1. Studies on drug use pattern and costStudies on drug use pattern and cost
efficiency in Upazilla Healthefficiency in Upazilla Health
Complexes in BangladeshComplexes in Bangladesh
H. M. AlamgirH. M. Alamgir
Department of Clinical Pharmacy and Pharmacology
Faculty of Pharmacy
University of Dhaka

2. Why this study?Why this study?
• In the developing countries like Bangladesh,In the developing countries like Bangladesh,
inappropriate, ineffective and economicallyinappropriate, ineffective and economically
inefficient use of drug is widespread in healthinefficient use of drug is widespread in health
care facilities like Upazilla Health Complexes incare facilities like Upazilla Health Complexes in
Bangladesh.Bangladesh.
• The cost of such irrational use of drugs isThe cost of such irrational use of drugs is
enormous in terms of both resources and theenormous in terms of both resources and the
adverse clinical consequences of which haveadverse clinical consequences of which have
many risks without any objective benefits.many risks without any objective benefits.
Studies on Drug Use Pattern and Cost Efficiency 2

3. Why this study?Why this study?
• This misuse or irrational use of drugs must beThis misuse or irrational use of drugs must be
minimized to an affordable limit to save limitedminimized to an affordable limit to save limited
resources and the consumers from unnecessaryresources and the consumers from unnecessary
sufferings from adverse effects of pharmaceuticalsufferings from adverse effects of pharmaceutical
products.products.
3Studies on Drug Use Pattern and Cost Efficiency

4. Studies on Drug Use Pattern and Cost Efficiency 4
Research ObjectivesResearch Objectives
• To assess the drug use pattern on 6 commonTo assess the drug use pattern on 6 common
diseases in Bangladeshdiseases in Bangladesh
• To identify magnitude and nature ofTo identify magnitude and nature of
inappropriate drug utilizationinappropriate drug utilization
• To understand the adverse impacts ofTo understand the adverse impacts of
inappropriate use of drugsinappropriate use of drugs
• To examine the impact of irrational prescribingTo examine the impact of irrational prescribing
on the drug cost for treatment of 6 selectedon the drug cost for treatment of 6 selected
common diseasescommon diseases

5. Research ObjectivesResearch Objectives
• To identify factors that influence the behavior ofTo identify factors that influence the behavior of
prescribers and patientsprescribers and patients
• To assess the availability of essential drugs inTo assess the availability of essential drugs in
health facilitieshealth facilities
• To assess the availability of EDL and STG inTo assess the availability of EDL and STG in
health facilitieshealth facilities
• To identify the role of economic incentives,To identify the role of economic incentives,
professional controls and bureaucraticprofessional controls and bureaucratic
regulations in the prescribing pattern of theregulations in the prescribing pattern of the
health care professionals and providershealth care professionals and providers
5Studies on Drug Use Pattern and Cost Efficiency

6. 6
What Is Rational Use of Drugs?What Is Rational Use of Drugs?
The rational use of drugs requires that patients receive medicinesThe rational use of drugs requires that patients receive medicines
appropriate to their clinical needs, in doses that meet their own individualappropriate to their clinical needs, in doses that meet their own individual
requirements, for an adequate period of time, and at the lowest cost torequirements, for an adequate period of time, and at the lowest cost to
them and the community.them and the community.
(WHO 1988)(WHO 1988)
Appropriate indicationAppropriate indication
Appropriate drugAppropriate drug
Appropriate administration, dosage and durationAppropriate administration, dosage and duration
Appropriate patientAppropriate patient
Appropriate patient informationAppropriate patient information
Appropriate evaluationAppropriate evaluation
Studies on Drug Use Pattern and Cost Efficiency

7. 7
Irrational Use of DrugsIrrational Use of Drugs
• The use of drugs when no drug therapy is indicatedThe use of drugs when no drug therapy is indicated
• The use of wrong drugs for a specific conditionThe use of wrong drugs for a specific condition
requiring drug therapyrequiring drug therapy
• The use of drugs with doubtful or unproven efficacyThe use of drugs with doubtful or unproven efficacy
• The use of drugs of uncertain safety statusThe use of drugs of uncertain safety status
• Failure to prescribe available, safe & effective drugsFailure to prescribe available, safe & effective drugs
• Incorrect administration, dosages or durationIncorrect administration, dosages or durationStudies on Drug Use Pattern and Cost Efficiency

