Impact of Pilot Intervention (Training) on Prescribing Patterns in Tajikistan Isupov S., Makhmudova M., Pachadjanova Sh., Bobo-khojaeva Z. WHO Project Strengthening the pharmaceutical sector of Tajikistan
Introduction • Tajikistan is the poorest post-soviet country which tremendously depends on external aid. The disintegration of the USSR in 1991, gaining independence and economical crisis has brought Tajikistan to the crossroads of political, social and cultural transformations. Following the brutal civil war of 1992-1993, migration flow by non-natives and internal migration by Tajiks from different regions of Tajikistan have been creating an educational gap as well as in industry and health care system including pharmaceutical sector. • In developing country like Tajikistan with 6 million people, limited financial resources in the health sector (expenditure of pharmaceutical products per capita in 2002 was US $ 0.19), poor social economic conditions and with high prevalence of poverty diseases the rational use of drugs is essential. No comprehensive study has been conducted to assess the extent of rational prescribing of drugs in Republic of Tajikistan. Taking into consideration that conducting such studies can be a powerful tool for reduction treatment cost of diseases, specialists of WHO Project Strengthening of pharmaceutical sector of Tajikistan conducted study of drug prescribing practice in PHC health facilities (outpatient department) in all regions of Tajikistan. Study of drug prescribing practice includes determination of the following indicators:
Average number of drugs per prescription, • Percentage of patients receiving antibiotics, • Percentage of patients receiving injections, • Percentage of drugs prescribed as generics, • Percentage of drugs enlisted in National EDL. • Inappropriate drug use has been identified by conducted study. Educational and managerial strategies were selected with the aim of improving prescribing practices among doctors in primary health care in Tajikistan. Doctors from outpatient departments from five pilot regions were trained at workshops on rational drug use. 12 months later drug use indicators study was conducted with the purpose of assessing pilot intervention.
Objectives General • To assess impact of pilot intervention (training) on prescribing patterns in Republic of Tajikistan Specific • To find out the prescribing pattern in PHC medical facilities in all regions of Tajikistan before pilot intervention • To find out the prescribing pattern in PHC medical facilities in five pilot regions of Tajikistan after pilot intervention • To compare the prescribing pattern in PHC medical facilities before and after pilot intervention Methods • Twenty-three PHC facilities (outpatient departments) were selected by systematic random sampling. Drug prescribing indicators were measured at these health facilities prior to the interventions. Five health facilities in pilot regions (Dangara, Varzob, Leninskiy, Bokhtar and Kuliab) were also selected by systematic random sampling, and their prescribing indicators were measured after the interventions.
Study Population: • Doctors from outpatient departments. The total study sample covered 1460 prescriptions, 1200 prescriptions pre- and 260 post- the intervention. • Prescriptions were evaluated using INRUD indicators (WHO/DAP 1993). Parameters studied: •  Average number of drugs per prescription •  Percentage of patients receiving antibiotics •  Percentage of patients receiving injections •  Percentage of drugs prescribed as generics •  Percentage of drugs enlisted in National EDL.
Figure 1. • Results showed that the average number of drugs prescribed per prescription decreased slightly from 2.7 in control group to 2.3 in intervention group. Figure 2. • Results showed that the intervention had no effect on the prescribing antibiotics (percentage of patients receiving antibiotics increased from 47% in control group to 49.6% in intervention group), and injections (percentage of patients receiving injections increased from 48% in control group to 49.6% in intervention group). Figure 3. • Results showed that the interventions had little effect on the prescribing of generic drugs (60% of the control group versus 61.4% of the intervention group) and essential drugs (66% in control group versus 67.2% in intervention group).
Implications/ Conclusions • Irrational drug use and inappropriate prescribing is a global phenomenon which also exists within Tajikistan. • Study of drug prescribing practice in PHC facilities (outpatient departments) in Tajikistan shows: • Over use of antibiotics, especially in children age group • Indiscriminate use of injections • Inadequate education and training of prescribers • Lack of educational programs • Lack of unbiased drug information.
Conclusions The intervention itself (baseline/repeat study, visit to health facilities, etc.) seemed to have little positive effect on prescribing patterns of prescribers. The prescribing indicators of main concern (i.e., number of antibiotics and injections prescribed) were not changed by the intervention. This prescribing behavior is deeply ingrained and rooted in sociocultural conditions and may be due to patient expectations, prescriber (doctor) self-interest, and peer norms. More effective and repeated educational programs that include supervision of prescribers and patient education may be necessary. Development of standard treatment protocols and education programs addressing them may also be of great importance.