Health Policy and Technology (2017) 6, 457–470

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/hlpt

LITERATURE REVIEW

Drug utilization patterns in the global

context: A systematic review
Muhammad Atifa,n, Shane Scahillb, Muhammad Azeema,
Muhammad Rehan Sarwara, Zaheer-Ud-Din Babarc

a
Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
b
School of Management, Massey University, Auckland, New Zealand
c
Department of Pharmacy, University of Huddersfield, Huddersfield, United Kingdom

Available online 10 November 2017

KEYWORDS Abstract
Prescribing indicators; Objectives: Standard drug use indicators have been developed by the World Health Organiza-
Patient-care indica- tion/International Network for Rational Use of Drugs (WHO/INRUD). The purpose of this
tors; systematic review was to examine and report the current status of health facilities in different
Facility-specific indi- regions of the world in terms of drug use based on WHO/INRUD core drug use indicators.
cators;
Design: Systematic review of the literature following PRISMA guidelines.
World Bank regions;
Income level;
Methods: The INRUD bibliography, WHO archives, Google Scholar, Medline, PubMed, Spring-
Rational drug use erLink, ScienceDirect and Management Sciences for Health (MSH) resource databases were
searched between 1985 and 2015 for studies -containing 12 WHO/INRUD core drug use
indicators. Secondary data sources were also searched.
Results: Four hundred and sixty three studies were retrieved and 398 were excluded as they
did not provide relevant information or fulfill the selection criteria. Sixty articles met the
criteria and were selected for final review. With respect to prescribing indicators, studies of
“drug use” showed mixed patterns across geographic regions. Overall trends in “patient-care”
and “facility-specific” indicators were similar across most of the World Bank regions. However,
based on the Index of Rational Drug Use (IRDU) values, East Asia and the Pacific region
demonstrated relatively better drug use practices compared with other regions.
Conclusions: This systematic review revealed that the drug use practices in all regions of the
world are suboptimal. A regulated, multi-disciplinary, national body with adequate funding

n
Corresponding author.
E-mail addresses: [email protected], [email protected] (M. Atif), [email protected] (S. Scahill),
[email protected] (M. Azeem), [email protected] (M.R. Sarwar), [email protected] (Z.-U. Babar).

https://doi.org/10.1016/j.hlpt.2017.11.001
2211-8837/& 2017 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.
458 M. Atif et al.

provided by governments throughout the world are a basic requirement for coordination of
activities and services, to improve the rational use of drugs at a local level.
& 2017 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.

Contents

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Data entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
Core drug use indicators by World Bank regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
Core drug use indicators by World Bank income level regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Summary indices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Prescribing indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Patient-care indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
Facility-specific indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
Conclusion and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
Strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
......................................................................... 467
Authors' contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Ethical approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Appendix A. Supporting information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
....................................................................... 467
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Introduction Irrational prescribing of drugs by doctors and suboptimal

drug use by patients is a global problem. Studies have shown
Medicines are the single most common therapeutic inter- that worldwide over 50% of all drugs are prescribed or sold
vention and a crucial component of medical care for any incorrectly, and 50% of patients do not use drugs optimally
healthcare system [1]. According to the World Bank, in [2]. Inappropriate prescribing practices and irrational use of
developing countries, 20–50% of the health care expendi- drugs can result in unsafe and ineffective treatment result-
tures are spent on drugs and other medical products [2]. ing in morbidity and mortality and harm and distress to
The appropriate use of drugs is essential for optimizing patients Increases in out-of-pocket expenses for patients
individual patient health and the population health of any and a general waste of resources also occurs [2,13]. In low
nation [3]. In 1985, the World Health Organization (WHO) and middle income countries, these problems are exacer-
organized a conference to promote the rational use of drugs bated by restrained economic resources and lack of regu-
[4]. Since then, efforts have been augmented to improve lated drug policies [14]. According to published studies,
drug use, particularly in under-developed as well as devel- poly-pharmacy, inappropriate antibiotic use, overuse of
oping countries [5]. According to the WHO, the rational use injectable drugs, use of prescription drugs inconsistent with
of drugs requires that patients receive drugs appropriate to clinical guidelines, and less than optimal self-medication
their health problems, in optimal doses for correct duration are the major reasons for irrational drug use [2]. The
at minimum cost to individuals and the nations’ health increase in resistance due to the overuse of antibiotics is
system [2,6,7]. There are numerous factors that influence a considerable problem of irrational drug use [2,15]. Irra-
rational prescribing for example; the medical state of tional drug use has also been reported to reduce patients’
patients, beliefs, values and prescribing behaviour of phy- confidence in their own health care systems [2].
sicians, the working environment within the health system, Essential Drugs List (EDL) promotes efficient and effective
the drug supply system, legislation, and information avail- use of medicines. The choice of essential drugs is complex
able about the drugs [8–12]. and the needs of the population must be considered as part
of the selection process. This is specifically with respect to
Drug utilization patterns in the global context: A systematic review 459

