RATIONAL use of drugs is one of the critical factors contributing to quality, cost-effective health care. Acknowledging this, over the last decade many developing and developed countries started to investigate drug use in order to identify problem areas. WHO and the International Network for the Rational Use of Drugs (INRUD) contributed to this vital process by developing simple indicators to monitor drug use in individual health facilities or in a country or region.^{1, 2}

Namibia is one of the countries committed to monitoring in order to improve its health system, and first used the WHO/INRUD indicators in 1994 in the North West Regional Directorate. The first national drug use survey took place in 1997, and it was decided to repeat surveys every two years, with the second one conducted from April to June 1999³. Survey results are being used to identify any changes over the previous two years, any knowledge gaps, and areas that need improvement through research and intervention activities.

The 1999 survey included 30 clinics and health centres, 10 district hospitals and Namibia’s four major referral hospitals. Data collection was done prospectively from at least 30 out-patient encounters at each facility.

The survey measured the parameters of drug prescribing, drug availability and quality of care, and documented changes observed during the previous two years. The average cost per prescription at health facilities and adherence of prescriptions to treatment guidelines were also analysed for the first time. See the figure below for the main results of the 1999 survey and the comparable results from the first survey.

National drug use survey results 1997-1999

The Ministry of Health and Social Services recently decided to expand monitoring. Evaluation of other pharmaceutical components and achievements, such as improving drug access and quality, will be included in a comprehensive national drug policy monitoring system.

Acting on results

Positive changes include the increase in generic prescribing and the decrease in the use of injections (even though the latter can mainly be attributed to the exclusion of family planning injections from the 1999 survey). Matters for concern are the increase in the number of antibiotics, the continuing low level of adequate labelling and the increase in the average number of drugs per prescription from 2.49 in 1997 to 2.55 in 1999. Adherence to treatment guidelines is low, which is shown by the wide range in the price of drugs prescribed for the same diagnosis.

Registered Nurse Salinde Guriras and Mrs. Veenda Nependa, Head of Family and Community Health Subdivision at Narraville Clinic, Walvis Bay, one of the health facilities that has taken part in drug use studies in Namibia

Photo: Ministry of Health and Social Services, Namibia

Following analysis of the survey results, recommendations included more training in diagnosis and prescribing at all levels, and increased attention to ensure correct labelling of drugs dispensed. Although drug availability is generally good, it was agreed that steps should be taken to ensure hospitals are not favoured over clinics in times of drug shortages. A further recommendation was for a costing study using retrospective data to give a clearer indication of average cost per prescription.

For further information contact: Ministry of Health and Social Services, Division of Pharmaceutical Services, Private Bag 13 198, Windhoek, Namibia.

References

1. WHO. How to investigate drug use in health facilities. Geneva: World Health Organization; 1993. WHO/DAP/ 93.1.

2. Brudon P, Rainhorn JD, Reich MR. Indicators for monitoring national drug policy. 2nd ed. Geneva: World Health Organization; 1999. WHO/EDM/PAR99.3.

3. Shiyandja N, Schümann M. Second national survey on the use of drugs in Namibia’s public health institutions. Windhoek: Ministry of Health and Social Services; 2000.

Research update

Antibiotic use in infants hospitalised with HIV-related pneumonia

I. Chitsike, Department of Paediatrics and Child Health, Medical School, University of Zimbabwe, Harare.

The aim of the study was to describe the clinical features of infants admitted with HIV-related pneumonia, and to describe antibiotic use in relation to recommended treatment guidelines. Researchers conducted a cross-sectional analysis of records from the paediatric wards of two university teaching hospitals in the capital, Parirenyatwa and Harare Central, to determine mortality and antibiotic use.

The records of 100 infants admitted for 48 hours or more with features of HIV-related pneumonia were analysed for clinical features and antibiotic use. The study showed that the peak age of children admitted was two months and overall mortality was 27%. The odds ratio of dying at Harare Central Hospital was three times that of Parirenyatwa. Increased mortality was associated with use of ampicillin, whereas decreased mortality was associated with use of benzyl penicillin, which is the recommended drug in the treatment guidelines. Uncertainty about the etiology of pneumonia resulted in overprescribing - the main cause of lack of compliance with standard treatment guidelines.

The study concludes that there is an urgent need to address rational prescribing in the face of changing pattern of disease as result of the HIV edpidemic.

Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial

G. Kidane, R.H. Morrow

No satisfactory strategy for reducing high child mortality from malaria has yet been established in tropical Africa. The authors compared the effect on under-5 mortality of teaching mothers to provide antimalarials promptly to their sick children at home, with the present community health worker approach.

Of 37 tabias (clusters of villages) in two districts with hyperendemic to holo-endemic malaria, tabias reported to have the highest malaria morbidity were selected. A census was done which included a maternity history to determine under-5 mortality. Tabias were paired according to under-5 mortality rates. One tabia from each pair was allocated by random number to an intervention group and the other was allocated to the control group. In the intervention villages, mother coordinators were trained to teach other local mothers to recognise symptoms of malaria in their children, and to promptly give chloroquine. Villages in the control group continued to use the community health worker/facility-based approach for health service delivery, and used mother coordinators for surveillance. In both intervention and control tabias, all births and deaths of under-5s were recorded monthly.

From January to December 1997, 190 of 6383 (29.8 per 1000) children under-5 died in the intervention tabias compared with 366 of 7294 (50.2 per 1000) in the control tabias. Under-5 mortality was reduced by 40% in the intervention villages. For every third child who died, a structured verbal autopsy was undertaken to decide if cause of death was consistent with malaria or possible malaria, or not. Of the 190 verbal autopsies, 13 (19%) of 70 in the intervention tabias were consistent with possible malaria compared with 68 (57%) of 120 in the control tabias.

The authors conclude that a major reduction in under-5 mortality can be achieved in holoendemic malaria areas through training local mother coordinators to teach other mothers to give children under-5 years old antimalarial drugs.

Reference: The Lancet 2000; 356(9229):550-5.

Framework for design and evaluation of complex interventions to improve health

M. Campbell, R. Fitzpatrick, A. Haines, A.L. Kinmonth, P. Sandercock, D. Spiegelhalter, P. Tyrer

Randomised controlled trials are widely accepted as the most reliable method of determining effectiveness, but most trials have evaluated the effects of a single intervention such as a drug. Recognition is increasing that other, non-pharmacological interventions should also be rigorously evaluated. This paper examines the design and execution of research required to address the additional problems resulting from evaluation of complex interventions - that is, those “made up of various interconnecting parts.” The issues dealt with are discussed in a longer Medical Research Council paper (www.mrc.ac.uk/complex_packages.html). The authors focus on randomised trials but believe that this approach could be adapted to other designs when they are more appropriate.

Reference: BMJ 2000; 321:694-6.

Details of these and other recent articles can be found in INRUD News, March 2001, available on the Web at: http://www.msh.org/inrud/