The Study of Evaluation of Drug Use by Using WHO ’ S Prescribing , Patient Care and Health Facility Indicators in Selected Health Facilities in Province Punjab , Pakistan

Article history: Received on: 12/08/2012 Revised on: 13/09/2012 Accepted on: 23/09/2012 Available online: 28/09/2012 Rational drug use study is important for the patient care, and also act as a measure of the quality of care which is provided to patients, this study was conductedin the outdoor departments of 20 selected health facilities out of total 36 facilities of province Punjab, Pakistan by applying the core indicators of WHO.Average number of drug prescribed was 3.2 per prescription, percentage of generic drugs was 29.7%, percentage of antibiotic prescribed, injection prescribed, and percentage of drugs from NEDL were 64%, 0%, 96.5% respectively while ciprofloxacin was the most commonly used antibiotic. Average consultation time was 2.58 minutes; average dispensing time 88.5 seconds, percentage of drug actually dispensed was 82.9%, percentage of drug adequately labeled 96.9%, percentage knowledge of correct dosage 24%. Availability of NEDL or formulary was 90%,percentage of availability of key drugs in stock was 64.3%.Overall condition of rational use of medicines was not satisfactory in hospitals; this study will promote the rational use of medicines and good clinical pharmacy practice in hospitals of province Punjab, Pakistan by identifying the problems in rational use of drugs.


INTRODUCTION
Rational use of medicine means by which patients take medicine according to their clinical needs, in doses according to peoples requirements, for suitable period of time, at the lowest cost to patients and to the community (WHO, the Rational Use of Drugs).Half of total medicines in the world are prescribed, dispensed or sold not in appropriate way and rest half of total medicines are not taken in exact way.Essential medicines are not in access of almost 33% of population of world.(WHO, Promoting rational use of medicines: core components, 2002).In developing countries 60 to 80 percent of people do not have access to the essential medicines and this is due to low income and rest of peoples have access to essential medicines receive wrong medicines, inappropriate dosage or in not such quantity to fulfill their needs.Furthermore unlicensed and untrained drug sellers are involved in dispensing of medicines.(MSH,Managing Access to Medicines and Health Technologies,third edition).To maximize the rational use of medicine The WHO conducted a conference on rational use of drugs in 1985 in Nairobi and give a method for measurements of drug use in health facilities that describes drug use patterns and prescribing behavior and this method include indicators used to make basic comparisons between situations in different areas or at different times and also used as supervisory tools to find problems in health facilities and also maximize efficient use of medicines and correcting the deviations from standards.Irrational use of medicine in health facilities of Pakistan is due to many factors like inappropriate prescribing of medicines, dispensing of medicines with poor label and without counseling to patients, poor knowledge of medicine to dispenser and absence of drug expert (pharmacist) in pharmacy, and most of patients come to outdoor department of health facility are illiterate so they do not have sound knowledge about the use of medicine, so there is need to address that worsen condition in health facilities of the province Punjab, Pakistan.The current study is therefore designed to evaluate the current practice which is carried out by physicians and the dispensers in health facilities of province Punjab of Pakistan according to WHO criteria based study by applying prescribing indicators, patient care indicators, and the facility indicators.

MATERIAL & METHOD
According to guidelines of WHO a cross sectional and retrospective study was carried out in outdoor departments of twenty health facilities out of 36 major health facilities of districts of the province Punjab from December 10, 2011 to May 10, 2012.Each health facility selected in district level was main referral public health facility for local people of that area and out of 20 hospitals eight were teaching hospitals and from each hospital 30 prescription were collected from outdoor department of each health facility and evaluated the prescribing indicators and then each patient of particular name is evaluated for the patient care indicators and after that evaluate the health facility indicators.According to WHO rational drug use indicators the Performa was made and data collected initially from each health facility and the results were calculated by applying formulas given by WHO.
Date written on prescription by prescriber was useful to verify that cases were evenly distributed throughout the period of study.Age was also analyzed by counting the number of cases in each age group, which allows for a check that patients were collected from every group.After that data were summarized and by using tools of Microsoft office 2010 gave the results final form in tables and shapes.

