Elmutaz Eltayeb AHMED

Student ID: UM11600SPH18677

Master of Public Health

An essay on:

Rational use of Medicines

Practical work paper on assessment of rational use of medicines in 5 health facilities run by GOAL (INGO) in Kutum locality _North Darfur Sudan

ATLANTIC INTERNATIONAL UNIVERSITYHONOLULU, HAWAII2011 June 12th

1

Table of contents:

TOPIC PageSummary 3Resources and methods 4Questionnaire and interview 5Indictors of rational use of medicine 5Analysis 6Results 6Discussion 17Conclusion 18Recommendation 18Annex 20References 26

Abbreviations:

EDL Essential drug list

INGO International non-governmental organization

(R/P) Retrospective /prospective

RUD rational use of drugs

WHO World Health Organization

2

Assessment of Rational Use of Medicines in GOAL clinics in Kutum locality North Darfur Apr 2011:

Done by:

1. Elmutaz Ahmed, Drug Management officer WHO, 2.Ismail Jukul _WHO’s Warehouse manager-North Darfur.

I. Objectives: To evaluate the prescriptions and patient care indicators of five health facilities (Furung,Kassab,Fata barno,Kutum center and Algarbya) run by GOAL in Kutum locality, for coherent prescribing and dispensing of drugs and to assess the patient’s understanding referring to use of medicines, using WHO’s indicators.

II. Methods: A multi-sectional, graphic study was carried out at the GOAL’s Clinic in Kutum locality in North Darfur state, during the time period from Apr 11th

-22nd.

III. Results: thoroughly 590 prescriptions were at random selected for study, wherein 1141 drugs were prescribed. Only 42% of drugs were prescribed with their generic name, 100% of drugs were from the Essential drug list of Sudan. Antibiotics products were most commonly prescribed (59% of prescription were with Antibiotics). It was found out that assistant pharmacist labeled only 90% of the medication packet with the name of the drugs, drug strength and length of treatment. Only 88% of the patient knew both the length of the treatment and administration time of drugs. The prescriptions have shown only 3% of Injectable.

IV. Conclusion: Drug use is the final step of the medical consultation. Health providers have accountability to guarantee that the correct drug is prescribed, dispensed and taken. In brief, there is need for minimum efforts from GOAL to improve the rational use of drugs in their supported clinics. .V. Key words: patients care, use of drugs, Rational, Irrational, GOAL, Prescribing, Dispensing

It is well known that harmless and efficient treatment with drugs is most possibly mainly when the end users are well enlightened about their drug use

3

All health care providers should be aware about the rational use of drugs. “Rational drug use means patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time and at the lowest cost to them and their community” (WHO,1995). On the other hand, misunderstanding of trade names, overwhelming consultations and dispensing of prescriber and dispensers, cost aspect, patient approach, disrupted drug cycle, lack of standard treatment guidelines and list of drug formulary can direct to irrational use of drugs. In instance, irrational drug use can negatively affect the quality of drug therapy, amplified hazard of discarded effects, promote drug resistance, enhance drug-drug interaction etc. Therefore, the five key criteria for rational drug use are correct diagnosis, appropriate prescribing, right dispensing, proper packing and patient obedience. In summary, prescribers should be well trained to be able to correctly diagnose the patients complains, while pharmacist and assistant pharmacist should be with good knowledge to advocate the patients about their treatment regime as well as to full packing the drugs with reliable informations.

Resources and methods

Settings:

‘Kutum principle area

4

    The assessment was conducted at the 5 GOAL clinics which were established in: Kassab IDPs camp in April 2004 It covers about 25, 810 IDPs. Fataborno clinic in April 2004 in Fataborno Camp.it covers about 4416, the total population is about 149,072 and there are five other functioning clinics.The services provided are OPDs, Pharmacy, Reproductive health (ANC, family planning, delivery room), dressing room, ORS corner, laboratory, EPI, Health promotion –GMP/OTP and Nutrition - sometimes moves to other rural locations).The average consultations per day in March 2011 have been 412Staff working there includes 17 MAs in the OPD, 2 MA and 8 Pharmacy assistants in the Pharmacy, 38 midwives and 2 health visitor in the RH department, 8 nurses in the dressing room, 1 lab assistant and 1 nurse in the laboratory. The leading morbidly causes are Acute Respiratory tract infections (ARI and Diarrheal diseases.Patients attending the clinic pharmacy with an official prescription from the consultation office were randomly registered in the study.

