11 - Rational Medicines Use

Principles of Rational
Medicines Use
Session Objectives
• By the end of the session you will be able to:
• Define appropriate and rational medicines use (RMU)

• Describe the medicines use process
• Provide examples of inappropriate prescribing practices
• Describe factors underlying irrational use of medicines
• Discuss the impact of inappropriate medicines use
• Explain ways to promote rational medicines use
2
What is Rational Medicines Use?
• Rational use of medicines requires that patients receive
medicines 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 the community. (WHO 1985)
3
Meaning of appropriate use
▪ Appropriate indication: prescribe medicine is based on a medical rationale
and the therapy is an effective and safe treatment.
▪ Appropriate medicine: based on efficacy, safety, suitability, and cost
considerations.
▪ Appropriate Dosage: administration and duration of treatment
▪ Appropriate patient: No contraindications exist, the likelihood of adverse
reactions is minimal, medicine is acceptable to the patient.
▪ Appropriate patient information. Patients provided with relevant, accurate,
important, and clear information regarding their conditions and the
medication(s) prescribed.
▪ Adherence: patients adheres to treatment
▪ Appropriate evaluation. Anticipated and unexpected effects of the
medications are appropriately monitored and interpreted.
4
The Medicines Use Process
Diagnosis / Follow-up
Adherence Prescribing
Dispensing
5
Diagnosis
• An accurate diagnosis is crucial to appropriate
prescribing
• Wrong diagnosis can be a starting point for irrational
medicines use as medicines will then be prescribed for
the wrong disease
1. Do we have good diagnosis here in Uganda?
2. What are some of the aids that can
help you make the right diagnosis?
6
Irrational Use of Medicines:
Diagnosis Problems
▪ Inaccurate diagnosis due to poor communication between prescriber and
patient
▪ Lack of appropriate prescriber skills impedes proper diagnosis, e.g., no physical

examination of the patient
▪ Excessive workload means less time to assess patient condition
▪ Lack of basic diagnostic equipment and tests
7
Prescribing
Steps in the rational prescribing process
1. Define the patient’s problem (diagnosis)
2. Specify the therapeutic objective
• what do you want to achieve with the treatment?
3. Verify the suitability of your treatment
4. Start the treatment
5. Give information, instruction and warnings
6. Document medical history
7. Monitor (and stop?) treatment
8
Examples of Irrational Prescribing
• Use of medicines when medicine therapy is not indicated
(self-limiting disease)
• Use of wrong medicines for a specific condition
• Use of medicines with doubtful or unproven efficacy
• Use of medicines of uncertain safety status
• Incorrect administration, dosages, or duration
• Excessive use of injections (e.g. for malaria)
• Using expensive medicines when cheap options available
(brand vs. generic, third line antimicrobial)
9
Examples of Irrational Prescribing cont.
• Non-adherence to UCG guidelines
• Using several medicines when one is enough

(polypharmacy)
• Poor handwriting/unreadable prescriptions
10
Dispensing
• Check the prescription for appropriateness of medicine, dose, duration

to treat the diagnosed condition and person (prescription control)
• Accurately count or pour the prescribed medicine to an appropriate

package
• Label the package appropriately

• Check that dispensed medicine is correct according to prescription
(dispensing control)
• Inform the patient on reason for and how to take medicine
11
Inappropriate dispensing practices
• Incorrect interpretation of prescription
• Wrong medicine dispensed
• Wrong quantity dispensed
• Medicine given to wrong patient
• Inadequate/wrong labelling
• Incorrect/insufficient dispensing information
• Unsanitary practices- contamination of drugs
• Poor quality of packing material
12
Patient adherence to treatment
• Mutual decision-making between patient and

prescriber about taking the medicine
• Ensure correct understanding of instruction
to take medicine before leaving the health
facility
• Attend scheduled follow-up visits
13
Irrational medicine use practices by patients
• Poor compliance with medicines
− Failure to complete doses

− Missing doses
• Sharing of individual doses with other family members
or community members
• Taking multiple therapies for the same illness including
combination with herbal medicines
14
I Want An Injection, Doctor . . .
15
Factors Influencing Rational Use of
Medicines
Factors Underlying Irrational Use of Medicines
Patients Health workers Industry Drug Regulation
• Medicines • Lack of • Promotion • Availability of

misinformation education and
training • Misleading non-essential
• Misleading claims medicines
beliefs • Lack of
medicines • Informal
• Inability to information prescribers
communicate
problems • Heavy patient
load Drug Supply
• Pressure to
prescribe
• Generalization • Required
of limited beliefs medicines not
• Misleading available
beliefs about • Inefficient
efficacy management
17
Factors underlying irrational use
A. Patient Factors
▪ Medicine misinformation
▪ Misleading beliefs
▪ Patient demands/expectations for specific forms of treatment
▪ Inability to communicate problems to the prescriber
Quote from prescriber at HC III

