MLHI SOCIETY FOR THE PROMOTION OF RATIONAL USE OF DRUGS
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CONTENTS
Introduction
1
1.
Activities in Delhi State
4
2.
Activities in Other States
12
Rajasthan
Himachal Pradesh
Maharashtra
Andhra Pradesh
Assam
Chandigarh
Karnataka
Madhya Pradesh
Punjab
Tamil Nadu
West Bengal
Ipf07
3.
New States
31
4.
Research Activities
33
5.
Activities in the area of Human Resource Development
43
6.
New focussed activities
47
7.
Service to other agencies
50
8.
Conclusion
52
9.
Names of persons participating in each state
53
PREFACE
'The WHO-India Essential Drugs Programme implemented by the Delhi
Society for the Promotion of Rational Use of Drugs has, in the year 2000 not
only expanded its activities to twelve states but has also ventured into new
areas. Some of these areas are to enhance rational use of drugs in the private
sector, to provide a leading role to pharmacists in implementing such
programmes, to explore areas such as health insurance and provision of
information about medicines to the patients and the public.
Another new development has been the service role being played by the
Society to the national government, state governments and national and
international organizations. This was not originally the mandate of this
programme but requests for carrying out analysis of the drug situation in the
states, for taking responsibility for quality assurance of drugs being supplied by
donor agencies, for preparing plans for establishing efficient drug procurement
and distribution systems are some of the areas in which our Society has actively
helped - largely because there is no other agency in the country which can carry
out some of these activities under one roof.
Again, seeing that there was a void in an area which needed filling the
Society organized a well attended Dialogue on HIV/AIDS and Traditional
Medicine which has served as a catalyst and set up a stream of innovative
activities. This was the first time that traditional medicine practitioners,
researchers of the allopathic medicine and policy makers met together to
resolve a serious threat to our country. The meeting was co-sponsored with
the Global Initiative for Traditional Systems of Medicine, Oxford.
The number of doctors and scientists taking part in the programme has
grown and there are about one hundred and fifty such persons scattered
throughout the country. The report contains the names of the key persons in
the different states.
It is my sincere hope that the programme is further consohdated and
sustained in the years to come.
The Society is very appreciative of the dedicated workers in the Society
and others who have made this programme possible. Our grateful thanks go to
the World Health Organization Geneva and the Regional Office at New Delhi
for their constant help, support and advice.
Special mention needs to be made of the sterling role played by Dr.
Harsh Vardhan, former Minister of Health and Family Welfare - Delhi State
and Dr. Hans V. Hogerzeil of the Essential Drugs and Medicine Programme,
WHO Geneva in our programme. Our thanks also go to the team of Dr.
(Mrs.) Usha Gupta, Dr. J.N. Gupta and Ms. A. Banerji for preparing the
Annual Report for the year 2000.
PROF. RANJIT ROY CHAUDHURY
PRESIDENT, DELHI SOCIETY FOR THE
PROMOTION OF RATIONAL USE OF DRUGS
Introduction
Programme on Rational Use of Drugs; The Beginning
The programme on the rational use of drugs was initiated in the state of Delhi in
the year 1994, when the then Health Minister of Delhi, Dr. Harsh Vardhan, found
that despite the government spending 30%-35% of the health budget on
medicines, they were not generally available to poor and needy patients. To tide
over this situation, a drug policy for the state of Delhi was developed and adopted.
This policy is based on the concept of essential drugs as proposed by the World
Health Organisation (WHO) and successfully implemented in several countries. In
keeping with this policy, an Essential Drugs List (EDL) for hospitals under the
government of the National Capital Territory (NCT) of Delhi was developed and
a system of pooled procurement of drugs as per the EDL was launched for all the
hospitals and health centres under the government of Delhi.
The WHO introduced the concept of essential drugs more than twenty years ago
m or^ei; to lncrease the accessibility of drugs to the majority of the population at
a fordable prices. These are the lines on which the government of the NCT of
Delhi started working to reach its goal of providing good quality drugs to the
majority of the population.
Formation of the Delhi Society for the Promotion of Rational Use of
Drugs (DSPRUD)
his society was formed in 1996 to coordinate efforts on all aspects of the radonal
use of drugs, including drug procurement, storage, supply, quality control and
monitoring, and research. It is important to note that mere formulation of a
national or state drug policy alone is not sufficient. What is important is the
ormation of a “triangle” of politicians, bureaucrats and technical experts all
edicated to the cause of the rational use of drugs. The DSPRUD was famed
precisely for this reason—to coordinate and facilitate the smooth functioning of
tins triumvirate.
