȱ
ofȱ medicinesȱ forȱ theȱ firstȱ Internationalȱ Conferenceȱ forȱ Improvingȱ theȱ Useȱ ofȱ
Medicinesȱ (RossȬDegnanȱ etȱ al.ȱ 1997,ȱ unpublishedȱ andȱ WHOȱ 199722).ȱ Theȱ methodȱ
– 12 –
Methods
summarizesȱrelativeȱeffectȱsizesȱofȱallȱinterventions,ȱinȱtheȱfaceȱofȱrelativeȱpaucityȱofȱ
studiesȱ andȱ variationȱ inȱ environments,ȱ strategies,ȱ targetȱ audiences,ȱ practicesȱ andȱ
outcomesȱused.ȱ
ȱ
Toȱ evaluateȱ eachȱ intervention,ȱ focusȱ wasȱ givenȱ toȱ theȱ outcomeȱ measuresȱ identifiedȱ
byȱtheȱauthorsȱasȱtheȱprincipalȱtargetsȱforȱtheirȱinterventions,ȱasȱwellȱasȱtoȱtheȱsingleȱ
measureȱ withȱ largestȱ positiveȱ changeȱ inȱ termsȱ ofȱ betterȱ medicinesȱ use,ȱ e.g.ȱ aȱ
reductionȱ inȱ antibioticȱ useȱ forȱ acuteȱ diarrhoeaȱ orȱ viralȱ upperȱ respiratoryȱ tractȱ
infectionȱorȱanȱincreaseȱinȱcomplianceȱwithȱstandardȱtreatmentȱguidelines.ȱForȱmostȱ
studies,ȱ outcomeȱ measuresȱ includedȱ indicatorsȱ ofȱ appropriateȱ prescribing,ȱ suchȱ asȱ
antibioticȱ use,ȱ injectionȱ useȱ orȱ adherenceȱ toȱ clinicalȱ guidelines;ȱ someȱ studiesȱ alsoȱ
includedȱ patientȱ careȱ indicators,ȱ suchȱ asȱ consultationȱ timeȱ orȱ patientȱ knowledgeȱ
aboutȱ howȱ toȱ useȱ dispensedȱ medications.ȱ ȱ Aȱ numberȱ ofȱ studiesȱ wereȱ designedȱ toȱ
improveȱ useȱ ofȱ medicinesȱ forȱ malaria,ȱ pneumonia,ȱ orȱ diarrhoeaȱ inȱ orderȱ toȱ reduceȱ
mortality;ȱtheseȱstudies,ȱinȱwhichȱmortalityȱratesȱareȱtheȱkeyȱoutcomeȱmeasures,ȱareȱ
excludedȱfromȱmostȱsummariesȱofȱinterventionȱeffects.ȱȱAllȱoutcomeȱmeasuresȱwereȱ
convertedȱtoȱaȱscaleȱwhereȱpositiveȱchangeȱwasȱindicatedȱbyȱpositiveȱnumbers.ȱȱȱ
ȱ
Forȱ eachȱ ofȱ theȱ outcomeȱ measuresȱ identifiedȱ asȱ relevant,ȱ anȱ effectȱ sizeȱ wasȱ
calculated.ȱ Ifȱ theȱ outcomeȱ wasȱ measuredȱ asȱ aȱ percentage,ȱ theȱ effectȱ sizeȱ wasȱ
computedȱ asȱ theȱ relativeȱ gainȱ inȱ theȱ interventionȱ group,ȱ i.e.ȱ theȱ percentageȬpointȱ
improvement,ȱ ofȱ theȱ interventionȱ groupȱ overȱ theȱ percentageȱ pointȱ improvementȱ inȱ
theȱ comparisonȱ group.ȱ Forȱ timeȬseriesȱ withȱ noȱ control,ȱ theȱ effectȱ sizeȱ wasȱ theȱ netȱ
differenceȱ betweenȱ theȱ lastȱ postȬinterventionȱ valueȱ reportedȱ andȱ preȬinterventionȱ
value.ȱIfȱtheȱoutcomeȱwasȱmeasuredȱasȱaȱnumberȱ(e.g.ȱaverageȱnumberȱofȱmedicinesȱ
perȱ patient),ȱ theȱ changesȱ (fromȱ preȬinterventionȱ toȱ post)ȱ wereȱ convertedȱ toȱ
percentageȱ improvementsȱ inȱ eachȱ groupȱ byȱ dividingȱ theȱ absoluteȱ changesȱ byȱ
baselineȱvalues.ȱȱTheȱcalculationȱofȱeffectȱsizesȱforȱeachȱtypeȱofȱoutcomeȱmeasureȱwasȱ
carriedȱoutȱasȱfollows:ȱ
ȱ
Forȱpercentageȱoutcomeȱmeasures:ȱ
EffectȱSizeȱ=ȱ(%PostȬ%Pre)InterventionȱȬȱ(%PostȬ%Pre)Controlȱ
ȱ
Forȱnumericȱoutcomeȱmeasures:ȱ
EffectȱSizeȱ=ȱ([PostȬPre]/Pre)InterventionȱȬȱ([PostȬPre]/Pre)Controlȱ
ȱ
Toȱindicateȱanȱinterventionȇsȱmagnitudeȱofȱeffect,ȱtwoȱapproachesȱwereȱtaken.ȱFirst,ȱ
theȱsingleȱoutcomeȱmeasureȱshowingȱtheȱlargestȱpositiveȱchangeȱ(inȱtermsȱofȱbetterȱ
medicinesȱuse)ȱwasȱusedȱandȱcomparisonsȱwereȱmadeȱacrossȱallȱrelevantȱstudiesȱandȱ
interventions.ȱ Secondly,ȱ sinceȱ oneȱ singleȱ indicatorȱ mayȱ notȱ adequatelyȱ reflectȱ theȱ
actualȱ overallȱ impactȱ ofȱ anȱ intervention,ȱ aȱ compositeȱ indicatorȱ wasȱ calculatedȱ byȱ
takingȱ theȱ medianȱ effectȱ withinȱ aȱ studyȱ acrossȱ allȱ ofȱ theȱ indicatorsȱ measuredȱ andȱ
thenȱusingȱtheseȱstudyȬspecificȱmediansȱforȱsummaryȱcomparisonsȱacrossȱstudies.ȱ
2.9 Limitations
Anȱidealȱstudyȱofȱpatternsȱandȱtrendsȱinȱmedicinesȱuseȱwouldȱconsistȱofȱaȱprobabilityȱ
sampleȱinȱtimeȱandȱplaceȱofȱprescriptionsȱandȱanalysesȱthatȱaccountȱforȱtheȱsamplingȱ
– 13 –
methodȱ andȱ provideȱ confidenceȱ intervalsȱ aroundȱ results.ȱ ȱ Aȱ secondȱ bestȱ studyȱ
approachȱmightȱbeȱaȱformalȱmetaȬanalysisȱofȱexistingȱstudiesȱthatȱwouldȱneedȱtoȱbeȱ
reasonablyȱrepresentativeȱandȱhomogenousȱinȱmethodology.ȱȱNeitherȱtheȱidealȱstudyȱ
norȱaȱmetaȬanalysisȱofȱstudiesȱonȱmedicinesȱuseȱinȱdevelopingȱcountriesȱisȱcurrentlyȱ
feasible.ȱȱ
ȱ
Theȱ presentȱ reportȱ constitutesȱ aȱ practicalȱ approachȱ toȱ assessingȱ medicinesȱ useȱ inȱ
primaryȱ careȱ byȱ compilingȱ informationȱ fromȱ existingȱ reports.ȱ However,ȱ bothȱ theȱ
collectionȱ ofȱ dataȱ enteredȱ inȱ theȱ databaseȱ andȱ theȱ analyticȱ approachesȱ toȱ analysingȱ
theseȱdataȱhaveȱnotableȱlimitations.ȱȱȱ
2.9.1 Limitations of the data collection
Theȱ WHOȱ databaseȱ ofȱ reportsȱ onȱ medicinesȱ useȱ isȱ notȱ entirelyȱ representativeȱ ofȱ
medicinesȱuseȱinȱdevelopingȱandȱtransitionalȱcountries.ȱȱWhileȱmuchȱeffortȱwasȱmadeȱ
toȱ findȱ allȱ existingȱ publishedȱ andȱ unpublishedȱ reportsȱ onȱ medicinesȱ useȱ inȱ
developingȱandȱtransitionalȱcountriesȱduringȱtheȱpastȱ25ȱyears,ȱweȱhaveȱundoubtedlyȱ
notȱfoundȱall.ȱȱTheȱdatabaseȱisȱlikelyȱlackingȱmanyȱunpublishedȱstudiesȱconductedȱatȱ
countryȱ levelȱasȱwellȱasȱmanyȱinterventionsȱcarriedȱoutȱandȱevaluatedȱinȱcountries,ȱ
suchȱasȱtraining,ȱformularies,ȱbulletinsȱandȱsupervision,ȱwhichȱwereȱnotȱevaluatedȱorȱ
reported.ȱȱEvenȱifȱweȱhadȱretrievedȱallȱevaluationsȱofȱmedicinesȱuseȱeverȱconducted,ȱ
theȱ resultsȱ wouldȱ notȱ necessarilyȱ reflectȱ countryȱ situations,ȱ sinceȱ medicinesȱ useȱ
studiesȱhappenȱselectivelyȱinȱspecificȱsettings.ȱȱȱ
ȱ
Theȱdataȱmayȱalsoȱnotȱbeȱcompletelyȱaccurate.ȱȱExtractionȱofȱquantitativeȱdataȱfromȱ
articlesȱandȱreportsȱwasȱoftenȱveryȱdifficultȱdueȱtoȱtheȱfollowingȱtypesȱofȱproblems:ȱ
ȱ
x Someȱstudiesȱwereȱpublishedȱinȱmoreȱthanȱoneȱarticle,ȱsometimesȱwithȱ
inconsistentȱresults.ȱ
x Standardȱindicatorsȱwereȱoftenȱnotȱused.ȱ
x Certainȱdataȱwereȱsometimesȱmissing,ȱparticularlyȱstudyȱyear,ȱfacilityȱtype,ȱ
facilityȱlevelȱandȱprescriberȱtype.ȱ
x Dataȱwereȱsometimesȱdifficultȱtoȱclassifyȱdueȱtoȱindicatorsȱbeingȱpoorlyȱ
described,ȱmedicinesȱuseȱbeingȱreportedȱforȱaȱmixȱofȱfacility/prescriberȱtypeȱ
(andȱnotȱseparately),ȱorȱpoorlyȱdescribedȱstudyȱdesignsȱwhichȱwereȱnotȱ
consistentȱwithȱtheȱresultsȱpresented,ȱe.g.,ȱanȱinterruptedȱtimeȬseriesȱdesignȱ
wasȱstatedȱbutȱdataȱpointsȱinȱsegmentsȱwereȱnotȱdescribed.ȱ
x Qualitativeȱinformationȱfromȱ“retrospective”ȱinterviewsȱandȱobservationsȱwereȱ
reportedȱwithoutȱadequateȱexplanationȱofȱwhatȱreallyȱoccurred.ȱ
x Additionalȱanalysesȱofȱstudyȱdataȱwereȱnecessaryȱbasedȱonȱcertainȱassumptionsȱ
inȱorderȱtoȱenterȱsummarizedȱdataȱintoȱtheȱdatabaseȱ(seeȱAnnexȱ3).ȱ
x Descriptionsȱofȱinterventionsȱoftenȱlackedȱdetail,ȱandȱitȱwasȱdifficultȱtoȱ
distinguishȱclearlyȱbetweenȱdifferentȱstrategies.ȱForȱexample,ȱtheȱIMCIȱstrategyȱ
alwaysȱincludedȱtraining,ȱbutȱtheȱtypeȱofȱtrainingȱandȱtheȱdegreeȱofȱsupervisionȱ
varied.ȱȱ
– 14 –
Methods
Aȱgreatȱeffortȱwasȱmadeȱtoȱabstractȱdataȱfromȱarticlesȱasȱaccuratelyȱasȱpossibleȱandȱtoȱ
giveȱ aȱ trueȱ descriptionȱ ofȱ allȱ studiesȱ enteredȱ intoȱ theȱ database.ȱ Forȱ everyȱ openȱ
questionȱ anȱ attemptȱ wasȱ madeȱ toȱ contactȱ theȱ studyȱ authors.ȱ However,ȱ onlyȱ aȱ
minorityȱofȱauthorsȱresponded.ȱȱ
2.9.2 Limitations of the data analysis: Description of medicines use
Ourȱ analysesȱ areȱ descriptiveȱ andȱ doȱ notȱ takeȱ variabilityȱ ofȱ dataȱ orȱ potentialȱ
confoundersȱproperlyȱintoȱaccount.ȱȱMedicinesȱuseȱindicatorsȱdifferedȱoverȱtimeȱandȱ
byȱ sector,ȱ facilityȱ andȱ prescriberȱ characteristics.ȱ ȱ Toȱ avoidȱ modellingȱ meanȱ (ratherȱ
thanȱmedian)ȱindicatorȱvaluesȱ(whichȱareȱundulyȱinfluencedȱbyȱoutliers),ȱweȱdidȱnotȱ
conductȱ multivariateȱ regressionȱ analyses.ȱ ȱ Weȱ stratifiedȱ byȱ keyȱ sector,ȱ facilityȱ andȱ
prescriberȱ characteristics,ȱ butȱ didȱ notȱ simultaneouslyȱ controlȱ forȱ differencesȱ inȱ allȱ
characteristics.ȱ ȱ Thereforeȱ apparentȱ differencesȱ inȱ performanceȱ betweenȱ groupsȱ onȱ
oneȱorȱmoreȱindicatorsȱmayȱbeȱdueȱtoȱmultipleȱfactors.ȱ
ȱ
Weȱ didȱ notȱ weightȱ studyȱ resultsȱ byȱ studyȱ sizeȱ toȱ avoidȱ undueȱ influenceȱ ofȱ largeȱ
studies;ȱ inȱ otherȱ words,ȱ eachȱ studyȱ becameȱ aȱ singleȱ dataȱ pointȱ withȱ equalȱ weight,ȱ
withoutȱregardȱtoȱsampleȱsizeȱandȱvariance.ȱȱWeȱdoȱnotȱprovideȱstatisticalȱestimatesȱ
ofȱdifferencesȱbetweenȱgroupsȱsinceȱvarianceȱwouldȱbeȱgreatlyȱunderestimated.ȱȱȱȱȱ
ȱ
Dueȱtoȱgenerallyȱlargeȱsampleȱsizes,ȱtheȱmedianȱindicatorȱresultsȱacrossȱstudiesȱwereȱ
lessȱproneȱtoȱbiasesȱdueȱtoȱextremeȱvalues.ȱInȱcasesȱwhereȱsampleȱsizesȱamountedȱtoȱ
fewerȱthanȱfourȱstudiesȱperȱgroupȱforȱaȱgivenȱindicator,ȱweȱexcludedȱtheȱdataȱpointȱ
fromȱ anyȱ graphicȱ presentations.ȱ ȱ However,ȱ allȱ summaryȱ dataȱ areȱ reportedȱ inȱ
Annexȱ1.ȱ
2.9.3 Limitations of the data analysis: Evaluation of interventions
Aȱ majorȱ limitationȱ toȱ theȱ evaluationȱ ofȱ interventionȱ studiesȱ isȱ theirȱ heterogeneityȱ
withȱ respectȱ toȱ theȱ natureȱ ofȱ theȱ interventionsȱ studied,ȱ theȱ settingsȱ ofȱ theȱ
interventions,ȱandȱtheirȱspecificȱtargets.ȱInȱtheȱlightȱofȱtheseȱuncertainties,ȱeffectȱsizeȱ
comparisonsȱ areȱ tenuousȱ andȱ shouldȱ beȱ usedȱ asȱ aȱ basisȱ forȱ furtherȱ carefulȱ
experimentalȱcomparisonsȱofȱinterventionȱmethodsȱinȱspecificȱsettings.ȱ
– 15 –
– 16 –
Description of studies
3. DESCRIPTION OF STUDIES
3.1 Results of search in published and unpublished literature

Abstractsȱ andȱ executiveȱ summariesȱ wereȱ screenedȱ fromȱ 7824ȱ articlesȱ fromȱ theȱ
INRUDȱ bibliographyȱ (16ȱ Decemberȱ 2007)ȱ andȱ allȱ theȱ reportsȱ inȱ theȱ documentationȱ
centresȱofȱtheȱDepartmentsȱofȱEssentialȱMedicinesȱandȱChildȱandȱAdolescentȱHealthȱ
inȱ WHO.ȱ Inȱ addition,ȱ variousȱ discreteȱ searchesȱ wereȱ undertakenȱ asȱ describedȱ inȱ
sectionȱ2.4.ȱOfȱallȱtheȱcompleteȱarticlesȱretrieved,ȱ404ȱarticlesȱwereȱfoundȱtoȱhaveȱnoȱ
relevantȱdataȱthatȱcouldȱbeȱextracted.ȱForȱtheȱperiodȱ1990Ȭ2006ȱ(asȱofȱDecemberȱ2006),ȱ
679ȱ studiesȱ fromȱ 97ȱ countriesȱ wereȱ identifiedȱ andȱ enteredȱ intoȱ theȱ databaseȱ asȱ 856ȱ
databaseȱ records.ȱ Aȱ thirdȱ ofȱ theȱ studiesȱ investigatedȱ medicinesȱ useȱ inȱ childrenȱ lessȱ
thanȱ 5ȱ yearsȱ old,ȱ andȱ 312ȱ ofȱ 679ȱ studiesȱ (46%)ȱ wereȱ doneȱ inȱ associationȱ withȱ
evaluatingȱanȱinterventionȱ(includingȱthoseȱofȱbothȱgoodȱandȱpoorȱstudyȱdesignsȱforȱ
evaluation).ȱȱ
3.2 Cross-sectional studies of medicines use and patient care

CrossȬsectionalȱ studiesȱ ofȱ medicinesȱ useȱ andȱ patientȱ careȱ identifiedȱ byȱ theȱ criteriaȱ
describedȱinȱSectionȱ2.4ȱwereȱorganizedȱbyȱperiodsȱofȱdataȱcollection.ȱBecauseȱofȱtheȱ
smallȱ numberȱ ofȱ earlierȱ studies,ȱ theȱ firstȱ 10ȱ yearsȱ wereȱ groupedȱ togetherȱ intoȱ oneȱ
period,ȱwithȱsubsequentȱyearsȱgroupedȱintoȱthreeȬyearȱperiods.ȱȱ
ȱ
Studiesȱ wereȱ alsoȱ organizedȱ byȱ geographicȱ origin.ȱ Indiaȱ hadȱ theȱ largestȱ numberȱ ofȱ
studiesȱwithȱ60,ȱfollowedȱbyȱNepalȱwithȱ35,ȱtheȱUnitedȱRepublicȱofȱTanzaniaȱwithȱ24,ȱ
andȱUgandaȱwithȱ23ȱstudies.ȱWeȱclassifiedȱstudiesȱgeographicallyȱinȱtwoȱways,ȱoneȱ
usingȱ WHOȱ regions,ȱ theȱ otherȱ usingȱ Worldȱ Bankȱ regions.ȱ Studiesȱ wereȱ alsoȱ
organizedȱbyȱtheȱeconomicȱlevelȱofȱcountriesȱwhereȱtheyȱwereȱconducted,ȱusingȱtheȱ
Worldȱ Bankȱ classificationȱ ȱ basedȱ onȱ 2006ȱ Grossȱ Nationalȱ Incomeȱ (GNI)ȱ perȱ capita.ȱ
BecauseȱofȱtheȱsmallȱnumberȱofȱstudiesȱcomingȱfromȱupperȬmiddleȱandȱhighȱincomeȱ
countriesȱ (givenȱ theȱ focusȱ ofȱ theȱ reviewȱ onȱ developingȱ andȱ transitionalȱ countries),ȱ
dataȱfromȱtheseȱtwoȱeconomicȱregionsȱwereȱanalysedȱasȱoneȱgroup.ȱ
ȱ
Studiesȱ wereȱ dividedȱ intoȱ fourȱ categoriesȱ definedȱ byȱ theȱ ownershipȱ ofȱ theȱ healthȬ
careȱ facilitiesȱ whereȱ theyȱ wereȱ conducted.ȱ Theȱ publicȱ sectorȱ categoryȱ includedȱ
studiesȱofȱmedicinesȱuseȱinȱhealthȬcareȱfacilitiesȱownedȱbyȱtheȱgovernment.ȱStudiesȱ
involvingȱhealthȬcareȱfacilitiesȱownedȱbyȱmissionsȱandȱotherȱcharitableȱorȱfaithȬbasedȱ
organizationsȱwereȱclassifiedȱinȱtheȱprivate,ȱnotȬforȬprofitȱcategory.ȱTheȱprivateȱforȬ
profitȱcategoryȱcontainsȱstudiesȱinvolvingȱforȬprofitȱhealthȬcareȱfacilities.ȱStudiesȱthatȱ
didȱ notȱ belongȱ toȱ anyȱ ofȱ theȱ aboveȱ categories,ȱ eitherȱ becauseȱ theyȱ evaluatedȱ selfȬ
medicationȱ (patients’ȱ interviewsȱ inȱ healthȬcareȱ facilities),ȱ includedȱ severalȱ typesȱ ofȱ
healthȬcareȱ facilities,ȱ orȱ didȱ notȱ includeȱ aȱ healthȬcareȱ facilityȱ description,ȱ wereȱ
classifiedȱ asȱ ‘notȱ applicable,ȱ selfȬmedication’.ȱ Moreȱ thanȱ halfȱ theȱ studiesȱ (66%)ȱ
focusedȱonȱtheȱpublicȱhealthȱsector,ȱ14%ȱonȱtheȱprivateȱforȬprofitȱsectorȱandȱ1.5%ȱonȱ
theȱ nonȬprofitȱ sector,ȱ whichȱ includesȱ missionsȱ andȱ otherȱ charitableȱ organizations.ȱ
Theȱ remainingȱ studiesȱ wereȱ classifiedȱ asȱ ‘unspecified’ȱ (unknown)ȱ orȱ ‘notȱ
applicable/selfȬmedication’.ȱ
– 17 –
Studiesȱwereȱalsoȱgroupedȱaccordingȱtoȱtheȱtypeȱofȱprescriberȱinvolved.ȱParamedicalȱ
healthȱ workers’ȱ and/orȱ nurses’ȱ prescribingȱ wasȱ measuredȱ inȱ 45%ȱ ofȱ studies,ȱ whileȱ
31%ȱfocusedȱonȱdoctors.ȱInȱ11%ȱofȱstudies,ȱmedicinesȱwereȱprescribedȱbyȱlayȱpersons.ȱ
Pharmacistsȱ andȱ pharmacyȱ assistantsȱ wereȱ theȱ focusȱ inȱ 3%ȱ ofȱ theȱ studies,ȱ whileȱ inȱ
10%ȱofȱstudiesȱeitherȱtheȱprescriberȱtypeȱwasȱnotȱdefinedȱorȱaȱmixtureȱofȱprescribersȱ
wasȱreported.ȱȱ
ȱ
ȱ
Figureȱ3.1ȱdescribesȱtheȱchronologicȱdistributionȱofȱstudies,ȱbyȱperiodȱinȱwhichȱdataȱ
wereȱcollected.ȱ
Figure 3.1: Medicines use studies by year in which the data were collected
42
6% 106
16%
131
19%
1982-1991
144
21%
1992-1994
1995-1997
119 1998-2000
18%
2001-2003
2004-2006
137
20% ȱ
Key Points:
x The entire database consisted of 679 studies of medicines use covering 25 years of data
collection up to December 2006.
x The first 10-year period from 1982 to 1991 contributed 16% of the compiled data.
x Each of the 3-year periods from 1992 to 2003 contributed about 20% of the data.
ȱ
ȱ
– 18 –
Figureȱ3.2ȱshowsȱtheȱnumberȱandȱpercentageȱofȱstudiesȱbyȱgeographicȱorigin,ȱusingȱ
theȱ Worldȱ Bankȱ regionalȱ classificationȱ toȱ groupȱ countries.ȱ Becauseȱ ofȱ theȱ smallȱ
numberȱofȱstudiesȱcomingȱfromȱcountriesȱinȱtheȱEuropeȱandȱCentralȱAsiaȱregionȱandȱ
inȱ theȱ Middleȱ Eastȱ andȱ Northȱ Africaȱ region,ȱ dataȱ fromȱ theseȱ twoȱ regionsȱ willȱ beȱ
presentedȱasȱoneȱgroupȱinȱtheȱremainingȱgraphsȱofȱtheȱreport.ȱȱȱ
ȱ
Figure 3.2: Medicines use studies by World Bank region
144
21%
283
42%
Sub-Saharan Africa
Latin America and Caribbean
102
15%
Eastern Europe and Central
Asia
Middle East and North Africa
East Asia and Pacific
47
7%
South Asia
22
81
3%
12% ȱ
ȱ
ȱ
Key Points:
x The largest number of studies came from the WB Africa region, representing over 40% of the
studies.
x Over a third of studies originated in the WB South Asia (21%) and East Asia/ Pacific (15%)
regions.
x About one in ten studies came from the WB Latin America/Caribbean region.
x The remaining studies came from the Middle East/ North Africa and the Europe/Central Asia
regions. Western Europe was not represented, as its countries were excluded by the scope of
this review.
ȱ
ȱ
Figureȱ 3.3ȱ presentsȱ theȱ numberȱ ofȱ surveysȱ byȱ WHOȱ regionalȱ area.ȱ Theȱ majorityȱ ofȱ
studiesȱ wereȱ undertakenȱ inȱ theȱ Africanȱ andȱ Southȱ Eastȱ Asianȱ regions.ȱ Veryȱ fewȱ
studiesȱ haveȱ beenȱ conductedȱ inȱ theȱ Europeanȱ region.ȱ ȱ Severalȱ studiesȱ areȱ includedȱ
fromȱ theȱ Easternȱ Europeanȱ regionȱ whichȱ coversȱ centralȱ Asiaȱ andȱ theȱ newlyȱ
independentȱstates;ȱWesternȱEuropeȱ(partȱofȱtheȱWHOȱEUROȱregion)ȱwasȱexcludedȱ
sinceȱtheȱdatabaseȱfocusedȱonȱdevelopingȱandȱtransitionalȱcountries.ȱ
– 19 –
Figure 3.3: Medicines use studies by WHO region
70
10%
151 283
42%
22% Africa
Americas
Eastern Mediterranean
27 Europe
4%
South-East Asia
67
10% 81 Western Pacific
12%
ȱ
ȱ
Key Points:
x The largest number of studies of medicines use came from the Africa WHO region (AFRO),
representing over 40% of the studies in the database.
x A third of the studies originated from the WHO South East Asia (SEARO) and Western Pacific
(WPRO) regions.
x About one in 10 studies came from the WHO Americas region (AMRO/PAHO).
x The remaining studies came from the WHO Eastern Mediterranean (EMRO) and Eastern
European (part of EURO) regions.
ȱ
ȱ
Figureȱ3.4ȱshowsȱtheȱnumberȱandȱpercentageȱofȱstudiesȱbyȱcountryȱeconomicȱlevel,ȱ
usingȱ Worldȱ Bankȱ dataȱ onȱ 2006ȱ Grossȱ Nationalȱ Incomeȱ (GNI)ȱ perȱ capitaȱ toȱ groupȱ
countries.ȱ Becauseȱ ofȱ theȱ smallȱ numberȱ ofȱ studiesȱ fromȱ upperȬmiddleȱ andȱ highȱ
incomeȱcountries,ȱtheseȱtwoȱeconomicȱregionsȱareȱpresentedȱasȱoneȱgroup.ȱ
– 20 –
Figure 3.4: Medicines use studies by World Bank country income level
100
15%
156
23%
Low Income
423
62% Lower-Middle Income
Upper-Middle & High Income
Key Points:
x Over 60% of studies of medicines use originated from low income countries.
x Almost nine in ten identified studies of medicines use were conducted in low income or lower-
middle income countries
x The remaining studies originated in upper-middle and high income countries, with the largest
contingent coming from Mexico, South Africa, Brazil, and Malaysia.
ȱ
ȱ
Figureȱ 3.5ȱ showsȱ theȱ numberȱ andȱ percentageȱ ofȱ studiesȱ ofȱ medicinesȱ useȱ byȱ
prescriberȱtype.ȱȱȱ
Figure 3.5: Medicines use studies by prescriber type
68
10%
75 213
11% 31%
MD
Paramedic or Nurse
18
3%
Pharmacist/ Assistant
Lay Person
Unspecified
305
45%
ȱ
Key Points:
x A subset of 518 studies of medicines use, representing 76% of the studies, identified the
prescriber to be a medical doctor, paramedical health worker, or a nurse.
x In this subset, four out of ten studies investigated prescribing of medical doctors (MDs).
ȱ
ȱ
ȱ
– 21 –
Figureȱ3.6ȱpresentsȱstudiesȱofȱmedicinesȱuseȱbyȱtypeȱofȱownershipȱofȱtheȱhealthȬcareȱ
facilitiesȱinvestigated.ȱȱ
Figure 3.6: Medicines use studies by health facility ownership
69
10%
58
9% Public
10
Private, for profit
1%
Private, not for profit
97 Not Applicable/Self-
14% Medication
Unspecified
445
66%
Key Points:
x The majority of studies of medicines use investigated health-care facilities from the public
sector.
x About one in seven studies reported medicines use in the private for-profit sector.
x Very few studies examined the private not-for-profit sector.
ȱ
ȱ
Figureȱ 3.7ȱ showsȱ theȱ numberȱ andȱ percentageȱ ofȱ studiesȱ ofȱ medicinesȱ useȱ withinȱ
differentȱtypesȱofȱhealthȬcareȱfacility.ȱȱȱ
Figure 3.7: Medicines use studies by facility type
22
54 3% 97
8% 14%
6
1%
60
9%
141
21%
Hospital
Hospital and PHC
Primary Health Center
Chemist or Pharmacist
299
44% Shop
Household
Unspecified
Key Points:
x Overall, 80% of studies in the database investigated medicines use in hospitals, primary care
facilities or health centres (PHCs), with over half of these evaluating practices in primary care
facilities.
x One in five studies examined use of medicines in chemists, other medicine retail outlets, or in
households.
– 22 –
3.3 Baseline medicines use studies for specific diseases

Theȱdatabaseȱcontainsȱmanyȱstudiesȱreportingȱgeneralȱuseȱofȱmedicinesȱforȱallȱages.ȱItȱ
alsoȱcontainsȱstudiesȱrelatedȱtoȱtheȱtreatmentȱofȱchildrenȱ(43%),ȱstudiesȱfocusingȱonȱ
specificȱdiseasesȱ(57%),ȱmostlyȱcommonȱchildhoodȱillnesses,ȱsuchȱasȱacuteȱdiarrhoeaȱ
(32%),ȱ acuteȱ respiratoryȱ tractȱ infectionsȱ (30%),ȱ andȱ malariaȱ (15%),ȱ orȱ sexuallyȱ
transmittedȱ diseasesȱ (4%).ȱ ȱ Manyȱ ofȱ theseȱ studiesȱ wereȱ associatedȱ withȱ variousȱ
nationalȱ andȱ internationalȱ verticalȱ controlȱ programmesȱ toȱ reduceȱ childhoodȱ
mortalityȱ and,ȱ moreȱ recently,ȱ toȱ theȱ implementationȱ ofȱ Integratedȱ Managementȱ ofȱ
ChildhoodȱIllnessesȱ(IMCI)ȱwhichȱrepresentsȱ8%ȱofȱstudiesȱinȱtheȱdatabase.23ȱResultsȱ
relatedȱ toȱ theȱ treatmentȱ ofȱ specificȱ diseasesȱ areȱ presentedȱ inȱ Sectionsȱ 6ȱ toȱ 8ȱ ofȱ theȱ
report.ȱȱ
ȱ
– 23 –
– 24 –
WHO/INRUD prescribing indicators
4. WHO/INRUD PRESCRIBING INDICATORS

WHO/INRUDȱ indicatorsȱ canȱ beȱ usedȱ toȱ exploreȱ patternsȱ ofȱ prescribingȱ inȱ primaryȱ
careȱ inȱ developingȱ andȱ transitionalȱ countries.ȱ Thisȱ sectionȱ examinesȱ WHO/INRUDȱ
prescribingȱindicatorsȱextractedȱfromȱstudiesȱofȱmedicinesȱuseȱasȱdescribedȱinȱTableȱ
2.1,ȱ regardlessȱ ofȱ patients’ȱ ageȱ orȱ disease.ȱ Resultsȱ areȱ presentedȱ inȱ relationȱ toȱ theȱ
chronologicalȱ periodȱ ofȱ dataȱ collection,ȱ geographicȱ originȱ ofȱ studies,ȱ healthȬcareȱ
facilityȱownership,ȱandȱtypeȱofȱprescriberȱforȱtheȱfollowingȱindicators:ȱpercentageȱofȱ
medicinesȱ fromȱ EML/formulary,ȱ percentageȱ ofȱ medicinesȱ prescribedȱ byȱ genericȱ
name,ȱ percentageȱ ofȱ patientsȱ withȱ anȱ antibioticȱ prescribed,ȱ percentageȱ ofȱ patientsȱ
withȱ anȱ injectionȱ prescribed,ȱ percentageȱ ofȱ patientsȱ treatedȱ accordingȱ toȱ clinicalȱ
guidelines,ȱandȱaverageȱnumberȱofȱmedicinesȱperȱpatient.ȱ
4.1 Medicines use over time

Figureȱ 4.1ȱ showsȱ resultsȱ forȱ WHO/INRUDȱ prescribingȱ indicatorsȱ inȱ studiesȱ ofȱ
medicinesȱ useȱ overȱ time.ȱ Observedȱ trendsȱ provideȱ aȱ meaningfulȱ indicationȱ ofȱ
changesȱ inȱ prescribingȱ patternsȱ overȱ time.ȱ However,ȱ prescribingȱ indicatorsȱ cannotȱ
differentiateȱ prescribers’ȱ practicesȱ fromȱ patientsȱ needs,ȱ andȱ extrapolatingȱ reasonsȱ
behindȱ observedȱ trendsȱ isȱ notȱ possibleȱ becauseȱ ofȱ theȱ multipleȱ factorsȱ influencingȱ
prescribing.ȱ
– 25 –
Figure 4.1: WHO/INRUD prescribing indicators, by time period
100 5
90
Average Number of Medicines

80 4
70
Percentage
60 3
50
40 2
30
20 1
10
0 0
1982-1991 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006
% Medicines from EML or Formulary % Medicines Prescribed by Generic Name

% Patients with an Antibiotic Prescribed % Patients with Injection Prescribed
% Treated According to Clinical Guidelines Average Number of Medicines per Patient
ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest that prescribing patterns have not improved
consistently overtime.
x The percentage of prescribed medicines present on an EML/formulary seems to have increased

in 25 years. This encouraging trend has been progressive, and may reflect an increased
availability of EML/formularies and/or better awareness of their existence.
x The percentage of medicines prescribed by generic name increased steadily to reach over 70%
in the 2004-2006 period of data collection. This trend may be related to an increased
availability of generics and implementation of generic prescribing and dispensing policies.
x In contrast to these positive trends, the percentage of patients treated according to clinical
guidelines remained at substandard levels, below 50% at every period of data collection from
1992 on.
x The percentage of patients with an antibiotic prescribed remained stable over time at between
40% and 50%. This indicator did not differentiate between appropriate and inappropriate
antibiotic prescribing.
x The percentage of patients with an injection prescribed and the average number of medicines
per patient showed no apparent trends over the years.
4.2 Medicines use by region

Figureȱ 4.2ȱ presentsȱ overallȱ resultsȱ ofȱ theȱ WHO/INRUDȱ prescribingȱ indicatorsȱ inȱ
studiesȱ ofȱ medicinesȱ useȱ byȱ Worldȱ Bankȱ region.ȱ Becauseȱ ofȱ theȱ smallȱ numberȱ ofȱ
studiesȱ fromȱ theȱ Middleȱ East/Northȱ Africaȱ andȱ Europe/Centralȱ Asiaȱ regions,ȱ theseȱ
wereȱgroupedȱunderȱoneȱMiddleȱEastȱandȱCentralȱAsiaȱregion.ȱȱ
– 26 –
Figure 4.2: WHO/INRUD prescribing indicators, by World Bank region
100 5
90

80 4
70
Percentage 60 3
50
40 2
30
20 1
10
0 0
% Medicines % Medicines % Patients % Patients % Treated Average
from EML or Prescribed by with an with Injection According to Number of
Formulary Generic Name Antibiotic Prescribed Clinical Medicines per
Prescribed Guidelines Patient
Sub-Saharan Africa Latin America and Caribbean Middle East and Central Asia
East Asia and Pacific South Asia
ȱ
ȱ
Key Points:
x Results from studies of medicines use provide a mixed picture of prescribing patterns across
different geographic regions over the entire period of data collection.
x Studies from Africa pointed towards positive characteristics in this region, with the highest
percentage of medicines prescribed from an EML/formulary, and the highest percentage of
patients treated according to clinical guidelines. However, they also showed the highest
percentage of patients with an injection prescribed.
x Studies from Latin America had the highest percentage of medicines prescribed by generic
name, while studies from Middle East and Central Asia had the lowest.
x The percentage of reported patients with an antibiotic prescribed was similar across regions.
x Across regions, studies reported up to 3 medicines prescribed per patient.
x The percentage of compliance with clinical guidelines was below 50% in all regions.
ȱ
ȱ
– 27 –
Figureȱ 4.3ȱ presentsȱ overallȱ resultsȱ ofȱ theȱ WHO/INRUDȱ prescribingȱ indicatorsȱ inȱ
studiesȱofȱmedicinesȱuseȱbyȱWorldȱBankȱincomeȱlevelȱofȱcountriesȱwhereȱtheyȱwereȱ
conducted.ȱȱ
Figure 4.3: WHO/INRUD prescribing indicators, by World Bank income level
100 5
90

80 4
70
Percentage
60 3
50
40 2
30
20 1
10
0 0
Low Income Lower-Middle Income Upper-Middle & High Income

ȱ
ȱ
Key Points:
x Results from studies of medicines use may indicate disparities in prescribing patterns across
regions of different economic level.
x Studies from low income settings suggest a higher percentage of medicines prescribed from
EML/formularies and by generic name in these countries. Nevertheless, they also report the
highest percentages of patients treated with an antibiotic and with an injection.
x The percentage of patients treated according to clinical guidelines was below 50% regardless
of income level of the country where studies were conducted.
x The average number of medicines prescribed was between 2 and 3 across country income
levels.
ȱ
ȱ
– 28 –
Figureȱ 4.4ȱ showsȱ resultsȱ ofȱ theȱ percentageȱ ofȱ patientsȱ treatedȱ accordingȱ toȱ clinicalȱ
guidelinesȱinȱtheȱidentifiedȱstudiesȱofȱmedicinesȱuse,ȱbyȱchronologicalȱperiodsȱofȱdataȱ
collectionȱ andȱ byȱ Worldȱ Bankȱ region.ȱ Adherenceȱ toȱ clinicalȱ guidelinesȱ refersȱ toȱ
adherenceȱ toȱ prescribingȱ guidelinesȱ asȱ itȱ relatesȱ toȱ theȱ choiceȱ ofȱ medicine,ȱ dosage,ȱ
andȱ duration.ȱ Chronologicalȱ periodsȱ haveȱ beenȱ groupedȱ intoȱ threeȱ toȱ highlightȱ
overallȱtrends.ȱȱ
Figure 4.4: Rates of adherence to clinical guidelines over time, by World Bank region
100
90
80
70
Percentage
60
50
40
30
20
10
0
1982-1994 1995-2000 2001-2006
Sub-Saharan Africa Latin America and Caribbean

Middle East and Central Asia East Asia and Pacific
South Asia
ȱ
ȱ
Key Points:
x Overall, results from studies of medicines use show that only half of the patients or less were
prescribed medicines according to clinical guidelines during the most recent period of data
collection, regardless of the geographic origin of studies.
x This percentage increased slightly in studies from Middle East & Central Asia and East Asia &
Pacific, suggesting some degree of improvement in adherence to prescribing guidelines
between the 1982-1994 and 2001-2006 periods in these regions. Overall compliance with
guidelines remained low.
x The sample of studies between 2001 and 2006 with data on adherence to prescribing clinical
guidelines may be too small in all regions but Africa to interpret results of this period with
confidence.
4.3 Medicines use by type of prescriber

Figureȱ4.5ȱpresentsȱoverallȱresultsȱofȱtheȱWHO/INRUDȱprescribingȱindicatorsȱbyȱtypeȱ
ofȱ prescriber,ȱ regardlessȱ ofȱ theȱ chronologicalȱ periodȱ ofȱ dataȱ collection,ȱ region,ȱ orȱ
ownershipȱofȱhealthȬcareȱfacility.ȱ
– 29 –
Figure 4.5: WHO/INRUD prescribing indicators by prescriber type

100 5
90

80 4
70
Percentage
60 3
50
40 2
30
20 1
10
0 0
MD Paramedic or Nurse Pharmacy Staff, Other, or Unspecified

ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest that prescribing patterns were substandard
regardless of the type of prescriber.
x Paramedical health-care workers/nurses prescribed more generic medicines and more
medicines from EML/formularies than medical doctors.
x Results did not uncover other important differences between the prescribing of medical doctors
and that of paramedical health-care workers/nurses.
4.4 Medicines use by health-care facility ownership

Figureȱ 4.6ȱ presentsȱ overallȱ resultsȱ ofȱ theȱ WHO/INRUDȱ prescribingȱ indicatorsȱ byȱ
ownershipȱofȱhealthȬcareȱfacility,ȱregardlessȱofȱchronologicalȱperiodȱofȱdataȱcollectionȱ
orȱ region.ȱ ȱ Aȱ keyȱ policyȱ issueȱ inȱ manyȱ countriesȱ isȱ whetherȱ prescribingȱ isȱ moreȱ
appropriateȱ inȱ theȱ publicȱ orȱ privateȱ sector.ȱ ȱ Sinceȱ manyȱ privateȱ sectorȱ studiesȱ
measureȱ theȱ practicesȱ ofȱ unqualifiedȱ pharmacistsȱ andȱ shopȱ attendantsȱ (seeȱ
Figureȱ4.5),ȱ theȱ comparisonȱ betweenȱ publicȱ andȱ privateȱ sectorȱ practicesȱ mayȱnotȱ beȱ
valid.ȱ ȱ Thereforeȱ theȱ followingȱ comparisonȱ isȱ basedȱ onlyȱ onȱ studiesȱ measuringȱ theȱ
prescribingȱofȱphysicians,ȱnurses,ȱorȱparamedics.ȱ
– 30 –
Figure 4.6: WHO/INRUD prescribing indicators by health facility ownership (prescribing

by physicians, nurses and paramedics only)
100 5
90

80 4
70
Percentage
60 3
50
40 2
30
20 1
10
0 0
% Medicines % Medicines % Patients % Patients % Treated Av erage
Formulary G eneric Name Antibiotic Prescribed Clinical Medicines per
Prescribed Guidelines P atient
Public Private, for profit Private, not for profit

