In 1985 WHO convened a major conference in Nairobi on the Rational Use of Drugs1. Since that time efforts have increased to improve drug use practices2,3. An essential tool for such work is an objective method to measure drug use in health facilities that will describe drug use patterns and prescribing behaviour. However, the lack of agreement on such a method has been a recurrent problem.
The main purpose of this manual is to define a limited number of objective measures that can describe the drug use situation in a country, region or individual health facility. Such measures, or indicators, will allow health planners, managers and researchers to make basic comparisons between situations in different areas or at different times. Also, when an intervention is undertaken to improve aspects of drug use, the indicators can be used to measure impact. Indicators can also serve as simple supervisory tools to detect problems in performance by individual providers or health facilities.
The drug use indicators described in this manual are intended to measure specific aspects of the behaviour of health providers in health facilities in a reproducible manner, irrespective of who measures them or when the measures are taken. The techniques for using the indicators have been well tested, and can be implemented in a standard way by individuals without special training or access to many resources. The indicators can be quickly and efficiently used in many settings to assess potential problems in drug use, and to prioritize and focus subsequent efforts to correct these problems.
The process of diagnosis and pharmaceutical treatment is complex. Techniques do not yet exist for adequately assessing the quality of this process in a standardized, objective way. The indicators described in this manual do not measure all dimensions of the appropriateness of pharmaceutical care, nor even necessarily the most important ones. For many of the aspects of care addressed by the indicators it is unclear at this time what the “gold standard” for correct behaviour should be. The drug use indicators are best understood as first-line measures, intended to stimulate further questioning and to guide subsequent action.
For example, consider a situation where the average number of drugs per prescription was found to be 4.2, with 13% of patients receiving injections. Although objective norms may not exist for either indicator, the health managers carrying out the study may feel that in their local health environment the expected norm should be about 2 drugs per encounter, with 20% of patients needing injections. In such a situation priority would be given to finding out why so many drugs were prescribed, and to reducing the total number if the reasons for such high use were inappropriate. Conversely, if they found an average of 1.8 drugs per encounter and 65% injectables, priority would be given to exploring the reasons for this apparent overuse of injections.
Other health programmes in developing countries have defined indicators and standard data collection methods with great success. For example, immunization coverage is used as one indicator of the success of immunization programmes, and in every country the same definitions and data collection methods are used. Within most health systems the provision of curative care is a far more substantial activity in terms of staff time, money spent on drugs and patient demand, and yet simple indicators of drug use do not widely exist.
This manual is a first attempt to fill this gap and to propose some standardization in the different methods that are increasingly being used in the field.