Staff leveling:

clinic MD MA A/PH Nurse CHW MWKassab 0 5 1 1 8 5Fata barno

0 1 1 2 2

Furung 0 1 1 1 2 2Kutum center

0 2 1 2 3

Questionnaire and interview:

A cross-section questionnaire using WHO standard indicator of the rational drug use were used, wherein, retrospective prescriptions and patient information were used as basis of the assessment. The prescriptions were analyzed. An exist interview were also conducted with patients for their knowledge of the duration, dose, frequency of drugs to be taken, and potential side effects of the dispensed drugs.

Indictors of rational use of drugs:

1 Prescribing indicators1.1 Average number of drugs consultation1.2 Drugs prescribed by generic name (%)1.3 Consultation resulting in an antibiotic prescription (%)1.4 Consultation resulting in an injection prescription (%)1.5 Drugs prescribed from Essential Drugs List (%)

5

2 Patient care indicators2.1 Average consulting time2.2 Average dispensing time2.3 Drugs actually dispensed (%)2.4 Drugs adequately labeled (%)2.5 Patient’s knowledge of correct dosage

3 Health facility indicators3.1 Availability of Essential Drugs List/Formulary3.2 Availability of key drugs

Analysis:

Prescriptions were randomly selected and analyzed for five indicators (average drugs, presence of antibiotic, incidence of Injectable, generic names of the drugs, and drugs from the national list of essential medicine of Sudan), while dispensed drugs were checked for their accuracy of labeling, including name of drug, duration of treatment, frequency of drug taking, name of the patient, age, and route of administration. Patients were assessed for consultations and dispensing time, and patients were checked for their relevant knowledge of the proper use of their medications.

Results:

The results were classified according to the WHO three groups of indicators:

Prescribing indicators

Patient care indicators

Health facility indicators

6

1. PRESCRIBING INDICATORS:

1.1 Average number of drugs consultation:

Furnug Algarbeea Kutum Center

Fatabarno Kassab0

50

100

150

200

250

300

350

400

450 427

194161

183 176

General Drugs prescribed

Total no. of drugs in all prescriptions

Figure 1: General drugs prescribed in 5 supported HFs by GOAL in Kutum locality

Furnug Algarbeea Kutum Center Fatabarno Kassab0

50

100

150

200

250

195

102 92 101 100

Total no. of prescriptions

Total no. of prescriptions

Figure 2: Total number of prescriptions in 5 supported HFs by GOAL in Kutum

7

Furnug Algarbeea Kutum Center Fatabarno Kassab0

1

10

GOAL supported HFs in Kutum Loc:Average no. of drugs per prescription (standard 2-3 drugs/

pres)

Figure 3: Average drugs prescribed in 5 supported HFs by GOAL in Kutum

For general drugs’ prescription, a total of 590 prescriptions were randomly analyzed, where in 1141 drugs were prescribed, with (two drugs/prescription) as average for the assessed clinics. This average is good when we compare it to the standards of International Rational Use of Drugs (INRUD) (2-3 drugs/prescription).

1.2 Drugs prescribed by generic name (%):

Furnug Algarbeea Kutum Center Fatabarno Kassab0%

10%20%30%40%50%60%70%80%90%

34%

83%

27%34% 37%

Drugs written with Generic Names

% of drugs written with Generic Names

Figure1:Drugs written with Generic Names in 5 supported HFs by GOAL in Kutum April2011

8

From the total prescribed drugs (1141), there was only 348 drugs were prescribed with their generic name, which represented (30%), and according to the WHO and INRUD; all drugs should prescribed by their generic names(100%). Here the performance of mentioned clinics was varied from, Algarbeea (83%) to Kutum center (27%), the results which requires a huge efforts to support with prescribing by generic name especially in Furnug, Kutum center,Fata barno, and Kassab.the below example from different countries

