The core drug use indicators represent first-level measures of prescribing and patient care performance in health facilities. They can be measured rapidly by personnel with a minimum of specialized training in pharmaceuticals, and without reference to particular health problems. They are intended for use by district health staff or other personnel interested in improving the quality of care. The results of a drug use indicator study should trigger action to improve aspects of performance identified as major problems.

Because the core drug use indicators are general, and do not refer to particular health problems, they do not lead directly to particular focused interventions. For example, if it is found during an indicators survey that there is a high rate of injection use, it is not necessarily clear what is responsible for causing this, nor what the best strategy for reducing their use might be. Understanding the dynamics of behaviour and designing interventions that respond to underlying factors requires more depth of understanding than a basic indicators study is able to provide.

For this reason, measuring the core drug use indicators can be seen only as a first step in a process of investigation. It can serve to focus attention on one or two aspects of performance, narrowing down the area of subsequent inquiry.

What kinds of follow-up activities are appropriate after an indicators study? There are a few general directions that these activities are likely to take, and some specific questions that might be addressed for each of the individual indicators. Some possibilities are: evaluation of specific treatment practices; examination of factors causing the variations between facilities; and study of beliefs and motivations by means of qualitative techniques.

Evaluation of specific treatment practices

The measures of prescribing and patient care behaviour captured by the core drug use indicators represent averages across a range of health problems and patient types. Because of the sampling methods used, these aggregate measures represent reasonable summaries independent of actual disease patterns. However, without further investigation on individual health problems and how they are treated, it is difficult to know how to address identified problems.

Follow-up studies that focus on particular health problems can take two general forms. If prescribing data have been collected on the detailed prescribing indicator form, and health problems have been recorded, it is possible to identify a subset of patients with particular diagnoses or reported symptoms and to conduct further investigations for this subgroup. This can be done by analyzing the basic indicators for patients with specific diseases (e.g. malaria, respiratory tract infections, diarrhoea). Although the sampling model will not allow strong statistical statements to be made about such subgroups, many of the conclusions about the treatment of particular health problems will be revealing and will point to areas for further work. For example, if 90% of patients with malaria receive an injection when this figure should be less than 10%, there is clearly a problem.

Alternatively, if data on health problems were not collected with the original sample, it is possible to return to health facilities to collect more data focused on cases with specific diagnoses. It might be possible to combine such return visits with interviews of health staff regarding particular practices and a feedback session on the overall survey.

Generally, the health problems studied at this second stage are those that have particular clinical or economic importance in the local area. For example, it may make sense in many countries to focus on malaria, acute respiratory infections or diarrhoea, since they are major sources of morbidity and mortality. Another approach might be to focus on particular sets of symptoms, to see how they are ultimately diagnosed and treated, including such complaints as fever, cough, or non-specific body pain.

Examination of factors causing variation between facilities

Another general area of inquiry is to examine the sources of variation in performance for one or more of the core indicators. Here the goal is to focus on identifiable factors which predict both appropriate and unsatisfactory performance. Rather than attending to sample-wide summaries, such a focus involves looking at the distribution of behaviour in the group of facilities studied. Do all facilities perform equally poorly or equally well? Are there clusters of facilities that stand out in either a positive or negative direction? If so, these facilities can be the focus of additional study. By understanding the reasons why some facilities are better or worse than average, suggestions for improvement may become apparent.

Bar charts similar to the ones given in Annex 3 can be used to identify facilities substantially different from the average. Initially, it may make sense to see if the subgroup of good or bad performers share certain characteristics. Factors such as staffing pattern (presence or absence of a physician), geographic location, socioeconomic levels of the surrounding communities, or features of medical administration, may stand out as important. If not, a series of interviews with key staff in these facilities, that focus on the particular behaviour in question, may begin to tease out some important factors that are shaping performance.

Study of beliefs and motivations by means of qualitative techniques

Informal interviews represent only one of a range of qualitative methods that might be used to examine in more depth some of the beliefs and motivations which underlie drug use behavior. Other qualitative approaches would include structured but more open-ended observation of patient care encounters in specific facilities; open-ended, in-depth interviews with medical staff or patients focusing on particular topics; or a systematic series of focus groups with small numbers of health providers or patients on subjects where group interaction might be useful. Such qualitative techniques are described elsewhere.