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Rational Drug Use: A ‘Sub-Mission’ under NRHM

This paper discusses the importance of rational drug use in the context of the National Rural Health Mission (NRHM) in India. It highlights the high costs of medical expenditure, the slow decline of mortality rates, and the persistence of nutritional deficiencies. The paper suggests measures to promote rational drug use, including providing free medicines and promoting the use of generics.

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Rational Drug Use: A ‘Sub-Mission’ under NRHM

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  1. Rational Drug Use: A ‘Sub-Mission’ under NRHM National Workshop on Equity, Quality & Accountability under NRHM Bhubaneswar, 4th-6th September, 2009 Dr. Ritu Priya National Health Systems Resource Centre National Rural Health Mission

  2. THE CONTEXT OF NRHM MAJOR CAUSE FOR RURAL INDEBTEDNESS = MEDICAL EXPENDITURE 70% OF THE MEDICAL EXPENDITURE = COST OF MEDICINES (NSSO 60th rd.) MORTALITY RATES DECLINING SLOWLY, 2003 to 2007 (SRS) IMR = 60 to 55 /1000 live births CDR= 8 to 7.4 / 1000 population

  3. GROWTH RATE OF THE NATIONAL ECONOMY = 6-9% DECLINE OF POOREST AS %age OF HOUSEHOLDS = 50%(NSSO, 1999 & 2004; 364 & 176/1000 hh.) HOUSEHOLD EXPENDITURES EXPENDITURE ON FOOD :54 to 52% of total EXPENDITURE ON Medical: 3.5 to 7.5% of total EXPENDITURE ON FOOD : MEDICAL SERVICES= decreasing (7.4:1 decreased to 6.3:1; NSSO) NUTRITIONAL DEFICIENCIES PERSIST Households not getting food to provide adequate cal./proteins= 70% Low Birth Weight babies= 30% Moderate & severe undernutrition (0-5yrs.)=58%

  4. Despite improvements in the two primary determinants of health: I. SOCIO-ECONOMIC STATUS High economic growth & Decrease in proportion of BPL II. HEALTH SERVICES AVAILABILITY & ACCESS Strengthening of Public Health infrastructure & Enhanced utilisation of health care WHY IS IMR and CDR DECLINE SO SLOW?

  5. Probable causes of Improvements in Health not Commensurate with those in Economy & Health services: • Low purchasing power & living/working • conditions of over 50% of the population • Increasing economic and social disparities • Increasing incomes going to medical (and • other non-food) expenditures rather than to • improving diets • CAN HEALTH BE GAINED WITH MEDICINES INSTEAD OF FOOD??

  6. IF WE ACCEPT THAT THIS IS NOT ACCEPTABLE, • THAT BOTH ARE NECESSARY, THEN: • Household expenditure on Medicines needs • to be cut. • Incomes have to allow increase in food expenditure & Social values have to promote dietary intakes for women and children. • So that: • Health can improve.

  7. Worldwide: • >50% of all medicines are prescribed/dispensed/sold inappropriately • 50% of patients fail to take medicines correctly. • Iatrogenic diseases are rapidly increasing, one-fourth of hospital patients in the USA suffering from iatrogenic problems • In India: • 300-400 medicines are essential, but • 70,000 formulations in the market!!! • 4 out of 5 vitamin preparations are irrational • 2 out of 5 contain are non-essentials • 80% cough & cold remedies irrational

  8. Items banned risks > benefits Reference: MIMS India, October 2002, GOI weed-out notifications

  9. POSSIBLE MEASURES • PROVISION OF RATIONAL & FREE MEDICINES BY THE PUBLIC HEALTH SERVICES TO: • BPL PATIENTS • ALL PATIENTS • THERE IS VARIATION ACROSS STATES, • MOST NOT GIVING ADEQUATE TO ALL

  10. IMPLICATIONS OF FREE TO ALL THREATS/BARRIERS BENEFITS • There is the moral hazard of grab and waste • The costs are too high to the service system • Cuts the Provider-Pharma nexus • Cuts costs of medical care to society as a whole

  11. Corrective Measures THREATS/BARRIERS CORRECTIVE MEASURES • There is the moral hazard of grab and waste • The costs are too high to the service system • Promote rational drug use prescribing • Buy Generic drugs • Negotiate lower prices with the benefit of bulk purchase. • Regulate drug prices

  12. Therefore to: Decrease side-effects Decrease costs Make healthcare more effective. Adopt: RATIONAL USE OF MEDICINES Procurement and Prescribing of Generics

  13. WHAT IS RATIONAL DRUG USE? • Patients receiving medications: • appropriate to their clinical needs • in the required dose • for an adequate period of time • at the lowest cost to them and their community. • (WHO, 1985) • Irrational or non-rational use is the use of medicines in a way that is not compliant with rational use as defined above.