Figure4.Public Sector Drug Use Indicator Studies 1990-1993

1.3 Consultation resulting in an antibiotic prescription (%):

76%

62%39%

47%

54%

% of Prescriptions with Anti-biotic

FurnugAlgarbeeaKutum CenterFatabarnoKassab

Figure5: percentage of Antibiotics in 5 HFs (supported by GOAL)Kutum locality

9

SudanIndonesiaZimbabweTanzania

NigeriaNepal

EcuadorGuatemala

Eastern CaribbeanGhana

CameroonEl Salvador

Jamaica0 20 40 60 80 100

% Generic

Overuse of antibiotics, found to be the major area of irrational use of medicine in all mentioned clinics, wherein, from 590 total analyzed prescriptions, 348 (59%), were prescribed with Antibiotics, in fact, this is relatively high percentage compared to the WHO/(INRUD) standard (25%),this is clearly can be seen in Furnug clinic (76%),followed by Algarbeea, (62%) , Kassab (54%)therefore, WHO/GOAL needs to focus on the underlying causes and reassess the use of Antibiotics in respect to the seasonal fluctuation to get the real picture, to promote the rational use of Antibiotics. and furthermore to minimize the antimicrobial resistance

1.4 Consultation resulting in an injection prescription (%):

Furnug Algarbeea Kutum Center Fatabarno Kassab

0%

1%

2%

3%

4%

5%

6%

7%

8%

4%

0% 0%

8%

0%

percentage of prescriptions with Injections(standard 10%)

Figure 6: percentage prescriptions with injectables in 5 HFs (supported by GOAL)Kutum locality

Rationally, the use of Injectable medicines is not recommended unless there are clear indications, For example, in comatose patients, in emergencies where swift actions are required, in cases when oral intake was restricted by gastric acid, ect..

From figure 6, all observed clinics were within the WHO/ (INRUD) standards (10%), furthermore, in 3 assessed clinics (Algarbeea,Kutum center and Kassab),the use of Injectable medicines was zero, although there were an assortments of Injectable medicines were kept in these clinics as part of life-saving medicine, but due to the limited time of this assessment ,the reported usage of Injectable was zero

10

1.5 Drugs prescribed from Essential Drugs List (%)

Furnug Algarbeea Kutum Center Fatabarno Kassab

0%10%20%30%40%50%60%70%80%90%

100% 100% 100% 100% 100% 100%

percentage of drugs prescriped from essential list of medicine (standard 100%)

Figure 7: percentage of drugs prescribed from essential list of medicine in 5 HFs (supported by GOAL)Kutum locality

In figure 7, we observed that, the prescribing from the essential list of medicine of the country is considered as the one of the major achievement of the RUD in all assessed clinics. (100%).

11

2 PATIENT CARE INDICATORS

2.1 Average consulting time

FurnugAlgarbeea

Kutum Center Fatabarno

Kassab

0

5

10

15

20

25

30

35

40

22 29

23

1729

5.3

6.4

7.4

5.9

6.4

Consultation time in 5 health facilities in Kutum locality

No. of Patients Observed Average consultation time /min

Figure 8: average consultations time in 5 HFs (supported by GOAL)Kutum locality(Apr 2011)

Accumulatively, the total consultations time for 120 observed patients was 759 minutes, with the total average (6.3) minutes/patient ,and according to the WHO definition, the consultation time is the time that enough for the health provider to take the social and medical history ,respond to the patients’ complains.

