Transcript Irrational use of medicines damages health

Promoting rational use of medicines:
a global perspective
Hans V. Hogerzeil, MD PhD FRCP Edin
Director,
Medicines Policy and Standards
World Health Organization
www.who.int/medicines
WHO/PSM
The problem
• Increasing antimicrobial resistance
– 70-90% resistance to original 1st line antibiotics for dysentery
(shigella), pneumonia (pneumococcal), gonorrhoea, and hospital
infections (staph. aureus)
– Driven by over-use and inappropriate use of antimicrobials and
poor infection control
• Over-use & incorrect use medicines
– Over half of all prescriptions are inappropriate or incorrect
– Over half of all medicines are not taken correctly by patients
– One-third of the world's population does not have regular access
to essential medicines
WHO/PSM
Irrational use
The number of drugs per prescription
varies from 1.3 to 4.3 per primary care encounter
A F R IC A
G ha na
N ige ria
C a m e ro o n
S wa zila nd
Uga nda
T a nza nia
S uda n
Z im ba bwe
A S IA
Indo ne s ia
N e pa l
Yemen
L.A M E R . & C A R .
J a m a ic a
E l S a lv a do r
E a s t e rn C a ribe a n
G ua t e m a la
E c ua do r
0.0
1.0
2.0
Number of drugs per prescription
Source: Managing Drug Supply, 1997
WHO/PSM
3.0
4.0
5.0
Irrational use
Over-prescribing is costly
- and spending on child health is highly cost sensitive
Drugs are the largest health expenditure for poor households
Azerbaijan
Drugs
61%
Bangladesh
Drugs
73%
Fees,
Other
39%
Mali
Drugs
80%
Fees,
Other
27%
Fees,
Other
20%
Source: Azerbaijan - UNICEF-Bamako Technical Report No. 35 ; Bangladesh 1995 - National Accounts 1996/97
Mali (1986) - Diarra K and Coulibaly S. Financing of recurrent health costs in Mali. Health Policy and planning; 1990,
5(2);126-138
WHO/PSM
Irrational use
30 to 60 % of PHC patients treated with antibiotics
- perhaps twice what is clinically needed
AFRICA
Sudan
Sw aziland
Cam eroon
Ghana
Tanzania
Zim babw e
ASIA
Indonesia
Nepal
Bangladesh
L.AMER. & CAR.
Eastern Caribean
El Salvador
Jam aica
Guatem ala
0%
10%
20%
30%
40%
50%
60%
70%
% of primary care patients receiving antibiotics
Source: Quick et al, 1997, Managing Drug Supply
WHO/PSM
Irrational use
Resistance to common pathogens is everywhere
on the rise - S. pneumonia
Mexico
South Africa
Japan
Hong Kong
Saudi Arabia
Argentina
Egypt
Brasil
Rwanda
Ethiopia
Colombia
0%
10%
20%
30%
40%
50%
% prevelance of intermediate or high level resistance S.
pneumoniae to pencillin, 1993-1997
Summarized by WHO/GPV
WHO/PSM
60%
Irrational use
Up to 56 % of primary care patients receive injections over 90% may be medically unnecessary
A F R IC A
G ha na
C a m e ro o n
N ige ria
S uda n
T a nza nia
Z im ba bwe
A S IA
 15
billion injections per year globally
 half are with unsterilized needle and
syringe
 by age 2 children in some countries
have received up to 20 injections
Yemen
Indo ne s ia
N e pa l
L.A M E R . & C A R .
E c ua do r
G ua t e m a la
E l S a lv a do r
J a m a ic a
E a s t e rn C a ribe a n
0%
10%
20%
30%
40%
50%
60%
% of primary care patients receiving injections
Source: Quick et al, 1997, Managing Drug Supply
WHO/PSM
Effective interventions
Proportion of visits
with injection
Injection use in Indonesia has been dramatically
reduced through a combination of interventions
Interactive group discussion (IGC group
only)
Seminar (both groups)
100%
80%
District-wide monitoring
(both groups)
60%
40%
20%
0%
1
3
5
7
9
11
13
15
17
19
21
23
Months
Comparison group
Interactive group discussion
Source: Santoso et al., 1996
WHO/PSM
25
Effective interventions
Review of 30 studies in developing countries
Drug use improvements with various interventions
Minor
Moderate
Large
Large group training
Small group training
Diarr. community case mgt
ARI community case mgt
Info/guidelines
Group process
Supervision/audit
EDP/Drug supply
Economic strategies
0
10
20
30
40
50
60
Improvement in outcome measure (%)
Source: Ross-Degnan et al, Plenary presentation, Conference on Improving the Use of
Medicines, 1997, Chiang Mai, Thailand.
