Although the indicators as a whole provide a useful summary of pharmaceutical care in public facilities, each of the indicators separately addresses a specific aspect of behaviour. A level of performance on any of the indicators that would be considered unacceptable should provoke specific kinds of follow-up activities. Examples of some of these activities are described below. The questions listed could be used in individual or group interviews, or in focus group discussions. A series of structured observations of actual practices may also be very useful.

1. Average number of drugs per encounter

High number of drugs per encounter

Are there shortages of therapeutically correct drugs? Do prescribers lack therapeutic training or appropriate diagnostic equipment? How secure are prescribers in their ability to diagnose and treat the common illnesses? How strongly do prescribers feel that patient demand influences their practice, and do observations of clinical encounters support this? Are there financial incentives to encourage polypharmacy?

Low number of drugs per encounter

Are there absolute constraints in the drug supply system such that very few drugs tend to be available? Are there administrative regulations that limit the number of drugs that can be prescribed? Do prescribers have appropriate training in therapeutics? Is there significant drug “leakage” from the system?

Economic factors

Is there a drug revolving fund in place that increases pressure on prescribing? Do prescribers profit from the sale of dispensed drugs? What is the level of user fees, and are fees charged per visit or per drug?

Community characteristics

What is the age distribution of the patient population? Do differences in case mix explain some of the observed differences in prescribing, for example, a high proportion of older people with multiple diseases who need more drugs in some facilities?

2. Percentage of drugs prescribed by generic name

Supply factors

Are predominantly generic or branded forms of drugs available in health facilities? How closely have brand names of products been chosen to model their generic name? Are drugs supplied in bulk containers and labelled at the facility, and how are the names written on the labels? Are branded products being prescribed which are not available in health facilities?

Prescriber factors

Do prescribers know the correct generic names for most drugs? How often are prescribers visited by pharmaceutical representatives, and what kind of promotional material is left for them to use? Does the training of the prescribers affect their willingness to prescribe generically?

Health problem factors

Which classes of drugs seem to be particularly problematic? Are there certain common health problems for which a generic form of treatment is not supplied in the system?

3. Percentage of encounters with an antibiotic prescribed

Specifics of antibiotic prescribing

What types of antibiotics and which modes of delivery (injections, tablets, syrups) are most commonly prescribed? What is the relative use of narrow vs. broad spectrum antibiotics? What proportion of antibiotic prescribing is represented by dermatological products, by ophthalmologic products? How much do antibiotics cost, as a percentage of all prescribing or for particularly expensive forms of antibiotic?

Possible influences on antibiotic prescribing

What are the cultural beliefs in the community about antibiotics, and are patient expectations of receiving certain types of antibiotic very high? How strongly are particular antibiotics marketed? Are some antibiotics distributed in the system more than would be indicated by local morbidity patterns? How effective is the drug quality assurance system, and do prescribers have faith that the drugs they are prescribing contain the appropriate therapeutic amounts? Are laboratory facilities necessary for differential diagnosis available and used by prescribers?

Impact of antibiotic use

What are the local resistance patterns to commonly-used antibiotics? How often are particular organisms treated with drugs to which they are likely to be resistant, for example, in specific sexually-transmitted diseases?

4. Percentage injections

Specifics of injection use

What are the specific health problems for which injections are given? Are injections given more often to adults or children treated for these conditions? What is the availability of syrups and mixtures as alternative modes of therapy for small children?

Possible influences on injection use

What are the beliefs and attitudes of patients and health providers about the relative efficacy of injections versus oral medications? Do prescribers report patient demand as an important factor in determining injection use, and do observations of clinical encounters support this? What is the availability of injections outside the public health facility, and is competition with the private injectionists for patient loyalty an important factor? Do patients bring their own needles or syringes? Is there a financial incentive for a health worker to give an injected rather than an oral form of medication?

Impact of overuse of injections

Are appropriate sterilizing units available in health facilities, and are they being used appropriately? What is the local prevalence of HIV and hepatitis-B infections, and is there evidence that lack of sterile technique is a possible source of these blood-borne infections? What are the cost implications of injection use, comparing oral and injected alternatives for the same health problem?

5. Percentage of drugs prescribed from essential drugs list or formulary

Specifics of prescribing

What are the most common drugs being prescribed that are not on the list or formulary? Which health problems are these drugs intended to treat? Are the drugs being prescribed from outside the list generic products or branded products? What is the value of non-EDL drugs compared to EDL drugs?

Supply factors

Is there an adequate supply of the drugs on the essential drugs list or formulary? Who makes decisions about which drugs are ordered for the health facility? Are the forms used for drug orders based on the essential drugs list or formulary, or are they developed from lists of previously-consumed drugs?

Characteristics of the list

How does the essential drugs list or formulary compare to other standard lists of this type, in terms of organization and number of products listed? Do prescribers know about the existence of the list, and which drugs are contained on the list? What efforts have been made to disseminate appropriate unbiased drug information linked to the list or formulary? What is the attitude of prescribers towards the essential drugs list or formulary and its role in the health system?

6. Average consultation time

Health facility aspects

What is the physical organization of the clinic, and is there appropriate allowance for privacy and confidentiality? What is the average workload of health staff, and does the volume of clinic visits allow time for appropriate interactions with patients? What is the volume of patient attendances at different times, during the course of the work day and by week? Could chronic disease patients be scheduled at times when the workload is less?

Prescriber factors

Do the training programmes for various categories of health workers include training in effective communication? Do health workers see communication as an important aspect of their work role? Are there important socioeconomic, ethnic, or status differences between health workers and their patients?

