Is education of the community in the use of medicines a necessity, or is it just a luxury - the "icing on the cake" - to be considered when all other aspects of a national drug policy are in place? Can most countries afford to undertake such education when so many problems of supply and access remain unsolved in the pharmaceutical sector? Is it perhaps a priority only for the more wealthy parts of the world? Or should the question be posed differently? Can countries afford NOT to commit themselves to such community education if health is to be improved and resources used rationally? These are key questions facing countries and development organizations.

The general public needs information and education on medicines and appropriate treatment seeking strategies for a number of compelling public health reasons:

• because of the important role of pharmaceuticals in modern health care;

• so that individuals and communities can take responsibility for their health, including decisions on appropriate therapeutic strategies: both a human right and prerequisite for sound decision-making;

• so that as consumers they have the basic tools for rational and safe direct purchase of medicines, and can put in context the claims of commercial drug promotion: both critical areas in view of the extent of self-medication and evidence of unethical marketing practices;

• so that as patients they can be informed partners in therapeutic decision making and subsequent drug use: an essential element for optimal therapeutic outcomes since the patient is the final determinant of drug use.

Rights/responsibilities

Community responsibilities and rights in health care have been articulated in many international gatherings. For example the Alma Ata Declaration¹ states: “People have the right and duty to participate individually and collectively in the planning and implementation of their health care”. The Ottawa Charter² recognizes the “community as the essential voice in matters of its health” and calls for a reorientation of health services towards health promotion; and power sharing with “other sectors, other disciplines and, most importantly, with people themselves”.

Misuse of drugs

Community rights and responsibilities must be underpinned by education and information. Many studies point to major misconceptions and misuse of drugs by prescribers, dispensers and consumers. Research from such countries as Ethiopia,³ Ghana,⁴ India,⁵ Kenya,⁶ Papua New Guinea,⁷ and the Philippines⁸ shows that consumers in general know very little about the drugs they use, their effects and their basic mechanisms. Other studies show that although modern pharmaceuticals are based on a rational-scientific model, in practice, they are distributed, prescribed and used in ways that frequently don’t accord with that model.^9-17

Pharmaceutical marketing to prescribers, dispensers and consumers may contribute to irrational use. Unethical marketing of drugs is widespread in developing countries^{18 19} and although standards have improved in developed countries, recent studies have found continuing problems, such as false and misleading claims, switch campaigns and commercial promotion disguised as scientific trials.^{20 21}

Consumers: the ultimate decision-makers

Self-medication, in both industrialized^{22 23} and developing countries, is the most common reaction to perceived symptoms. Global sales of products which are traditionally considered as OTC (over-the-counter, non prescription) drugs accounted for roughly 17% of the world pharmaceutical market (sales value) in 1993. Three quarters of these sales were in Europe, Japan and the United States of America.²⁴

However, these figures do not reflect the full picture. OTC medicines are generally less expensive than prescription medications so that the relative volume consumed is greater than 17% of total sales. More significantly, self-medication has many manifestations which are not reflected in OTC sales data. These include the use of traditional medicines, the stocking and re-use of prescription drugs, and the direct purchase of prescription medications by consumers. Household survey and other community based studies in Africa, Asia and Latin America have found that up to 80% of illness episodes are self-treated with modern pharmaceuticals.^2325-28

Prescription drugs are widely available from a variety of sources which include street peddlers, traditional healers and unlicensed stores.²⁹ In many developing countries, prescription-only drugs are also routinely available direct to consumers even from licensed pharmacies due to lack of state regulatory enforcement capacity. ³⁰

Even when consumers use formal health care channels, their decision-making and not that of the health care provider, is the ultimate determinant of drug use. Once they have a prescription, patients decide whether to buy the drugs or not, whether they are going to buy all the items on the prescription or only some of them. In doing so they may need to decide what items are important and worth buying. Patients also decide whether and when to take the medicines, whether to continue taking them if side effects occur or symptoms disappear, and what to do with any unused medicines.

These decisions are influenced by the beliefs of family or friends or the larger community. Pharmacists are often the health professionals with closest contact to the public and may be a key source of advice. Physicians and other prescribers may have an indirect impact on consumer decisions, particularly if a patient was initially introduced to a product through a prescription. And, of course, the promotional material of drug manufacturers is intended to influence consumer choice. How medicines are obtained and used is therefore not just about individual choices made by a prescriber or consumer but reflects a matrix of societal, economic and health factors which influence those decisions.

The role of public education

Public education has an important role to play to influence these decisions positively. Consumers need access to accurate and understandable information about the potential benefits and risks of medicines in general; how they act within the body; the limitations of pharmacotherapy and other treatment options. Patients during a therapeutic or dispensing encounter need information about the risk/benefit of different treatment options, including side-effects.

This report of a WHO global study of current work in public education in rational drug use examines who and what is being targeted; who is doing the work, how and why; what are the needs and lessons learned; where could we go from here. The study attempts to contribute to the body of knowledge in what is an under-reported and neglected field so that countries, organizations and individuals embarking on public education initiatives can maximize their chances of success, draw on the work and experience of others, and truly contribute to community empowerment.