A cross sectional comparison of drug use indicators using WHO methodology in primary level hospitals participating in an Auditable Pharmaceutical Transactions and Services program versus non-APTS primary hospitals in Southern Ethiopia

Autoři: Biruk Wogayehu aff001;  Yilma Chisha aff002;  Be’emnetu Tekabe aff002;  Ayalew Adinew aff003;  Mulugeta Asefaw aff004
Působiště autorů: Department of Pharmacy, Arbaminch College of Health Sciences, Arbaminch, Ethiopia aff001;  Department of Public Health, Arbaminch University, Arbaminch, Ethiopia aff002;  Pharmacy Service, Federal Ministry of Health, Addis Ababa, Ethiopia aff003;  Pharmacy Service, Regional Health Bureau, Hawassa, Ethiopia aff004
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223523



Ethiopian pharmaceutical sector has been facing inaccessibility and unaffordability to key essential medicines due to medicines diversion from the public to private health care facilities, lack of transparency, poor inventory management, and poor dispensing workflow. In an effort to improve the pharmaceutical sector, the government of Ethiopia in 2011 introduced Auditable Pharmaceutical Transactions and Services program. This study intended to compare drug use indicators in auditable and non-auditable primary level hospitals.


A cross-sectional comparative study was conducted between January 2018 and December 2018 at primary level hospitals in southern Ethiopia: one with Auditable Pharmaceutical Transactions and Services (APTS) program; another without APTS (Non-APTS).WHO drug use indicators in auditable primary hospitals (n = 10) and similar non-auditable primary hospitals (n = 10) were compared. The prescribing indicators and average cost of medicines were evaluated retrospectively using 1000 prescriptions from each group. Patient care indicators were evaluated prospectively by interviewing and observing 1000 patients from each group. Patient satisfaction was assessed by interviewing 1000 patients from each group. Health care facilities were evaluated through observation. We performed descriptive analysis, t-test, logistic regression, Mann-Whitney U test and linear regression using SPSS version 20.0.


The mean consultation time in auditable and non-auditable hospitals was found to be 6.5 minutes and 3.46 minutes, respectively. The average dispensing time in auditable and non-auditable hospitals was found to be 6.6 minutes and 1.02 minutes, respectively.The proportion of drugs actually dispensed was 97.59% in APTS facilities and 76.44% in the non-auditable facilities with the lowest value seen in a non-auditable facility (51.65%). The average number of drugs per prescription was 2.32 (±1.26) and 2.84 (±1.17) in auditable and non-auditable facilities, respectively. The level of patient satisfaction on the convenience of pharmacy location, information on contraindications, availability of drugs and amount of time for counseling was significantly higher in the auditable facilities than the non-auditable facilities (p<0.001).


This study revealed that patient care indicator values, the level of patient satisfaction on the pharmacy services and health facility indicator values were significantly better in APTS than Non-APTS primary level hospitals. Most of prescribing indicators and labeling practices were not met WHO stated standard in both auditable and non-auditable facilities.This indicates that the auditable programshould include additional strategies to reverse the existing irrational prescribing and inadequate labeling practices.

Klíčová slova:

Adverse reactions – Antibiotics – Drug screening – Drugs – Health care facilities – Outpatients – Routes of administration – Drug information


1. United Nations. Millennium Development Goal 8. Delivering on the Global Partnership for Achieving the Millennium Development Goals. New York: MDG Gap Task Force Report 2008; 2008.

2. Syhakhang L, Sengaloundeth S, Paphassarang C, Freudenthal S. Availability of essential drugs and sustainability of village revolving drug funds in remote areas of Lao PDR. Stud HSO&P. 2008; 519–43.

3. WHO. World Health Situation.Geneva: WHO Press; 2004.

4. WHO. Promoting rational use of medicines: core components.Geneva: WHO press;2002. Available from:http://www.who.int/medicines/publications/policyperspectives/ppm05en.

5. Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. Lancet. 2009; 373(9659):240–9. doi: 10.1016/S0140-6736(08)61762-6 19042012

6. Federal Ministry of Health of Ethiopia and World Health Organization. Assessment of the pharmaceutical sector in Ethiopia.Addis Ababa, Ethiopia: Ministry of Health; 2003 Oct.

7. Plummer Janelle. The World Bank, UK AID. Diagnosing Corruption in Ethiopia, perceptions realities and the way forward. Washington D.C: 2012.

8. Tadeg H, Ejigu E, Geremew E, Adinew A.Auditable Pharmaceutical Transactions and Services (APTS): Findings of the Baseline Assessment at Federal, Addis Ababa, and Teaching Hospitals. Arlington, VA: 2014.

9. WHO.How to investigate drug use in health facilities: selected drug use indicators.Geneva:WHO/DAP/93.1;1993.Available at http://apps.who.int/medicinedocs/en/d/Js2289e/ Accessed Feb 2016.

10. Federal Ministry of Health of Ethiopia plan and program directorate, Health sector development plan I (HSDP I/1997/98-2002), Addis Ababa, Ethiopia.1997.

