A baseline survey on use of drugs at theprimary health care level in Bangladesh*A.B. Guyon,1 A. Barman,2 J.U. Ahmed,3 A.U. Ahmed,4 & M.S. AIam5

The drug use pattern and the quality of care were assessed in 80 public sector facilities throughoutrural Bangladesh. A total of 40 thana health complexes and 40 union subcentres, the lowest level inprimary health care facilities, were selected at random. A total of 2880 prescriptions, consultations, anddrug-dispensing practices were studied, and the availability and use of essential drugs and of theessential drugs list were recorded.

The average consulting time (54 seconds), the proportion of adequate examinations (37%/o), andprescription of drugs according to standard treatment guidelines (41%) were unsatisfactory. The meannumber of drugs prescribed per patient was 1.44; 25% were treated with antibiotics, and 17% with met-ronidazole, irrespective of the diagnoses. The availability of drugs (54%) and the presence of an essen-tial drugs list (16%) in the health facilities were low. However, 78% of the drugs were prescribed bytheir generic names, 85% complied with the essential drugs list, and 81% were dispensed according toprescription. The average dispensing time (23 seconds) and the proportion of patients who correctlyunderstood the dosage (55%) were poor.

IntroductionThe International Conference on Primary HealthCare at Alma-Ata in 1978 provided a guiding frame-work for public health initiatives (1). Its declarationincluded appropriate treatment of common diseasesand injuries, and the provision of essential drugs astwo vital components of the primary health careconcept. The provision of drugs is the component ofprimary health care that patients most often demandand expect. Nevertheless, drugs continue to be inshort supply, even when large portions of the healthcare budget are allocated for their procurement.

In June 1982 Bangladesh introduced a nationaldrug policy (NDP) and a drugs ordinance (2), whichfollow WHO guidelines on the selection of essentialdrugs (3). Since the enactment of the drug policy, theproduction, quality, and availability of essential drugs

* This article reflects only the opinions of the authors and doesnot represent the endorsement of any of the affiliated institu-tions.1 Project Officer, Improvement of Drug Management Project,UNICEF, BP 58, Dhaka 1000, Bangladesh. Requests for reprintsshould be sent to this author.2 Head, Community Medicine Department, Rajshahi MedicalCollege, Rajshahi, Bangladesh.3Assistant Professor, Pharmacology Department, Barisal Medi-cal College, Barisal, Bangladesh.4 Lecturer, Community Medicine Department, Mymensingh Med-ical College, Mymensingh, Bangladesh.5 Head, Community Medicine Department, Chittagong MedicalCollege, Chittagong, Bangladesh.Reprint No. 5477

have significantly improved (4). Although consulta-tions with doctors most commonly result in drugsbeing prescribed, very little is known about the prop-er use of drugs. The quality of health care, particular-ly the rational use of drugs, depends on a wide rangeof activities, such as making the correct diagnosis,prescribing the appropriate drug(s), and dispensingthem properly. When used rationally, drugs cure ail-ments; on the other hand, they may be dangerous andcan threaten life when used irrationally (5).

The WHO Conference of Experts on the Ration-al Use of Drugs, held in Nairobi on 25-29 November1985, was an important turning-point (6). The Inter-national Network for the Rational Use of Drugs(INRUD) was established in 1989 to promote therational use of drugs in developing countries (7). Thenetwork generated indicators in three main drug useareas; prescribing, patient care, and drug systems; 20randomly selected facilities and 36 encounters ineach area were the minimum required to have repre-sentative data.a Eleven studies on the rational use ofdrugs have been undertaken since 1989. The firststudy using these indicators was conducted in Dhaka,Bangladesh, in 1991, in two rural health centres inthe same district, and may not reflect the situation inthe whole of the country (8). Therefore, we carriedout a larger study representing Bangladesh in general.

The aim of the current survey was to assess druguse for six common diseases and to record the avail-

a How to investigate drug use in health facilities: selected druguse indicators. Unpublished document WHO/DAP/93.1, 1993.

Bulletin of the World Health Organization, 1994, 72 (2): 265-271 © World Health Organization 1994 265

A.B. Guyon et al.

ability of essential drugs. The survey examined cur-rent treatment practices at outpatient clinics, includ-ing assessment of patient care in terms of history-taking, physical examination, and the time given toeach patient; assessment of the dispensing process interms of the time taken and whether drugs were dis-pensed according to prescription; patient's knowl-edge of how to take the drugs; the availability oftwelve essential drugs on the survey date; and theavailability of an essential drugs list in the facilities.

