Keywords

Essential medicines; Rational use; Prescribing indicators; Community pharmacy; Public sector; Private sector; Thiès; Senegal

Introduction

Medicines contribute to the improvement of health and well-being when they are rationally used [1]. According to the World Health Organization (WHO), the rational use of medicines assumes that "patients receive medications 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 their community"[2]. Conversely, irrational use occurs when these conditions are not met [1]. It exists in different forms such as polypharmacy, excessive use of antimicrobials and injections and unnecessary prescription of brand name drugs [1,3].

The irrational use of medicines is a major problem worldwide [3], especially in resource-poor countries [4]. WHO estimates that more than half of drugs are used inappropriately [4].

In the WHO African Region, recent studies have shown irrational prescribing practices [5,6]. This situation worsened in both public and private sectors between the periods 1995-2005 and 2006- 2015 [5].

The irrational use of medicines can be harmful to the patient and to economic resources [7]. It also impairs people's confidence in the health system [1].

In this situation, responsible use of medicines has long been considered a necessity [1]. For example, WHO has created an essential medicines list [8]. Essential medicines are regarded as those medicines that satisfy the priority health care needs of the population [3].

Next, it developed five prescribing indicators to monitor drug use [9]. It is about:

- Average number of medicines per prescription

- Percentage of medicines prescribed by generic name or international nonproprietary name (INN)

- Percentage of prescriptions with at least one antibiotic

- Percentage of prescriptions with at least one injection

- Percentage of drugs prescribed from essential medicines list or form

Similarly, the new sustainable development agenda advocates appropriate prescribing and use of medicines to ensure universal health coverage [10,11].

Senegal has also taken initiatives by implementing a national drug policy (NDP) [12], a national essential medicines list (NEML) [13], a handbook of therapeutic equivalences [14] and a drug database [15].

However, few studies are conducted to evaluate drug use in Senegal [16-18]. Thus, it became necessary to have new data to inform decision-making. Our study falls within this framework. The choice of our study concerns prescribing practices and is justified by the fact that the prescriber is an important actor who mainly intervenes at two levels of the cycle of medicine use such as diagnosis and prescribing [3]. Our objective was to evaluate the prescribing indicators in the city of Thiès and to compare them with WHO standards [5].

Methods

Study setting

The study took place in the city of Thiès. This city, located 70 km from Dakar, is the capital of the department and the region of the same name and is made up of three borough districts [19].

Its population was estimated at 354,386 inhabitants in 2017 [20].

According to the sanitary pyramid, the city of Thiès belongs to the health district of the same name. The number of health facilities is 45, of which 31 are in the public (27 health posts, 1 health center, 1 regional hospital and 2 military health facilities) and 14 in the private sector (8 health posts, 4 clinics, 2 denominational hospitals) [19,21].

The number of community pharmacies is 46 at the time of the study. The city hosts a faculty of medicine for training physicians and a regional health-training center for paramedics such as nurses and midwives [19].

Type of study and period of study

We conducted a cross-sectional, prospective study. Data were collected from December 1, 2017 to January 16, 2018.

Study population

The study population consisted of prescriptions received in community pharmacies in Thiès on the day of the survey.

Sampling

Selection criteria: The prescriptions included were those of patients treated on an outpatient basis. Parapharmaceutical products or vaccines were excluded from the study.

Sample size: Sampling was done according to WHO recommendations [22]. The number of community pharmacies required is twenty. In each of these pharmacies, we included 30 prescriptions. Thus, the size of the sample required was 600 prescriptions.

Sampling procedure: The list of community pharmacies in the city of Thiès served as a sampling frame for the random selection of the 20 community pharmacies. For this purpose, we used the Microsoft Excel 2010 to generate random numbers which were sorted in ascending order. The first 20 community pharmacies were included.

We included the first 30 prescriptions received at each community pharmacy on the day of the survey and meeting the inclusion criteria.

Data collection

Data collection tool: The survey tool was the WHO form 1 which was adapted to our study [22]. It was previously tested in one community pharmacy in Thiès. One form was provided for each community pharmacy. It consisted of eight columns. The first corresponded to prescription numbers ranging from one to thirty. The second column was used to record the name of each prescribed drug. The third was used to determine whether or not a drug is prescribed with an INN. It was coded 1 if the drug was prescribed by INN or 0 otherwise. The fourth and fifth columns identified prescriptions containing at least one antibiotic and at least one injection, respectively. The code 1 was assigned in case of presence of at least one antibiotic and at least one injection and 0 otherwise, respectively.