11. Bogale T, Mariam Dh, Ali.Costs of illness and coping strategies in a coffee-growing rural district of Ethiopia. Journal of Health, Population, and Nutrition.2005; 15: 229–37.

12. Russell S, Abdella K. Too Poor to Be Sick.Coping with the Costs of Illness in East Hararghe, Ethiopia. Save The Children, London.2002.

13. Abdosh B.The quality of hospital services in eastern Ethiopia: patient’s perspective. Ethiopia Journal of Health Dev. 2006; 20(3):199–200.

14. Adinew A, Alemu S, Admasu E. Auditable Pharmaceutical Transaction and Services: Guide for Implementation, Amhara Region.2012.

15. Teferi G, Dawit T, Bethelhem G, Tamrat A. Outcomes of Auditable Pharmaceutical Transactions and Services (APTS) Implementation: Assessment Report. Submitted to the Federal Ministry of Health (FMOH), Ethiopian Pharmaceutical Association (EPA), and Systems for Improved Access to Pharmaceuticals and Services (SIAPS). Addis Ababa: FMOH, EPA, and SIAPS.2016.

16. Federal Ministry of Health.Auditable pharmaceutical transactions and services (APTS) training course participant’s manual.2016.

17. Federal Democratic Republic of Ethiopia /Central Statistical Agency (FDRE/CSA) Population Projection of Ethiopia for All Regions at Wereda Level from 2014-2017.Addis Ababa, Ethiopia: FDRE /CSA; 2013.

18. Aubrey C, Tamara K. Patients' Satisfaction with outpatient pharmacy services at the university teaching hospital and Ndola central hospital in Zambia.Journal of Preventive and Rehabilitative Medicine.2016; 1(1): 13–18.

19. Surur AS, Teni FS, Girmay G, Moges E, Tesfa M, Abraha M.Satisfaction of clients with the services of an outpatient pharmacy at a university hospital in northwestern Ethiopia: a cross-sectional study. BMC Health Services Research.2015; 15:229–37. doi: 10.1186/s12913-015-0900-6 26062912

20. Adane T, Gebru H, Teshale A.Clients’ perception and satisfaction toward service provided by pharmacy professionals at a teaching hospital in Ethiopia. Integrated Pharmacy Research and Practice.2016; 5:85–94. doi: 10.2147/IPRP.S118657 29354544

21. El Mahalli A, Akl O, Al-Dawood S, Al-Nehab A, Al-Kubaish H, Al-Saeed S, et al. WHO/INRUD patient care and facility-specific drug use indicators at primary health care centres in Eastern province, Saudi Arabia. East Mediterr Health J. 2012; 18(11):1086–90. 23301368

22. Atif M, Sarwar MR, Azeem M, Naz M, Amir S, Nazir K. Assessment of core drug use indicators using WHO/INRUD methodology at primary healthcare centers in Bahawalpur, Pakistan. BMC Health Services Research. 2016; 16:684–93. doi: 10.1186/s12913-016-1932-2 27931213

23. Bilal AI, Osman ED, Mulugeta A. Assessment of medicines use pattern using World Health Organization’s Prescribing, Patient Care and Health facility indicators in selected health facilities in eastern Ethiopia.BMC Health Services Research. 2016; 16:144–52. doi: 10.1186/s12913-016-1414-6 27106610

24. Shiferaw G, Gedif T, Gebre-Mariam T. Short Communication: Drug utilization attern in selected health facilities of Bahir Dar and West Gojam Zones, North Western Ethiopia. Ethiop Pharm J. 2010;28(1):55–62.

25. Gelders S. World Health Organization, Drug use indicator survey, 1991- Malawi Essential Drugs Programme. 1992. http://apps.who.int/medicinedocs/en/d/Js21679en/.

26. Awad A, Al-Saffar N. Evaluation of drug use practices at primary healthcare centers of Kuwait. Eur J Clin Pharmacol. 2010;66 (12):1247–55. doi: 10.1007/s00228-010-0872-8 20669012

27. Hogerzeil H, Ross-Degnan D, Laing R, Ofori-Adjei D, Santoso B, Chowdhury AA, et al. Field tests for rational drug use in twelve developing countries.Lancet. 1993; 342(8884):1408–10. doi: 10.1016/0140-6736(93)92760-q 7901689

28. Henry CN, Ogaji IJ, Sariem CN. Drug use pattern with standard indicators in Jos University Teaching Hospital Nigeria. West Afr J Pharm. 2013;24(1):88–93.

29. Wang J-p, Jia Y-h, Wang S-h, Xie S-y, Wang W-q. Interventional investigation on international indicators for rational drug use. China Pharm. 2008;35:38.

30. Tomson G. Pilot study of drug use indicators in Sweden. INRUD News. 1992; 3(1):3.

31. Guan A, Li L, Sheng L, Zhang L. On-the-spot survey of rational use of drugs in our hospital using selected indicators. China Pharm. 2007; 25:39.

