Transcript Poster presentation

Authors: Lates JA, Shiyandja NN
Funding Institution: Ministry of Health and Social Services, Namibia
Title: Third National Survey on the Use of Drugs in Namibia’s Public Health
Institutions, Including Monitoring the Implementation of the National
Drug Policy
Problem Statement: The National Drug Policy (NDP) was launched in Namibia in
1998, but its impact is not easy to see.
Objective: This survey was designed to monitor implementation of the NDP and the
consequent impact of this implementation on drug use in Namibia.
Design: Prospective cross-sectional survey, with results compared with those from
two similar surveys done in 1997 and 1999.
Setting: 44 randomly selected public health facilities, ranging in level from primary
health care clinics to the National Referral Hospital; facilities were stratified by level
before randomization. Data was collected from a consecutive sample of 30 outpatient
department prescriptions and from the pharmacies of the health facilities.
Outcome Measures: Average number of drugs prescribed per patient, percentage of
generic drugs prescribed, percentage of prescribed drugs on the essential drugs list
(EDL), percentage of patients prescribed an antibiotic, percentage of patients
prescribed an injection, percentage of drugs prescribed according to standard
treatment guidelines (STGs), percentage of drugs dispensed, percentage of drugs
adequately labelled, availability of key items, and availability of reference materials.
Results: Results are described as changes from baseline in 1997 to the latest results in
2001. The average number of drugs prescribed per patient increased from 2.49 to
2.72. Generic prescribing increased from 50% to 60%. Prescriptions containing an
antibiotic increased from 39% to 51%. Adherence to STGs was 53% (new indicator).
Percentage of drugs dispensed decreased from 96% to 93%. Percentage of drugs
adequately labelled increased from 48% to 67%. Availability of key drugs increased
from 89% to 92%. Availability of basic reference materials has dropped since 1997.
Conclusions: Availability of drugs remains high but is not ideal. Generic prescribing
has increased, but there is far to go. The main improvement seen is in the adequacy of
labelling of drugs, but still many patients leave the health facility not knowing how to
take their drugs. Polypharmacy and over-prescribing of antibiotics are problems that
are increasingly worrisome. The lack of adherence to STGs is linked closely to
overuse of antibiotics. Availability of basic reference materials in health facilities is
poor. The report recommends that concrete action is urgently needed to address
problems of antibiotic prescribing, polypharmacy, and lack of adherence to STGs.
Introduction
Drugs are of special importance to any health care system
because they save lives and improve health, promote trust
and participation in health services, and are very costly. In
addition the quality and cost-effectiveness of health care
provision is highly dependent on the appropriate use of
drugs.
The development by INRUD and WHO of simple and
uniform indicators has greatly facilitated the process of
investigating drug use. In Namibia these indicators were
used for the first time in a drug use survey conducted in
the North West Regional Directorate in 1994. The first
national drug use survey was conducted in 1997, and one
of the recommendations from this survey was to carry out
a drug use survey every 2 years in order to monitor trends.
The second national drug use survey was thus conducted
in 1999.
The aim of this third national survey (conducted in 2001)
was to monitor and obtain information about current drug
use practices in public health facilities in Namibia for
selected prescribing, patient care and facility indicators.
Furthermore, this survey aimed to monitor the
implementation of the NDP, which was launched in
November 1998.
The results of this survey were used to identify areas
where further training is needed and identify knowledge
gaps and areas for further research.
Study Design & Methodology
A prospective cross-sectional survey, involving 44
randomly selected health facilities was conducted. The
health facilities included the 4 main referral hospitals, 10
out of 30 district hospitals and 30 out of 97 clinics and
health centres that see more than 30 patients per day.
Drug use indicators as well as the sampling method were
selected from the WHO manuals “How to investigate drug
use in health facilities” and “Core indicators on country
pharmaceutical situation, Draft May 2000”.
Data collection took place from May to July 2001 and was
carried out by Regional and hospital pharmacists with
support from Pharmacist’s Assistants.
The data was collected from 30 outpatients as they left the
health facility. The data sources for patient indicators were
the patient health passports, the drug packages dispensed
to the patients and the patients themselves.
In addition, the pharmacies were visited to check on the
percentage of key items in stock, expiry dates and stock
history of key drugs, adequacy of storage and availability
of basic reference material.
The completed data collection forms were sent to the
Division: Pharmaceutical Services at national level, where
they were analysed using a computerised spreadsheet
program.
Drug Use Indicators
The indicators to be included in the survey were agreed at
the National Pharmacists Workshop 2000.
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Average number of drugs per prescription*
% of drugs prescribed by generic name*
% of encounters with an antibiotic prescribed*
% of encounters with an injection prescribed*
% of prescriptions in accordance with standard
treatment guidelines (STGs)*
% of drugs actually dispensed*
% of drugs adequately labelled*
% of drugs prescribed according to the
Essential Drugs List
% patients familiar with how to take their
medicine
% of key items in stock*
% of facilities where basic reference materials
are available
Average time key drugs out of stock
Adequacy of storage conditions in health
facilities.
Only these Indicators will be discussed on this poster.
Results
Data for 1132 patient encounters, from 38 health facilities
were included in the results analysis.
The data collected from 6 clinics were not included
because it was not possible to collect data from the
required minimum of 30 patients in these facilities.
The results obtained were compared to results from the
previous two National Drug Use surveys (1997 & 1999).
