When sick people visit a doctor, nurse or pharmacist they expect to be prescribed with medication that will restore them to health.
The expectation is that the health care provider has applied their knowledge of therapeutics to select an appropriate treatment regimen: the correct drugs, the right dosage and the ideal treatment duration.
But this is not always the case.
Irrational prescriptions are a major global health problem. The World Health Organisation estimates that more than half of all medicines are inappropriately prescribed, dispensed or sold. In addition, half of all patients fail to take them correctly.
In Africa, where most countries have weak health systems and underdeveloped mechanisms for routine monitoring of medicines, this problem is common.
Our study found sub-optimal measures of prescribing at primary health care centres across Africa. Too many medicines are being prescribed to patients in general and too many antibiotics and injections are being administered.
The implications of these findings are far reaching and may include antibiotic resistance as well as exposing patients to undue risk and creating shortages for those who do critically need the medication.
Africa’s health system challenges
In the early nineties, the World Health Organisation set indicators to assess trends in prescribing within primary health care settings.
These indicators guide the average number of medicines prescribed per patient, what percentage should have a generic name; how often antibiotics or injections should be prescribed as well as the percentage of medicines that should come from an essential medicines list.
We reviewed studies from 11 countries: Ghana, Nigeria, Burkina Faso, Ethiopia, South Africa, Tanzania, Kenya, Zambia, Zimbabwe, Botswana and Gambia. These studies collected data from more than 141,000 patient visits at 572 primary care centres. Of these, 359 were public and 213 private.
We found that prescription patterns at primary health care centres in Africa had not improved much over two decades.
Primary health care is usually the first point of contact with the health system. This could mean an outpatient department of a hospital run by doctors, or a community health centre staffed by nurses and dispensers.
On average, just over three medicines were prescribed per patient. This was higher than the recommended value of less than two medicines. Nearly half of the patients who were served received antibiotics and a quarter were given injections. This exceeds the recommendations in primary care settings that health care practitioners may only prescribe antibiotics to one in every three patients they consult with each day. Similarly, they may only prescribe an injection for one in every five patients they consult every day.
This means that ideally if 10 people visit a health care centre, up to three may receive an antibiotic and no more than two an injection.
The World Health Organisation recommends that generic medicines are prescribed and that medicines on the approved essential medicines list are used. But in many countries, adherence to these recommendations require major improvements.
The results highlight the weaknesses in health systems. These include:
a lack of adequate diagnostic tools that often facilitate more presumptive treatment,
the limited availability of in-service-training to teach health personnel,
poor community understanding around medicines that are prescribed and
The implications of poor medicine use in these countries can be enormous. Irrational antibiotic use can increase health care costs. In one study, antibiotics made up 40% of the patient’s costs.
Prescribing antibiotics inappropriately also contributes to antibiotic resistance, which may result in more expensive and unavailable antibiotics being needed.
The use of injections also increases the workload: health care personnel must administer these doses. It also heightens the risks of spreading blood-borne infections including hepatitis and HIV.
Therapies that are outside the established local essential medicines lists may be risky. Such therapies have not been thoroughly assessed in terms of safety, efficacy and cost-effectiveness within the settings in which they are being used.
Prescribing outside approved essential medicines lists could therefore mean high cost for patients – especially in Africa where out-of-pocket payments remain prevalent. This could drive many families below the poverty line.
A patient who receives an inappropriate drug could be exposed to undue risk. And another patient who may genuinely need such a therapy could be denied.
Promoting rational medicines use
A significant proportion of health care spending in the countries we studied goes to pharmaceuticals. Much of this comes straight out of patients’ pockets. Improvements in medicine use could lead to major savings and release funds for other health areas.
Improving on medicines use requires effective monitoring so that prevailing practices and challenges can be understood.
Irrational use of medicines leads to health care wastage. It can harm both individuals and whole communities. Prescribing needs to be justifiable, evidence-based and must demonstrate sound clinical practice.
African governments, health professionals and non state actors must put in more effort to urgently implement measures to tackle the continent’s poor prescribing practices.
These must include adoption of broad approaches that seek to strengthen health systems, and rational prescribing.