diagnosis, prophylaxis, treatment (therapy) and rehabilita- greater generalizability of individual indicators within a
tion using parameters of the risk-to-benefit ratio, quality variety of World Bank regions. This paper also uses pub-
and practical management, cost effectiveness, and patient lished indices [15,21,22] to compare the rational use of
acceptance and compliance [8,9,16]. Approximately one- drugs within different regions of the world. This systematic
third of the world's population does not have access to review provides useful information for researchers, admin-
essential drugs [2] either because they are not included in istrators, policymakers and other important stakeholders to
the EDL, or key drugs on the EDL are not available at the evaluate existing patterns of drug utilization at global,
time of prescribing. national, regional and local levels. Furthermore, this review
Previous studies have shown that drug use practices are informs the formulation of educational interventions,
less than optimal [16]. To better understand pattern of drug national drug policies and National Essential Drugs Lists
use and to allow quantification and comparison through (NEDL), as well as hospital formularies to improve prescrib-
systematic means, standardized drug use indicators have ing patterns and the cost-effective use of drugs.
been developed by the World Health Organization/Interna-
tional Network for Rational Use of Drugs (WHO/INRUD) [3]. Methods
To-date, these standard drug use indicators have been
successfully used in developing countries for performance Published studies and scientific reports containing 12 WHO/INRUD
management and process improvement [3,17,18]. core drug use indicators were systematically identified for the
The purpose of this systematic review was to examine period 1st January 1985 to 31st December 2015. Studies from
and report the current status of health facilities in different developed, developing and transitional countries that presented
regions of the world in terms of drug use based on WHO/ drug use data were extracted. A systematic review ensured
INRUD core drug use indicators [2] (see Table 1). A review complete collection of literature. The PRISMA guidelines [23] were
article [19] and a fact book published by the WHO [20] followed [Appendix 1: PRISMA Checklist].
reports the results based on data available up to 2009. The
contribution that this current systematic review makes is in Search strategy
the detailed description of patient-care and facility-specific
indicators and presentation of evidence that results in A systematic search strategy was implemented using WHO archives,
Google Scholar, Medline, PubMed, SpringerLink, ScienceDirect and
Management Sciences for Health (MSH). Search terminologies
Table 1 Core drug use indicators and their optimal included: “Drug use indicators”, “WHO/INRUD”, “Prescribing indi-
values. cators”, “Patient-care indicators”, “Facility-specific indicators”
and “Prescribing behavior” which were used in diverse combina-
Core drug use indicators Optimal tions with BOOLEAN and MeSH search methods. In addition, all
values studies available in the conference proceedings of the Third
International Conference for Improving Use of Medicines (held in
Prescribing indicators Turkey, 2011), were reviewed and included in the search for
Average number of drugs prescribed per 1.6–1.8 completeness [24]. Appropriate secondary data sources were also
patient encounter sourced [19,20,25]. Initially, 463 studies were identified and
Percent medicines prescribed by generic 100 retrieved. Of these, 106 were duplicates that were excluded. From
name the remaining 357 articles, over half (169) were excluded based on
having irrelevant titles and/or ambiguous content. Subsequently,
Percent encounters with an antibiotic 20.0–26.8
the full text of 188 articles was read and 123 studies were removed
prescribed
at this point due to failure to provide relevant information.
Percent encounters with an injection 13.4–24.1 Constructive disagreement amongst the research team regarding
prescribed study eligibility was resolved through discussion and mutual agree-
Percent medicines prescribed from 100 ment within team meetings. Sixty five articles made the final
essential medicines list or formulary selection (Fig. 1) based on criteria outlined in Table 2. Three
reviewers SS, MRS and MAZ systematically searched the studies from
the INRUD bibliography, whilst two independent reviewers checked
Patient-care indicators all studies to verify the validity of screening processes. All authors
Average consultation time (minutes) Z10 agreed to include these final studies in the review.
Average dispensing time (seconds) Z90
Percent medicines actually dispensed 100 Data entry
Percent medicines adequately labeled 100
Percent patients with knowledge of cor- 100 A purpose designed data extraction form was used for data entry.
rect doses Each record described; drug use patterns in countries based on
classification by geographical and income level in World Bank
regions. A maximum of three studies per country were selected
Facility-specific indicators
regardless of the number available. Studies were selected which
Availability of essential medicines list or 100 included all standard indicators (or a maximum number) of the most
formulary to practitioners recent ones. A careful literature search revealed that there are a
Percent key medicines available 100 good number of INRUD indicator studies available from counties like
China, India, and Ethiopia etc. Contrary to this, only a few studies
Note: Core drug use indicators are obtained from World were available from European countries. Therefore, to maintain
Health Organization sources [2,3]. uniformity in the data, the researchers developed a criterion that if
460 M. Atif et al.

