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Understanding and conceptualising
irrational prescription pattern for
antimicrobials in Nigeria: economic
and other implications
Obinna Onwujekwe
Professor of Pharmaco-economics and
College of Medicine, UNEC, Enugu
Prescription pattern in Nigeria:
abuse and implications for the
health of Nigerians
Two main disciplinary domains
–They are new emerging areas of study
–Both were conceived in the 1980s.
–Both deal with health outcomes
–Both are linked, but are individual
–Central goals are improving drug
prescribing, provision and utilisation
• It is the systematic assessment of the costs
and consequences (outcomes) of
pharmaceutical products and services
• Research in this field identifies, measures and
compares the costs (i.e. the resources
consumed) and outcomes (clinical, economic,
humanistic) of pharmaceutical products and
Components of Pharmaco-economics
• Costs and outcomes measurements
• Economic techniques that are used in
pharmacoeconomics for decision making
• Economic and non-economic techniques for
measuring the burden of disease and quality
of life, so that we will know whether our
patients are improving in ways that clinical
parameters cannot easily measure.
• Central theme for maximising the
pharmaceutical services is the ECHO model
– Economic; Clinical Science; Humanistic outcomes
• The optimal decisions for pharmaceutical
products and services are those which balance
the ECHO model
ECHO principle
• Treating patients with pharmaceuticals has to
be a balance of good clinical science,
economics, and outcomes
• For example, the best drug therapy for a
patient from a clinical point of view may not be
the "best" option overall if the patient either
cannot afford to take it (e.g. economic), of if
there lives are so disrupted by the treatment
that they refuse to comply with it (e.g.
humanistic outcomes) (Cosler, 2002).
ECHO in practice
• Economic principles:
– Cost minimisation analysis (CMA); Cost-effectiveness
analysis (CEA), Cost-benefit analysis (CBA), Cost-Utility
analysis (CUA).
– Measurement of outcomes: Natural units (deaths
averted, cases prevented, Quality Adjusted Life Years
(QALYs), Disability Adjusted Life Years (DALYs), etc);
Monetary units in terms of willingness to pay as a
valuation of benefit.
• Humanistic principles: Quality of life measurements, talking
to the patients
• Clinical: Symptoms, Signs, investigations etc
• Specialised area specialised area of epidemiology
that uses various research tools to determine the
best pharmaceutical treatments in a population.
• Traditionally called drug epidemiology
• Investigates the use of drugs and adverse effects
of drug therapy in populations to improve the
individual patient's regimen with respect to
effectiveness and safety (Heidelberg University).
• It is the application of epidemiological reasoning,
methods and knowledge to the study of the uses
and effects (beneficial and adverse) of drugs in
human populations (Trinity College, Dublin).
• It examines the population and the diseases for
which drugs are used to treat, and the problems
and benefits, which these medications may bring.
• Such research is critical for assuring that drugs
meet health needs and are used safely, optimally
and efficiently.
Prescribing patterns
Rational Drug use
Adverse drug reactions
Drug resistance
Drug interactions
Pharmacovigilance - It is the process of
identifying and then responding to safety
issues about marketed drugs
• Post-marketing drug surveillance
Antimicrobial resistance
• The evolving public health threat of
antimicrobial resistance (AMR) is driven by
both appropriate and inappropriate use of
anti-infective medicines for human and animal
health and food production (WHO, 2012).
• Today many common and life threatening
infections are becoming difficult or even
impossible to treat
Rational use of drugs
• It requires that 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, 2001)
Case study of irrational prescribing: Treatment
of malaria in Enugu state
• Study in Enugu urban and Udi LGA
• Findings
– 22.4% of febrile patients for whom treatment was
sought received an ACT
– 57.8% of the ACTs were dispensed in the correct dose
– 37% of patients received SP in public facilities and 39%
in drug retailers
– 14% of patients received artemisinin monotherapy
– Most of the facilities had ACTs in stock and
artemisinin-based monotherapy in stock
Findings CONTD
• 0.7% of febrile patients received malaria diagnostic
test at the health facility (3% in public facilities)
• Many health workers did not know nationally
recommended treatment for uncomplicated
malaria and the correct dosage
• 28.6% of HW knew the regimen for AL in a child
aged 2yrs
• These variables varied by location and type of
• Some providers, especially in the rural areas do not
stock ACTs because people do not ask for them.
• Some patients still ask for Chloroquine because they
think it still effective in treatment of malaria.
Fawibe et al (2012). Drug prescription pattern for
asthma among Nigerian doctors in general practice
• About 48% of the doctors had never attended any form of
update training on asthma management
• Only 16.3% attended update training on asthma within the
last year preceding the study.
• Only 16.4% were able to mention any correct guideline on
asthma management
• Poor anti-asthma prescribing behavior among
doctors is associated with a low level of
participation at update training on asthma
management and poor awareness of asthma
Adebayo ET, Hussain NA (2012).Pattern of prescription
drug use in Nigerian army hospitals.
• 90.5% of prescribers were. aware of the existence of
national essential drugs list
• 58.1% of them did not use it as basis of prescriptions.
• Only 12.1% of prescribers could accurately detail the 5
steps of rational prescribing.
• The pattern of prescription drug use in Nigerian Army
hospitals is characterised by high number of drugs per
prescription, high rate of antibiotic usage and
unscientific prescription by doctors.
• There is a need for further education and research on
rational drug use among prescribers in Nigerian
military health facilities.