“these patients know what they want, they come expecting to get septrin when
they have a cough, if you refuse to prescribe it, they report you to the authorities
that that ‘health worker’ doesn’t want to give us medicines yet we saw the
pickup’ (NMS) deliver them
18
Factors underlying irrational use cont.
B. Health workers C. Workplace
▪ lack of education and
training
• heavy patient load
▪inappropriate role models • pressure to prescribe

▪lack of objective medicine
information • lack of adequate lab
capacity
▪limited experience
▪misleading beliefs about • insufficient staffing

medicine efficacy
19
Factors underlying irrational use cont.
D. Medicine Supply System E. Medicine Regulation

▪Medicines shortages in •N items available in
central warehouses health facilities
▪Wrong ordering by •Lack of regulation
health facilities (ex. not enforcement especially
staying within budget) in public sector
▪Insufficient EMHS •Lack of reference
funding material
20
The Impact of Irrational Use of
Medicines
Impact of irrational medicines use
Mortality
Reduced quality of
therapy
Morbidity
Reduced availability of
medicines
Irrational use of Waste of resources
medicines
Increased cost
Risk of unwanted effects Adverse reactions
antimicrobial resistance
Psychosocial impacts Patients rely on

unnecessary medicine
22
Promotion of Rational Medicines
Use
Promotion of appropriate diagnosis
• Improve consultation time by:
▪ Taking a complete history of the patient’s illness. Identify the main reason the
patient came to the clinic
▪ Perform a physical examination relevant to the patient’s symptoms
▪ Do lab tests relevant to the patient’s complaints
24
Promotion of rational prescribing
▪ Follow standard treatment guidelines
▪ Use of problem-based curricula in pre-service training of health workers
▪ Continuing in-service education for prescribers
▪ Establishing medicine and therapeutic committees (MTC) in health facilities
▪ Monitoring and supervision of prescribers
▪ Improved regulation by professional councils
▪ Restricting drug promotion
25
Promotion of good dispensing
• Improve dispensing practices by—
▪ Recruiting and training competent personnel
▪ Organizing the dispensing area so that it allows for efficient work flow
▪ Verifying the quantity of medicine that is being dispensed to a patient
▪ Giving correct and adequate instructions to the patient
▪ Providing appropriate dispensing tools
26
Promotion of patient compliance
• Improve compliance by—
▪ Labelling appropriately
▪ Asking for the patient’s feedback to verify his/her understanding of the

treatment
▪ Taking into consideration local beliefs and customs that influence use of
medicines when prescribing and dispensing
27
Key Points
▪ RMU means that patient gets right medicine in right quantity

at right time at an affordable cost
▪ Improving medicines use improves the quality of care and
often lowers costs
▪ Various factors influence the way medicines are used
▪ Health professionals have the responsibility to ensure that the

right medicine is prescribed, dispensed, and taken
28

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Principles of Rational

• By the end of the session you will be able to:

• Define appropriate and rational medicines use (RMU)

2. What are some of the aids that can

help you make the right diagnosis?

▪ Lack of appropriate prescriber skills impedes proper diagnosis, e.g., no physical

▪ Excessive workload means less time to assess patient condition

▪ Lack of basic diagnostic equipment and tests

• Using several medicines when one is enough

• Check the prescription for appropriateness of medicine, dose, duration

• Accurately count or pour the prescribed medicine to an appropriate

• Label the package appropriately

• Inform the patient on reason for and how to take medicine

• Wrong medicine dispensed

• Wrong quantity dispensed

• Medicine given to wrong patient

• Incorrect/insufficient dispensing information

• Unsanitary practices- contamination of drugs

• Poor quality of packing material

• Mutual decision-making between patient and

• Poor compliance with medicines

− Failure to complete doses

Patients Health workers Industry Drug Regulation

• Medicines • Lack of • Promotion • Availability of

▪ Patient demands/expectations for specific forms of treatment

▪ Inability to communicate problems to the prescriber

Quote from prescriber at HC III

▪inappropriate role models • pressure to prescribe

▪misleading beliefs about • insufficient staffing

D. Medicine Supply System E. Medicine Regulation

Risk of unwanted effects Adverse reactions

Psychosocial impacts Patients rely on

• Improve consultation time by:

▪ Perform a physical examination relevant to the patient’s symptoms

▪ Do lab tests relevant to the patient’s complaints

▪ Follow standard treatment guidelines

▪ Use of problem-based curricula in pre-service training of health workers

▪ Continuing in-service education for prescribers

▪ Establishing medicine and therapeutic committees (MTC) in health facilities

▪ Monitoring and supervision of prescribers

▪ Improved regulation by professional councils

▪ Restricting drug promotion

• Improve dispensing practices by—

▪ Recruiting and training competent personnel

▪ Verifying the quantity of medicine that is being dispensed to a patient

▪ Giving correct and adequate instructions to the patient

▪ Providing appropriate dispensing tools

• Improve compliance by—

▪ Asking for the patient’s feedback to verify his/her understanding of the

▪ RMU means that patient gets right medicine in right quantity

▪ Health professionals have the responsibility to ensure that the

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