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| Journal of the New Zealand Medical Association,
26-September-2003, Vol 116 No 1182
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A comparative study of drug utilisation at different levels
of the primary healthcare system in Kaski district, Western Nepal
Ravi Shankar, Pawan Kumar, Manu Rana, Arun Dubey and Nagesh
Shenoy
Medical audit is concerned with the observance of standards
of medical treatment at all levels of the healthcare delivery
system.1 Drug utilisation studies are a part of
medical audit and seek to monitor, evaluate and modify, if necessary, the
prescribing habits of practitioners. The goal is to make medical care more
rational and cost effective.
The Nepalese primary healthcare system operates at different
levels. The primary health centre (PHC), health post (HP) and the sub-health
post (SHP) are the three components of the primary healthcare system. For the
majority of the rural population, the SHP serves as the first level of contact
with the healthcare delivery system. SHPs have been established in the majority
of village development committees (VDCs) in Nepal and it is proposed that they
be established in the remaining VDCs. The VDC is the basic unit of governance in
Nepal. Trained birth attendants and female community health volunteers are
mobilised for various outreach programmes from the
SHP.2 Patients from the SHP are referred to the
HP and then to the PHC. The next levels of referral are the district hospital,
the zonal hospital and finally the tertiary healthcare centres in Kathmandu.
Health workers with different levels of experience and training man the SHPs,
HPs and PHCs in Nepal. The SHPs are manned by certified medical assistants
(CMAs), the HPs are manned by health assistants (HAs), while MB BS doctors are
supposed to be posted in the PHCs. If they are not present, as is often the
case, HAs man the PHCs. The qualifications and levels of training of the health
personnel are detailed in the discussion section of this paper.
The anatomical therapeutic chemical (ATC) classification
system divides drugs into different groups according to the organ or system on
which they act and their chemical, pharmacological and therapeutic
properties.3,4 Each drug is assigned a
particular combination of letters and numbers. The defined daily dose (DDD) is
the assumed average maintenance dose per day for a drug used for its main
indication in adults.3 DDD was developed to
overcome objections against traditional units of measurement of drug consumption
and to ensure comparability between drug utilisation studies carried out at
different locations and different time periods.
Information on prescribing patterns at different levels of
the primary healthcare system is lacking in Western Nepal. Also, there have been
no studies comparing the prescribing patterns and morbidity profiles at the SHP,
HP and PHC, the three levels of the primary healthcare system in Nepal. Use of
the DDD concept to measure drug consumption at different levels of the primary
healthcare system has not been attempted. Hence, the present study was carried
out in two SHPs, one HP and one PHC in the Kaski district of Western Nepal. The
objectives of the study were to:
MethodsThe study was carried out at
three levels of the Nepalese primary healthcare system in the Kaski district of
Western Nepal. The centres chosen for the study were the Bedabari PHC, the
Batulechaur HP and the Riban and Armala SHPs. Each SHP serves a population of
around 3000; the HP serves a population of around 30 000; and the PHC serves
around 100 000. The study was carried out over a three-month period (1 June 2000
to 31 August 2000) at the chosen centres.
Specially designed prescription forms in duplicate were
supplied to the prescribers at the study centres. The original was handed over
to the patient while the duplicate prescription was retained by the prescribers.
The investigators collected the duplicate prescriptions at a time period of 15
days.
The information in the prescription was entered into a
prescription indicator form (PIF) for analysis. The age and sex of the patient
were noted. The names, dose, frequency and duration of the drugs prescribed were
entered into the PIF. The total number of drugs prescribed, and the number of
parenteral preparations and topical preparations were determined at the PHC, HP
and SHP level. Data from the two SHPs were combined for further
analysis.
The number of drugs prescribed from the Nepal essential
drug list5 and the WHO model list of essential
drugs6 was calculated. The WHO standard
drug-use indicators were used to evaluate drug-use practices in the different
health centres.7 The mean ± SD number of
drugs prescribed per encounter and the mean ± SD cost per prescription were
calculated. The percentage of drugs prescribed by generic name was
determined.