8. 8
Examples of Common InappropriateExamples of Common Inappropriate
Prescribing PracticesPrescribing Practices
• Overuse of antibiotics and antidiarrheals forOveruse of antibiotics and antidiarrheals for
nonspecific childhood diarrheanonspecific childhood diarrhea
• Indiscriminate use of injections for malariaIndiscriminate use of injections for malaria
• Multiple or overprescriptionMultiple or overprescription
• Use of antibiotics for mild, nonbacterialUse of antibiotics for mild, nonbacterial
infection, e.g., ARIinfection, e.g., ARI
• Tonics and multivitamins for malnutritionTonics and multivitamins for malnutrition
Studies on Drug Use Pattern and Cost Efficiency

9. 9
Components of the Drug UseComponents of the Drug Use
SystemSystem
Drug ImportsDrug Imports
LocalLocal
ManufactureManufacture
HospitalHospital oror
HealthHealth CenteCenterr
Private Physician orPrivate Physician or
Other PractitionerOther Practitioner Pharmacist orPharmacist or
Drug TraderDrug Trader
The DrugThe Drug SupplySupply
ProcessProcess
Provider andProvider and
Consumer BehaviorConsumer Behavior
Illness PatternsIllness Patterns
++
PublicPublic
Studies on Drug Use Pattern and Cost Efficiency

10. 10
Factors Underlying Irrational UseFactors Underlying Irrational Use
of Drugsof Drugs
• inefficientinefficient
managementmanagement
• nonavailabilitynonavailability
of requiredof required
drugsdrugs
Drug SupplyDrug SupplyDrug SupplyDrug Supply
• availability ofavailability of
non-essentialnon-essential
drugsdrugs
• informalinformal
prescribersprescribers
Drug RegulationDrug RegulationDrug RegulationDrug Regulation
• promotionpromotion
• misleadingmisleading
claimsclaims
IndustryIndustryIndustryIndustry
• lack of educationlack of education
and trainingand training
• lack of druglack of drug
informationinformation
• heavy patient loadheavy patient load
• pressure topressure to
prescribeprescribe
• generalization ofgeneralization of
limited beliefslimited beliefs
• misleading beliefsmisleading beliefs
about efficacyabout efficacy
PrescribersPrescribersPrescribersPrescribers
• drugdrug
misinformationmisinformation
• misleadingmisleading
beliefsbeliefs
• inability toinability to
communicatecommunicate
problemsproblems
PatientsPatientsPatientsPatients
Studies on Drug Use Pattern and Cost Efficiency

11. 11
Impact of InappropriateImpact of Inappropriate
Use of DrugsUse of Drugs
ReducedReduced
quality ofquality of
therapytherapy
•morbiditymorbidity
•mortalitymortality
Waste ofWaste of
resourcesresources Risk ofRisk of
unwantedunwanted
effectseffects
•patients rely onpatients rely on
unnecessary drugsunnecessary drugs
PsychosocialPsychosocial
impactsimpacts
•reduced availabilityreduced availability
•increased costincreased cost
•adverse reactionsadverse reactions
•bacterial resistancebacterial resistance
Studies on Drug Use Pattern and Cost Efficiency

12. Study SettingStudy Setting
Area Dhaka Division
Facilities Included 20 (Out of 119 UHCs)
Facility Selection Procedure Systemic Random Sampling
Time Frame of Study 1 Year
Prescribing or Patient Care
Encounters Per Facility
30
Type of Prescribing or Patient Care
Data
Prospective
12Studies on Drug Use Pattern and Cost Efficiency

13. Selection of Health FacilitiesSelection of Health Facilities
13Studies on Drug Use Pattern and Cost Efficiency

14. Selected Health FacilitiesSelected Health Facilities
Serial No. UHC Serial No. UHC
1 Goshaipur 11 Kaliakair
2 Sibehar 12 Sakhipur
3 Gopalganj 13 Sarisabari
4 Faridpur 14 Bakshiganj
5 Pangsha 15 Nalitabari
6 Ghior 16 Mymensingh
7 Keraniganj 17 Nandail
8 Tongibari 18 Bhairab
9 Araihazar 19 Tarail
10 Shibpur 20 Mohonganj
14Studies on Drug Use Pattern and Cost Efficiency

15. Study IndicatorsStudy Indicators
Prescribing IndicatorsPrescribing Indicators
• Average number of drugs per encounterAverage number of drugs per encounter
• % of drugs prescribed by generic name% of drugs prescribed by generic name
• % of encounters with antibiotic prescribed% of encounters with antibiotic prescribed
• % of encounters with injection prescribed% of encounters with injection prescribed
• % of drugs prescribed from essential drug list% of drugs prescribed from essential drug list
• Providers knowledge about standard treatmentProviders knowledge about standard treatment
practices and prescribing drugspractices and prescribing drugs
• Use and application of regulatory measuresUse and application of regulatory measures
necessary to implement rational drug usenecessary to implement rational drug use
15Studies on Drug Use Pattern and Cost Efficiency

