Sm. Sci.Med. Vol.31.No. 7,pp.823-828.1990 53.00+ 0.

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0277-9536/90
Printed in Great Britain Pcrgamon Press plc

EVALUATION OF RATIONAL DRUG PRESCRIBING IN

DEMOCRATIC YEMEN
GODFREY J. A. WALKER,’HANS V. HOGERZEIL,**ALI 0. SALLAMI,~ALA’DINA. S. ALWAN,’
GEORGE FERNANDO’ and FAHDL A. KASSEM~
‘Action Programme on Essential Drugs and Vaccines, World Health Organisation, 1211 Geneva-27,
Switzerland, *Ministry of Health, Aden, Democratic Yemen, ‘Ministry of Health, Baghdad, Iraq and
‘Ministry of Health, Columbo, Sri Lanka

Abstract-The government of Democratic Yemen started an essential drugs programme in 1984. Every
month quantities of 30 drugs are delivered in prepacked kits to health units and standard treatment
schedules have been agreed. The quantities of each drug were estimated by applying the standard
treatment schedules to the typical morbidity patterns seen at these facilities. Most health workers attended
a training course on the correct use of the standard treatment schedules. Hospital and health centres have
been included in the programme to a more limited extent.
In March 1988 an evaluation of the programme was carried out. Comparisons were made between
random samples of health units included in the programme and those where it had not yet been
implemented.
The adequacy of knowledge necessary for reasonable use of drugs was assessed by interviewing health
workers.
Actual drug prescription was studied by means of quantitative indicators. A more qualitative insight
was obtained by reviewing drug prescriptions for four tracer diseases at a sample of health centre and
hospital out-patient departments.
Health workers at units included in the programme had significantly (P < 0.05) higher levels of rational
drug knowledge and ‘better’ actual drug prescription in terms of proportions of patients receiving
injections (25% vs 58%). antibiotics (45% vs 67%) and the average number of drugs per patient (1.5 vs
2.4)-all P c 0.001. Many patients treated at health centres and hospitals were receiving irrational drug
treatment for the tracer conditions.
It is suggested that the methods used in this evaluation to measure rational drug prescription could be
appropriate in the assessment of other essential drugs programmes.

Key words-evaluation methods, essential drugs, drug prescription, Democratic Yemen