MethodsMedical colleges play a key role in improving thequality of diagnosis, drug use, and supervision andmanagement capabilities of health professionals. Thepresent survey was therefore implemented by onemedical college's community medicine and pharma-cology department in each of the four administrativedivisions of Bangladesh. The survey was coordinatedby the Improvement of Drug Management Project(IDM) at UNICEF/Dhaka, and by INRUD membersin Bangladesh. The study was undertaken at the twolowest primary level facilities in the public sector:thana health complexes (THCs) staffed by five toeight doctors, who attend 200-300 outpatients perday; and union subcentres (USCs), staffed by a

medical assistant who attends 50-100 outpatients perday.

A three-day workshop was organized in July1992 to adapt the WHO/INRUD Indicators on DrugUse and to identify the six commonest diseasesencountered in the outpatient clinics in rural Bangla-desh. These were as follows: watery diarrhoea, dys-entery with blood, helminthiasis, pneumonia, acuterespiratory tract infections, and scabies. During theworkshop, standard treatments and minimum exam-ination requirements were defined. The revised indi-cators, listed in Tables 2-4, were tested during theworkshop in two different sites.

The survey had a cross-sectional descriptivedesign, using both retrospective and prospective

Table 1: Details of districts and health care facilities, bydivision, Included In the sampling frame of the study

No. of facilitiesa

Division No. of districts THC USC

Chittagong 6 42 99Rajshahi 8 54 163Khulna 6 41 77Dhaka 4 40 122

Total 24 177 461a THC = thana health centre; USC = union subcentre.

data. Stratification was by division and by type offacility, to identify possible variations. The fouradministrative divisions in Bangladesh consist of 64districts; however, only 24 districts were selected forthe present study because the IDM project, which issupported by UNICEF, is scheduled to be imple-mented there. From all the rural government healthfacilities in these districts, ten thana health complex-es (THCs) and ten union subcentres (USCs) were

selected in each division using a stratified randomsampling procedure. Table 1 shows the number ofdistricts, THCs and USCs, by division, included inthe sampling frame.

For each facility, retrospective data from Sep-tember 1991 to August 1992 were collected from theoutpatient registers; 36 encounters were selected bysystematic random sampling. Prospective data on thequality of patient care were collected by observingthe consultation and the examination of 36 cases pre-senting with one of the six, selected common diseas-es. Observations were made in the consultation room

without interrupting normal activities. The consulta-tion time was taken to be the time of exchangebetween the patient and the doctor. The quality ofdispensing and each patient's understanding aboutthe dosage were assessed prospectively by observa-tion and exit interviews of all 36 selected patients.Each facility's main store was visited to assess theavailability of twelve essential drugs. The essential

Table 2: Quality of care, regarding consultations in the study health facilities

Facilitya

THC USC

Indicator (n = 1440) (n = 1440)Average consultation time perpatient ± SD (sec) 60 ± 12 48 ± 12% of patients receiving anadequate examination ± SD 41 ± 9 32 ± 7% of patients treated accordingto defined standard ± SD 43 ± 12 39 ± 7

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Country(n = 2880)

54 ± 12

37 ± 9

41 ± 10a THC = thana health centre; USC = union subcentre; country = THC + USC.

266

Use of drugs In primary health care in Bangladesh

drugs list had to be shown before it was recorded asbeing present.

A three-day training programme for field work-ers was held in each of the four divisions. In eachdivision three investigators and eight interviewers par-ticipated in the training on data collection and super-vision given by INRUD members and UNICEFstaff. Medical students, medical graduates, intern doc-tors, and medical faculty lecturers served as interview-ers. Field visits were undertaken to provide the inves-tigators and interviewers with practical experience.During this training the THCs and USCs to be sur-veyed were randomly selected.

In each division four pairs of interviewers col-lected data from health facilities; the activities of theinterviewers were supervised by two investigators.The data were analysed manually by the principalinvestigator and one co-investigator over a two-dayperiod. Data were consolidated using a summaryform. The analysis was presented by facility, by divi-sion and by the country as a whole. The statisticalsignificance of the results was determined usingStudent's t-test.