The below figures from different studies for consultations time, shows that the average consultation was range from (2-7 minutes), the below example from

12

figure9: Public Sector Drug Use Indicator Studies 2000-2003

2.2 Average dispensing time:

Furnug Algarbeea Kutum Center Fatabarno Kassab0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

50

6862

47

66

22

29

23

17

29

2.3 2.3 2.7 2.8 2.3

Dispensing TimeTotal dispensing time /min NO. of Patients ObservedAverage dispensing time /min

Figure 10: average dispensing time in 5 HFs (supported by GOAL)Kutum locality(Apr 2011)

From the assessment, the average dispensing time for all clinics (2.4) minutes The below example from study conducted in different countries

13

Malawi

Indonesia

Tanzania

Nigeria

Nepal

0 1 2 3 4 5 6 7Average Consultation Time (mins)

Figure 11: Public Sector Drug Use Indicator Studies 2000-2003 Usually, good dispensing process should include the following: (see annex 1)Receiving the prescription, Preparation for issuing, and Information to the patient

2.3 Drugs actually dispensed (%):

Furnug Algarbeea Kutum Center Fatabarno Kassab

4681

47 3957

44

73

4435

57

96% 90% 94% 90% 100%

Drugs Actually Dispensed

No. of Prescribed Drugs No. of Dispensed Drugs% of Actually Dispensed Drugs

Figure 12: percentage of drugs actually dispensed in 5 HFs (supported by GOAL)Kutum locality(Apr 2011)

14

Tanzania

Nigeria

Nepal

Eastern Carribean

Ghana

0 50 100 150 200Average Dispensing Time (seconds)

Figure 12 shows, a higher percentage of drugs actually dispensed in GOAL clinics, especially in Kassab health facility (100%), the issue which reflects the good drug supply management system within GOAL, in fact, this indicates appropriate supply of drugs in all the clinics and such policy guarantees a minimum level of health care to the population. in contrast, This result was better than the percentages obtained among the other studies done in North Darfur last year in 10 health facilities in IDPs setting (in Mallet and Elfashir) which showed (78%-85%).

2.4 Drugs adequately labeled (%):

Furnug Algarbeea Kutum Center Fatabarno Kassab

4473

44 3557

37

66

4331

51

84% 90% 98% 89% 89%

Drugs adequetly labeledTotal no. of drugs acatually dispensed Total no. of drugs adequately labeled% OF Drugs adequetly labeled

Figure 13: percent of drugs adequately labeled in 5 HFs (supported by GOAL)Kutum locality(Apr 2011)

Adequately labeling of prescribed drugs the selected Health facilities is varied from 84% to 98%, as it shown in the figure13. In fact, prescription drug labeling is to give patients information they need to take medications properly, including, name of the patient, date of dispensing, age, residence, sex, name of the drug, duration of the treatment, doses, ect..,

15

2.5 Patient’s knowledge of correct dosage:

Furnug Algarbeea Kutum Center

Fatabarno Kassab0%

1000%

2000%

3000%

4000%

5000%

6000%

2229

2317

29

19

25

21

15

25

86% 86% 91% 88% 86%

Patient Knowedge of correct doses

Patients knowing accurate dosesNo. of interviewed patients% of Patients with Knowledge

Figure 14: patient knowledge of correct doses in 5 HFs (supported by GOAL)Kutum locality(Apr 2011)An exit interviews were conducted outside the selected facilities, the interview was about the proper use of prescribed drugs, the result shows, 87% of interviewed patients from the five selected facilities were able to know how to use their prescribed medication correctly. On average, this is as same as the results obtained from the similar assessment in other health facilities in North Darfur state, which off course, indicate the ultimately needs for more educational efforts at the both levels of prescribers and dispensers.

3 HEALTH FACILITY INDICATORS

3.1 Availability of Essential Drugs List/Formulary:

From the direct observation and interview with existing staff within the selected health facilities, we observed that, there were no copies of national list of essential medicine, or national treatment guidelines in all assessed clinics, in fact, such documents will support the health providers to manage cases according to the FMoH standards case management protocols, besides supporting them in prescribing with generic names and properly label prescribed drugs.

3.2 Availability of key drugs:

A list of key drugs was found in all selected facilities, see annex 2.

16

Discussion:

The average number of drugs per prescription was found to be more or less two in our assessment which is matching with WHO/(INRUD) standard; fewer number of drugs in prescription is a positive indication as polypharmacy is known to be a causal factor for drug-drug interactions, , patient confusion over use of multi drugs, unpleasant drug reactions. However, this is not desirable in all conditions as in some diseases like heart failure, the treatment requires more drugs.