more than three studies were available from a single country, then drugs, summary indices were calculated: Index of Rational Drug
a maximum of three of the most recent studies reporting the Prescribing (IRDP), Index of Rational Patient-Care Drug Use
maximum number of INRUD indicators would be included in the (IRPCDU) and Index of Rational Facility-Specific Drug Use (IRFSDU).
review. These indices were developed by employing a validated mathema-
All data was entered then rechecked before being exported into tical model derived by Zhang and Zhi [26]. This is an established
Statistical Package for Social Sciences (SPSS v 21.0) and Microsoft model for developing indices that has been well cited with respect
Excel 2010 for analysis. to the drug prescribing indicator literature in developing nations
including China, Saudi Arabia, United Arab Emirates, Egypt, Paki-
stan, Sierra Leone, Zambia and Ethiopia [15,21,27–32]. For the
Analysis
calculation of indices (index of non-polypharmacy, index of rational
antibiotic use and index of safe injection drug use), the following
Descriptive statistics were used to analyze the data. In this formula was used;
systematic review the primary outcome measures were the 12
commonly reported WHO/INRUD indicators as outlined in Table 1. Optimalvalue
Index ¼
The optimal values for prescribing [13], patient-care and facility- Observedvalue
specific indicators [15,21] were adopted from previous studies. All other indices (index of generic name, index of EDL, consulta-
The median value for each indicator was calculated based on the tion time index, dispensing time index, index of drugs actually
total number of studies in each geographic region according to the dispensed, index of labeling of drugs, index of patients’ knowledge,
World Bank regional classification, as well as the income level index of EDL availability and index of key drug availability in stock)
classification of the countries analyzed. To assess the rational use of were calculated using the following formula;
Observedvalue
Index ¼
Optimalvalue
The maximum value for each of the indices was 1. The close the
value to 1 the better the performance for that indices. The Index of
Rational Drug Use (IRDU) was calculated by summing the IRDP,
IRPCDU, and IRFSDU. The World Bank regions (geographic and
income level) were ranked based on the IRDU and the regions with
the highest IRDU value were considered to be performing the best
and so; were ascribed a rank of 1.

Results

Core drug use indicators by World Bank regions

Table 3 outlines studies of prescribing indicators by geographic

origin. The majority of studies were undertaken in Sub Saharan
Africa, followed by South Asia, East Asia and the Pacific, the Middle
East and North African regions, respectively. Very few studies have
been conducted in Europe and Central Asia, or Latin America and
the Caribbean regions.
Findings from this internationally focused systematic review
suggest a mixed picture of prescribing patterns across various
geographic regions (Table 3). Studies from East Asia and the Pacific
Fig. 1 Schematic diagram explaining the assortment of stu- region point towards positive performance in this region, with the
dies/reports. highest percentage of drugs prescribed from an EDL/formulary, and
the highest percentage of generic prescribing. Studies from Latin
America and the Caribbean region had the lowest number of drugs

Table 2 Inclusion and exclusion criteria.

Sr. No Inclusion criteria

1 Studies on WHO/INRUD core drug use indicators published during 1985 to March 2015.
2 All original studies, reviews and abstracts available in scientific literature.
3 In this review, our primary outcome measures were the 12 WHO/INRUD drug use indicators.
5 If more than three studies were available from a single country, then only the three most recent studies describing all
or the maximum number of standard indicators were selected.
6 All included studies followed WHO/INRUD methodology. So, there were no issues regarding methods, study design,
data collection and analysis that could lead to bias.
Sr. No Exclusion criteria
1 Studies reporting less than 3 indicators were excluded.
2 Studies reporting the indicators for infectious diseases (for example diarrhea, pneumonia) were excluded.
3 Studies published in a language other than English were excluded.
Drug utilization patterns in the global context: A systematic review 461

Table 3 Prescribing indicators by World Bank regions.