1NTRODUCt’lON Both approaches have been shown to be effective

A major objective of national drug policies is to
improve rational drug therapy [l, 21. Several
countries or groups working in hospitals or ambulat-
ory care have made efforts to improve the effective
prescription of drugs [3-51. As with all measures to
improve the quality of care it is important that there
are systems to assess their success [6,7]. This is even
more important with the increasing complexity of
available treatment strategies in an environment of
scarce resources.
There has been increasing concern about the
importance of improving rational drug therapy if
good quality medical care is to be provided [7-91.
Responses to this have concentrated on two strat-
egies: (I) regulatory and (2) educational approaches.
In the first, emphasis has been placed on mechanisms
to regulate the ease of availability of drugs, taking
into account efficacy, quality, side-effects costs and
supply control; the second has included educational
programmes concerned with the comparative benefits
of alternative treatments, prescription audits and
information on rational drug prescription.
*Address correspondence to: Dr Hans V. Hogeraeil, Action
Programme on Essential Drugs and Vaccines, World
Health Organisation, 1211 Geneva-27, Switzerland.
in industrial&d countries. It appears that countries
with more strict and logical drug registration and
regulation systems have more cost-effective drug pre-
scription [lo]. The implementation of formularies or
drug use guides at the local level, which are tailored
to the particular needs of patients treated and the
skills of the prescribers, have led to improvements
in the quality of care provided [l I-131. This is
particularly so when the prescribers are actively
involved in the decisions over the inclusion of specific
drugs and indications for their correct use and if this
is supported by objective information [14]. Specific
educational activities which incorporate discussions
with prescribers have been shown to be far more
effective in improving drug prescription than those
which only provide written information [15, 161.
Over the past five or so years many governments
have established national drug policies concerned
with improving the availability and effective prescrip-
tion of essential drugs 1171. Most developing
countries have placed greater emphasis on improving
supply rather than the prescription of drugs. It is not
clear how successful such efforts primarily directed to
improving the availability of the most needed drugs
have been in improving rational drug therapy. The
regular provision of a limited number of drugs, in
drug kits for instance, restricts the possible range
824 GODFREY J.
Table I. Health facilities in Democratic Yemen by Governorate
Governorate Hospitals Health centres
Aden 7 9
Lahej 8 5
Abyan 6 2
Shcbwa 4 I
Hadramauth 8 10
Al-Mahra 7 I
Total 40 28
Source: Helling-Borda M. and Hogcrzeil H. V. Essential drugs for Democratic Yemen: estimating
drug requirements. World Health Organisation, Alexandria, 1986. Document PTS/YEA/OOl.
p. 19.
of drugs for irrational therapy but still allows inap
propriate prescription of those drugs which are sup
plied. Limited attention has been given to evaluating
these developments specifically with regard to the
improved prescription of drugs.
In Democratic Yemen the government began a
national essential drugs programme in 1984. Specific
attention has been given to improving the availability
and prescribing of drugs particularly at health units
which provide care to the majority of the rural
population. A regular monthly supply of 30 drugs is
made to these units in kits similar to the successful
systems used in a few other countries [18, 191.
The range of drugs included in the kits was decided
upon after information was collected on the diagnos-
tic case-mix of patients attending the health units.
The quantities of each drug were arrived at by
calculating the amounts required to treat 750 patients
with the typical morbidity patterns seen at these
facilities if standard patterns of treatment were fol-
lowed. This method has been used successfully else-
where [20-231. The standard treatment schedules used
in these calculations had been agreed by the Ministry
of Health after review of available scientific evidence
and local consultation. The schedules covered 53
conditions for children and adults and indicate the
preferred drugs to be prescribed with the dosage,
route of administration, frequency and duration of
the course. Health personnel working at health units
were each given a copy of these standard treatment
schedules and most attended a week long training
course on their correct use.
Hospitals and health centres can only order drugs
from the national drug list, with some restriction on
the items ordered and the quantities. A limited num-
ber of seminars have been held for doctors and
medical assistants working in these institutions on the
correct use of the standard treatment schedules and
reasonable prescribing practices.
In March 1988 an evaluation of the essential drugs
programme in Democratic Yemen was undertaken
which included an assessment of the extent to which
the programme had affected availability and rational
drug prescription. This article is principally con-
cerned with presenting the methodology used in the
evaluation to assess rational drug therapy. The over-
all results of the evaluation have been presented
elsewhere [23].
Democratic Yemen is a country situated in the
south-western comer of the Arabian Peninsular with
A. WALKER et al.
Health facilities
Number of annual
out-patient
consultations
Health units 1985
II I ,206,ooo
81 974,000
60 1,091,otxl
47 4Q8.000
117 1,368,OOO
19 346,000
335 5,394,ooo
a population of just over two million. A little over a
half of the people live in rural areas, a third in towns
and a tenth are nomads. The country became inde-
pendent in 1967. The socialist government has given
priority to equitable provision of health care with
emphasis on the primary health care approach [24].
Large numbers of village health workers (health
guides) have been trained in basic preventive and
curative care. The country is divided into six governo-
rates and the organisation of health care follows this
pattern with a referral teaching hospital in the capital
Aden and secondary care level hospitals in each of the
governorate capitals (see Table 1). The govemorates
are each divided into several districts, in the main
centre of which there is a hospital providing first
referral level services. In smaller towns there are
health centres which also provide some in-patient
care and are staffed by one or two doctors and a
number of medical assistants, nurses and midwives.
Medical assistants and nurses have had three years of
basic training. Larger villages have health units which
are usually two to three roomed buildings. They are
each staffed by a health assistant (male) and some-
times with a nurse or a nurse-midwife (female) and
provide primary preventive and curative care.
METHODS
Six months before the evaluation, preparatory
discussions were held on the general aspects it would
cover. It was decided that a team of six people would
be involved in the evaluation (two staff members of
WHO’s Action Programme on Essential Drugs and