ȱ
ȱ
Key Points:
x Overall, results suggest better prescribing patterns in public health-care facilities than in
private for-profit facilities.
x Generics and medicines prescribed from an EML/formulary were much higher in studies in both
the public and private not-for-profit sectors than in the private for-profit sector.
x The percentage of patients with an antibiotic prescribed was equivalently high in all sectors, at
nearly half of all patients; about 20% of patients received an injection in the public and private
for-profit sectors, but this percentage was much higher in studies from the private not-for-
profit sectors.
x The percentages of patients treated according to clinical guidelines were low in both the public
and private for-profit sectors, although somewhat higher in the public sector.
x Fewer medicines were prescribed on average in the public sector (2.4 per patient) than in
either of the private sectors (3.0 per patient).
ȱ
– 31 –
– 32 –
WHO/INRUD patient care and facility indicators
5. WHO/INRUD PATIENT CARE AND HEALTH FACILITY

INDICATORS
WHO/INRUDȱpatientȱcareȱandȱhealthȱfacilityȱindicatorsȱcanȱbeȱmeasuredȱtoȱexploreȱ
theȱqualityȱofȱpatientȱcareȱandȱofȱhealthȬcareȱfacilitiesȱasȱtheyȱrelateȱtoȱmedicinesȱuse.ȱ
Thisȱ sectionȱ examinesȱ WHO/INRUDȱ indicatorsȱ ofȱ patientȱ careȱ andȱ healthȬcareȱ
facilityȱextractedȱfromȱstudiesȱofȱmedicinesȱuseȱasȱdescribedȱinȱTableȱ2.1,ȱregardlessȱ
ofȱpatients’ȱageȱorȱdisease.ȱResultsȱofȱtheseȱindicatorsȱareȱpresentedȱinȱrelationȱtoȱtheȱ
chronologicalȱperiodȱofȱdataȱcollection,ȱtheȱgeographicȱoriginȱofȱstudies,ȱhealthȬcareȱ
ownership,ȱ andȱ typeȱ ofȱ prescriber.ȱ Theȱ followingȱ indicatorsȱ ofȱ patientȱ careȱ wereȱ
evaluated:ȱ percentageȱ ofȱ prescribedȱ medicinesȱ actuallyȱ dispensed,ȱ percentageȱ ofȱ
medicinesȱ adequatelyȱ labelled,ȱ percentageȱ ofȱ patientsȱ givenȱ dosageȱ instructions,ȱ
percentageȱofȱpatientsȱwithȱknowledgeȱofȱcorrectȱdose,ȱaverageȱconsultationȱtimeȱinȱ
minutes,ȱandȱaverageȱdispensingȱtimeȱinȱminutes.ȱTheȱfollowingȱhealthȬcareȱfacilityȱ
indicatorsȱ wereȱ evaluated:ȱ percentageȱ ofȱ keyȱ medicinesȱ availableȱ inȱ facility,ȱ
availabilityȱofȱclinicalȱguidelines,ȱandȱavailabilityȱofȱEML/formulary.ȱȱȱȱ
5.1 Patient care indicators

Figureȱ5.1ȱdisplaysȱresultsȱofȱtheȱWHO/INRUDȱpatientȱcareȱindicatorsȱinȱstudiesȱofȱ
medicinesȱ useȱ byȱ chronologicalȱ periodsȱ ofȱ dataȱ collection,ȱ regardlessȱ ofȱ region,ȱ
ownershipȱofȱhealthȬcareȱfacility,ȱorȱtypeȱofȱprescriber.ȱȱ
– 33 –
Figure 5.1: WHO/INRUD patient care indicators, by time period
100 10
90 9
80 8
70 7
Time (in Minutes)

Percentage
60 6
50 5
40 4
30 3
20 2
10 1
0 0
1982-1991 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006
% Prescribed Medicines Dispensed % Medicines Adequately Labeled

% Patients Given Dosage Instructions % Patients with Knowledge of Correct Dose
Average Consultation Time (minutes) Average Dispensing Time (minutes)
ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest some improvement over time in many aspects
of patient care related to the use of medicines. Most positive trends remain even after taking
into account the fact that some of the low baseline values may be due to a very small 1982-
1991 sample of studies collecting data on these indicators.
x The percentage of reported prescribed medicines that are actually dispensed increased by 10%
over time to reach 92% in the most recent data collection period.
x The average consultation time showed improvement over time and the percentage of reported
patients who were given dosage instructions increased slightly.
x The percentage of reported medicines adequately labelled increased noticeably over time.
x The percentage of patients with knowledge of the correct dose also showed a positive trend.
However, over 25% of patients did not know which dose of medicine to take in the most recent
studies.
x The average dispensing time, which includes preparation of a prescription and interaction
between patient and dispenser, started low and remained at just over one minute in the most
recent data collection period.
ȱ
ȱ
Figureȱ 5.2ȱ displaysȱ resultsȱ ofȱ theȱ WHO/INRUDȱ patientȱ careȱ indicatorsȱ inȱ theȱ
identifiedȱstudiesȱofȱmedicinesȱuseȱbyȱregion,ȱregardlessȱofȱchronologicalȱperiodsȱofȱ
dataȱ collection,ȱ ownershipȱ ofȱ healthȬcareȱ facility,ȱ orȱ typeȱ ofȱ prescriber.ȱ ȱ Becauseȱ ofȱ
theȱsmallȱnumberȱofȱstudiesȱfromȱtheȱMiddleȱEast/NorthȱAfricaȱandȱEurope/Centralȱ
Asiaȱregions,ȱtheseȱwereȱgroupedȱintoȱoneȱMiddleȱEastȱandȱCentralȱAsiaȱregion.ȱ
– 34 –
Figure 5.2: WHO/INRUD patient care indicators, by World Bank region

100 10
90 9
80 8
Time (in minutes)

70 7
Percentage 60 6
50 5
40 4
30 3
20 2
10 1
0 0
% Prescribed % Medicines % Patients % Patients Average Average
Medicines Adequately Given Dosage with Consultation Dispensing
Dispensed Labeled Instructions Knowledge of Time Time
Correct Dose (minutes) (minutes)
ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest that overall trends in patient care indicators
were similar across different regions of the world for the 1982-2006 period of data collection.
x Low average dispensing times, insufficient instructions to patients, and lack of patient
knowledge about how to take their medicines were problems in all regions of the world.
x Studies from East Asia and Pacific reported the highest percentage of prescribed medicines
actually dispensed, the highest percentage of patients given dosage instructions, and the
highest percentage of patients with knowledge of the correct dose.
x Studies from Latin America reported highest average consultation time.
x Studies from Middle East and Central Asia reported the highest rate of adequate labelling while
South Asia studies reported almost no medicines adequately labelled.
ȱ
– 35 –
Figureȱ 5.3ȱ presentsȱ overallȱ resultsȱ ofȱ theȱ patientȱ careȱ indicatorsȱ inȱ studiesȱ ofȱ
medicinesȱuseȱbyȱWorldȱBankȱincomeȱlevelȱofȱcountriesȱwhereȱtheyȱwereȱconducted.ȱȱ
Figure 5.3: WHO/INRUD patient care indicators, by World Bank income level
100 10
90 9
80 8
70 7
Time (in minutes)

Percentage
60 6
50 5
40 4
30 3
20 2
10 1
0 0
Dispensed Labeled Instructions Knowledge of Time Time
Correct Dose (minutes) (minutes)

ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest variable differences in patient care indicators
across regions of different economic level.
x Studies from low income settings have the lowest percentage of medicines adequately labelled,
the lowest percentage of patients given dosage instructions, the lowest percentage of patients
with knowledge of correct dose, and the lowest percentage of prescribed medicines actually
dispensed.
x Studies from low-middle income countries have the highest percentage of medicines
adequately labelled, highest percentage of patients with knowledge of correct dose, and
highest average consultation time.
ȱ
ȱ
Figureȱ5.4ȱdisplaysȱresultsȱofȱtheȱWHO/INRUDȱpatientȱcareȱindicatorsȱinȱtheȱstudiesȱ
ofȱ medicinesȱ useȱ byȱ ownershipȱ ofȱ healthȬcareȱ facility,ȱ regardlessȱ ofȱ chronologicalȱ
periodsȱ ofȱ dataȱ collection,ȱ region,ȱ orȱ typeȱ ofȱ prescribers.ȱ Forȱ theseȱ indicators,ȱ theȱ
sampleȱ sizeȱ ofȱ privateȱ healthȬcareȱ facilitiesȱ wasȱ consistentlyȱ belowȱ 15,ȱ whichȱ limitsȱ
theȱ interpretationȱ ofȱ differencesȱ betweenȱ theȱ privateȱ andȱ publicȱ sectors.ȱ Noȱ dataȱ
pointsȱ wereȱ availableȱ toȱ calculateȱ theȱ percentageȱ ofȱ patientsȱ givenȱ dosageȱ
instructionsȱinȱstudiesȱconductedȱinȱprivateȱnotȬforȬprofitȱfacilities.ȱ
– 36 –
Figure 5.4: WHO/INRUD patient care indicators, by health facility ownership
100 10
90 9
80 8
70 7
Time (in minutes)

Percentage
60 6
50 5
40 4
30 3
20 2
10 1
0 0
% Prescribed % Medicines % Patients % Patients with Average Average
Medicines Adequately Given Dosage Knowledge of Consultation Dispensing Time
Dispensed Labeled Instructions Correct Dose Time (minutes) (minutes)

ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest that overall patient care indicators were better
in studies from private sectors. However, the small sample size of studies in both private for-
profit and not-for-profit facilities with data on patient care indicators limits the reliability of this
finding.
x The sample size of studies in the public sector was large, and results there suggest inadequate
patient care indicators of medicines use.
x In studies of public health-care facilities, only half of the patients received dosage instructions,
and more than a third of patients did not know which dose of prescribed medicine to take.
x Average consultation time in public health-care facility studies was only four minutes and
average dispensing time was just over one minute.
5.2 Health-care facility indicators

Figureȱ5.5ȱdisplaysȱresultsȱofȱtheȱWHO/INRUDȱpatientȱcareȱindicatorsȱinȱtheȱstudiesȱ
ofȱmedicinesȱuseȱbyȱchronologicalȱperiodsȱofȱdataȱcollection,ȱregardlessȱofȱregionȱorȱ
ownershipȱofȱhealthȬcareȱfacility.ȱȱ
– 37 –
Figure 5.5: WHO/INRUD health facility indicators, by time period
90
80
70
60
Percentage
50
40
30
20
10
0
1982-1991 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006
% Key Medicines Available in Facility Availability of Clinical Guidelines

Availability of EML or Formulary
ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest a lack of improvement in key health-care facility
indicators over time.
x Reported availability of an EML or formulary to prescribers was highly variable across the time
periods, ranging from about 40% to about 80% without a consistent pattern.
x Availability of clinical guidelines to prescribers did not seem to improve over time. In 2004-
2006, only half of health-care facilities were reported to have clinical guidelines available
during indicator surveys.
x The percentage of key medicines available in health-care facilities fluctuated between 70% and
80%. Overall, about two out of ten key medicines were not available in the health-care
facilities investigated.
ȱ
ȱ
Figureȱ 5.6ȱ displaysȱ resultsȱ ofȱ WHO/INRUDȱ healthȬcareȱ facilityȱ indicatorsȱ inȱ theȱ
studiesȱofȱmedicinesȱuseȱbyȱWorldȱBankȱregion,ȱregardlessȱofȱchronologicalȱperiodsȱ
ofȱdataȱcollectionȱorȱownershipȱofȱhealthȬcareȱfacility.ȱBecauseȱofȱtheȱsmallȱnumberȱofȱ
studiesȱ fromȱ theȱ Middleȱ East/Northȱ Africaȱ andȱ Europe/Centralȱ Asiaȱ regions,ȱ theseȱ
wereȱgroupedȱintoȱoneȱMiddleȱEastȱandȱCentralȱAsiaȱregion.ȱȱȱȱȱ
– 38 –
Figure 5.6: WHO/INRUD health facility indicators, by World Bank region
100
90
80
70
60
Percentage
50
40
30
20
10
0
% Key Medicines Available in Availability of Clinical Guidelines Availability of EML or Formulary
Facility
ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest that overall trends in patient care and health-
care facility indicators varied across different regions for the 1982-2006 period of data
collection.
x Studies from South Asia suggest that clinical guidelines and EML/formularies were rarely
accessible to prescribers in this region; however, the small sample size may limit the
significance of this finding.
x In studies conducted in other regions of the world, the availability of clinical guidelines and
EML/formularies was higher. Still clinical guidelines were not accessible to prescribers in half of
the health-care facilities in studies from Africa and Latin America.
x The percentage of key medicines available in health-care facilities was lowest in studies from
Latin America where three out of ten key medicines were not available in health-care facilities.
ȱ
– 39 –
Figureȱ 5.7ȱ presentsȱ overallȱ resultsȱ ofȱ theȱ healthȬcareȱ facilityȱ indicatorsȱ inȱ studiesȱ ofȱ
medicinesȱuseȱbyȱWorldȱBankȱincomeȱlevelȱofȱcountriesȱwhereȱtheyȱwereȱconducted.ȱȱ
Figure 5.7: WHO/INRUD health facility indicators, by World Bank income level
100
90
80
70
Percentage
60
50
40
30
20
10
0
% Key Medicines Available in Availability of Clinical Availability of EML or
Facility Guidelines Formulary

ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest differences in availability of clinical guidelines
across regions of different economic level.
x Studies from low income settings have the lowest percentages of clinical guidelines and
EML/formularies available to prescribers. These percentages increased with country income
level.
x The percentage of key medicines available in the health-care facility seemed similar across
regions of different economic level.
ȱ
ȱ
Figureȱ 5.8ȱ displaysȱ resultsȱ ofȱ WHO/INRUDȱ healthȬcareȱ facilityȱ indicatorsȱ inȱ theȱ
studiesȱ ofȱ medicinesȱ useȱ byȱ ownershipȱ ofȱ healthȬcareȱ facility,ȱ regardlessȱ ofȱ
chronologicalȱperiodsȱofȱdataȱcollectionȱorȱregion.ȱTooȱfewȱdataȱpointsȱwereȱavailableȱ
toȱ calculateȱ twoȱ ofȱ theȱ threeȱ indicatorsȱ inȱ theȱ privateȱ notȬforȬprofitȱ sectorȱ andȱ oneȱ
indicatorȱinȱtheȱprivateȱforȬprofitȱsector.ȱ
– 40 –
Figure 5.8: WHO/INRUD health facility indicators, by facility ownership
100
90
80
70
Percentage
60
50
40
30
20
10
0
% Key Medicines Available in Availability of Clinical Guidelines Availability of EML or Formulary
Facility

ȱ
ȱ
Key Points:
x Two out of ten key medicines were not available in public and private for-profit health-care
facilities. The percentage of key medicines available in private not-for-profit health-care
facilities was slightly higher.
x In about 40% of public health-care facilities, prescribers did not have access to clinical
guidelines. However, the situation appeared to be much worse in the private for-profit sector.
x In half of public health-care facilities, EML/formularies were not available to prescribers.
ȱ
– 41 –
– 42 –
Treatment of respiratory infections
6. TREATMENT OF ACUTE RESPIRATORY TRACT

INFECTIONS
Thisȱ sectionȱ focusesȱ onȱ resultsȱ aboutȱ treatmentȱ ofȱ acuteȱ respiratoryȱ tractȱ infectionsȱ
(ARI)ȱ fromȱ studiesȱ conductedȱ betweenȱ 1982ȱ andȱ 2006.ȱ ARIȱ prescribingȱ indicatorsȱ
wereȱ extractedȱ fromȱ thisȱ subgroupȱ ofȱ studiesȱ andȱ areȱ presentedȱ belowȱ toȱ showȱ
patternsȱofȱARIȱtreatmentȱoverȱtime.ȱȱTheȱfollowingȱARIȱindicatorsȱwereȱevaluated:ȱȱ
x Percentageȱofȱcasesȱofȱupperȱrespiratoryȱtractȱinfectionsȱ(URTI)ȱtreatedȱwithȱ
antibiotics.ȱURTIȱwasȱdefinedȱasȱanyȱtypeȱofȱURTIȱthatȱauthorsȱofȱtheȱstudiesȱ
consideredȱnotȱneedingȱantibiotics.ȱ‘Commonȱcold’ȱandȱ‘soreȱthroat’ȱcasesȱwereȱ
consideredȱviralȱURTI,ȱi.e.ȱnotȱneedingȱantibiotics.ȱ
x Percentageȱofȱpneumoniaȱcasesȱtreatedȱwithȱappropriateȱantibiotics.ȱ
Pneumoniaȱwasȱdefinedȱasȱanyȱtypeȱofȱlowerȱrespiratoryȱtractȱinfectionȱthatȱ
authorsȱconsideredȱneedingȱantibiotics.ȱTheȱassessmentȱbyȱstudyȱauthorsȱwasȱ
usedȱtoȱqualifyȱantibioticȱuseȱasȱ‘appropriate’ȱorȱ‘inappropriate’.ȱThisȱindicatorȱ
wasȱjudgedȱonȱtheȱbasisȱofȱwhetherȱanȱantibioticȱwasȱindicatedȱandȱifȱso,ȱ
whetherȱtheȱcorrectȱoneȱwasȱgiven.ȱItȱdidȱnotȱincludeȱjudgmentȱaboutȱdosageȱorȱ
duration.ȱȱ
x Percentageȱofȱpatientsȱtreatedȱaccordingȱtoȱclinicalȱguidelines.ȱClinicalȱ
guidelinesȱspecificallyȱrelatedȱtoȱtreatmentȱofȱallȱtypesȱofȱARI.ȱThisȱindicatorȱ
includedȱjudgmentȱaboutȱwhetherȱtheȱcorrectȱtreatmentȱwasȱgivenȱincludingȱ
dosageȱandȱduration.ȱȱ
x PercentageȱofȱARIȱcasesȱtreatedȱwithȱcoughȱsyrups.ȱCoughȱsyrupsȱwereȱdefinedȱ
asȱnonȬantibioticȱcoughȱsuppressants,ȱexpectorants,ȱdemulcentȱcoughȱ
preparations,ȱdecongestants,ȱandȱmedicinesȱdescribedȱbyȱauthorsȱofȱstudiesȱasȱ
relievingȱsymptomsȱofȱcoughȱandȱcold.ȱȱȱ
6.1 Patterns in treatment of ARI over time

Figureȱ 6.1ȱ presentsȱ ARIȱ prescribingȱ indicatorsȱ forȱ patientsȱ ofȱ allȱ agesȱ overȱ theȱ
chronologicalȱperiodsȱofȱdataȱcollection.ȱ
– 43 –
Figure 6.1: ARI prescribing indicators over time, including all studies of medicines use in
ARI
100
90
80
Percentage 70
60
50
40
30
20
10
0
1982-1991 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006
% Cases of URTI Treated with Antibiotics

% Pneumonia Cases Treated with Recommended Antibiotics
% Treated According to Clinical Guidelines
% ARI Cases Treated with Cough Syrups
ȱ
ȱ
Key Points:
x Results from studies reporting medicines use in ARI suggest that ARI prescribing patterns may
have deteriorated over time.
x The percentage of reported viral URTI treated with antibiotics increased over time to 71%
during the 2004-2006 period.
x Over 20% of reported pneumonia cases were not treated with appropriate antibiotics during
that period.
x Reported compliance with ARI standard treatment guidelines appeared to decrease overtime.
During the most recent period of data collection, the percentage of reported patients treated
according to ARI clinical guidelines was below 40%.
x There may have been a decrease in the use of cough syrups over time, although small sample
sizes may limit the significance of this finding.
ȱ
ȱ
AȱlargeȱmajorityȱofȱtheȱstudiesȱofȱmedicinesȱuseȱduringȱARIȱconcentratedȱonȱchildrenȱ
underȱ 5ȱ yearsȱ old.ȱ ȱ Figureȱ 6.2ȱ presentsȱ ARIȱ prescribingȱ indicatorsȱ overȱ timeȱ inȱ theȱ
subsetȱofȱstudiesȱfocusingȱonȱchildrenȱlessȱthanȱ5ȱyearsȱoldȱwithȱARI.ȱ
– 44 –
Figure 6.2: ARI treatment indicators over time, including only studies of medicines use
in children < 5 years with ARI
100
90
80
Percentage 70
60
50
40
30
20
10
0
1982-1991 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006

ȱ
ȱ
Key Points:
x Results from studies reporting medicines use suggest that treatment of ARI in children less
than 5 years old did not improve over 25 years of data collection.
x The percentage of children under 5 years old with reported viral URTI who were treated with
antibiotics almost doubled over 25 years to reach over 70% in 2004-2006.
x During 2004-2006, over 30% of children less than 5 years old with reported pneumonia were
not treated with appropriate antibiotics.
x The percentage of children under 5 years old with ARI who were treated according to clinical
guidelines did not improve overtime, and was below 40% during the 2004-2006 period of data
collection.
x The small sample size of studies with data on cough syrup use may explain the observed
fluctuations in percentage of ARI cases treated with cough syrups.
6.2 Patterns in treatment of ARI by region, facility ownership,

and prescriber type
Figureȱ6.3ȱpresentsȱoverallȱresultsȱofȱARIȱprescribingȱindicatorsȱaveragedȱbyȱWorldȱ
Bankȱ region.ȱ Studiesȱ wereȱ classifiedȱ accordingȱ toȱ whereȱ theyȱ wereȱ conductedȱ intoȱ
categoriesȱofȱWorldȱBankȱregions.ȱToȱensureȱaȱreasonableȱsampleȱsizeȱinȱeachȱgroup,ȱ
studiesȱ fromȱ theȱ Middleȱ East,ȱ Northȱ Africa,ȱ Europeȱ andȱ Centralȱ Asiaȱ regionȱ wereȱ
groupedȱintoȱoneȱMiddleȱEastȱandȱCentralȱAsiaȱregion.ȱȱ
– 45 –
Figure 6.3: ARI treatment indicators including all studies of medicines use in ARI, by
World Bank region
100
90
80
Percentage 70
60
50
40
30
20
10
0
% Cases of URTI Treated % Pneumonia Cases % Treated According to % ARI Cases Treated
with Antibiotics Treated with Clinical Guidelines with Cough Syrups
Recommended Antibiotics
ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest inadequate ARI prescribing patterns in every
geographic region of the world.
x Everywhere, a large percentage of viral URTI study cases were treated with antibiotics, over
70% in Africa.
x In every region at least 25% of reported pneumonia cases were treated with inappropriate
antibiotics.
x The percentage of ARI cases treated according to clinical guidelines was reported below 50% in
studies from all regions, except from Latin America.
x Results suggest that the use of cough syrups was more prevalent in the Middle East and
Central Asia region.
ȱ
ȱ
Figureȱ6.4ȱpresentsȱoverallȱresultsȱofȱARIȱprescribingȱindicatorsȱaveragedȱbyȱWorldȱ
Bankȱincomeȱlevelȱofȱcountriesȱwhereȱtheȱstudiesȱwereȱconducted.ȱȱ
– 46 –
World Bank income level
100
90
80
70
Percentage
60
50
40
30
20
10
0
% Cases of URTI % Pneumonia Cases % Treated According % ARI Cases Treated
Treated with Treated with to Clinical Guidelines with Cough Syrups
Antibiotics Recommended
Antibiotics

ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest similarities and differences in prescribing
patterns for ARI across income regions.
x Everywhere, a large percentage of viral URTI study cases were treated with antibiotics.
x Studies from low income countries had the lowest percentage of pneumonia cases treated with
recommended antibiotics, and the lowest percentage of patients treated according to clinical
guidelines.
x The percentage of ARI cases treated with cough syrups was lowest in low income countries.
ȱ
ȱ
– 47 –
Figureȱ6.5ȱpresentsȱoverallȱresultsȱofȱARIȱtreatmentȱindicatorsȱbyȱtypeȱofȱprescriber.ȱȱ
type of prescriber
100
90
80
70
Percentage
60
50
40
30
20
10
0

ȱ
ȱ
ȱ
Key Points:
x Results from studies of medicines use in ARI suggest unsatisfactory prescribing patterns by all
cadres of health worker.
x Medical doctors prescribed antibiotics in reported cases of viral URTI more often than
paramedical health workers/nurses.
x Almost 30% of reported cases of pneumonia treated by medical doctors were not prescribed
appropriate antibiotics. This percentage was higher for paramedical health workers/nurses
(close to 40%) and highest for the third category, which included pharmacy staff, lay persons,
or unspecified prescribers.
x Only about 40% of prescribers were reported to treat ARI according to clinical guidelines, with
medical doctors and paramedical health workers/nurses having similarly poor prescribing
practices.
ȱ
ȱ
Figureȱ 6.6ȱ presentsȱ overallȱ resultsȱ ofȱ ARIȱ treatmentȱ indicatorsȱ averagedȱ byȱ
ownershipȱ ofȱ healthȬcareȱ facility.ȱ Noȱ dataȱ wereȱ availableȱ forȱ twoȱ ofȱ theȱ fourȱ ARIȱ
treatmentȱ indicatorsȱ inȱ studiesȱ conductedȱ inȱ theȱ privateȱ notȬforȬprofitȱ sectorȱ andȱ
thereȱ wereȱ fewerȱ thanȱ fourȱ studiesȱ reportingȱ theȱ otherȱ twoȱ indicators,ȱ thusȱ theseȱ
resultsȱ areȱ notȱ displayedȱ inȱ theȱ figure.ȱ ȱ Toȱ enhanceȱ comparabilityȱ betweenȱ sectors,ȱ
theȱ figureȱ includesȱ dataȱ onlyȱ fromȱ studiesȱ assessingȱ prescribingȱ byȱ physicians,ȱ
nurses,ȱorȱparamedics.ȱȱ
– 48 –
health-care facility ownership (prescribing by physicians, nurses and paramedics only)
100
90
80
Percentage 70
60
50
40
30
20
10
0

ȱ
ȱ
Key Points:
x Overall quality of care for ARI was poor in both the public and private sectors.
x The percentage of cases of viral URTI treated with antibiotics was substantially higher in
private for-profit facilities than in public facilities.
x Only about two-thirds of reported pneumonia cases treated in both public health-care and
private for-profit facilities received appropriate antibiotics.
x The percentage of ARI patients treated according to clinical guidelines was about 40% in public
health-care facilities; there were too few studies in the private sectors to evaluate this
indicator.
x Over 40% of cases in both the public and private for-profit sectors were treated with cough
syrups, which are unnecessary for proper clinical management.
ȱ
ȱ
Figureȱ6.7ȱfocusesȱonȱtheȱavailabilityȱofȱkeyȱmedicinesȱinȱstudiesȱofȱmedicinesȱuseȱinȱ
ARIȱbyȱWorldȱBankȱregion.ȱTheȱMiddleȱEastȱandȱCentralȱAsiaȱregionȱisȱnotȱshownȱonȱ
theȱgraphȱbecauseȱofȱinsufficientȱdataȱinȱthisȱregionȱforȱthatȱindicator.ȱ
– 49 –
Figure 6.7: Availability of key medicines in studies of medicines use in ARI, by World
Bank region
100
90
80
70
Percentage
60
50
40
30
20
10
0
% Key Medicines Available in Facility
ȱ
ȱ
Key Points:
x The availability of key medicines to treat acute respiratory tract infection was below 80% in
studies in all regions (too few studies were reported in Middle East and Central Asia and in East
Asia and Pacific to summarize practice).
x Availability of medicines was particularly low in health facilities in Latin America and the
Caribbean (60%) and South Asia (70%).
ȱ
ȱ
– 50 –
Treatment of acute diarrhoea
7. TREATMENT OF ACUTE DIARRHOEA

Thisȱsectionȱfocusesȱonȱstudiesȱofȱmedicinesȱuseȱthatȱreportedȱresultsȱaboutȱtreatmentȱ
ofȱ acuteȱ diarrhoeaȱ fromȱ dataȱ collectedȱ betweenȱ 1982ȱ andȱ 2006.ȱ Theȱ termȱ acuteȱ
diarrhoeaȱ includedȱ allȱ typesȱ ofȱ acuteȱ diarrhoea,ȱ includingȱ bloodyȱ diarrhoea.ȱ Acuteȱ
diarrhoeaȱ prescribingȱ indicatorsȱ wereȱ extractedȱ fromȱ thisȱ subgroupȱ ofȱ studiesȱ andȱ
areȱ presentedȱ belowȱ toȱ showȱ patternsȱ ofȱ acuteȱ diarrhoeaȱ treatmentȱ overȱ time.ȱ Theȱ
followingȱacuteȱdiarrhoeaȱindicatorsȱwereȱselected:ȱȱ
x Percentageȱofȱdiarrhoeaȱcasesȱtreatedȱwithȱantibiotics.ȱThisȱpercentageȱ
generally,ȱthoughȱnotȱalways,ȱdifferentiatedȱunnecessaryȱuseȱofȱantibioticsȱfromȱ
appropriateȱuseȱrelatedȱtoȱinvasiveȱbacterialȱdiarrhoeaȱorȱtoȱotherȱconcomitantȱ
illnessesȱsuchȱasȱpneumoniaȱorȱotherȱbacterialȱinfections.ȱJudgmentȱwasȱbasedȱ
onȱtheȱauthorȱassessmentȱofȱinappropriateȱantibioticȱforȱdiarrhoea.ȱAntibioticȱ
useȱinȱdysenteryȱwasȱspecificallyȱexcluded.ȱSomeȱpublicationsȱdidȱnotȱmentionȱ
theȱtypeȱofȱdiarrhoea,ȱinȱwhichȱcaseȱitȱwasȱassumedȱthatȱaȱmajorityȱofȱcasesȱ
wereȱviralȱdiarrhoea.ȱȱ
x Percentageȱofȱdiarrhoeaȱcasesȱtreatedȱwithȱantidiarrhoeals.ȱAntidiarrhoealsȱ
wereȱdefinedȱasȱnonȬantibioticȱmedicines,ȱincludingȱadsorbentsȱandȱbulkȱ
formingȱmedicines,ȱantiȬmotilityȱmedicines,ȱantispasmodics,ȱandȱmedicinesȱ
describedȱbyȱauthorsȱofȱstudiesȱasȱrelievingȱsymptomsȱofȱdiarrhoea.ȱȱȱȱ
x Percentageȱofȱdiarrhoeaȱcasesȱtreatedȱwithȱoralȱrehydrationȱtherapyȱ(ORT).ȱ
ORTȱwasȱdefinedȱasȱprescriptionȱofȱoralȱrehydrationȱsaltsȱorȱintravenousȱfluids,ȱ
butȱdidȱnotȱmakeȱanyȱjudgmentȱonȱdoseȱorȱduration.ȱWhenȱtheȱonlyȱactionȱ
takenȱwasȱadviceȱtoȱincreaseȱbreastȱfeedingȱorȱhomeȱfluids,ȱtheȱcaseȱwasȱ
excluded.ȱȱ
x Percentageȱofȱdiarrhoeaȱcasesȱtreatedȱaccordingȱtoȱclinicalȱguidelines.ȱClinicalȱ
guidelinesȱspecificallyȱreferredȱtoȱcorrectȱrehydrationȱofȱacuteȱdiarrhoeaȱcases,ȱ
includingȱdoseȱandȱdurationȱofȱoralȱandȱintravenousȱrehydrationȱtherapy.ȱ
7.1 Patterns in treatment of acute diarrhoea over time

Figureȱ7.1ȱdisplaysȱacuteȱdiarrhoeaȱtreatmentȱindicatorsȱforȱpatientsȱofȱallȱagesȱoverȱ
theȱchronologicalȱperiodsȱofȱdataȱcollection.ȱȱ
– 51 –
Figure 7.1: Diarrhoea treatment indicators over time, including all studies of medicines
use in acute diarrhoea
100
90
80
70
Percentage
60
50
40
30
20
10
0
1982-1991 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006
% Diarrhoea Cases Treated with Antibiotics

% Diarrhoea Cases Treated with Antidiarrhoeals
% Diarrhoea Cases Treated with ORT
ȱ
ȱ
Key Points:
x Results from studies reporting medicines use suggest that patterns of acute diarrhoea
prescribing have not improved consistently over time.
x Results suggest encouraging progress in ORT prescribing. The percentage of reported
diarrhoea cases treated with ORT increased over time, to over 70% in 2004-2006.
x The reported use of antibiotics for acute diarrhoea fluctuated without distinct trends, while the
use of antidiarrhoeals markedly decreased over time.
x Reported compliance with standard treatment guidelines for acute diarrhoea appeared to
remain low over time. During the most recent period of data collection, the percentage of
patients with acute diarrhoea who were treated according to clinical guidelines was still
reported below 40%.
ȱ
ȱ
Theȱ majorityȱ ofȱ studiesȱ ofȱ medicinesȱ useȱ inȱ acuteȱ diarrhoeaȱ concentratedȱ onȱ childrenȱ
underȱ5ȱyearsȱold.ȱFigureȱ7.2ȱpresentsȱacuteȱdiarrhoeaȱtreatmentȱindicatorsȱoverȱtimeȱinȱ
theȱsubsetȱofȱstudiesȱfocusingȱonȱchildrenȱlessȱthanȱ5ȱyearsȱoldȱdiagnosedȱwithȱacuteȱ
diarrhoea.ȱ
– 52 –
Figure 7.2: Diarrhoea treatment indicators over time, including only studies of medicines
use in children <5 years with acute diarrhoea
100
90
80
Percentage 70
60
50
40
30
20
10
0
1982-1991 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006
% Diarrhoea Cases Treated with Antibiotics % Diarrhoea Cases Treated with Antidiarrhoeals
% Diarrhoea Cases Treated with ORT % Treated According to Clinical Guidelines
ȱ
ȱ
Key Points:
x Results suggest that prescribing patterns for children less than 5 years old diagnosed with
acute diarrhoea have not consistently improved over time.
x The reported use of ORT for acute diarrhoea increased over time, while the use of antibiotics
appeared to decrease in the mid-1990’s but has risen again since then.
x Results suggest a slight positive trend with regards to antidiarrhoeal use. The percentage of
reported diarrhoea cases treated with antidiarrhoeals decreased to 10% in 2004-2006, from
20% initially.
x Reported compliance with standard treatment guidelines for acute diarrhoea has improved
over time although it remains low. During the most recent period of data collection, 40% of
children less than 5 years old with acute diarrhoea were treated according to clinical
guidelines.
7.2 Patterns in treatment of acute diarrhoea by region, facility

ownership and prescriber type
Figureȱ 7.3ȱ presentsȱ overallȱ resultsȱ ofȱ acuteȱ diarrhoeaȱ treatmentȱ indicatorsȱ averagedȱ
byȱ geographicȱ region.ȱ ȱ Studiesȱ wereȱ classifiedȱ accordingȱ toȱ theirȱ originȱ intoȱ
categoriesȱofȱWorldȱBankȱregions.ȱToȱensureȱaȱreasonableȱsampleȱsizeȱinȱeachȱgroup,ȱ
studiesȱ fromȱ theȱ Middleȱ East,ȱ Northȱ Africa,ȱ Europeȱ andȱ Centralȱ Asiaȱ regionȱ wereȱ
groupedȱintoȱoneȱMiddleȱEastȱandȱCentralȱAsiaȱregion.ȱȱ
– 53 –
Figure 7.3: Diarrhoea treatment indicators including all studies of medicines use for
acute diarrhoea, by World Bank region
100
90
80
70
Percentage
60
50
40
30
20
10
0
% Diarrhoea Cases % Diarrhoea Cases % Diarrhoea Cases % Treated According
Treated with Treated with Treated with ORT to Clinical Guidelines
Antibiotics Antidiarrhoeals
ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest that inadequate prescribing for acute diarrhoea
is present in every region of the world.
x The percentage of reported cases of acute diarrhoea treated with antibiotics varied across
regions, from 22% in the Middle East and Central Asia region to over 50% in the East Asia and
Pacific region.
x The use of ORT was reported low everywhere, with 60% or less of reported cases of acute
diarrhoea receiving ORT.
x Across all regions, the percentage of reported acute diarrhoea cases treated according to
clinical guidelines was below 50%.
ȱ
ȱ
– 54 –
Figureȱ 7.4ȱ presentsȱ overallȱ resultsȱ ofȱ prescribingȱ indicatorsȱ forȱ acuteȱ diarrhoeaȱ
averagedȱ byȱ Worldȱ Bankȱ incomeȱ levelȱ ofȱ theȱ countriesȱ inȱ whichȱ theȱ studiesȱ wereȱ
conducted.ȱȱ
acute diarrhoea, by World Bank income level
100
90
80
70
Percentage
60
50
40
30
20
10
0

ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest similarities in the treatment of acute diarrhoea
across regions at different income level.
x Percentages of diarrhoea cases treated with antidiarrhoeals, with ORT, and percentage of
patients treated according to clinical guidelines were similar in all three categories of countries.
x However, the percentage of diarrhoea cases treated with antibiotics was twice as high in
studies from low and lower-middle income countries than in studies from upper-middle and
high income countries.
ȱ
ȱ
– 55 –
Figureȱ 7.5ȱ presentsȱ overallȱ resultsȱ ofȱ acuteȱ diarrhoeaȱ treatmentȱ indicatorsȱ byȱ
prescriberȱtype.ȱȱ
acute diarrhoea, by prescriber type
100
90
80
70
Percentage
60
50
40
30
20
10
0

ȱ
ȱ
Key Points:
x Results from studies of medicines use suggest that prescribing for acute diarrhoea by
paramedical health workers/nurses may be slightly better than by medical doctors according to
all four practices assessed.
x The percentage of diarrhoea cases treated with antidiarrhoeals was lowest when the reported
prescriber was a paramedical health worker/nurse.
x The percentage of diarrhoea cases treated with ORT was lowest when the reported prescriber
was not a nurse or a medical doctor.
x The percentage of reported acute diarrhoeas treated according to clinical guidelines was below
40%, regardless of the type of prescriber.
ȱ
ȱ
– 56 –
Figureȱ7.6ȱpresentsȱresultsȱforȱacuteȱdiarrhoeaȱtreatmentȱindicatorsȱbyȱownershipȱofȱ
healthȬcareȱ facility.ȱ Onlyȱ dataȱ fromȱ studiesȱ measuringȱ prescribingȱ ofȱ physicians,ȱ
nurses,ȱ andȱ paramedicsȱ areȱ includedȱ inȱ theȱ figure.ȱ Noȱ studiesȱ thatȱ measuredȱ
prescribingȱ byȱ theseȱ trainedȱ healthȱ providersȱ inȱ theȱ privateȱ notȬforȬprofitȱ sectorȱ
collectedȱ dataȱ forȱ theȱ acuteȱ diarrhoeaȱ treatmentȱ indicatorsȱ inȱ thisȱ category,ȱ soȱ theȱ
graphȱdoesȱnotȱpresentȱanyȱresultsȱforȱthisȱsector.ȱ
acute diarrhoea, by health facility ownership (prescribing by physicians, nurses, and
paramedics only)
100
90
80
70
Percentage
60
50
40
30
20
10
0

ȱ
ȱ
Key Points:
x Results from studies of medicines use in acute diarrhoea suggest substantially better
prescribing patterns by physicians, nurses, and paramedics in public health-care facilities than
in private for-profit health-care facilities.
x The percentage of reported cases of diarrhoea treated with ORT was much higher in studies
from public health-care facilities (62%) compared to private for-profit health-care facilities
(41%).
x The percentages of diarrhoea cases treated with antidiarrhoeals and antibiotics were much
lower in studies from public health-care facilities than in studies from private for-profit health-
care facilities.
x The percentage of acute diarrhoea cases treated according to clinical guidelines was only 40%
in public health-care facilities; there were too few studies in the private sectors to evaluate this
indicator.
ȱ
ȱ
– 57 –
Figureȱ 7.7ȱ summarizesȱ theȱ availabilityȱ ofȱ medicinesȱ toȱ treatȱ diarrhoealȱ illnessȱ inȱ
studiesȱthatȱfocusedȱonȱtheȱtreatmentȱofȱdiarrhoea.ȱ
Figure 7.7: Availability of key medicines in studies of medicines use for acute diarrhoea,
by World Bank region
100
90
80
70
Percentage
60
50
40
30
20
10
0
ȱ
ȱ
Key Points:
x The availability of key medicines to treat acute diarrhoea was below 90% in studies from all
regions except the East Asia and Pacific region.
x Availability of medicines was particularly low in health facilities in Latin America and the
Caribbean (58%) as well as in Middle East and Central Asia and South Asia (62%).
ȱ
ȱ
– 58 –
Treatment of malaria
8. TREATMENT OF MALARIA
Thisȱ sectionȱ focusesȱ onȱ studiesȱ ofȱ medicinesȱ useȱ thatȱ reportedȱ resultsȱ aboutȱ
antimalarialȱtreatmentȱfromȱdataȱcollectedȱbetweenȱ1982ȱandȱ2006.ȱTheȱpercentageȱofȱ
malariaȱcasesȱgivenȱrecommendedȱantimalarialsȱwasȱextractedȱfromȱthisȱsubgroupȱofȱ
studiesȱandȱisȱpresentedȱbelowȱtoȱshowȱpatternsȱofȱantimalarialȱtreatmentȱoverȱtime.ȱ
Theȱ indicatorȱ ‘percentȱ ofȱ malariaȱ casesȱ givenȱ recommendedȱ antimalarial’ȱ accountsȱ
forȱ theȱ choiceȱ ofȱ antimalarialȱ medicine:ȱ itȱ doesȱ notȱ takeȱ intoȱ considerationȱ whetherȱ
dosingȱ wasȱ correct.ȱ Theȱ ‘recommended’ȱ attributeȱ wasȱ definedȱ byȱ authorsȱ ofȱ theȱ
studies.ȱInjectableȱantimalarialsȱwereȱconsideredȱnotȱrecommended,ȱunlessȱotherwiseȱ
statedȱbyȱauthorsȱofȱstudies.ȱȱ
ȱ
Figureȱ8.1ȱshowsȱtheȱpercentageȱofȱmalariaȱcasesȱgivenȱrecommendedȱantimalarialsȱ
inȱpatientsȱofȱallȱages,ȱoverȱtheȱchronologicalȱperiodsȱofȱdataȱcollection.ȱȱ
Figure 8.1: Prescribing of recommended antimalarial treatment over time, including all
studies of antimalarial use
100
90
80
70
60
Percentage
50
40
30
20
10
0
1982-1991 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006
% Malaria Cases Treated with Recommended Antimalarials