Country Prescribing Indicators

Average drugs/ % drugs % encounters with an % encounters with an % drugs prescribed from
encounter prescribed antibiotic prescribed injection prescribed EDL/formulary
by generic
name

South Asia
Afghanistan [33] 3.9 67.0 65.0 17.0 –
Bangladesh [34] 1.4 78.0 25.0 – 85.0
Bangladesh [17] 1.4 – 31.0 0.2 –
India [35] 5.6 2.6 81.1 0.7 90.2
India [36] 3.1 10.1 33.0 2.4 65.2
India [14] 2.8 11.5 75.0 45.8 45.5
Nepal [37] 2.1 44.0 43.0 5.0 86.0
Pakistan [38] 2.8 – 52.0 14.7 –
Pakistan [39] 3.2 29.7 64.0 0.0 96.5
Sri Lanka [40] 3.0 36.7 – – 39.6
Median 2.9 33.2 52.0 3.7 85.0

East Asia and Pacific

Burma [41] 3.5 76.3 76.0 – 94.8
Cambodia [42] 2.4 99.8 66.0 2.4 99.7
China [43] 3.5 96.1 29.9 20.0 48.9
China [44] 2.3 100 45.7 11.0 –
China [45] 2.2 – 24.7 10.3 97.4
Indonesia [17] 3.3 59.0 43.0 17.0 –
Lao People's [46] 3.0 78.0 47.0 18.0 84.0
Malaysia [25] – 42.1 21.7 0.0 100
Philippines [47] – – 55.4 0.0 58.6
Samoa [25] – 28.0 56.0 18.0 75.0
Timor-Leste [48] 3.3 92.0 70.0 0.1 –
Tonga [47] – 37.0 53.5 7.0 99.0
Vietnam [49] 2.2 – 70.0 14.0 –
Median 3.0 77.2 53.5 10.6 94.8

Sub Saharan Africa

Angola [25] – 60.8 38.2 4.6 58.8
Botswana [50] 2.3 54.0 27.0 9.0 –
Burkina Faso [51] – 93.0 58.0 23.0 –
Burkina Faso [52] 2.3 85.9 33.1 24.6 88.0
Burundi [47] – 87.3 50.0 10.0 92.4
Cameroon [25] – 88.8 62.9 45.0 92.5
Cameroon [53] 3.0 56.1 48.9 41.8 82.1
Central African 3.5 68.6 31.4 29.0 82.1
Republic [54]
Congo [47] – 57.0 43.4 40.0 59.1
Eritrea [55] 1.8 79.0 44.0 17.0 94.0
Ethiopia [13] 1.9 98.7 58.1 38.1 96.6
Ethiopia [56] 2.2 79.4 24.9 10.6 90.3
Ethiopia [57] 2.5 96.6 50.7 18.4 –
Gambia [58] – 69.6 50.0 28.4 100
Ghana [59] 4.8 65.0 60.0 80.0 97.0
Kenya [25] – 48.6 73.4 34.1 79.3
Malawi [60] 1.8 – 34.0 19.0 –
Mali [47] – 93.3 58.9 35.2 94.6
Mozambique [61] 2.2 99.0 43.0 18.0 98.8
Namibia [25] – 65.5 50.5 – –
Niger [62] 3.1 100 68.0 36.6 100.0
Nigeria [63] 3.8 58.0 48.0 37.0 –
462 M. Atif et al.

Table 3 (continued )

Country Prescribing Indicators

Average drugs/ % drugs % encounters with an % encounters with an % drugs prescribed from
encounter prescribed antibiotic prescribed injection prescribed EDL/formulary
by generic
name

Nigeria [64] 3.7 48.0 54.2 37.0 94.4

Nigeria [65] 5.2 61.9 57.6 63.1 78.4
Rwanda [47] – 80.0 50.0 20.0 94.0
Senegal [25] – 60.0 46.0 25.0 83.2
South Africa [66] 3.0 34.8 50.0 15.8 80.6
Sudan [67] 1.4 63.0 63.0 36.0 –
Swaziland [65] 3.0 63.1 54.2 38.0 75.6
Tanzania [68] 2.2 79.1 38.3 29.3 70.0
Tanzania [69] 2.2 82.0 39.0 29.0 88.0
Tanzania [70] 2.3 75.5 35.4 19.0 87.1
Uganda [71] 1.9 – 56.0 48.0 –
Zaire [72] 2.0 – 21.7 – –
Zambia [73] 2.5 56.9 65.4 9.7 95.9
Zimbabwe [74] 2.0 43.7 53.0 19.0 70.7
Zimbabwe [17] 1.3 94.0 29.0 11.0 –
Median 2.3 69.1 50.0 28.4 88.0