Vaccines, two international consultants with exten-
sive experience in essential drug programmes and the
head and deputy manager of the Democratic Yemen
Drug Programme). During these preliminary discus-
sions it was decided to spend about two weeks on
data collection.
At the time of the evaluation health units in two of
the six govemorates were supplied by monthly drug
kits. To make comparisons between the programme
area and an area where the essential drugs pro-
gramme had not yet been implemented, a random
sample of units was selected from the two programme
govemorates and one adjacent control govemorate to
give about a one in seven sample (19/122 and 7158
respectively). To ensure that health units were
included from the two main topographical areas of
the govemorates (the relatively more accessible desert
 Drug prescribing in Democratic Yemen
and less accessible mountainous parts) the health
units in both governorates were stratified accordingly
and health units were selected randomly from each.
The evaluation team split into two groups each
visiting about a half of the selected programme and
non-programme health units. The same sequence of
activities was followed during all visits.
It was decided to use two main approaches to make
assessments relevant to rational drug therapy. The
first approach was to assess theoretical knowledge of
health workers on the rational prescription of drugs.
For this purpose all health workers at the 26 study
health units were interviewed and asked a set of
standard questions. The questions were designed to
enquire about the health workers’ knowledge cover-
ing items of history, physical examination, diagnosis
and treatment for a range of conditions included
in the standard treatment schedules; one question
was also asked relevant to good drug management
(see Appendix). If all the questions were correctly
answered a score of 27 was possible. The questions
were decided upon during the first day of the evalu-
ation (with the advice of local clinicians) and were
chosen to reflect issues related to prescribing for
different groups of patients (children and adults) and
categories of conditions (acute and chronic). The
marking of the questionnaires were all carried out
by one person (H.H.) in an attempt to ensure consist-
ency; in the few instances where answers were am-
biguous their scoring was discussed by the whole
team.
The second group of data was concerned with
actual drug prescription. At each of the health units
(except for two, one in the programme area and the
other in the non-programme area where the records
had not been sufficiently well maintained), the patient
attendance register was reviewed and for the last 100
consultations, the total number of drugs prescribed
was calculated, as well as the numbers of patients
prescribed antibiotics and those given injections.
These ‘observed’ figures of drug therapy were com-
pared with ‘expected’ ones if the standard treatment
schedules had been consistently followed; in other
words, the locally appropriate norms for rational
drug prescription of antibiotics, injections and
drugs per patient. These were calculated by applying
the standard treatment schedules to the reported
morbidity of patients attending health units.
In order to obtain a more in-depth qualitative view
of prescribing practises prescriptions were reviewed
for four tracer conditions: hypertension, osteo-
arthritis/chronic joint pains, upper respiratory trace
infection (URTI) and urinary tract infection (UTI).
These four conditions were selected for several
reasons. They were known to be high consumers of
drugs and URTI and UT1 specifically of antibiotics.
As a group they represent care provided for different
age groups and for acute and chronic conditions. This
prescription review was carried out at health centres
and hospitals adjacent to the health units included in
the larger survey as it was considered that in these
institutions prescriptions would be sufficiently fre-
quent to review drugs prescribed for the chosen tracer
conditions. It was also agreed that logical treatment
regimes were essential for good quality care of these
conditions.
825
Copies of prescriptions retained in the pharmacies
were reviewed for new general out-patients at three
health centres, two district hospitals and the teaching
hospital in Aden. The prescriptions record the name
of the health facility, the patient’s name, sex and age,
the diagnosis, the drugs prescribed and the name of
the prescriber. Just over 3000 prescriptions were
sorted through, usually those for at least the last five
days, to identify those on which the tracer diagnoses
were recorded. The prescriptions from 26 health
workers were included and the following numbers
were analysed; hypertension (41), osteoarthritis
(S), URTI (189), UT1 (74). The ‘rationality’ or
appropriateness of the drugs prescribed for the stated
diagnoses was assessed by comparison with the drug
therapy recommended in the national standard treat-
ment schedules, WHO illustrative standard treatment
schedules [20] and the standard medical texts used in
the basic training programmes.
RESULTS
Twenty-eight prescribing health workers were
interviewed at health units (13 medical assistants and
15 practical nurses). The scores for ‘rational drug
knowledge’ were statistically significantly higher
among those who had received special training
(P < 0.05) even though for some this had taken place
about three years previously. There were also signifi-
cant differences in actual drug therapy between health
units in and out of the programme (all P < 0.001).
Far smaller proportions of patients in the project area
received antibiotics .(4S% vs 67%) and injections
(25% vs 58%) and on the average, they also were
given fewer drugs per prescription (I .5 vs 2.4). Sever-
theless these indicators were higher than would have
been expected if standard treatment schedules had
consistently been followed, i.e. 23% antibiotics. 17%
injections and 1.4 drugs per person.
In certain respects drug therapy was worst for
out-patients seen at hospitals and health centres (with
61% of patients receiving antibiotics and an average
of 3.0 drugs per prescription). This situation is more
clearly seen when the drugs prescribed for the four
tracer conditions are considered (see Table 2). Over
two thirds of patients with hypertension had been
prescribed methyldopa, over a half furosemide but
fewer than a quarter a thiazide, the first-line
treatment recommended in the national standard
treatment schedules.
Many patients with chronic bone and joint
pains were prescribed several analgesic or anti-
inflammatory drugs, the most popular of which were
indometacin and ibuprofen at 47% and 45% respect-
ively of prescriptions. Vitamins were prescribed for
80% of these patients.
A high proportion of patients with urinary tract
infections were receiving co-trimoxazole (43%), the
antibiotic listed in the standard treatment schedules
for cases with severe infections, while only 4% were
prescribed sulfadimidine, the first-line treatment.
Many patients with UT1 were receiving anticholin-
ergic drugs (42%) and furosemide (20%).
The national standard treatment schedules recom-
mend that for URTI’s only in cases with tonsillitis is
826 GODFREY J. A. WALKER er al.