Characteristics of patient-provider interactions

What actually takes place during the clinical encounter between a patient and a health worker? What is the quality of this interaction in terms of effective communication about illness, explanation about illnesses and drugs, and nonverbal expressions of empathy? Are patients and health workers satisfied with what takes place during clinical encounters? Do their expectations about what should take place differ, for example, do patients expect to be more thoroughly examined than providers feel is necessary?

7. Average dispensing time

Health facility aspects

What is the layout of the dispensary, and does it allow for private pharmacist-patient interactions? What is the workload of dispensers, and do they have sufficient time to explain medications to patients? Are dispensing supplies available? What impact does drug supply have on the dispensing process, in terms of the availability of products, how efficiently they are stored, and whether appropriate hygienic techniques are followed? How is decision-making organized within the dispensary, in regard to product substitution, the number of days' supply dispensed, and so forth? What is the impact of patient fees for drugs on the type and quantity of drugs that are dispensed?

Dispenser's background

What is the average level of training of personnel working in the dispensary? Have they been appropriately trained in educating patients about drugs? What is the understanding of dispensary personnel about their responsibilities, and do they feel it includes patient education? Do dispensers ask patients to repeat how they will take the drugs?

Characteristics of patient-dispenser interactions

What is the quality of the interaction between dispensers and patients? Is there communication about the purpose for individual drugs, how they should be taken, and possible side effects? Are dispensers and patients satisfied with their interaction? What is the patient's understanding of the dispenser's role? Do patients expect to learn more from dispensers about drugs?

8. Percentage of drugs actually dispensed

Differences between prescribed and dispensed drugs

Are there certain types of drugs that are routinely prescribed, yet not dispensed? Is the problem more common for specific therapeutic classes or drugs to treat particular illnesses? Are drugs not being dispensed even when they are available in health facility stores? Are drugs which are not dispensed available in the local community? What are the reasons why pharmacists did not dispense the drugs as they were prescribed? Are there rules laid down for what they will dispense?

Patient attitudes

Do patients plan to purchase the drugs that were not dispensed at the health facility? If they do not plan to purchase them, is it because they cannot afford to pay for them, or because they do not think the drugs are important? If they plan to purchase only a proportion of the drugs prescribed, how do they prioritize? What do patients understand are the reasons for products not being given in the amounts they were prescribed, or are they even aware that this was the case?

9. Percentage of drugs adequately labelled

Specify inadequate labelling

What element of appropriate labelling is missing: the name of the patient, the correct generic name of the drug, or the drug strength? Is the information written legibly? Is information on how the drug is to be taken also written on the label, using terminology that patients are likely to understand? Is the information on dosage correct according to the standard for this drug?

Reasons for inadequate labelling

Are dispensers adequately trained in how drugs are to be packaged and labelled? Are there adequate packaging materials available at health facilities? Do dispensers have time, given their typical workload, to package and label drugs appropriately? Are procedures adequately supervised by pharmacy and medical personnel?

10. Patients' knowledge of correct dosage

Patient-provider communication

Is the physical layout of the clinic (examination and dispensing areas) conducive to communication about health problems and drugs? How do different health workers (physicians, nurses, pharmacy attendants) describe their role in communicating about drugs, and how often do they perform the functions they describe? What is the typical content of communication about pharmaceuticals: what drugs do, how they should be taken, possible side effects and precautions, relative importance of different products, and so forth? Is information about drugs offered voluntarily by health workers, or do they depend on patients to ask specific questions? Do patients ask questions?

Patient understanding and compliance

What do patients actually understand about the drugs they have received: what drugs do, how they should be taken, side effects, and so forth? How does patient understanding compare with the information communicated during clinical and dispensing encounters? What are the sources of misunderstanding about drugs: lack of correct information, cultural or language differences between patients and providers, lack of patient interest, or other factors? Do patients leaving health facilities intend to comply with recommendations about drugs? What are the reasons for expected or actual noncompliance with recommended drug therapies?

11. Availability of copy of essential drugs list or formulary

Characteristics of the list or formulary

Which products are included on the drugs list or formulary? How does the list compare with WHO recommendations? Does the same list apply to different levels of care, or are only subsets of drugs recommended at lower levels? Does the list or formulary contain descriptive information about drugs or therapeutic guidelines? What efforts have been made to disseminate the essential drugs list or formulary to individual prescribers? Is the formulary or EDL clean with unbroken binding, or dirty indicating that it has been used?

Prescriber attitudes

How do prescribers describe the purpose of the essential drugs list? Are they generally aware of which drugs are on the list? Do health personnel responsible for drug procurement at individual facilities consult the list when making purchase decisions? Do prescribers recommend similar types of therapy in both their public sector and private sector practices? Do prescribers think they could affect the next list?

12. Availability of key drugs

Supply system

Are there particular classes of drugs or particular dose forms (for example, paediatric syrups) which are more likely to be out of stock? Does the incidence of the stock-outs tend to vary seasonally with the drug procurement cycle? Once products go out of stock, how long do they tend to remain out of stock? What is the system for informing prescribers about pharmacy stock-outs, and are there procedures for therapeutic substitution by pharmacists or dispensers?

Focus on key drugs

Are there particular health problems for which drugs tend to go out of stock on a regular basis, for example, malaria or tuberculosis? Are there therapeutic alternatives in stock for the drugs which are found to be out of stock? Do prescribers respond to the absence of a drug by continuing to prescribe it and expecting patients to purchase the product in the private sector, or by switching to a therapeutic alternative?