ȱ
ȱ
Key Points:
x Results from studies reporting antimalarial use suggest that patterns of antimalarial
prescribing worsened during the overall period of data collection.
x One possible explanation for this negative trend may be changes in national malaria treatment
policy that have occurred in the last 10 years aimed at fighting antimalarial resistance and the
lag time inherent in implementing these changes.
x The percentage of reported malaria cases treated with recommended antimalarials in studies
of antimalarial use was only 51% during the period 2004-2006.
ȱ
– 59 –
Recentȱ emphasisȱ onȱ malariaȱ controlȱ andȱ alsoȱ theȱ integratedȱ managementȱ ofȱ
childhoodȱ illnessȱ hasȱ resultedȱ inȱ manyȱ studiesȱ beingȱ conductedȱ inȱ childrenȱ sinceȱ
2000.ȱFigureȱ8.2ȱdisplaysȱtheȱpercentageȱofȱmalariaȱcasesȱtreatedȱwithȱrecommendedȱ
antimalarialsȱoverȱtimeȱfromȱstudiesȱonlyȱincludingȱchildrenȱunderȱ5ȱyearsȱoldȱwithȱ
studiesȱofȱpatientsȱofȱallȱotherȱages.ȱȱ
Figure 8.2: Prescribing of recommended antimalarial treatment over time, comparing

studies of children <5 years versus studies of the general population
100
90
80
70
Percentage
60
50
40
30
20
10
0
1982-1994 1995-2000 2001-2006
% Malaria Cases Treated with Recommended Antimalarials, Children <5 years only
% Malaria Cases Treated with Recommended Antimalarials, General Population
ȱ
ȱ
Key Points:
x Results from studies of medicines use in malaria suggest comparable trends in prescribing
antimalarials for children < 5 years and the general population (adults and children) during
recent periods of data collection.
x Between 1995 and 2006, the percentage of malaria cases treated with recommended
antimalarials in children less than 5 years old increased by about 10%, to just under 60% of
cases.
x Overall, the adequacy of antimalarial prescribing, as reported in studies of antimalarial use,
has worsened since the 1982-1994 time period both in the general population (adults and
children) and in children under 5 years old.
ȱ
ȱ
MostȱstudiesȱofȱmedicinesȱuseȱinȱmalariaȱwereȱcarriedȱoutȱinȱAfricaȱinȱtheȱcontextȱofȱ
primaryȱ careȱ whereȱ theȱ mainȱ prescriberȱ wasȱ aȱ nurseȱ orȱ paramedicalȱ healthȬcareȱ
worker.ȱThusȱaȱdescriptionȱofȱprescribingȱpatternsȱbyȱregionȱorȱprescriberȱtypeȱwasȱ
notȱpossible.ȱȱ
– 60 –
Inappropriate antibiotic use
9. INAPPROPRIATE ANTIBIOTIC USE

Thisȱsectionȱfocusesȱonȱstudiesȱthatȱreportedȱresultsȱaboutȱantibioticȱtreatment.ȱTwoȱ
indicatorsȱ ofȱ appropriatenessȱ ofȱ antibioticȱ useȱ extractedȱ fromȱ thisȱ subgroupȱ ofȱ
studiesȱ areȱ presentedȱ belowȱ toȱ illustrateȱ patternsȱ ofȱ appropriatenessȱ ofȱ antibioticȱ
prescribingȱoverȱtime.ȱTheȱfollowingȱindicatorsȱwereȱevaluated:ȱȱ
x Percentageȱofȱpatientsȱprescribedȱantibioticsȱinappropriately.ȱInappropriateȱuseȱ
wasȱdefinedȱbyȱtheȱauthorsȱofȱeachȱstudy.ȱTheȱmeasureȱreportedȱhereȱalsoȱ
includedȱprescribingȱofȱantibioticsȱforȱacuteȱdiarrhoealȱdiseaseȱandȱURTI.ȱTheȱ
WHO/IMCIȱstudies,ȱwhichȱrepresentȱaȱlargeȱproportionȱofȱtheȱstudiesȱfromȱ
1997ȱonwards,ȱmeasuredȱanȱindicatorȱdefinedȱasȱtheȱpercentageȱofȱchildrenȱnotȱ
needingȱanȱantibioticȱwhoȱleaveȱtheȱhealthȱfacilityȱwithȱanȱantibiotic.ȱȱ
x Percentageȱofȱantibioticsȱprescribedȱinȱunderdosage.ȱȱUnderdosageȱwasȱusuallyȱ
reportedȱinȱtheȱstudiesȱaccordingȱtoȱdurationȱonly,ȱbutȱinȱsomeȱcasesȱitȱwasȱalsoȱ
documentedȱinȱinappropriateȱstrengthȱandȱfrequency.ȱ
9.1 Inappropriate antibiotic prescribing over time

Figureȱ9.1ȱpresentsȱtheȱtwoȱindicatorsȱofȱantibioticȱtreatmentȱoverȱtheȱchronologicalȱ
periodsȱofȱdataȱcollection.ȱȱ
Figure 9.1: Inappropriate prescribing of antibiotics over time
100
90
80
70
Percentage
60
50
40
30
20
10
0
1982-1994 1995-2000 2001-2006
% Antibiotics Prescribed in Underdosage

% Patients Prescribed Antibiotics Inappropriately
ȱ
ȱ
Key Points:
x Results suggest a large, persistent and growing problem of inappropriate use of antibiotics.
x The percentage of patients prescribed antibiotics inappropriately increased to over 50% in
studies conducted between 2001 and 2006, up from 40% in earlier studies.
x The percentage of antibiotics prescribed in underdosage remained over 50% in all time
periods.
– 61 –
9.2 Inappropriate antibiotic prescribing by region, facility

ownership and type of prescriber
Figureȱ 9.2ȱ presentsȱ overallȱ resultsȱ ofȱ bothȱ indicatorsȱ ofȱ inappropriateȱ antibioticȱ
treatmentȱindicatorsȱbyȱgeographicȱregion.ȱTheȱsampleȱsizeȱofȱstudiesȱinȱtheȱMiddleȱ
Eastȱ andȱ Centralȱ Asiaȱ regionȱ forȱ theȱ firstȱ indicatorȱ isȱ tooȱ smallȱ toȱ displayȱ onȱ theȱ
graph.ȱ
Figure 9.2: Inappropriate prescribing of antibiotics, by World Bank region

100
90
80
70
Percentage
60
50
40
30
20
10
0
% Antibiotics Prescribed in Underdosage % Patients Prescribed Antibiotics
Inappropriately
ȱ
ȱ
Key Points:
x Results suggest that inappropriate prescribing of antibiotics is a widespread problem in every
geographic region.
x In all regions except Latin America, over 40% of reported prescriptions of antibiotics were
inappropriate, with countries in South Asia having the highest rates of inappropriate antibiotic
use.
x In Latin America, prescribing insufficient doses of antibiotics was reported more frequently
than in other regions: 67% of antibiotics prescribed were dosed incorrectly.
ȱ
ȱ
Figureȱ 9.3ȱ presentsȱ overallȱ resultsȱ ofȱ theȱ antibioticȱ prescribingȱ indicatorsȱ byȱ theȱ
WorldȱBankȱincomeȱlevelȱofȱtheȱcountriesȱinȱwhichȱtheȱstudiesȱwereȱconducted.ȱTheȱ
sampleȱsizeȱofȱstudiesȱinȱtheȱlowerȬmiddleȱincomeȱregionȱforȱtheȱfirstȱindicatorȱisȱtooȱ
smallȱtoȱdisplayȱonȱtheȱgraph.ȱ
– 62 –
Figure 9.3: Inappropriate prescribing of antibiotics, by World Bank income level

100
90
80
70
Percentage
60
50
40
30
20
10
0
Inappropriately

ȱ
ȱ
Key Points:
x The percentage of antibiotics prescribed in under dosage was slightly higher in studies from
upper-middle and high income countries; over 60% of prescribed antibiotics in this income
group were at inappropriately low doses.
x The lowest rates of patients prescribed antibiotics inappropriately were seen in upper-middle
and high income countries, although over one third of patients there received antibiotics
inappropriately.
ȱ
ȱ
– 63 –
Figureȱ9.4ȱpresentsȱoverallȱresultsȱofȱantibioticȱtreatmentȱindicatorsȱaveragedȱbyȱtypeȱ
ofȱprescriber.ȱ
Figure 9.4: Inappropriate prescribing of antibiotics, by type of prescriber

100
90
80
70
Percentage
60
50
40
30
20
10
0
Inappropriately

ȱ
Key Points:
x Results of studies of medicines use suggest unsatisfactory antibiotic prescribing patterns by all
cadres of health worker.
x Over 40% of antibiotics were prescribed in underdosage by all types of health providers.
x The percentage of patients prescribed antibiotics inappropriately was highest when the
reported prescriber was a medical doctor.
ȱ
ȱ
Figureȱ9.5ȱpresentsȱtheȱoverallȱresultsȱofȱtheȱantibioticȱtreatmentȱindicatorsȱbyȱhealthȬ
careȱ facilityȱ ownership,ȱ includingȱ onlyȱ thoseȱ studiesȱ thatȱ measuredȱ prescribingȱ byȱ
physicians,ȱ nurses,ȱ orȱ paramedics.ȱ Theȱ numberȱ ofȱ studiesȱ conductedȱ inȱ theȱ privateȱ
notȬforȬprofitȱsectorȱwasȱinsufficientȱtoȱevaluateȱantibioticȱuseȱinȱthisȱsector.ȱ
– 64 –
Figure 9.5: Inappropriate prescribing of antibiotics, by health-care facility ownership

(prescribing by physicians, nurses, and paramedics only)
100
90
80
Percentage 70
60
50
40
30
20
10
0
Inappropriately

ȱ
ȱ
Key Points:
x Results from studies of inappropriate antibiotic prescribing by physicians, nurses, and
paramedics suggest better antibiotic prescribing patterns in public health-care facilities than in
private for-profit health-care facilities.
x The prescribing of antibiotics in under dosage was slightly higher in private for-profit facilities
than in public facilities (56% versus 53%) and the percentage of patients prescribed antibiotics
inappropriately was markedly higher in the private for-profit sector (72% versus 45%).
ȱ
– 65 –
ȱ
ȱ
– 66 –
Interventions to improve use of medicines
10. INTERVENTIONS TO IMPROVE USE OF MEDICINES

Thisȱ sectionȱ focusesȱ onȱ studiesȱ examiningȱ useȱ ofȱ medicinesȱ thatȱ includedȱ anȱ
intervention.ȱȱTheseȱstudiesȱvariedȱwidelyȱinȱtheȱtypesȱandȱscopeȱofȱtheȱinterventionsȱ
investigated.ȱ ȱ Manyȱ studiesȱ testedȱ theȱ impactȱ ofȱ prospectiveȱ effortsȱ toȱ improveȱ
prescribingȱ inȱ smallȱ samplesȱ ofȱ healthȱ facilities,ȱ healthȱ providers,ȱ orȱ patients.ȱȱ
However,ȱsomeȱcommunityȱcaseȱmanagementȱstudiesȱexaminedȱtheȱimpactȱofȱlargeȱ
prospectivelyȱ designedȱ interventionsȱ inȱ improvingȱ howȱ specificȱ commonȱ healthȱ
problemsȱ wereȱ managedȱ inȱ orderȱ toȱ reduceȱ mortality.ȱ ȱ Theȱ interventionsȱ inȱ theȱ
databaseȱ alsoȱ includeȱ severalȱ differentȱ typesȱ ofȱ systemȬbasedȱ interventions,ȱ
includingȱ changesȱ inȱ financialȱ incentivesȱ toȱ healthȱ providersȱ orȱ patients,ȱ
implementationȱofȱtheȱIMCIȱstrategy,ȱorȱchangesȱinȱmedicinesȱformularies.ȱȱFinally,ȱaȱ
numberȱofȱstudiesȱhaveȱexaminedȱtheȱimpactȱofȱimplementationȱofȱaȱnationalȱpolicy,ȱ
suchȱasȱaȱNationalȱMedicinesȱPolicyȱorȱanȱEssentialȱMedicinesȱProgramme.ȱ
10.1 Overview of interventions to improve medicines use

Forȱtheȱperiodȱ1990Ȭ2006,ȱtheȱdatabaseȱincludesȱinformationȱaboutȱ386ȱinterventionsȱ
toȱimproveȱuseȱofȱmedicinesȱthatȱwereȱevaluatedȱinȱ317ȱstudies.ȱȱFigureȱ10.1ȱshowsȱ
theȱ distributionȱ ofȱ theseȱ interventions,ȱ classifiedȱ accordingȱ toȱ theȱ componentȱ thatȱ
bestȱcapturesȱtheȱnatureȱofȱtheȱinterventionȱstrategyȱevaluated.ȱ
– 67 –
Figure 10.1: Types of intervention studies classified by dominant intervention

component
9
2%
73 P rinted educational materials
111 19%
P rovider education (no consumer
28%
education)
P rovider plus consumer
education
C onsum er education (no provider
education)
C ommunity case management
P rovider group educational

68 process
22 18% Enhanced supervision +/- audit
6%
Economic incentives to providers
/ patients
3 EMP, NMP, other policy or

51 1% regulation
13% 37
12
10%
3%
ȱ
ȱ
Key Points:
x Overall, 37% of the 386 interventions in the database tested an educational programme
directed at health providers; about half of these interventions also included consumer or
patient education.
x One in ten interventions tested community case management strategies aimed at preventing
mortality from ARI, diarrhoea, or malaria, typically involving provider and community
education, training of community health workers, and community availability of essential
medicines.
x The largest single group of studies represented in the database included surveys to measured
medicine indicators during the implementation of an NMP, EMP, or another regulatory strategy;
most commonly these were one time cross-sectional studies to measure whether the policy
was achieving its intended effects.
x An increasing number of interventions (13% of those in the database) include enhanced
supervisory programmes, with or without routine audits of health provider practices; these
approaches are frequently used in the implementation in the IMCI programme as a strategy to
improve the performance of lower level health workers.
ȱ
Althoughȱsomeȱstudiesȱhaveȱtestedȱaȱspecificȱtypeȱofȱsingleȱcomponentȱinterventionȱ
(suchȱ asȱ aȱ oneȬtimeȱ providerȱ trainingȱ seminar),ȱ manyȱ haveȱ incorporatedȱ severalȱ
educational,ȱ managerial,ȱ financial,ȱ orȱ regulatoryȱ components.ȱ Tableȱ 10.1ȱ belowȱ
showsȱtheȱindividualȱcomponentsȱthatȱwereȱpartȱofȱtheseȱinterventions.ȱ
ȱ
Mostȱ interventionsȱ ofȱ everyȱ typeȱ involvedȱ aȱ mixȱ ofȱ components.ȱ Onlyȱ theȱ
interventionsȱ thatȱ evaluatedȱ theȱ effectsȱ ofȱ economicȱ incentivesȱ directedȱ atȱ healthȱ
providersȱorȱpatientsȱtendedȱnotȱtoȱincludeȱotherȱstrategies.ȱ
ȱ
TwoȬthirdsȱ ofȱ allȱ interventionsȱ reportedȱ usingȱ printedȱ educationalȱ materials,ȱ butȱ
onlyȱnineȱinterventionsȱtestedȱtheȱefficacyȱofȱtheseȱmaterialsȱasȱaȱspecificȱcomponentȱ
ofȱ theȱ study.ȱ Generally,ȱ almostȱ allȱ studiesȱ withȱ educationalȱ activitiesȱ directedȱ atȱ
healthȱ providersȱ usedȱ someȱ typeȱ ofȱ printedȱ materials;ȱ aȱ smallerȱ percentageȱ ofȱ theȱ
behaviourȱ changeȱ interventionsȱ thatȱ targetedȱ consumers,ȱ patients,ȱ andȱ theȱ
communityȱreportedȱusingȱprintedȱmaterials.ȱ
ȱ
– 68 –
Theȱ interventionsȱ classifiedȱ asȱ groupȱ educationalȱ processȱ incorporatedȱ educationalȱ

programmesȱ forȱ healthȱ providers,ȱ includingȱ peerȱ reviewȱ orȱ selfȬmonitoringȱ ofȱ
prescribingȱ practices,ȱ typicallyȱ combinedȱ withȱ guidelinesȱ orȱ otherȱ printedȱ
educationalȱ materials.ȱ Oneȱ inȱ fiveȱ ofȱ theseȱ studiesȱ alsoȱ includedȱ enhancedȱ healthȱ
workerȱ supervision.ȱ ȱ Interventionsȱ thatȱ wereȱ classifiedȱ asȱ supervisionȱ withȱ orȱ
withoutȱ practiceȱ auditsȱ wereȱ similarȱ inȱ design,ȱ exceptȱ thatȱ theyȱ didȱ notȱ includeȱ aȱ
specificȱgroupȱeducationalȱprocess.ȱ
ȱ
TheȱstudiesȱconductedȱinȱtheȱcontextȱofȱanȱNMPȱorȱEMPȱincludedȱaȱdiverseȱmixȱofȱ
interventionȱ components,ȱ reflectingȱ theȱ broadȬbasedȱ strategiesȱ typicallyȱ
implementedȱ asȱ partȱ ofȱ theseȱ programmes.ȱ Becauseȱ ofȱ theirȱ diversity,ȱ theseȱ studiesȱ
areȱmoreȱdifficultȱtoȱcharacterize.ȱ
Table 10.1: Individual approaches included in different types of interventions

Percentage of interventions of each type that include:
Number Commu- Group
Intervention type of Percent of Consumer/ nity case p rovider Enhanced
classified by dominant interven- interven- Print Provider patient manage- education super-vison Economic Other
component tions tions materials education education ment process +/- audit incentives EMP or NMP regulation
Printed e ducational
9 2% 100% 0% 0% 0% 0% 0% 0% 11% 0%
materials
Provider education 73 19% 84% 100% 0% 0% 0% 0% 0% 3% 1%
Provider and consumer/

68 18% 84% 100% 100% 0% 4% 29% 0% 3% 0%
patient education
Consumer/patient
3 1% 33% 0% 100% 0% 0% 0% 0% 0% 0%
education
Community case
37 10% 32% 73% 81% 100% 0% 70% 8% 70% 11%
management
Provider group educational
12 3% 92% 92% 8% 0% 100% 17% 0% 8% 17%
process
Enhanced supervision +/-
51 13% 76% 88% 0% 0% 0% 100% 0% 4% 0%
audit
Economic incentives t o
22 6% 5% 9% 0% 0% 0% 5% 100% 0% 0%
providers / patients
EMP, NMP, other national
111 29% 60% 64% 33% 0% 1% 40% 14% 91% 6%
policy or regulation
All interventions 386 100% 67% 77% 36% 10% 4% 37% 10% 35% 4%
ȱ
ȱ
ȱ
– 69 –
Figureȱ 10.2ȱ showsȱ theȱ typesȱ ofȱ studyȱ designsȱ thatȱ wereȱ usedȱ toȱ evaluateȱ theȱ
interventionsȱincludedȱinȱthisȱreview.ȱȱȱȱ
Figure 10.2: Types of study designs in studies to evaluate medicines use interventions,
by methodological quality
45%
n=129
40%
Percentage of intervention studies
35%
30%
25%
20% n=58
n=48
15% n=43
10%
n=20
n=17
5%
n=2
0%
Randomized Time series Time series Pre-post Post-only Pre -post Post-only
controlle d w ith control w ithout with control with control without without
trial series contr ol group group control control
ser ies group group
Acceptable quality (n=82) Poor quality (n=235)

ȱ
ȱ
Key Points:
x Of the 317 intervention studies included in the database, only 82 (26%) were evaluated using
a research design that is considered methodologically adequate for drawing reliable
conclusions about intervention impacts.
x Overall, 41% of studies were evaluated using post-only without control group designs that did
not include either a control group or measurement before and after the intervention; another
18% had pre- and post-measurement but no controls, while 15% used a control group but
measured the medicines use indicators only after the intervention was completed.
x The methodologically adequate research designs included randomized controlled trials (n=17,
5% of studies), time-series with control groups (n=2, 1% of studies) or without control groups
(n=20, 6% of studies), and pre-post studies with control groups (n=43, 14% of studies).
ȱ
ȱ
Asȱ shownȱ inȱ Figureȱ 10.3,ȱ theȱ overallȱ qualityȱ ofȱ studiesȱ testingȱ interventionsȱ toȱ
improveȱ theȱ useȱ ofȱ medicinesȱ hasȱ notȱ improvedȱ substantiallyȱ overȱ time,ȱ andȱ theȱ
majorityȱofȱstudiesȱareȱstillȱofȱpoorȱmethodologicalȱquality.ȱȱȱ
– 70 –
Figure 10.3: Methodological quality of intervention studies by time period

70
60
Number of studies 50
52
40 55
37 38 35
30
20
18
10 17 17
16 16
12
4
0
<1992 1992-1994 1995-1997 1998-2000 2001-2003 2004-2006
Year of intervention

ȱ
ȱ
Key Points:
x There was an increase in the overall volume of reported research on interventions to improve
medicines use in the mid-1990s, but the number of available studies has declined in the last
10 years.
x The quality of the research designs has not improved markedly over time; 25% of studies up
to the year 2000 had acceptable designs, compared to 28% of studies since then.
ȱ
ȱ
Tableȱ 10.2ȱ presentsȱ dataȱ onȱ theȱ distributionȱ ofȱ theȱ interventionȱ researchȱ studiesȱ
includedȱ inȱ theȱ databaseȱ byȱ geographicȱ region,ȱ countryȱ income,ȱ healthȱ facilityȱ
ownershipȱ andȱ prescriberȱ type.ȱ ȱ Althoughȱ thereȱ areȱ interventionȱ studiesȱ fromȱ allȱ
geographicȱ regions,ȱ aboutȱ oneȱ thirdȱ ofȱ theȱ studiesȱ ofȱ acceptableȱ qualityȱ comeȱ fromȱ
SubȬSaharanȱAfrica,ȱanotherȱthirdȱfromȱSouthȱAsia,ȱandȱanȱadditionalȱ20%ȱfromȱtheȱ
AsiaȱPacificȱregion.ȱȱRelativelyȱlittleȱwellȬdesignedȱresearchȱonȱimprovingȱmedicinesȱ
useȱ hasȱ beenȱ reportedȱ fromȱ theȱ nonȬindustrializedȱ countriesȱ inȱ Latinȱ America,ȱ
Europe,ȱCentralȱAsia,ȱorȱtheȱMiddleȱEast.ȱȱAboutȱ70%ȱofȱwellȬdesignedȱstudiesȱhaveȱ
beenȱ conductedȱ inȱ poorȱ countriesȱ andȱ onlyȱ 7%ȱ inȱ upperȬmiddleȱ orȱ highȱ incomeȱ
countries.ȱ
ȱ
Overȱ70%ȱofȱallȱstudies,ȱandȱoverȱ60%ȱofȱthoseȱwithȱadequateȱresearchȱdesigns,ȱwereȱ
conductedȱinȱpublicȱsectorȱhealthȱfacilities.ȱȱInȱall,ȱonlyȱ12ȱwellȬdesignedȱstudiesȱhaveȱ
beenȱ reportedȱ thatȱ examinedȱ strategiesȱ toȱ improveȱ practiceȱ inȱ theȱ privateȱ forȬprofitȱ
sector,ȱwhileȱanotherȱ12ȱstudiesȱhaveȱtestedȱwaysȱtoȱimproveȱselfȬmedication.ȱAboutȱ
halfȱofȱtheȱexistingȱresearchȱhasȱexaminedȱinterventionsȱtoȱimproveȱtheȱpracticesȱofȱ
nursesȱorȱparamedics,ȱwhileȱphysiciansȱwereȱtheȱprimaryȱfocusȱinȱaboutȱoneȬquarterȱ
ofȱstudies.ȱȱ
– 71 –
Table 10.2: Distribution of intervention studies by World Bank Region, country

income, health facility ownership, prescriber type
Accepta ble qualit y Poor quality All studies
Number of studies 82 235 317
World Bank Regi on

Sub-Saharan Africa 28 103 131
34% 44% 41%
Europe and Central Asia 2 6 8
2% 3% 3%
Latin America and Caribbean 6 38 44
7% 16% 14%
Middle East and North Africa 3 17 20
4% 7% 6%
South Asia 27 34 61
33% 14% 19%
East Asia and Pacific 16 37 53
20% 16% 17%
World Bank Country Income
Low income 57 137 194
70% 58% 61%
Lower-middle income 19 63 82
23% 27% 26%
Upper-middle & high income 6 35 41
7% 15% 13%
Healt h Facility Ownership
Private, for profit 12 19 31
15% 8% 10%
Private, not for profit 1 1 2
1% 0% 1%
Public 50 179 229
61% 76% 72%
Not applicable, self-medication 13 21 34
16% 9% 11%
Unspecified 6 15 21
7% 6% 7%
Prescriber Type
MD 19 52 71
23% 22% 22%
Paramedic or nurse 39 141 180
48% 60% 57%
Pharmacy staff 3 6 9
4% 3% 3%
Other 16 29 45
20% 12% 14%
Unspecified 5 7 12
6% 3% 4%
ȱ
ȱ
– 72 –
Inȱadditionȱtoȱstudyȱdesign,ȱanotherȱkeyȱaspectȱofȱmethodologicalȱqualityȱofȱaȱstudyȱ
isȱ theȱ overallȱ sizeȱ ofȱ theȱ samplesȱ ofȱ prescribingȱ andȱ dispensingȱ episodesȱ assessed,ȱ
andȱ theȱ numberȱ ofȱ healthȱ facilitiesȱ andȱ providersȱ participatingȱ inȱ theȱ intervention.ȱ
Studiesȱthatȱinvolveȱonlyȱsmallȱsamplesȱofȱpatientsȱorȱfacilitiesȱmayȱnotȱbeȱreliableȱorȱ
representative.ȱȱȱ
ȱ
Theȱstudiesȱinȱtheȱdatabaseȱwereȱconductedȱinȱaȱdiverseȱarrayȱofȱsettings.ȱȱSomeȱwereȱ
focusedȱ andȱ targetedȱ specificȱ providersȱ andȱ patients,ȱ whileȱ othersȱ representedȱ
researchȱ aboutȱ theȱ impactsȱ ofȱ broadȱ policyȱ approaches;ȱ thus,ȱ itȱ isȱ challengingȱ toȱ
characterizeȱtheȱadequacyȱofȱtheirȱsamples.ȱTableȱ10.3ȱpresentsȱaȱroughȱclassificationȱ
ofȱtheȱtotalȱnumbersȱofȱpatientsȱorȱcasesȱsurveyedȱinȱeachȱwaveȱofȱdataȱcollectionȱandȱ
theȱtotalȱnumberȱofȱhealthȱfacilitiesȱincludedȱinȱallȱinterventionȱgroupsȱtheȱstudy.ȱ
ȱ
Table 10.3: Numbers of patients and health facilities included in the basic
samples of intervention studies, by quality of research design
Number of pat ients in total sample Total
Quality of No. of
design faci lities <100 100-999 1000-9999 10,000 + NA Number Percent
Acceptable
1 0 0 0 0 1 1 1%
desi gn 2-5 0 1 4 0 1 6 7%
6-10 1 3 3 1 1 9 11%
11-20 0 2 7 3 2 14 17%
21-99 0 5 13 8 3 29 35%
100 + 0 4 2 1 0 7 9%
NA 0 2 2 3 9 16 20%
Total Number 1 17 31 16 17 82 100%
Percent 1% 21% 38% 20% 21% 100%
Poor design 1 0 8 3 4 0 15 6%
2-5 1 7 1 0 0 9 4%
6-10 1 10 2 0 1 14 6%
11-20 2 8 10 1 2 23 10%
21-99 16 75 15 3 13 122 52%
100 + 0 13 6 1 4 24 10%
NA 2 7 8 3 8 28 12%
Total Number 22 128 45 12 28 235 100%
Percent 9% 54% 19% 5% 12% 100%
ȱ
Theȱrangeȱofȱsampleȱsizesȱhasȱvariedȱwidelyȱinȱbothȱacceptablyȱandȱpoorlyȱdesignedȱ
interventions.ȱTheȱmostȱfrequentȱwellȬdesignedȱinterventionȱinvolvedȱaȱtotalȱsampleȱ
(combiningȱ allȱ interventionȱ groups)ȱ ofȱ overȱ 1000ȱ patientsȱ andȱ moreȱ thanȱ 20ȱ healthȱ
facilities.ȱ ȱ Althoughȱ poorlyȱ designedȱ andȱ wellȬdesignedȱ studiesȱ haveȱ involvedȱ
similarȱnumbersȱofȱhealthȱfacilities,ȱstudiesȱwithȱbetterȱdesignsȱtendȱtoȱsurveyȱlargerȱ
numbersȱofȱpatients;ȱ78%ȱofȱwellȬdesignedȱstudiesȱhaveȱsamplesȱofȱmoreȱthanȱ1000ȱ
patients,ȱwhileȱonlyȱ37%ȱofȱpoorlyȱdesignedȱstudiesȱmeasureȱpracticesȱinȱthisȱmanyȱ
patients.ȱ
ȱ
Becauseȱsmallȱstudiesȱmayȱposeȱaȱgreaterȱriskȱofȱspuriousȱpositiveȱresults,ȱinȱanalysesȱ
examiningȱ theȱ effectsȱ ofȱ interventions,ȱ weȱ willȱ examineȱ theȱ sensitivityȱ ofȱ resultsȱ toȱ
exclusionȱ ofȱ theȱ 11ȱ wellȬdesignedȱ interventionsȱ testedȱ inȱ 8ȱ studiesȱ withȱ fewerȱ thanȱ
100ȱpatientsȱorȱ6ȱhealthȱfacilities.ȱȱ
ȱ
– 73 –
Tableȱ 10.4ȱ displaysȱ theȱ wideȱ arrayȱ ofȱ indicatorsȱ thatȱ haveȱ beenȱ measuredȱ inȱ
interventionȱstudies.ȱȱȱ
Table 10.4: Proportion of intervention studies measuring each medicines use

outcome recorded in the database, by study quality
Indicator group Acceptable Poor quality All studies

quality
Total number of studies 82 235 317
Appropriate prescribing
Avg. no. medicines per patient 61% 28% 36%
% patients prescribed antibiotics 56% 27% 35%
% patients prescribed injection 41% 20% 25%
% injections inappropriate 2% 1% 1%
% prescribed from EML 20% 11% 14%
% prescribed by generic name 23% 11% 14%
% patients treated by STG 48% 59% 56%
% treated without medicines 1% 2% 2%
Avg. drug cost per patient 22% 12% 15%
% patients prescribed vitamins/tonics 6% 2% 3%
Appropriate patient care
Avg. consultation time 12% 9% 9%
Avg. dispensing time 10% 7% 8%
% patients given dosing instructions 13% 34% 29%
% patients who know regimen 11% 43% 35%
% medicines adequately labeled 10% 7% 8%
% patients satisfied with treatment 0% 0% 0%
Health facility resources
% facilities with EML available 9% 4% 5%
% facilities with STG available 1% 20% 15%
% facilities with impartial information 1% 1% 1%
% key medicines available 23% 26% 25%
% specific recommended medicines available 0% 23% 17%
% prescribed medicines dispensed 11% 10% 10%
Community case management
Overall mortality rate 9% 2% 4%
ARI mortality rate 4% 3% 3%
Diarrhoea mortality rate 2% 1% 1%
Malaria mortality rate 1% 0% 0%
Treatment of specific conditions
% with antidiarrhoeal for diarrhoea 23% 13% 15%
% with antibiotic for diarrhoea 33% 20% 24%
% with ORT for diarrhoea 39% 31% 33%
% URTI treated with antibiotic 28% 18% 21%
% antibiotics for pneumonia 17% 33% 29%
% cough syrup for ARI 12% 4% 6%
% prescribed appropriate antimalarial 9% 19% 16%
% iron-folate in pregnancy 4% 0% 1%
Antibiotic use
% antibiotics inappropriate 7% 20% 16%
% antibiotics underdosed 4% 2% 3%
% drug cost on antibiotics 0% 0% 0%
ȱ
– 74 –
Theȱ mostȱ commonȱ behavioursȱ targetedȱ byȱ wellȬdesignedȱ interventionsȱ areȱ generalȱ
indicatorsȱ ofȱ appropriateȱ prescribing,ȱ includingȱ numberȱ ofȱ medicinesȱ perȱ patientȱ
(60%ȱ ofȱ interventions),ȱ prescribingȱ ofȱ antibioticsȱ (55ȱ percent),ȱ andȱ prescribingȱ
accordingȱ toȱ standardȱ treatmentȱ guidelinesȱ (47ȱ percent).ȱ ȱ Overȱ oneȬthirdȱ ofȱ
interventionȱstudiesȱtargetedȱtreatmentȱofȱdiarrhoea,ȱandȱaboutȱoneȬfourthȱaddressedȱ
treatmentȱofȱURTIȱandȱpneumonia.ȱTreatmentȱofȱtheseȱtwoȱconditionsȱinȱchildrenȱisȱ
commonlyȱtargetedȱasȱpartȱofȱtheȱimplementationȱofȱIMCIȱprogrammes.ȱ
ȱ
Figureȱ10.4ȱarraysȱtheȱ121ȱinterventionsȱwithȱadequateȱresearchȱdesignsȱaccordingȱtoȱ
theȱprimaryȱtypeȱofȱinterventionȱemployed.ȱ
Figure 10.4: Interventions of adequate methodological quality classified by dominant intervention

component
5
14
4%
12%
P rinted educational materials
7 25
P rovider education (no consumer
6% 20%
education)
P rovider plus consumer
education
C onsum er education (no provider
education)
C ommunity case management
25 P rovider group educational

20% process
Enhanced supervision +/- audit
20
17% Economic incentives to providers
/ patients
EMP, NMP, other policy or
8 3 regulation
7% 14 2%
12%
Key Points:
x The database contains information about 121 interventions tested in 82 well-designed studies.
x Two thirds of well-designed studies (a total of 70 interventions) assess the impacts of provider
education with or without consumer education or enhanced supervision.
x Reflecting the difficulty of designing a valid longitudinal policy assessment, the database
contains only 14 adequately designed studies of the impacts of Essential Medicines
Programmes, National Medicines Policies, or other national regulations.
x Despite the importance of economic factors as determinants of medicines use among both
prescribers and patients, there are only 7 methodologically sound assessments of the impacts
of changes in economic incentives.
10.2 Impact of well-designed interventions to improve medicines

use
Focusingȱ onȱ theȱ 121ȱ interventionsȱ withȱ adequateȱ studyȱ designs,ȱ twoȱ differentȱ
measuresȱofȱeffectȱwereȱusedȱtoȱcharacterizeȱtheȱimpactȱofȱinterventions:ȱ
x Theȱgreatestȱpositiveȱpercentageȱchangeȱ(calculatedȱasȱdescribedȱinȱtheȱ
Methodsȱsection)ȱreportedȱinȱtheȱstudyȱforȱoneȱofȱtheȱprimaryȱoutcomeȱ
indicatorsȱidentifiedȱbyȱstudyȱinvestigators;ȱ
x Theȱmedianȱpercentageȱchangeȱinȱallȱofȱtheȱoutcomesȱmeasuresȱthatȱwereȱ
capturedȱinȱtheȱdatabase.ȱȱ
– 75 –
Figureȱ 10.5ȱ showsȱ estimatesȱ ofȱ theȱ firstȱ measureȱ ofȱ effect,ȱ namely,ȱ theȱ greatestȱ
percentageȱ changesȱ attributedȱ toȱ allȱ wellȬdesignedȱ interventions,ȱ asȱ wellȱ asȱ theȱ
medianȱeffectȱsizeȱacrossȱallȱstudiesȱinȱeachȱinterventionȱgroup.ȱȱAllȱindicatorsȱhaveȱ
beenȱscaledȱsuchȱthatȱaȱpositiveȱchangeȱisȱdesirable.ȱ
Figure 10.5: Largest reported percentage change in any study outcome for all
interventions, by type of intervention
8%
Prin ted edu catio nal materi als
alon e (n =5 ) 18%
__ __ __ ___ __ __ __ ___ __ __
Pro vider e ducation witho ut
consum er e ducation (n =2 5)
20%
__ __ __ ___ __ __ __ ___ __ __
P rovid er p lus consum er
edu cation ( n= 20 ) 26%
__ __ __ ___ __ __ __ ___ __ __
Co nsum er ed ucation withou t - 107%
provi der ed ucation (n= 3) 28%
_ __ __ ___ __ __ ___ __ __ __ _
C om mu nity case m anag emen t
(n =14 ) 37%
__ ___ __ __ __ ___ __ __ __ __
P rovide r gro up e ducation al
p rocess ( n= 8)
22%
___ __ __ __ __ ___ __ __ __ __
E nh anced su pervision +/ - aud it
(n =2 5) 15%
_ __ __ __ __ __ ___ __ __ __ __
Econo mic in cen tives to
p rovid ers / p atients (n =7 ) 25%
_ __ __ ___ __ __ ___ __ __ __ _
EMP, NMP, other nation al po licy
or reg ulatio n (n =1 4)
-20 0 20 40 60 80 10 0
Grea test pe rcen tage cha nge in o utco me
Highest change in individual study Median across studies in group
Key Points:
x The median of the largest effect sizes across all 121 studies was 21%, a magnitude of
improvement consistent with prescribing interventions from industrialized countries. However,
interventions reported a wide range of effects (25th: 75th percentiles were 14%:32%). Overall
23 of 121 studies reported positive effects lower than 10%.
x Excluding the 11 interventions with small samples had no effect on results; the median of the
largest effect size remained 21% (25th:75th percentiles 13%:33%).
x Interventions built on group processes for health providers (such as peer review or group STG
development) demonstrated the highest median positive effect (37%), and only one of the
eight interventions reported a positive change of lower than 19%.
x The lowest median effect size (8%) was for interventions using only printed educational
materials, a finding that is consistent with the failure of print materials to change prescribing in
systematic reviews from industrialized countries. While a component of most interventions,
printed materials tend to be ineffective by themselves.
x Interventions primarily based on the use of economic incentives to change prescribing reported
the second lowest median effect size.
x For community case management intervention, approximately half the studies examined
mortality rate and half prescribing outcomes; however, the median largest effect sizes in both
types of study were similar.
x Interventions using provider and consumer education to improve the use of medicines included
studies with and without enhanced supervision. The median largest effect size for provider and
consumer education without supervision (13 studies) was 18% (25th:75th percentiles
7%:21%) and with supervision (7 studies) was 40% (25th:75th percentiles 23%:54%).
x The intervention group covering EMP, NMP, other national policy or regulation includes a
diverse set of interventions. However, the EMP group differs from the other groups in having
an element of medicines supply in the intervention. The median largest effect size for EMP (7
studies) was 27% (25th:75th percentiles 20%:45%), for NMP (6 studies) was 15% (25th:75th
percentiles 14%:24%) and for regulation (1 study) was 24%.
– 76 –
Ofȱtheȱ121ȱinterventionsȱreportedȱinȱFigureȱ10.5,ȱ109ȱfocusedȱprimarilyȱonȱimprovingȱ
prescribingȱ indicators,ȱ whileȱ theȱ remainingȱ 12ȱ studiesȱ measuredȱ theȱ effectsȱ onȱ
mortalityȱ ratesȱ ofȱ interventionsȱ toȱ improveȱ treatmentȱ ofȱ malaria,ȱ pneumonia,ȱ orȱ
diarrhoea.ȱ ȱ Theȱ studiesȱ focusedȱ onȱ mortalityȱ reductionȱ includedȱ 9ȱ communityȱ caseȱ
managementȱ studies,ȱ 2ȱ studiesȱ evaluatingȱ nationalȱ medicinesȱ policies,ȱ andȱ
1ȱinterventionȱ involvingȱ providerȱ andȱ consumerȱ education.ȱ ȱ Theȱ medianȱ largestȱ
effectȱsizesȱforȱtheȱprescribingȱimprovementȱandȱmortalityȱreductionȱstudiesȱ(21%ȱvs.ȱ
19%ȱ respectively)ȱ wereȱ roughlyȱ similar.ȱ ȱ However,ȱ givenȱ theȱ smallȱ numberȱ ofȱ
mortalityȱ studiesȱ andȱ theirȱ fundamentalȱ differenceȱ inȱ focus,ȱ theȱ resultsȱ thatȱ followȱ
includeȱonlyȱtheȱ109ȱinterventionsȱfocusedȱonȱprescribingȱimprovement.ȱ
ȱ
ȱ
Figureȱ 10.6ȱ showsȱ theȱ estimatedȱ impactsȱ ofȱ allȱ wellȬdesignedȱ prescribingȱ
improvementȱ interventionsȱ forȱ theȱ secondȱ summaryȱ measureȱ ofȱ effect,ȱ namely,ȱ theȱ
medianȱ changeȱ acrossȱ allȱ prescribingȱ outcomesȱ forȱ aȱ givenȱ study.ȱ ȱ Onceȱ again,ȱ allȱ
indicatorsȱhaveȱbeenȱscaledȱsuchȱthatȱaȱpositiveȱchangeȱisȱdesirable.ȱȱOnȱaverage,ȱtheȱ
databaseȱ containsȱ informationȱ onȱ 4.0ȱ outcomesȱ perȱ study.ȱ ȱ Studiesȱ examiningȱ theȱ
impactȱ ofȱ consumerȱ educationȱ reportedȱ substantiallyȱ fewerȱ prescribingȱ outcomesȱ
(2.0)ȱthanȱotherȱtypesȱofȱintervention,ȱwhileȱstudiesȱofȱprintedȱeducationalȱmaterialsȱ
(7.4)ȱreportedȱsubstantiallyȱmore.ȱ
– 77 –
Figure 10.6: Median reported percentage change across all study outcomes for
prescribing improvement interventions, by type of intervention
10
5%
Prin ted ed ucation al ma te rials alon e