Table 2. Drugs prescribed for tracer conditions

DrWZ % Prcscriotions
Hypertension (41 prescriptions reviewed;
average number of drugs per prescription 4.0)
Methyldopa 71
Thiazides 24
Propranolol 10
Nifcdipine 2
Furosemide 54
Diazepam 68
Vitamins 23
Osteoarthritis (55 prescriptions reviewed;
average number of drugs per prescription 2.6)
Indomctacin 47
Ibuprofen 45
Acetylsalicyclic acid 18
Paracetamol 2
Vitamins 80
Corticostcroids I3
Calcium lactate I3
Urinary tract infections (83 prescriptions reviewed;
average number of drugs per prescription 3.3)
An antibiotic 89
Co-trimoxazole 39
Ampicillin 18
Nitrofurantoin 14
Tetracycline 6
Procaine benzylpcnicillin 5
Sulfadimidine 4
Erythromycin 2
Chloramphenicol I
Anticholinergic 42
Furosemide 20
Analgesicjantipyretic 22
Upper respiratory tract infections (189 prescriptions
reviewed; average number of drugs per prescription 3.0)
An antibiotic 83
Procaine benzylpcnicillin 27
Phcnoxymethylpeniciilin 22
Tetracycline 17
Ampicillin I2
Co-trimoxazole 9
Erythromycin 4
Cloxacillin 3
Sulfadimidine 2
Benzathinc bcnzylpenicillin I
Vitamins 33
Analaesicslantitwctics 77

