Dr kathy holloway 2

Interventions and innovations at community level to improve antibiotic access and use: global overview Kathleen Holloway

Regional Advisor Essential Drugs and Other Medicines WHO South East Asia Regional Office

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New Delhi, 3-5 October 2011

Database on medicines use !

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Database of all medicines use surveys using standard indicators in primary care in developing and transitional countries Studies identified from INRUD bibliog, PUBMED, WHO archives Data on study setting, interventions, methods and drug use extracted & entered All data extraction and entry checked by 2 persons Now > 900 studies entered Systematic quantitative review Evidence from analysis used for WHA60.16 in 2007 1st Global Forum on Bacterial Infections

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New Delhi, 3-5 October 2011

Treatment of ARI by prescriber type: WHO 2009 80 70 60 50 40 30 20 10 0 % viral URTI cases prescribed antibiotic Doctor (n=26-62)

% pneumonia cases prescribed antibiotic

Nurse/paramedic (n=12-86)

% ARI cases treated with cough syrup Pharmacy staff (n=9-17)

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New Delhi, 3-5 October 2011

Public / private treatment of acute diarrhoea by doctors, nurses, paramedical staff: WHO 2009 80 70 60 50 40 30 20 10 0 % diarrhoea cases prescribed antibiotic

% diarrhoea cases prescribed antidiarrhoeals

Public (n=54-90)

% diarrhoea cases prescribed ORS

Private-for-profit (n=5-10)

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Many Factors Influence Use of Medicines Prior Knowledge

Information

Scientific Information

Influence of Drug Industry

Habits Social & Cultural Factors

Treatment Choices

Workload & Staffing

Workplace

Intrinsic

Infrastructure

Relationships With Peers

Societal Economic & Legal Factors Authority & Supervision

Workgroup

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Community surveillance of AMR and use (1) !

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Developing & piloting method for integrated surveillance of AMR & AB use & collection of baseline data in 2 resource-constrained settings 3 sites in India & 2 in S. Africa AMR & AB use data collected monthly for 1-2 years from same communities 4 sites measured AMR in E.Coli & 1 in S.pneum & H.influenzae AB use by private GPs, retailers, public & priv hospitals & PHCs by exiting patient interview or prescribing & dispensing records Qualitative study (FGDs) into provider & consumer behaviour 1st Global Forum on Bacterial Infections

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New Delhi, 3-5 October 2011

Community surveillance of AMR and use (2): results !

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Antimicrobial resistance ! pathogenic E.Coli in pregnant women's urine in India ! Cotrim 46-65%; Ampi 52-85%; Cipro 32-59%; Cefalex 16-50% ! S.Pneumoniae & H.influenzae in sputa in S. Africa ! Cotrim > 50% (both organisms); Ampi >70% (H.influenzae) Antibiotic use ! About ½ patients in India & ¼ or less of patients in S.Africa get ABs ! Much inappropriate AB use especially in India e.g. use of fluoroquinolones for coughs and colds in private sector Motivation of providers & consumers ! Patient demand – looking for quick cure ! Lack of CME & unwillingness to attend for fear of losing custom ! Uncontrolled pharmaceutical promotion, involving financial gain 1st Global Forum on Bacterial Infections

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New Delhi, 3-5 October 2011

% school children treated with antibiotics for cough & cold in the previous winter in Moldova Intervention: volunteer students Cebotarenco & Bush, Health Ed. Res, 2008 70

train fellow students & parents on ABs, using video, newsletter, meetings, booklets, contests

60 50 40 30 20 10 0 Pre-intervention

Post-intervention

Control group

Intervention group

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New Delhi, 3-5 October 2011

Impact of user fees on prescribing quality in Nepal Source: Holloway et al: HPP 2001 & SSM 2002 User Fees (complete drug courses)

control fee / Px N=12

1-band item fee N=10

2-band item fee N=11

2.9 2.9 (+/- 0)

2.9 2.0 (-0.9 drugs)

2.8 2.2 (-0.6 drugs)

% prescriptions containing ABs

66.7 67.5 (+0.8%)

63.5 54.8 (-8.7%)

60.7 54.3 (-6.4%)

% prescriptions according to STGs

23.5 26.3 (+2.7%)

31.5 45.0 (+13.5%)

31.2 47.7 (+16.5%)

Average cost per prescription (Rs)

24.3 33.0 (+8.7 Rs)

27.7 28.0 (+0.3 Rs)

25.6 24.0 (-1.6 Rs)

Av. no. drugs per prescription (Px)

Interviews with patients & providers

Both wanted the most drugs for least cost so the item fee resulted in many people opting for fewer drugs

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New Delhi, 3-5 October 2011

Impact of Patient-Provider Discussion Groups on % patients receiving injections in Indonesian PHC Facilities Hadiyono et al, SSM, 1996, 42:1185 80

