Introduction

2. Introduction Drugs are of special importance to any health care system because they save lives and improve health, promote trust and participation in health services, and are very costly. In addition the quality and cost-effectiveness of health care provision is highly dependent on the appropriate use of drugs. The development by INRUD and WHO of simple and uniform indicators has greatly facilitated the process of investigating drug use. In Namibia these indicators were used for the first time in a drug use survey conducted in the North West Regional Directorate in 1994. The first national drug use survey was conducted in 1997, and one of the recommendations from this survey was to carry out a drug use survey every 2 years in order to monitor trends. The second national drug use survey was thus conducted in 1999. The aim of this third national survey (conducted in 2001) was to monitor and obtain information about current drug use practices in public health facilities in Namibia for selected prescribing, patient care and facility indicators. Furthermore, this survey aimed to monitor the implementation of the NDP, which was launched in November 1998. The results of this survey were used to identify areas where further training is needed and identify knowledge gaps and areas for further research.

3. Study Design & Methodology A prospective cross-sectional survey, involving 44 randomly selected health facilities was conducted. The health facilities included the 4 main referral hospitals, 10 out of 30 district hospitals and 30 out of 97 clinics and health centres that see more than 30 patients per day. Drug use indicators as well as the sampling method were selected from the WHO manuals “How to investigate drug use in health facilities” and “Core indicators on country pharmaceutical situation, Draft May 2000”. Data collection took place from May to July 2001 and was carried out by Regional and hospital pharmacists with support from Pharmacist’s Assistants. The data was collected from 30 outpatients as they left the health facility. The data sources for patient indicators were the patient health passports, the drug packages dispensed to the patients and the patients themselves. In addition, the pharmacies were visited to check on the percentage of key items in stock, expiry dates and stock history of key drugs, adequacy of storage and availability of basic reference material. The completed data collection forms were sent to the Division: Pharmaceutical Services at national level, where they were analysed using a computerised spreadsheet program.

4. Drug Use Indicators Average number of drugs per prescription* % of drugs prescribed by generic name* % of encounters with an antibiotic prescribed* % of encounters with an injection prescribed* % of prescriptions in accordance with standard treatment guidelines (STGs)* % of drugs actually dispensed* % of drugs adequately labelled* % of drugs prescribed according to the Essential Drugs List % patients familiar with how to take their medicine % of key items in stock* % of facilities where basic reference materials are available Average time key drugs out of stock Adequacy of storage conditions in health facilities. * Only these Indicators will be discussed on this poster. The indicators to be included in the survey were agreed at the National Pharmacists Workshop 2000.

5. Results Data for 1132 patient encounters, from 38 health facilities were included in the results analysis. The data collected from 6 clinics were not included because it was not possible to collect data from the required minimum of 30 patients in these facilities. The results obtained were compared to results from the previous two National Drug Use surveys (1997 & 1999). The average number of drugs per prescription of 2.72 for outpatients in Namibia is relatively high. There has been a steady increase from 2.49 (1997) to 2.55 (1999) to 2.72 (2001). Generic prescribing showed a marked improvement from 50% to 61% between the 1997 and 1999 surveys. Comparing that to the current survey, there has been a slight decrease to 60%. Percentage of encounters with an antibiotic prescribed was 51%. This is higher than that obtained from the previous surveys (39% in 1997 and 43% in 1999). Percentage of encounters with an injection prescribed was 9% whichis slightly higher than in 1999 survey (7.3%), but this value is still low enough for us not to consider the use of injections in Namibia a problem. Adherence to standard treatment guidelines is very low with only 53% of prescriptions according to the STGs.