Only 30% of drugs were prescribed by generic name in this study. This value is less than that reported in other assessments done in PHC clinics in other IDPs settings in North Darfur (Sudan) in 2010. Prescribing by generic name assists in reduction of confusion of health providers while prescribing or dispensing. Moreover, using generic names can help in drug inventory within the facility, and support the purchase system, and over all, it can promote for translucently as most of drugs companies are pushing for using their brands.

The percentage of drugs prescribed from the essential list of Sudan was found 100% which represent an excellent result. Prescribing from standard formulary can trim down the number of unreasonable combinations incoming the market and ensure quality of registered drugs within a given country.

Informations obtained from assessing the patient care indicators have showed that a relatively adequate consultation and dispensing times (6.3 minutes and 2.4 minutes respectively), putting in mind that the assessed facilities were a primary health settings which in general received patients with minor complains, and all the health providers there were from the local community, therefore, it looks that there was no problems in communication between health provider and their patients, but still there an efforts to be exert to ensure a good patients advocacy and information sharing. In the other hand, some drugs dispensed were poorly labeled (92% proper labeling) this percentage looks good at general, but, dispensing is an core component of rational drug use, as it is the final position of contact between the health providers and their parents so written informations on the drug bag gives an ideas about how the pharmacist/assistant pharmacist were involve in the cycle of rational use of drugs. In brief, we have to say all drugs prescribe should be of adequately labeling.

17

In this study, 87% of the patients knew the direction time and quantity of drugs to be taken and for how long. The knowledge growled by the patients during dispensing is essential in ensuring patient adherence.

In this assessment, it has been noticed that the overuse of Antibiotics was considered as a major problem of the rational use of drugs in the assessed clinics, as (59%) of prescription were with Antibiotics compared to WHO standards (25%) or less, which off course need collaborative effort to advice on the rational use of it as the overuse of Antibiotics can enhance microbial resistance to antibiotics.

Conclusion:

The assessment result shows relatively good implementation of rational use of drugs among the most of the selected clinics, especially, in prescribing from the national list of essential medicine of Sudan, relatively enough consultation/dispensing time, and limited use of Injectable, therefore, the assessment suggests that there is still scope of improvement in prescribing and dispensing in the clinics. Writing with generic names is urgently needed, the object which may support in increasing the understanding at dispenser’s level, and lowering the drug cost. Overuses of antibiotics, reduced patients’ knowledge about correct doses, trim down drug labeling in drug envelope, also contributed to be the main areas of irrational use of medicine in GOAL clinics.

Recommendations:

1. Conduct trainings of health care providers in GOAL clinics to:

Look at the increased usage of Antibiotics, and refer to the standard treatment guidelines in case management.

Perk up the labeling of drugs, and promote for information sharing and getting feedback from the patients.

Maintain and strength the good supply management system at GOAL clinics

To promote prescribing with the generic names

2. Supervision and Monitoring of drug management and rational use of drugs are required in all supported facilities.

18

3. Support all health care providers with standard protocols on prescribing and dispensing process.

4. Distribute copies of the national list of essential medicine and standard treatment guidelines to the PHC facilities.

5. Conduct collaboratively (WHO-MoH) Education campaign at community level to raise community awareness about the use of drugs as well as to minimize the push- to -prescribe behavior of the patients.

19

Annex 1: Good dispensing process:

Steps Done

Not done

Receiving the prescription1. Receive and validate prescription

Confirm name of patient

2. Understand and interpret prescription

Check prescription for completeness

Name of the patient Name of the drug and the

strength Time and/or frequency of

administration Duration of treatment Route by which the drug

is to be administered Date and time when the

order was written Signature of the person

writing the prescription

Confirm that doses are in safe range

Correctly perform any calculations of dose and issue quantity

Identify any common drug-drug interactions

In case of any doubt or incompleteness, check with the prescriberPreparation for issuingWork in teams of two for dispensing in order to double-check prescription

o The first collects the drugs prescribedo The second then verifies and gives them to patients with all necessary

explanations1. Write label before drugs are

Tablets and capsules should be

The label should indicate the following

o Name of the

20

packed packed in a sealed plastic dispensing bag

patiento Drug name (use

generic name)o Strength (usually

in mg)o Dose - amount and

frequency (Clear instructions for use in a familiar language)

o Quantity dispensed o Name of the health

facilityo Date of dispensingo Cautionary label

(e.g. “Keep out of reach of children”)