The six most commonly prescribed drugs at the three
levels of primary healthcare delivery were noted. The DDD/1000 inhabitants/day
(DID) of these drugs were calculated. Differences in the morbidity profiles and
prescribing patterns between the different centres were analysed using the
chi-square test. A p value <0.01 was taken as statistically significant. The
institutional review board of the Manipal College of Medical Sciences, Pokhara,
Nepal, approved the study.
ResultsThe study sample included 775
patients from the Bedabari PHC, 485 patients from the Batulechaur HP and 501
patients from the two SHPs of Riban and Armala. The total number of drugs
prescribed was 2454 at the PHC, 518 at the HP, and 606 drugs at the
SHP.
Individuals below the age of 20 years constituted 256 out of
the 775 patients (33%) at the Bedabari PHC. At the HP and SHP level individuals
below the age of 20 years constituted 47.6% and 45.9% of the total patients,
respectively. Individuals aged 60 years or above constituted 5.3% of patients at
the PHC level, 10.5% of patients at the HP level, and 10.4% of patients at the
SHP level.
The number of drugs per prescription showed a significant
difference across different levels of the primary healthcare system. Table 1
shows the incidence of polypharmacy. More drugs were prescribed at the PHC level
and the number of drugs per prescription progressively decreased at the HP and
SHP level. A significant number of prescriptions contained four or more drugs at
the PHC level.
Table 1. Incidence of
polypharmacy* at different levels of the
primary healthcare system (PHC = primary health centre; HP = health post; SHP =
sub-health post)
*χ2 = 678.2, df =
10, p <0.01
Table 2. Morbidity profiles of patients at different
levels of the primary healthcare system (PHC = primary health centre; HP =
health post; SHP = sub-health post)
*χ2 = 18, df = 2,
p <0.01;
†χ2
= 56.2, df = 2, p <0.01;
‡χ2
= 18, df = 2, p <0.01;
§χ2
= 21.2, df = 2, p <0.01
The morbidity profile of patients is shown in Table 2. Acute
respiratory infection was significantly more common at the HP level
(χ2 = 17.9, df = 2, p <0.01). Cases of
dental caries were fewer at the SHP level. Frequency of wounds and wound
infection (χ2 =56.2, df = 2, p <0.01),
and of worm infestation (χ2 = 21.2, df =
2, p <0.01), also differed at different levels of the primary healthcare
system.
The frequency of prescribing of individual drugs is shown in
Table 3. The prescribing frequency of the ten most commonly prescribed drugs was
analysed. Vitamins were most commonly prescribed at the PHC level
(χ2 = 45.3, df = 2, p <0.01).
Paracetamol (χ2 = 181.5, df = 2, p
<0.01), co-trimoxazole (χ2 = 152.8, df
= 2, p <0.01) and mebendazole (χ2 =
192.5, df = 2, p <0.01) were more frequently prescribed at the SHP level.
Amoxicillin was more frequently prescribed at the HP level but the difference
was not statistically significant.
Table 3. Frequency of prescribing of individual drugs
at different levels of the primary healthcare system (PHC = primary health
centre; HP = health post; SHP = sub-health post)
*χ2 = 45.3, df =
2, p <0.01;
†χ2
= 181.5, df = 2, p <0.01;
‡χ2
= 152.8, df = 2, p <0.01;
§χ2
= 192.5, df = 2, p <0.01; n = number of drugs prescribed at the particular
level of primary healthcare
The mean ± SD cost of drugs per prescription was 30.6
± 25.8 Nepalese rupees (0.39 ± 0.33 US$) at the PHC level, 18.8 ±
15.7 Nepalese rupees (0.24 ± 0.2 US$) at the HP level, and 16.8 ± 14.3
Nepalese rupees (0.21 ± 0.18 US$) at the SHP level. At the PHC level, 74%
of the drugs were prescribed from the essential drug list of
Nepal5 and 67.3% were prescribed from the WHO
list of essential drugs.6 The corresponding
figures at the HP level were 72.6% and 81.3%. At the SHP level the percentages
prescribed from the Nepalese5 and the WHO
essential drug lists6 were 70.9 and 77.5
respectively.