6. There has been a steady decrease since the 1997 baseline survey in percentage of drugs dispensed; 1997: 96%, 1999: 95% and 2001: 93%, however a result above 90% is encouraging. Percentage of drugs adequately labelled was 67%. This is a significant improvement from the 1997 and the 1999 surveys, when only 48% of drugs were adequately labelled. On average, 93% of key items were available. If the expired key items (0.7%) are considered out of stock the national result drops to 92%. This is a slight drop from the 1999 result of 93% of key items available but an improvement from the baseline result of 89% available. Average No. Drugs per Prescription

7. Discussion The steady increase in number of drugs prescribed to outpatients is a worrying trend. Analysis of the Standard Treatment Manual reveals that the mean number of drugs proposed for treatment is 1.7 per condition. Therefore the national result of 2.72 drugs prescribed clearly indicates a problem with polypharmacy which can increase the incidence of adverse drug reactions and drug – drug reactions and also wastes scarce resources. One of the contributing factors to polypharmacy is obviously over prescribing of antibiotics, with every second prescription containing an antibiotic. This overuse of antibiotics is not only a waste of resources but is a matter of global concern as it accelerates development of antibiotic resistance. Going hand in hand with overuse of antibiotics is the non-adherence to STGs. Further analysis of the data for this indicator revealed that 86% of the prescriptions that were found not to be according to STGs were due to inappropriate antibiotic use. Most commonly this involved prescribing an antibiotic for a non-bacterial condition. Adherence to STGs was found to be lowest at clinic level (where prescribers are nurses) and may therefore indicate shortcomings in diagnostic skills. An intervention study on antibiotic prescribing habits conducted in clinics in Central Directorate, Namibia

8. revealed that two rounds of face to face education significantly improved antibiotic prescribing habits. This approach should be seriously considered country wide to address misuse of antibiotics. Generic prescribing has improved since 1997 but still is far from ideal. Nurses had better rates for generic prescribing than doctors, which maybe due to a slower turn over in nurses (Namibians) than doctors (mainly non-Namibians on 2 year contracts). The improvement in labelling of dispensed drugs must be commended but still one in 3 drugs is inadequately labelled so more work is needed. Pharmacy Staff in Katutura State Hospital

9. Implementation of the NDP The goals of the NDP are constant availability of safe and efficacious drugs, equitable access and rational use of essential drugs. Drug availability, as reflected by key drugs in stock (92%) and percent of drugs dispensed (93%), is fairly good. Equitability of access is somewhat lacking as the results show that during times of drug shortages preference is given to hospitals over health centres and clinics. Rational drug use in Namibia has dropped since the baseline study in 1997, with increasing polypharmacy and prescribing of antibiotics and poor adherence to STGs. Education on antibiotic prescribing habits in Okanguati Clinic, Kunene Region

10. Conclusion & Recommendations The results show that despite on going work since 1998 to implement the National Drug Policy, several key factors of drug use in Namibia have steadily worsened since the baseline survey in 1997. Areas requiring particular attention are mainly associated with prescribing of drugs, such as number of items prescribed per prescription, prescribing of antibiotics, generic prescribing and adherence to STGs. It is well known that the task of changing prescribing habits is a difficult one, however it is clear that this needs to be tackled as a matter of urgency in Namibia if the goals of the NDP are to be reached. The report recommends that the urgent action be taken to address the major problems identified. This includes a country wide campaign of face to face education to reduce the over-prescribing of antibiotics. Other key recommendations are for increased efforts to be made to enforce adherence to STGs, promote generic prescribing and ensure availability of drugs at clinics and health centres during times of shortage. The report also recommends that the next drug use survey only be conducted after concrete interventions have been implemented. The next survey can thus be used to assess the impact of these interventions.

11. Prescribing Indicators 80% 60% 1997 1999 40% 2001 67% 61% 51% 50% 43% 20% 39% 9% 7% 0% % of Drugs % of Rx Including % of Rx Including Prescribed by an Antibiotic an Injection Generic Name

12. Dispensing and Drug Availability Indicators 100% 80% 60% 1997 1999 96% 95% 93% 93% 92% 89% 40% 2001 67% 48% 48% 20% 0% % of Drugs % of Drugs % of Key Items in Adequately Dispensed Stock Labelled