9
7%
_ __ __ __ __ ___ __ __ __(n =5_)
___
Pro vider e ducation witho ut consum 8 er
16%
edu catio n ( n=2 5)
_ __ __ __ __ ___ __ __ __ ___ _
Prov ider p lus consu mer e ducation
7
2%
( n=1 9)
__ __ __ __ __ ___ __ __ __ ___
6
Co nsum er ed ucation withou t pro vider
29%
edu ca tio n ( n=3 )
_ __ __ __ ___ __ __ ___ __ __ _
5
C omm u nity case ma nage men t (n= 5) 13%
__ __ __ __ ___ __ __ __ ___ __
P rovid er gro up edu catio nal process
4
(n= 8) 13%
_ __ __ __ ___ __ __ __ ___ __ _
En han ce d sup ervision + /- 3 dit
au
6%
( n=2 5)
__ __ ___ __ __ ___ __ __ __ __
2
Econ om ic incentives to p rovid ers /
5%
patien
_ __ __ __ ___ __ ts___
__ __ ( n= 7)
__ _
EMP, NMP, other nation al p olicy 1 or
regu lation (n =1 2)
0
-20 0 20 40 60 80 100
Med ian pe rcenta ge chang e in all outcom es r ecor de d
Median change in individual study Median across studies in group
Key Points:
x The median across all studies of the study-specific median change in outcomes was 9%
(25th:75th percentiles 2%:20%), or less than half the size of the largest observed effect.
Overall, 31 of 109 studies reported median effect sizes of 5% or less across all of the
outcomes measured.
x Excluding the 11 studies with small sample sizes from the analysis again had no discernable
effect on the median or range of effect sizes; the median effect size across the remaining
98 studies was 9% (25th:75th percentiles 3%:19%).
x Interventions that used a combination of provider and consumer education to improve use of
medicines report a median 16% improvement across the outcomes they measured (an
average of 2.4 outcomes per study); this is a 9% greater median positive impact than the 25
studies (measuring an average of 4.6 outcomes) which tested provider education alone.
x Many educational interventions targeting health providers include supervision as either a major
or minor intervention component. On average, educational interventions targeting health
providers that included enhanced supervision as either a major or minor intervention
component (median improvement 14%, 25th:75th percentiles 7%:22%) had a 7% larger effect
size than those that did not (median improvement 7%, 25th:75th percentiles 4%:16%).
x For the intervention group covering provider and consumer education to improve the use of
medicines, the median effect size for provider and consumer education without supervision
(12 studies) was 9% (25th:75th percentiles, -1%:+18%) and with supervision (7 studies) was
24% (25th:75th percentiles 18%:28%).
x For the intervention group covering EMP, NMP, other national policy or regulation, the median
improvement in prescribing was 5% (for an average of 4.1 outcomes), suggesting that these
broad based, multidimensional programmes may have modest positive impacts on an array of
outcomes. However, within this group, the median effect size for EMP (5 studies) was 15%
(25th:75th percentiles 1%:45%), for NMP (6 studies) was 5% (25th:75th percentiles
0%:15%) and for regulation (1 study) was 5%.
ȱ
Theȱ medianȱ improvementȱ acrossȱ allȱ reportedȱ indicatorsȱ providesȱ aȱ moreȱ conservativeȱ
estimateȱofȱinterventionȱimpactsȱthanȱtheȱlargestȱreportedȱimpact.ȱȱInȱsubsequentȱanalyses,ȱ
weȱwillȱadoptȱthisȱconservativeȱapproachȱbyȱreportingȱonlyȱtheȱmedianȱeffectsȱacrossȱallȱtheȱ
prescribingȱindicatorsȱreportedȱinȱeachȱstudy.ȱ
– 78 –
10.3 Comparison of paediatric and non-paediatric interventions

Theȱ databaseȱ containsȱ twoȱ distinctȱ groupsȱ ofȱ interventions:ȱ 226ȱ studiesȱ focusedȱ onȱ
improvingȱ theȱ useȱ ofȱ medicinesȱ forȱ treatingȱ commonȱ healthȱ problemsȱ amongȱ sickȱ
children;ȱ andȱ 160ȱ studiesȱ thatȱ examineȱ moreȱ generalȱ prescribingȱ improvementȱ
interventionsȱ withoutȱ aȱ specificȱ focusȱ onȱ paediatricȱ healthȱ problems.ȱ ȱ Theseȱ twoȱ
groupsȱofȱstudiesȱtendȱtoȱhaveȱdifferentȱinterventionȱdesigns.ȱ
ȱ
ȱ
Figuresȱ10.7ȱandȱ10.8ȱcompareȱtheȱinterventionȱtypesȱandȱmethodologicalȱqualityȱofȱ
theseȱtwoȱgroupsȱofȱnonȬpaediatricȱandȱpaediatricȱstudies.ȱ
Figure 10.7: Quality of study designs used in non-paediatric interventions, by type of

intervention
Printed educational
4 3
materials
Provider education
16 12
(no consumer education)
Provider plus consumer
10 2
education
Consumer education
1
(no provider education)
Community case
11
management
Provider group
6 3
educational process
Enhanced supervision
+/- audit 19 3
Economic incentives to
6 15
providers/patients
EMP, NMP, other policy
11 47
or regulation
0 10 20 30 40 50 60
Number of interventions
Key Points:
x Overall, 74 of the 160 non-paediatric studies (46%) had acceptable research designs; 73 of
the 74 well-designed interventions targeted prescribing or patient care improvements, while 1
intervention targeted mortality reduction.
x Most of the non-paediatric interventions with poor research designs involved evaluations of
EMP, NMP, or other national policies; only 1 in 6 of these interventions had a design that
allowed it to be included in summary analyses of intervention effects.
x Over 70% of the studies of the impact of economic incentives on use of medicines also had
poor research designs, with only 6 studies strong enough to be included in the summary
analysis of impacts.
x The largest number of well-designed non-paediatric studies were those that measured the
impacts of enhanced supervision and practice audits (19 studies), followed by studies of
provider education (16 studies) or provider plus consumer education (10 studies).
– 79 –
Figure 10.8: Quality of study designs used in paediatric interventions, by type of

intervention
Printed educational materials 11
Provider education (no consumer education) 9 36
Provider plus consumer education 10 46
Consumer education (no provider education) 2
Community case management 13 22
Provider group educational process 2 1
Enhanced supervision +/- audit 6 23
Economic incentives to providers / patients 1
EMP, NMP, other policy or regulation 3 50
0 10 20 30 40 50 60
Number of interventions
Acceptable quality (N=47) Poor quality (n=179)
Key Points:
x Only 21% of the 226 paediatric intervention studies had acceptable research designs, in
contrast to nearly half of the non-paediatric studies; 36 of the 47 well-designed interventions
targeted prescribing or patient care improvements, while 11 interventions targeted mortality
reduction. .
x A very large proportion of the evaluations of EMP, NMP, or other national policies had
unacceptable research designs; only 6% of these interventions could be included in summary
analyses of intervention effects.
x In contrast to non-paediatric studies, only a small proportion of the studies of enhanced
supervision and provider education had acceptable research designs.
x The largest group of well-designed paediatric studies were interventions that focused on
assessing the impact of community case management for ARI, diarrhoea, or malaria on
mortality (9 studies) or prescribing (4 studies).
ȱ
ȱ
– 80 –
Figuresȱ10.9ȱandȱ10.10ȱpresentȱtheȱsummaryȱresultsȱseparatelyȱforȱtheȱnonȬpaediatricȱ
andȱpaediatricȱinterventions.ȱȱTheseȱfiguresȱonceȱagainȱexcludeȱtheȱ12ȱinterventionsȱ
focusedȱ mainlyȱ onȱ mortalityȱ reduction,ȱ andȱ theyȱ useȱ theȱ medianȱ ofȱ allȱ prescribingȱ
outcomesȱasȱtheȱsummaryȱmeasureȱofȱeffect.ȱ
Figure 10.9: Median reported percentage change across all prescribing outcomes for
well-designed non-paediatric prescribing improvement interventions, by type of
intervention
10
2%
9
Printed educational materials
6%
alone (n=4)
______________________ 8
Provider education without 17%
consumer education (n=16)
______________________ 7
Provider plus consumer
2%
education (n=10)
______________________ 6
Consumer education/without
provider education (n=1)
______________________ 5
13%
(n=0)
______________________ 4
Provider group educational 9%
process (n=6)
______________________3
4%
(n=19)
______________________ 2
Economic incentives to
5%
providers/patients (n=6)
______________________
1
EMP, NMP, other national policy
or regulation (n=11)
0
-20 0 20 40 60 80 100
Median percentage change in all outcomes recorded
Key Points:
x The median effect size in the non-paediatric interventions was 7% improvement in study
outcomes (25th:75th percentiles 1%:15%). Overall, 25 of the 73 studies reported a median
change of 5% or less across all prescribing outcomes.
x Although several categories have only a few studies, the overall estimates of median effects
for most categories are modest (10% or less).
x The largest median effects were observed for interventions that combined several components,
including interventions involving provider and consumer education (a median improvement in
the indicators measured across studies of 17%), a provider group educational process (13%),
followed by enhanced supervisory programmes (9%) and provider education alone (6%).
x Among the interventions that combined provider and consumer education, the three which
included a supervisory component reported a median improvement of 27% in prescribing
indicators, while the seven that did not include supervision reported a median improvement of
11%.
ȱ
– 81 –
Figure 10.10: Median reported percentage change across all prescribing outcomes for
well-designed paediatric prescribing improvement interventions, by type of intervention
7%
Printed educational materials9

11%
alone (n=1)
______________________
Provider education without8
16%
consumer education (n=9)
______________________
Provider plus consumer education7
13%
(n=9)
______________________
Consumer education without6
provider education (n=2) 29%
______________________
Community case management5
(n=5) 14%
______________________
Provider group educational4
17%
process (n=2)
______________________
3
6%
(n=6)
______________________
Economic incentives to providers
2
63%
/ patients (n=1)
______________________
1
EMP, NMP, other national policy
or regulation (n=1)
0
-20 0 20 40 60 80 100
Key Points:
x The median reported effect size was a 16% improvement in study outcomes (25th:75th
percentiles 7%:26%); this represents a 9% greater magnitude of change than that observed
in the non-paediatric studies. Overall, 7 of the 36 studies reported a median change of 5% or
less across all prescribing outcomes.
x There was a very large effect size in the single well-designed study (classified as an EMP
intervention - see figures 10.5 and 10.6), which examined the effects of the implementation of
the national IMCI programme in Bangladesh on a range of prescribing indicators. The poor
quality of research on the impacts of these types of national policies makes it impossible to
know whether this finding is at all generalizable.
x All types of educational interventions to improve paediatric prescribing (whether directed at
providers alone, consumers alone, or both providers and consumers) had median effect sizes
between 11% and 16%.
x Among the interventions that combined provider and consumer education, the four which
included a supervisory component reported a median improvement of 18% in prescribing
indicators, while the five that did not include supervision reported a median improvement of
6%.
ȱ
– 82 –
10.4 Comparison of paediatric interventions targeting different

conditions
Inȱ additionȱ toȱ differencesȱ inȱ interventionȱ design,ȱ paediatricȱ interventionsȱ alsoȱ varyȱ
byȱ theȱ healthȱ problemȱ targeted.ȱ ȱ Earlierȱ paediatricȱ studiesȱ reportedȱ inȱ theȱ databaseȱ
tendedȱtoȱ focusȱ onȱ improvingȱ treatmentȱ forȱ oneȱ ofȱ threeȱ commonȱ healthȱ problems:ȱ
acuteȱ respiratoryȱ infections,ȱ diarrhoea,ȱ orȱ malaria.ȱ ȱ Inȱ recentȱ years,ȱ paediatricȱ
interventionsȱhaveȱtendedȱtoȱaddressȱallȱthreeȱofȱtheseȱcommonȱinfectionsȱtogetherȱinȱ
theȱ contextȱ ofȱ implementingȱ IMCIȱ treatmentȱ approaches.ȱ ȱ Weȱ willȱ considerȱ theseȱ
interventionsȱtargetingȱcommonȱpaediatricȱinfectionsȱtogetherȱasȱaȱgroup.ȱ
ȱ
ȱ
Figureȱ 10.11ȱ presentsȱ theȱ qualityȱ ofȱ theȱ researchȱ designsȱ forȱ theȱ paediatricȱ
interventionsȱ targetingȱ commonȱ infectionsȱ categorizedȱ inȱ theseȱ fourȱ groupsȱ ofȱ
interventionȱstudies,ȱwhileȱFigureȱ10.12ȱcomparesȱtheȱeffectsȱsizesȱobservedȱforȱtheseȱ
interventions.ȱ
Figure 10.11: Methodological quality of prescribing improvement interventions targeting

common paediatric infections, by problem focus
ARI treatment 14 16
Diarrhoea treatment 8 8
Malaria treatment 5 7
IMCI implementation 8 26
0 5 10 15 20 25 30 35 40
Number of studies

ȱ
Key Points:
x There are four distinct clusters of well-designed paediatric studies in the database, those
focused on improving prescribing and patient care for ARI, diarrhoea, and malaria, and a more
recent group of studies assessing the impacts of the implementation of IMCI programmes.
x Although IMCI evaluations comprise the largest group of paediatric studies, only 24% of these
34 studies have adequate research designs.
ȱ
– 83 –
Figure 10.12: Median reported percentage change in prescribing outcomes in well-

designed paediatric prescribing improvement interventions targeting common
infections, by problem focus
14%
ARI treatment 1
(n=14)
7%
Diarrhoea treatment 2
(n=8)
29%
Malaria treatment 3
(n=5)
18%
IMCI implementation 4
(n=8)
5
-20 0 20 40 60 80 100
Highest change in individual study Median across studies in group

ȱ
Key Points:
x The largest median improvement in prescribing outcomes (29%) was observed for studies
focused on improving malaria treatment; all 5 of these studies had median improvements in
study outcomes between 23% and 39%.
x Overall, well-designed ARI and IMCI studies resulted in similar median improvements in key
prescribing outcomes of 14% and 18% respectively; however 4 of 14 ARI studies reported
median improvements of less than 5% in the prescribing outcomes studied, while only 1 of
8 IMCI studies had a median improvement that low.
x The 8 studies focused on prescribing for paediatric diarrhoea reported the lowest median
improvement in study outcomes of 7%, substantially lower than other types of studies
targeting paediatric infections.
ȱ
– 84 –
Discussion and Recommendations
11. DISCUSSION AND RECOMMENDATIONS

Thisȱ factȱ bookȱ summarizesȱ theȱ informationȱ containedȱ inȱ aȱ databaseȱ ofȱ existingȱ
publishedȱliteratureȱandȱunpublishedȱreportsȱrelatedȱtoȱmedicinesȱuse.ȱThisȱdatabaseȱ
wasȱ createdȱ byȱ WHOȱ toȱ monitorȱ theȱ useȱ ofȱ medicinesȱ inȱ primaryȱ careȱ andȱ toȱ
measureȱ theȱ impactsȱ ofȱ interventionsȱ aimedȱ atȱ improvingȱ medicinesȱ useȱ inȱ
developingȱ andȱ transitionalȱ countries.ȱ Theȱ analysisȱ ofȱ existingȱ publishedȱ literatureȱ
andȱ unpublishedȱ reportsȱ providesȱ anȱ alternativeȱ toȱ directȱ monitoringȱ ofȱ medicinesȱ
use,ȱ especiallyȱ sinceȱ manyȱ countriesȱ doȱ notȱ doȱ soȱ inȱ anyȱ systematicȱ way.ȱ ȱ Thisȱ
approachȱ canȱ focusȱ onȱ generalȱ medicinesȱ useȱ andȱ onȱ theȱ treatmentȱ ofȱ theȱ mostȱ
prevalentȱconditionsȱinȱprimaryȱcare,ȱandȱitȱcanȱevaluateȱtheȱuseȱofȱmedicinesȱoverȱ
specificȱ periodsȱ ofȱ time,ȱ inȱ differentȱ regions,ȱ andȱ byȱ typesȱ ofȱ facilityȱ orȱ prescriber.ȱ
WHOȱ undertookȱ anȱ analysisȱ ofȱ theȱ databaseȱ onȱ medicinesȱ use,ȱ andȱ theȱ resultsȱ areȱ
presentedȱ inȱ thisȱ Factȱ Book.ȱ Theȱ findingsȱ provideȱ adequateȱ informationȱ toȱ drawȱ
severalȱ conclusionsȱ aboutȱ theȱ useȱ ofȱ medicinesȱ inȱ primaryȱ careȱ inȱ developingȱ andȱ
transitionalȱcountries.ȱȱ
11.1 Major findings

Theȱ WHOȱ databaseȱ constitutesȱ aȱ largeȱ bodyȱ ofȱ collectedȱ evidenceȱ aboutȱ medicinesȱ
use.ȱ Itȱ containsȱ dataȱ collectedȱ inȱ 97ȱ countriesȱ overȱ aȱ periodȱ ofȱ 25ȱ years,ȱ aboutȱ 856ȱ
studyȱpopulations.ȱBecauseȱofȱlongȬstandingȱsupportȱforȱworkȱonȱmedicinesȱuseȱbyȱ
WHOȱ andȱ donorȱ organizations,ȱ theȱ majorityȱ ofȱ dataȱ comeȱ fromȱ publicȱ healthȬcareȱ
facilities.ȱTheȱnumberȱ ofȱstudiesȱconductedȱinȱ pharmacyȱshopsȱandȱinȱ nonȬlicensedȱ
shopsȱ wasȱ veryȱ small,ȱ onlyȱ 13ȱ andȱ 2%ȱ respectively,ȱ andȱ theȱ numberȱ ofȱ studiesȱ
investigatingȱprescribingȱpracticesȱofȱpharmacyȱassistantsȱandȱpharmacistsȱwasȱonlyȱ
3%,ȱprecludingȱanalysesȱofȱtheseȱtypesȱofȱfacilitiesȱandȱprescribers.ȱ
ȱ
Inȱ general,ȱ theȱ resultsȱ areȱ similarȱ inȱ allȱ geographicȱ regionsȱ andȱ timeȱ periods,ȱ andȱ
suggestȱ thatȱ prescribingȱ patternsȱ haveȱ notȱ improvedȱ inȱ anyȱ systematicȱ wayȱ overȱ
time.ȱ Duringȱ theȱ mostȱ recentȱ periodȱ ofȱ dataȱ collection,ȱ fewerȱ thanȱ halfȱ ofȱ patientsȱ
wereȱ treatedȱ accordingȱ toȱ clinicalȱ guidelinesȱ forȱ theȱ commonȱ diseasesȱ seenȱ inȱ
primaryȱcareȱsettings.ȱTheȱuseȱofȱantibioticsȱhasȱincreasedȱoverȱtimeȱtoȱreachȱ50%ȱofȱ
prescriptionsȱinȱprimaryȱcareȱstudiesȱwithȱbothȱpercentagesȱofȱantibioticsȱprescribedȱ
inappropriatelyȱ andȱ inȱ underdosageȱ increasingȱ toȱ overȱ halfȱ ofȱ antibioticȱ
prescriptions.ȱ Studiesȱ inȱ acuteȱ respiratoryȱ tractȱ infectionȱ andȱ malariaȱ suggestȱ thatȱ
medicinesȱuseȱinȱtheseȱconditionsȱmayȱhaveȱdeterioratedȱsomewhatȱoverȱtime.ȱOverȱ
twoȬthirdȱ ofȱ allȱ casesȱ ofȱ upperȱ respiratoryȱ tractȱ infectionȱ receivedȱ antibioticsȱ
unnecessarily,ȱ whileȱ lessȱ thanȱ 80%ȱ ofȱ pneumoniaȱ casesȱ wereȱ treatedȱ withȱ anȱ
appropriateȱ antibioticȱ inȱ mostȱ recentȱ studies.ȱ Duringȱ theȱ sameȱ period,ȱ onlyȱ halfȱ ofȱ
malariaȱ casesȱ receivedȱ appropriateȱ antimalarials.ȱ Onȱ theȱ otherȱ hand,ȱ someȱ
encouragingȱ trendsȱ wereȱ observedȱ withȱ regardsȱ toȱ theȱ percentageȱ ofȱ medicinesȱ
prescribedȱfromȱEML/formulariesȱandȱtheȱuseȱofȱgenerics.ȱInȱaddition,ȱtheȱpercentageȱ
ofȱ childrenȱ receivingȱ ORTȱ forȱ diarrheaȱ doubledȱ overȱ time,ȱ althoughȱ reachingȱ onlyȱ
60%;ȱaȱsubstantialȱdecreaseȱwasȱobservedȱinȱtheȱuseȱofȱantidiarrhoeals.ȱȱ
ȱ
– 85 –
Mostȱstudiesȱreportȱresultsȱfromȱtheȱpublicȱsector.ȱNevertheless,ȱresultsȱsuggestȱthatȱ
theȱ useȱ ofȱ medicinesȱ inȱ studiesȱ inȱ publicȱ healthȬcareȱ facilities,ȱ whileȱ stillȱ deficient,ȱ
wasȱ substantiallyȱ betterȱ thanȱ inȱ privateȱ facilities:ȱ thisȱ wasȱ trueȱ forȱ WHO/INRUDȱ
prescribingȱ indicatorsȱ andȱ alsoȱ forȱ ARI,ȱ diarrhoeaȱ andȱ appropriateȱ antibioticȱ use.ȱ
Theseȱresultsȱmayȱindicateȱaȱhighȱproportionȱofȱclinicallyȱ inefficientȱandȱineffectiveȱ
careȱ inȱ settingsȱ whereȱ theȱ privateȱ sectorȱ carriesȱ outȱ theȱ majorityȱ ofȱ primaryȱ careȱ
prescribing.ȱInȱcontrast,ȱpatientȱcareȱindicatorsȱappearedȱtoȱbeȱbetterȱinȱstudiesȱfromȱ
theȱ privateȱ sector,ȱ whereȱ consultationȱ andȱ dispensingȱ timesȱ wereȱ longer,ȱ labellingȱ
wasȱ moreȱ oftenȱ adequate,ȱ andȱ patientȱ knowledgeȱ ofȱ dosingȱ wasȱ alsoȱ better.ȱ
Prescribingȱ byȱ paramedicalȱ andȱ nursingȱ staffȱ wasȱ similarȱ toȱ thatȱ ofȱ doctorsȱ whenȱ
measuredȱ byȱ theȱ WHO/INRUDȱ indicators,ȱ asȱ wellȱ asȱ specificȱ indicatorsȱ relatedȱ toȱ
treatmentȱ ofȱ ARI,ȱ diarrhoeaȱ andȱ toȱ theȱ inappropriateȱ useȱ ofȱ antibiotics.ȱ Theȱ poorerȱ
prescribingȱ practicesȱ seenȱ inȱ theȱ privateȱ sectorȱ mayȱ accountȱ inȱ partȱ forȱ theȱ overallȱ
deteriorationȱofȱsomeȱprescribingȱpractices,ȱsinceȱanȱincreasingȱproportionȱofȱhealthȱ
careȱisȱbeingȱprovidedȱbyȱtheȱprivateȱsector.ȱȱ
ȱ
Aȱtotalȱofȱ121ȱinterventionsȱadequatelyȱevaluatedȱinȱ81ȱstudiesȱisȱaȱveryȱsmallȱbodyȱ
ofȱevidenceȱforȱallȱdevelopingȱandȱtransitionalȱcountriesȱoverȱaȱperiodȱofȱ25ȱyears.ȱInȱ
additionȱ toȱ theȱ smallȱ numberȱ ofȱ studies,ȱ theȱ researchȱ topicsȱ andȱ approachesȱ areȱ
fragmented,ȱandȱresearchȱstudiesȱareȱoftenȱdesignedȱandȱconductedȱwithoutȱtakingȱ
intoȱ accountȱ whatȱ isȱ alreadyȱ knownȱ aboutȱ theȱ medicinesȱ useȱ problemȱ orȱ aboutȱ
successfulȱinterventionȱapproaches.ȱȱMethodsȱareȱnotȱstandardized,ȱwhichȱlimitsȱtheȱ
qualityȱofȱstudiesȱasȱwellȱasȱcomparability.ȱȱManyȱimportantȱtopicsȱremainȱvirtuallyȱ
unexplored,ȱsuchȱasȱtheȱimpactȱofȱinterventionsȱonȱcostȱofȱmedicinesȱorȱtotalȱcostȱofȱ
treatment.ȱȱ
ȱ
Inȱ general,ȱ theȱ levelsȱ andȱ patternsȱ ofȱ interventionȱ impactsȱ areȱ similarȱ toȱ thoseȱ
reportedȱ inȱ systematicȱ reviewsȱ ofȱ interventionȱ studiesȱ conductedȱ inȱ theȱ
industrializedȱ world.24,25ȱ ȱ Asȱ hasȱ beenȱ foundȱ inȱ aȱ majorityȱ ofȱ systematicȱ reviewsȱ ofȱ
interventionsȱ inȱ industrializedȱ countries,ȱ interventionsȱ thatȱ involvedȱ severalȱ
componentsȱ appearedȱ toȱ haveȱ greaterȱ effectsȱ onȱ clinicalȱ practice.26,27ȱ ȱ Interventionsȱ
withȱ multipleȱ componentsȱ thatȱ involvedȱ educationȱ forȱ bothȱ healthȱ providersȱ andȱ
consumers,ȱ providerȱ groupȱ educationalȱ processes,ȱ andȱ especiallyȱ interventionsȱ
involvingȱ enhancedȱ supervisionȱ ofȱ prescribingȱ practiceȱ appearedȱ toȱ beȱ particularlyȱ
promising.ȱȱGivenȱtheirȱwidespreadȱimplementation,ȱthereȱisȱaȱneedȱtoȱconductȱmoreȱ
rigorousȱ longitudinalȱ researchȱ ofȱ theȱ effectsȱ ofȱ Nationalȱ Medicinesȱ Policiesȱ andȱ
EssentialȱMedicinesȱProgrammes.ȱ
11.2 Remaining gaps in knowledge

Whileȱtheȱdatabaseȱofȱmedicinesȱuseȱsurveysȱhasȱprovidedȱmuchȱinformationȱaboutȱ
prescribingȱinȱtheȱpublicȱprimaryȱcareȱsector,ȱmuchȱstillȱremainsȱunknownȱaboutȱtheȱ
privateȱ sector.ȱ Theȱ qualityȱ ofȱ careȱ providedȱ byȱ privateȱ practitionersȱ includingȱ
clinicians,ȱ pharmacists,ȱ pharmacyȱ assistantsȱ andȱ informalȱ medicineȱ sellersȱ remainȱ
largelyȱunknown.ȱȱ
ȱ
– 86 –
Noȱ attemptȱ wasȱ madeȱ toȱ collectȱ dataȱ onȱ useȱ ofȱ medicinesȱ inȱ inpatientȱ orȱ specialtyȱ
care,ȱparticularlyȱforȱchronicȱdisease;ȱthisȱremainsȱaȱlargeȱgapȱinȱcurrentȱknowledgeȱ
thatȱ remainsȱ toȱ beȱ investigated.ȱ Inȱ addition,ȱ almostȱ noȱ dataȱ areȱ availableȱ onȱ costȬ
effectivenessȱofȱinterventionsȱtoȱimproveȱmedicinesȱuse,ȱandȱveryȱfewȱofȱtheȱstudiesȱ
enteredȱintoȱtheȱdatabaseȱhadȱanyȱcostingȱdataȱthatȱcouldȱbeȱusedȱtoȱestimateȱcostȬ
effectiveness.ȱȱȱȱ
ȱ
Itȱ isȱ importantȱ toȱ noteȱ thatȱ thereȱ areȱ severalȱ importantȱ aspectsȱ ofȱ medicinesȱ useȱ
whichȱ areȱ notȱ yetȱ abstractedȱ intoȱ theȱ database,ȱ includingȱ geographicȱ andȱ financialȱ
accessȱ toȱ andȱ affordabilityȱ ofȱ medicines,ȱ safetyȱ ofȱ medicinesȱ use;ȱ healthȬseekingȱ
behaviourȱ andȱ selfȬmedicationȱ practices;ȱ accuracyȱ ofȱ diagnosticȱ decisionȬmaking;ȱȱ
andȱmedicinesȱuseȱinȱhospitalȱinpatientȱsettings.ȱȱ
ȱ
Theȱ proportionȱ ofȱ policiesȱ andȱ plannedȱ interventionsȱ targetingȱ medicinesȱ useȱ thatȱ
areȱevaluatedȱwithȱmethodologicallyȱadequateȱresearchȱdesignsȱisȱveryȱlowȱandȱtheȱ
evidenceȱ baseȱ forȱ recommendingȱ effectiveȱ interventionȱ approachesȱ isȱ growingȱ
slowlyȱandȱhaphazardly.ȱNationalȱgovernmentsȱneedȱtoȱbeȱmoreȱcommittedȱtoȱwellȬ
designedȱ researchȱ toȱ evaluateȱ theȱ impactsȱ ofȱ publicȱ pharmaceuticalȱ sectorȱ
programmes,ȱandȱthereȱisȱaȱcriticalȱneedȱtoȱevaluateȱstrategiesȱtoȱimproveȱtheȱuseȱofȱ
medicinesȱinȱtheȱprivateȱsector.ȱ
11.3 Recommendations
11.3.1 Maintaining, updating, and disseminating the database
Informationȱonȱaccessȱtoȱmedicines,ȱaffordability,ȱandȱappropriatenessȱofȱmedicinesȱ
use,ȱ andȱ onȱ theȱ impactsȱ ofȱ interventionsȱ designedȱ toȱ improveȱ theȱ medicinesȱ
situation,ȱ isȱ crucialȱ forȱ decisionȱ makingȱ atȱ nationalȱ andȱ internationalȱ levels.ȱ ȱ Toȱ
developȱ strategiesȱ forȱ improvingȱ theȱ medicinesȱ situationȱ forȱ theȱ mostȱ vulnerableȱ
populations,ȱ globalȱ andȱ domesticȱ policyȱ makersȱ needȱ toȱ knowȱ theȱ statusȱ ofȱ
medicinesȱ use,ȱ whereȱ gapsȱ inȱ knowledgeȱ exist,ȱ andȱ whichȱ interventionsȱ areȱ mostȱ
likelyȱtoȱsucceed.ȱȱ
ȱ
Atȱ present,ȱ noȱ processȱ forȱ systematicallyȱ compilingȱ andȱ evaluatingȱ informationȱ onȱ
medicinesȱ useȱ existsȱ globally.ȱ Withoutȱ suchȱ data,ȱ stakeholdersȱ willȱ haveȱ difficultyȱ
graspingȱ theȱ severityȱ ofȱ theȱ problemȱ ofȱ inappropriateȱ useȱ andȱ willȱ haveȱ littleȱ
motivationȱ toȱ makeȱ investmentsȱ toȱ solveȱ theȱ problem.ȱ Ideally,ȱ aȱ programmeȱ toȱ
monitorȱmedicinesȱuseȱonȱaȱsystematicȱbasisȱshouldȱbeȱestablishedȱatȱtheȱglobalȱlevel,ȱ
withȱaȱmissionȱtoȱprovideȱtimelyȱevidenceȱforȱnationalȱpolicyȬmaking.ȱȱȱ
ȱ
TheȱWHOȱdatabaseȱofȱstudiesȱonȱmedicinesȱuseȱisȱcurrentlyȱtheȱonlyȱtoolȱavailableȱtoȱ
monitorȱmedicinesȱuseȱindicatorsȱoverȱtimeȱinȱdevelopingȱandȱtransitionalȱcountries.ȱȱȱ
– 87 –
Despiteȱtheȱlimitationsȱofȱtheȱcurrentȱdatabaseȱandȱinȱtheȱanalysesȱpresentedȱinȱthisȱ
reportȱ(discussedȱinȱdetailȱinȱChapterȱ2),ȱweȱsuggestȱtheȱfollowing:ȱȱȱ
x TheȱmedicinesȱuseȱdatabaseȱshouldȱbeȱcontinuouslyȱupdatedȱwithȱregularȱupȬ
toȬdateȱanalysesȱtoȱmonitorȱtrendsȱinȱuseȱandȱinterventionȱimpacts.ȱȱWeȱexpectȱ
thatȱmoreȱdataȱonȱmedicinesȱaccess,ȱaffordability,ȱandȱuseȱwillȱbecomeȱ
availableȱinȱtheȱnearȱfuture,ȱgivenȱtheȱlargeȬscaleȱinvestmentsȱofȱtheȱ
internationalȱdonorȱcommunityȱinȱrecentȱyears,ȱandȱtheȱfocusȱofȱplannedȱmajorȱ
internationalȱinitiatives.ȱAȱsystemȱtoȱcontinuouslyȱupdateȱandȱdisseminateȱ
resultsȱfromȱtheȱdatabaseȱrequiresȱdedicatedȱresources.ȱȱComparedȱtoȱtheȱ
billionȱdollarȱglobalȱinvestmentsȱtoȱimproveȱaccessȱtoȱmedicinesȱforȱHIV/AIDS,ȱ
TB,ȱandȱmalaria,ȱmaintainingȱtheȱWHOȱdatabaseȱofȱstudiesȱinȱitsȱcurrentȱformȱ
wouldȱrequireȱaȱrelativelyȱminorȱbudgetȱcoveringȱportionsȱofȱtheȱeffortȱofȱaȱ
smallȱnumberȱofȱprofessionalȱstaff.ȱExpansionȱofȱtheȱdatabaseȱtoȱcoverȱavailableȱ
dataȱonȱtheȱadditionalȱareasȱofȱmedicinesȱuseȱrecommendedȱbelowȱwouldȱ
requireȱfurtherȱinvestment.ȱ
x TheȱcontinuouslyȱupdatedȱdatabaseȱandȱupdatedȱuserȬfriendlyȱsummariesȱofȱ
itsȱcontentsȱshouldȱbeȱmadeȱpubliclyȱavailableȱonȱtheȱInternet,ȱwithȱsearchȱ
enginesȱthatȱallowȱeasyȱaccessȱtoȱandȱuseȱofȱtheȱinformationȱforȱgovernments,ȱ
civilȱsociety,ȱandȱtheȱinternationalȱdevelopmentȱcommunity.ȱȱWHOȱ
CollaboratingȱCentres,ȱinternationalȱnetworks,ȱandȱnetworksȱlikeȱINRUDȱ
shouldȱprovideȱlinksȱtoȱtheȱWHOȱdatabaseȱonȱtheirȱwebsites.ȱȱResourcesȱwillȱ
alsoȱneedȱtoȱbeȱallocatedȱtoȱdevelopȱandȱmaintainȱaȱuserȬfriendlyȱInternetȬ
basedȱplatformȱforȱtheȱdatabaseȱandȱtoȱpublishȱtheȱsummaryȱreportsȱandȱ
recommendationsȱresultingȱfromȱit.ȱȱ
11.3.2 Expanding the database content
x Theȱdatabaseȱshouldȱgraduallyȱbeȱexpandedȱtoȱincludeȱadditionalȱkeyȱaspectsȱ
ofȱmedicinesȱuse.ȱȱImportantȱdomainsȱcurrentlyȱnotȱrepresentedȱincludeȱ
geographicȱaccessȱto,ȱandȱhouseholdȱaffordabilityȱof,ȱmedicines;ȱsafetyȱofȱ
medicinesȱuse;ȱhealthȬseekingȱbehaviourȱandȱselfȬmedicationȱpractices;ȱhospitalȱ
inpatientȱandȱspecialtyȱmedicinesȱuse;ȱandȱpatientȱadherenceȱtoȱtreatment.ȱȱ
Informationȱonȱmanyȱofȱtheseȱtopicsȱwillȱneedȱtoȱcomeȱfromȱaȱvarietyȱofȱ
sources,ȱincludingȱhouseholdȱsurveys.ȱȱStandardizedȱindicatorsȱofȱtheseȱ
additionalȱdomainsȱwillȱneedȱtoȱbeȱcarefullyȱdefinedȱinȱorderȱtoȱsystematicallyȱ
captureȱthemȱinȱanȱexpandedȱdatabase.ȱȱȱȱȱȱȱȱȱ
x Governments,ȱacademia,ȱtheȱprivateȱsectorȱandȱinternationalȱorganizationsȱ
shouldȱbeȱencouragedȱtoȱfillȱgapsȱinȱknowledgeȱaboutȱmedicinesȱaccess,ȱ
householdȱaffordabilityȱandȱuseȱbyȱconductingȱevaluationsȱandȱmonitoringȱ
situationsȱinȱtheirȱsettings.ȱ
x Aȱmajorȱgapȱinȱknowledgeȱexistsȱonȱmedicinesȱuseȱinȱtheȱprivateȱsector.ȱwhichȱ
providesȱmostȱofȱtheȱcareȱinȱdevelopingȱandȱtransitionalȱcountries.ȱNationalȱ
andȱinternationalȱinitiativesȱareȱurgentlyȱneededȱtoȱfillȱthisȱgap.ȱ
x AȱWHOȬbasedȱregistryȱofȱevaluationȱandȱmonitoringȱstudiesȱonȱmedicinesȱ
accessȱandȱuseȱcouldȱfacilitateȱtheȱinclusionȱofȱresultsȱfromȱstudiesȱintoȱtheȱ
WHOȱdatabase.ȱȱȱȱȱȱȱ
– 88 –
x Toȱimproveȱtheȱqualityȱofȱinterventions,ȱinformationȱonȱdesignȱoptionsȱandȱonȱ
statisticalȱtoolsȱandȱapproachesȱforȱanalysesȱneedȱtoȱbeȱdisseminatedȱtoȱthoseȱ
whoȱconductȱevaluationsȱandȱmonitorȱprogrammesȱatȱcountryȱandȱ
internationalȱlevels.ȱȱNetworksȱlikeȱtheȱInternationalȱNetworkȱforȱtheȱRationalȱ
UseȱofȱDrugsȱ(INRUD)ȱandȱtheȱnewlyȱcreatedȱAccessȱtoȱMedicinesȱ(ATM)ȱ
researchȱnetworkȱcouldȱdevelopȱInternetȬbasedȱtrainingȱprogrammesȱandȱ
sharingȱofȱtoolsȱforȱresearchȱfocusedȱonȱinterventionsȱtoȱimproveȱmedicinesȱ
use.ȱȱȱ
– 89 –
ȱȱȱȱȱ
– 90 –
Annex 1: Summary of data in figures
ANNEX 1: SUMMARY OF DATA INCLUDED IN FIGURES

Note:ȱTheȱmediansȱofȱallȱgroupsȱwithȱsampleȱsizesȱofȱlessȱthanȱfourȱstudiesȱareȱexcludedȱ
fromȱfiguresȱinȱtheȱmainȱtext.ȱ
ȱ
Figure 4.1: WHO/INRUD prescribing i ndi cators, by time period
Sample 25t h 75th
Indicator and ca tegory Size Median %ile %i le
% Medicines from EML or Formula ry
1982-1991 6 66.0 40.0 86.0
1992-1994 23 83.7 68.0 94.4
1995-1997 38 73.6 55.3 88.1
1998-2000 50 71.2 45.7 88.1
2001-2003 36 90.2 78.7 96.0
2004-2006 9 89.4 82.5 92.5
% Medicines Prescribed by Generic Name
1982-1991 11 44.0 16.0 80.0
1992-1994 43 59.0 42.8 72.0
1995-1997 44 49.0 33.6 74.6
1998-2000 53 55.0 15.4 76.0
2001-2003 27 60.0 48.6 84.0
2004-2006 14 72.3 27.0 83.7
% Patients with a n Antibi otic Prescribed
1982-1991 38 42.8 28.4 54.0
1992-1994 62 43.9 34.0 57.1
1995-1997 72 48.8 36.3 56.4
1998-2000 71 46.9 35.0 56.0
2001-2003 75 46.7 35.8 58.1
2004-2006 24 46.4 32.0 55.3
% Patients with Injection Prescribed
1982-1991 28 23.7 13.6 48.0
1992-1994 51 20.0 11.5 34.9
1995-1997 61 20.0 11.1 28.0
1998-2000 58 20.6 9.1 31.0
2001-2003 52 21.9 8.1 34.1
2004-2006 18 19.0 7.6 37.1
% Treated Accordi ng to Clinical Guideli nes
1982-1991 14 49.4 41.0 77.0
1992-1994 51 28.7 12.4 48.0
1995-1997 55 33.0 16.2 50.0
1998-2000 33 33.9 13.7 46.4
2001-2003 39 43.0 18.1 61.8
2004-2006 13 39.3 21.0 58.0
Average Number of Medi cines per Patient
1982-1991 38 2.0 1.4 2.4
1992-1994 78 2.5 2.0 3.4
1995-1997 85 2.4 2.0 3.0
1998-2000 86 2.6 2.1 3.2
2001-2003 66 2.7 2.2 3.4
2004-2006 17 2.5 2.2 2.8 ȱ
ȱ
– 91 –
Figure 4.2: WHO/INRUD prescribing i ndi cators, by World Bank region

Sample 25t h 75th
Sub-Saharan Africa 67 87.8 69.0 94.0
Latin America and Caribbean 16 71.4 43.0 85.3
Middle East and Central Asia 13 79.4 46.7 95.0
East Asia and Pacific 26 71.7 46.5 85.8
South Asia 40 84.0 58.5 89.7
South Asia 49 44.0 15.4 69.8
South Asia 92 49.1 37.2 57.0
South Asia 63 11.5 5.1 22.0
South Asia 29 28.7 12.5 41.0
South Asia 95 2.5 2.1 2.9 ȱ
ȱ
Figure 4.3: WHO/INRUD prescribing i ndi cators, by World Bank i ncome level
Sample 25t h 75th
Low Income 103 86.0 67.0 93.9
Lower-Middle Income 38 75.1 56.0 91.2
Upper-Middle & High Income 21 43.9 38.5 79.4
Low Income 130 60.8 36.0 78.0
Low Income 224 48.7 37.7 57.1
Low Income 186 23.2 13.0 37.1
Low Income 134 35.0 17.0 58.0
Low Income 233 2.5 2.0 3.2
Upper-Middle & High Income 57 2.3 1.8 2.6 ȱ
ȱ
– 92 –
ȱ
Figure 4.4: Rat es of adherence t o cli nica l guidelines over time, by World Bank region
Sample 25t h 75th
Indicator and ca tegory Period Size Median %ile %i le
Sub-Saharan Africa 1982-1994 29 46.3 21.0 78.3
1995-2000 48 27.4 11.5 57.2
2001-2006 29 48.1 23.2 62.0
Latin America and Caribbean 1982-1994 13 32.2 22.0 44.0
1995-2000 10 47.5 35.0 61.0
2001-2006 5 39.3 14.7 51.4
Middle East and Central Asia 1982-1994 4 29.9 3.5 55.8
1995-2000 8 32.5 23.0 44.7
2001-2006 5 38.9 35.6 40.5
East Asia and Pacific 1982-1994 7 25.0 12.4 45.0
1995-2000 11 29.5 5.0 38.2
2001-2006 7 36.3 15.4 58.0
South Asia 1982-1994 12 28.6 13.4 39.4
1995-2000 11 33.3 23.1 49.0
2001-2006 6 14.3 2.6 51.6 ȱ
ȱ
Figure 4.5: WHO/INRUD prescribing indi cators by prescriber type
Sample 25th 75th
Indicator and ca tegory Size Median %ile %ile
MD 63 73.0 47.0 90.8
Paramedic or Nurse 86 87.4 68.0 94.0
Pharmacy Staff, Other, or Unspecified 20 64.5 44.0 83.0
MD 84 37.9 15.4 68.0
MD 134 48.6 30.6 62.3
MD 90 17.3 7.8 34.9
% T reated According to Clinical Guidelines
MD 42 37.2 19.5 51.6
Average Number of Drugs per Patient
MD 158 2.6 2.2 3.2
Pharmacy Staff, Other, or Unspecified 45 2.2 1.4 2.8 ȱ
ȱ
– 93 –
Figure 4.6: WHOINRUD prescribing indicators by health facil ity ownership (prescri bing by
physicia ns, nurses, para medics)
Sample 25t h 75th
Public 104 88.0 74.3 94.0
Private, for profit 19 52.6 38.0 67.0
Private, not for profit 8 77.0 58.9 84.0
Public 131 60.6 36.1 80.0
Public 223 48.4 37.0 57.1
Public 173 20.0 10.0 32.7
Public 146 39.3 21.5 59.0
Public 236 2.4 2.0 2.9
Private, not for profit 14 3.0 2.4 3.3 ȱ
– 94 –
Figure 5.1: WHO/INRUD pat ient care i ndicators, by time period