Middle East and North Africa

Bahrain [75] 2.6 14.3 26.2 8.3 99.8
Egypt [15] 2.5 95.4 39.2 9.9 95.4
Iran [76] 2.9 – 45.0 41.0 –
Jordan [77] 2.3 5.1 60.9 1.2 93.0
Kuwait [78] 2.9 17.7 39.1 9.1 –
Lebanon [79] 1.6 2.9 17.5 – 2.9
Morocco [80] 3.3 – 43.3 17.3 15.5
Oman [25] – – 38.6 6.4 97.5
Palestine [81] 1.9 5.5 – – 97.9
Saudi Arabia [21] 2.4 61.2 32.2 2.0 99.2
United Arab Emi- 2.2 4.4 13.5 1.6 –
rates [82]
Yemen [83] 2.8 39.2 66.2 46.0 81.2
Yemen [84] 1.5 – 46.0 25.0 –
Median 2.4 14.3 39.2 9.1 95.4

Latin America and Caribbean

Brazil [85] 2.2 74.0 37.0 11.0 78.0
Colombia [47] – – 30.0 13.3 94.2
Ecuador [17] 1.3 37.0 27.0 19.0 –
Guatemala [17] 1.4 72.0 27.0 13.0 –
Guatemala [47] – – 41.5 10.5 97.0
Peru [25] – 70.0 59.0 26.0 72.0
Median 1.4 71.0 33.5 13.2 86.1

Europe and Central Asia

Andorra [86] 2.0 6.0 29.0 3.0 30.0
Kyrgyzstan [47] – – 35.0 30.0 59.0
Macedonia [55] 2.5 – 22.0 17.3 –
Russia [87] 2.3 38.0 – 38.0 –
Serbia [88] 2.1 21.5 62.0 74.0 –
Serbia [89] 1.9 27.5 37.0 10.0 43.0
Sweden [90] 0.7 – 10.4 0.0 –
Uzbekistan [55] 2.9 38.3 56.5 57.0 79.4
Median 2.1 27.5 35.0 23.6 51.0
Drug utilization patterns in the global context: A systematic review 463

Table 4 Patient-care and facility-specific indicators by World Bank regions.

Country Patient Care and Facility Specific Indicators

Average consultation Average dispensing % drugs % drugs adequately % patients % copy of % key drugs in
time (min) time (sec) dispensed labeled knowledgeable EDL stock

South Asia
Bangladesh [17] 1.0 23.0 81.0 – 82.0 – 54.0
Bangladesh [34] 0.9 23.0 81.0 – 55.0 16.0 54.0
India [35] 7.0 240 96.1 – 89.9 100.0 89.4
India [36] 2.3 258 81.0 99.4 74.3 100.0 84.0
Nepal [37] 3.5 86.1 83.0 – 56.0 – 90.0
Pakistan [38] 1.8 38.9 80.9 10.8 58.5 – –
Pakistan [39] 2.6 88.5 82.9 96.9 24.0 90.0 64.3
Median 2.3 86.1 81.0 96.9 58.5 95.0 74.2

East Asia and Pacific Region

Cambodia [42] 4.4 234 100.0 0.0 55.0 100.0 86.6
China [44] 8.5 25.6 100.0 100.0 81.3 – –
China [45] 3.8 25.0 100.0 95.0 85.0 – –
Indonesia [17] 3.0 – – – 82.0 – –
Median 4.1 25.6 100.0 95.0 81.6 100 86.6

Sub Saharan Africa

Central African 8.3 300.0 – 78.5 69.6 – –
Republic [54]
Ethiopia [57] 2.9 45.5 – 75.7 77.3 – –
Ethiopia [56] 6.2 78.0 83.4 70.1 72.8 50.0 65.0
Malawi [60] 2.3 – – – 27.0 – 67.0
Mozambique [61] 3.7 37.0 84.5 86.2 81.7 100.0 86.5
Niger [62] 6.1 204 100.0 89.7 75.5 100.0 85.6
Nigeria [63] 6.3 12.5 70.0 – 81.0 – 62.0
Nigeria [65] 5.0 18.1 94.3 0.0 89.1 100.0 90.9
Swaziland [65] 6.1 18.1 99.1 55.9 86.5 100.0 91.7
Tanzania [68] 3.0 77.7 – – 70.0 15.0 –
Tanzania [69] 3.0 77.8 – – 75.0 – 72.0
Tanzania [70] 3.6 39.9 91.6 87.6 96.1 100.0 100.0
Median 4.4 45.5 91.6 77.1 76.4 100.0 85.6

Middle East and North Africa

Egypt [15] 7.1 47.4 95.9 0.0 94.0 80.0 78.3
Jordan [91] 3.9 28.8 81.8 91.4 77.7 100.0 80.0
Kuwait [78] 2.8 54.6 97.9 66.9 26.9 – –
Saudi Arabia [22] 7.3 100.0 99.6 10.0 79.3 90.0 59.2
Median 5.5 51.0 96.9 38.4 78.5 90.0 78.3

