Drug Use Practices in Primary Care Facilities in Serbia: A Comparative Study

2. BACKGROUND • Republic of Serbia is the part of Serbia and Montenegro (former FR Yugoslavia) • The population of Serbia is 7,478,820 (2002 census) • The economy has begun to recover but political stability is not assured yet • Increasing inequality, decreasing purchasing power, high unemployment • Average monthly salary about 176 Euros • Life expectancy 69 years for men and 74.46 for women • Cardiovascular diseases, cancers, and injuries responsible for 80% of the total mortality burden • Very low availability of essential medicines in private and public sector in last decade • Study on prescribing habits in primary health care conducted in 2000 by WHO Office in Belgrade • Study showed high level of irrational drug prescribing and gave significant indicators for improvement • Since 2000 various activities undertaken – new prescription form, formulary, clinical guidelines for some diseases • Limited public resources for improvement of the situation

3. OBJECTIVES • Theobjectives of the Study were: • To describe current drug use practices in a representative sample of primary care facilities in a standardized, reproducible manner, • To compare results with the 2000 Study, • To show the availability of medicines in public pharmacies, • To compare the prices of medicines regulated by law, international prices and prices found in pharmacies. • It was expected that Study will help us: • To show that undertaken steps were useful, • To realize weak points in prescribing habits, • To confirm that availability of medicines is sufficient at least in private pharmacies, • To prove that locally manufactured medicines have consistent prices, • To indicate further activities for improvement.

4. METHODS • The Study was a follow-up of the 2000 Study with additional part concerning availability and pricing • The type of Study was cross sectional survey of representative sample • Sampling units were primary health care facility and pharmacy: • 20 primary health facilities (10 Primary Health Centers and 10 linked Health Stations) with 30 patient encounters in each – the first 30 files of patients that visited one GP on October 6th, 2003. • 20 state pharmacies within those centers plus 20 private pharmacies randomly selected • Simple random sampling was used for health facilities and combined two-phase cluster sampling for pharmacies • There were exclusion criteria: • Specialist primary health care doctors – immunization, pediatrics, gynecology and obstetrics, occupational health • Foreign doctors employed by international organizations • Patients under 16

5. METHODS • 6 students from Faculty of Pharmacy were engaged and trained for data collection – groups of two students visited each facility • Students were supervised by authors of the Study • Data processing and analysis were done in EPI INFO according to validated questionnaires • Questionnaires were created based on the number of indicators considering: • Data on doctors • Data on patients • Diagnoses • Prescribed drugs – groups of drugs, different forms of drugs • Available literature • Treatment of medical waste • Generic substitution (local and foreign) • Availability • Prices • Inspection visits

6. RESULTS • There is a high number of patients elder than 61 • Surprising number of female GPs • All GPs have some kind of professional literature: • Drug register (89,2% mainly old edition) • Reimbursable drug list (94,6 %) • Treatment protocols (43%) – at the moment exist only for 4 diseases • Professional magazines (30%) • Advertising material (20%)

7. RESULTSMorbidity of the sampled patients and top 10 diagnosed diseases

8. RESULTS • All medicines are prescribed as brands; practice of generic prescribing is not in place yet • There are insufficient information and lack of training in generic prescribing • In 13,2% cases GPs prescribe drugs according to specialist recommendation • In 34,2% of cases GPs verbally recommend: vitamin C, diet, hydration, resting

9. RESULTSMost prescribed medicines (presented as generics)

10. RESULTS • 81.62% (84.11% in 2000) of prescribed drugs were oral • 13.45% (14.33% in 2000) were prescribed injections • Cardio-vascular diseases – the most prescribed were ACE inhibitors, Ca antagonists and diuretics • Benzodiazepins are less prescribed than in 2000 • Most prescribed antibiotics are amoxicillin, cephalexin and cotrimoxasole • 9.73% oral antibiotics and 2.07% injections (better than in 2000 – 12.22/4.67) • Other significantly prescribed groups: • Analgesics • Vitamins • Steroids • H2-blockers • Beta-blockers • Antidiabetics

11. RESULTS Availability of drugs and pricing • 10 out of 18 studied medicines were taken for analysis (cephalexin, gentamycine, ibuprofen, nimesulid, alprazolam, fluoxetin, dexamethasone, methylprednisolone, enalapril, verapamil) • All chosen medicines are in reimbursable list and have marketing authorization • Availability is not satisfactory especially in private pharmacies • Price ranges are too high considering the regulated prices for domestic manufacturers • Prices are compared with median prices from International Drug Price Indicator Guide (2002 edition) and medicines in Serbian market is much more expensive Conclusions: • Drug pricing system needs to be adapted • Control mechanism for prices in pharmacies need to be enforced • The reimbursable list needs to be reviewed • Training and strengthening of pharmacists awareness is necessary

12. CONCLUSIONS • The situation is slightly different than in 2000 • Rational drug prescribing promotion for professionals is necessary • Introduction of generic prescribing is needed • Introduction of new clinical guidelines and adequate promotion of new and existing guidelines • Public and patient education would be useful – there is a pressure on professionals since in last decade practice of self-medication was intensified • Preventive health care system has to be strengthen as well as health promotion • Efficient control mechanisms for pricing and prescribing have to be developed