Sample 25t h 75th
% Prescribed Medi cines Dispensed
1982-1991 7 81.0 57.5 83.3
1992-1994 17 84.5 77.2 90.0
1995-1997 24 81.2 65.8 88.3
1998-2000 32 81.7 70.3 90.0
2001-2003 38 87.0 76.9 98.0
2004-2006 10 92.4 85.5 97.1
% Medicines Adequately Labeled
1982-1991 1 44.0 44.0 44.0
1992-1994 11 49.0 12.0 82.0
1995-1997 17 44.0 19.0 59.5
1998-2000 15 49.4 1.1 91.4
2001-2003 30 47.6 5.0 82.6
2004-2006 10 79.0 64.6 100.0
% Patients Given Dosage Instructions
1982-1991 3 10.0 0.0 15.0
1992-1994 21 53.0 26.0 64.0
1995-1997 28 45.1 26.5 64.5
1998-2000 19 41.0 20.0 60.0
2001-2003 25 47.0 37.0 74.0
2004-2006 7 57.3 49.0 85.0
% Patients with K nowledge of Correct Dose
1982-1991 5 55.0 27.0 56.0
1992-1994 34 57.5 35.0 77.0
1995-1997 34 67.5 50.0 77.0
1998-2000 29 58.0 46.0 65.0
2001-2003 58 68.8 54.4 80.4
2004-2006 20 72.5 56.5 80.8
Average Consultati on Time (minutes)
1982-1991 4 2.8 1.7 3.3
1992-1994 22 3.9 2.9 6.3
1995-1997 19 5.5 4.0 6.0
1998-2000 13 4.3 3.6 6.7
2001-2003 11 4.8 3.5 7.8
2004-2006 5 5.6 4.5 6.2
Average Dispensing Ti me (seconds)
1982-1991 3 86.0 23.0 178.0
1992-1994 15 77.8 14.0 125.0
1995-1997 14 90.4 30.1 130.0
1998-2000 9 47.2 31.0 123.0
2001-2003 6 79.0 25.4 149.0
2004-2006 3 71.3 46.3 176.0 ȱ
– 95 –
Figure 5.2: WHO/INRUD pat ient care i ndicators, by World Bank region
Sample 25t h 75th
South Asia 30 80.8 70.2 88.0
South Asia 20 1.1 0.0 28.5
South Asia 10 44.0 31.1 82.0
South Asia 34 56.1 47.6 66.0
South Asia 22 3.5 2.0 4.8
South Asia 12 82.3 37.5 136.0 ȱ
ȱ
Figure 5.3: WHO/INRUD pat ient care i ndicators, by World Bank income level
Sample 25t h 75th
Low Income 86 83.3 73.0 89.9
Low Income 66 46.4 32.0 60.0
Low Income 112 61.4 47.3 76.3
Low Income 55 4.4 2.9 6.0
Low Income 36 81.3 34.0 140.5
ȱ
– 96 –
Figure 5.4: WHO/INRUD pat ient care i ndicators, by hea lth facility ownership
Sample 25t h 75th
Public 103 85.0 73.0 94.0
Public 69 48.0 7.0 84.0
Public 86 47.5 29.0 68.0
Private, not for profit 0 . . .
Public 159 62.8 47.6 78.0
Public 51 4.3 2.9 6.3
Public 36 77.9 29.3 127.3
ȱ
Figure 5.5: WHO/INRUD heal th facility indicators, by time period
Sample 25t h 75th
1982-1991 8 68.5 55.6 76.0
1992-1994 26 76.5 70.0 85.7
1995-1997 24 81.5 59.9 90.5
1998-2000 34 70.0 58.0 84.6
2001-2003 68 80.0 68.5 89.5
2004-2006 22 82.5 80.0 89.0
Availability of Clinical Guidelines
1982-1991 0 . . .
1992-1994 9 65.8 38.0 71.9
1995-1997 11 61.0 22.2 77.0
1998-2000 14 47.0 9.0 61.0
2001-2003 37 66.5 34.0 91.0
2004-2006 15 51.0 40.0 75.0
1982-1991 1 16.0 16.0 16.0
1992-1994 9 80.0 17.5 87.5
1995-1997 8 60.5 30.6 77.5
1998-2000 10 34.8 7.7 81.0
2001-2003 26 42.7 10.0 90.0
2004-2006 7 67.0 37.0 85.0 ȱ
ȱ
– 97 –
Figure 5.6: WHO/INRUD heal th facility indicators, by World Bank region

Sample 25t h 75th
South Asia 31 81.1 69.9 88.1
South Asia 4 26.7 1.2 51.5
South Asia 9 4.8 0.0 16.0 ȱ
ȱ
Figure 5.7: WHO/INRUD heal th facility indicators, by World Bank income level
Sample 25t h 75th
Low Income 118 80.0 68.4 86.7
Low Income 48 50.5 25.0 71.0
Low Income 39 45.0 10.0 85.0
ȱ
Figure 5.8: WHO/INRUD heal th facility indicators, by facility ownership
Sample 25th 75th
% of K ey Medi cines Available in Facilit y
Public 135 80.0 64.9 86.7
Public 78 60.5 38.0 83.0
Availability of EML/Formulary
Public 52 51.5 10.6 88.2
– 98 –
Figure 6.1: ARI prescri bing indica tors over time, including all studies of medicine use in A RI
Sample 25t h 75th

% Cases of URTI Treat ed with Antibiotics
1982-1991 11 43.4 26.0 76.0
1992-1994 18 54.2 31.0 83.0
1995-1997 26 40.4 25.0 66.0
1998-2000 24 50.9 24.2 71.1
2001-2003 35 68.8 52.0 85.2
2004-2006 12 70.5 48.0 83.5
% Pneumonia Cases Treated with R ecommended Antibiotics
1982-1991 5 80.0 66.7 80.0
1992-1994 15 69.0 42.2 82.5
1995-1997 16 60.5 46.5 78.0
1998-2000 25 58.1 42.0 79.0
2001-2003 39 53.7 28.0 75.0
2004-2006 16 76.5 45.5 92.2
1982-1991 3 52.7 41.0 58.8
1992-1994 8 42.1 29.0 58.2
1995-1997 11 38.2 29.0 43.3
1998-2000 13 35.0 25.2 50.0
2001-2003 22 43.0 18.1 62.0
2004-2006 8 34.9 22.0 51.5
% ARI Cases Treated wi th Cough Syrups
1982-1991 7 54.0 24.8 96.4
1992-1994 4 37.9 23.8 51.2
1995-1997 6 61.2 45.0 63.0
1998-2000 7 49.9 16.5 61.5
2001-2003 12 34.3 12.8 46.5
2004-2006 0 . . . ȱ
ȱ
Figure 6.2: ARI treatment indicators over time, including onl y studies of medicine use in children
< 5 years wit h ARI
Sample 25t h 75th
1982-1991 8 42.9 28.0 75.0
1992-1994 14 36.9 18.0 70.0
1995-1997 23 39.6 24.0 65.0
1998-2000 16 42.5 21.5 61.0
2001-2003 12 58.7 29.0 74.9
2004-2006 5 71.0 65.1 71.5
1982-1991 5 80.0 66.7 80.0
1992-1994 15 69.0 42.2 82.5
1995-1997 15 63.0 50.0 81.0
1998-2000 22 55.4 40.0 66.0
2001-2003 29 50.0 25.3 73.0
2004-2006 10 64.5 27.0 77.0
1982-1991 2 55.8 52.7 58.8
1992-1994 8 42.1 29.0 58.2
1995-1997 8 38.7 29.6 43.2
1998-2000 11 35.0 25.2 53.0
2001-2003 19 51.4 18.1 71.0
2004-2006 8 34.9 22.0 51.5
1982-1991 4 60.6 24.1 97.6
1992-1994 3 34.5 13.0 41.2
1995-1997 4 62.7 53.7 81.5
1998-2000 3 51.0 49.9 86.6
2001-2003 5 10.0 6.2 30.0
2004-2006 0 . . . ȱ
– 99 –
Figure 6.3: ARI treatment indicators including all studies of medicine use i n ARI, by World Bank
region
Sample 25t h 75th

South Asia 11 53.0 18.0 75.7
South Asia 12 33.8 11.9 61.0
South Asia 7 16.0 11.1 41.0
South Asia 7 26.4 13.0 51.0 ȱ
ȱ
Figure 6.4: ARI treatment indicators including all studies of medicine use i n ARI, by World Bank
income level
Sample 25t h 75th
Low Income 59 63 31 81.2
Low Middle Income 44 54.65 25.51 65.28
Upper Middle & High Income 23 59 27.7 80.3
Low Income 65 52.85 27 76
Upper Middle & High Income 19 75 58.12 89
Low Income 34.9 18.12 46.3
Upper Middle & High Income 9 62 51.4 67.5
Low Income 19 30 15.6 47.8
Low Middle Income 9 62.3 40 63.97
Upper Middle & High Income 8 60.6 49.5 64.5 ȱ
ȱ
– 100 –
Figure 6.5: ARI treatment indicators including all studies of medicine use i n ARI, by type of
prescriber
Sample 25t h 75th
MD 39 67.9 42.4 82.4
MD 19 72.0 53.3 83.0
MD 12 45.1 35.1 63.2
MD 17 45.2 35.6 64.0
ȱ
Figure 6.6: ARI treatment indicators for al l studies of medici ne use in ARI, by health care facil ity
ownership (prescribing by physi cians, nurses, pa ramedics)
Sample 25t h 75th
Public 86 58.8 29.9 76.9
Public 95 66.0 43.0 81.0
Public 58 39.3 27.8 58.0
Public 16 45.1 27.9 62.7
ȱ
Figure 6.7: Percentage of key medici nes availabl e in health facilit ies for ARI treatment, by World
Bank region
Sample 25t h 75th
East A sia and Pacific 3 86.0 80.0 89.0
South Asia 4 62.0 44.2 70.0 ȱ
– 101 –
Figure 7.1: Diarrhoea treatment indicators over time, including all studies of medicine use in
acute diarrhoea
Sample 25t h 75th

% Diarrhoea Cases Treated with Ant ibiot ics
1982-1991 24 47.9 29.7 79.3
1992-1994 36 38.5 19.6 56.2
1995-1997 23 33.3 11.0 50.5
1998-2000 13 35.7 19.5 50.0
2001-2003 27 62.0 44.4 73.1
2004-2006 11 46.0 24.3 60.0
% Diarrhoea Cases Treated with Ant idiarrhoeals
1982-1991 14 20.2 18.0 51.0
1992-1994 26 17.0 10.0 46.2
1995-1997 13 14.0 0.0 25.0
1998-2000 10 8.7 0.8 36.4
2001-2003 21 10.0 5.0 25.7
2004-2006 7 5.0 0.0 20.1
1982-1991 27 35.0 13.9 60.0
1992-1994 38 52.9 30.1 80.0
1995-1997 24 45.6 29.5 61.0
1998-2000 21 43.0 20.0 78.1
2001-2003 36 52.0 36.7 74.9
2004-2006 13 77.5 60.0 80.6
1982-1991 2 36.6 32.2 41.0
1992-1994 31 25.0 8.3 46.3
1995-1997 15 24.0 7.6 47.0
1998-2000 10 39.5 27.8 53.0
2001-2003 13 42.9 17.1 60.5
2004-2006 7 39.3 21.0 57.0 ȱ
ȱ
Figure 7.2: Diarrhoea treatment indicators over time, including only studies of medicine use i n
chi ldren <5 years with acut e diarrhoea
Sample 25t h 75th
1982-1991 16 53.8 29.7 84.8
1992-1994 28 27.5 18.6 52.3
1995-1997 18 22.0 10.0 48.0
1998-2000 9 34.3 19.0 50.0
2001-2003 9 56.5 26.0 66.0
2004-2006 4 41.5 19.8 60.6
1982-1991 11 20.0 17.5 51.0
1992-1994 20 15.0 9.7 35.8
1995-1997 9 5.0 0.0 17.3
1998-2000 6 17.7 1.0 36.4
2001-2003 7 10.0 4.5 32.0
1982-1991 21 27.6 13.6 60.0
1992-1994 29 52.8 32.0 81.4
1995-1997 16 48.5 22.3 61.5
1998-2000 15 23.1 10.0 62.0
2001-2003 19 50.0 20.0 60.0
2004-2006 6 69.5 40.0 80.6
1982-1991 0 . . .
1992-1994 29 25.0 13.0 46.2
1995-1997 13 20.0 7.6 35.7
1998-2000 9 44.0 27.8 53.0
2001-2003 13 42.9 17.1 60.5
2004-2006 7 39.3 21.0 57.0 ȱ
– 102 –
Figure 7.3: Diarrhoea treatment indicators including all studies of medicine use for acut e
diarrhoea, by World Bank region
Sample 25t h 75th

South Asia 28 50.7 30.8 75.5
South Asia 14 19.8 10.0 38.6
South Asia 33 53.1 30.4 80.0
South Asia 10 14.8 8.3 33.0 ȱ
ȱ
diarrhoea, by World Bank income level
Sample 25t h 75th
Low Income 77 49.0 23.0 65.5
Low Income 50 10.0 2.8 37.0
Low Income 100 52.8 28.4 77.5
Low Income 43 35.0 17.0 51.0
ȱ
ȱ
– 103 –
diarrhoea, by prescriber type
Sample 25t h 75th

MD 34 60.0 37.0 82.3
MD 24 18.2 10.5 22.5
MD 33 56.0 44.0 80.0
MD 14 25.0 15.0 44.2
ȱ
Figure 7.6: Diarrhoea treatment indicators for all studies of medi cine use for acute diarrhoea, by
healt h faci lity ownership (prescribing by physicians, nurses, paramedics)
Sample 25t h 75th

Public 87 49.0 20.2 64.0
Public 54 10.0 4.7 19.0
Public 90 62.5 45.1 81.4
Public 70 34.0 15.0 50.0
Private, not for profit 0 . . . ȱ
ȱ
Figure 7.7: Percentage of key medici nes availabl e in health facilities for diarrhoea treatment, by
World Bank region
Sample 25th 75th
South Asia 4 62.0 44.2 70.0 ȱ
ȱ
Figure 8.1: Prescri bing of recommended ant imala rial t reatment over time, including all studies of
ant imala rial use
Sample 25t h 75th
% Malaria Ca ses Treated with Recommended Ant imal arials (All Ages)
1982-1991 4 72.2 57.7 90.4
1992-1994 6 70.6 56.0 90.6
1995-1997 5 47.0 21.5 68.0
1998-2000 21 60.6 27.0 75.0
2001-2003 27 56.5 18.7 71.0
2004-2006 9 51.0 37.0 68.0 ȱ
ȱ
– 104 –
Figure 8.2: Prescri bing of recommended ant imala rial t reatment over time, comparing st udi es that
included only children <5 with all ot her studies
Sample 25t h 75th
% Malaria Ca ses Treated with Recommended Ant imal arials (Children < 5 Years)
1982-1994 4 70.0 55.0 89.5
1995-2000 23 47.0 21.5 74.8
2001-2006 29 56.5 29.0 69.2
% Malaria Ca ses Treated with Recommended Ant imal arials (Adults)
1982-1994 6 72.2 57.2 90.6
1995-2000 3 71.5 60.6 89.9
2001-2006 7 55.0 16.0 94.9 ȱ
ȱ
Figure 9.1: Inappropriat e prescribing of antibiotics over time
Sample 25t h 75th
1982-1994 6 66.0 40.0 72.0
1995-2000 14 54.7 38.5 73.0
2001-2006 8 54.9 31.1 66.0
% Patients Prescribed Ant ibiotics Inappropri ately
1982-1994 97 42.0 21.0 70.0
1995-2000 103 39.6 21.0 61.9
2001-2006 121 55.4 27.7 72.9 ȱ
ȱ
Figure 9.2: Inappropriat e prescribing of antibiotics, by World Bank region
Sample 25t h 75th
South Asia 6 38.1 22.8 55.0
% Patients Prescribed Ant ibiotics Inappropri ately
South Asia 47 52.8 29.0 73.1 ȱ
ȱ
Figure 9.3: Inappropriate prescribing of antibiotics, by World Bank income level
Sample 25th 75th
Low Income 20 53.7 37.4 71.5
% Patients Prescribed Antibiotics Inappropri ately
Low Income 166 49.3 25.0 70.3
ȱ
Figure 9.4: Inappropriate prescribing of antibiotics, by type of prescriber
Sample 25th 75th
MD 10 55.9 29.7 62.0
MD 91 59.3 36.8 79.0
ȱ
– 105 –
Figure 9.5: Inappropriate prescribing of antibiotics, by heal th care faci lity ownership (prescribing
by physi cians, nurses, paramedics)
Sample 25th 75th
Public 228 44.7 22.0 66.2
Public 13 52.7 26.0 59.0
Private, not for profit 0 . . . ȱ
ȱ
Annex Figure 2.1: WHO/INRUD prescribing indicators by WHO region
Sample 25t h 75th
Africa 67 87.8 69.0 94.0
Americas 16 71.4 43.0 85.3
Eastern Mediterranean 13 82.5 50.0 95.0
Europe 4 55.1 43.8 69.2
South- East Asia 47 81.0 48.8 89.4
Western Pacific 15 78.1 58.6 86.6
Africa 89 60.0 36.1 80.0
Americas 14 67.3 52.0 74.0
Europe 14 48.9 34.0 63.0
South- East Asia 50 44.0 17.1 69.8
Africa 135 47.0 38.0 55.5
Americas 28 39.3 30.9 65.6
Europe 16 33.5 24.3 55.8
South- East Asia 94 46.3 36.0 55.0
Africa 124 27.5 17.6 38.0
Americas 14 13.2 10.5 24.0
Europe 14 17.2 13.0 30.0
South- East Asia 61 9.1 5.0 17.0
Africa 106 43.2 19.0 62.0
Americas 28 39.3 21.5 52.2
Europe 4 37.2 17.8 39.7
South- East Asia 37 28.7 15.0 42.8
Africa 145 2.6 2.1 3.2
Americas 32 1.8 1.3 2.3
Europe 22 2.5 1.8 2.9
Western Pacific 25 2.6 2.2 3.7 ȱ
– 106 –
Annex Figure 2.2: WHO/INRUD pa tient care indicators by WHO region

Sample 25t h 75th
Africa 60 86.0 76.9 90.0
Americas 13 69.4 65.5 84.3
Europe 3 69.6 61.0 98.0
South- East Asia 27 81.2 66.0 90.3
Africa 34 49.3 20.2 69.5
Americas 5 49.0 24.0 74.5
Europe 1 100.0 100.0 100.0
Africa 49 46.0 32.0 60.2
Americas 16 36.5 22.3 71.2
Europe 3 56.0 14.0 93.0
South- East Asia 14 41.3 15.0 64.0
Africa 78 68.5 46.0 80.0
Americas 21 64.0 55.0 88.5
Europe 4 77.0 49.5 90.5
South- East Asia 41 57.7 47.6 75.0
Africa 33 5.1 3.8 6.1
Americas 5 10.0 6.7 14.0
Europe 1 2.0 2.0 2.0
Africa 25 84.0 37.0 132.0
Americas 1 17.0 17.0 17.0
Europe 1 29.7 29.7 29.7
South- East Asia 13 51.0 31.0 102.0
ȱ
Annex Figure 2.3: WHO/INRUD health fa cility i ndi cators by WHO region
Sample 25th 75th
Africa 85 81.5 70.0 89.0
Americas 29 66.9 57.1 79.5
Europe 3 30.0 28.0 64.9
South- East Asia 33 81.1 69.9 89.4
Africa 46 55.3 34.0 79.5
Americas 13 46.0 17.4 70.0
Europe 2 3.5 0.0 7.0
South- East Asia 9 51.0 38.0 65.8
Africa 28 51.5 17.3 82.9
Americas 10 58.5 39.3 87.5
Europe 1 100.0 100.0 100.0
– 107 –
Annex Figure 2.4: ARI treatment indicators in studies that included patients of all ages by
WHO region
25th 75th
Indicator and category Sample Size Median %ile %ile
Africa 36.0 73.0 51.1 89.8
Americas 20.0 54.7 21.2 73.9
Eastern Mediterranean 11.0 53.0 43.4 67.9
Europe 15.0 62.4 24.0 73.0
South-East Asia 18.0 50.2 26.0 70.0
Western Pacific 26.0 37.4 24.0 64.9
Africa 50.0 58.5 34.0 78.0
Americas 21.0 70.0 45.0 87.5
Europe 8.0 60.6 33.5 74.5
South-East Asia 14.0 52.5 12.5 76.4
Africa 27.0 43.0 22.5 60.0
Americas 11.0 51.4 39.2 66.0
Europe 1.0 38.9 38.9 38.9
South-East Asia 10.0 33.1 12.5 43.3
Africa 11.0 34.5 15.6 49.9
Americas 4.0 51.5 41.5 63.8
Europe 0.0 . . .
South-East Asia 8.0 35.8 23.8 57.0
– 108 –
Annex Figure 2.5: Diarrhoea treatment i ndi cators i n studies that included patients of all ages by
WHO region
Sample 25t h 75th

Africa 45 42.0 20.2 63.0
Americas 30 40.0 21.7 57.5
Europe 1 31.0 31.0 31.0
South- East Asia 34 53.8 35.7 83.0
Africa 36 10.0 3.7 36.0
Americas 17 17.5 9.5 26.3
Europe 1 11.0 11.0 11.0
South- East Asia 21 18.4 11.9 40.0
Africa 64 55.0 30.1 77.8
Americas 25 43.0 10.0 60.0
Europe 1 0.0 0.0 0.0
South- East Asia 41 54.7 30.1 80.0
Africa 32 43.5 19.5 57.5
Americas 17 39.3 23.0 53.0
Europe 2 19.4 0.0 38.9
South- East Asia 16 20.0 9.7 31.3
ȱ
Annex Figure 2.6: Inappropria te antibiotic prescribing by WHO region
Sample 25th 75th
Africa 11 54.8 38.5 73.0
Americas 4 67.0 60.5 76.8
Europe 1 29.7 29.7 29.7
South- East Asia 5 40.0 22.8 55.0
Africa 104 47.3 21.5 71.5
Americas 67 37.0 19.0 59.0
Europe 18 58.8 22.0 71.0
South- East Asia 61 54.0 34.0 74.0
ȱ
– 109 –
– 110 –
Annex 2: Results by WHO region
ANNEX 2: RESULTS BY WHO REGION
Annex Figure 2.1: WHO/INRUD prescribing indicators by WHO region
100 5
90

80 4
70
Percentage
60 3
50
40 2
30
20 1
10
0 0
Formulary G eneric Name Antibiotic Prescribed Clinical Medicines per
Prescribed Guidelines P atient
Africa Americas Eastern Mediterranean Europe South-East Asia Western Pacific

ȱ
ȱ
ȱ
ȱ
Annex Figure 2.2: WHO/INRUD patient care indicators by WHO region
100 10
90 9
80 8
70 7
Time (in minutes)
Percentage
60 6
50 5
40 4
30 3
20 2
10 1
0 0
Dispensed Labeled Instructions Knowledge of Time Tim e
Correct Dose (minutes) (m inutes)

ȱ
– 111 –
Annex Figure 2.3: WHO/INRUD health facility indicators by WHO region
100
90
80
70
Percentage
60
50
40
30
20
10
0
% Key Medicines Available in Availability of Clinical Availability of EML or
Facility Guidelines Formulary

ȱ
ȱ
ȱ
ȱ
Annex Figure 2.4: ARI treatment indicators in studies that included patients
of all ages by WHO region
100
90
80
70
Percentage
60
50
40
30
20
10
0
% Cases of URTI % Pneumonia Cases % Treated According % ARI Cases Treated
Treated with Treated w ith to Clinical Guidelines with Cough Syrups
Antibiotics Recomm ended
Antibiotics

ȱ
– 112 –
Annex 2: Results by WHO region
Annex Figure 2.5: Diarrhoea treatment indicators in studies that included patients
of all ages by WHO region
100
90
80
70
Percentage
60
50
40
30
20
10
0
% Diarrhoea Cases % Diarrhoea C ases % Diarrhoea Cases % Treated According

ȱ
ȱ
ȱ
ȱ
Annex Figure 2.6: Inappropriate antibiotic prescribing by WHO region
100
90
80
70
Percentage
60
50
40
30
20
10
0
Inappropriately

ȱ
ȱ
– 113 –
– 114 –
Annex 3: indicators database manual
ANNEX 3: WHO INDICATORS DATABASE MANUAL
Database on drug*ȱ use in developing and transitional countries —