The sixth column allowed us to check whether or not the medicine was prescribed from the Senegal’s NEML. The presence was coded 1 and the absence 0.

Finally, columns 7 and 8 were related to the qualification of the prescriber (physician, dentist, nurse, midwife, dental assistant) and the origin of each prescription (public sector, private sector), respectively.

Data collection method: A prescriptions review was carried out. The Data were collected from the first 30 prescriptions presented in each community pharmacy. Every day was dedicated to a community pharmacy. The investigation began at 8 am until the required number of prescriptions was reached.

The data collector was a sixth-year pharmacy student at the Cheikh Anta Diop University in Dakar and assistant in a pharmacy in Thiès. He was trained on the data collection method and sensitized on the objectives of the study. The training materials were the data collecting form, WHO documents [9,22], the Senegal’s NEML [13], the handbook of therapeutic equivalences [14] and the drug database [15].

The investigator's tasks consisted of completing columns 1, 2, 4, 5, 7 and 8 while the supervisor completed columns 3 and 6.

Ethics

This study was conducted as of a Pharm. D thesis. It was an observational study and did not identify patients. The study did not involve any physical risk for patients and had no impact on the environment.

However, the informed consent of each patient was collected and the data were collected confidentially.

Statistics

The data were entered and analyzed using Microsoft Excel 2010.

The statistical analysis was descriptive. Quantitative variables were expressed as mean ± standard deviation, while qualitative variables were in percent.

The calculation of the five prescribing indicators was performed as follow [9]:

i) Average number of drugs per prescription=total number of different drugs prescribed divided by the number of prescriptions reviewed. Combination drugs are counted as one.

ii) Percentage of medicines prescribed by INN=number of medicines prescribed by INN divided by the total number of medicines prescribed and multiplied by 100.

iii) Percentage of medicines prescribed from Senegal’s NEML=number of medicines prescribed from Senegal’s NEML divided by the total number of drugs prescribed and multiplied by 100.

iv) Percentage of prescriptions with at least one antibiotic=number of prescriptions with at least one antibiotic divided by the number of prescriptions surveyed and multiplied by 100.

v) Percentage of prescriptions with at least one injection=number of prescriptions with at least one injection divided by the number of prescriptions surveyed and multiplied by 100.

Results

Prescription identification

A total of 600 prescriptions were included in our study. The number of prescriptions from public and private sectors was 417 (70%) and 169 (28%), respectively. However, the origin of 14 prescriptions (2%) was unknown (Table 1).

Table 1: Distribution of prescriptions according to the sector and the prescriber qualification, Thiès, Senegal, December 2017-January 2018 (N=600).

Prescribing indicators

The total number of medicines prescribed was 1513, of which 1063 (70.26%) and 414 (27.36%) were from public and private sectors, respectively. Half of the prescriptions contained at least three drugs. One prescription included 7 drugs (Table 2).

Table 2: Prescription distribution by number of prescribed medicines, Thiès, Senegal, December 2017-January 2018 (N=600).

Average number of medicines per prescription

The average number of medicines per prescription was 2.52 ± 1.08 (Table 3). In the public sector, the average number of medicines per prescription was 2.55 while in the private sector it was 2.45 (Table 3).

Table 3: Prescribing indicators, Thiès, Senegal, December 2017-January 2018 (N=600).

Percentage of medicines prescribed by INN

The percentage of medicines prescribed by INN was estimated at 7%. It was almost identical in the public (7.8%) and private (7%) sectors (Table 3).

Percentage of medicines prescribed from the Senegal’s NEML

Only 32% of medicines were prescribed from the Senegal’s NEML.

Most prescriptions were written by physicians (40%) followed by nurses (30%). The prescriber qualification was not specified in 11% of cases (Table 1).

This percentage was 31% in the public sector versus 34.3% in the private sector (Table 3).

Percentage of prescriptions with at least one antibiotic

At least one antibiotic was prescribed in 40% of prescriptions including 42% in the public sector and 34% in the private sector (Table 3). The three most prescribed classes of antibiotics were beta-lactams (72%), quinolones (12% and macrolides (7%) (Figure 1).

Figure 1: Prescribed antibiotic classes, Thiès, Senegal, December 2017-January 2018 (N=600); Percentage of prescriptions with at least one injection.

The results of our study showed that 7% of prescriptions contained at least one injection. The same proportion was found in both the public and private sectors (Table 3).