ResultsConsultation patternThe quality of care (Table 2) provided to patientswas assessed by examining the consulting practicesof doctors in the THCs (n = 1440) and medical assis-tants in the USCs (n = 1440). The average consultingtime per patient was 54 seconds (range: 36-72seconds). The average consultation time in the THCs(60 seconds) was significantly greater than that in theUSCs (48 seconds; P<0.001). Only 37% (22-52%)of the patients were adequately examined relative tothe previously defined standard; the difference in thisrespect between those examined in the THCs (41%)and in the USCs (32%) was statistically significant(P <0.001). The variations between the divisions andfacilities in terms of consulting times and the propor-tion of patients who were adequately examined areshown in Fig. 1 and 2, respectively. Prescribers fol-lowed the standard treatment guidelines for only41% of the patients. Although use of standard treat-ments did not differ significantly between the THCsand USCs, there was a broad variation between divi-sions and facilities from a minimum of 29% to amaximum of 59% (Fig. 3).

Drug use

The drug use pattern examined in the 80 health faci-lities is shown in Table 3. The mean number ofdrugs prescribed for an individual patient was 1.44;

Fig. 1. Consulting times in the thana health centres(THC) and union subcentres (USC) in the study.

p 80.0UZcnc0

C a0c 40.0

CDc

0E 20.0

co

2 0.0ChitTHC ChitUSC RajTHC RaJUSC DhaTHC DhaUSC KhuTHC KhuUSC

Division and facilities

Fig. 2. Proportion of adequate examinations in thethana health centres (THC) and union subcentres (USC)in the study.

60-0

,> .50C

0

<s.40

(a 30

<>011D 20

)0'a010r0

INI

ChitTHC ChitUSC RajTHC RalUSC DhaTHC DhaUSC KhuTHC KhuUSCDivision and facilities

Fig. 3. Proportion of treatments that were standard inthe thana health centres (THC) and union subcentres(USC) in the study.

70

a~50E520.W0

Ica'20 1 1 | 1 1 l

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Division and facilities

WHO Bulletin OMS. Vol 72 1994

;z<4Stm

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=

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267

A.B. Guyon et al.

Table 3: Drug use patterns in the study health facilities

Facilitya

THC USC CountryIndicator (n = 1440) (n = 1440) (n = 2880)

Mean number of drugs prescribedper patient ± SD 1.40 ± 0.16 1.48 + 0.12 1.44 ± 0.15

% prescribed antibiotics ± SD 25 ± 8 24 ± 4 25 + 7

% prescribed metronidazole ± SD 15 ± 7 18 ± 9 17 ± 8

% prescribed drugs by genericname ± SD 77 + 5 78 + 6 78 ± 6

% prescribed drugs from essentialdrugs list ± SD 89 ± 6 82 ± 10 85 ± 9

a THC = thana health centre; USC = union subcentre; country = THC + USC.

of 2880 prescriptions studied, 59% were for onedrug, 36% were for two drugs, and 5% for three ormore drugs. The difference in the mean numberof drugs prescribed was significantly different(P <0.05) in the USCs (1.48) and THCs (1.40). Theproportion of patients treated with an antibiotic,irrespective of the specific disease was 25% (range:14-37%) (Fig. 4). The rate of metronidazole pre-scription was 17% (range: 4-31% for all diagnoses(Fig. 5)); however, the THCs and USCs did not dif-fer significantly in their rates of antibiotic or metro-nidazole prescription.

A total of 78% (range: 69-86%) of the drugswere prescribed using their generic name. The pre-scribers followed the essential drugs list, i.e., 85% ofthe prescribed drugs were from the list (range:71-98%). THCs (89%) complied significantly betterwith the list than USCs (82%) (P <0.01). The pro-portions of generic use and use of drugs from theessential drugs list varied slightly between facilitiesand divisions.

Dispensing practicesThe quality of care was assessed by examining thedispensing practices (Table 4). The average timetaken to dispense the drugs was 23 seconds (range:20-30 seconds) for each patient, with no differencebetween THCs and USCs. Of the drugs prescribed,on average 81% (range: 75-91%) were given to thepatients. A total of 55% of the patients knew whenand how to take the quantity of drugs dispensed; atthe THCs 57% of the patients understood the correctdosage, a significantly higher proportion than at theUSCs (53%; P <0.01). However, the dispensingtimes, proportion of patients whose knowledge wascorrect, and the percentage of prescribed drugs dis-pensed varied slightly between facilities and divi-sions.