Symbols might be necessary to indicate amount and frequency of dosage for patients who cannot read

2. Select stock container

Select by reading the label of the container and check it with the prescription

Check the expiration date on the container

Do not keep too many containers open at the same time

3. Measure or count quantity from the stock container

Hands must never be in direct contact with the medicine

Counting can be done with a clean piece of paper and spatula, tablet counter, lid of the container in use or other clean surface

Use a spoon to put tablets and capsules onto the counting tray

Keep the counting devices clean at all times!

Immediately after counting, the container

21

should be closed again Recheck the container

label for the drug name and strength

4. Record the distributed items in the documentation sheetInformation to the patient

1. Give the patient clear instructions and advice to re-enforce the right instructions on the label

Information that will maximize the effect of the treatment

How often to take the drug When to take the drug

(particularly in relation to food and other medicines)

How long the treatment is to last (e.g. why the entire course of an antibiotic treatment must be taken)

How to take the drug (e.g. with plenty of water, chewing or swallowing),

How to store the drug (e.g. avoid heat, light and dampness),

Do not share drugs with other persons,

Keep drugs out of the reach of children

2. Additional

information

Every effort should be made to confirm that the patient understands the instructions!To check if a patient really understands, have them repeat what they were told

22

Annex 2:List of key drugs in Health facilities

No Drug items Unit

1 Oral Rehydration Salt Sachet2 Cotrimoxazole tablets tablets

3 Procaine penicillin Injection

4 Benzyl penicillin Injection

5 Paracetamol tablets tablets

6 Ferrous salt+folic Acid tablets

7 Mebendazole tablets tablets

8 Tetracycline eye ointment Tube

9 Iodine Bottle

10 Gentian Bottle

11 Benzoic Acid Bottle

12 Acetyl salicylic tablet tablets

13 Artesunate 50 mg, 100mg tablets

23

Annex 3: Prescribing indicator form:

Location:----------------------------------------------------------

Investigator:----------------------------------------------------- Date:-------------------------

Seq

Type(R/P) DATE OF Rx

Age(yr) No. drugs No generic

Antibi (0/1)

Inj(0/1) No on EDL

Diagnosis (optional)

123456789101112131415161718192021222324252627TotalAveragepercentage % of Total

drugs% of Total cases

% of Total cases

% of Total drugs

24

Annex 4: Patient care form:

Location:------------------------------------------------------------------------

Investigator:------------------------------------------------------------Date:-------------------

Seq

Patient identifier (if needed)

Consultation time (mins)

Dispensing time (secs)

Number of drugs prescribed

Number of drugs dispensed

No adequate labelled

Knows dosage (0/1)

123456789101112131415161718192021222324252627countTotalAveragepercentage

25

0=No 1=yes

References:

1. A baseline survey on use of drugs at the primary health care level in Bangladesh. Bull WHO; 72: 265-271.Hassan, M.Y, Das, M. and Mourad, F. (1997).

2. Action Programme on Essential Drugs, WHO: Geneva, pp 87.3. Assessment of rational drug use and prescribing in primary health care

facilities in North West Ethiopia. East Afr. Med. J., 74: 758-763.Dowse, R. and Ehlers, M.S. (2001). Chareonkul, C., Khun, V.L. and Boonshuyar, C. (2002).

4. Drug utilization and antibiotic use in the primary care centres in Sharjah. East. Med Health J; 3: 444-451 Hazra, A., Tripathi, S.K. and Alam, M.S. (2000).

5. Field test for rational drug use in twelve developing countries. Lancet, 342: 1408-10.Kafle, K.K., Karkee, S.B. and Prasad, R.R. (1992).