Manual, WHO/EMP, Geneva, 2007
Authors: Kathleen Holloway and Verica Ivanovska
INTRODUCTION
Entering articles or reports in the database
Oneȱofȱtheȱobjectivesȱofȱtheȱdrugȱuseȱdatabaseȱisȱtoȱbeȱableȱtoȱmonitorȱhowȱmuchȱworkȱhasȱ
beenȱdoneȱinȱthisȱareaȱoverȱtime.ȱThereforeȱaȱveryȱimportantȱprincipleȱunderlyingȱdataȬentryȱ
intoȱ theȱ databaseȱ isȱ toȱ enterȱ oneȱ recordȱ forȱ oneȱ describedȱ studyȱ orȱ surveyȱ andȱ toȱ avoidȱ
duplicationȱofȱanyȱparticularȱstudyȱwithinȱtheȱdatabase.ȱȱ
ȱ
TheȱdefinitionȱofȱaȱȈstudyȈ**ȱorȱȈsurveyȈȱis:ȱ
ȱ
Quantitativeȱdataȱonȱdrugȱuseȱbyȱaȱspecifiedȱdrugȱuserȱinȱaȱspecifiedȱcountryȱinȱaȱspecifiedȱ
timeȱperiod.ȱȱ
ȱ
Oftenȱ oneȱ articleȱ orȱ reportȱ describesȱ onlyȱ oneȱ studyȱ orȱ surveyȱ inȱ whichȱ caseȱ oneȱ recordȱ isȱ
enteredȱ intoȱ theȱ databaseȱ forȱ thatȱ articleȱ orȱ report.ȱ However,ȱ thisȱ mayȱ notȱ applyȱ inȱ twoȱ
circumstances.ȱ Firstly,ȱ studiesȱ orȱ surveysȱ mayȱ beȱ describedȱ inȱ moreȱ thanȱ oneȱ reportȱ orȱ
articleȱȬȱinȱwhichȱcaseȱupȱtoȱthreeȱreferencesȱ(ofȱarticlesȱorȱreports)ȱmayȱbeȱenteredȱintoȱtheȱ
databaseȱtoȱciteȱtheȱoneȱstudyȱorȱsurvey.ȱSecondly,ȱarticlesȱandȱreportsȱmayȱdescribeȱmoreȱ
thanȱ oneȱ studyȱ orȱ surveyȱ Ȭȱ inȱ whichȱ caseȱ eachȱ describedȱ studyȱ orȱ surveyȱ isȱ enteredȱ asȱ aȱ
separateȱrecord,ȱi.e.ȱoneȱarticle/reportȱmayȱbeȱdividedȱintoȱtwoȱorȱmoreȱrecords.ȱDivisionȱofȱ
oneȱ articleȱ orȱ reportȱ intoȱ twoȱ orȱ moreȱ studies/surveys,ȱ toȱ beȱ enteredȱ intoȱ theȱ databaseȱ asȱ
separateȱrecords,ȱshouldȱnormallyȱonlyȱbeȱdoneȱaccordingȱto:ȱ
ȱ
x timeȱperiodȱifȱthereȱisȱnoȱassociatedȱintervention,ȱ
x drugȱoutletȱtypeȱ(e.g.ȱprimaryȱhealthȬcareȱfacility,ȱhospital,ȱdrugȱshop)ȱȱ
x drugȱoutletȱownershipȱ(e.g.ȱpublic,ȱprivate)ȱȱ
x prescriberȱtypeȱ(e.g.ȱdoctor,ȱparamedic,ȱnurse,ȱlayperson)ȱ
x dispenserȱtypeȱ(e.g.ȱpharmacist,ȱparamedic,ȱtrainedȱlayperson)ȱ
x patientȱtypeȱonlyȱinȱtermsȱofȱinpatientȱorȱoutpatientȱwhenȱallȱtheȱaboveȱcriteriaȱareȱtheȱ
same.ȱȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
*ȱȱ Theȱwordsȱ“drug”ȱandȱ“medicine”ȱareȱusedȱinterchangeablyȱinȱtheȱmanual.ȱ
**ȱȱȱ Theȱwordȱ“study”,ȱtogetherȱwithȱtheȱwordȱ“survey”ȱinȱtheȱmanualȱisȱusedȱtoȱdefineȱandȱreferȱtoȱ
databaseȱrecords.ȱȱThisȱisȱdifferentȱfromȱtheȱuseȱofȱtheȱwordȱ“study”ȱinȱtheȱanalysisȱ(seeȱ
Sectionȱ2.7).ȱ
– 115 –
ȱ
Articles/reportsȱshouldȱnotȱbeȱdividedȱonȱtheȱbasisȱofȱpatientȱageȱorȱdiseaseȱtypeȱforȱentryȱ
intoȱtheȱdatabase.ȱTheȱfollowingȱclassificationsȱwouldȱapplyȱinȱdecidingȱwhetherȱanȱarticleȱ
orȱreportȱdescribesȱoneȱorȱmoreȱstudy.ȱ
Different time periods
Ifȱnoȱinterventionsȱareȱdescribedȱinȱassociationȱwithȱtheȱdrugȱuseȱdata,ȱthenȱsurveysȱdoneȱatȱ
differentȱ timeȱ periodsȱ onȱ theȱ sameȱ drugȱ usersȱ areȱ enteredȱ inȱ differentȱ records.ȱ Ifȱ
interventionsȱareȱdescribedȱinȱassociationȱwithȱtheȱdrugȱuseȱsurveys,ȱthenȱtheȱsurveysȱdoneȱ
atȱdifferentȱtimeȱperiodsȱonȱtheȱsameȱdrugȱusersȱinȱassociationȱwithȱtheȱintervention(s)ȱareȱ
enteredȱ inȱ theȱ sameȱ record.ȱ Forȱ example,ȱ forȱ aȱ preȬpostȱ studyȱ toȱ evaluateȱ anȱ intervention,ȱ
theȱ preȬinterventionȱ andȱ postȬinterventionȱ surveysȱ shouldȱ beȱ enteredȱ inȱ theȱ sameȱ record.ȱ
Differentȱ drugȱ useȱ surveysȱ forȱ differentȱ yearsȱ doneȱ notȱ inȱ associationȱ withȱ anyȱ
intervention(s),ȱbutȱdescribedȱinȱoneȱreport,ȱshouldȱbeȱenteredȱasȱdifferentȱrecords.ȱ
Different drug outlet type, outlet ownership, prescriber & dispenser type
Ifȱdrugȱuseȱindicatorsȱareȱdescribedȱseparatelyȱforȱdifferentȱdrugȱoutletȱtypesȱorȱownershipȱ
orȱ differentȱ prescriber/dispenserȱ type,ȱ thenȱ theȱ resultsȱ forȱ eachȱ typeȱ ofȱ facilityȱ orȱ
prescriber/dispenserȱ shouldȱ beȱ enteredȱ asȱ aȱ separateȱ record.ȱ Ifȱ theȱ drugȱ useȱ indicatorsȱ areȱ
describedȱforȱdifferentȱtypesȱofȱfacilityȱȱorȱprescriber,ȱcombined,ȱthenȱonlyȱoneȱrecordȱmayȱ
beȱ enteredȱ andȱ theȱ appropriateȱ mixedȱ categoryȱ forȱ outletȱ typeȱ orȱ prescriberȱ typeȱ chosenȱ
fromȱtheȱmenuȱ(seeȱSectionȱ1).ȱ
Different patient type
Ifȱ anȱ article/reportȱ describesȱ drugȱ useȱ indicatorsȱ separatelyȱ forȱ inpatientsȱ andȱ outpatientsȱ
thatȱ areȱ treatedȱ inȱ theȱ sameȱ facilitiesȱ andȱ byȱ theȱ sameȱ prescribers,ȱ thenȱ theȱ resultsȱ forȱ
inpatientsȱ andȱ outpatientsȱ shouldȱ beȱ enteredȱ intoȱ theȱ databaseȱ asȱ separateȱ records.ȱ Inȱ allȱ
otherȱcircumstancesȱstudiesȱorȱsurveysȱwillȱbeȱdividedȱintoȱdifferentȱrecordsȱonȱtheȱbasisȱofȱ
facilityȱorȱprescriberȱtypeȱratherȱthanȱpatientȱtypeȱ(seeȱSectionȱ1).ȱ
Different patient age
Ifȱ anȱ article/reportȱ describesȱ drugȱ useȱ separatelyȱ forȱ patientsȱ ofȱ differentȱ ages,ȱ theȱ
study/surveyȱshouldȱbeȱenteredȱintoȱtheȱdatabaseȱasȱoneȱrecord.ȱSuchȱaȱsurveyȱshouldȱnotȱbeȱ
dividedȱintoȱtwoȱrecordsȱmerelyȱonȱtheȱbasisȱofȱpatientȱageȱevenȱifȱthisȱmeansȱthatȱcertainȱ
generalȱ drugȱ useȱ indicatorsȱ haveȱ toȱ beȱ calculatedȱ byȱ averagingȱ acrossȱ resultsȱ forȱ differentȱ
patientȱ ages.ȱ Someȱ articles/reportsȱ mayȱ describeȱ someȱ drugȱ useȱ indicatorsȱ forȱ allȱ agesȱ andȱ
someȱforȱchildrenȱ<ȱ5ȱyears.ȱInȱsuchȱarticles/reports,ȱtheȱageȱgroupȱrelatingȱtoȱtheȱmajorityȱofȱ
drugȱuseȱindicatorsȱshouldȱbeȱchosenȱandȱnotesȱmadeȱinȱSectionsȱ3ȱandȱ4ȱaboutȱindicatorsȱ
relatingȱtoȱtheȱageȱgroupȱnotȱchosenȱinȱSectionȱ1.ȱ
Different diseases
Ifȱ anȱ article/reportȱ describesȱ drugȱ useȱ forȱ differentȱ diseases,ȱ theȱ study/surveyȱ shouldȱ beȱ
enteredȱ intoȱ theȱ databaseȱ asȱ oneȱ record.ȱ Suchȱ aȱ surveyȱ shouldȱ notȱ beȱ dividedȱ intoȱ twoȱ
recordsȱmerelyȱonȱtheȱbasisȱofȱdiseaseȱevenȱifȱthisȱmeansȱthatȱcertainȱgeneralȱindicatorsȱthatȱ
– 116 –
areȱnotȱspecificȱtoȱaȱdiseaseȱ(e.g.ȱ%ȱpatientsȱtreatedȱinȱcomplianceȱwithȱstandardȱtreatmentȱ
guidelines),ȱhaveȱtoȱbeȱcalculatedȱbyȱaveragingȱacrossȱresultsȱforȱdifferentȱdiseases.ȱȱ
– 117 –
Entering a new study or survey
Toȱ enterȱ aȱ newȱ study,ȱ clickȱ theȱ cursorȱ onȱ theȱ starredȱ rightȬhandȱ arrowȱ atȱ theȱ bottomȱ ofȱ
sectionȱoneȱtoȱgetȱaȱnewȱblankȱrecord.ȱ
Survey ID (auto-generated) and country name
Theseȱtwoȱboxesȱ(inȱyellowȱandȱaboveȱtheȱsectionȱmenu)ȱareȱautomaticallyȱgeneratedȱonceȱ
oneȱ choosesȱ aȱ countryȱ fromȱ theȱ menuȱ inȱ theȱ firstȱ upperȱ leftȬhandȱ boxȱ inȱ sectionȱ 1.ȱ Theȱ
SurveyȱIDȱnumberȱgeneratedȱshouldȱbeȱwrittenȱonȱtheȱhardȱcopyȱofȱtheȱarticleȱinȱorderȱthatȱ
theȱrecordȱforȱthatȱarticleȱmayȱbeȱeasilyȱfoundȱinȱtheȱdatabase.ȱ
Searching for a study
Itȱisȱveryȱusefulȱtoȱbeȱableȱtoȱsearchȱtheȱdatabaseȱforȱspecificȱstudiesȱorȱsurveysȱonȱtheȱbasisȱ
ofȱdifferentȱfieldsȱ(boxes)ȱinȱorderȱto:ȱ
ȱ
x checkȱwhatȱstudiesȱorȱsurveysȱhaveȱbeenȱenteredȱintoȱtheȱdatabaseȱ
x checkȱtheȱaccuracyȱofȱdataȱenteredȱintoȱtheȱdatabaseȱ
ȱ
Inȱ orderȱ toȱ searchȱ forȱ records,ȱ putȱ theȱ cursorȱ inȱ theȱ fieldȱ (box)ȱ youȱ wishȱ toȱ searchȱ by,ȱ e.g.ȱ
countryȱorȱIDȱnumberȱorȱyearȱofȱsurvey.ȱThenȱclickȱonȱtheȱbinocularȱiconȱinȱtheȱmenuȱofȱtheȱ
accessȱsoftware.ȱAȱȈFindȱandȱreplaceȈȱboxȱwillȱappear,ȱusuallyȱinȱtheȱȈFindȈȱmodeȱbyȱdefault.ȱ
Ifȱ theȱ boxȱ isȱ inȱ theȱ ȈReplaceȈȱ mode,ȱ itȱ mustȱ beȱ changedȱ toȱ theȱ ȈFindȈȱ modeȱ byȱ clickingȱ onȱ
ȈFindȱ Ȉȱ atȱ theȱ topȱ ofȱ theȱ ȈFindȱ andȱ replaceȈȱ box.ȱ Placeȱ theȱ cursorȱ inȱ theȱ ȈFindȱ whatȈȱ blankȱ
spaceȱinȱtheȱboxȱandȱtypeȱinȱwhatȱitȱisȱyouȱwishȱtoȱsearchȱforȱȬȱIDȱnumber,ȱcountry,ȱyearȱofȱ
survey,ȱetc.ȱTheȱnextȱrecordȱwithȱtheȱspecificationȱyouȱhaveȱsearchedȱbyȱwillȱthenȱappear.ȱȱȱ
Deleting a record
Sometimesȱ aȱ recordȱ mustȱ beȱ deletedȱ whenȱ itȱ isȱ laterȱ foundȱ thatȱ aȱ study/surveyȱ hasȱ beenȱ
enteredȱ twiceȱ intoȱ theȱ database.ȱ Thisȱ mayȱ easilyȱ happenȱ whenȱ theȱ sameȱ study/surveyȱ hasȱ
beenȱpublishedȱinȱdifferentȱjournals.ȱ
ȱ
Inȱorderȱtoȱdeleteȱaȱrecord,ȱplaceȱtheȱcursorȱinȱanyȱfieldȱ(box)ȱinȱsectionȱ1ȱandȱthenȱclickȱonȱ
edit.ȱYouȱmayȱthenȱselectȱȱandȱclickȱonȱdelete.ȱYouȱwillȱthenȱbeȱaskedȱifȱyouȱreallyȱwantȱtoȱ
deleteȱtheȱrecordȱandȱthatȱdeletingȱtheȱrecordȱwillȱdeleteȱallȱtheȱassociatedȱcascadesȱofȱtables.ȱ
YouȱshouldȱsayȱȈyesȈȱonlyȱifȱyouȱareȱsureȱthatȱyouȱwantȱtoȱdeleteȱtheȱrecordȱcompletely.ȱAȱ
completeȱrecordȱ(allȱsections)ȱcannotȱbeȱdeletedȱifȱtheȱcursorȱisȱplacedȱinȱanyȱsectionȱapartȱ
fromȱsectionȱ1.ȱ(Blankȱoutcomeȱfieldȱboxesȱcanȱbeȱdeletedȱinȱsectionȱ4,ȱbyȱclickingȱonȱtheȱfirstȱ
blankȱboxȱunderneathȱaȱfilledȱinȱbox,ȱthenȱgoingȱtoȱeditȱandȱchoosingȱtoȱdeleteȱaȱrecord.)ȱ
– 118 –
SECTION 1
Thisȱsectionȱcontainsȱfieldsȱwhereȱdemographicȱinformationȱaboutȱanyȱstudyȱorȱsurveyȱmayȱ
beȱentered.ȱTheȱfigureȱbelowȱshowsȱtheȱappearanceȱofȱtheȱdataȬentryȱinterface.ȱ
ȱ
Country
Selectȱ theȱ countryȱ fromȱ theȱ menu.ȱTheȱ countriesȱ listedȱ areȱ thoseȱ recognizedȱ byȱ theȱ Unitedȱ
Nations.ȱCertainȱcountriesȱsuchȱPalestine,ȱTaiwan,ȱHongȱKong,ȱTibetȱareȱnotȱrecognizedȱbyȱ
theȱUN.ȱInȱtheseȱcasesȱtheȱcountryȱofȱclosestȱaffiliationȱmustȱbeȱselectedȱe.g.ȱIsraelȱinȱtheȱcaseȱ
ofȱPalestineȱandȱChinaȱinȱtheȱcasesȱofȱTaiwan,ȱHongȱKongȱandȱTibet.ȱIfȱoneȱarticleȱorȱreportȱ
coversȱ 2ȱ orȱ moreȱ countries,ȱ separateȱ recordsȱ mustȱ beȱ enteredȱ forȱ eachȱ country.ȱ Thisȱ boxȱ
mustȱbeȱfilledȱin.ȱ
WHO Region
Thisȱisȱautomaticallyȱgenerated.ȱ
Year of publication
Typeȱinȱtheȱyearȱtheȱarticleȱorȱreportȱwasȱpublished.ȱIfȱtheȱyearȱofȱpublicationȱisȱunknownȱ
everyȱeffortȱshouldȱbeȱmadeȱtoȱtraceȱtheȱauthorsȱtoȱfindȱoutȱtheȱyearȱofȱpublication;ȱlackȱofȱ
thisȱ informationȱ castsȱ doubtȱ onȱ theȱ authenticityȱ andȱ usefulnessȱ ofȱ theȱ surveyȱ withinȱ theȱ
database.ȱ
– 119 –
Year of baseline study
Thereȱareȱtwoȱboxesȱhere.ȱInȱtheȱfirstȱbox,ȱtypeȱinȱtheȱfirstȱyearȱofȱanyȱdataȱcollectionȱperiodȱ
thatȱisȱreported.ȱInȱtheȱcaseȱofȱstudiesȱwhereȱthereȱisȱdataȱcollectionȱatȱdifferentȱtimeȱperiodsȱ
(e.g.ȱpreȬpostȱstudies)ȱitȱisȱtheȱyearȱofȱtheȱfirstȱdataȱcollectionȱperiodȱthatȱshouldȱbeȱentered.ȱ
Inȱ theȱ secondȱ box,ȱ oneȱ mustȱ chooseȱ betweenȱ ȈactualȈȱ meaningȱ thatȱ theȱ yearȱ wasȱ actuallyȱ
statedȱinȱtheȱarticleȱorȱreportȱorȱȈestimatedȈȱmeaningȱthatȱtheȱyearȱhasȱbeenȱcalculatedȱfromȱ
otherȱindirectȱinformationȱstatedȱinȱtheȱarticle.ȱIfȱtheȱyearȱofȱbaselineȱsurveyȱisȱunknownȱtheȱ
boxesȱshouldȱbeȱleftȱblank.ȱ
Study # and Show list of studies
Theȱ boxȱ Ȉstudyȱ #Ȉȱ isȱ designedȱ toȱ helpȱ oneȱ keepȱ trackȱ ofȱ theȱ numberȱ ofȱ baselineȱ studiesȱ
alreadyȱenteredȱforȱtheȱspecifiedȱcountryȱeachȱyear.ȱBeforeȱenteringȱaȱnumberȱinȱtheȱȈstudyȱ
#Ȉȱboxȱforȱaȱnewȱrecord,ȱtheȱdataȬentryȱpersonȱshouldȱclickȱonȱboxȱȈshowȱlistȱofȱstudiesȈȱtoȱ
seeȱ ifȱ thereȱ areȱ anyȱ otherȱ recordsȱ alreadyȱ enteredȱ forȱ thatȱ countryȱ withȱ aȱ baselineȱ surveyȱ
doneȱtheȱsameȱyear.ȱIfȱthereȱareȱnoȱotherȱrecordsȱenteredȱwithȱaȱbaselineȱsurveyȱforȱtheȱsameȱ
yearȱasȱtheȱstudyȱbeingȱpresentlyȱentered,ȱthenȱȈ1ȈȱmayȱbeȱenteredȱinȱtheȱȈstudyȱ#Ȉȱbox,ȱasȱ
thisȱ isȱ theȱ firstȱ baselineȱ surveyȱ inȱ theȱ databaseȱ forȱ thisȱ countryȱ inȱ thisȱ year.ȱ Ifȱ thereȱ areȱ
alreadyȱ studiesȱ enteredȱ withȱ baselineȱ surveysȱ forȱ theȱ sameȱ yearȱ inȱ question,ȱ thenȱ theȱ nextȱ
consecutiveȱnumberȱshouldȱbeȱenteredȱinȱtheȱȈstudyȱ#Ȉȱbox.ȱForȱexample,ȱifȱthereȱareȱalreadyȱ
twoȱ studiesȱ enteredȱ withȱ baselineȱ surveysȱ forȱ theȱ sameȱ yearȱ asȱ theȱ studyȱ beingȱ presentlyȱ
entered,ȱ thenȱ Ȉ3Ȉȱ shouldȱ beȱ enteredȱ inȱ theȱ Ȉstudyȱ #Ȉȱ boxȱ asȱ thisȱ isȱ theȱ thirdȱ surveyȱ inȱ theȱ
databaseȱ forȱ thisȱ countryȱ inȱ thisȱ year.ȱ Theȱ Ȉstudyȱ #Ȉȱ cannotȱ beȱ filledȱ inȱ forȱ thoseȱ studiesȱ
whereȱtheȱyearȱofȱbaselineȱsurveyȱisȱunknown.ȱȱ
ȱ
Sometimes,ȱtheȱfieldȱȈshowȱlistȱofȱstudiesȈȱdoesȱnotȱshowȱtheȱstudiesȱuntilȱaȱcitationȱhasȱbeenȱ
enteredȱintoȱtheȱȈcitationȈȱboxȱandȱtheȱdatabaseȱ(notȱtheȱsoftware)ȱbeenȱsubsequentlyȱclosedȱ
andȱ reopened.ȱ Inȱ suchȱ circumstancesȱ Ȉstudyȱ #Ȉȱ canȱ onlyȱ beȱ enteredȱ onceȱ theȱ citationȱ hasȱ
beenȱenteredȱintoȱtheȱcitationȱboxȱandȱtheȱdatabaseȱclosedȱandȱopenedȱagain.ȱ
Study includes and intervention
ThisȱboxȱshouldȱbeȱmarkedȱasȱȈyesȈȱifȱthereȱisȱanyȱkindȱofȱinterventionȱthatȱtheȱauthorsȱsayȱisȱ
beingȱevaluated,ȱevenȱifȱoneȱfeelsȱthatȱtheȱdataȱtheyȱpresentȱorȱtheȱstudyȱdesignȱusedȱisȱnotȱ
adequateȱforȱevaluatingȱtheȱintervention.ȱIfȱnoȱinterventionȱisȱdescribed,ȱtheȱboxȱshouldȱbeȱ
markedȱȈnoȈ.ȱ
Year of post intervention survey
Thisȱboxȱshouldȱonlyȱbeȱfilledȱinȱforȱthoseȱstudiesȱwithȱanȱintervention.ȱTheȱfinalȱyearȱofȱanyȱ
dataȱ collectionȱ isȱ theȱ yearȱ thatȱ shouldȱ beȱ entered.ȱ Thusȱ forȱ studiesȱ withȱ severalȱ dataȱ
collectionȱ periodsȱ postȬintervention,ȱ itȱ isȱ theȱ yearȱ ofȱ theȱ finalȱ dataȱ collectionȱ periodȱ thatȱ
shouldȱbeȱentered.ȱȱ
ȱ
Ifȱ theȱ dateȱ orȱ yearȱ ofȱ theȱ postȱ interventionȱ surveyȱ isȱ notȱ given,ȱ andȱ theȱ interventionȱ takesȱ
lessȱthanȱsixȱmonths,ȱthenȱitȱisȱconsideredȱthatȱtheȱpostȱinterventionȱsurveyȱtakesȱplaceȱtheȱ
sameȱyearȱasȱtheȱbaselineȱsurvey.ȱȱIfȱtheȱinterventionȱtakesȱmoreȱthanȱsixȱmonths,ȱthenȱtheȱ
postȱinterventionȱsurveyȱtakesȱplaceȱoneȱyearȱafterȱtheȱbaselineȱsurvey.ȱȱȱ
– 120 –
Drug outlet type
Selectȱtheȱdrugȱoutletȱtypeȱfromȱtheȱmenu.ȱȱ
ȱ
Drugȱoutletȱtypeȱ(e.g.ȱhospital,ȱPHC,ȱshops,ȱetc)ȱrefersȱtoȱwhichȱhealthȱfacilityȇsȱdrugȱuseȱisȱ
measuredȱ(andȱnotȱtoȱtheȱinterventionȱtargetȱgroupȱorȱplaceȱofȱrecruitmentȱofȱinterviewees).ȱ
Forȱexample,ȱifȱanȱinterventionȱtargetsȱconsumersȱthroughȱtheȱmediaȱorȱcommunityȱhealthȱ
workerȱ homeȱ visitsȱ butȱ itȱ isȱ drugȱ useȱ inȱ primaryȱ healthȬcareȱ facilitiesȱ thatȱ isȱ actuallyȱ
measuredȱ throughȱ aȱ prescriptionȱ survey,ȱ thenȱtheȱ drugȱ outletȱ typeȱ isȱ Ȉprimaryȱ healthȬcareȱ
facilityȈ.ȱIfȱexitingȱpatientsȱareȱinterviewedȱatȱhealthȱfacilitiesȱaboutȱtheirȱdrugȱuseȱpracticesȱ
atȱhomeȱforȱtheȱcurrentȱillnessȱpriorȱtoȱcomingȱtoȱtheȱhealthȱfacilityȱthenȱtheȱdrugȱoutletȱtypeȱ
isȱ ȈhouseholdȈ.ȱ ȱ Ifȱ householdersȱ areȱ interviewedȱ aboutȱ treatmentȱ receivedȱ forȱ theȱ currentȱ
illnessȱ fromȱ theȱ localȱ primaryȱ healthȬcareȱ facility,ȱ thenȱ theȱ drugȱ outletȱ typeȱ isȱ Ȉȱ primaryȱ
healthȬcareȱfacilityȈ.ȱIfȱtheȱdrugȱoutletȱtypeȱdiffersȱfromȱwhereȱtheȱdataȱhasȱbeenȱcollected,ȱaȱ
noteȱshouldȱbeȱmadeȱaboutȱthisȱinȱsectionȱ3.ȱȱ
ȱ
Drugȱoutletȱtype,ȱaȱȈchemist/pharmacistȈȱdescribesȱshopsȱwhereȱonlyȱdrugsȱareȱsoldȱandȱaȱ
ȈshopȈȱdescribesȱshopsȱwhichȱsellȱdrugsȱandȱotherȱcommoditiesȱorȱdrugȱpedlars.ȱ
ȱ
Drugȱoutletȱtype,ȱȈhouseholdȈ,ȱrefersȱgenerallyȱtoȱhouseholdȱdrugȱuse.ȱThus,ȱtheȱprescriberȱ
typeȱshouldȱbeȱȈselfȈȱorȱȈcommunityȱhealthȱworkerȈȱ(inȱtheȱcaseȱofȱcommunityȱprogrammesȱ
usingȱ communityȱ membersȱ toȱ deliverȱ treatments)ȱ ,ȱ orȱ Ȉdon’tȇȱ knowȱ (ifȱ aȱ varietyȱ ofȱ healthȬ
careȱprovidersȱareȱused).ȱWhereȱtheȱprescriberȱtypeȱisȱaȱhealthȱprofessionalȱe.g.ȱdoctor,ȱtheȱ
drugȱoutletȱtypeȱwouldȱbeȱtheȱplaceȱwhereȱtheȱprofessionalȱworksȱinȱe.g.ȱȈhospitalȈȱandȱnotȱ
theȱȈhouseholdȈ,ȱevenȱifȱtheȱinformationȱwereȱcollectedȱbyȱhouseholdȱsurvey.ȱ
ȱ
Ifȱoutcomeȱvariablesȱareȱreportedȱforȱaȱmixtureȱofȱdrugȱoutletȱorȱfacilityȱtypes,ȱnormallyȱtheȱ
mixedȱ variableȱ responseȱ canȱ beȱ usedȱ e.g.ȱ ȈHospitalȱ andȱ PHCȱ facilityȈ.ȱ Ifȱ thereȱ isȱ noȱ
equivalentȱ mixedȱ variableȱ response,ȱ e.g.ȱ shopsȱ andȱ household,ȱ thenȱ theȱ drugȱ outletȱ typeȱ
shouldȱ beȱ Ȉdonȇtȱ knowȈȱ ifȱ noȱ particularȱ facilityȱ typeȱ predominatesȱ byȱ 80%ȱ orȱ more.ȱ Ifȱ oneȱ
particularȱfacilityȱtypeȱpredominatesȱbyȱ80%ȱorȱmore,ȱthenȱthatȱfacilityȱtypeȱshouldȱbeȱusedȱ
ratherȱ thanȱ Ȉdonȇtȱ knowȱ Ȉ.ȱ Inȱ allȱ cases,ȱ aȱ noteȱ shouldȱ beȱ madeȱ inȱ sectionȱ 3ȱ ofȱ theȱ %ȱ
distributionȱofȱdrugȱoutletȱorȱfacilityȱtypes.ȱȱ
Drug outlet ownership
Selectȱtheȱdrugȱoutletȱownershipȱfromȱtheȱmenu.ȱȱ
ȱ
Drugȱ outletȱ ownershipȱrefersȱ toȱ theȱ distinctionȱbetweenȱ publicȱ orȱ privateȱ facilities.ȱPrivateȱ
facilitiesȱ areȱ dividedȱ intoȱ privateȬnotȬforȬprofitȱ facilitiesȱ whichȱ includeȱ missionȱ andȱ otherȱ
charitableȱfacilitiesȱandȱprivateȬforȬprofitȱfacilitiesȱwhichȱincludeȱallȱcommercialȱinstitutionsȱ
andȱprivateȱpractitioners.ȱȱ
ȱ
Drugȱoutletȱownershipȱisȱnotȱapplicableȱinȱhouseholdȱsurveysȱwhereȱtheȱoutcomeȱvariableȱinȱ
sectionȱ4ȱisȱnotȱspecificȱtoȱaȱparticularȱprescriber.ȱ
ȱ
Ifȱ outcomeȱ variablesȱ areȱ reportedȱ forȱ aȱ mixtureȱ ofȱ facilityȱ ownership,ȱ thenȱ theȱ facilityȱ
ownershipȱshouldȱbeȱȈdonȇtȱknowȈȱifȱnoȱparticularȱtypeȱofȱfacilityȱownershipȱpredominatesȱ
– 121 –
byȱ80%ȱorȱmore.ȱIfȱoneȱparticularȱtypeȱofȱfacilityȱownershipȱpredominatesȱbyȱ80%ȱorȱmore,ȱ
thenȱ thatȱ typeȱ ofȱ ownershipȱ shouldȱ beȱ usedȱ ratherȱ thanȱ Ȉdonȇtȱ knowȱ Ȉ.ȱ Inȱ allȱ cases,ȱ aȱ noteȱ
shouldȱbeȱmadeȱinȱsectionȱ3ȱofȱtheȱ%ȱdistributionȱofȱtypesȱofȱfacilityȱownership.ȱ
Prescriber type
Selectȱtheȱprescriberȱtypeȱfromȱtheȱmenu.ȱȱ
ȱ
Prescriberȱ typeȱ (e.g.ȱ doctor,ȱ paramedic,ȱ etc)ȱ refersȱ toȱ whoseȱ prescribingȱ isȱ measured.ȱ Thisȱ
mayȱnotȱnecessarilyȱbeȱtheȱpersonsȱinterviewedȱorȱobserved.ȱForȱexample,ȱifȱexitingȱpatientsȱ
areȱ interviewedȱ atȱ healthȱ facilitiesȱ aboutȱ theirȱ drugȱ useȱ practicesȱ atȱ homeȱ forȱ theȱ currentȱ
illnessȱpriorȱtoȱcomingȱtoȱtheȱhealthȱfacilityȱthenȱtheȱprescriberȱtypeȱisȱȈselfȈ.ȱȱIfȱhouseholdersȱ
areȱ interviewedȱ aboutȱ treatmentȱ receivedȱ forȱ theȱ currentȱ illnessȱ fromȱ theȱ localȱ primaryȱ
healthȬcareȱ facilityȱ staffedȱ byȱ paramedics,ȱ thenȱ theȱ prescriberȱ typeȱ isȱ Ȉparamedicȱ Ȉ.ȱ Ifȱ
prescriptionsȱfromȱhospitalȱdoctorsȱareȱcollectedȱfromȱpharmacyȱshops,ȱthenȱtheȱprescriberȱ
typeȱisȱȈdoctorȈ.ȱIfȱtheȱprescriberȱtypeȱdiffersȱfromȱwhereȱtheȱdataȱhasȱbeenȱcollected,ȱaȱnoteȱ
shouldȱbeȱmadeȱaboutȱthisȱinȱsectionȱ3.ȱ
ȱ
Prescriberȱ typeȱ refersȱ toȱ theȱ mainȱ prescriberȱ inȱ theȱ studyȱ irrespectiveȱ ofȱ whetherȱ theȱ
interventionȱisȱaimedȱatȱthatȱprescriberȱorȱwhetherȱthereȱareȱprescribingȱoutcomeȱvariables.ȱ
Ifȱ theȱ outcomeȱ variablesȱ inȱ sectionȱ 4ȱ areȱ notȱ specificȱ toȱ aȱ particularȱ prescriberȱ type,ȱ thenȱ
prescriberȱtypeȱisȱ“don’tȱknow”.ȱȱ
ȱ
IfȱprescriberȱtypeȱisȱonlyȱreferredȱtoȱasȱȈHealthȱworkerȈȱwithȱnoȱotherȱdescription,ȱthenȱtheȱ
prescriberȱtypeȱisȱclassifiedȱasȱȈparamedicalȈ.ȱȱ
ȱ
Inȱhouseholdȱsurveys,ȱwhereȱtheȱsourceȱofȱtreatmentȱfromȱvariousȱprovidersȱisȱascertainedȱ
byȱ interview,ȱ theȱ prescriberȱ typeȱ isȱ oftenȱ “don’tȱ know”ȱ becauseȱ peopleȱ consultȱ variousȱ
prescribers;ȱinȱthisȱcaseȱaȱnoteȱofȱtheȱ%ȱofȱpeopleȱconsultingȱdifferentȱprescribersȱshouldȱbeȱ
madeȱ inȱ sectionȱ 3ȱ underȱ “commentsȱ aboutȱ studyȱ design”.ȱ Ifȱ drugȱ useȱ indicatorsȱ areȱ
providedȱforȱoneȱspecificȱprescriberȱtypeȱthenȱthisȱcanȱbeȱenteredȱratherȱthanȱȈdonȇtȱknowȈ.ȱ
Theȱonlyȱtimeȱwhenȱtheȱprescriberȱtypeȱisȱ“self”ȱisȱinȱstudiesȱwhereȱthereȱhasȱbeenȱaȱstudyȱ
specificallyȱinvestigatingȱcommunityȱmembersȱselfȱmedicating.ȱNormally,ȱifȱdrugȱoutletȱtypeȱ
isȱmarkedȱȱasȱhousehold,ȱthenȱtheȱprescriberȱtypeȱshouldȱbeȱeitherȱȈdon’tȇȱknow,ȱorȱȈselfȈȱorȱ
Ȉcommunityȱ healthȱ workerȈȱ (inȱ theȱ caseȱ ofȱ communityȱ programmesȱ usingȱ communityȱ
membersȱtoȱdeliverȱtreatments).ȱ
ȱ
Ifȱoutcomeȱvariablesȱareȱreportedȱforȱaȱmixtureȱofȱprescribers,ȱnormallyȱtheȱmixedȱvariableȱ
responseȱ canȱ beȱ usedȱ e.g.ȱ ȈMD/paramedic/nurseȈ,ȱ etc.ȱ Ifȱ thereȱ isȱ noȱ equivalentȱ mixedȱ
variableȱ response,ȱ e.g.ȱ MDsȱ andȱ pharmacists,ȱ thenȱ theȱ prescriberȱ typeȱ shouldȱ beȱ Ȉdonȇtȱ
knowȈȱifȱnoȱparticularȱprescriberȱtypeȱpredominatesȱbyȱ80%ȱorȱmore.ȱIfȱoneȱprescriberȱtypeȱ
doesȱ predominateȱ byȱ 80%ȱ orȱ more,ȱ thenȱ thatȱ prescriberȱ typeȱ shouldȱ beȱ usedȱ ratherȱ thanȱ
Ȉdonȇtȱ knowȈ.ȱ Inȱ allȱ cases,ȱ aȱ noteȱ shouldȱ beȱ madeȱ inȱ sectionȱ 3ȱ ofȱ theȱ %ȱ distributionȱ ofȱ theȱ
prescriberȱtypes.ȱȱ
ȱ
Inȱ theȱ caseȱ ofȱ householdȱ studies/surveysȱ whereȱ onlyȱ mortalityȱ ratesȱ andȱ noȱ prescribingȱ
outcomesȱ areȱ reported,ȱ theȱ prescriberȱ typeȱ isȱ usuallyȱ Ȉdonȇtȱ knowȈ.ȱ Inȱ mostȱ butȱ notȱ allȱ ofȱ
suchȱmortalityȱstudiesȱtheȱinterventionsȱtargetȱmanyȱcadresȱofȱhealthȬcareȱproviderȱandȱtheȱ
– 122 –
consumerȱandȱitȱisȱimpossibleȱtoȱsayȱwhichȱȈprescriberȱtypeȈȱisȱresponsibleȱforȱanyȱchangeȱinȱ
mortality.ȱ Inȱ someȱ studies,ȱ anȱ interventionȱ doesȱ targetȱ oneȱ specificȱ prescriberȱ type,ȱ andȱ inȱ
thisȱ case,ȱ theȱ targetedȱ prescriberȱ typeȱ mayȱ beȱ enteredȱ intoȱ theȱ database.ȱ Forȱ example,ȱ inȱ
studiesȱ whereȱ communityȱ caseȱ managementȱ interventionsȱ haveȱ beenȱ usedȱ toȱ decreaseȱ
mortalityȱ fromȱ childhoodȱ infections,ȱ theȱ interventionsȱ targetȱ communities,ȱ includingȱ
communityȱhealthȱworkerȱ(CHW)ȱwhoȱliveȱandȱworkȱinȱtheseȱcommunities.ȱSinceȱtheȱCHWsȱ
areȱknownȱtoȱbeȱresponsibleȱforȱmostȱofȱtheȱpatientȱcareȱwithinȱsuchȱcommunities,ȱtheyȱmayȱ
beȱ citedȱ asȱ theȱ Ȉprescriberȱ typeȈ.ȱ Allȱ suchȱ studiesȱ shouldȱ beȱ discussedȱ betweenȱ theȱ dataȬ
entryȱpersonȱandȱtheȱpersonȱinȱchargeȱofȱtheȱdatabase.ȱ
Dispenser type
Selectȱtheȱdispenserȱtypeȱfromȱtheȱmenu.ȱȱ
ȱ
Dispenserȱ typeȱ refersȱ toȱ theȱ mainȱ dispenserȱ inȱ theȱ studyȱ irrespectiveȱ ofȱ whetherȱ theȱ
interventionȱisȱaimedȱatȱthatȱdispenserȱorȱwhetherȱthereȱareȱdispensingȱoutcomeȱvariables.ȱIfȱ
theȱ outcomeȱ variablesȱ inȱ sectionȱ 4ȱ areȱ notȱ specificȱ toȱ aȱ particularȱ dispenserȱ type,ȱ thenȱ
dispenserȱtypeȱisȱ“don’tȱknow”.ȱȱ
ȱ
IfȱdispenserȱtypeȱisȱonlyȱreferredȱtoȱasȱȈHealthȱworkerȈȱwithȱnoȱotherȱdescription,ȱthenȱtheȱ
dispenserȱtypeȱisȱclassifiedȱasȱȈparamedicalȈ.ȱȱ
ȱ
Ifȱoutcomeȱvariablesȱareȱreportedȱforȱaȱmixtureȱofȱdispensers,ȱnormallyȱtheȱmixedȱvariableȱ
responseȱ canȱ beȱ usedȱ e.g.ȱ Ȉȱ pharmacistȱ andȱ pharmacyȱ asst.Ȉ,ȱ etc.ȱ Ifȱ thereȱ isȱ noȱ equivalentȱ
mixedȱvariableȱresponse,ȱe.g.ȱȈpharmacyȱasst.ȱandȱnursesȈ,ȱthenȱtheȱdispenserȱtypeȱshouldȱbeȱ
ȈdonȇtȱknowȈȱifȱnoȱparticularȱdispenserȱtypeȱpredominatesȱbyȱ80%ȱorȱmore.ȱIfȱoneȱdispenserȱ
typeȱdoesȱpredominateȱbyȱ80%ȱorȱmore,ȱthenȱthatȱdispenserȱtypeȱshouldȱbeȱusedȱratherȱthanȱ
Ȉdonȇtȱ knowȈ.ȱ Inȱ allȱ cases,ȱ aȱ noteȱ shouldȱ beȱ madeȱ inȱ sectionȱ 3ȱ ofȱ theȱ %ȱ distributionȱ ofȱ theȱ
dispenserȱtypes.ȱȱ
Patient type
Selectȱtheȱpatientȱtypeȱfromȱtheȱmenu.ȱȱ
ȱ
Patientsȱattendingȱhospitalsȱorȱclinicsȱmayȱbeȱclassifiedȱasȱinpatientsȱorȱoutpatients.ȱ
ȱ
Patientsȱ attendingȱ primaryȱ healthȬcareȱ facilitiesȱ areȱ usuallyȱ classifiedȱ asȱ outpatients.ȱ (Ifȱ
patientsȱ attendingȱ primaryȱ healthȬcareȱ facilitiesȱ areȱ classifiedȱ asȱ inpatients,ȱ seriousȱ
considerationȱshouldȱbeȱgivenȱtoȱwhetherȱtheȱclassificationȱofȱtheȱfacilityȱtypeȱisȱcorrect).ȱ
ȱ
Patientsȱattendingȱshopsȱorȱinterviewedȱinȱhouseholdȱsurveysȱareȱclassifiedȱasȱconsumers.ȱ
ȱ
Forȱaȱmixtureȱofȱinpatientȱandȱoutpatientsȱonly,ȱwhereȱoutcomeȱvariablesȱareȱnotȱreportedȱ
separatelyȱ (inȱ whichȱ caseȱ twoȱ recordsȱ mayȱ beȱ enteredȱ intoȱ theȱ database),ȱ thenȱ theȱ patientȱ
typeȱshouldȱbeȱȈdonȇtȱknowȈȱifȱnoȱparticularȱpatientȱtypeȱpredominatesȱbyȱ80%ȱorȱmore.ȱIfȱ
oneȱpatientȱtypeȱdoesȱpredominateȱbyȱ80%ȱorȱmore,ȱthenȱthatȱpatientȱtypeȱshouldȱbeȱusedȱ
ratherȱ thanȱ Ȉdonȇtȱ knowȈ.ȱ Inȱ allȱ cases,ȱ aȱ noteȱ shouldȱ beȱ madeȱ inȱ sectionȱ 3ȱ ofȱ theȱ %ȱ
distributionȱofȱtheȱpatientȱtypes.ȱ
– 123 –
Patient age group
Selectȱtheȱpatientȱageȱfromȱtheȱmenu:ȱ
ȱ
x Allȱ(includesȱallȱages)ȱ
x Adultsȱ
x Childrenȱlessȱthanȱ1ȱyearȱ
x Childrenȱlessȱthanȱ5ȱyearsȱ
x Childrenȱaboveȱ5ȱyearsȱ
x Allȱchildrenȱ(upperȱageȱlimitȱasȱdefinedȱbyȱtheȱarticle/study)ȱ
x Donȇtȱknowȱ
ȱ
Theȱ ageȱ groupȱ chosenȱ shouldȱ beȱ accordingȱ toȱ theȱ upperȱ ageȱ limitȱ allowed.ȱ Forȱ example,ȱ
childrenȱ lessȱthanȱoneȱyearȱshouldȱbeȱplacedȱinȱtheȱȈ<ȱ1ȱyearȈȱcategoryȱandȱnotȱinȱtheȱȈ<ȱ5ȱ
yearsȈȱcategory,ȱevenȱthoughȱtheyȱareȱclearlyȱunderȱ5ȱyearsȱasȱwellȱasȱunderȱ1ȱyear.ȱ
ȱ
Ifȱ anȱ article/reportȱ describesȱ drugȱ useȱ separatelyȱ forȱ patientsȱ ofȱ differentȱ ages,ȱ theȱ
study/surveyȱshouldȱbeȱenteredȱintoȱtheȱdatabaseȱasȱoneȱrecord.ȱSuchȱaȱsurveyȱshouldȱnotȱbeȱ
dividedȱintoȱtwoȱrecordsȱmerelyȱonȱtheȱbasisȱofȱpatientȱageȱevenȱifȱthisȱmeansȱthatȱcertainȱ
generalȱ drugȱ useȱ indicatorsȱ haveȱ toȱ beȱ calculatedȱ byȱ averagingȱ acrossȱ resultsȱ forȱ differentȱ
patientȱ ages.ȱ Someȱ articles/reportsȱ mayȱ describeȱ someȱ drugȱ useȱ indicatorsȱ forȱ allȱ agesȱ andȱ
someȱforȱchildrenȱ<ȱ5ȱyears.ȱInȱsuchȱarticles/reports,ȱtheȱageȱgroupȱrelatingȱtoȱtheȱmajorityȱofȱ
drugȱ useȱindicatorsȱshouldȱ beȱchosenȱandȱnotesȱmadeȱinȱsectionsȱ3ȱandȱ4ȱaboutȱindicatorsȱ
relatingȱtoȱtheȱageȱgroupȱnotȱchosenȱinȱsectionȱ1.ȱ
Cases include all illnesses or specific illnesses only
SelectȱȈallȱillnessesȈȱorȱȈspecificȱillnessesȱonlyȈȱfromȱtheȱmenu.ȱ
ȱ
“Specificȱillnessesȱonly”ȱshouldȱbeȱchosenȱifȱdrugȱuseȱforȱcasesȱofȱspecificȱdiseasesȱonlyȱareȱ
investigated.ȱȱ“Allȱillnesses”ȱshouldȱbeȱchosenȱifȱdrugȱuseȱforȱallȱdiseasesȱareȱinvestigated.ȱInȱ
theȱcaseȱofȱ“specificȱillnessesȱonly”ȱoneȱofȱtheȱvariablesȱunderȱtheȱsectionȱȱȈstudyȱmeasuresȱ
specificȱindicatorsȱforȱtheȱfollowingȱdiseasesȈȱshouldȱbeȱmarkedȱ“yes”.ȱInȱotherȱwords,ȱoneȱ
orȱ moreȱ ofȱ theȱ variablesȱ ȈmalariaȈ,ȱ ȈdiarrhoeaȈ,ȱ ȈhypertensionȈ,ȱ ȈAcuteȱ respiratoryȱ tractȱ
infectionȱ(ARI)Ȉ,ȱȈMaternalȱchildȱhealthȱ(MCH)Ȉ,ȱȈSexuallyȱtransmittedȱinfectionsȱ(STIs)Ȉȱorȱ
“otherȱillnesses”ȱshouldȱbeȱmarkedȱȈyesȈ.ȱȱ
ȱ
ȈAllȱ illnessesȈȱ shouldȱ beȱ chosenȱ ifȱ drugȱ useȱ forȱ allȱ casesȱ areȱ investigated.ȱ Evenȱ ifȱ ȈAllȱ
illnesses”ȱ isȱ chosen,ȱ oneȱ orȱ moreȱ ofȱ theȱ variablesȱ ȈmalariaȈ,ȱ ȈdiarrhoeaȈ,ȱ ȈhypertensionȈ,ȱ
ȈARIȈ,ȱȈMCHȈ,ȱȈSTIsȈȱorȱ“otherȱillnesses”ȱȱmayȱstillȱbeȱmarkedȱ“yes”ȱifȱthereȱisȱanȱindicatorȱ
whichȱisȱspecificȱtoȱaȱdiseaseȱinȱtheȱsurvey.ȱForȱexample,ȱaȱgeneralȱsurveyȱmarkedȱ“all”ȱmayȱ
alsoȱ beȱ markedȱ “diarrhoea=yes”ȱ ifȱ theȱ indicatorȱ “%ȱ diarrhoeaȱ casesȱ treatedȱ withȱ ORT”ȱ isȱ
present.ȱ
– 124 –
Study measures specific indicators for the following diseases
Forȱ eachȱ boxȱ labelledȱ ȱ ȈmalariaȈ,ȱ ȈdiarrhoeaȈ,ȱ ȈhypertensionȈ,ȱ ȈARIȈ,ȱ ȈMCHȈ,ȱ ȈSTIsȈ,ȱ choseȱ
ȈyesȈȱorȱȈnoȈȱ
ȱ
Forȱ theȱ boxȱ labelledȱ ȈOtherȱ illnessesȱ (describe)Ȉ,ȱ enterȱ anyȱ otherȱ specificȱ illnessȱ forȱ whichȱ
drugȱuseȱhasȱbeenȱinvestigated.ȱ
ȱ
TheȱspecificȱdiseaseȱboxesȱmayȱbeȱmarkedȱasȱȈyesȈȱif:ȱ
ȱ
x aȱ study/surveyȱ investigatesȱ drugȱ useȱ onlyȱ forȱ aȱ specificȱ diseaseȱ evenȱ thoughȱ generalȱ
drugȱuseȱindicatorsȱnotȱspecificȱtoȱaȱdiseaseȱ(e.g.ȱaverageȱnumberȱofȱdrugsȱperȱpatient)ȱ
areȱreported.ȱ
x drugȱuseȱindicatorsȱspecificȱtoȱaȱdiseaseȱ(e.g.ȱ%ȱARIȱcasesȱtreatedȱwithȱcoughȱsyrups)ȱareȱ
reportedȱevenȱthoughȱotherȱgeneralȱdrugȱuseȱindicatorsȱforȱpatientsȱwithȱallȱillnessesȱareȱ
reported.ȱ
ȱ
Forȱ surveysȱ concerningȱ theȱ integratedȱ managementȱ ofȱ childhoodȱ illnessȱ (IMCI),ȱ enterȱ
ȈIMCIȈȱ underȱ “otherȱ illnessesȱ (describe)”ȱ andȱ alsoȱ insertȱ ȈyesȈȱ forȱ theȱ fieldsȱ ȈmalariaȈ,ȱ
ȈdiarrhoeaȈȱ orȱ ȈARIȈȱ ifȱ anȱ outcomeȱ indicatorȱ specificȱ forȱ theseȱ illnessesȱ isȱ reported.ȱ Theȱ
indicatorsȱforȱspecificȱillnessesȱareȱlistedȱbelow:ȱ
Malaria
x %ȱmalariaȱcasesȱtreatedȱwithȱappropriateȱantiȬmalarialsȱ
Diarrhoea
x %ȱdiarrhoeaȱcasesȱtreatedȱwithȱoralȱrehydrationȱtherapyȱ(ORT)ȱ
x %ȱdiarrhoeaȱcasesȱtreatedȱwithȱantibioticsȱ
x %ȱdiarrhoeaȱcasesȱtreatedȱwithȱantiȬdiarrhoealsȱ
Acute respiratory tract infection
x %ȱARIȱcasesȱtreatedȱwithȱcoughȱsyrupȱ
x %ȱpneumoniaȱcasesȱtreatedȱwithȱappropriateȱantibioticsȱ
x %ȱviralȱupperȱrespiratoryȱtractȱinfectionsȱ(URTI)ȱtreatedȱwithȱantibioticsȱ
ȱ
Ifȱ anȱ article/reportȱ describesȱ drugȱ useȱ forȱ differentȱ diseases,ȱ theȱ study/surveyȱ shouldȱ beȱ
enteredȱ intoȱ theȱ databaseȱ asȱ oneȱ record.ȱ Suchȱ aȱ surveyȱ shouldȱ notȱ beȱ dividedȱ intoȱ twoȱ
recordsȱmerelyȱonȱtheȱbasisȱofȱdiseaseȱevenȱifȱthisȱmeansȱthatȱcertainȱgeneralȱindicatorsȱthatȱ
areȱnotȱspecificȱtoȱaȱdiseaseȱ(e.g.ȱ%ȱpatientsȱtreatedȱinȱcomplianceȱwithȱstandardȱtreatmentȱ
guidelines),ȱhaveȱtoȱbeȱcalculatedȱbyȱaveragingȱacrossȱresultsȱforȱdifferentȱdiseases.ȱȱ
– 125 –
Data from this study can be found in the following publications
Thereȱ areȱ threeȱ boxesȱ forȱ upȱ toȱ aȱ maximumȱ ofȱ threeȱ referencesȱ perȱ studyȱ orȱ survey.ȱ Theȱ
referenceȱshouldȱbeȱchosenȱbyȱclickingȱtheȱcursorȱinȱtheȱboxȱandȱthenȱselectingȱtheȱreferenceȱ
fromȱtheȱmenu.ȱPreviouslyȱenteredȱreferencesȱwillȱappearȱinȱtheȱmenu.ȱNewȱreferencesȱmustȱ
beȱenteredȱintoȱtheȱdatabaseȱusingȱȈAddȱorȱmodifyȱcitationȈȱ(seeȱbelow).ȱ
Add or modify citation
Toȱenterȱaȱnewȱcitationȱintoȱtheȱdatabase,ȱclickȱtheȱcursorȱonȱtheȱȈAddȱorȱmodifyȱcitationȈȱbox.ȱ
Onceȱ theȱ boxȱ appears,ȱ clickȱ onȱ starredȱ rightȱ arrowȱ atȱ theȱ bottomȱ ofȱ theȱ box.ȱ Aȱ newȱ
ȈRUD_CitationsȈȱ boxȱ willȱ appearȱ intoȱ whichȱ theȱ newȱ citationȱ mayȱ beȱ typed.ȱ Immediatelyȱ
oneȱstartsȱtypingȱinȱaȱnewȱcitation,ȱanȱautomaticȱpublicationȱnumberȱisȱgenerated.ȱOnceȱtheȱ
citationȱhasȱbeenȱtyped,ȱtheȱȈRUD_CitationsȈȱboxȱmayȱbeȱclosedȱbyȱclickingȱonȱtheȱȈxȈȱatȱtheȱ
topȱrightȬhandȱcornerȱofȱtheȱbox.ȱȱ
ȱ
SometimesȱtheȱnewȱcitationȱisȱimmediatelyȱavailableȱinȱtheȱmenuȱinȱtheȱboxesȱunderȱȈDataȱ
fromȱ thisȱ studyȱ canȱ beȱ foundȱ inȱ theȱ followingȱ publicationsȈ.ȱ However,ȱ usuallyȱ oneȱ mustȱ
closeȱtheȱdatabaseȱ(notȱshutȱdownȱtheȱsoftware)ȱandȱreȬopenȱtheȱdatabaseȱagainȱinȱorderȱtoȱ
findȱtheȱnewȱcitationȱinȱtheȱmenuȱavailableȱinȱtheseȱboxes.ȱ
ȱ
Toȱmodifyȱaȱcitationȱalreadyȱinȱtheȱdatabase,ȱclickȱtheȱcursorȱonȱtheȱȈAddȱorȱmodifyȱcitationȈȱ
box.ȱOnceȱtheȱboxȱappears,ȱclickȱonȱtheȱrightȬhandȱorȱleftȬhandȱarrowsȱ(notȱstarred)ȱtoȱsearchȱ
theȱalreadyȱexistingȱcitationsȱwhichȱappearȱinȱalphabeticalȱorder.ȱOnceȱtheȱrequiredȱcitationȱ
appearsȱinȱtheȱȈRUD_CitationsȈȱbox,ȱitȱcanȱbeȱedited.ȱȱ
ȱ
Theȱcitationsȱshouldȱbeȱtypedȱinȱtheȱsameȱmanner,ȱnormallyȱstartingȱwithȱtheȱauthors,ȱthenȱ
theȱdate,ȱtheȱtitleȱofȱtheȱarticle,ȱtheȱjournal,ȱtheȱvolumeȱnumberȱandȱlastlyȱtheȱpageȱnumbers.ȱ
Usingȱtheȱsameȱformatȱforȱtypingȱinȱtheȱcitationsȱwillȱfacilitateȱsearchingȱforȱreferences.ȱȱ
– 126 –
SECTION 2
Thisȱsectionȱcontainsȱfieldsȱwhereȱinformationȱaboutȱinterventionsȱconductedȱinȱassociationȱ
withȱtheȱdrugȱuseȱstudies/surveysȱmayȱbeȱentered.ȱTheȱfigureȱbelowȱshowsȱtheȱappearanceȱ
ofȱtheȱdataȬentryȱinterface.ȱ
ȱ
ȱ
ȱ
Allȱ relevantȱ componentsȱ ofȱ aȱ packageȱ ofȱ interventionsȱ forȱ howeverȱ manyȱ interventionȱ
groupsȱwithinȱaȱstudy/surveyȱshouldȱbeȱtickedȱȈyesȈȱevenȱthough:ȱ
ȱ
x aȱdescriptionȱisȱmadeȱinȱtheȱinterventionȱbox(es),ȱandȱȱ
x notȱallȱgroupsȱwithinȱaȱstudyȱhaveȱreceivedȱallȱcomponentsȱofȱeveryȱintervention.ȱ
ȱ
Underȱ Ȉinterventionȱ descriptionȈȱ atȱ theȱ bottomȱ ofȱ sectionȱ 2,ȱ thereȱ areȱ 3ȱ boxesȱ labelledȱ
Ȉinterventionȱ 1Ȉ,ȱ Ȉinterventionȱ 2Ȉ,ȱ Ȉinterventionȱ 3Ȉ.ȱ Normallyȱ aȱ descriptionȱ ofȱ theȱ
interventionȱ shouldȱ beȱ enteredȱ intoȱ oneȱ orȱ moreȱ ofȱ theseȱ boxes.ȱ Theȱ databaseȱ canȱ
accommodateȱupȱtoȱ3ȱinterventionȱgroupsȱandȱ oneȱcontrolȱ groupȱwithinȱoneȱstudy/surveyȱ
enteredȱ asȱ oneȱ record.ȱ Whereȱ thereȱ isȱ moreȱ thanȱ oneȱ groupȱ receivingȱ anȱ intervention,ȱ aȱ
descriptionȱofȱeachȱinterventionȱorȱpackageȱofȱinterventionsȱforȱeachȱdifferentȱgroupȱmustȱbeȱ
enteredȱintoȱinterventionȱboxesȱprovided.ȱȱ
ȱ
Theȱsectionȱonȱinterventionsȱisȱdividedȱbyȱmajorȱtypeȱofȱinterventionȱandȱagainȱsubdividedȱ
byȱ differentȱ interventionsȱ thatȱ mayȱ beȱ undertakenȱ withȱ eachȱ majorȱ typeȱ ofȱ intervention.ȱ
– 127 –
Eachȱ sectionȱ hasȱ aȱ boxȱ ȈotherȈȱ forȱ interventionsȱ thatȱ areȱ notȱ adequatelyȱ describedȱ byȱ theȱ
interventionsȱlistedȱunderȱeachȱcategory.ȱTheȱmajorȱtypesȱofȱinterventionȱare:ȱ
ȱ
x Providerȱeducationȱ
x Administrative/managerialȱȱ
x Communityȱcaseȱmanagementȱ
x Printedȱmaterialsȱ
x Consumerȱeducationȱ
x Groupȱprocessȱstrategiesȱ
x Regulatoryȱinterventionsȱ
x Economicȱstrategiesȱ
x EssentialȱDrugsȱProgramme/Supplyȱ
ȱ
Inȱ someȱ studies,ȱ informationȱ isȱ givenȱ aboutȱ theȱ extentȱ toȱ whichȱ theȱ interventionȱ isȱ
implementedȱ e.g.ȱ coverage.ȱ Forȱ example,ȱ inȱ IMCIȱ studies,ȱ thereȱ isȱ anȱ indicatorȱ Ȉ%ȱ healthȱ
facilitiesȱ withȱ atȱ leastȱ 60%ȱ ofȱ healthȱ workersȱ whoȱ manageȱ childrenȱ trainedȱ inȱ IMCIȈ.ȱ Thisȱ
shouldȱbeȱrecordedȱinȱtheȱinterventionȱbox.ȱȱ
Provider education
Aȱproviderȱisȱanybodyȱdeliveringȱhealthȱservicesȱevenȱifȱs/heȱisȱnotȱqualifiedȱinȱanyȱwayȱtoȱ
beȱprovidingȱthoseȱservices.ȱ
ȱ
Typesȱofȱactivityȱconductedȱduringȱeducationalȱprogrammes,ȱincludingȱcontinuingȱmedicalȱ
education,ȱshouldȱifȱpossibleȱbeȱidentified.ȱOftenȱthereȱareȱdifferentȱcomponentsȱwhichȱmayȱ
requireȱenteringȱȈyesȈȱinȱdifferentȱboxesȱwithinȱtheȱsectionȱonȱproviderȱeducationȱandȱmaybeȱ
alsoȱinȱotherȱsections.ȱ
ȱ
Largeȱ groupȱ providerȱ educationȱ consistsȱ ofȱ >ȱ 15ȱ participantsȱ andȱ smallȱ groupȱ educationȱ
consistsȱofȱ<ȱ15ȱparticipants.ȱ
Administrative/managerial
Interventionsȱ inȱ thisȱ groupȱ includeȱ supervision,ȱ audit,ȱ ȱ drugȱ andȱ therapeuticȱ committeesȱ
andȱdrugȱuseȱevaluationȱ(DrugȱURȱ/ȱevaluation).ȱ
ȱ
Drugȱ useȱ evaluationȱ (drugȱ utilizationȱ review)ȱ isȱ aȱ systemȱ ofȱ onȬgoing,ȱ systematic,ȱ criteriaȬ
basedȱ evaluationȱ ofȱ drugȱ useȱ thatȱ willȱ helpȱ ensureȱ thatȱ appropriateȱ medicineȱ useȱ (atȱ theȱ
individualȱpatientȱlevel)ȱisȱprovided.ȱ
ȱ
DrugȱandȱTherapeuticȱcommitteesȱ(medicineȱandȱtherapeuticȱcommitteesȱorȱpharmacyȱandȱ
therapeuticȱ committees)ȱ isȱ aȱ committeeȱ designatedȱ toȱ ensureȱ theȱ safeȱ andȱ effectiveȱ useȱ ofȱ
medicinesȱinȱtheȱfacilityȱorȱareaȱunderȱitsȱjurisdiction.ȱ
ȱ
– 128 –
InȱIMCIȱstudiesȱmentionȱisȱmadeȱofȱtheȱ%ȱofȱhealthȱfacilitiesȱthatȱreceivedȱaȱsupervisoryȱvisitȱ
inȱtheȱpastȱ6ȱmonths.ȱThisȱshouldȱbeȱnotedȱinȱtheȱinterventionȱboxȱandȱifȱtheȱ%ȱofȱfacilitiesȱ
receivingȱsupervisionȱisȱmoreȱthanȱ50%,ȱtheȱȈsupervisionȱonlyȈȱboxȱcanȱbeȱmarkedȱȈyesȈ.ȱ
Interventionsȱinȱthisȱgroupȱinvolveȱtrainedȱmembersȱofȱtheȱcommunityȱprovidingȱtreatmentȱ
toȱ membersȱ ofȱ theirȱ ownȱ community.ȱ Theȱ subcategoriesȱ inȱ thisȱ groupȱ concernȱ theȱ typeȱ ofȱ
diseaseȱ thatȱ isȱ toȱ beȱ managedȱ inȱ theȱ communityȱ andȱ eachȱ boxȱ shouldȱ beȱ markedȱ ȈyesȈȱ orȱ
ȈnoȈȱrespectively.ȱȱ
ȱ
Communityȱ caseȱ managementȱ usuallyȱ involvesȱ severalȱ interventionsȱ whichȱ mayȱ beȱ
classifiedȱunderȱotherȱsectionsȱinȱadditionȱtoȱtheȱȈcommunityȱcaseȱmanagementȈȱsection.ȱTheȱ
relevantȱboxesȱwithinȱanyȱsectionȱonȱinterventionȱtypeȱshouldȱbeȱmarkedȱȈyesȈ.ȱForȱexample,ȱ
communityȱ caseȱ managementȱ mayȱ involveȱ aȱ packageȱ ofȱ interventions.ȱ Theseȱ mayȱ includeȱ
(1)ȱtrainingȱandȱsupervisionȱofȱmembersȱofȱtheȱcommunityȱtoȱprovideȱtreatmentȱforȱcertainȱ
diseases,ȱ (2)ȱ consumerȱ educationȱ onȱ selfȱ treatmentȱ andȱ (3)ȱ supplyingȱ drugsȱ toȱ aȱ trainedȱ
layperson.ȱ Inȱ suchȱ aȱ case,ȱ interventionsȱ underȱ theȱ sectionsȱ onȱ consumerȱ education,ȱȱ
administrative/managerialȱ andȱ essentialȱ drugsȱ programme/supplyȱ mayȱ beȱ markedȱ ȈyesȈ.ȱ
Communityȱ caseȱ managementȱ doesȱ requireȱ thatȱ patientsȱ areȱ treatedȱ inȱ theȱ communityȱ byȱ
trainedȱcommunityȱmembers.ȱ
Printed materials
Thisȱsectionȱonlyȱrefersȱtoȱprintedȱmaterialsȱaimedȱatȱproviders.ȱPrintedȱmaterialsȱaimedȱatȱ
consumersȱareȱlistedȱunderȱconsumerȱeducation.ȱ
ȱ
Clinicalȱguidelinesȱ(standardȱtreatmentȱguidelines,ȱprescribingȱpoliciesȱorȱprotocols)ȱconsistȱ
ofȱ systematicallyȱ developedȱ statementsȱ toȱ helpȱ prescribersȱ makeȱ decisionsȱ aboutȱ
appropriateȱtreatmentsȱforȱspecificȱclinicalȱconditions.ȱ
ȱ
Formularyȱ manualsȱ areȱ manualsȱ containingȱ theȱ listȱ ofȱ essentialȱ drugsȱ plusȱ informationȱ onȱ
theȱdrugsȱwithinȱtheȱlist.ȱ
ȱ
Newslettersȱandȱbulletinsȱareȱregularȱpublicationsȱwithȱinformationȱonȱdrugsȱandȱtreatment.ȱȱ
Consumer education
Thisȱsectionȱrefersȱtoȱconsumersȱonlyȱandȱnotȱotherȱmembersȱofȱtheȱcommunityȱwhoȱmayȱbeȱ
providingȱ healthȱ services.ȱ Forȱ example,ȱ trainedȱ laypersons,ȱ traditionalȱ healers,ȱ informalȱ
drugȱ pedlarsȱ areȱ allȱ consideredȱ providers,ȱ notȱ consumers.ȱ Educationalȱ interventionsȱ
conductedȱ throughȱ theȱ mediaȱ (e.g.ȱ TV,ȱ radio),ȱ aimedȱ atȱ communitiesȱ inȱ general,ȱ includingȱ
informalȱ providersȱ inȱ theȱ communityȱ (e.g.ȱ drugȱ pedlarsȱ orȱ traditionalȱ healers),ȱ areȱ
consideredȱ asȱ consumerȱ education.ȱ Onlyȱ ifȱ theȱ messagesȱ specificallyȱ targetȱ healthȬcareȱ
providersȱinȱtheȱmediaȱshouldȱsuchȱinterventionȱnotȱbeȱconsideredȱasȱconsumerȱeducationȱ
only.ȱ
– 129 –
Group process strategies
Thisȱsectionȱrefersȱtoȱactivitiesȱwhereȱprovidersȱthemselvesȱidentifyȱaȱdrugȱuseȱproblemȱandȱ
develop,ȱ implementȱ andȱ evaluateȱ aȱ strategyȱ toȱ correctȱ theȱ problem.ȱ Suchȱ processesȱ mayȱ
includeȱ peerȱ review,ȱ drugȱ andȱ therapeuticȱ committees,ȱ andȱ management,ȱ trainingȱ andȱ
planningȱactivities.ȱ
ȱ
Regulatory interventions
Thisȱsectionȱrefersȱtoȱgovernmentȱregulations,ȱsuchȱas:ȱ
ȱ
x licensingȱofȱprescribers,ȱ
x licensingȱofȱdrugȱoutlets,ȱ
x drugȱregistrationȱandȱbanningȱdrugs,ȱȱ
x limitingȱ prescriptionȱ ofȱ medicinesȱ byȱ levelȱ ofȱ prescriber;ȱ thisȱ includesȱ enforcingȱ aȱ
prescriptionȬonlyȱ(PxȬonly)ȱpolicyȱforȱcertainȱdrugs,ȱ
x monitoringȱofȱmedicinesȱpromotion.ȱ
Economic strategies
Thisȱ sectionȱ refersȱ toȱ anyȱ economicȱ incentiveȱ thatȱ mayȱ impactȱ onȱ drugȱ use.ȱ Theȱ followingȱ
definitionsȱapply:ȱ
ȱ
x Aȱprescriptionȱfeeȱisȱaȱfeeȱcoveringȱallȱtheȱdrugsȱinȱwhateverȱquantitiesȱwrittenȱonȱtheȱ
prescriptionȱformȱandȱpaidȱbyȱtheȱpatient.ȱ
ȱ
x Aȱconsultationȱfeeȱisȱaȱfeeȱcoveringȱaȱconsultationȱbutȱnotȱincludingȱdrugsȱandȱpaidȱbyȱ
theȱpatient.ȱ
ȱ
x Aȱfeeȱperȱdrugȱitemȱisȱaȱfeeȱforȱoneȱdrugȱpaidȱbyȱtheȱpatient;ȱtheȱexactȱtypeȱofȱfeeȱshouldȱ
beȱspecifiedȱinȱtheȱinterventionȱdescriptionȱandȱincludes:ȱ
o aȱfeeȱcoveringȱaȱcompleteȱcourseȱ(ofȱhoweverȱmanyȱtablets),ȱwhichȱmayȱbeȱfixedȱ
forȱallȱdrugsȱorȱvaryȱdependingȱonȱtheȱdrugȱ
o aȱfeeȱcoveringȱoneȱtabletȱwhichȱmayȱbeȱaȱ%ȱofȱtheȱcostȱpriceȱorȱfixedȱfeeȱperȱtabletȱȱȱ
ȱ
x Aȱ capitationȱ feeȱ isȱ aȱ feeȱ paidȱ toȱ theȱ providerȱ byȱ theȱ governmentȱ orȱ anȱ insuranceȱ
companyȱ orȱ aȱ healthȱ maintenanceȱ organizationȱ forȱ providingȱ aȱ specifiedȱ packageȱ ofȱ
healthȱcareȱtoȱaȱpatientȱoverȱaȱspecifiedȱtimeȱperiod.ȱ
ȱ
x Aȱ feeȱ perȱ serviceȱ isȱ aȱ feeȱ paidȱ forȱ aȱ service;ȱ itȱ mayȱ beȱ paidȱ byȱ theȱ patientȱ orȱ byȱ aȱ
purchaserȱofȱservicesȱonȱbehalfȱofȱtheȱpatientȱ(governmentȱorȱanȱinsuranceȱcompanyȱorȱaȱ
healthȱmaintenanceȱorganization).ȱ
ȱ
x Revolvingȱdrugȱfundȱisȱaȱdrugȱsalesȱprogrammeȱinȱwhichȱrevenuesȱfromȱdrugȱfeesȱareȱ
usedȱtoȱreplenishȱdrugȱsupplies.ȱ
– 130 –
x Healthȱ insuranceȱ isȱ aȱ financingȱ schemeȱ characterizedȱ byȱ riskȱ sharingȱ inȱ whichȱ regularȱ
paymentsȱ ofȱ premiumsȱ areȱ madeȱ byȱ orȱ onȱ behalfȱ ofȱ membersȱ (theȱ insured)ȱ andȱ whereȱ
theȱ insurerȱ paysȱ theȱ costȱ orȱ aȱ setȱ proportionȱ ofȱ theȱ costȱ forȱ coveredȱ healthȱ services;ȱ
Insuranceȱmayȱbe:ȱ
o privateȱ healthȱ insuranceȱ whereȱ voluntaryȱ privateȱ indemnityȱ insuranceȱ isȱ providedȱ
byȱprivateȱinsuranceȱcompaniesȱthroughȱemployees,ȱmutualȱsocietiesȱorȱcooperativesȱȱ
o socialȱ healthȱ insuranceȱ whereȱ thereȱ isȱ compulsoryȱ insuranceȱ providedȱ toȱ civilȱ
servants,ȱpeopleȱinȱtheȱformalȱemploymentȱsector,ȱandȱcertainȱotherȱgroupsȱthroughȱ
programmesȱsuchȱasȱsocialȱsecurityȱfunds,ȱnationalȱhealthȱinsuranceȱfunds,ȱandȱotherȱ
systems;ȱpremiumsȱareȱoftenȱdeductedȱdirectlyȱfromȱsalariesȱorȱwagesȱ
Essential Drugs Programme/Supply
Interventionsȱ inȱ thisȱ groupȱ includeȱ anyȱ interventionsȱ thatȱ impactsȱ onȱ drugȱ supply,ȱ
distributionȱ orȱ availability,ȱ butȱ excludingȱ economicȱ incentivesȱ suchȱ asȱ pricingȱ orȱ feeȱ
systems.ȱAlthoughȱdrugȱsupplyȱandȱdistributionȱsystemsȱwouldȱbeȱincludedȱinȱthisȱsection,ȱ
theȱ majorityȱ ofȱ interventionsȱ hereȱ concernȱ methodsȱ ofȱ restrictingȱ theȱ typeȱ orȱ quantityȱ ofȱ
drugsȱdispensedȱtoȱpatients.ȱSuchȱtypesȱofȱinterventionsȱinclude:ȱ
ȱ
x essentialȱdrugsȱlistȱisȱaȱlistȱofȱessentialȱdrugsȱthatȱsatisfyȱtheȱpriorityȱhealthȱcareȱneedsȱofȱ
theȱpopulationȱservedȱbyȱtheȱfacilitiesȱinȱquestionȱ
ȱ
x structuredȱstockȱorderȱforms,ȱwhereȱdrugsȱmayȱbeȱorderedȱbyȱfillingȱinȱaȱstructuredȱ
orderȱformȱ
ȱ
x structuredȱprescribingȱforms,ȱwhereȱcertainȱdrugsȱcanȱonlyȱbeȱprescribedȱifȱaȱparticularȱ
formȱwithȱmoreȱpatientȱdetailȱisȱfilledȱinȱ
ȱ
x preȬpackagingȱofȱdispensedȱmedicines,ȱsuchȱthatȱmedicinesȱcanȱonlyȱbeȱdispensedȱinȱ
amountsȱconsistentȱwithȱaȱfullȱcourseȱ
ȱ
x genericȱsubstitution,ȱwhereȱaȱgenericallyȱequivalentȱproduct,ȱ(withȱtheȱsameȱactiveȱ
ingredientsȱinȱtheȱsameȱdosageȱformsȱandȱidenticalȱinȱstrength,ȱconcentrationȱandȱrouteȱ
ofȱadministration)ȱisȱsubstitutedȱbyȱtheȱdispenserȱforȱaȱbrandedȱoneȱprescribed.ȱ
ȱ
x automaticȱstopȱorder,ȱwhereȱdrugsȱareȱautomaticallyȱstoppedȱafterȱaȱfixedȱperiodȱofȱtimeȱ
(e.g.ȱ3ȱdays)ȱandȱmustȱbeȱreȬprescribedȱifȱtheȱpatientȱisȱtoȱcontinueȱtakingȱthem.ȱ
ȱ
x priorȱauthorization,ȱwhereȱcertainȱdrugsȱcanȱonlyȱbeȱprescribedȱwithȱtheȱpriorȱ
authorizationȱofȱseniorȱprescribers.ȱ
ȱ
x kitȱsystem,ȱwhereȱaȱfixedȱamountȱofȱdrugsȱisȱsentȱtoȱaȱhealthȱunitȱatȱregularȱintervalsȱ
(e.g.ȱ3ȱmonthlyȱorȱannually),ȱtheȱamountȱbeingȱdeterminedȱinȱadvanceȱbyȱtheȱcentralȱ
authorityȱ(andȱnotȱbyȱlocalȱestimation).ȱȱ
ȱ
AȱfullȱessentialȱdrugȱprogrammeȱthatȱincludesȱdrugȱsupplyȱshouldȱhaveȱtheȱȈotherȈȱcategoryȱ
markedȱyesȱinȱthisȱsection.ȱ
– 131 –
SECTION 3
Thisȱsectionȱcontainsȱfieldsȱwhereȱinformationȱaboutȱtheȱmethodologyȱofȱtheȱstudyȱorȱsurveyȱ
mayȱbeȱentered.ȱTheȱfigureȱbelowȱshowsȱtheȱappearanceȱofȱtheȱdataȬentryȱinterface.ȱ
ȱ
Study design
Selectȱtheȱstudyȱdesignȱfromȱtheȱmenu.ȱ
ȱ
Theȱstudyȱdesignȱshouldȱbeȱdefinedȱaccordingȱtoȱtheȱresultsȱgivenȱandȱenteredȱinȱsectionȱ4ȱ
andȱ notȱ necessarilyȱ accordingȱ toȱ whatȱ isȱ statedȱ byȱ theȱ authors.ȱ Forȱ example,ȱ ifȱ aȱ studyȱ isȱ
describedȱasȱaȱtimeȱseriesȱwithȱcontrolȱbutȱresultsȱforȱlessȱthanȱ4ȱtimeȱpointsȱareȱgiven,ȱthenȱ
theȱdefinitionȱforȱtheȱdatabaseȱisȱpreȬpostȱwithȱcontrol.ȱIfȱaȱstudyȱisȱdescribedȱasȱaȱpreȬpostȱ
withȱcontrolȱbutȱnoȱpreȬinterventionȱmeasurementsȱareȱreportedȱthenȱtheȱdefinitionȱforȱtheȱ
databaseȱisȱpostȬonlyȱwithȱcontrol.ȱ
ȱ
Postȱinterventionȱsurveyȱwithoutȱcontrolȱisȱdefinedȱasȱaȱcrossȱsectionalȱsurvey.ȱ
ȱ
Timeȱseriesȱstudyȱdesignȱisȱdefinedȱasȱhavingȱmoreȱthanȱ4ȱdataȱpoints.ȱ
– 132 –
Type of data collected
Chooseȱ retrospectiveȱ orȱ prospective.ȱ Interviewsȱ orȱ observationȱ canȱ onlyȱ beȱ doneȱ
prospectively.ȱȱ
Place where data is collected
Thisȱ refersȱ toȱ whereȱ theȱ dataȱ isȱ collectedȱ ȱ andȱ notȱ toȱ whoseȱ drugȱ useȱ isȱ measured.ȱ Forȱ
example,ȱ ifȱ dataȱ onȱ prescriptionsȱ fromȱ theȱ primaryȱ healthȱ facilityȱ isȱ collectedȱ duringȱ aȱ
householdȱ survey,ȱ thenȱ theȱ placeȱ ofȱ dataȱ collectionȱ isȱ theȱ householdȱ andȱ notȱ theȱ primaryȱ
healthȬcareȱfacility.ȱSimilarlyȱifȱdataȱonȱtreatmentȱtakenȱatȱhomeȱisȱcollectedȱduringȱexitingȱ
patientȱ interviewȱ atȱ theȱ primaryȱ healthȬcareȱ facilityȱ thenȱ theȱ placeȱ ofȱ dataȱ collectionȱ isȱ theȱ
primaryȱhealthȬcareȱfacilityȱandȱnotȱtheȱhousehold.ȱ
Method of data collection
Thisȱ refersȱ toȱ whetherȱ dataȱ isȱ collectedȱ byȱ recordȱ review,ȱ observationȱ and/orȱ interview.ȱȱ
Simulatedȱ patientȱ surveysȱ areȱ countedȱ asȱ observation.ȱ Patientȱ knowledgeȱ canȱ onlyȱ beȱ
collectedȱbyȱinterview.ȱ
Number of rounds of data collection
Thisȱrefersȱtoȱtheȱnumberȱofȱdifferentȱtimeȱperiodsȱthatȱdataȱhasȱbeenȱcollected.ȱTheȱnumberȱ
hereȱshouldȱbeȱconsistentȱwithȱtheȱinformationȱinȱsectionȱ3ȱonȱȈstudyȱdesignȈȱandȱinȱsectionȱ
4ȱonȱȈperiodȈȱandȱȈyearȱofȱmeasureȈ.ȱ
Total number of cases/prescriptions (all rounds)
Totalȱ numberȱ ofȱ casesȱ orȱ prescriptionsȱ inȱ theȱ surveyȱ isȱ calculatedȱ asȱ aȱ totalȱ basedȱ onȱ allȱ
cases,ȱ prescriptionsȱ orȱ patientsȱ inȱ allȱ groupsȱ inȱ theȱ studyȱ forȱ allȱ timeȱ periodsȱ ofȱ
measurement.ȱ Thereforeȱ theȱ numberȱ ofȱ cases,ȱ prescriptionsȱ orȱ patientsȱ forȱ allȱ groupsȱ
(controlȱ andȱ interventionȱ groups)ȱ atȱ anyȱ oneȱ timeȱ periodȱ needsȱ toȱ beȱ multipliedȱ byȱ theȱ
numberȱ ofȱ timesȱ aȱ measurementȱ isȱ done.ȱ Ifȱ theȱ numbersȱ varyȱ forȱ differentȱ outcomes,ȱ orȱ
differentȱ periods,ȱ thenȱ theȱ lowestȱ numberȱ shouldȱ beȱ chosen.ȱ Theȱ sameȱ appliesȱ forȱ
catchment’sȱpopulationȱfigureȱforȱmortalityȱrates.ȱ
Patients or prescriptions were randomly selected
Randomȱselectionȱofȱfacilitiesȱdoesȱnotȱmeanȱthatȱthereȱisȱrandomȱselectionȱofȱpatientsȱandȱ
theȱtwoȱshouldȱbeȱclassifiedȱseparately.ȱȱ
ȱ
Patientȱ observationsȱ orȱ interviewsȱ areȱ usuallyȱ convenience,ȱ notȱ randomȱ samplesȱ unlessȱ
specificallyȱotherwiseȱspecified.ȱIfȱtheȱperiodȱofȱtimeȱwasȱspecificallyȱrandomlyȱchosenȱandȱ
eitherȱ allȱ orȱ aȱ randomȱ sampleȱ ofȱ patientsȱ duringȱ thatȱ timeȱ wereȱ chosenȱ thenȱ weȱ canȱ sayȱ
patientȱselectionȱwasȱrandom.ȱȱ
ȱ
ManyȱIMCIȱstudiesȱstateȱthatȱpatientȱselectionȱforȱobservationȱofȱtreatmentȱwasȱrandomȱbutȱ
areȱunableȱtoȱgiveȱdetailsȱofȱrandomȱselectionȱofȱpatientsȱatȱtheȱhealthȱfacilityȱȬȱinȱtheseȱcaseȱ
putȱȈdonȇtȱknowȈȱforȱrandomȱselectionȱofȱpatients.ȱȱ
– 133 –
Inȱaȱhouseholdȱsurvey,ȱtheȱchildȱsufferingȱfromȱaȱdiseaseȱofȱinterestȱisȱnotȱrandomlyȱselectedȱ
(althoughȱ theȱ householdȱ s/heȱ livesȱ inȱ mayȱ haveȱ beenȱ randomlyȱ selectedȱ inȱ whichȱ caseȱ theȱ
otherȱfieldȱȈSamplingȱpointȱ(facilities/villages)ȱwereȱrandomlyȱselectedȈȱwillȱbeȱȈyesȈ.ȱ
Total number of health facilities
Numberȱ ofȱ healthȱ facilitiesȱ inȱ theȱ surveyȱ isȱ basedȱ onȱ theȱ lowestȱ numberȱ duringȱ anyȱ oneȱ
measurementȱorȱforȱanyȱtimeȱperiodȱorȱforȱanyȱoutcomeȱvariableȱ(enteredȱintoȱtheȱdatabase).ȱ
Itȱ isȱ notȱ calculatedȱ byȱ multiplyingȱ upȱ differentȱ timeȱ periodsȱ asȱ forȱ totalȱ numberȱ ofȱ
patients/prescriptionsȱetc.ȱTheȱnumberȱofȱfacilitiesȱdoesȱincludeȱaddingȱupȱallȱfacilitiesȱfromȱ
bothȱcontrolȱandȱinterventionȱgroupsȱatȱoneȱpointȱinȱtime.ȱȱ
Number of cases/prescriptions per facility
Numberȱ ofȱ cases/prescriptionsȱ perȱ facilityȱ refersȱ toȱ theȱ lowestȱ numberȱ cases/prescriptionsȱ
perȱfacilityȱatȱanyȱoneȱtimeȱperiodȱofȱmeasurement.ȱIfȱonlyȱtheȱaverageȱnumberȱperȱfacilityȱisȱ
reportedȱ(notȱnumbersȱforȱindividualȱfacilities)ȱthenȱthisȱisȱreported.ȱTheȱnumberȱofȱpatients/ȱ
prescriptionsȱ perȱ healthȱ facilityȱ cannotȱ beȱ calculatedȱ byȱ dividingȱ theȱ totalȱ numberȱ ofȱ
prescriptionsȱbyȱtheȱnumberȱofȱfacilities.ȱ
Number of villages and households
Numberȱofȱvillagesȱȱorȱhouseholdsȱinȱaȱstudy/surveyȱisȱbasedȱonȱtheȱlowestȱnumberȱduringȱ
anyȱoneȱmeasurementȱorȱforȱanyȱtimeȱperiodȱorȱforȱanyȱoutcomeȱvariableȱ(enteredȱintoȱtheȱ
database).ȱItȱisȱnotȱcalculatedȱbyȱmultiplyingȱupȱdifferentȱtimeȱperiodsȱasȱforȱtotalȱnumberȱofȱ
patients/prescriptionsȱetc.ȱȱ
ȱ
Theȱnumberȱofȱvillagesȱorȱhouseholdsȱdoesȱincludeȱaddingȱupȱallȱfacilitiesȱfromȱbothȱcontrolȱ
andȱinterventionȱgroupsȱatȱoneȱpointȱinȱtime.ȱȱ
Number of households per village
Numberȱofȱhouseholdsȱperȱvillageȱrefersȱtoȱtheȱlowestȱnumberȱhouseholdsȱperȱvillageȱatȱanyȱ
oneȱtimeȱperiodȱofȱmeasurement.ȱ
Sampling point (facilities/villages) were randomly selected
Chooseȱ whetherȱ selectionȱ wasȱ randomȱ orȱ notȱ fromȱ theȱ menu.ȱ Ifȱ nothingȱ isȱ statedȱ aboutȱ
selectionȱofȱfacilitiesȱthenȱȈdonȇtȱknowȈȱshouldȱbeȱchosen.ȱIfȱallȱfacilitiesȱofȱtheȱpopulationȱofȱ
facilitiesȱunderȱexaminationȱareȱselected,ȱthenȱtheȱselectionȱisȱregardedȱasȱrandomȱsinceȱtheȱ
outcomesȱwillȱbeȱrepresentativeȱofȱtheȱpopulationȱstudiedȱȬȱbutȱaȱnoteȱshouldȱbeȱmadeȱinȱtheȱ
commentsȱboxȱinȱsectionȱ3.ȱ
Comments about study design
Thisȱ boxȱ allowsȱ oneȱ toȱ commentȱ onȱ theȱ methodologyȱ andȱ noteȱ downȱ inconsistenciesȱ ȱ andȱ
difficultiesȱinȱtheȱmethodologyȱe.g.ȱdifferentȱsampleȱsizesȱforȱdifferentȱindicators.ȱ
– 134 –
If mortality study: age group
Theȱageȱgroupȱshouldȱbeȱspecifiedȱasȱlessȱthanȱaȱspecifiedȱageȱlimit.ȱThusȱchildrenȱlessȱthanȱ
oneȱyearȱofȱageȱfallȱintoȱtheȱcategoryȱȈ<ȱ1ȱyearȈȱandȱnotȱȈ<ȱ5ȱyearsȈ.ȱ
ȱ
Infantȱmortalityȱrefersȱtoȱmortalityȱinȱchildrenȱ<ȱ12ȱmonthsȱ
ȱ
Neonatalȱmortalityȱrefersȱtoȱmortalityȱinȱchildrenȱ<ȱ1ȱmonthsȱ
If mortality study: total population
Theȱtotalȱpopulationȱrefersȱtoȱtheȱpopulationȱatȱriskȱofȱtheȱdiseasesȱofȱinterest,ȱnotȱtheȱcasesȱ
ofȱdiseasesȱthemselves.ȱTheȱtotalȱpopulationȱisȱusedȱwhenȱmortalityȱratesȱareȱreported.ȱTotalȱ
numberȱcases/prescriptionsȱ(allȱrounds)ȱreferȱtoȱtheȱtotalȱnumberȱofȱcasesȱorȱprescriptionsȱonȱ
whichȱtheȱdrugȱuseȱindicatorsȱareȱcalculated.ȱ
ȱ
SECTION 4
Thisȱ sectionȱ containsȱ fieldsȱ whereȱ quantitativeȱ informationȱ onȱ drugȱ useȱ isȱ entered.ȱ Theȱ
figureȱbelowȱshowsȱtheȱappearanceȱofȱtheȱdataȬentryȱinterface.ȱ
ȱ
– 135 –
Forȱeveryȱdrugȱuseȱindicatorȱtoȱbeȱenteredȱintoȱtheȱdatabase,ȱthereȱareȱ5ȱfieldsȱ(boxes)ȱintoȱ
whichȱdataȱshouldȱbeȱentered:ȱ
ȱ
x Groupȱ
x Periodȱ
x Yearȱofȱmeasureȱ
x Outcomeȱtypeȱ
x Rateȱ
Group
Theȱ groupȱ refersȱ toȱ whichȱ groupȱ ofȱ peopleȇsȱ drugȱ useȱ isȱ measured.ȱ Inȱ theȱ caseȱ ofȱ baselineȱ
studies/surveysȱ withȱ noȱ intervention,ȱ theȱ groupȱ wouldȱ beȱ ȈAllȈ.ȱ Forȱ interventionȱ
studies/surveys,ȱ thereȱ willȱ beȱ oneȱ orȱ moreȱ interventionȱ groups,ȱ Ȉintervenȱ 1Ȉ,ȱ Ȉintervenȱ 2Ȉ,ȱ
Ȉintervenȱ3Ȉ,ȱandȱthereȱmayȱbeȱaȱȈcontrolȈȱgroupȱwhichȱdidȱnotȱreceiveȱtheȱintervention.ȱȱ
ȱ
WhateverȱisȱenteredȱinȱȈgroupȈȱshouldȱbeȱconsistentȱwithȱoverallȱstudyȱdesignȱinȱsectionȱ3.ȱ
Forȱ example,ȱ ifȱ sectionȱ 3ȱ mentionsȱ aȱ preȬpostȱ studyȱ withȱ control,ȱ thenȱ thereȱ shouldȱ beȱ
outcomeȱ variablesȱ forȱ controlȱ andȱ interventionȱ groupsȱ inȱ sectionȱ 4.ȱ Ifȱ sectionȱ 3ȱ mentionsȱ aȱ
preȬpostȱstudyȱwithȱnoȱcontrol,ȱthereȱwillȱonlyȱbeȱoutcomeȱvariablesȱforȱinterventionȱȱgroupsȱ
andȱnotȱforȱaȱcontrolȱgroup.ȱ
ȱ
Sometimes,ȱ notȱ allȱ drugȱ useȱ outcomesȱ (indicators)ȱ areȱ reportedȱ forȱ eachȱ groupȱ andȱ thenȱ
someȱindicatorsȱmayȱrequireȱgroupȱcategoriesȱthatȱappearȱinconsistentȱwithȱtheȱstudyȱdesignȱ
selectedȱinȱsectionȱ3.ȱForȱexample,ȱaȱpostȬonlyȱwithȱcontrolȱstudyȱmayȱreportȱoutcomesȱforȱ
bothȱinterventionȱandȱcontrolȱgroupsȱforȱseveralȱindicatorsȱbutȱonlyȱoneȱcombinedȱresultȱforȱ
bothȱ interventionȱ andȱ controlȱ groupsȱ forȱ oneȱ indicator.ȱ Inȱ suchȱ aȱ study,ȱ theȱ drugȱ useȱ
indicatorȱreportedȱforȱbothȱinterventionȱandȱcontrolȱgroupsȱcombinedȱshouldȱbeȱenteredȱinȱ
theȱȈGroupȈȱfieldȱ(box)ȱasȱȈAllȈ.ȱ
Period
Theȱperiodȱrefersȱtoȱperiodȱofȱdataȱcollectionȱinȱrelationȱtoȱtheȱstudyȱdesign.ȱForȱexample,ȱinȱ
aȱbaselineȱsurveyȱwithoutȱanȱintervention,ȱtheȱperiodȱwillȱbeȱȈbaselineȈ.ȱHowever,ȱifȱthereȱisȱ
anȱintervention,ȱthenȱtheȱperiodȱwillȱbe:ȱ
ȱ
Baseline:ȱ forȱdataȱcollectedȱbeforeȱtheȱinterventionȱ
During:ȱ forȱdataȱcollectedȱduringȱtheȱinterventionȱ
Postȱ1:ȱ firstȱcollectionȱofȱdataȱafterȱtheȱinterventionȱ
Postȱ2:ȱ secondȱcollectionȱofȱdataȱafterȱtheȱinterventionȱ
Postȱ3:ȱ thirdȱcollectionȱofȱdataȱafterȱtheȱinterventionȱ
ȱ
WhateverȱisȱenteredȱinȱȈperiodȈȱshouldȱbeȱconsistentȱwithȱoverallȱstudyȱdesignȱinȱsectionȱ3.ȱ
Forȱ example,ȱ aȱ crossȬsectionalȱ surveyȱ withȱ noȱ interventionȱ wouldȱ onlyȱ haveȱ ȈbaselineȈȱ
enteredȱasȱtheȱperiodȱforȱeachȱoutcomeȱvariable.ȱAȱpostȬonlyȱwithȱcontrolȱstudyȱwithȱonlyȱ
oneȱ periodȱ ofȱ dataȱ collectionȱ wouldȱ onlyȱ haveȱ Ȉpostȱ 1Ȉȱ enteredȱ asȱ theȱ periodȱ forȱ eachȱ
outcomeȱ variable.ȱ Aȱ timeȱ seriesȱ studyȱ withȱ noȱ control,ȱ withȱ dataȱ collectedȱ before,ȱ duringȱ
– 136 –
andȱ 3ȱ timesȱ afterȱ anȱ intervention,ȱ wouldȱ haveȱ forȱ eachȱ outcomeȱ variableȱ theȱ periodsȱ
ȈbaselineȈ,ȱ ȈduringȈ,ȱ Ȉpostȱ 1Ȉ,ȱ Ȉpostȱ 2Ȉ,ȱ Ȉpostȱ 3Ȉ.ȱ Ifȱ thereȱ wereȱ moreȱ thanȱ 5ȱ periodsȱ ofȱ dataȱ
collection,ȱthenȱtheȱdataȬentryȱpersonȱmustȱchooseȱtheȱmostȱappropriateȱperiodsȱequivalentȱ
toȱmenuȱselectionȱavailableȱ(i.e.ȱȈbaselineȈ,ȱȈduringȈ,ȱȈpostȱ1Ȉ,ȱȈpostȱ2Ȉ,ȱȈpostȱ3Ȉ).ȱ
ȱ
Theȱperiodȱ“during”ȱshouldȱonlyȱbeȱusedȱforȱinterventionȱstudies:ȱ
ȱ
x whenȱdataȱisȱaggregatedȱoverȱdifferentȱareas,ȱonlyȱsomeȱofȱwhichȱhaveȱimplementedȱtheȱ
intervention,ȱorȱ
x whenȱdataȱisȱaggregatedȱoverȱtheȱpreȬpostȱperiod,ȱorȱ
x whenȱtheȱinterventionȱstrategiesȱorȱactivitiesȱareȱinȱtheȱprocessȱofȱbeingȱintroduced.ȱȱ
ȱ
ȈDuringȈȱshouldȱnotȱbeȱusedȱforȱinterventionsȱthatȱconsistȱofȱestablishedȱonȬgoingȱactivitiesȱ
andȱstrategiesȱe.g.ȱinsurance,ȱsupplyȱsystems,ȱuserȱfees,ȱetc.ȱ
Year of measure
Theȱyearȱofȱmeasureȱisȱtheȱyearȱspecifiedȱinȱtheȱreport/articleȱthatȱdataȱcollectionȱoccurred.ȱIfȱ
theȱyearȱofȱmeasureȱisȱnotȱspecifiedȱorȱcoversȱaȱperiodȱofȱseveralȱyears,ȱthenȱtheȱmidȬperiodȱ
betweenȱwhenȱmeasurementȱstartedȱandȱendedȱshouldȱbeȱused.ȱ
ȱ
IfȱtheȱȈperiodȈȱisȱmarkedȱasȱȈbaselineȈ,ȱthenȱtheȱyearȱofȱmeasureȱshouldȱbeȱtheȱsameȱasȱtheȱ
Ȉyearȱ ofȱ baselineȱ surveyȈȱ inȱ sectionȱ 1.ȱ Forȱ allȱ interventionȱ studies/surveys,ȱ theȱ yearȱ ofȱ
measureȱ forȱ theȱ finalȱ periodȱ (postȱ 1,ȱ 2ȱ orȱ 3)ȱ shouldȱ beȱ theȱ sameȱ asȱ theȱ Ȉyearȱ ofȱ postȱ
interventionȱsurveyȈȱinȱsectionȱ1.ȱ
Notes on study outcome measures
Thisȱboxȱisȱtoȱmakeȱcommentsȱconcerningȱtheȱcalculationȱofȱanyȱofȱtheȱindicators,ȱwhetherȱitȱ
beȱdoneȱbyȱtheȱauthorsȱthemselvesȱorȱtheȱdataȬentryȱperson.ȱIfȱdifferentȱsampleȱsizesȱhaveȱ
beenȱusedȱinȱtheȱcalculationȱofȱindicatorsȱthisȱshouldȱbeȱmentioned.ȱ
Outcome type
Theȱoutcomeȱtypeȱrefersȱtoȱtheȱdrugȱuseȱindicatorȱreported.ȱItȱisȱimportantȱtoȱcheckȱthatȱtheȱ
definitionsȱ usedȱ byȱ theȱ authorsȱ areȱ theȱ sameȱ asȱ theȱ onesȱ usedȱ inȱ theȱ database.ȱ Particularȱ
attentionȱshouldȱbeȱpaidȱtoȱtheȱnumeratorsȱandȱdenominatorsȱusedȱinȱcalculatingȱindicators.ȱ
ABs: % antibiotics prescribed in under dosage
No. antibiotics prescribed in under-doseȱ