5
Good reside foUowed, and by 1997-within throe years of the launch of the drue
policy in Delhi-there was a dramatic change in the scenario regarding drug
’vadaMlty in the capital’s hospitals. Pooled procurement enabled the government
in Delhi to obtam drugs at about 30% of the rates being paid by other government
agencies. More than 90% of the budget for drugs waKow bemg spenfonly on
essennal drugs that were on the EDL. Unwanted drugs and combmadon dLg.
1
were gradually phased out and shortages became less frequent. A functional
system of quality control was established, raising the overall quality of the
medicines dispensed to patients.
Finally, there was a remarkable rise in the awareness of both medical professionals
and the general public about the benefits of rational drug use, which was achieved
through several training workshops and media exposure.
Drug availability in hospitals and dispensaries in Delhi improved to the extent that
this endeavour was christened the ‘Delhi Model’ amongst development and health
circles.
The WHO-India Essential Drugs Programme: The Objectives
The main objective of the WHO-India Essential Drugs Programme (WHO-India
Programme) is to improve the availability of good quality medicines to all sections
of society, and to ensure that these medicines are prescribed and used rationally.
Based on the ‘Delhi Model’, one may, however, enumerate the following
objectives:
• Improving the availability of safe and effective drugs: Essential drugs
should be available at all times and in sufficient quantities at all levels of
healthcare without any bias or discrimination against patients.
• Establishing a quality control and assurance system: In the absence of
such a system, there can be no guarantee that the drugs available are safe
and effective.
• Improving procurement, storage and distribution systems for
medicines: This is necessary to implement objective (1), enlisted above,
and also to promote economic efficiency.
• Encouraging rational prescribing and use of medicines: This is a
fundamental objective. Only the most appropriate drugs should be
prescribed in the correct dosage and for the correct duration.
• Strengthening and expanding health education programmes: The
concept of rational use of drugs (RUD) needs to be introduced in the
medical and pharmacy curricula. The WHO-India Programme also aims to
continually raise the awareness of practising medical and paramedical
personnel about the benefits and developments in the field of RUD.
2
•
Increasing patient awareness: Making the general public aware of the
hazards of irrational drug use is an important part of the programme, as it
raises the level of health consciousness and lessens the incidence of drug
resistance and misuse of medicines.
•
Research and monitoring on all aspects of drug use: The final
objective of the WHO-India Programme is to promote research and
monitoring on drug use so as to provide a guide for future improvements
and gauge the impact of the interventions made.
Components of the WHO-India Essential Drugs Programme
Based on the objectives enumerated above, the programme has been working to
implement the following nine components:
1. Development of a drug policy
2. Selection of a list of essential drugs
3. Establishment of a pooled procurement
4. Development of a quality assurance system
5. Training in rational prescribing
6. Provision of objective information to doctors about medicines
7. Research leading to monitoring and evaluation of the programme
8. Human resource development in the field of rational use of drugs
9. Provision of information to patients for improving patient
compliance.
While work on the last component commenced only in the year 2000, the other
components are already being implemented. Details of these components have
199^ kCen d*scussed i11
activity report of the programme for the years 1998-
The following chapter of this document contains a brief statement of the activities
undertaken
in various
------------- j states of India under this programme in 2000.
3
EDP Components Operative in Delhi
••
• Drug Policy
Essential Drugs List
• Pooled Procurement
• Quality Assurance
• Training in Rational Prescribing
• Information to Prescribers
® Research & Monitoring
Human Resource Development
• Information to Patients
Activities in the State
Of Delhi
The year 2000 witnessed a quantum leap in activities in Delhi. Numerous projects
were undertaken to implement the many enumerated components of the WHOIndia Essential Drugs Programme (WHO-India Programme). While
implementing the various ongoing components, such as conduct of training
courses, lectures and workshops, and research and monitoring activities on the
rational use of drugs (RUD), several new dimensions were added to the
programme, like provision of information to patients, interaction with general
practitioners and the extension of cost analysis of treatments and traditional herbal
medicine. A brief survey of the various activities and projects is given below:
(1) Developments in the field of pooled procurement: The pooled
procurement system is now in place for all the thirty-one hospitals and one
hundred and fifty primary healthcare centres under the government of the
National Capital Territory (NCT^ of Delhi. Drug procurement storage and
distribution is now streamlined and fully computerised. Paperwork has
decreased because a single procurement agency working under the
Directorate of Health Services of the government of the NCT of Delhi is
purchasing drugs for all health establishments under the government of
Delhi.
