1. Investigating Medicine Use in Healthcare Facilities Dr Vijay Thawani Professor & Head, Pharmacology Department, VCSG Govt Institute of Medical Science & Research, Srikot, Pauri-Garhwal, Uttarakhand. vijaythawani@rediffmail.com

2. Objectives To find common medicine use practice To study if these practices are rational To plan intervention Methods to collect data on medicine use

3. Need of Studying Medicine Use Consumers commonly use medicines without HW advice Have subjective experience in medicine use Multiple sources for obtaining medicines Important to understand consumer behavior with medicine use and problems from their view

4. Basic Research Questions in Medicine Use Pattern What are common medicine use practices, which medicines are used, for what ills, how procured, how long used, who advices ? To what extent are the medicine use practices rational ? What are perceived to be medicine use problems by people and health workers in the community ?

5. Medicine Use Encounters Investigating medicine use problem involves collecting data from medicine use encounters to find exact problem and underlying causes. Physician Nurse Traditional healer Injectionist Dresser / Attendant Pharmacist Shopkeeper Relative / friend Patient

6. MEDICINE USE INDICATORS

7. Prescribing Indicators Average no. of medicines per encounter % of medicines prescribed by generic name % of encounters with AM prescribed % of encounters with inj. prescribed % of medicine prescribed from EML / Institutional Formulary / STGs

8. Patient Care Indicators Average consultation time Average dispensing time % of medicines dispensed % of medicines adequately labeled Pts knowledge of correct dosage

9. Facility Indicators Availability of copy of EML / Formulary, STG Presence of vital medicines Cost of medicines and markup Generic substitution Info to buyer on medicine use

10. Other Analysis ABC Cost analysis Unit price x Total consumption = Value, Total value, % of total value, Descending order, Rank, Cumulative %, 60 : 80 : rest Regression analysis for forecasting Excel function VED (VEN) Criticality analysis ABC-VED matrix

11. Access IndicatorPublic facilities Private facilities Availability of key medicines % prescribed medicines actually dispensed Stock-out duration of key medicines Adequate record keeping of stock record Affordability of key treatments Price / cost of key medicines Geographic accessibility of dispensaries 11

12. Quality IndicatorPublic facilities Private facilities % key medicines expired Adequate storage conditions 12

13. Rational Use of Medicines IndicatorPublic facilitie s Private facilitie s % medicines adequately labelled % knowledge how to take medicines Ave. # of medicines / prescription % antibiotics, injections % on EML, generic, Availability of STGs, EML  % cases treated according to STG  % POM bought without prescription  13

14. Planning Interventional Project Study medicine use Identify problems Prioritize problems Analyze problem Identify solution Plan intervention Pretest intervention Implement intervention Monitor Evaluate

15. Research Methods Useful in Studying Medicine Use Quantitative Methods Number based Frequency of use Representative picture Instrument preparation important Careful selection of variables and indicators Qualitative Methods Text based Ideas and perceptions of people In-depth understanding Identification of dimensions to be probed - important

16. Structured Interview Close-ended questions for large survey Selected through pilot study Sequence and language same for all respondents To learn about frequency of use and opinions Easy to analyze for comparison and hypothesis testing

17. Structured Observation in Health Facility / medicine shop To investigate medicine use pattern and cost / quality of HW prescribing Observe behavior of client - seller; pt - HW Info can be quantified and statistically processed Time consuming Ethical dimension

18. Patient Record Review Quick and cheap method to collect data Quality of prescription can be investigated Data can be quantified and statistically processed Comparison and generalization possible Ethical : consent of data owner needed

19. Exit Interviews Quick way to collect data Study of actual / recent prescriptions Data can be quantified / analyzed Can be used in combination with observation Reliability of information?

20. Sales Statistics Useful for investigating public / pvt expenditure, commonly sold medicines, availability and cost Helps in medicine supply planning Data can be quantified and statistically treated

21. Semi-structured Interview Open ended questions for long answers Useful in investigating perceived need for medicine, quality of care, medicine use problem, opinions on medicine use practice and medicine source. Can generate in-depth data with new and unexpected dimensions Difficult to analyze, compare and generalize

22. Key Informant Interview Conducted with experts, leaders, health policy makers Have interview guide, lead questions, probing questions Can modify on spot Generates rich information - depending on expertise and experience Tape record and transcribe Time consuming and difficult to analyze Problem in getting appointment

23. Free Listing Useful in exploration of commonly used medicines, sources, prescribers Generates exhaustive data Can help in identifying salient features Requires less time Reliability questionable

24. Focus Group Discussion Useful in investigating medicine use practices, problems, quality of care, sources of medicines, evaluation and probable solutions Highly skilled, requires efficient researchers Quicker and cheaper than individual interviews Problems can be identified and solutions arrived Great expertise can be tapped

25. Which method to use ? Best methods depends upon: - Nature of the problem - Objectives - Resources - Time - Capacity and experience Use Multiple methods - Quantitative + Qualitative - ‘Triangulate’ findings - Different aspects of the problem