x 100ȱ
Total no. antibiotics prescribedȱ
ȱ
%ȱAntibioticsȱprescribedȱinȱunderȬdosageȱisȱreportedȱusuallyȱaccordingȱtoȱdurationȱonlyȱbutȱ
mayȱincludeȱstrengthȱandȱfrequencyȱalso.ȱTheȱdefinitionȱofȱunderȬdosageȱshouldȱbeȱmadeȱinȱ
sectionȱ4.ȱIfȱthereȱisȱaȱchoice,ȱtheȱstudy/surveyȱshouldȱbeȱdiscussedȱbetweenȱtheȱdataȬentryȱ
personȱandȱtheȱpersonȱinȱchargeȱofȱtheȱdatabase.ȱ
– 137 –
ABs: % antibiotics prescribed inappropriately
No. patients prescribed antibiotics

inappropriately ȱ
x 100ȱ
Total no. patients (whether or not prescribed
antibiotics)
ȱ
Inappropriateȱuseȱshouldȱbeȱdefinedȱbyȱtheȱauthors.ȱIfȱtheȱauthorsȱstateȱthatȱviralȱinfectionsȱ
areȱanȱappropriateȱindicationȱforȱantibiotics,ȱaȱnoteȱshouldȱbeȱmadeȱinȱsectionȱ4.ȱSuchȱcasesȱ
shouldȱbeȱdiscussedȱbetweenȱtheȱdataȬentryȱpersonȱandȱtheȱpersonȱinȱchargeȱofȱtheȱdatabase.ȱ
ȱ
Forȱ WHO/IMCIȱ studies,ȱ theȱ indicatorȱ Ȉ%ȱ antibioticsȱ prescribedȱ inappropriatelyȈȱ isȱ
calculatedȱbyȱsubtractingȱtheȱpercentageȱofȱȈChildȱnotȱneedingȱantibioticȱleavesȱtheȱfacilityȱ
withoutȱantibioticȈȱfromȱ100%.ȱȱ
ABs: % pneum. cases w. appr. antibiotics
No. cases of pneumonia prescribed

appropriate antibiotics x 100ȱ
Total no. cases of pneumonia
ȱ
%ȱ pneumoniaȱ casesȱ treatedȱ withȱ appropriateȱ antibioticsȱ includesȱ anyȱ typeȱ ofȱ lowerȱ
respiratoryȱ tractȱ infectionȱ thatȱ theȱ authorsȱ sayȱ doȱ needȱ antibiotics.ȱ Appropriateȱ antibioticsȱ
shouldȱ beȱ definedȱ byȱ theȱ authors.ȱ Ifȱ thereȱ isȱ noȱ mentionȱ ofȱ theȱ appropriatenessȱ ofȱ theȱ
antibioticȱtreatment,ȱitȱshouldȱbeȱassumedȱtoȱbeȱappropriateȱbutȱaȱcommentȱshouldȱbeȱmadeȱ
inȱtheȱnotesȱboxȱinȱsectionȱ4.ȱ
ȱ
Classificationȱ ofȱ casesȱ ofȱ bacterialȱ upperȱ respiratoryȱ tractȱ infectionȱ (e.g.ȱ otitisȱ media,ȱ
tonsillitis)ȱthatȱtheȱauthorsȱsayȱshouldȱbeȱtreatedȱwithȱantibioticsȱshouldȱalwaysȱbeȱdiscussedȱ
betweenȱtheȱdataȬentryȱpersonȱandȱtheȱpersonȱinȱchargeȱofȱtheȱdatabase.ȱ
ȱ
Inȱ WHO,ȱ Divisionȱ ofȱ Childȱ Healthȱ andȱ Developmentȱ (WHO/CHD)ȱ controlȱ ofȱ ARIȱ studies,ȱ
theȱ indicatorȱ Ȉpneumoniaȱ casesȱ managedȱ correctlyȈȱ isȱ notȱ theȱ sameȱ becauseȱ allȱ aspectsȱ ofȱ
caseȱ managementȱ includingȱ referralȱ andȱ adviceȱ areȱ considered,ȱ notȱ justȱ theȱ appropriateȱ
antibiotic.ȱHoweverȱaȱnoteȱofȱtheȱindicatorȱshouldȱbeȱmadeȱinȱtheȱnotesȱboxȱinȱsectionȱ4.ȱ
ȱ
Inȱ WHO/IMCIȱ studiesȱ theȱ indicatorȱ ȈChildȱ withȱ pneumoniaȱ isȱ correctlyȱ treatedȈȱ isȱ
interpretedȱ asȱ Ȉ%ȱ pneum.ȱ casesȱ w.ȱ appr.ȱ AntibioticsȈȱ becauseȱ thisȱ indicatorȱ doesȱ notȱ
generallyȱincludeȱotherȱaspectsȱofȱcaseȱmanagementȱ(suchȱasȱdosing,ȱreferralȱandȱadvice).ȱ
ABs: % cases of URTI treated with antibiotics
No. cases upper respiratory tract infection