RESULTS
Date collected from the outdoor department of health facilities from province Punjab, Pakistan and from each hospital 30 cases were selected randomly from more than 100 prescriptions.In this way a total of six hundred cases were compiled and evaluated for the core indicators of WHO for rational drug use.
According to study there were three main categories for the age of patients, <5 years age patients were 65 (10.8%), 5 to 12 years 85 (14.1%), >12 years were 450 (75%).And from total 600 patients 363 (60.5%) were males and 273 (39.5%) were females.From the educational status of the patients, completely illiterate patients were 353 (58.8%), literate patients were 165 (27.5%) and student patients were 82 (13.6%) as data given in table no.1.This data showed that lowest Average number of drugs prescribed was 2.6 in three hospitals DHQ of Jhang, Sheikpora & Sheikh Zaid Hospital Lahore and highest rate of Average number of drugs prescribed was 4.2 at Nishter hospital Multan.Lowest percentage of generic drugs was observed at Sheikh Zaid Hospital Lahore (5.2%) and highest percentage of generic drugs was seen at DHQ of Rhaim Yar Khan (66.7%), lowest percentage of antibiotics prescribed in DHQ of Rhaim Yar Khan (56.7%) while highest percentage of antibiotics prescribed in BHAWAL Victoria hospital Bahawalpur (76.6%),and it was also observed that no injection is prescribed in any outdoor department of hospital, and lowest Percentage of drugs from National Essential Drug List was observed at Nishter hospital Multan (82.4%) while highest Percentage of drugs from NEDL was seen at fifteen hospitals out of total twenty.According to study results average number of drugs prescribed in province Punjab was 3.2 with total 1915, percentage of generic drugs was 29.7% total 569, percentage of antibiotic prescribed in each prescription was 64%, total number of antibiotics prescribed were 452 and 384 prescription were with antibiotics out of total 600 prescriptions, percentage of injection prescribed in outdoor department was zero, percentage of drugs prescribed from NEDL was 96.5% with 1849 drugs from NEDL out of total 1915 drugs of six hundred prescriptions data given in table no.3.While most commonly used antibiotics and their percentage of use in province Punjab hospitals given in table no. 4. Patient care indicators were evaluated in all health facilities and data showed that shortest consultation time 1.9 minutes was in DHQ Saiwal Hospital while longest consultation time was 3.4 minutes in DHQ of Faisalabad, minimum dispensing time was 72 seconds in DHQ of Gujranwala and Saiwal while longest dispensing time 120 seconds in DHQ of Faisalabad, lowest percentage of drugs actually dispensed seen at THQ of Jaranawala & Holly hospital of Rawalpindi (74.3%) while highest percentage of drugs actually dispensed (90%) in DHQ of D.G.Khan, lowest percentage of drugs adequately labeled in DHQ of Jhang & Muzafar Garh was 89.2% while there was 100% accurately labeled drugs from twelve hospitals out of twenty, there was minimum patients how correctly know about the dosage of medicines in almost all of the health facilities as given in table no. 5. Average data about the patient care indicators given in table no. 6. Health facility indicators data was given in table no.7.Data showed that two health facilities, DHQ D.G Khan & THQ of Jaranawala did not have the NEDL or formulary while rest of (90%) health facilities had NEDL or formulary during the study period.The average data about the health facility indicators given in table no. 8 While a list of key drugs was made according to WHO guidelines and check the availability of key drugs in stock of health facilities given in table no.9.Numeric written above in 1 st row from 1 to 20 indicating the names of hospitals as in previous table no.6 Quinine sulfate tablets 0 0 0 0 1 1 1 0 0 1 1 0 1 0 1 1 1 1 0 0 14 vitamin B complex tablets (WHO, How to investigate drug use in health facilities: selected drug use indicators, 1993) ________________________ * Corresponding Author Email: msaeed.akram@hotmail.com.Mobile: +92321947165, Landline: +92414311426 So because of poor drug use in developing countries the WHO has devised indicators, standardized and evaluated it and also grouped these into three indicators as prescribing indicators, patient care indicators and the facility indicators.(WHO, How to investigate drug use in health facilities: selected drug use indicators, 1993).

Table no : 2prescribing care indicators in twenty health facilities of province of Punjab. sr.no Name of Hospital Average number of drugs prescribed Percentage of generic drugs Percentage of antibiotics Percentage of injections
Studies were carried out on twenty health facilities in outdoor departments of hospitals and note the prescribing indicators of WHO given in table *= represent the minimum value, != represent the highest value

Table . 5
: patient care indicators results in twenty health facilities of province Punjab.World Health Organization devised the core indicators after the applying of these indicators we got information about the age, sex, education status of patients, prescribing indicators, patient care indicators, and health facility indicators.According to the results it showed that the average number of drugs per encounter was 3.2, that is outside the range of WHO standards that is less than or equal to 2. (WHO, Policy Perspective on Medicines,