Europe and Latin America

Brazil [85] 5.8 17.0 66.0 63.0 54.0 50.0 55.0
Serbia [89] – 24.0 53.5 – – 100.0 –
Sweden [90] 22.5 – – – 70.0 – –
Median 14.2 20.5 59.8 63.0 62.0 75.0 55.0

per prescription and the lowest number of antibiotics. The percen- Core drug use indicators by World Bank income level
tage of injections prescribed per prescription was similar when regions
comparing all the regions.
Table 4 shows the studies from different countries that measured Figs. 2 and 3 present the overall results of the core drug use
patient-care and facility-specific indicators in different settings by indicators by World Bank income level regions. This systematic
geographic location. Because of the smaller number of studies, the review indicates disparities in prescribing patterns across regions
data from Europe and Central Asia, and Latin America and [Additional file: WHO/INRUD indicators by World Bank income
Caribbean regions is merged into one group. level]. Studies from high income level countries report the lowest
This systematic review suggests that overall trends in patient- percentage of patients prescribed antibiotics and injectable and
care and facility-specific indicators were similar when comparing all the highest percentage of drugs prescribed from an EDL/formulary.
regions of the world (Table 4). Low average consultation times as The generic prescribing rate per prescription was highest for the
well as dispensing times were observed in all regions of the world low income countries which also report the lowest number of drugs
except for Europe and Latin America, and South Asia. Studies from per encounter.
East Asia and the Pacific region reported the highest percentage of With respect to patient-care indicators, studies from high
drugs actually dispensed, the highest proportion of patients with income level countries showed the highest average consultation
correct knowledge of drug doses, the highest percentage of EDL and dispensing times, along with the greatest percentage of drugs
availability and the highest percentage of key drugs in stock at the actually dispensed [Additional file: WHO/INRUD indicators by World
time of prescribing. Studies from South Asia reported the highest Bank income level]. Studies from lower-middle and upper-middle
percentage of adequate labeling. income level countries report the highest percentage of patients
464 M. Atif et al.

Fig. 2 Prescribing indicators by World Bank income level regions.

Fig. 3 Patient-care and facility-specific indicators by World Bank income level regions.

with knowledge of the correct doses and the highest percentage of findings provide useful baseline information for future
adequate labeling, respectively. Similarly, with reference to facil- monitoring and assessments of the rational use of drugs in
ity-specific indicators, low income level countries had the highest the international context.
percentage of EDL availability and the highest percentage of key
drugs in stock [Appendix 2: WHO/INRUD indicators by World Bank
income level].
Prescribing indicators
Summary indices
The results of this review show that the average number of
Table 5 summarizes the overall results of the core drug use drugs per prescription was above optimal levels for all World
indicators in terms of indices; IRDP, IRPCDU, and IRFSDU. Bank classified regions except for Latin America and the
Caribbean. This is an important finding as poly-pharmacy
leads to escalated risk of drug interactions [92], prescribing
Discussion errors [93], reduced compliance [35], possible adverse
effects, and wastage of drugs. This leads ultimately to
The irrational use of drugs exists all over the world and increased hospital costs [94], as well as fiscal implications
ultimately can lead to unwanted effects in most patients for the health-care system. Evidence-based clinical guide-
[15]. In this systematic review, we identified current treat- lines such as prescribing policies and standard treatment
ment practices in different regions of the world using guidelines are crucial for promoting the rational use of
established indicators. This is expected to help prioritize drugs as they help prescribers in making appropriate clinical
interventions for improving drug use practices, and the decisions [2]. This study supports an increased focus on this.
evaluation of the outcome of these interventions. Our
 Drug utilization patterns in the global context: A systematic review
Table 5 Index of Rational Drug Use (IRDU) in selected countries.

IRDU World Bank Regions (geographical) World Bank Regions (income level)

South Asia East Asia and Sub Saharan Middle East and Latin America and Europe and Cen- Low Lower- Upper- High
Region Pacific Region Africa North Africa Caribbean tral Asia middle middle