an antibiotic indicated and then just phenoxymethyl-
penicillin; yet antibiotics were prescribed in 83% of
URTI’s of which a substantial proportion (40%)
received a broad spectrum antibiotic and less than a
quarter phenoxymethylpenicillin.
DlSCUSSlON
The present study used information of two types to
assess the impact of the national drugs programme
in Democratic Yemen on rational drug therapy.
A structured questionnaire was used to obtain an
indication of whether health workers had reasonable
levels of knowledge necessary for rational drug
therapy. It appeared that those who had received
training dealing specifically with reasonable drug
prescription had a better understanding of these
crucial issues, however the differences were not great.
This is not surprising as the in-service seminars in
rational drug prescription had occurred three years
previously, although in the programme area regular
visits are made by district drug programme super-
visors. It was felt however that the questionnaire used
to assess rational drug knowledge was too brief to
do this adequately and in future evaluations it is
suggested that more questions should be included to
cover in more depth a wider range of issues.
To assess actual drug prescription at health units
three indicators were calculated and compared to
what their values would have been if standard treat-
ment schedules had been invariably followed. The
specific indicators were chosen because, as well as
reflecting cost-effectiveness, they represent other
major issues of current concern in relation to rational
drug therapy: injections in view of the high level of
complications including the transmission of diseases
such as hepatitis and AIDS if they are not used
correctly [25,26]; antibiotics because of increasing
rates of resistance [27,28]; and the number of drugs
per prescription as an indicator of diagnostic and
therapeutic competency. In addition the methods
followed to collect the necessary data from patient
attendance books to calculate the indicators were
easily replicable in different health units. All three
indicators had scores which were significantly better
in the area covered by the national drugs programme.
A more detailed qualitative insight into actual drug
prescription for specific conditions was obtained at
 Drug prescribing in Democratic Yemen
hospital and health centre out-patient clinics. The
patterns of irrational drug therapy were similar
to those reported elsewhere [29-323. This applied
particularly to the inappropriate prescription of:
broad spectrum antibiotics in upper respiratory tract
infection [33,34]; the use of more expensive non-ster-
oidal anti-inflammatory drugs instead of cheaper and
as effective ones [35]; the apparent non-systematic use
of hypotensive drugs and high utilisation rates of
drugs which have never been shown to be effective in
the management of hypertension, including vitamins
and tranquillisers [36]. In other settings it might also
be instructive to add further tracer diagnoses or
review the range of stated diagnoses for which certain
drugs are prescribed, e.g. psychotropic drugs, anti-di-
arrhoeal preparations, or analgesics.
These two sets of information on rational drug
therapy form only a part of the wide range of issues
which theoretically could be included in evaluations
of essential drugs programmes [371. Nevertheless we
consider them particularly relevant to assessing
rational drug therapy. They might have applicability
in the evaluation of similar programmes in other
countries. The evaluation has been of direct useful-
ness to the management of the programme in Demo-
cratic Yemen, where it has led to the extension of the
kit distribution and training programme to the con-
trol area, and where the data collected will serve as
baseline information for future evaluations. A similar
approach is presently being followed in other devel-
oping countries, e.g. North Yemen and the Sudan.
The chosen indicators are relatively easy to
measure, make use of existing data, are quantifiable
and have immediate relevance to programme and
clinical management. We realise that they do not
measure the adequacy of diagnosis but accept the
stated diagnosis as the starting point in assessing the
‘rationality’ of prescribed drugs. Nor do they include
an assessment of patient compliance with prescribed
therapy, although it is well established that many
prescribed drugs are either not taken by patients or
are incorrectly taken [3841]. However it is felt that
the indicators used in this evaluation can be helpful
in summarising the complex situation regarding
different issues crucial for rational drug therapy:
adequacy of diagnostic and therapeutic knowledge,
quantitative indicators of general aspects of drug
therapy, and the specific drug treatment patterns for
certain defined diagnoses.
Acknowledgemenr-We wish to thank the many health
workers in Democratic Yemen without whose help this
evaluation could not have been carried out.
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APPENDIX
Clinical Care Questions Used to Assess Rational
Knowledge
For each drug treatment mentioned the drug name
should be specified, the dosage, formulation, route of
al.
administration and the duration of treatment.
(Maximum score if correct)
1. A child aged 18 months is brought to the health unit
by his mother, who says he has passed eight watery stools
over the past 24 hr. He has no fever but has vomited twice.
On examination he is lethargic, but his chest, ears and throat
are clear.
What diagnosis would you make? (I)
What treatment would you prescribe? (5)
2. A child aged 12 years complains of fever (> 39 degrees)
with headache and pain on swallowing for the past two
days.
What treatment would you prescribe? (5)
3. A young man complains of a dry cough for the previous
two days, especially in the evening. He has no fever or other
signs or symptoms.
What treatment would you prescribe? (4)
4. A 35-year-old man complains of passing loose stools
with mucus, tenesmus and abdominal cramps for the past
five days. He has no fever or signs of dehydration. He had
a similar episode four weeks ago.
What is the most likely diagnosis? (2)
What treatment would you prescribe? (2)
5. A child aged two years has a fever and congested eyes.
On examination a rash is found on the face and trunk. There
have been three similar cases during this week.
What is the diagnosis? (1)
What treatment would you give? (3)
6. Do you know what an expiry date means? (1)
Can you show me an example? (I)
Is there any other way to find out whether a drug is not
in good condition? (1)
Can you give an example? (1)
Drug N.B. Further details of the differential scoring for individ-
ual questions where possible maximum scores for each
question or part of a question were more than one, are
available from the authors (H.H.).