16. Study IndicatorsStudy Indicators
Patient care indicatorsPatient care indicators
• Average consultation timeAverage consultation time
• Average dispensing timeAverage dispensing time
• % of drug actually dispensed% of drug actually dispensed
• Patients knowledge of correct dosePatients knowledge of correct dose
16Studies on Drug Use Pattern and Cost Efficiency

17. Study IndicatorsStudy Indicators
Health Facility IndicatorsHealth Facility Indicators
• Availability of copy of essential drug list orAvailability of copy of essential drug list or
formularyformulary
• Availability of key drugsAvailability of key drugs
• Total drug costs of the UHC per dayTotal drug costs of the UHC per day
• Average drug cost per encounterAverage drug cost per encounter
• Total cost and average cost of antibiotics perTotal cost and average cost of antibiotics per
encounterencounter
• Cost of ARI treatment etcCost of ARI treatment etc
17Studies on Drug Use Pattern and Cost Efficiency

18. 6 Common Diseases to be6 Common Diseases to be
ConsideredConsidered
• DiarrheaDiarrhea
• DysenteryDysentery
• Acute Respiratory tract InfectionAcute Respiratory tract Infection
• ScabiesScabies
• Worm InfectionsWorm Infections
• Fungal Skin InfectionsFungal Skin Infections
18Studies on Drug Use Pattern and Cost Efficiency

19. Drug Use IndicatorDrug Use Indicator
Consolidation FormConsolidation Form
19
Click Here
Studies on Drug Use Pattern and Cost Efficiency

20. 20
Average Number of Drugs perAverage Number of Drugs per
EncounterEncounter
Studies on Drug Use Pattern and Cost Efficiency

21. 21
Percent of Drugs Prescribed asPercent of Drugs Prescribed as
GenericsGenerics
Studies on Drug Use Pattern and Cost Efficiency

22. 22
Percent of Encounters withPercent of Encounters with
AntibioticsAntibiotics
Studies on Drug Use Pattern and Cost Efficiency

23. Percent of Encounters withPercent of Encounters with
InjectionsInjections
• Not a single encounter with injectionNot a single encounter with injection
was observed in any health complexwas observed in any health complex
under investigation. This trend is veryunder investigation. This trend is very
appreciable and encouraging.appreciable and encouraging.
23Studies on Drug Use Pattern and Cost Efficiency

24. Percent of Drugs PrescribedPercent of Drugs Prescribed
from EDLfrom EDL
24Studies on Drug Use Pattern and Cost Efficiency

25. 25
Average Consultation TimeAverage Consultation Time
Studies on Drug Use Pattern and Cost Efficiency

26. 26
Average Dispensing TimeAverage Dispensing Time
Studies on Drug Use Pattern and Cost Efficiency

27. Percent of Drugs ActuallyPercent of Drugs Actually
DispensedDispensed
27Studies on Drug Use Pattern and Cost Efficiency

28. 28
Percent of Patients withPercent of Patients with
Adequate Dosing KnowledgeAdequate Dosing Knowledge
Studies on Drug Use Pattern and Cost Efficiency

29. 29
Percent of Key Drugs in StockPercent of Key Drugs in Stock
Studies on Drug Use Pattern and Cost Efficiency

30. Disease PrevalenceDisease Prevalence
30Studies on Drug Use Pattern and Cost Efficiency

31. Health Care ExpenditureHealth Care Expenditure
31Studies on Drug Use Pattern and Cost Efficiency

32. Cost of Antibiotics for ARICost of Antibiotics for ARI
32Studies on Drug Use Pattern and Cost Efficiency

33. Drug Cost for Each SelectedDrug Cost for Each Selected
Category DiseaseCategory Disease
33Studies on Drug Use Pattern and Cost Efficiency

34. Percent Drug Cost for EachPercent Drug Cost for Each
Selected Category DiseaseSelected Category Disease
34Studies on Drug Use Pattern and Cost Efficiency

35. ConclusionConclusion
• High number of drugs (3 per encounter)High number of drugs (3 per encounter)
prescribed to patients tends to increaseprescribed to patients tends to increase
the risk of drugs interactions, affectsthe risk of drugs interactions, affects
patient compliance, encouragespatient compliance, encourages
polypharmacy and causes serious patientpolypharmacy and causes serious patient
harmharm
• Generic prescription of drugs wasGeneric prescription of drugs was
considerably low (49%)considerably low (49%)
35Studies on Drug Use Pattern and Cost Efficiency