Discussion

Since 2006, Senegal has a NDP document [12]. The main objectives of this NDP are, among others:

(i) To promote rational use of medicines by health professionals and consumers;

(ii) To promote research in the use of medicines;

(iii) To promote generic essential medicines to health workers and the general public

The NDP relies on various tools to rationalize the use of drugs. These are the NEML, handbook of therapeutic equivalences and Drug Database.

Senegal has a NEML since 1990. The last update dates from 2015. It is elaborated according to the levels of the health pyramid. It must be available in all health facilities in the public sector [13].

The handbook of therapeutic equivalences is developed in 2016 by the Senegal’s Pharmacy and Drug Department. It is the list of substitutable medicines in Senegal. The medicines listed therein are referred to by their brand name and INN. They are presented under their dosage, their pharmaceutical form, their route of administration and, secondarily, their conditioning [14].

The drug database is set up in 2017. It allows knowing the types of drugs marketed in Senegal, their indications and their price. It is available online on the website of the Senegal’s Pharmacy and Drug Department [15].

The purpose of this NDP and these tools is to promote availability and accessibility of essential medicines [12].

WHO recommends evaluating the performance of NDPs using core prescribing indicators [9]. Previous studies in Senegal showed shortcomings about availability of essential medicines and prescribing practices [16-18]. Our study, conducted in an urban setting, aimed to evaluate five key indicators of rational drug use both in public and private sectors. It has yielded important results and their implications in public health. These were compared with those found in previous studies. On the other hand, we compare them with the WHO optimal values, as well as with the results highlighted in other countries. These comparisons allow us not only to evaluate Senegal's performance in terms of rational use of medicines but also to guide decision-making for health system strengthening.

Average number of medicines per prescription

Our study showed that almost half (49.5%) of prescriptions contained at least three drugs. This has resulted in an average number of medicines per prescription equal to 2.52. In the public and the private sectors, this number was 2.55 and 2.45, respectively. These values do not comply with the WHO standard (<2). They have not changed much over time. In 1993-94, the average number of medicines per prescription was 3 in the region of Dakar and 2.3 in the rest of the country [17]. In 2003, it was estimated at 2.4 [18].

Slightly lower or comparable results were found in Ethiopia (2.34) [6], Egypt (2.5) [23] and Guyana (2.5) [24]. Higher results were found in Botswana (2.8) [25], Kenya (3) [26] and Nigeria (5.8) [27].

Our study revealed a tendency to prescribe several drugs (polypharmacy). Several causes are reported in the literature. It could be the lack of knowledge of health professionals [6], the aging of the population and the double burden of communicable and non-communicable diseases [5]. Polypharmacy- related problems are the occurrence of side effects and drug-drug interactions, which in turn can lead to treatment interruption or prescribing cascade [28]. The latter is described as an event that begins when an adverse drug reaction to a prescribed drug is interpreted as a new medical problem involving the prescription of a second drug, and so on [29].

In addition, polypharmacy is expensive in that it accounts for a large share of health expenditure [30]. In developing countries, health insurance schemes are weak [31]. Between 70% and 90% of drugs are paid by households at a cost representing 9.5% of their total expenditure [1,32]. Thus, the introduction of clinical guidelines would be essential in order to rationalize the number of drugs prescribed.

Percentage of medicines prescribed by INN

In our study, only 7% of drugs were prescribed by INN while the WHO standard is 100%. In 2003, this proportion was 60% [18].

This result is well below those found in the WHO African Region (68%) [5] and Botswana (78.6%) [25]. This situation could be explained by the influence of the medical representatives on the one hand [33,24] and the low level of knowledge among prescribers on the concept of generic medicine on the other hand [26]. At the same time, in the public sector, stocks out of drugs are recurrent in Senegal [34]. Thus, prescribers fall back on brand name drugs that are usually only available in community pharmacies.

INN prescribing has many advantages. It reduces the risk of confusion during dispensing [35] and facilitates communication between health professionals [36]. It also improves people's access to cheaper medicines [35].

Our study showed that the low use of INN prescribing remains a major challenge that it is urgent to meet. For this purpose, three strategies, among others, are necessary. First, prescribers should be made more aware of INNs by updating and disseminating documents such as the NEML, the handbook of therapeutic equivalences and the drug database. Second, independent drug information should be made available to limit the influence of medical representatives. Finally, the third strategy will be to promote the local production of generic and essential medicines.

Percentage of medicines prescribed from the Senegal’s NEML

According to our survey, the percentage of medicines prescribed from the Senegal’s NEML is low (32%). Paradoxically, it was slightly higher in the private sector (34.3%) than in the public sector (31%). In 2003, this indicator was estimated at 83.2% [18].

