Number of drugs prescribed per patient contact at public health facilities

• The median number of drugs prescribed per patient at public health facilities was found to be 3.4 (i.e. each patient received 3 or 4 drugs) (average 3.46)

• 5 out of 6 facilities (84.2%) were prescribing more than 3 drugs to each patient; in 6 (15.8%) prescribing more than 4 drugs per patient; and 1 in 6 (15.8%) prescribing less than 3 drugs per patient; 1

• Results from a similar survey ⁸ in 1998 reported an average of 4.6 drugs per patient - this survey reporting average of 3.46 drugs per patient shows an apparent improvement

⁸ See Annex 2 for more detail

Number of drugs prescribed per patient in public health facilities - distribution by facilities

Recommendation: Investigate and develop interventions as to why 1 in 6 facilities can prescribe an average of less than 3 drugs per prescription and why 1 in 6 facilities need to prescribe an average of more than 4 drugs per prescription

Percentage of patients receiving an antibiotic at public health facilities

• The median percentage of patients receiving one or more antibiotic in public health facilities was found to be 43.3% (average 42.8%)

• In 42.2% of facilities, less than 40% of the patients received an antibiotic, whereas in 21% of facilities more than half the patients received an antibiotic

• Results from a similar survey⁹ in 1998 reported an average of 54% of patients receiving an antibiotic - this survey reporting an average of 42.8% shows an improvement

⁹ See Annex 2 for more detail

% patients receiving an antibiotic - distribution of results

% patients receiving an antibiotic - distribution by facilities

Recommendations:

Investigate and develop interventions on the wide variations found in the use of antibiotics - especially why more than 1 in 5 facilities (21%) are prescribing antibiotics to more than half of the patients

Identify, develop and continue implementing interventions to further decrease the number of patients receiving antibiotics

Percentage of patients receiving an injection at public health facilities

• The median percentage of patients receiving one or more injection in public health facilities was found to be 30% (average 34.9%)

• In 21.1% of facilities, less than 20% of the patients received an injection, whereas in 31.6% of facilities more than 40% the patients received an injection; in 10.5% of facilities, greater than 70% of patients received an injection

• Results from a similar survey¹⁰ in 1998 reported 42% of patients receiving an antibiotic - this survey reporting an average of 34.9% shows an improvement

¹⁰ See Annex 2 for more detail

% patients receving an injection - distribution by facilities

Recommendations:

Investigate and develop interventions on the wide variations found in the use of injections - especially why more than 1 in 10 facilities (10.5%) to greater than 70% of patients receive an injection, whereas in 1 in 5 facilities (21.1%) less than 20% of the patients receive an injection

Identify, develop and continue implementing interventions to further decrease the number of patients receiving injections

Percentage of prescribed drugs on EDL in public health facilities

• The median percentage of drugs prescribed that were on the EDL in public health facilities was 96.1% which is consistent with similar surveys carried out in 1998¹¹

¹¹ See Annex 2 for more detail

• In 73.7% of facilities were prescribing from the EDL more than 95% of the time

• In 10.6% of facilities were prescribing from the EDL less than 90% of the time

Prescribing according to EDL - distribution by facilities

Recommendation: Investigate and develop interventions as to why a minority of facilities are not prescribing consistently according to the EDL

Adequacy of labelling at public health facilities

• The median adequacy of labelling ¹² at public health facilities was found to be zero

¹² an adequate label was defined as a label containing the name and quantity of drug, the dosage and frequency, and duration of treatment

• In 84.2% of facilities there were no adequate labels; no facility had more than 60% of labels adequate

Adequacy of labelling - distribution by facilities

Recommendation: Develop, disseminate and enforce clear guidelines and training on the importance of labelling for dispensed drugs. This should include consumer-targeted and community-based information, education and communication campaigns

Adequacy of patient knowledge of how to take drugs at public health facilities

• The median adequacy of patient knowledge on how to take their drugs¹³ at public health facilities was found to be 56.7%

¹³ adequate patient knowledge was defined as the patient being able to correctly give the name of all the drugs or state what the drugs are for, and how often they should be taken

• In 42.1% of facilities less than half of the patients had adequate knowledge

• In only around 1 in 6 facilities (15.8%) did greater than 75% of patients have adequate knowledge

Adequacy of patient knowledge - distribution by facilities

Adequacy of labelling and patient knowledge

Recommendations:

Develop, disseminate and enforce clear guidelines and training on the importance of ensuring that patients know how to take their drugs correctly.

These initiatives should include consumer-targeted and community-based information, education
and communication campaigns.

Availability and prescribing according to STG's and EDL at public health facilities

• The National Standard Treatment Guidelines (2000) were found in 94.4% of the facilities, which compared with 73% in a similar survey in 1998 ¹⁴

¹⁴ See Annex 2 for more detail

• The EDL was found in 96.1% of facilities

Diarrhoea in children under 5 years¹⁵

¹⁵ National standard treatment guideline for diarrhoea in a child under 5 years recommends: ORS only

• The median percentages of child patients with diarrhoea at public health facilities that were prescribed ORS was 80%

• The median percentages of child patients with diarrhoea at public health facilities prescribed an antibiotic was 50%

Prescribing by group of drugs in children under 5 with diarrhoea

% children under 5 prescribed ORS - distribution of facilities

% children under 5 prescribed an antibiotic - distribution of facilities

Mild/moderate pneumonia in children under 5 years¹⁶

¹⁶ National standard treatment guideline for mild/moderate pneumonia in a child under 5 years recommends: 1^st line antibiotic: amoxicillin

• In all cases, a first line antibiotic was prescribed, however in 33% of cases, more than 1 antibiotic was prescribed

Acute respiratory tract infection¹⁷

¹⁷ National standard treatment guideline for acute respiratory tract infection recommends: no antibiotic

• The median percentage of patients prescribed an antibiotic for ARI was 80%

• In 26.7% of facilities, all patients were prescribed an antibiotic for ARI, only in 6.7% of facilities were less than half the patients prescribed an antibiotic

% patients prescribed an antibiotic for non-pneumonia ARI - distribution by facilities

Recommendations

Investigate and develop interventions for the treatment of diarrhoea in children <5 years: why are 50% of children receiving antibiotics and why are 20% of children not receiving ORS? Investigate and develop interventions why more than one antibiotic is being prescribed fro mild/moderate pneumonia in 33% of cases

Investigate and develop interventions to address the very poor adherence to the standard treatment guideline for ARI