Antibiotics were prescribed in 67.2% of encounters at the
PHC level, 52.6% at the HP level, and 52.7% at the SHP level
(χ2 = 115.6, df = 2, p <0.01).
Injections were prescribed in 20.2% of encounters at the PHC level, 3.1% of
encounters at the HP level and 3% of encounters at the SHP level
(χ2 = 135.7, df = 2, p
<0.01).
At the PHC level 28.8% of drugs were prescribed by brand
name. At the HP and SHP level the corresponding percentages were 31.1% and
58.4%. The total numbers of prescriptions for individual drugs at the three
levels of the primary healthcare system were calculated to determine the six
most commonly prescribed drugs. Table 4 shows the DID of the six most commonly
prescribed drugs.
Table 4: Defined daily dose per thousand inhabitants
per day (DID) of the six most commonly prescribed drugs at different levels of
the primary healthcare system (PHC = primary health centre; HP = health post;
SHP = sub-health post)
At the Bedabari PHC during the study period, the health
assistant (HA) filled in 96% of the prescriptions. The HA was on leave for a
period of five days during the period of study and during this period the staff
nurse was in charge. She treated the patients and filled in the prescriptions.
At the HP level, the HA filled in the prescriptions. He had a certified medical
assistant (CMA) and an auxiliary nurse midwife (ANM) to assist him but they did
not fill any prescriptions. At the SHPs the CMAs filled the prescriptions. In
the health facilities in Nepal, in general, only the most senior member of staff
sees the patients and fills the prescriptions. The other members of staff assist
the senior staff member but do not fill the prescriptions on their
own.
DiscussionIn Nepal, public expenditure in the
health sector has increased from 3.2% in the financial year 1993/94 to 5.7% in
the financial year 1999/2000. In view of the immense human cost of disease in
Nepal, primary healthcare receives the highest allocation in national health
spending and about three quarters of the total health
budget.8
The training of the health personnel manning the different
levels of the primary healthcare system differs. SHPs are manned by a certified
medical assistant (CMA). CMAs undergo a one-year course after schooling followed
by a three-month internship. HPs are manned by health assistants (HAs) who
complete a two-year course after schooling followed by six months of internship.
Medical officers are posted to man the PHCs but if they are not present, as is
often the case, HAs take their place.
The Bedabari PHC was manned by an HA, a staff nurse, an ANM,
a family planning assistant, two maternal and child health workers, a
pharmacist, an accountant, an administrative assistant and two peons
(attendants). The staff nurse is in charge of the PHC when the HA is absent. The
staff nurse had completed a three-year course of BSc Nursing while the ANM had
completed a 15-month course.
The Batulechaur HP was manned by an HA, a CMA, a maternal
and child health worker, a pharmacist, an accountant and a peon. In the absence
of the HA, the CMA runs the HP.
SHPs are staffed by a CMA, an ANM, a maternal and child
health worker and a peon. In the absence of the CMA, the ANM is in charge of the
SHP.
The procedure for taking leave for the most senior member of
the health facility is that they must communicate their intention in writing to
the district public health office at least one week in advance. The office will
send a suitably qualified person to man the health facility during the period of
absence; alternatively, the next most senior member of staff in the facility may
be put in charge.
The health facilities conduct outpatient departments (OPDs)
from 10am to 2pm from Sunday to Thursday. On Fridays the OPD functions from 10am
to 1pm. Inpatient beds are available at the Bedabari PHC but are not being used
and the patients are referred to the Western Regional Hospital in
Pokhara.
The average number of drugs per prescription is an important
index in drug utilisation studies. A high value may call for educational
intervention in prescribing practices. In a study in Bangalore district, South
India,9 the average number of drugs was 1.99 at
the primary level, 2.16 at the tertiary level and 2.41 at the general practice
level. Bapna et al found that a prescription on average contained 2.71
drugs.10 The increased number of drugs
prescribed at the PHC level in our study is a matter of concern. A greater
percentage of tonics, vitamins and parenteral preparations were prescribed and
this may partly account for the increase in the average number of drugs per
prescription. The increased number needs to be justified in view of the
increased risk of drug interactions, errors of prescribing and non-compliance
seen with polypharmacy.