6. http://www.unhcr.org/publ/PUBL/43cf66132.pdf 7. Impact of an essential drugs program on availability and rational use of

drugs. Lancet, 1: 141-142.Hogerzeil, H.V., Bimo, Ross-Degnan, D., Laing, R.O., Oforie-Adjei, D., Santoso, B., Azad Chowdury, A.K., Das, A.M., Kafle, K.K., Mabadaje, A.F.B., Wiedenmayer, K., D Mtasiwa, D., Majapa, Z., Lorenz, N. and Quick, J.D. (1993).

8. INRUD drug use indicators in Nepal: practice patterns in health post in four districts. INRUD news 1992, 3: p 15.Krause,G., Borchert, M. and Benzler, J. (1999).

9. International Network for the Rational Use of Drugs (INRUD), 2nd International Conference for Improving the Use of Medicines (ICIUM 2004), Policies and Programmes to Improve Use of Medicines: Recommendations from ICIUM 2004, URL: http://mednet3.who.int/icium/icium2004/recommendations.asp

10.Managing drug supply. Management Science for Health, 2nd ed. Kumarian press, Inc., Connecticut, USA. Pp 137 – 143.

11.Pharmacist's attitudes towards dispensing errors: their causes and prevention. J Clin Pharm Ther; 24: 57-71Quick, J.D., Hogerzeil, H.V., Ross-Degnan, D., Laing, R.O., Oforie-Adjei, D. and Santoso,B. (1997).

12.Prescribing and dispensing activities at the health facilities of a non-governmental organization. Natl Med J India; 13: 177-182.Hogerzeil, H.V., Walker, G.J.A., Salami, A.O. and Fernando, G. (1989).

26

13.Prescribing habits in church-owned primary health care facilities in Dar Es Salaam and other Tanzanian coast regions. East Afr. Med. J., 78: 510-514.Peterson, G.M., Wu, M.S. and Bergin, J.K. (1999).

14.RATIONAL DRUG USE IN CAMBODIA: STUDY OF THREE PILOT HEALTH CENTERS IN KAMPONG THOM PROVINCE , Chanin Chareonkul Va Luong Khun and Chaweewon Boonshuyar, accessed through http://www.tm.mahidol.ac.th/seameo/2002_33_2/33-2854.pdf

15.Rationality of drug prescriptions in rural health centres in Burkina Faso. Health Policy Plan,14: 291-298 Massele, A.Y., Nsimba, S.E. and Rimoy, G. (2001).

16.The evaluation of pharmaceutical pictograms in a low-literate South African population. Patient Educ Couns; 45: 87-99.Guyon, A.B., Barman, A., Ahmed, J.U. Ahmed, A.U., and Alam, M.S. (1994).

17.The International Network for Rational Drug Use. Promoting rational drug use. 1998. Available at h t t p : / / d c c 2 b u m c . b u , e d u / p r d u / H T M L _DOCS_TOC.htm

18.World Health Organization and International Network for Rational Use of Drugs (1993). How to investigate drug use in health facilities: Selected drug use indicators. EDM Research Series No. 7 [WHO/DAP/93.1]. Geneva: World Health Organization.

19.World Health Organization. (1995). How to investigate drug use in health facilities (Selected drug use indicators).

20.World Health Organization. The Rational Use of Drugs. Report of the Conference of Experts. Geneva: World Health Organization; 1985.

21. World Health Organization Promoting rational use of medicines: core components. WHO Policy Perspectives on Medicines no. 5. Document WHO/EDM/2002.3. Geneva, WHO, 2002. Available at URL: http://www.who.int/medicines

22. World Health Organization, “International Conference for Improving the Use of Medicines”, Essential Drugs Monitor; 1997; 23:6-12.

23. World Health Organization, Database on medicines use in developing and transitional countries; work in progress. Department of Medicines Policy and Standards, WHO, Geneva. Initial results presented at the 2nd

International Conference for Improving the Use of Medicines, Chiang Mai, 2004. Available at URL: http://www.icium.org

24. World Health Organization, Rational use of medicines: progress in implementing the WHO medicines strategy, EB118/6, 2006; WHO Geneva; URL: http://www.who.int/gb/e/e_eb118.html

27