Prescribing practices in private health facilities in Delhi (India)

Vandana Roy¹, Usha Gupta², Monica Gupta¹, Arun Kumar Agarwal³,  
¹ Department of Pharmacology, Maulana Azad Medical College, University of Delhi, New Delhi, India
² Department of Pharmacology, Delhi Society for Promotion of Rational Use of Drugs, Delhi, India
³ Department of ENT, Lok Nayak Hospital, New Delhi, India

Correspondence Address:
Vandana Roy
Department of Pharmacology, Maulana Azad Medical College, University of Delhi, New Delhi
India

Full Text

Sir,

The private health sector provides 80% of all out-patient care in India.[1] The main thrust of the Government's drug policy has been on the manufacturing and marketing of medicines in the private sector and very little to the actual use of medicines, which are left to the market forces. The National Health policy 2002 (Government of India), has emphasized on the need for standard treatment regimens, in both public and private sector. The Government of Delhi also has a policy of use of only essential medicines. This however is applicable only in public health facilities.

The present study was designed with the aim of assessing prescribing pattern and compliance of medicines prescribed and sold in the private health facilities with the essential medicines list (EML). A prospective, randomized, study using the methodology stated in the World Health Organization's (WHO) manual on indicators for monitoring national drug policies was conducted.[2] The study was approved by the Institutional Ethics Committee. The sample frame was the city of Delhi. Its nine administrative districts were combined to give five zones north, south, east, west, and central. A total of 27 pharmacies were selected by multistage sampling. A minimum of 30 prescriptions each were collected from all pharmacies. They were analyzed using WHO's basic drug (medicine) use indicators for health facilities and some indicators for evaluating national drug policies.[2],[3]

The indicators used were (i) average number of drugs per prescription (ii) percentage of prescriptions encounters with at least one injection (iii) percentage of prescriptions encounters with anti-microbials (the list of anti-microbials was defined before) (iv) percentage of drugs prescribed by generic names (v) percentage of drugs prescribed from the EML.

In addition, (vi) percentage of tonics (vitamins, minerals, hematinics, enzymes, nutritional supplements) (vii) percentage of fixed dose drug combinations (FDCs) prescribed and (viii) percentage of complete prescriptions were also analyzed. A complete prescription was defined as one, where the name of the medicine, dose and frequency of administration and duration of therapy were all written by the prescriber. The prescribing of medicines from the EML was assessed by analyzing the sales of medicines in the private pharmacies in two ways.

Country drug sales: The number of medicines being sold from the most recent National (2003) and Delhi State EML (2006), out of the 50 best-selling medicines in the market in India was analyzed for the years 2006, 2007, and 2008. There is a national EML and states may formulate their own EML based on local morbidity patterns and need.

State medicine sales: To assess the use of medicines from the Delhi State EML, the percentage of medicines from the state EML sold, out of the total number of medicines sold was calculated. To calculate this indicator, the first 30 medicines sold in the private pharmacies were recorded. All brand or generic medicines sold with or without a prescription with dosage form were included. If the medicines contained one active ingredient, which is on the EML and other active constituents, which are not on the EML, they were not included. For combination medicines, only the ones from the EML were included.

The number of prescriptions obtained was 823 with a total of 2164 medicines prescribed. Anti-microbials were the largest number of medicines prescribed (19.6%), followed by analgesics, anti-inflammatory, anti-pyretics (15.5%), and tonics (11.55%). The prescribing indicators are shown in [Table 1]. The number of medicines from the EML, among the top 50 selling medicines in the country ranged from 42% to 44% for national and 42% to 48% for Delhi State EML over 3 years. The percentage of medicines sold from the EML ranged from 27.64% to 39.24.2% in different zones in Delhi.{Table 1}

Majority of prescriptions were incompletely written. This could be due to a basic lack of training in prescription writing or unawareness about the importance of writing a complete prescription. Prescribing of generics was very less. Brand names are reminded continuously to doctors by medical representatives of drug companies and other forms of drug advertising, whereas non-proprietary names are only taught in medical colleges. Prescribing generics offers economic advantages to patients. In most countries where use of generic medicines has been promoted it has primarily been through supportive legislation and regulations.[4]

There appears to be excessive use of FDCs, which are not recommended, unless they are of proven efficacy and rationality. Although only a handful of essential FDC have been recognized by WHO, National (India) and Delhi State EML, a wide variety of FDCs are available in the Indian market today, accounting for 40-60% of the total number of formulations (nearly 100,000) in India.[5] Inter zone comparison of prescribing indicators revealed significant differences. These differences highlight the lack of uniformity or standards in prescription writing.

The impact of the Governments EML, both National and State on medicine prescribing and sales in the city was very less. Only one-third of the medicines were prescribed and approximately the same number were among the top 50 selling medicines in the country and in the first 30 medicines sold in the private pharmacies. The WHO has encouraged countries to adopt a list of essential medicines. Use of essential medicines offers many advantages such as increasing availability of medicines and decreasing costs. It is also easier to be better informed about a restricted list of medicines. Hence, greater use of the EML would aid in rational use of medicines.

The study has highlighted lacunae in skills in prescription writing with less use of medicines from the EML and increased use of proprietary medicines in private health facilities in Delhi. Regulatory and educational interventions to sensitize doctors on issues related to essential medicine concept and rational prescribing are urgently required.

 Acknowledgement

References