(2004; 98 pages)
2.4 The health institution level
Health facilities, including health centres and hospitals in the private and public sectors, influence consumers’ medicines use.
Consulting health workers
Household drug use studies in developing countries suggest that most medicines are taken without advice from health workers. Of particular importance are the findings of community-based studies conducted in Thailand, the Philippines, Pakistan and Ghana (Hardon and Le Grand, 1993). In these studies, researchers visited families at regular intervals to record the occurrence of common health problems, such as cough and diarrhoea, and the chosen therapy. The findings suggest that a large proportion of common health problems are treated by family members without first seeking health worker advice. Roughly half of the self-care cases were treated with modern pharmaceuticals (Hardon and Le Grand, 1993; Rasmussen, 1996).
Quality of prescribing
The quality of health workers’ prescribing is a major determinant of how consumers use medicines. This is true, even if in terms of volume, most medicines are taken without health worker advice. The quality of prescribing plays a crucial role in the treatment of serious health conditions when people do tend to consult health workers. It also affects the treatment of less severe conditions, as people tend to remember the advice given and use it in later episodes of self-medication. In the Philippines it was observed that people keep prescriptions in their homes for re-use (Hardon, 1991).
BOX 3. CONSUMERS’ ADVICE-SEEKING BEHAVIOUR
Researchers conducted a household survey in four Thai villages covered by a primary health care (PHC) programme that promoted the use of herbal medicines in self-care. One hundred and twenty families participated in the two-month study in which a total of 1,755 cases of illness were recorded. The study found that people in the four villages only consulted a health professional in 7% of the illness episodes. Seventy percent of the illnesses were initially treated by self-care. Approximately half of the cases were treated with modern pharmaceuticals and the other half with herbal remedies.
Le Grand A, Sringernyuang L (1989). Herbal drugs in primary health care. Amsterdam, Royal Tropical Institute.
A household survey was conducted in two villages covered by an NGO primary health care programme (AKHS) and two control communities in Pakistan’s Karakoram Mountains during a period of seven months. A total of 897 illness episodes were recorded. In the PHC communities 44% of the recorded illness episodes were treated without health worker advice; in the control communities this percentage was slightly higher, 52%. Self-care practices included the use of traditional and herbal remedies, the use of modern pharmaceuticals and no treatment. In the PHC communities 16% of the recorded illness episodes were treated with modern pharmaceuticals without health worker advice. This number was 11% for the control communities.
Rasmussen ZA et al. (1996). Enhancing appropriate medicine use in the Karakoram Mountains. Community Drug Use Studies. Amsterdam, Het Spinhuis.
Studies conducted by members of the International Network for Rational Use of Drugs (INRUD) document how health workers practice poly-pharmacy. A study conducted in Indonesia found that the average number of drugs used to treat illnesses presented to the health worker was 3.8, both for children under five and for the five and over age group. Patients seemed to receive a similar mix of vitamins, analgesics and antibiotics irrespective of their disorders. The way in which health workers prescribe multiple medicines reinforces consumer beliefs that they need “a pill for every ill”; and that a cure is unlikely without using medicines.
In some countries, professional organizations have been created to inform health workers about rational prescribing and rational drug use. Health institutions can also adopt an essential medicines list and standard treatment guidelines in order to increase rational use of medicines.
Quality of the consultation
Numerous studies on adherence (Homedes and Ugalde, 1993) suggest that people rarely take medicines as prescribed. Some obvious examples include the use of antibiotics and antituberculosis medications in inadequate dosages. People also follow irregular drug regimes for chronic conditions such as hypertension and diabetes. It has been estimated that half of the medicines prescribed for chronic conditions are not taken (Haynes et al., 1996).
Non-adherence can be related to the health worker - consumer interaction. If the health worker does not explain the need to complete treatments, the dosages required, and ways to handle side-effects, then adherence to the prescribed regime is less likely. In a study of 69 hypertensive and diabetic patients in Zimbabwe, Nyazema (1984) found that 60% of the patients did not understand their diagnosis and how to take the prescribed drugs. A study of 119 patients in the Dominican Republic found that 50% could not recall the dosage, frequency or interval of recommended use (Ugalde et al., 1986). This was particularly problematic among the elderly, those with minimal literacy skills and when multiple prescriptions were given.
While non-adherence generally has a negative connotation, Conrad (1985) points out its positive aspects. Children with asthma, for example, have been reported to keep their medicines as their own property, and adjust the frequency and intensity of inhalations depending on the severity of their symptoms (Sanz, 2003). Middle-aged patients with multiple health problems have likewise been shown to adopt ´flexible´ drug use regimes, in response to their experiences of symptoms and side-effects and varying demands of their daily lives. They generally intend to take as few drugs as possible because they hope to maximize the quality of their lives (Hunt et al., 2003). Doctors say that not taking medicines according to the prescription means poorer health outcomes, but patients argue that only they can know what works for them and what does not. To bridge this gap, it has been proposed that concordance is a better concept. It means shared decision-making and arriving at an agreement on the use of medicines that respects the beliefs and experiences of the patient (Jones, 2003).
Quality of dispensing
Medicine dispensing is strictly regulated in most industrialized countries. Those who dispense drugs must complete certain levels of training depending on the types of medicines they dispense. It is increasingly recognized that pharmacists have an important role to play in providing information on medicines, to complement the information given by doctors.
Pharmacies are also important targets for drug promotion campaigns. In developing countries untrained pharmacy workers tend to dispense medicines in shops owned by pharmacists. These workers have little background knowledge about medicines. However, they are important sources of information on a wide range of medicines (including prescription-only drugs). Medicines are often dispensed in small sachets with little information about their content, use and precautions. Often package inserts meant to inform consumers about a medicine are not given to them when the drug is purchased. Medicines dispensed at markets or informal drug stores usually include no written information at all. Often they are wrapped in newspaper and sold by the tablet.
Doctors who also dispense drugs for profit are likely to prescribe more than non-dispensing doctors. A comparative study in Zimbabwe found that dispensing doctors prescribed on average 2.3 drugs per prescription, while non-dispensing doctors prescribed only 1.7 drugs. Dispensing doctors were also more likely to inject patients, 18.4% versus 9.5% (Trap et al., 2002).
People judge health centres by whether they have a regular supply of medicines. Often when consulting health workers in developing countries, people find that there are no drugs available. Because consumers know that public health centres often lack medicines, they may go directly to pharmacies and informal drug shops when they or someone in the family become ill.
Cost of medicines
Often fees for medicines in public health services are relatively low. People pay more in the private sector. They often do so because medicines in the private sector are believed to be more effective.