Drug availabilityThe availability of the twelve marker essential drugsin stock and the presence of the essential drugs list in

Fig. 4. Proportion of patients prescribed antibiotics in Fig. 5. Proportion of patients prescribed metronidazolethe thana health centres (THC) and union subcentres in the thana health centres (THC) and union subcentres(USC) in the study. (USC) in the study.

uivIsIon ana taciiutes

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Use of drugs In primary health care in Bangladesh

Table 4: Availability of essential drugs and the essentialdrugs list In the study health facilities

Facility8

THC USC CountryIndicator (n = 40) (n = 40) (n = 80)

% availability of 12 essentialdrugs ± SD 63 ± 2 46 ± 11 54 ± 12

% presence of the nationalessential drugs list ± SD 28 11 5 ± 9 16 ± 15

a THC = thana health centre; USC = union subcentre; country =THC + USC.

the drug store on the day of survey were other indi-cators studied (Table 5). On average, the facilitieshad 54% (range: 27-65%) of these twelve markerdrugs in stock. In the USCs 46% of the drugs wereavailable, while in the THCs 63% were available.This difference was significant (P <0.001). Only16% of the facilities possessed the essential drugslist; 28% of the THCs had an essential drugs list,compared with 5% of the USCs (P <0.001).

DiscussionThe average consultation time (54 seconds) wasquite low; at the THCs the average consultation time(60 seconds) was higher than at the USCs (48seconds) but was still unsatisfactory. Only 37% ofthe patients were examined adequately, with the pro-portion being slightly higher in the THCs (41%) thanin the USCs (39%). At the THCs, where the medicalstaff were doctors, the quality of care, in terms oftime spent with the patient and the proportion whowere adequately examined, was slightly better thanin the USCs, where the staff were medical assistants.Nevertheless, the quality of care was unsatisfactoryin both facilities. The very short consultation timesas well as the lack of adequate examinations bringinto question the appropriateness of the diagnosesbeing made. Furthermore, only 41% of the patients

received adequate treatment in line with the standardguidelines.

Generally, the mean number of drugs being pre-scribed was adequate compared with the standardtreatment defined (1.44 drugs per patient); doctors atthe THC level prescribed slightly less (38% ofpatients received two or more drugs) than medicalassistants at the USCs, where 43% of the patientsreceived two or more drugs. The rates of prescribingantibiotics and metronidazole were not different fordoctors (THCs) and medical assistants (USCs). Theproportion of the patients treated with antibiotics(25%) was relatively low compared with levelsreported in studies conducted in other countries, e.g.,43% in Nepal, 56% in Uganda, 63% in Sudan (8).The use of metronidazole was high for all diagnoses(17%), given that none of the diseases studiedrequired this drug as treatment. Also, it reflects thehigh national prevalence of diarrhoea and the exces-sive use of metronidazole to treat this condition. Asecondary analysis for diarrhoeal diseases would per-mit better understanding as to how they are treated.

In the 80 facilities studied, an average of 78% ofthe drugs were prescribed using generic names, and85% were from the essential drugs list. Both of theselevels are satisfactory and result from the implemen-tation of the national drug policy, which emphasizesthe use of essential drugs in Bangladesh. It is manda-tory for THCs and USCs to purchase 70% of theirdrugs from a partly state-owned drug manufacturer(Essential Drugs Companies Ltd.), which marketsall of its products under generic names. The avail-ability of the essential drugs list was low (16%), butthis did not adversely affect the generic prescribing.However, at the USCs, where the list was often notavailable, the tendency of prescribers to comply withits recommendations was lower.

Pharmacists took an extremely short time (aver-age, 23 seconds) to dispense drugs to the patientsand there was no difference between THCs andUSCs in this respect. This, as well as the short con-

Table 5: Quality of care, regarding dispensing of drugs in the study health facilities

Facilitya

THC USC CountryIndicator (n = 1440) (n = 1440) (n = 2880)

Average dispensing time perpatient (sec) ± SD

% of patients dispensed drugsaccording to prescription ± SD

23 ± 3

80 ± 3

23 ± 4

82 ± 6

% of patients with knowledge abouttheir dispensed drugs 57 ± 5 53 ± 7

a THC = thana health centre; USC = union subcentre; country = THC + USC.

23 ± 3

81 ± 5

55 ± 6

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A.B. Guyon et al.

sultation time, could explain why only 55% of thepatients knew how and when to take their medicines.A poor level of comprehension among the patientsmight have been expected; however, the number ofdrugs prescribed was low, and this might explainwhy patients' understanding was relatively high. Atotal of 81% of the drugs dispensed were by pre-scription. This finding should be viewed with cau-tion. Medicines are often prescribed according to thesupplies available at the health centre on the dayconcerned, and not necessarily according to what thepatient needs. During the consultations most of theprescribers had a list of the drugs that were available.The availability of the twelve drugs under reviewwas low (54%), and was lower for USCs (46%) thanTHCs (63%). The low or nonavailability of essentialdrugs directly affects prescribing patterns. In Bangla-desh, the drug supply is limited because of financialconstraints. However, even without the governmentincreasing its drugs expenditure, specific improve-ments in the management of drugs, could reducewastage, expiry, and irrational use; improved drugmanagement improves the availability of drugs with-in the health system without increasing expenses (9).