32. Guyon AB, Barman A, Ahmed J, Ahmed A, Alam M. A baseline survey on use of drugs at the primary health care level in Bangladesh. Bull World Health Organ. 1994;72(2):265–71. 8205647

33. Otoom S, Batieha A, Hadidi H, Hasan M, Al SK. Evaluation of drug use in Jordan using WHO patient care and health facility indicators. East Mediterr Health J.2002; 8(4/5):544–9.

34. Antonia EfrauzinaCampeto Lopes ADAT. Drug use evaluation in health services in Fortaleza, Brazil. INRUD News. 1996; 6:17.

35. Bimo D. Report on Nigerian field test. INRUD news. 1992; 3:9–10.

36. Uzoma AL S.O.N., Eva Ombaka. Drug Use studies in Church Facilities in Africa. INRUD News. 1995; 5(1):20.

37. Folkedal SF G, Banqueiro EG. Rational Drug Use Field Tests: Experience from Mozambique. INRUD News. 1994; 4(2):21.

38. Nsimba SED. Assessing prescribing and patient care indicator for children under five years old with malaria and other disease conditions in public primary health care facilities. Southeast Asian J Trop Med Public Health.2006;37(1):206–16. 16771236

39. Bosu W, Ofori-Adjei D. An audit of prescribing practices in health care facilities of the Wassa West district of Ghana. West Afr J Med. 1999; 19(4):298–303.

40. Kumari R, Idris MZ, Bhushan V, Khanna A, Agrawal M, Singh SK.Assessment of prescription pattern at the public health facilities of Lucknow district.Indian J Pharmacol.2008;40(6):243–247. doi: 10.4103/0253-7613.45148 21279178

41. Lima MG, Alvares J, Guerra Junior AA, Costa EA, Guibu IA, Soeiro OM,etal.Indicators related to the rational use of medicines and its associated factors.RevSaude Publica.2017;51.

42. Fatema N., Fatema AA, Ansari A.Prevalence of medication errors in primary health care at Bahrain Defence Force Hospital–prescription-based study.Drug, Healthcare and Patient Safety, 2018; 10:1–7. doi: 10.2147/DHPS.S147994 29445304

43. Wiffen P. Adverse drug reactions in hospital patients: a systematic review of the prospective and retrospective studies. Bandolier Extra, 2002, June [online] (http://www.medicine.ox.ac.uk/bandolier/Extraforbando/ADRPM.pdf, accessed 18 September 2012).

44. Irrational drug use causing rise of anti-microbial resistance. Geneva, World Health Organization, 2005.

45. Medicines: rational use of medicines. Fact sheet No. 338. World Health Organization [online] (http://www.who.int/mediacentre/factsheets/fs338/en/, accessed 16 September 2012).

46. Gebru: O030: Towards patient safety: health care professionals’ knowledge, attitude and practice of safe injection in public hospitals in Mekelle, Tigra, North Ethiopia. Antimicrobial Resistance and Infection Control 2013 2(suppl):O30.

47. Akl OA, El Mahalli AA, Elkahky AA, Salem AM. WHO/INRUD drug use indicators at primary healthcare centers in Alexandria, Egypt. J Taibah Univ Med Sci. 2014;9(1):54–64.

48. Holloway KA, Henry D. WHO Essential Medicines Policies and Use in Developing and Transitional Countries: An Analysis of Reported Policy Implementation and Medicines Use Surveys. PLoS Med. 2014; 11(9):e1001724. doi: 10.1371/journal.pmed.1001724 25226527

49. Boonstra E, Lindbaek M, Khulumani P, Ngome E, Fugelli P. Adherence to treatment guidelines in primary health care facilities in Botswana. Trop Med Int Health. 2002; 7(2):178–86. doi: 10.1046/j.1365-3156.2002.00842.x 11841708

50. H de Valk BO. Prescribing practices at health center level in the south west province, Cameroon, with special reference to drug use indicators. INRUD News. 1994; 4(2):20.

51. Ayalew MB, Taye K, Asfaw D, Lemma B, Dadi F, Solomon H, et al. Patients'/clients' expectation toward and satisfaction from pharmacy services. J Res Pharm Pract.2017; 6:21–6. doi: 10.4103/2279-042X.200995 28331862

52. World Health Organization & Health Action International. Measuring medicine prices, availability, affordability and price components. Geneva,2008. Availablefrom:http://www.haiweb.org/medicineprices/manual/documents.html [accessed 8 August 2017].

53. P. Anson A, Ramay B, Esparza A, Bero L. Availability, prices and affordability of the World Health Organization’s essential medicines for children in Guatemala. Glob Health. 2012; 8:22.

54. Khuluza F1, Heide L.Availability andaffordability of antimalarial and antibiotic medicinesin Malawi. PLoS ONE.2017; 12(4): https://doi.org/10.1371/journal.pone.0175399.

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2019 Číslo 10