(1) Index of non- 0.62 0.60 0.78 0.75 1.0 0.86 0.82 0.60 0.78 0.78
polypharmacy
(2) Index of generic name 0.33 0.77 0.69 0.14 0.71 0.26 0.82 0.58 0.42 0.16
(3) Index of rational 0.52 0.50 0.54 0.68 0.80 0.76 0.57 0.44 0.72 0.92
antibiotic
(4) Index of safety 1.0 1.0 0.85 1.0 1.0 1.0 1.0 1.0 1.0 1.0
injection
(5) Index of EDL 0.85 0.95 0.88 0.95 0.86 0.51 0.92 0.82 0.79 0.98
IRDP 3.32 3.82 3.74 3.52 4.37 3.39 4.13 3.44 3.71 3.84
Rank 6 2 3 4 1 5 1 4 3 2
(6) Consultation time 0.23 0.41 0.44 0.55 1.0 1.0 0.36 0.30 0.48 0.73
index.
(7) Dispensing time index 0.96 0.28 0.50 0.56 0.23 0.23 0.86 0.34 0.28 0.86
(8) Dispensed drugs index 0.81 1.0 0.92 0.97 0.60 0.60 0.88 0.82 0.82 0.99
(9) Labeled drugs index 0.97 0.95 0.77 0.38 0.63 0.63 0.78 0.33 0.93 0.38
(10) Patients’ knowledge 0.58 0.82 0.76 0.78 0.62 0.62 0.73 0.82 0.80 0.70
index
IRPCDU 3.55 3.46 3.39 3.24 3.08 3.08 3.61 2.61 3.31 3.66
Rank 1 2 3 4 5 5 2 4 3 1
(11) Index of EDL 0.95 1.0 1.0 0.90 0.75 0.75 1.0 1.0 1.0 0.90
availability
(12) Index of key drugs in 0.74 0.87 0.86 0.78 0.55 0.55 0.86 0.78 0.68 0.59
stock
IRFSDU 1.69 1.87 1.86 1.68 1.3 1.3 1.86 1.78 1.68 1.49
Rank 3 1 2 4 5 5 1 2 3 4
IRDU 8.56 9.15 8.99 8.44 8.75 7.77 9.60 7.83 8.70 8.99
Rank 4 1 2 5 3 6 1 4 3 2

IRDP (Index Rational Drug Prescribing); IRPCDU (Index Rational Patient-care Drug Use); IRFSDU (Index Rational Facility-specific Drug Use).

465
466 M. Atif et al.

The percentage of antibiotics prescribed per prescription reported in all regions could be the result of a large number
in these studies suggests that improvement is needed in all of patients to be examined per physician. Similarly, the
regions of the world. Misuse and over-prescribing of anti- average dispensing time was also not optimal for all regions
biotics is a common global problem with potentially dire of the world (Table 5). The short dispensing time is
circumstances. One of the important manifestations of insufficient to provide complete information to patients
irrational use of antibiotics is the higher probability of about dosage regimen, unwanted drug effects, precautions
antibiotic resistance developing [15]. This review suggests and checking for adequate labeling and dispensing of drugs.
that the percentage of encounters for which an injectable The optimal dispensing time may relate to patient compli-
dosage form is prescribed is optimal all over the globe, ance through the information provided and knowledge
except in Sub Saharan Africa (Table 3). An excessive use of gained about drugs, which is a primary step in improving
injections when oral formulations are available is not cost- patient care.
effective nor clinically inappropriate [2] because patients The percentage of drugs actually dispensed was close to
are more likely to suffer from blood borne diseases such as the optimal index for most regions except Europe and Latin
Hepatitis C and HIV [15] and there is no obvious increase in America (Table 5). An inadequate drug supply will lead to
clinical benefit. the use of non-essential drugs that will ultimately cause an
This international review suggests that nowhere in the increase in out-of-pocket expenses for patients. It will have
world is the percentage of drugs prescribed by generic a negative impact on patients’ health status, convenience
name, at optimal levels. This suggests that practice is not in and trust of the health care system [2]. The WHO recom-
accordance with policy; the WHO guidelines for rational mends that each dispensed drug should be adequately
prescribing [92]. The situation is most alarming in the labeled including the patient's name, dose of the drug and
Middle East and North Africa, as well as in high income dosage regimen [3]. At the same time, patient knowledge
level countries; although in high-income countries it may be about the correct dosage is highly influential in promoting
less of an issue with drug availability and affordability being treatment adherence. The findings from this systematic
potentially greater. Non-generic prescribing practices sug- review reveal that drug labeling practices were sub-optimal
gests that there is room for reducing national pharmaceu- throughout the world (Table 5). Moreover, patients did not
tical expenditure; particularly in the developing world. have the correct drug dosage knowledge. Omission of the
Interventions that reduce the significant influence of origi- patient's name on the product label is a serious issue that
nator brand pharmaceutical companies on medical prescri- has significant consequences including drug misuse and
bers should be thought about. The main advantages of abuse. Similarly, without satisfactory knowledge about the
generic prescribing are lower treatment costs and the risks and benefits of drugs and an understanding of proper
avoidance of prescription and dispensing errors that may dosage regimens, patients might not achieve expected
arise due to “look-alike” or “sound-alike” brand names [95]. clinical results [2].
The WHO deems generic prescribing to be a safety measure
for patients as the process allows professionals to clearly Facility-specific indicators
depict the drug name and also allows easily accessible
information about the drug, and leads to less ambiguous
The percentage of availability of EDL/formulary listed drugs
communication among health care providers [15].
was close to the optimal index for most regions except
Unlike with generic prescribing, the percentage of drugs
Europe and Latin America. However, the percentage of key
prescribed from EDL/formulary was seen to be almost
drugs in stock at the time of prescribing was found to be
optimal in most regions except Europe and Central Asia
below the optimal index. Shortage of essential drugs is
(Table 5). Drugs included in EDL are older, tested in
disadvantageous as it leads to prescribing more costly drugs
practice, low cost and have established clinical use [15].
from the open market. According to the WHO, physicians
Furthermore, a smaller number of drugs in EDL makes
should be adherent to prescribing the drugs listed in the
inventory management less complicated. Similarly, there
EDL/formulary. At the same time, concerned authorities at
is less chance of medication errors by prescribers and
a government level must ensure the availability of essential
pharmacists, because access to the appropriate knowledge
drugs at health care facilities.
and information is available for a smaller number of drugs
[2].
Conclusion and recommendations