36. ConclusionConclusion
• Not a single encounter with injection wasNot a single encounter with injection was
observed in any health facility underobserved in any health facility under
investigation which is very appreciableinvestigation which is very appreciable
and encouraging (0%)and encouraging (0%)
• Prescribing of antibiotics in the healthPrescribing of antibiotics in the health
facilities was very high (44%)facilities was very high (44%)
36Studies on Drug Use Pattern and Cost Efficiency

37. ConclusionConclusion
• Mean duration for consultation (2 min) andMean duration for consultation (2 min) and
for dispensing (22 sec), both consideredfor dispensing (22 sec), both considered
as insufficient for effective patient careas insufficient for effective patient care
• Average percent availability of drugs in theAverage percent availability of drugs in the
health facilities was very poor (51%)health facilities was very poor (51%)
37Studies on Drug Use Pattern and Cost Efficiency

38. ConclusionConclusion
• Many of the health facilities visited did notMany of the health facilities visited did not
have copies of EDL; however, 59% drugshave copies of EDL; however, 59% drugs
prescribed were listed on the EDLprescribed were listed on the EDL
• Only four out of twenty health complexesOnly four out of twenty health complexes
were found to possess the nationalwere found to possess the national
essential drug list (18%)essential drug list (18%)
38Studies on Drug Use Pattern and Cost Efficiency

39. ConclusionConclusion
• Almost all health facilities lacked STGs forAlmost all health facilities lacked STGs for
common diseases except diarrheacommon diseases except diarrhea
• Marketing and product promotionMarketing and product promotion
strategies may lead to unnecessary drugsstrategies may lead to unnecessary drugs
useuse
• Doctors in most cases prescribeDoctors in most cases prescribe
helplessly inappropriate drugs for thehelplessly inappropriate drugs for the
patients due to inadequate supply of keypatients due to inadequate supply of key
essential drugsessential drugs 39Studies on Drug Use Pattern and Cost Efficiency

40. ConclusionConclusion
• Not a single dispensed drug wasNot a single dispensed drug was
adequately labeled (0%)adequately labeled (0%)
• Poor adequate knowledge of patients onPoor adequate knowledge of patients on
correct dose (36% only)correct dose (36% only)
• Cost of drugs per encounter was very highCost of drugs per encounter was very high
(Tk.236)(Tk.236)
40Studies on Drug Use Pattern and Cost Efficiency

41. ConclusionConclusion
• Majority of the dispensers interviewed didMajority of the dispensers interviewed did
not have any formal trainingnot have any formal training
• Many of the dispensaries visited lackedMany of the dispensaries visited lacked
the necessary dispensing toolsthe necessary dispensing tools
41Studies on Drug Use Pattern and Cost Efficiency

42. 42
RecommendationsRecommendations
Interventions toInterventions to improve drug use canimprove drug use can
reduce unnecessary drug expenditure andreduce unnecessary drug expenditure and
lead to improvement in the quality of healthlead to improvement in the quality of health
and medical care.and medical care.
33 major approaches are----major approaches are----
Educational :Educational : Seek to inform or persuadeSeek to inform or persuade
prescriber, dispenser and patients to useprescriber, dispenser and patients to use
drug in rational waydrug in rational way Studies on Drug Use Pattern and Cost Efficiency

43. RecommendationsRecommendations
Managerial :Managerial : Guide decision through theGuide decision through the
use of specific process, packages oruse of specific process, packages or
monetary incentivesmonetary incentives
Regulatory :Regulatory : Seek to restrict decisionSeek to restrict decision
43Studies on Drug Use Pattern and Cost Efficiency

44. RecommendationsRecommendations
For policy implications, findings suggestFor policy implications, findings suggest
the below courses of actions:the below courses of actions:
Continuous monitoring and supervision ofContinuous monitoring and supervision of
the drugs management systemthe drugs management system
Continuous development for healthContinuous development for health
providers to reduce indiscriminateproviders to reduce indiscriminate
prescribing and dispensingprescribing and dispensing
44Studies on Drug Use Pattern and Cost Efficiency

45. RecommendationsRecommendations
Availability of the STGs, EDL andAvailability of the STGs, EDL and
appropriate dispensing tools in all healthappropriate dispensing tools in all health
facilities and prescribers be mandated tofacilities and prescribers be mandated to
adhere to the use of these documents inadhere to the use of these documents in
prescribing drugsprescribing drugs
45Studies on Drug Use Pattern and Cost Efficiency