The average number of drugs per prescription of 2.72
for outpatients in Namibia is relatively high. There has
been a steady increase from 2.49 (1997) to 2.55 (1999) to
2.72 (2001).
Generic prescribing showed a marked improvement from
50% to 61% between the 1997 and 1999 surveys.
Comparing that to the current survey, there has been a
slight decrease to 60%.
Percentage of encounters with an antibiotic prescribed
was 51%. This is higher than that obtained from the
previous surveys (39% in 1997 and 43% in 1999).
Percentage of encounters with an injection prescribed
was 9% which is slightly higher than in 1999 survey
(7.3%), but this value is still low enough for us not to
consider the use of injections in Namibia a problem.
Adherence to standard treatment guidelines is very low
with only 53% of prescriptions according to the STGs.
There has been a steady decrease since the 1997 baseline
survey in percentage of drugs dispensed; 1997: 96%,
1999: 95% and 2001: 93%, however a result above 90% is
encouraging.
Percentage of drugs adequately labelled was 67%. This
is a significant improvement from the 1997 and the 1999
surveys, when only 48% of drugs were adequately labelled.
On average, 93% of key items were available. If the
expired key items (0.7%) are considered out of stock the
national result drops to 92%. This is a slight drop from the
1999 result of 93% of key items available but an
improvement from the baseline result of 89% available.
Average No. Drugs per Prescription
2.80
2.60
2.72
2.49
2.55
2.40
2.20
1997
1999
2001
Discussion
The steady increase in number of drugs prescribed to
outpatients is a worrying trend. Analysis of the Standard
Treatment Manual reveals that the mean number of drugs
proposed for treatment is 1.7 per condition. Therefore the
national result of 2.72 drugs prescribed clearly indicates a
problem with polypharmacy which can increase the
incidence of adverse drug reactions and drug – drug
reactions and also wastes scarce resources.
One of the contributing factors to polypharmacy is
obviously over prescribing of antibiotics, with every
second prescription containing an antibiotic. This overuse
of antibiotics is not only a waste of resources but is a
matter of global concern as it accelerates development of
antibiotic resistance.
Going hand in hand with overuse of antibiotics is the nonadherence to STGs. Further analysis of the data for this
indicator revealed that 86% of the prescriptions that were
found not to be according to STGs were due to
inappropriate antibiotic use. Most commonly this involved
prescribing an antibiotic for a non-bacterial condition.
Adherence to STGs was found to be lowest at clinic level
(where prescribers are nurses) and may therefore indicate
shortcomings in diagnostic skills.
An intervention study on antibiotic prescribing habits
conducted in clinics in Central Directorate, Namibia
revealed that two rounds of face to face education
significantly improved antibiotic prescribing habits. This
approach should be seriously considered country wide to
address misuse of antibiotics.
Generic prescribing has improved since 1997 but still is
far from ideal. Nurses had better rates for generic
prescribing than doctors, which maybe due to a slower
turn over in nurses (Namibians) than doctors (mainly nonNamibians on 2 year contracts).
The improvement in labelling of dispensed drugs must
be commended but still one in 3 drugs is inadequately
labelled so more work is needed.
Pharmacy Staff in Katutura State Hospital
Education on antibiotic prescribing habits in
Okanguati Clinic, Kunene Region
Implementation of the NDP
The goals of the NDP are constant availability of safe
and efficacious drugs, equitable access and rational use
of essential drugs.
Drug availability, as reflected by key drugs in stock
(92%) and percent of drugs dispensed (93%), is fairly
good.
Equitability of access is somewhat lacking as the results
show that during times of drug shortages preference is
given to hospitals over health centres and clinics.
Rational drug use in Namibia has dropped since the
baseline study in 1997, with increasing polypharmacy and
prescribing of antibiotics and poor adherence to STGs.
Conclusion & Recommendations
The results show that despite on going work since 1998 to
implement the National Drug Policy, several key factors of
drug use in Namibia have steadily worsened since the
baseline survey in 1997.
Areas requiring particular attention are mainly associated
with prescribing of drugs, such as number of items
prescribed per prescription, prescribing of antibiotics,
generic prescribing and adherence to STGs.
It is well known that the task of changing prescribing
habits is a difficult one, however it is clear that this needs
to be tackled as a matter of urgency in Namibia if the
goals of the NDP are to be reached.
The report recommends that the urgent action be taken to
address the major problems identified. This includes a
country wide campaign of face to face education to reduce
the over-prescribing of antibiotics. Other key
recommendations are for increased efforts to be made to
enforce adherence to STGs, promote generic prescribing
and ensure availability of drugs at clinics and health
centres during times of shortage.
The report also recommends that the next drug use survey
only be conducted after concrete interventions have been
implemented. The next survey can thus be used to assess
the impact of these interventions.
Prescribing Indicators
80%
60%
1997
1999
40%
2001
67%
61%
51%
50%
20%
39%
43%
7%
9%
0%
% of Drugs
Prescribed by
Generic Name
% of Rx Including % of Rx Including
an Antibiotic
an Injection
Dispensing and Drug Availability Indicators
100%
80%
60%
1997
96% 95% 93%
89% 93% 92%
40%
1999
2001
67%
48% 48%
20%
0%
% of Drugs
% of Drugs
Adequately
Dispensed
Labelled
% of Key Items in
Stock