Patient-care indicators The results of this systematic review reveal that irrational
drug use practices are occurring in all regions according to
This systematic review suggests that the average consulta- World Bank classification. Irrational utilization of drugs may
tion time of the physicians for all regions ranged from 2.3 to lead to increased adverse effects, increased morbidity and
7.3 minutes, which was below the optimal value Z10 mortality, greater wastage of resources and higher out-of-
minutes except for Europe and Latin America where it was pocket expenses for patients. Based on this review the
14.2 minutes (Table 4). According to the WHO, a shorter authors recommend that continuous education and training
consultation time is inadequate to conduct a complete of physicians is needed to reinforce rational prescribing.
patient examination, that is; to conduct proper history This is particularly with regards to antibiotics, injectable,
taking, complete physical examination, appropriate health generic medicines and prescribing from an EDL. The patient-
education, sound physician-patient interaction and to pre- to-physician ratio should be decreased to allow for prolon-
scription of therapy [15]. The short consultation time
Drug utilization patterns in the global context: A systematic review 467

gation of consultation time, which allows thorough history Acknowledgements

taking, comprehensive examination and sound therapeutic
relationships between patients and physicians. This should None.
also be the case to ensure sound drug dispensing and
improvement of patient knowledge through increased dura-
tion of counselling sessions. Availability of key drugs in stock
should be improved to ensure timely and effective treat-
Authors' contribution
ment of health related problems.
For the effectiveness of given national program which MAT, MRS and MAZ are the primary authors who conceptua-
focusses on the safe and rational use of drugs, monitoring of lized the article. SS MRS and MAZ screened all titles and
drug use and utilization of collected data for the develop- abstracts and determined whether the studies met inclusion
ment, implementation and evaluation of strategies is essen- criteria. MAT and ZUDB checked all studies to verify the
tial. The authors strongly believe that through the validity of screening. MAT, ZUDB and SS provided intellec-
implementation of the 12 core WHO interventions [2] the tual ideas included in the development and review of the
situation might improve, resulting in more rational pre- article. MRS and MAZ drafted the initial manuscript. MAT,
scribing and optimal use of drugs. Future studies should look ZUDB and SS undertook critical revisions of the manuscript.
at the outcomes of these intervention plans for continuous All authors read and approved the final version of the
process improvement. manuscript.

Competing interests

Strengths None declared.

This systematic review fills a significant gap in the literature Ethical approval
and has the following main strengths;
Not required.
 Coverage of the recent studies on the topic under review.
 Detailed description of patient-care and facility-specific Funding
indicators which previous reviews have not summarized.
The results are presented such that greater general-
No funding was involved in the preparation of this systema-
izability of individual indicators in different regions of
tic review or in the decision to submit it for publication.
the world is apparent.
 The authors have used the published WHO/INRUD indices
to systematically compare the rational use of drugs Appendix A. Supporting information
among different regions of the world.
 The findings from this review provide useful information Supplementary data associated with this article can be
for researchers, administrators, policy-makers and other found in the online version at doi:10.1016/j.hlpt.2017.11.
important stakeholders to evaluate existing patterns of 001.
drug utilization at global, regional and national country
level.
 This systematic review is expected to assist in the References
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