70 60 50 40 30 20 10 0 Pre-intervention

Post-intervention

Control group

Intervention group

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New Delhi, 3-5 October 2011

Proportion of visits with injection

Impact of multiple interventions on injection use in Indonesia 100% 80% 60% 40%

Interactive group discussion (IGC group only) Seminar (both groups) District-wide monitoring (both groups)

20% 0% 1 3 5 7 9 11 13 15 17 19 21 23 25

Months Comparison group Interactive group discussion Source: Long-term impact of small group interventions, Santoso et al., 1996 1st Global Forum on Bacterial Infections 11

New Delhi, 3-5 October 2011

Review: Public education campaigns in industrialised nations Huttner et al 2009, Lancet Infectious Diseases, 2009,10(1):17-31.

Country

Period

France

2002 -

Belgium

2000 -

UK

Yearly

Australia

2000-8

USA

1995 -

Canada*

1996-2005

Spain Portugal

2006-8 2004-7

Germany Norway

2000 2004

* Providers

Campaign Type

Antibiotic (AB) reduction

Yearly mass media targeting Providers & Consumers

27% AB prescriptions

Limited Seasonal mass media campaign targeting consumers

9% AB Prescriptions

36% reimbursed packages Stable use 14% AB consumption (DDDs) 18-36% in ABs for ARI

High use / No change Low use / No change

also targeted 1st Global Forum on Bacterial Infections

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Intervention impact: largest % change in any outcome measured: Source - WHO database on medicines use 2009 Intervention type

No. studies Med. impact

25,75th centiles

Printed materials only

5

8%

7%, 18%

National medicines policy

6

15%

14%, 24%

Economic strategies

7

15%

14%, 31%

Provider education

25

18%

11%, 24%

Consumer education

3

26%

13%, 27%

Provider+consumer education

12

18%

7%, 21%

Provider supervision

25

22%

16%, 40%

Provider group process

8

37%

21%, 59%

Essential drug program

5

28%

26%, 50%

Community case management

5

28%

28%, 37%

Provider+consumer ed & supervis

7

40%

23%, 54%

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New Delhi, 3-5 October 2011

Intervention impact: median % change in all outcomes measured (av. 4/study): Source - WHO database on medicines use 2009 Intervention type

No. studies Med. impact

25,75th centiles

Printed materials only

5

5%

-2%, 7%

National medicines policy

6

5%

0%, 15%

Economic strategies

7

6%

-1%, 8%

Provider education

25

7%

4%, 15%

Consumer education

3

2%

1%, 14%

Provider+consumer education

12

9%

-1%, 18%

Provider supervision

25

13%

5%, 17%

Provider group process

8

13%

9%, 28%

Essential drug program

5

15%

1%, 45%

Community case management

5

29%

24%, 36%

Provider+consumer ed & supervis

7

24%

18%, 28%

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New Delhi, 3-5 October 2011

What national policies do countries have to promote rational use?

Source: MOH Pharmaceutical policy surveys 2003 and 2007 Drug use audit in last 2 years National strategy to contain AMR Antibiotic OTC non-availability Public education on antibiotic use DTCs in >half general hospitals Drug Info Centre for prescribers Obligatory CME for doctors UG doctors trained on EML/STGs STGs updated in last 2 years EML updated in last 2 years

0 2007 (n>85)

20

2003 (n>90)

40

60

% countries implementing policies

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80

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100

2nd International Conference for Improving Use of Medicines, Chiang Mai, Thailand, 2004 472 participants from 70 countries

http://www.icium.org

Recommendations for countries to: ! ! !

Implement national medicines programmes to improve medicines use Scale up successful interventions Implement interventions to address community medicines use

3rd ICIUM to be held 14-18 November 2011 1st Global Forum on Bacterial Infections 16

New Delhi, 3-5 October 2011

What are we spending to promote rational use of medicines ? !

Global sales of medicines 2002-3 (IMS):

US$ 867 billion

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Drug promotion costs in USA 2002-3:

US$ >30 billion

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Global WHO expenditure in 2002-3:

US$ 2.3 billion

! Essential Medicines expenditure

2% (of 2.3 billion)

! Essential Medicines expenditure on

promoting rational use of medicines

10% (of 2%)

! WHO expenditure on promoting

rational use of medicines

0.2% (of 2.3 billion)

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New Delhi, 3-5 October 2011

Conclusions !

Irrational use of medicines is a very serious global public health problem

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Much is known about how to improve rational use of medicines but much more needs to be done ! policy implementation at the national level ! implementation and evaluation of more interventions,

particularly managerial, economic and regulatory interventions aimed at prescribers and the community

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Rational use of medicines could be greatly improved if a fraction of the resources spent on medicines and their promotion were spent on improving use.

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New Delhi, 3-5 October 2011