Irrational use of drugs (WHO, 2012)
• Over prescription (too many drugs)
• Under prescription
• Prescription and dispensing of unnecessary
• Overtly expensive drugs when there are
inexpensive alternatives (branded vs generics)
• Prescription of inappropriate drugs
Why over prescription by doctors and
other healthcare providers (WHO, 2012)?
• Because of fear of treatment failure
• Lack of knowledge of the local AMR situation
• Real or perceived patients’ expectations
• Drug company promotional efforts
• Personal financial gain
• Leads to high levels of health and economic
– Increased burden of diseases
– High level of costs due to diseases, which could
become catastrophic
• Costs to the health system (providers, individuals,
households, the government etc)
Cause and effect (WHO, 2012)
• Bacteria and other microbes react to drugs that
are used as treatment by becoming resistant to
them sooner or later – this natural process
adaptation means that the effective lifespan of
antibiotics and other antimicrobials is limited
• Unnecessary use and inappropriate use of
antibiotics favours the emergence and spread of
resistant bacteria
Common examples of drug resistance
to antimicrobials (WHO, 2012)
• Multidrug-resistance tuberculosis (TB)
• Malaria – resistance exists for all classes of
• HIV infection – resistance rates to anti-HIV
drug regimens range from 10 – 20% in Europe
and USA.
• Antibiotic-resistant bacteria
The 2001 WHO Global Strategy for the
containment of AMR
• Reducing the disease burden and spread of
• Improving access to appropriate antimicrobials
• Improving the use of antimicrobials
• Strengthening health systems and their
surveillance capabilities
• Enforcing regulation and legislation
• Encouraging the development of appropriate new
drugs and vaccines
Five domains targeted for AMR
containment (WHO, 2001)
• Surveillance of antimicrobial resistance and
• Rational antimicrobial use and regulation
• Antimicrobial use in animal husbandry
• Infection prevention and control
• Fostering innovations
• Political commitment
Six-point policy package for tackling
antimicrobial resistance (WHO, 2011)
• All countries should
– Commit to a comprehensive, financed national plan
with accountability and civil society engagement
– Strengthen surveillance and laboratory capacity
– Ensure uninterrupted access to essential medicines of
assured quality
– Regulate and promote rational use of medicines in
animal husbandry and to ensure proper patient care
– Foster innovations and research and development of
new tools
Organisational frameworks for
promoting rational use of drugs
• International conference for the improved use
of medicines (ICIUM) – once every seven years
• International Network for the Rational use of
drugs - INRUD
• International Society for Pharmaco-economics
and outcomes Research (ISPOR)
• Etc etc
The Nigerian Health System and
rational drug use
• One of the worst in the world
• Ranked 187 out of 191 in 2000
• Now second worst in terms of maternal
• Is not primed to achieve MDGs and Universal
• Role of healthcare providers is critical
A health system is the sum total of all the organisations,
institutions and resources whose primary function is to
improve health. The term includes all levels from service
delivery, to policy making and implementation.
A Health system needs staff, funds, information, supplies, transport,
communication and overall guidance and direction. It needs to
provide services that are responsive and financially fair, while
treating people decently.
The Nigerian health system should
achieve Universal Health coverage
• Providing financial risk protection for all
(100%) from the costs of health care
– Everybody should have access to pre-payment
mechanisms such as Health insurance
• Enabling access to needed health care for all
(100%) - financial and geographic access
– Rational drug use and prescription for all
– Optimal quality health services to all
Four target indicators proposed by WHO to
M&E progress to achieving universal coverage
• Total health expenditure should be at least 4% 5% of the gross domestic product
• Out-of-pocket spending should not exceed 3040% of total health expenditure
• Over 90% of the population is covered by prepayment and risk pooling schemes
• Close to 100% coverage of population with
social assistance and safety-net programmes
Is Nigeria on track to achieve Universal
Health coverage (UHC)?
• Nigeria decides!
– Total health expenditure is 0.7% of GDP instead of the
recommended 4% - 5%
– Out-of-pocket spending is more than 60% of total
health expenditure instead of the recommended 30-40%
– Less than 5% the population is covered by prepayment and risk pooling schemes instead of the
recommended 90%
– Less than 2% coverage of population with social
assistance and safety-net programmes instead of the
recommended 100%
• All hands at the federal, state and LGA levels must be on deck
References and further reading
Adebayo ET, Hussain NA. Pattern of prescription drug use in Nigerian army
hospitals. Ann Afr Med. 2010 Jul-Sep;9(3):152-8.
Fawibe AE, Onyedum CC, Sogaolu OM, Ajayi AO, Fasae AJ. Drug prescription
pattern for asthma among nigerian doctors in general practice: A crosssectional survey. Ann Thorac Med. 2012 Apr;7(2):78-83.
WHO (2001) WHO Global strategy for the containment of antimicrobial
resistance. Geneva: World Health Organization
WHO (2001). How to develop and implement a national drug policy. 2nd ed.
Geneva: World Health Organization
WHO (2011). World Health Day 2011: Policy briefs. Geneva: World Health
World Health Organization (2012).The evolving threat of antimicrobial
resistance: options for action. Geneva: World Health Organization
Mangham L, Cundill B, Ezeoke O, Nwala E, Uzochukwu BSC, Wiseman V,
Onwujekwe O (2011). Treatment of uncomplicated malaria at public health
facilities and medicine retailers in south-eastern Nigeria. Malaria Journal,