(a) Revision of qualifying criteria for manufacturers: An important
development in the area of pooled procurement is that the qualifying
criteria for manufacturers have been revised. The ceiling of the
minimum annual turnover of manufacturing firms has now been
raised to rupees twelve crores from the earlier figure of rupees eight
crores. Reputed firms, for example, Novartis, Glaxo-Wellcome,
Astra-IDL and SmithKline and Beecham are amongst those which
have recently supplied drugs to the government of Delhi. Thus,
poor patients visiting Delhi government hospitals can now be sure
that the drugs supplied to them by the government are those, which
previously could only be afforded by the affluent, and are of die best
standard.
(b) Further savings in drug purchase: Another very significant aspect
of pooled procurement is that despite all inflationary trends in recent
years, the prices at which drugs are being procured under this
scheme have not shown any significant increase. Drugs purchased
under this scheme, using a two-envelope selective tender system, are
4
already 30%-35% cheaper than those purchased by government
agencies using an open tender system. The prices of certain
important drugs have shown a further decline in the year 2000, with
the exception of a few drugs such as Inj. Sodium Thiopentone, Inj.
Crystalline Penicillin and Homatropine eye drops. This trend is
illustrated in Table 1.
If we sum up the prices of one unit of each of the nineteen essential
drugs purchased for Delhi hospitals shown in the Table, we find that
the total price of the purchase in 1996 was Rs.2319.87, declining
over the years to Rs.2105.51 (1997), Rs.2055.71 (1999) and
Rs. 1985.23 in the year 2000. This shows a persistent increase in
savings, which has benefited poor patients in Delhi government
hospitals. This is because the capital saved is spent on purchasing
more drugs, and in the process, increasing the availability of good
quality essential drugs for the common people.
A similar trend was observed in the prices of the drugs purchased
for primary health centres under the government of Delhi.
(c) Meeting with representatives of drug manufacturers: Another
milestone achieved was the organisation of a meeting between
representatives of drug manufacturers and central procurement
agency officials of the Delhi government. This meeting was held
under the auspices of the DSPRUD on March 15th, 2000. It was a
unique event, in which representatives of over seventy
pharmaceutical houses participated. This was the first time that a
meeting was held directly with representatives from manufacturing
companies. Various problems in the field of drug procurement were
discussed at the meeting:
• Pharmaceutical firms manufacturing but not quoting prices
of certain drugs in the tendering process.
• Pharmaceutical firms quoting for certain drugs but not
supplying them when the rate contract was given.
• Supplying these drugs in insufficient quantities.
Several steps were taken in order to further streamline the
procurement of drugs. The results of the meeting were gratifying,
and established manufacturing houses are now supplying drugs to
the Delhi government under this scheme.
5
Tabic 1
Cost of some essential drugs purchased under the pooled procurement
scheme for Delhi Government hospitals
SI.
Drug Name
No.
1996
Price in Rs.
1997
1999
2000
Drugs showing decrease in price in the year 2000
1. Inj. Ampicillin, 500 mg vial
3.20
3.42
3.45
3.40
2. Inj. Ceftazidime, 1 gm vial
187.72 128.94
124.46
84.41
3. Cap.Omeprazole,20 mg lOcaps 11.54 10.33
7.30
6.47
4. Inj.Pentazocine, 30 mg amp
4.09
4.03
4.18
3.90
5. Cap l<ifampicin,450mg lOcaps 29.20 29.50
28.98
24.42
6. Inj. Deriphylline, 1 amp
1.20
1.18
2.12
1.98
7. Inj. Dextrose 5%, 1 botde
5.50
6.47
8.53
8.22
8. Inj. Normal Saline, 1 bottle
5.25
6.47
8.53
8.22
9. Inj. Diclofenac Sodium, 1 amp
1.07
1.00
1.19
1.05
10. lab. Phcnobarbitone,
60 mg 10 tabs
1.17
1.45
2.52
2.00
11. Inj. Streptokinase,
15 lac unit vial
1770.00 1625.00 1540.00 1540.00
12. Polymer degraded gelatin,
500ml bottle
109.00
99.00 133.58
99.00
13. Soln. Amino Acid,
200 ml bottle
105.00 109.00 103.00
99.00
Drugs showing increase in price in the year 2000
14. Inj. Crystalline penicillin,
4 lac unit vial
3.30
15. Inj. Sodium Thiopentone,
1 ^m vial
23.44
16. Inj. Hydrocortisone, 1 vial
12.94
17. Inj. Antispasmodic, 1 amp
4.36
18. Homatropine Eye Drops,1 vial 5.(X)
19. Inj. Heparin 5000 lU/ml,
5 ml amp
36.89
Total
3.16
3.00
3.50
23.04
9.60
3.64
5.50
27.00
11.42
2.45
28.22
11.84
3.56
8.20
34.78
44.00
47.84
2319.87 2105.51 2055.71 1985.23
5a
TABLE 2
Effect of providing written information on leaflets to
patients, on their knowledge about drug use
Parameters
Knowledge of Patient
Read leaflet
Not read
n = 109
n = 9
Pre
Post
Pre
Post
Sum of Primary
indicators
9.51
‘“15.71
7 55
*15.11
Sum of
Supplementary
indicators
**‘3.30
9.75
2.89
'*6.67
P < 0.01
P < 0.02
***
P < 0.000
**
5b
(2) Impact of drug information on patients’ knowledge about drug use
and compliance: The objective of this study was to provide verbal and
written information to patients about the drugs prescribed to them so that
they use medicines in an appropriate, safe and judicious manner. The study
also desired to assess the impact of drug information on patients’
knowledge on drug use.
