The World Health Organization (WHO) estimates that around half of all medicines that are prescribed, distributed, or sold are done so inappropriately, and that half of patients globally who take medicines do so incorrectly.1 Irrational use of medicines manifests in many ways, such as the overprescription of antibiotics, the selling of counterfeit and ineffective drugs, or the stipulation of improper medicine for a particular disease.2 Correct medications do not always reach the right patients and many people continue to suffer from preventable diseases or conditions.
According to the WHO, “medicine use is rational (appropriate, proper, correct) when patients receive the appropriate medicines, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost both to them and the community.”1 The irrational use of medicines is when one or more of these conditions are not met. Unfortunately, much of this burden falls on low- and middle- income countries (LMICs), where many of these conditions are often not met. Through the CHMI database, we found 25 programs that tackle irrational medicine use through advocacy, provider or consumer education, monitoring & evaluation mechanisms, and other innovative approaches.
Advocacy: Raising Awareness on a National Level:
The International Network for Rational Use of Drugs (INRUD) is an advocacy network of doctors, nurses, and public health professionals who are trying to create policy-level changes to improve patient drug adherence, clinic attendance, and the calculation of key indicators to monitor patient adherence to medicines. For example, in India, the public interest litigation group All India Drug Action Network (AIDAN), supported by INRUD, filed a case in the Supreme Court to lower the price of essential medicines, which are often too expensive for the average consumer in India. Dr. Gopal Dabade, a doctor and member of AIDAN and INRUD said, “This high pricing contributes to the irrational use or sale of drugs if a person has to seek alternative and unsafe ways to obtain their medications.” Dr. Dabade hopes the case, which is still ongoing, will control drug pricing once and for all.
However, advocacy groups like INRUD have struggled over the past years to raise the irrational use of drugs as a serious area of concern with Indian policymakers.
“Many times, it’s difficult for us to get support from the media because the media often has strong ties with the pharmaceutical industry,” he said. Often, policymakers and private sector actors like INRUD also have different ideas on what constitutes “rational.”
Provider and Consumer Education to Raise Awareness and Adherence of Medicines:
Several CHMI programs educate and train providers on how to dispense, prescribe, and gain technical expertise on essential medicines.
Healthy Entrepreneurs (HE), a for-profit organization that operates in Burundi, the Democratic Republic of the Congo, Rwanda, and Haiti trains entrepreneurs through ICT systems. Each entrepreneur is equipped with a tablet that contains the prices, information, and educational videos on the drugs available to consumers. Additionally, HE conducts refresher trainings for entrepreneurs every two to six months to learn about the new medicines and how they should be prescribed.
ADDO (Accredited Drug Dispensing Outlets) in Tanzania provides three types of trainings to providers, inspectors, and pharmacy owners. Inspectors undergo two days of training to learn how to inspect pharmacies and drug dispensaries for safe and high quality drugs and practices. Business owners undergo six days of training to learn the ethics of running a pharmacy. Drug dispensers undergo 36 days of training in the areas of drug regulation, treatment of minor illnesses, communication skills, documenting data, and more.
Educating consumers about using medicines properly is essential to lowering the burden of morbidity and mortality due to the irrational use of drugs.
LOCOST, based primarily in the Indian state of Gujarat, distributes a monthly educational pamphlet, “Apnu Swasthya,” and produces a number of publications to teach consumers about the proper adherence and dosage of different types of medicines.
The National Agency for Food and Drug Administration and Control (NAFDAC) in Nigeria similarly disseminates knowledge through pamphlets, monthly newsletters, and a bi-annual magazine about rational drug use. NAFDAC focuses on preventing the consumption and sale of dangerous, counterfeit drugs.
Regulation and M&E for Quality Assurance and Drug Adherence:
Many CHMI programs incorporate strong Monitoring & Evaluation (M&E) strategies into their models in order to track how drugs are being dispensed.
Healthy Entrepreneurs regularly tracks how entrepreneurs dispense medicines to patients. If an entrepreneur deviates from an approved pattern of drug distribution, then HE sends workers to the field to observe the entrepreneur’s activity. If an entrepreneur has been found selling substandard drugs or buying counterfeit medicine, their contract is immediately terminated. Additionally, HE also conducts random field exams to observe entrepreneur behavior and practice.
ADDO works with the Pharmacy Counselors of Tanzania (PCT) to ensure that their dispensers and pharmacy owners are adhering to proper protocol. If a drug dispenser is engaging in irrational use of medicines, the PCT can fine, discipline, and shut down pharmacies. Moreover, ADDO has established regulatory groups in countries like Liberia that are semi-autonomous and establish standards of operation for which drugs should be sold. In Tanzania, ADDO works with stakeholders from the private and public sectors to co-develop national policies and regulations surrounding the selling, distribution, and rational use of medicines.
CHMI will continue to profile and reach out to organizations that counter the irrational use of medicines, encourage program managers to integrate rational medicine use into primary care settings, and encourage the rational use of medicines in all global health programs.
By Kara Suvada, with contribution from Ankita Panda.
Photo: Mwanahawa shows a certificate of accreditation from ADDO for the pharmacy she works at in Mikese Morogoro, Vijijini, Tanzania . Photo c/o ADDO.