The present study represents the largest surveycarried out using the WHO/INRUD indicators ondrug useb and serves as a basis for evaluating futureinterventions undertaken by the Improvement of DrugManagement Project in Bangladesh. The results arevery similar to those reported in a study carried outin Dhaka in 1991 (8). Because of the large samplesize used in our study (80 facilities) and the low var-iability of the results, the findings should be repre-sentative of the situation regarding drug use in thepublic health system in rural Bangladesh. However,further similar studies also need to be carried out tocover the private health sector, which provides carefor a large number of patients in Bangladesh. Also,inpatient prescribing and care were not included inthis study. In particular, studies need to be conductedto investigate the drug use pattern in the medical col-leges and teaching hospitals, where medical studentsfirst leam and practise prescribing.

b See footnote a, p. 265.

AcknowledgementsWe thank Professor A.M. Das, Professor A.K.M. Chowd-hury, and Professor S.A.R. Chowdhury for their support;Dr R. Laing for his help with the analysis of the data andfor reviewing the article; Professor A.M. Das, Dr M.A. Car-nell and Mr M. Mulder-Sibanda, for their comments; andalso Dr B. Sack and Dr M. Yunus.

The survey was funded by UNICEF.

ResumeEnqu6te sur l'utilisation des m6dicamentsdans les centres de soins de sant6primaires au BangladeshLe mode d'utilisation des medicaments et la qua-lit6 des soins ont ete 6valu6s dans 80 centres desoins du secteur public (40 centres de thana et 40centres secondaires constituant le premier 6che-Ion des soins de sante primaires), choisis auhasard dans l'ensemble des zones rurales duBangladesh. Au total, 2880 prescriptions, consul-tations et visites avec d6livrance de m6dicamentsont ete etudi6es. En outre les enqueteurs ont not6si la liste des medicaments essentiels et les medi-caments essentiels eux-memes etaient dispo-nibles.

La dur6e moyenne des consultations (54 se-condes), la proportion des examens r6alis6s dansdes conditions ad6quates (37%) et le taux deprescription des m6dicaments conform6ment auxdirectives normalis6es de traitement (41%) lais-saient a d6sirer. Le nombre moyen de medica-ments prescrits par patient a 6t6 de 1,44; 25%des patients ont requ des antibiotiques et 17% dum6tronidazole, quel que soit le diagnostic. La dis-ponibilit6 des m6dicaments dans les centres desante 6tait faible (54%) et 16% seulement descentres poss6daient la liste des m6dicamentsessentiels. Toutefois, 78% des m6dicaments ontete prescrits par leur nom generique, 85% d'entreeux figuraient sur la liste des medicaments essen-tiels et le pourcentage de m6dicaments d6livr6sconform6ment a la prescription 6tait de 81%. Lesr6sultats sont mediocres en ce qui concerne letemps moyen consacr6 a la d6livrance des m6di-caments (23 secondes) et la proportion depatients ayant bien compris la fagon de lesprendre (55%).

References1. Primary health care: report on the International

Conference on Primary Health Care, Alma-Ata,6-12 September 1978. Geneva, World Health Or-ganization.

2. The drugs (control) ordinance, 1982. Dhaka, Minis-try of Law and Land Reforms, June 1982.

3. The selection of essential drugs. Report of a WHOExpert Committee. Geneva, World Health Organiza-tion, 1979 (WHO Technical Report Series, No. 641).

4. Chetley A. From policy to practice: the future of theBangladesh National Drug Policy. Penang, Interna-tional Organization of Consumers Unions, 1992.

5. Chowdhury SAR. Prescribing a rational drug. Bang-ladesh journal of physiology and pharmacology,1991, 7: 000-000.

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Use of drugs in primary health care in Bangladesh

6. The rational use of drugs: report of the Conferenceof Experts, Nairobi. Geneva, World Health Organ-ization, 1987.

7. Laing RO. Rational drug use: an unsolved problem.Tropical doctor, 1990, 20: 101-103.

8. INRUD drug use indicators in diarrhoeal disease

and ARI in two Upazila health centers in ManikganjDistrict, Bangladesh. INRUD news, 1992, 3(1): 15.

9. Managing drug supply: the selection, procurement,distribution, and use of pharmaceuticals in primaryhealth care. Boston, MA, Management Sciences forHealth, 1981: 18-19.

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