WHO/PSM
Effective interventions
Antimalarial treatment in Kenya has become more
prompt and appropriate through shopkeeper training
% of surrogate shoppers
Training
70%
60%
50%
40%
30%
20%
10%
0%
1998
1999
Training
2000
Southern zone
Fevers treated with antimalarials
Source: Marsh et al, 2001
WHO/PSM
1998
1999
2000
Northern zone
Antimalarials given appropriately
Effective interventions
Actions to improve use of medicines:
consider effectiveness and feasibility
• Recommended approaches
– Standard treatment guidelines
– Essential drugs list based on treatments of choice
– Hospital pharmacy and therapeutics committees
– Problem-based pharmacotherapy training
– Problem-based in-service and continuing education
• Promising approaches
– Interactive group process among providers and consumers
– Pharmacist and drug seller training
– Consumer involvement in public education
Source: Laing, Hogerzeil and Ross-Degnanl, Health Policy and Planning, 2001
WHO/PSM
Trends
Trends in the use of medicines: 1988-2003
60
3
50
2.5
40
2
30
1.5
20
1
10
0.5
Av. no. drugs / Px
% patients receiving AB/Inj
Source: WHO/PSM database 2004
0
0
88/9
90/1
92/3
94/5
96/7
97/8
00/1
02/3
Year
% Px with AB (n=22)
% Px with Inj (n=19)
Av.no.drugs/Px (n=24)
n=average number of studies per year i.e. data point
WHO/PSM
Trends
Regional variation in prescribing 1990-2004
60
50
40
30
20
10
0
% Px with AB
Asia
% Px with Inj
Africa
% STG compliance
Lat. America
Source: WHO/PSM database August 2004
Baseline data covering all diseases and all ages
WHO/PSM
Trends
% diarrhoea cases treated
Public/private diarrhoea treatment: 1990-2004
70
60
50
40
30
20
10
0
ORS
Antibiotics
Antidiarrhoeals
Private for profit
Public
Source: WHO/PSM database 2004
WHO/PSM
STG
compliance
Variation in outpatient antibiotic use
26 European countries, 2002
35
DDD per 1000 inh. per day
30
25
20
15
10
5
0
FR GR LU PT IT BE SK HR PL IS
IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL
Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.
WHO/PSM
WHO data base: 844 interventions in 204 sites
18% evaluated with adequate study design
7.6% 0.4%
Provider education
7.2%
Consumer education
1.1%
2.2%
Printed materials
38.3%
Supervision & audit
7.6%
Community case mgt
Group process
Economic strategies
Essential drug prog
25.1%
10.5%
Regulation
Source: WHO/PSM database, ICIUM 2004
WHO/PSM
2nd International Conference for
Improving Use of Medicines
http://www.icium.org
Chiang Mai, Thailand, 2004,
472 participants from 70 countries.
Recommendations for countries to:
• Implement national medicines programmes to improve
medicines use in private and public sectors
– Long term with in-built monitoring system
• Scale up successful interventions
– Coordinated multi-faceted rather than single interventions
• Implement interventions to address community drug use
– School programs, and regulation of pharmaceutical promotion
WHO/PSM
AMR recommendations from ICIUM
1. Develop standard surveillance methodology for anti-microbial
use and resistance, for community and hospitals
2. Develop, implement, evaluate targeted multi-component
interventions, adapted to health care system and regulation
3. Focus on high priority areas to contain AMR such as
–
–
–
–
–
Infection control, surgical prophylaxis, use by drug sellers
Regulatory approaches to restrict use of some antimicrobials
Incentives to prescribers and consumers
Inclusion of AMR in graduate curricula and CME
improved quality control of laboratories for AMR surveillance
4. Develop surveillance systems and regulation to control nonhuman antimicrobial use
WHO/PSM
Percentage of countries implementing national policies
to promote rational use and contain resistance
National strategy to contain AMR
National Reference laboratory
Px-only antibiotic (AB) availability
AB public education in last 2 years
Drug use audit in last 5 years
Independent CME for prescribers
DTCs in most referral hospitals
Drug Info centre for prescribers
EML for insurance reimbursement
STGs updated in last 5 years
0
10
20
30
40
50
60
70
Source: pharmaceutical database WHO/TCM 2003
WHO/PSM
What is WHO doing to promote rational use?
• Advocacy for the rational use of medicines (RUM)
– Essential Drug Monitor, effective drug info, meetings, ICIUM
• Model Formulary process
– Model List of Essential Medicines, Essential Medicines Library, WHO
Model Formulary (five languages)
• Training programmes - about 250 participants/year
– Promoting rational use of drugs at primary health care, community
levels and hospital levels (Drugs and Therapeutic Committees)
• WHO Global Strategy on antimicrobial resistance
– Operational research, advocacy for implementation
• Intervention research to promote RUM
– Identifying cost-effectiveness of interventions and policies
– Database to monitor trends in use and impact of interventions
WHO/PSM
Selection
The WHO Essential Medicines Library, status 2005
WHO clusters
Clinical guideline
WHO/EDM
Summary of clinical guideline
WHO Model
Formulary
WHO/EC, Cochrane, BMJ-CE
Reasons for inclusion
Systematic reviews
Key references
RPS
WHO
Model List
WHO/QSM
MSH
UNICEF
MSF
Link to price
information
WHO/PSM
Statistics:
- ATC
- DDD
WCCs
Oslo/Uppsala
Quality information:
- Basic quality tests
- Intern. Pharmacopoea
- Reference standards
25%
20%
15%
10%
5%
0%
100%
80%
60%
40%
20%
0%
% resistant
sputum
isolates
% patients
treated
with cotri
Monitoring community cotrimoxazole resistance
and use in Durban, S.Africa, 2002-3
10 11 12 1 2 3 4 5 6 7
PHC clinics
Pharmacies
H.influenzae resist.
S.pneumoniae resist.
WHO/PSM
Private Practitioners
Conclusions
• AMR and irrational use of antimicrobials is a
very serious global public health problem
• Much is known about how to improve rational
use of medicines but much more policy
implementation is needed at the national level
• Rational use could be greatly improved and
resistance contained if a fraction of the
resources spent on medicines were spent on
improving use
WHO/PSM