prescribed antibiotics
x 100ȱ
Total no. cases of upper respiratory tract
infection
– 138 –
%ȱofȱupperȱrespiratoryȱtractȱinfectionsȱ(URTI)ȱtreatedȱwithȱantibioticsȱincludesȱanyȱtypeȱofȱ
upperȱ respiratoryȱ tractȱ infectionȱ thatȱ theȱ authorsȱ sayȱ doȱ notȱ needȱ antibiotics.ȱ Inȱ someȱ
studies/surveys,ȱ theȱ authorsȱ mayȱ stateȱ thatȱ viralȱ URTIȱ (e.g.ȱ commonȱ cold,ȱ soreȱ throat)ȱ
shouldȱ beȱ treatedȱ withȱ antibiotics.ȱ Forȱ suchȱ studiesȱ theȱ indicatorȱ Ȉ%ȱ casesȱ ofȱ URTIȱ treatedȱ
withȱ antibioticsȈȱ ȱ mayȱ stillȱ beȱ usedȱ butȱ aȱ noteȱ onȱ theȱ authorsȇȱ viewsȱ onȱ treatmentȱ shouldȱ
alwaysȱbeȱmadeȱinȱsectionȱ4.ȱȱ
ȱ
Manyȱ ARI/IMCIȱ studiesȱ classifyȱ ARIȱ intoȱ eitherȱ pneumoniaȱ (requiringȱ antibiotics)ȱ orȱ nonȬ
pneumoniaȱ(notȱrequiringȱantibiotics).ȱNonȬpneumoniaȱisȱclassifiedȱasȱURTIȱinȱtheȱdatabase.ȱ
ȱ
Inȱ WHO,ȱ Divisionȱ ofȱ Childȱ Healthȱ andȱ Developmentȱ (WHO/CHD)ȱ controlȱ ofȱ ARIȱ studies,ȱ
theȱ indicatorȱ ȈARIȱ casesȱ whoȱ shouldȱ notȱ receiveȱ antibioticsȱ butȱ wereȱ givenȱ themȈȱ isȱ
interpretedȱasȱȈ%ȱcasesȱofȱURTIȱtreatedȱwithȱantibioticsȈ.ȱ
ABs: % patients prescribed antibiotics
No. patient encounters where one or more

antibiotics are prescribed x 100ȱ
Total no. patient encounters surveyed
ȱ
Antibioticsȱareȱasȱdefinedȱbyȱtheȱauthors.ȱNormallyȱinȱprimaryȱhealthȱcare,ȱmetronidazoleȱisȱ
notȱ definedȱ asȱ anȱ antibiotic;ȱ ȱ ifȱ theȱ authorsȱ defineȱ metronidazoleȱ asȱ anȱ antibiotic,ȱ aȱ noteȱ
shouldȱbeȱmadeȱinȱsectionȱ4.ȱ
ARI: % ARI cases treated with cough syrups
No. cases acute respiratory tract infection

prescribed cough syrups
x 100ȱ
Total no. cases of acute respiratory tract
infection
ȱ
Coughȱsyrupsȱareȱmedicinesȱdefinedȱbyȱtheȱauthorsȱasȱrelievingȱtheȱsymptomsȱofȱcoughȱandȱ
cold.ȱTheyȱareȱnonȬantibioticȱdrugs,ȱoftenȱavailableȱasȱfixedȱdoseȱcombinationȱproductsȱandȱ
include:ȱ
ȱ
x coughȱsuppressantsȱ(includingȱsedatingȱantihistamines,ȱcodeine,ȱpholcodine,ȱ
dextromethorphan)ȱ
x coughȱexpectorantsȱ(includingȱammoniumȱchloride)ȱȱ
x demulcentȱcoughȱpreparationsȱ(containingȱsoothingȱsubstancesȱsuchȱasȱsyrupȱorȱ
glycerol)ȱȱ
x decongestantsȱ(includingȱpseudoephedrine).ȱȱ
ȱ
ȱ
ȱ
– 139 –
Avail: % facilities with spec. drug avail
No. facilities with a specific drug available

x 100ȱ
Total no. facilities
ȱ
ForȱWHO,ȱDivisionȱofȱChildȱHealthȱandȱDevelopmentȱ(WHO/CHD)ȱcontrolȱofȱARIȱstudies,ȱ
theȱ indicatorȱ ȈFacilitiesȱ withȱ firstȬlineȱ antibioticsȈȱ isȱ interpretedȱ asȱ Ȉ%ȱ facilitiesȱ withȱ spec.ȱ
drugȱavail.Ȉȱ
ȱ
ForȱWHO/IMCIȱstudies,ȱtheȱindicatorȱȈFacilitiesȱwithȱallȱessentialȱoralȱtreatmentsȱavailableȈȱ
isȱinterpretedȱasȱtheȱindicatorȱȈ%ȱfacilitiesȱwithȱspec.ȱdrugȱavail.Ȉȱ
Cost: % drug costs on antibiotics
Cost for all antibiotics

x 100ȱ
Total drug cost
ȱ
AllȱcostsȱshouldȱbeȱconvertedȱtoȱUS$ȱusingȱtheȱconversionȱrateȱapplicableȱduringȱtheȱyearȱofȱ
theȱ survey.ȱ Ifȱ theȱ yearȱ ofȱ surveyȱ isȱ unknown,ȱ theȱ yearȱ ofȱ publicationȱ mayȱ beȱ used,ȱ aȱ noteȱ
beingȱmadeȱinȱtheȱnotesȱboxȱofȱsectionȱ4.ȱ
Cost: % drug costs on injections
Cost for all injections

x 100ȱ
Total drug cost
ȱ
theȱ survey.ȱ Ifȱ theȱ yearȱ ofȱ surveyȱ isȱ unknown,ȱ theȱ yearȱ ofȱ publicationȱ mayȱ beȱ used,ȱ aȱ noteȱ
beingȱmadeȱinȱtheȱnotesȱboxȱofȱsectionȱ4.ȱ
Cost: Av. drug cost per patient (USD)
Cost for all drugs prescribed

ȱ
No. patient encounters surveyed
ȱ
theȱsurvey.ȱIfȱtheȱyearȱofȱtheȱsurveyȱisȱunknown,ȱtheȱyearȱofȱpublicationȱmayȱbeȱusedȱbutȱaȱ
noteȱshouldȱbeȱmadeȱinȱtheȱnotesȱboxȱofȱsectionȱ4.ȱ
Diarrhoea: % treated with ORT
No. cases of diarrhoea treated with oral

rehydration therapy x 100ȱ
Total no. cases of diarrhoea
ȱ
– 140 –
Inȱ WHO,ȱ Divisionȱ ofȱ Childȱ Healthȱ andȱ Developmentȱ (WHO/CHD)ȱ controlȱ ofȱ diarrhoeaȱ
studies,ȱtheȱindicatorȱȈCorrectlyȱrehydratedȈȱisȱnotȱinterpretedȱasȱ%ȱdiarrhoeaȱtreatedȱwithȱ
ORTȱ becauseȱ allȱ aspectsȱ ofȱ rehydrationȱ areȱ includedȱ notȱ justȱ prescriptionȱ ofȱ Oralȱ
rehydrationȱ therapyȱ (ORT).ȱ Alsoȱ adviceȱ toȱ giveȱ ORTȱ orȱ otherȱ rehydrationȱ solutionsȱ (ORS)ȱ
andȱfluidsȱisȱnotȱinterpretedȱasȱ%ȱdiarrhoeaȱtreatedȱwithȱORTȱbecauseȱsuchȱadviceȱdoesȱnotȱ
meanȱthatȱtheȱpatientȱisȱnecessarilyȱtreatedȱwithȱORT.ȱSuchȱadviceȱisȱpartiallyȱcoveredȱinȱtheȱ
indicatorȱȈInfo:ȱ%ȱpatientsȱgivenȱdosageȱinstructionsȈȱ(seeȱrelevantȱindicator).ȱ
ȱ
Inȱ WHO/IMCIȱ studiesȱ theȱ indicatorȱ ȈChildȱ withȱ dehydrationȱ isȱ correctlyȱ treatedȈȱ isȱ
interpretedȱasȱȈ%ȱdiarrhoeaȱcasesȱtreatedȱwithȱORTȈȱbecauseȱthisȱindicatorȱcoversȱtheȱuseȱofȱ
ORTȱasȱobservedȱbyȱinvestigatorsȱatȱfacilitiesȱbutȱdoesȱnotȱincludeȱotherȱaspectsȱofȱdiarrhoeaȱ
caseȱmanagement.ȱ
Diarrhoea: % treated with anti-diarrhoeals
No. cases of diarrhoea treated with anti-

diarrhoeals x 100ȱ
ȱ
AntiȬdiarrhoealȱ drugsȱ areȱ medicinesȱ definedȱ byȱ theȱ authorsȱ asȱ relievingȱ theȱ symptomsȱ ofȱ
diarrhoea.ȱ Theyȱ areȱ nonȬantibioticȱ drugsȱ andȱ includeȱ adsorbentsȱ andȱ bulkȱ formingȱ drugs,ȱ
antiȬmotilityȱ drugsȱ andȱ antiȬspasmodicȱ drugs.ȱ Oftenȱ suchȱ preparationsȱ areȱ fixedȱ doseȱ
combinationȱproducts.ȱ
Diarrhoea: % treated w. antibiotics
No. cases of diarrhoea treated with antibioticsȱ

x 100ȱ
ȱ
AntiȬamoebicȱ drugsȱ suchȱ asȱ metronidazoleȱ areȱ oftenȱ inappropriatelyȱ usedȱ toȱ treatȱ acuteȱ
diarrhoea.ȱ Theyȱ shouldȱ notȱ beȱ classedȱ asȱ anȱ antibioticȱ inȱ theȱ database.ȱ Ifȱ aȱ study/surveyȱ
reportsȱuseȱofȱantiȬamoebicȱdrugsȱtoȱtreatȱdiarrhoea,ȱaȱnoteȱshouldȱbeȱmadeȱinȱsectionȱ4ȱofȱ
theȱ%ȱofȱdiarrhoeaȱcasesȱtreatedȱwithȱmetronidazoleȱ(orȱantiȬamoebicȱdrug).ȱ
Drugs: Av. no drugs per patient
Total no. of different drug products prescribed

ȱ
No. of patient encounters observed
Drugs: % patients treated without drugs
No. patient consultations in which drugs are

not prescribed x 100ȱ
Total no. of patient consultations surveyed
– 141 –
Drugs: % key drugs available in facility
No. specified drug products actually in stock

Total no. of drug products on a pre- x 100ȱ
determined list of key drugs
ȱ
Forȱ WHO/IMCIȱ studies,ȱ theȱ indicatorȱ ȈIndexȱ ofȱ availabilityȱ ofȱ essentialȱ oralȱ treatmentsȈȱ isȱ
interpretedȱasȱtheȱindicatorȱȈ%ȱkeyȱdrugsȱavailableȱinȱtheȱfacilityȈ.ȱ
Drugs: % prescribed that are dispensed
No. drugs actually dispensed at the health

facility x 100ȱ
Total no. drugs prescribed
EDL: % prescribed drugs from EML (EDL)
No. drug products prescribed which are listed

on the EML x 100ȱ
Total no. drug products prescribed
EDL: % facilities with EML (EDL) available
No. facilities with national EML or local

formulary available in facility x 100%ȱ
Total no. of facilities
Generic: % prescribed by generic name
No. drugs prescribed by generic name

x 100ȱ
Total no. drugs prescribed
Info: % patients given dosage instructions
No. of patients given dosage instructions

x 100ȱ
Total no. of patients observed
ȱ
Inȱ WHO,ȱ Divisionȱ ofȱ Childȱ Healthȱ andȱ Developmentȱ (WHO/CHD)ȱ controlȱ ofȱ diarrhoeaȱ
studies,ȱtheȱ%ȱofȱcaretakersȱinstructedȱonȱhowȱmuchȱandȱwhenȱtoȱgiveȱORSȱisȱinterpretedȱasȱ
Ȉ%ȱpatientsȱgivenȱdosageȱinstructionsȈȱbecauseȱthisȱisȱtheȱnearestȱequivalentȱtoȱdosing.ȱOtherȱ
indicatorsȱonȱpatientsȱbeingȱtaughtȱhowȱtoȱmakeȱORSȱorȱhowȱtoȱrecognizeȱdehydrationȱareȱ
notȱuseȱforȱthisȱindicator.ȱȱ
ȱ
Inȱ WHO/CHDȱ controlȱ ofȱ ARIȱ studiesȱ Ȉ%ȱ caretakersȱ givenȱ dosageȱ instructionsȈȱ shouldȱ beȱ
interpretedȱfromȱtheȱtextȱwithȱregardȱtoȱ%ȱcaretakersȱgivenȱdosingȱinstructionsȱwithȱregardȱ
– 142 –
toȱantibiotics.ȱInȱtheȱabsenceȱofȱaȱdetailedȱindividualȱreportȱforȱtheȱsurvey,ȱtheȱindicatorȱȈ%ȱ
caretakersȱ correctlyȱ advisedȈȱ fromȱ theȱ multiȬcountryȱ reportȱ WHO/CHDȱ 1996Ȭ7ȱ reportȱ mayȱ
beȱused,ȱinȱwhichȱcaseȱaȱnoteȱshouldȱbeȱmadeȱinȱtheȱnotesȱboxȱinȱsectionȱ4.ȱ
ȱ
Forȱ WHO/IMCIȱ studies,ȱ theȱ indicatorȱ ȈChildȱ prescribedȱ oralȱ medicationȱ whoseȱ caretakerȱ
receivedȱcounsellingȱonȱhowȱtoȱadministerȱtheȱtreatmentȈȱisȱinterpretedȱasȱtheȱindicatorȱȈ%ȱ
patientsȱgivenȱdosageȱinstructionsȈ.ȱ
Info: % facilities with impartial information
No. facilities where a listed source of impartial

information is present x 100ȱ
Total no. of facilities surveyed
Inject: % patients prescribed injections
No. patient encounters where one or more

injections are prescribed x 100ȱ
Inject: % patients prescribed injections inappropriately
No. patients prescribed injections

inappropriately
x 100ȱ
Total no. patients (whether or not prescribed
injections)
ȱ
Inappropriateȱinjectionsȱshouldȱbeȱdefinedȱbyȱtheȱauthors.ȱ
Know: % patients with correct dosage knowledge
No. patients adequately reporting dosage

schedule for all drugs x 100ȱ
Total no. patients interviewed
ȱ
Inȱ WHO/CHDȱ diarrhoeaȱ controlȱ studies,ȱ patientȱ knowledgeȱ aboutȱ theȱ preparationȱ andȱ
administrationȱ ofȱ oralȱ rehydrationȱ solutionȱ (ORS)ȱ isȱ usedȱ forȱ interpretingȱ theȱ indicatorȱ onȱ
Ȉ%ȱpatientsȱwithȱcorrectȱdosageȱknowledgeȈȱbecauseȱthisȱisȱtheȱnearestȱequivalentȱtoȱdosingȱ
information.ȱ Sometimesȱ thisȱ overallȱ indicatorȱ isȱ notȱ givenȱ andȱ onlyȱ theȱ individualȱ
componentsȱareȱgivenȱconsistingȱofȱORSȱpreparation,ȱhowȱmuchȱandȱwhenȱtoȱgive,ȱandȱhowȱ
longȱtoȱkeepȱwhenȱprepared.ȱInȱtheseȱcircumstancesȱtheȱresultȱforȱȈwhenȱandȱhowȱmuchȱtoȱ
giveȈȱ isȱ used,ȱ thisȱ beingȱ theȱ nearestȱ equivalentȱ toȱ dosing.ȱ Theȱ otherȱ aspectsȱ ofȱ diarrhoeaȱ
managementȱ concerningȱ patientȱ knowledgeȱ ofȱ homeȱ careȱ andȱ preventionȱ ofȱ diarrhoeaȱ areȱ
notȱused.ȱ
ȱ
– 143 –
Inȱ WHO/CHDȱ ARIȱ controlȱ studies,ȱ patientȱ knowledgeȱ shouldȱ beȱ interpretedȱ fromȱ theȱ textȱ
withȱ regardȱ toȱ knowingȱ aboutȱ antibioticȱ dosingȱ andȱ duration.ȱ Ifȱ theseȱ twoȱ aspectsȱ areȱ
reportedȱseparately,ȱtheȱlowestȱfigureȱisȱtaken.ȱ
ȱ
ForȱWHO/IMCIȱstudies,ȱtheȱindicatorȱȈCaretakerȱofȱchildȱprescribedȱORSȱand/orȱantibioticsȱ
and/orȱ antimalarialȱ canȱ describeȱ howȱ toȱ giveȱ treatmentȈȱ isȱ interpretedȱ asȱ theȱ indicatorȱ Ȉ%ȱ
patientsȱwithȱcorrectȱdosageȱknowledgeȈ.ȱ
Label: % drugs adequately labelled
No. of drug packages adequately labelled

x 100ȱ
Total no. drug packages dispensed
ȱ
Adequateȱ labellingȱ shouldȱ beȱ definedȱ byȱ theȱ authors.ȱ Anȱ adequateȱ labelȱ shouldȱ normallyȱ
includeȱatȱleastȱpatientȱname,ȱdrugȱnameȱandȱwhenȱtheȱdrugȱshouldȱbeȱtaken.ȱIfȱtheȱauthorsȱ
definitionȱdiffersȱfromȱthis,ȱaȱnoteȱshouldȱbeȱmadeȱinȱsectionȱ4.ȱ
Malaria: % treated w appr.anti-malarials
No. cases of malaria prescribed appropriate

anti-malarial x 100ȱ
Total no. cases of pneumonia
ȱ
Appropriateȱ antimalarialsȱ shouldȱ beȱ definedȱ byȱ theȱ authors.ȱ Ifȱ thereȱ isȱ noȱ mentionȱ ofȱ theȱ
appropriatenessȱofȱtheȱantimalarialȱtreatment,ȱitȱshouldȱbeȱassumedȱtoȱbeȱappropriateȱbutȱaȱ
commentȱshouldȱbeȱmadeȱinȱtheȱnotesȱboxȱinȱsectionȱ4.ȱInjectableȱantimalarialsȱareȱregardedȱ
asȱinappropriateȱunlessȱotherwiseȱstatedȱbyȱtheȱauthors.ȱSuchȱaȱstudy/surveyȱshouldȱalwaysȱ
beȱdiscussedȱbetweenȱtheȱdataȬentryȱpersonȱandȱtheȱpersonȱinȱchargeȱofȱtheȱdatabase.ȱ
ȱ
InȱWHO/IMCIȱstudiesȱtheȱindicatorȱȈChildȱwithȱmalariaȱisȱcorrectlyȱtreatedȈȱisȱinterpretedȱasȱ
Ȉȱ Malaria:ȱ %ȱ treatedȱ wȱ appr.antiȬmalarialsȈȱ becauseȱ thisȱ indicatorȱ doesȱ notȱ includeȱ otherȱ
aspectsȱofȱcaseȱmanagement.ȱ
Mortality rates
No. deaths over a defined period of time in a

defined population
ȱ
Defined population at risk of death in the time
period
ȱ
Mortalityȱ ratesȱ areȱ usuallyȱ expressedȱ asȱ no.ȱ deathsȱ perȱ 1000ȱ personsȱ atȱ riskȱ andȱ canȱ beȱ
expressedȱ byȱ causeȱ (allȱ causesȱ orȱ certainȱ diseaseȱ categories)ȱ orȱ byȱ ageȱ (infantȱ mortality,ȱ
underȱ5ȱyearsȱmortality,ȱetc):ȱ
ȱ
x MR:ȱallȱcausesȱperȱ1000ȱ
x MR:ȱdueȱtoȱARIȱperȱ1000ȱ
– 144 –
x MR:ȱdueȱtoȱdiarrhoeaȱperȱ1000ȱ
x MR:ȱdueȱtoȱmalariaȱperȱ1000ȱ
ȱ
Theȱ ageȱ groupȱ ofȱ theȱ populationȱ atȱ riskȱ andȱ theȱ sizeȱ ofȱ theȱ populationȱ atȱ riskȱ shouldȱ beȱ
enteredȱ inȱ theȱ relevantȱ boxesȱ ȈAgeȱ groupȈȱ andȱ ȈTotalȱ populationȈȱ inȱ sectionȱ 3ȱ underȱ ȈIfȱ
mortalityȱstudyȈ.ȱ
Pregnant: % treated with iron +/- folic acid
No. pregnant women treated with iron +/-

folic acid x 100ȱ
Total no. pregnant women
ȱ
Theȱindicatorȱconcernsȱtheȱtreatmentȱofȱpregnantȱwomenȱwithȱironȱplusȱorȱminusȱfolicȱacid.ȱ
VitaminsȱandȱfolicȱacidȱaloneȱwithoutȱironȱdoȱnotȱcountȱasȱȈtreatedȱwithȱironȱ+/ȬȱfolicȱacidȈ.ȱ
POM: % patients receiving without prescription
No. patients that receive a POM without a

prescription ȱ x 100ȱ
Total no. patients receiving a POM
ȱ
PrescriptionȬonlyȬmedicinesȱ(POM)ȱareȱeitherȱdefinedȱasȱsuchȱinȱtheȱarticleȱorȱareȱotherwiseȱ
consideredȱtoȱbeȱinjectionsȱandȱantibiotics.ȱ
ȱ
POMȱindicatorȱfigureȱcannotȱbeȱbasedȱonȱaȱsimulatedȱpatientsȱsurvey.ȱ
Satis: % patients satisfied with treatment
No. of patients who report being generally

satisfied x 100ȱ
Total no. patients interviewed
ȱ
Patientȱsatisfactionȱisȱdefinedȱbyȱtheȱauthorsȱandȱaȱnoteȱshouldȱbeȱmadeȱofȱtheȱdefinitionȱinȱ
sectionȱ4.ȱȱ
STG: % treated in accordance with STGs
No. cases treated in accordance with standard

treatment guidelines x 100ȱ
Total no. of cases reviewed
ȱ
Treatmentȱ inȱ accordanceȱ withȱ Standardȱ Treatmentȱ Guidelinesȱ isȱ asȱ judgedȱ byȱ theȱ authors.ȱ
Thisȱ STGȱ adherenceȱ indicatorȱ normallyȱ concernsȱ drugȱ treatmentȱ only.ȱ Ifȱ itȱ concernsȱ alsoȱ
– 145 –
patientȱ assessment,ȱ referralȱ andȱ caretakerȱ adviceȱ asȱ inȱ ARI/CDD/IMCIȱ studies,ȱ thenȱ thisȱ
shouldȱbeȱindicatedȱinȱtheȱnotesȱboxȱinȱsectionȱ4.ȱ
ȱ
Forȱ WHO/CHDȱ ARIȱ controlȱ studies,ȱ theȱ STGȱ indicatorȱ concernsȱ treatmentȱ forȱ allȱ typesȱ ofȱ
ARIȱandȱnotȱjustȱpneumonia.ȱȱ
ȱ
Forȱ WHO/CHDȱ diarrhoeaȱ controlȱ studies,ȱ theȱ STGȱ indicatorȱ concernsȱ theȱ correctȱ
rehydrationȱforȱdiarrhoeaȱcasesȱ(bothȱORS,ȱIVI,ȱdose,ȱduration,ȱetc.)ȱandȱdoesȱnotȱreferȱtoȱtheȱ
%ȱ ofȱ diarrhoeaȱ orȱ dysenteryȱ casesȱ treatedȱ withȱ antibioticsȱ orȱ ORSȱ forȱ whichȱ thereȱ areȱ
separateȱ indicators.ȱ Itȱ doesȱ notȱ referȱ toȱ theȱ %ȱ ofȱ childrenȱ correctlyȱ managedȱ becauseȱ thatȱ
indicatorȱincludesȱcorrectȱassessment,ȱadviceȱandȱreferral.ȱ
ȱ
Forȱ WHO/IMCIȱ studies,ȱ theȱ indicatorȱ ȈChildȱ needingȱ oralȱ antibioticȱ and/orȱ antimalarialȱ isȱ
prescribedȱ drug(s)ȱ correctlyȈȱ isȱ interpretedȱ asȱ theȱ indicatorȱ Ȉ%ȱ treatedȱ inȱ accordanceȱ withȱ
STGsȈ.ȱItȱdoesȱnotȱreferȱtoȱtheȱ%ȱofȱchildrenȱcorrectlyȱmanagedȱbecauseȱthatȱincludesȱcorrectȱ
assessment,ȱadviceȱandȱreferral.ȱ
STG: % facilities with STGs available
No. facilities with national STG or local

protocols available in facility x 100ȱ
Total no. of facilities
ȱ
InȱWHO/IMCIȱstudies,ȱȈIMCIȱchart,ȱbooklet(s)ȱandȱmothersȇȱcounsellingȱcardsȈȱareȱcountedȱ
asȱ STGs.ȱ Ifȱ notȱ allȱ theseȱ threeȱ areȱ present,ȱ theȱ minimumȱ thatȱ mustȱ beȱ presentȱ forȱ
interpretationȱasȱSTGȱavailabilityȱisȱtheȱbooklet.ȱ
Time: Av. consultation time (min.)
Total time for a series of patient consultations

ȱ
Number of patient consultations
ȱ
Excludesȱwaitingȱtime.ȱ
Time: Av. dispensing time (sec.)
Total time for dispensing drugs to a series of

patientsȱ ȱ
Number of patient encounters
ȱ
Dispensingȱ includesȱ preparationȱ ofȱ aȱ prescriptionȱ andȱ interactionȱ betweenȱ theȱ patientȱ andȱ
theȱ dispenser.ȱ Dispensingȱ timeȱ mayȱ includeȱ orȱ excludeȱ prescriptionȱ preparationȱ time.ȱ
Dispensingȱ timeȱ shouldȱ beȱ definedȱ byȱ theȱ authorsȱ andȱ aȱ noteȱ shouldȱ beȱ madeȱ ofȱ theȱ
definitionȱinȱsectionȱ4.ȱȱ
ȱ
ȱ
– 146 –
Vits: % cases prescribed multivit/tonics
No. patient encounters where 1 or more

vitamins/tonics are prescribed x 100ȱ
ȱ
Thisȱindicatorȱincludesȱallȱvitamins,ȱmultivitaminsȱandȱtonics.ȱ
ȱ
Rate
Thisȱisȱtheȱnumberȱstatedȱinȱtheȱreportȱ/ȱarticleȱforȱaȱspecifiedȱoutcomeȱvariableȱforȱaȱspecificȱ
groupȱandȱperiod.ȱȱ
ȱ
Sometimesȱarticlesȱ/ȱreportsȱdoȱnotȱgiveȱindicatorsȱinȱtheȱrequiredȱformatȱbutȱhaveȱsufficientȱ
dataȱtoȱenableȱtheȱindicatorsȱusedȱinȱtheȱdatabaseȱtoȱbeȱcalculated.ȱIfȱcalculationsȱareȱdone,ȱaȱ
noteȱ shouldȱ beȱ madeȱ ofȱ exactlyȱ whatȱ wasȱ doneȱ inȱ theȱ boxȱ Ȉnotesȱ onȱ studyȱ outcomeȱ
measuresȈȱatȱtheȱbottomȱofȱsectionȱ4.ȱInȱallȱcases,ȱaveragingȱshouldȱbeȱdoneȱatȱtheȱlevelȱofȱtheȱ
healthȱfacilityȱratherȱthanȱtheȱindividualȱpatient,ȱifȱpossible.ȱWeightingȱofȱaveragesȱshouldȱ
onlyȱbeȱdoneȱatȱtheȱlevelȱofȱfacility.ȱTheȱfollowingȱtypesȱofȱcalculationȱmayȱoccur:ȱ
ȱ
Averagingȱofȱanȱindicatorȱacross:ȱ
ȱ
x patientsȱwithȱdifferentȱdiseasesȱ
x patientsȱwithȱdifferentȱseverityȱofȱtheȱsameȱdiseaseȱ
x patientsȱofȱdifferentȱagesȱ
x patientsȱofȱdifferentȱgenderȱ
x differentȱgeographicalȱareas,ȱincludingȱruralȱ/ȱurbanȱ
x differentȱdrugȱoutletsȱofȱtheȱsameȱtypeȱ
ȱ
Calculatingȱindicatorsȱwhereȱtheȱindicatorȱisȱnotȱgiven,ȱbutȱwhereȱdataȱonȱtheȱnecessaryȱ
numeratorȱandȱdenominatorȱtoȱcalculateȱtheȱindicatorȱareȱgiven,ȱe.g.ȱ
ȱ
x CalculationȱofȱtheȱȈaverageȱno.ȱdrugsȱperȱpatientȈȱfromȱthe:ȱ
Î Numberȱofȱpatientsȱreceivingȱaȱparticularȱdrugȱandȱtheȱtotalȱnumberȱofȱpatients,ȱ
Î Numberȱofȱpatientsȱprescribedȱoneȱdrug,ȱtwoȱdrugs,ȱthreeȱdrugs,ȱetc.ȱ
ȱ
x CalculationȱofȱtheȱȈ%ȱdrugsȱprescribedȱbyȱgenericȱnameȈȱorȱȈ%ȱprescribedȱdrugsȱ
belongingȱtoȱtheȱEMLȈ,ȱrespectivelyȱfromȱthe:ȱ
Î Numberȱofȱdrugsȱprescribedȱbyȱgenericȱandȱtheȱtotalȱnumberȱofȱdrugsȱprescribed,ȱ
Î NumberȱofȱdrugsȱbelongingȱtoȱtheȱEMLȱandȱtheȱtotalȱnumberȱofȱdrugsȱprescribed.ȱ
ȱ
– 147 –
x CalculationȱofȱtheȱȈ%ȱprescribedȱdrugsȱdispensedȈȱfromȱthe:ȱ
Î Numberȱofȱdispensedȱdrugsȱandȱtheȱnumberȱofȱprescribedȱdrugs.ȱ
ȱ
x CalculationȱofȱtheȱȈ%ȱdiarrhoeaȱcasesȱtreatedȱwithȱORTȈȱfromȱthe:ȱ
Î Numberȱofȱcasesȱofȱdiarrhoeaȱandȱdataȱonȱtheȱnumberȱofȱcasesȱofȱdiarrhoeaȱtreatedȱ
withȱORT,ȱtheȱlatterȱbeingȱpresentedȱasȱcasesȱtreatedȱwithȱORTȱaloneȱandȱinȱ
combinationȱwithȱotherȱdrugsȱsuchȱasȱantibiotics,ȱantiȬdiarrhoealsȱandȱotherȱdrugs.ȱ
ȱ
Calculatingȱ indicatorsȱ whereȱ theȱ indicatorȱ isȱ notȱ givenȱ andȱ whereȱ onlyȱ someȱ dataȱ onȱ
numeratorȱ andȱ denominatorȱ isȱ given;ȱ calculationȱ ofȱ indicatorsȱ canȱ onlyȱ beȱ doneȱ byȱ
makingȱ certainȱ assumptions,ȱ whichȱ shouldȱ alwaysȱ beȱ discussedȱ betweenȱ theȱ dataȬentryȱ
personȱandȱtheȱpersonȱinȱchargeȱofȱtheȱdatabase.ȱSuchȱcalculationsȱshouldȱonlyȱbeȱdoneȱ
whereȱtheȱassumptionȱisȱveryȱlikelyȱandȱsomeȱexamplesȱareȱgivenȱbelow:ȱȱ
ȱ
x Averageȱnumberȱofȱdrugsȱperȱchildȱ<ȱ5ȱyearsȱ=ȱ2.2;ȱ20%ȱdrugsȱwereȱinjections;ȱ
500ȱchildrenȱ
ȱ
No.ȱofȱdrugsȱ=ȱ500ȱxȱ2.2ȱ=ȱ1100ȱ
No.ȱofȱinjectionsȱ=ȱ20%ȱofȱ1100ȱ=ȱ1100/5ȱ=ȱ220ȱ
ȱ
Assumingȱoneȱinjectionȱgivenȱperȱpatientȱ(veryȱlikelyȱinȱaȱchildȱ<ȱ5ȱyearsȱwithȱanȱ
averageȱofȱ2.2.ȱdrugsȱperȱchild),ȱthen:ȱ
%ȱpatientsȱgivenȱanȱinjectionȱ=ȱ(220/500)ȱxȱ100ȱ=ȱ44%ȱ
ȱ
ȱ
x 200ȱcasesȱofȱdiarrhoea;ȱ400ȱdrugsȱgiven;ȱ20%ȱdrugsȱwereȱORTȱ
ȱ
No.ȱofȱdrugsȱthatȱwereȱORTȱ=ȱ20%ȱofȱ400ȱ=ȱ400/5ȱ=ȱ80ȱ
ȱ
AssumingȱoneȱORTȱprescriptionȱgivenȱperȱpatient,ȱthen:ȱ
%ȱofȱdiarrhoeaȱcasesȱreceivingȱORTȱ=ȱ(80/200)ȱxȱ100ȱ=ȱ40%ȱȱ
ȱ
ȱ
x 60ȱpatientȱconsultations;ȱ30%ȱconsultationȱ<5ȱmins,ȱ50%ȱ5Ȭ10ȱmins,ȱandȱ20%ȱ>10ȱminsȱ
ȱ
No.ȱconsultationsȱofȱ<5ȱminsȱȱ =ȱ30%ȱofȱ60ȱ=ȱ(60/100)ȱxȱ30=18ȱ
No.ȱconsultationsȱofȱ5Ȭ10ȱminsȱȱ =ȱ50%ȱofȱ60ȱ=ȱ(60/100)ȱxȱ50=30ȱ
No.ȱconsultationsȱofȱ>10insȱ =ȱ20%ȱofȱ60ȱ=ȱ(60/100)ȱxȱ20=12ȱ
ȱ
Assumingȱconsultationsȱ<ȱ5ȱmins=ȱ5ȱmins,ȱconsultationsȱofȱ5Ȭ10ȱminsȱ=ȱ7.5ȱminsȱ
andȱconsultationsȱofȱ>ȱ10ȱminsȱ=ȱ10ȱmins,ȱthen:ȱ
Av.ȱconsultationȱtimeȱȱ ȱ =ȱ[(18ȱxȱ5)+(30ȱxȱ7.5)ȱ+ȱ(12ȱxȱ10)]/(18ȱ+30ȱ+ȱ12)ȱ
ȱ ȱ ȱ ȱȱȱȱȱȱȱȱȱ ȱ =ȱ(90ȱ+ȱ225ȱ+ȱ120)/60ȱ=ȱ444/60ȱ=ȱ7.4ȱminsȱ
ȱ
– 148 –
References
REFERENCES
ȱ
1
International Network for the Rational Use of Drugs. INRUD Medicines Use bibliography. Available at:
http://www1.inrud.org:81/rmwp?&func=advSearch.
2
How to investigate drug use in health facilities: Selected drug use indicators. (DAP Research Series N°7.
WHO/DAP/93.1). Geneva, World Heath Organization, 1993.
3
Integrated Management of Childhood Illness. Geneva, World Health Organization. Available at:
http://www.idpas.org/58relatedprograms1.html
4
The rational use of drugs. World Health Assembly Resolution WHA39.27. Geneva, World Health
Organization, 1985.
5
Promoting rational use of medicines: core components. WHO Policy Perspectives on Medicines, Number 5.
Geneva, World Health Organization, 2002.
6
Hutin YJ, Chen RT. Injection safety: a global challenge. Bulletin of WHO, 1999; 77:787-788.
7
Kane A, Lloyd J,Zaffran M, Simonsen L, Kane M. Transmission of hepatitis B and C and human
immunodeficiency viruses through unsafe injections in the developing world: model-based estimates.
Bulletin of WHO, 1999; 77:801-807.
8
Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and
transmission of blood-borne pathogens: a review. Bulletin of WHO, 1999; 77:789-800.
9
Quick JD, Laing RO, Ross-Degnan DG. Intervention research to promote clinically effective and
economically efficient use of pharmaceuticals: The International Network for Rational Use of Drugs. J Clin
Epidem, 1991; 44, Supplement II:57S-65S.
10
Ross-Degnan D, Laing R, Quick J, Ali HM, Ofori-Adjei D, Salako L, Santoso B. A strategy for promoting
improved pharmaceutical use: The International Network for Rational Use of Drugs. Soc. Sci. Med., 1992;
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11
Recommendations of the 1st International Conference for Improving the Use of Medicines, Chiang Mai,
Thailand, 1997. Available at: http://archives.who.int/icium/icium1997/proceedings.html
12
Ross-Degnan D, Laing R, Santoso B, Ofori-Adjei D, Diwan V, Lamoureux C, Hogerzeil H. Improving
pharmaceutical use in primary care in developing countries: a critical review of experience and lack of
experience. Paper presented at the 1st International Conference on Improving the Use of Medicines,
Chiang Mai, Thailand, 1-4 April, 1997.
13
Recommendations of the 2nd International Conference for Improving the Use of Medicines, Chiang Mai,
Thailand, 2004. Available at: http://archives.who.int/icium/icium2004/proceedings.html
14
Progress in the rational use of medicines. World Health Assembly Resolution WHA60.16. Geneva, World
Health Organization, 2007.
15
Holloway K, Ivanovska V. Measuring use of medicines: progress in the last decade. Plenary presentation at
the 2nd International Conference on Improving the Use of Medicines, Chiang Mai, Thailand, 30 March - 2
April, 2004.
16
How to investigate drug use in health facilities: Selected drug use indicators. (DAP Research Series N°7.
WHO/DAP/93.1). Geneva, World Heath Organization, 1993.
17
CHD 1996-1997 report, Division of Child Health and Development. WHO/CHD/98.5. Geneva, World Health
Organization, 1998.
18
Using indicators to measure country pharmaceutical situations. Fact Book on WHO level I and level II
monitoring indicators. WHO/TCM/2006.2. Geneva, World Health Organization, 2006.
19
Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and
overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bulletin of
WHO, 1997, 75 Suppl 1:7-24.
20
International Network for the Rational Use of Drugs. INRUD Medicines Use Bibliography. Available at
http://www.inrud.org/.
21
U.S. National Library of Medicine and the National Institutes of Health. Medline/PubMed, available at
http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed.
22
International conference on improving use of medicines. Essential Drugs Monitor, 1997; 23:6-12.
Available at http://mednet2.who.int/edmonitor/.
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23
Gove S. (For the WHO Working Group on Guidelines for Integrated Management of the Sick Child).
Integrated management of childhood illness by outpatient health workers: technical basis and overview.
Bulletin of WHO, 1997;75 (supplement 1):7–24.
24
Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, Whitty P, Eccles MP, Matowe L,
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– 150 –

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ȱ WHO/EMP/MAR/2009.

Medicines use in primary care

Fact Book summarizing results from studies

SUMMARY OF KEY POINTS

1.2 Working towards rational use of medicines

Table 1.1: Twelve core interventions recommended by WHO to promote more

1. A mandated multi-disciplinary national body – to coordinate medicines use policies.

1.3 Overview of this report

2.1 Objectives of the WHO database on medicines use

2.2 Steps to create the database

2.3 Database format and design

Disease-specific medicines use indicators

2.4 Search strategy and criteria

2.5 Data entry

2.6 Data cleaning

2.7 Definitions, variables, and data sources

2.7.1 Data sources for descriptive analyses

2.7.2 Data sources for intervention analyses

2.8 Data analysis

2.8.1 Baseline analysis of medicines use indicators

2.8.2 Intervention impact analysis

2.9.1 Limitations of the data collection

2.9.2 Limitations of the data analysis: Description of medicines use

2.9.3 Limitations of the data analysis: Evaluation of interventions

3.1 Results of search in published and unpublished literature

3.2 Cross-sectional studies of medicines use and patient care

Figure 3.2: Medicines use studies by World Bank region

Latin America and Caribbean

East Asia and Pacific

Figure 3.3: Medicines use studies by WHO region

Upper-Middle & High Income

Figure 3.5: Medicines use studies by prescriber type

Figure 3.6: Medicines use studies by health facility ownership

Private, not for profit

Figure 3.7: Medicines use studies by facility type

3.3 Baseline medicines use studies for specific diseases

4. WHO/INRUD PRESCRIBING INDICATORS

4.1 Medicines use over time

Figure 4.1: WHO/INRUD prescribing indicators, by time period

Average Number of Medicines

% Medicines from EML or Formulary % Medicines Prescribed by Generic Name

x The percentage of prescribed medicines present on an EML/formulary seems to have increased

4.2 Medicines use by region

Figure 4.2: WHO/INRUD prescribing indicators, by World Bank region

Average Number of Medicines

Figure 4.3: WHO/INRUD prescribing indicators, by World Bank income level

Average Number of Medicines

Low Income Lower-Middle Income Upper-Middle & High Income

Sub-Saharan Africa Latin America and Caribbean

4.3 Medicines use by type of prescriber

Figure 4.5: WHO/INRUD prescribing indicators by prescriber type

Average Number of Medicines

MD Paramedic or Nurse Pharmacy Staff, Other, or Unspecified

4.4 Medicines use by health-care facility ownership

Figure 4.6: WHO/INRUD prescribing indicators by health facility ownership (prescribing

Average Number of Medicines

Public Private, for profit Private, not for profit

5. WHO/INRUD PATIENT CARE AND HEALTH FACILITY

5.1 Patient care indicators

Figure 5.1: WHO/INRUD patient care indicators, by time period

Time (in Minutes)

% Prescribed Medicines Dispensed % Medicines Adequately Labeled

Figure 5.2: WHO/INRUD patient care indicators, by World Bank region