KATHLEEN HOLLOWAY, VERICA IVANOVSKA
K. Holloway
V. Ivanovska
RATIONAL use of medicines requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost to them and their community. Unfortunately irrational use of medicines is widespread throughout the world. Problems include the unnecessary prescription of drugs, particularly antimicrobials and injections. This is harmful in terms of economic loss, unnecessary adverse drug events, antimicrobial resistance and the spread of hepatitis B and C and HIV though unsterile needles.
Much has been done in the past 15 years to improve the use of medicines. The International Network for the Rational Use of Drugs (INRUD) was formed in 1989 with the objective of undertaking multidisciplinary intervention research to promote more rational use of drugs in developing countries. INRUD was instrumental in developing the WHO indicators of drug use and a rapid appraisal method for investigating drug use. In 1997 the first international conference for rational use of medicines (ICIUM) was held in Chiang Mai, Thailand, where 272 participants from 46 countries met to review experience and define future directions, particularly for developing countries.
In April 2004 the second International Conference For Rational Use of Drugs will be held, again in Chiang Mai. Here progress made since the first conference will be assessed, and remaining gaps and future directions discussed. A new WHO database containing quantitative drug use data is being constructed in order to provide a general overview of drug use patterns in primary health care settings in developing countries over the past decade. Specifically, the database will tell us whether there has been any improvement in drug use over the period, what interventions have been done and where, and their impact and what serious gaps remain. The results will be presented in the conference and used to help define a future global agenda and also as an advocacy tool for promotion of rational use of medicines in the developing world.
Table 1
Drug use surveys and interventions conducted in WHO regions 1993 - 2002
WHO region |
AFRO |
EURO |
EMRO |
SEARO |
WPRO |
PAHO |
No.of surveys |
103 |
4 |
26 |
61 |
28 |
27 |
No.of interventions |
33 |
0 |
11 |
15 |
13 |
10 |
WHO Regional Offices for Africa (AFRO), Europe (EURO), Eastern Mediterranean (EMRO), South-East Asia (SEARO), Western Pacific (WPRO), the Americas (PAHO)
Relevant studies on rational use of medicines for the period 1990 - 2003 are being identified using the latest INRUD bibliography and WHO/EDM country's archives including articles, research proposals, theses, and reports on the subject studied. The database is based on standard WHO/INRUD indicators and some additionally developed indicators that describe drug use patterns more completely. Details concerning methodology and interventions are being entered into the database so that the impact of interventions can be assessed. The database will also be linked to other WHO databases, in order to obtain more comprehensive picture of drug use practices and how they are affected by health system factors.
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The world of essential medicines loses a pioneer
DR Molly Thomas, former Professor and Head of Pharmacology and Clinical Pharmacology at the Christian Medical College, Vellore, India, died on 22 March 2003. As Head of the Christian Medical Association of India's Working Group on Rational Drug Use she was a true champion for the cause of rational therapy. Dr Thomas edited the Rational Drugs News Letter, and was an active member of the All India Drug Action Network. Her abiding belief was that rational medicines use would bring health care within the reach of the poor by reducing costs.
Dr Thomas travelled tirelessly across the country conducting training workshops for mission hospitals, developing their policy on rational drug use, undertaking prescription audits and coordinating drug reaction reporting. In 1983 she set up the first adverse drug reaction monitoring centre, in Vellore.
An excellent teacher, who went beyond the class room to care for her students, Dr Thomas was made a Fellow of the Royal College of Physicians of Edinburgh, UK.
Article and photograph courtesy of the Christian Medical Association of India
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By September 2003, 2739 articles from the INRUD bibliography for 1993 - 2002 had been screened, 187 relevant articles identified and 249 survey results entered into the database. Table 1 shows more detail of where surveys and interventions have been conducted.
Figure 1 shows some initial findings for one indicator of drug use - the percentage of patients treated in accordance with clinical guidelines. These initial results should be treated with caution as a complete analysis has not yet been done, and the database does not yet contain many of the unpublished surveys held within the WHO archives. Thus the final results may be quite different and will be accompanied by other details such as disease and prescriber type and impact of interventions implemented. Nevertheless, initial data show that there continues a great need to improve prescribing habits, as more than half of all patients have not been treated in accordance with guidelines. Also it is clear that relatively few studies have been done.
Figure 1. Primary health care patients treated according to guidelines
In summary, this database will be presented at the second ICIUM and used to help to identify progress and gaps and a future agenda for achieving global rational use of drugs in the developing world. We hope that as many of you as possible will join us at the second ICIUM in Thailand in April 2004 to share experiences and help us develop a future global agenda to promote more rational use of medicines. For more details see p.9.
Kathleen Holloway is a Medical Officer and Verika Ivanovska is a Technical Officer in the Policy, Access and Rational Use team, Department of Essential Drugs and Medicines Policy, WHO, Geneva. E-mail: hollowayk@who.int, or ivanovskav@who.int
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