Leaflets on forty commonly used drugs were prepared in Hindi and were
distributed to patients in the outpatients’ department of the Deen Dayal
Upadhyay Hospital, New Delhi (DDU, New Delhi). The leaflets contained
information on dosage, precautions and commonly observed side effects of
drugs in layman terms. Pre-intervention and post-intervention studies were
done on a hundred patients in a sample study group and an equal number
of patients in a control group in order to find out the extent of their
knowledge about the drugs prescribed to them.
Results of the study showed that as a result of the intervention, patients’
' knowledge about drugs improved remarkably in the sample study group as
compared to the control group. The knowledge of the patients about the
drugs prescribed to them was measured using the scores for primary and
secondary indicators of drug use.
(3) Impact of an educational intervention on prescribing behaviour of
physicians, especially the extent of antibiotic use in acute respiratory
infection (ARI) and acute diarrhoea at primary health centres in
Delhi: The objective of the study was to study the extent of antibiotic use
and other drug use problems in the treatment of ARI and acute diarrhoea
at health facilities in Delhi. The study was conducted in three phases:
Phase One dealt with determining the extent of the use of antibiotics in
ARI and acute diarrhoea, by evaluating prescriptions from thirty-two
primary health centres (PHs), seven community health centres (CHs) and
three peripheral hospitals. The extent of usage was found to be very high
in 80% of the cases.
In Phase Two, intervention was done by way of group discussions with
prescribers, as well as the introduction of therapeutic guidelines for the
treatment of these conditions. The role of prophylactic use of antibiotics,
reasons for the development of drug resistance, and the ‘P’ Drug concept
were discussed, using the Guide to Good Prescribing. Information on the use
of Essential Drug Lists and the Essential Drug Formulary was also given.
6
Phase Three entailed the assessment of the impact of intervention on the
use of antibiotics in the cases of ARI and acute diarrhoea. This was done by
means of a prospective prescribing survey, after six months of intervention.
The result showed an appreciable retention of the effect of intervention by
prescribers.
(4) Publication and distribution of a medical newsletter: The primary
purpose of the project is to publish and circulate a newsletter to medical
professionals, based on published articles and up-to-date drug information,
in order to provide objective information on commonly used drugs. The
first issue of the newsletter was released in July 1999, and the second issue
included a questionnaire seeking feedback on the newsletter from medical
professionals. There has been a positive response to this newsletter, though
it still remains to be seen whether its circulation has brought about any
changes in prescribing habits.
(5) To study the impact of an educational intervention on prescribing by
using the ‘Guide to Good Prescribing’ amongst private practitioners:
This was the first effort to involve private practitioners in the RUD
programme. A workshop was conducted by the DSPRUD, in collaboration
with the Delhi Medical Council (DMC) and the East Delhi Branch of the
Indian Medical Association at the Institute of Human Behaviour and Allied
Sciences (IHBAS), Shahadra, in March 2000. The objective of this
workshop was to sensitise the private practitioners of East Delhi (the area
of Delhi where irrational prescribing is reported to be most rampant) to the
essential drugs concept and the principles of rational prescribing using the
Guide to Good Prescribing, published by the WHO. In addition to this book,
the Delhi State Formulary of Essential Drugs and handouts for various
sessions were also distributed to the participants.
