Complexity of the issue

The factors that influence drug use are many and interrelated. Changing complex practices that are embedded in cultural and social beliefs and shaped by knowledge, attitudes, infrastructure and economic interests is very difficult. No single approach is likely to work, and some interventions may produce unintended effects. A combination of strategies tailored to the needs of the different groups and different environments is needed.

Conflicting interests

Policies to promote rational use are often controversial and may be opposed for various reasons. Prescribers, and particularly those who also dispense, may have a financial interest in prescribing more drugs or drugs with the highest profit margins; they may resent any interference with their freedom to prescribe. They may also derive a certain status from prescribing many newly marketed or expensive drugs. Pharmacists and drug sellers have a financial interest in increasing the volume of their business; producers want to increase their sales and their marketing practices may conflict with the goals of rational use. Consumers and prescribers may believe that interventions to encourage rational use are intended to cut costs rather than to improve therapy. It is important to identify and consider all these various interests, which are basic barriers to change.

Lack of independent information

In many countries there is little or no access to regular, up-to-date drug information, and health workers and consumers are almost entirely dependent on commercial sources of information. As a result the prescribers and consumers in most developing countries are poorly informed. Even where prescribers and consumers have access to independent drug bulletins, drug information centres and other sources of information, they are also exposed to a huge volume of commercial information. This information imbalance is a serious constraint on policies to promote the rational use of drugs.

Inappropriate drug promotion

Drugs have a potential not only for benefit but also for harm, and their promotion therefore requires special controls to protect the public. Inappropriate promotion of medicinal drugs remains a problem in both developing and developed countries.

Problems relate to scientific accuracy and balance of information, improper inducements to prescribers or dispensers, lack of full product information, misleading presentations by medical representatives, and promotional activities disguised as educational or scientific exercises.

Unrestricted availability of prescription drugs

In many countries medicines that require medical supervision and a prescription are freely available from drug sellers and pharmacies. This can lead to inappropriate use and to delays in the correct diagnosis and treatment. Unrestricted availability can also contribute to the emergence of drug resistance, drug interactions and adverse effects, and inefficient use of scarce household resources.