In Nepal in the last 15 years SHPs have been established in
most village development committees. Lack of medicines and staff inadequacies
were major reasons for dissatisfaction with the healthcare
services.11 If standard procedures like the
ATC-DDD methodology3,4 are employed by all
researchers in drug utilisation, there can be meaningful comparison of the
results. Gaitonde suggested an important role for pharmacologists in the
monitoring of prescribing patterns at different levels of healthcare
delivery.12
Acute respiratory infection, wounds, dental caries, skin
disease and worm infestation were the five most commonly observed illnesses in
our study. These are diseases of poverty that are common in developing countries
with poor standards of socioeconomic development. In a study in Taiwan the most
common illnesses were acute respiratory infection, skeletal and joint disease,
hypertension, and acid peptic
disease.13
Sulfonamides were the most commonly prescribed antibiotics
at the HP and SHP level but not at the PHC level. Our findings are similar to
those observed by Srishyla et al and Bapna et
al.9,10 In contrast to the previous
results9 there were differences in the
prescribing patterns of drugs at different levels. Differences in the morbidity
profiles may partly explain the differences in prescribing patterns. Analgesics
and vitamins were prescribed in amounts similar to those in a study in Saudi
Arabia.14
The average cost per prescription varied from 0.39 US$ at
the PHC level to 0.21 US$ at the SHP level. In a previous study in
India15 the mean ± SD cost per
prescription was 0.18 ± 0.17 US$. Direct comparison of the results is
difficult because of the increase in cost of drugs since the Indian study was
carried out. The cost was higher at the PHC level and this could be due to the
increased prescribing of antibiotics, parenteral preparations and
vitamins.
Variations were seen in the DID of the six most commonly
prescribed drugs. In contrast to a Spanish
study,16 cephalosporins were not commonly used
in our study. In another previous study17
penicillins and macrolides were the most commonly prescribed antibiotics, but
macrolides were not commonly used in our study. Our DID for antibiotics was
lower than that observed in the previous two
studies.16,17 Culture and sensitivity testing
is not carried out at the primary healthcare level. Older antibiotics were
commonly used; these were generally cheaper.
We have compared prescribing patterns at one PHC, one HP and
two SHPs in Kaski district, Western Nepal. At the PHC level two individuals
completed the prescriptions while at the HP and the SHP level only one
individual completed the prescriptions. The levels of training and experience of
these individuals were different. The low number of health facilities included
in the study raises the possibility that the different individuals involved were
responsible for the noted differences in prescribing. In order to conclude that
the differences in prescribing may be due to the different levels of training of
the staff involved and their site of practice, a larger study involving more
health facilities would need to be undertaken.
Comparisons of morbidity and prescribing patterns at the
primary, secondary and tertiary healthcare levels in Nepal are required.
Comparisons are also required between the prescribing patterns of government and
private healthcare institutions. These studies are being planned in association
with the Department of Community Medicine of the Manipal College of Medical
Sciences and the western regional health directorate, His Majesty’s
Government of Nepal.
Author information:
P Ravi Shankar, Assistant Professor, Department of Pharmacology; Pawan Kumar,
Professor; Manu S Rana, Tutor, Department of Community Medicine; Arun K Dubey,
Lecturer, Department of Pharmacology, Manipal College of Medical Sciences;
Nagesh Shenoy, Lecturer, Department of Pharmacy, Manipal Teaching Hospital,
Pokhara, Nepal
Acknowledgements: We
thank Dr Blix and Dr Harr of the Centre for Drug Statistics Methodology, Oslo,
Norway, for their help in the use of the DDD concept to measure drug
utilisation.
Correspondence: Dr P
Ravi Shankar, Department of Pharmacology, Manipal College of Medical Sciences,
PO Box 155, Deep Heights, Pokhara, Nepal. Fax: +977 61 527862; email: pathiyilravi@hotmail.com
References:
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