Professor Ranjit Roy Chaudhury, the President of the Delhi Medical
Council, Professor J.S. Bapna, Director, IHBAS, Chairman of the
Continuing Medical Education Committee, DMC and other experts,
inaugurated the workshop. The feedback received from the participants
was very positive. As a part of programme evaluation, the participants
stated that the programme would help them to improve their prescribing.
Suggestions were also given on possible topics of discussion as well as the
timings of the programme, to suit the practitioners’ needs and hours of
practice. Overall, the response from the participants was that such
programmes were extremely beneficial and, therefore, essential.
7
(6) Cost analysis for the treatment of mild hypertension and mild
chronic bronchial asthma: This is the first cost analysis carried out by the
DSPRUD. The objective of the study was to observe drug use patterns and
costs of treatment in mild hypertension and mild chronic bronchial asthma.
A hundred prescriptions each for the two ailments were collected from me
outpatients’ department of Lok Nayak Hospital (a tertiary educational
hospital), and from the Malviya Nagar and Kalkaji hospitals, two colony
hospitals of Delhi. These prescriptions were analysed using a detailed pro
forma to delineate the patterns of drug use.
For making standard treatment guidelines (STGs) for mild hypertension
and bronchial asthma, a meeting of specialists from these two areas of
expertise was called, and STGs were prepared on the lines suggested by the
WHO. The cost analysis of these prescriptions is currendy in progress.
(7) Effect of rational prescribing on cost therapy in acute respiiatory
infection (ARI) and diarrhoea: The aim of this project was to determine
the cost of therapy in cases of ARI and diarrhoea, with and without the use
of STGs, and to compare the costs of both in order to.observe any possible
savings made by using the Standard Treatment Guidelines.
The methodology involved the collection of thirty prescriptions each for
ARI and diarrhoea from several health facilities under the government of
the NCT of Delhi. The facilities were divided into study and control
groups, and STGs were introduced into the study groups during
interventional workshops.
The results showed that the average cost of therapy in all the health
facilities was much higher than it would be if the STGs were adhered to.
(8) Training programme for healthcare professionals in the rational use
of drugs (RUD) at Deen Dayal Upadhyay (DDU) hospital: This
programme was held as a workshop at the DDU hospital, New Delhi on
7th and 8th of July 2000. The objective of the workshop was to sensitise
doctors to the concept of RUD, and to highlight the irrational patterns of
drug use in the departments of medicine and surgery. Twenty-four doctors
from the two departments participated in the workshop. The areas
discussed were die components of rational prescribing, the T Drug’
concept, antibiotic policy and infection control, patient education and the
use of STGs. A post-intervention study showed that most of the
participants found the programme “verj’’ good”.
8
(9) Preparation of standard treatment guidelines (STGs) for hospitals in
Delhi: Encouraged by the positive response to STGs for primary health
centres and sub-centres in Delhi, it was decided that the same would be
prepared for Delhi government hospitals as well. The objective of the
project was to prepare standard treatment protocols for about one hundred
priority health problems, as well as to print and distribute these to
government and private doctors all over Delhi. As a first step, the
morbidity and mortality data from various departments of Delhi
government hospitals has been collected and analysed to decide which
conditions are to be included in the STGs. An editorial committee and
several sub-committees of experts have been formed to write on the
different sections of the STGs. These committees have been meeting
regularly to finalise the write-ups. The project is on in full swing at present
and the STGs are likely to be released in the initial months of the year 2001.
(10) Training programme for drug store managers: This two-day workshop
was held at the Institute of Human Behaviour and Allied Sciences
(IHBAS), Shahdara, on the 6th and 7th of May 2000. The participants
comprised forty-five pharmacists working in various drugstores at hospitals
under the government of Delhi. The aim of the workshop primarily was to
sensitise pharmacists to good drug store management practices. The issues
discussed at the workshop included methods for quantification of drugs for
procurement, systems for receiving supplies and accounting, warehousing
and computerisation at drugstores. The participants felt that the
programme was a successful educational intervention, and its
recommendations were documented.