  14. IRRATIONAL USE OF MEDICINES • Inappropriate Medication • Too many medicines prescribed perpatient • (poly- pharmacy) • Cross reacting drugs • Inappropriate Prescription of • antimicrobialsfor non-bacterial infections • Over-prescription of Inj. when oral drugs • effective

  15. B. Poor Communication • Non-drug aspects not communicated • Poor communication of information • regarding drugs to patient. • Inappropriate self-medication

  16. Tools to Facilitate Rational Prescribing Practices Essential Drug List Drug Formulary Standard Treatment Guidelines Prescription Audits

  17. The Essential Drug List (EDL): • satisfies priority health care needs of the • population • with due regard to disease prevalence • evidence on efficacy and safety, and • comparative cost-effectiveness. • The Essential Drug List (EDL): • Is meant to treat ALL common health problems • It is not only a list of ‘life-saving’ medicines

  18. DRUG FORMULARY & STANDARD TREAMENT GUIDELINES • A Drug Formulary: • lists each drug • its indications • doses and formulations • its side effects • contraindications and • interactions with other drugs.

  19. STANDARD TREATMENT GUIDELINES • List the preferred drug and nondrug treatments (including reassurance) • Include instructions /messages for patients • For each drug include the name, dosage form, strength, average dose (pediatric and adult), number of doses per day, and number of days of treatment.

  20. Standard treatment guidelines are necessary: • fortherapeutically effective and economically efficient use of drugs and diagnostics • to decide about drug & equipment supplies • to assist with adherence to the prescribed treatment.

  21. COMPONENTS OF ACTION FOR RDU I. Drug & Equipmet Procurement and Distribution System developed on principles of: Local Need; Systems for no stock out; Cost and Quality considerations; Transparency in procurement and distribution II. Drug and Therapeutics Committee to develop & regularly revise the EDL & Formulary III. Development of Standard Treatment Guidelines IV. ORIENTING Providers & Monitoring through regular Prescription Audits V. IEC/BCC/Social Marketing for Public Education

  22. RELEVANCE OF RDU FOR NRHM For Meeting ITS GOALS Incremental Additions to the architectural correction • Reducing IMR TO 30/1000 • Increasing Utilization of public health facilities from current level of OPD <20% to >75% • Increasing health expenditure by Govt. as a % of GDP from the existing 0.9% to 2.0% • Infra-structure being strengthened • Personnel being added • NOW QUALITY OF FUNCTIONING, PROCESSES, & CLINICAL CONTENT MUST BE THE FOCUS • KAP OF PROVIDERS IS KEY

  23. THUS, IN THE HEALTH SYSTEM, RATIONAL DRUG USE IS FOR Equity Quality Accountability SO SHOULD THERE BE A RDU Sub-Mission Under the NRHM????

  24. THE ISSUES FOR AN RDU Sub-Mission • A concerted effort on all three fronts must be launched simultaneously: • Procurement, Prescribing & Public information. • 2. Do we provide free medicines to BPL only or to ALL? • 3. Where will the funds come from? • 4. Rational & Generics only in public services? What about the private sector, & its costs?

  25. MALNUTRITION [Govt. of Rajasthan, BPL Census 2002] BPL APL • % OF TOTAL POP.= 22.7 • % OF BPL NOT GETTING 2 MEALS THROUGHTOUT THE YEAR= 88 • % OF TOTAL POP. NOT GETTING ENOUGH FOOD=20 • % OF TOTAL POP.= 77.3 • % OF APL NOT GETTING 2 MEALS THROUGHOUT THE YEAR= 33 • % OF TOTAL POP. NOT GETTING ENOUGH FOOD=25.5

  26. Looking Forward To Optimising Opportunities of the NRHM THANK YOU

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