These results revealed a significant departure from the WHO standard (100%). This was also evident in India where only 37.3% [37] of the drugs belonged to an essential medicines list or form. However, in the WHO African Region, the use of the essential medicines list is higher (88%) [5]. In Nigeria, it is very close to the WHO standard (95.5%) [38]. In the Gambia, this value was 100% [39].

Our study highlighted a low adherence of prescribers to Senegal's NEML. In some countries, poor dissemination of essential medicines list and the influence of medical representatives have been demonstrated as factors that may explain this situation [5]. Further studies should be conducted to assess the availability of the latest version of the NEML among prescribers.

The use of a limited number of essential drugs allows rationalizing prescribing practices and costs of drugs [40]. Thus, the promotion of the concept of an essential medicines list would be necessary, especially in resource-limited countries [3].

Percentage of prescriptions with at least one antibiotic

In our study, 40% of prescriptions contained at least one antibiotic. This proportion was higher in the public sector (42%) than in the private sector (34%). The use of antibiotics has not generally evolved in Senegal since it was estimated at 39% and 46% in 1990 [16] and 2003 [18], respectively.

The results of our study exceeded the threshold set by WHO (<30%) and were comparable to those found in Botswana (42.7%) [25], Cameroon (36.71%) [41] and Pakistan (39.6%) [42]. On the other hand, they were lower than those highlighted in Vietnam (69%) and China (52.6%) [43].

In West Africa, the absence of a bacterial resistance monitoring system and a presumptive diagnosis established by prescribers who are often poorly trained are at the origin of inappropriate antibiotic prescribing [44]. For example, antibiotics are used for the treatment of respiratory infections, which are generally of viral origin [45]. In our study, those which were most prescribed belong to beta-lactams, quinolones and macrolides classes. Antimicrobial resistance, especially antibiotic resistance, is strongly associated with the irrational use of antibiotics and causes nearly 700,000 deaths per year [46].

Faced with this situation, it seems urgent to prevent the unnecessary consumption of antibiotics and reduce the burden of infectious diseases through effective policies [47]. These include the improvement of hygiene and sanitary conditions, vaccination, and access to high-performance diagnostic tools [47].

Percentage of prescriptions with at least one injection

This indicator was estimated at 7% in both the public and private sectors. The situation improved compared to that (25%) found in 2003 [18]. It complies with the threshold set by WHO (<20%). In India and Ghana, studies have also shown optimal use of injection with respective proportions of 7.2% [48] and 6.4% [49]. However, other studies have found higher results in sub-Saharan Africa (25%) [5], China (40.75%) [43] and Pakistan (27.1%) [50]. Excessive use of injection is recognized as a form of irrational use of drugs [1]. It exposes patients to infectious diseases transmitted by the blood and represents an additional workload for health professional [3,36]. In addition, injectable products are generally more expensive than oral forms [50].

The low rate of prescriptions with at least one injection demonstrated by our study represents an opportunity not only to reduce the incidence of blood-borne diseases but also to improve prescribing practices. In addition, population sensitization is essential because there is evidence in the literature that patients ask health workers to prescribe injection forms because of a misconception that the latter are more effective than oral forms [50]. At the regulatory level, one of the solutions would be to limit the prescription of injectable antibiotics in primary health care facilities [3].

Limits

The results of our study are not generalizable because of their very limited geographical and temporal character. On the one hand, the study only took place in an urban setting. On the other hand, we did it over a short period without taking into account seasonal variations. However, they represent new data on drug use in Senegal and will help in making-decision.

Conclusion

Our study has highlighted irrational prescribing practices both in the public and private sectors. These include polypharmacy, excessive use of antibiotics and prescribers’ low level of adherence to the concept of essential drugs. In contrast, the use of injections complies with the WHO optimal value.

The results of our study indicate the need for implementing interventions to promote rational use of medicines among prescribers. These include training prescribers, implementing clinical guidelines, updating and disseminating tools such as the Senegal’s NLEM, the handbook of therapeutic equivalences and the drugs database. Furthermore, it would be necessary to sensitize populations and to regulate pharmaceutical sector. Extensive studies in other regions of Senegal over a long period would be needed to better understand the extent of the problem and its determinants.

Conflict of Interest

The authors do not declare any conflict of interest.

Funding

This research received no external funding

Acknowledgement

We are very grateful to the community pharmacists who agreed to welcome us to their pharmacies. We also extend our warmest thanks to the patients/care-takers for giving us their prescription in order to register the drugs that are prescribed.

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