(11) International meeting on HIV/AIDS and traditional medicines:
This was the first international meeting of its kind in India which was
organised by the DSPRUD on the 10th and 11th of November 2000 at
the India International Centre, New Delhi, in collaboration with the Global
Initiative for Traditional Systems (GIFTS) of Health, Oxford. The World
Health Organisation (WHO) primarily funded the meeting. Some
financial support was also provided by the Indian Council of Medical
Research (ICMR) and the Population Foundation of India
The meeting was very appropriately tided 'A Journey to Dia/o&ue', bringing
together, on a common platform, researchers in various traditional and
complementary remedies like ayurveda, siddha, unani and homeopathy, as
well as researchers and experts in medicine, epidemiologists, bureaucrats
and policy makers on health matters.
I
9
Seventy-six participants from India and all over the world held discussions
on several relevant issues. Seven renowned practitioners of ayurveda,
siddha and homeopathy treating patients of HIV/AIDS in various parts of
India presented their findings to international delegates. The meeting was
addressed by, among others, Professor Ranjit Roy Chaudhury, President,
DSPRUD; Dr. Gerry Bodeker, Chairman, GIFTS of Health; Dr. Palitha
Abekoon, Director, Health Technology and Pharmaceuticals, South East
Asia, Office of the WHO, New Delhi; Ms. Shailaja Chandra, Secretary,
Department of Indian Systems of Medicine and Homeopathy, Government
of India; Vaidya Shriram Sharma, Secretary, All India Ayurveda Prachar
Sabha, Mumbai; and Dr. Harsh Vardhan, former Health Minister of Delhi.
The meeting was concluded with a set of recommendations for various
agencies working for the cause of medical research, traditional medicine
and HIV/AIDS. These recommendations are currently being circulated.
The proceedings of the meeting would be compiled in book form in the
near future. This activity is in the planning stage at present.
The meeting received wide media coverage in the national newspapers.
It is hoped that the meeting will help mitigate the plight of HIV/AIDS
victims in the country by enhancing the accessibility of cheaper and
effective traditional medicines.
(12) Preparation of a list of essential herbal medicines: A list of essential
herbal medicines has been prepared by the Department of Indian Systems
of Medicine and Homeopathy, Government of India, in technical
collaboration with the DSPRUD. The WHO-India Essential Drugs
Programme (WHO-India Programme) has ventured into this new area of
essential herbal medicines in order to promote the rational use of
inexpensive herbal medicine in the numerous villages of India, where access
to modern medication is limited.
(13) Enhanced media advocacy: Extensive coverage has been given to the
concept of rational use of drugs (RUD) and the WHO-India Programme in
the year 2000 in both the electronic and print media. Doordarshan, the
national government-owned television network, along with other private
broadcasting networks, invited senior experts from the DSPRUD and
telecast their interviews on several occasions. More than six interviews were
telecast on Doordarshan alone. These interviews concentrated mainly on
the benefits of RUD and the dangers of irrational drug use, especially that
of antibiotics.
10
(14) The Annual Coordination Meeting: This meeting was held on the 27th
and 28th of November 2000, at Hotel Mountview, Chandigarh. The
objective of this conference was to review the work completed during the
course of the year and to make a plan of action for the forthcoming year.
The participants included Dr. H.V. Hogerzeil, WHO, Geneva, Dr. Graham
Dukes, consultant to the World Bank, as well as the coordinators from the
different states.
The two-day meeting commenced with thematic sessions on the
programme activities of human resource development, quality assurance,
and research and monitoring. Presentations were made by representatives
of the states on the activities being carried out in their respective states.
Two field visits were also organised, to the National Institute of
Pharmaceutical Education and Research, Chandigarh, and to the
Government Medical College, Chandigarh. After the two day meeting at
Chandigarh a few members of the group including Professor Roy
Chaudhury, President, DSPRUD, and Dr. Hans V. Hogerzeil from WHO
Geneva visited Himachal Pradesh. In this hilly state, a programme of
rational use of drugs is being implemented since the last two years. Visits
to a zonal health centre, a sub-centre and the drug testing laboratory were
organized en route to Shimla.
The Health Minister of the state, Mr. J.P. Nadda, formally released the
Himachal Pradesh Essential Drugs Formulary and the Standard Treatment
Guidelines.
(15) Meeting with various international development agencies: A meeting
with representatives from international development agencies was held at
the DSPRUD office on 1st of December 2000. The activities of the Society
were presented to the participants at this meeting. The participants
included Dr. H.V. Hogerzeil, Professor Ranjit Roy Chaudhury and other
senior persons participating in the India-WHO Programme in Delhi. Some
of the international agencies that were represented were the World Bank,
DFID, the European Commission and the UNICEF.
11
EDP Components Operative in
Himachal Pradesh
• Drug Policy
Essential Drugs List
• Pooled Procurement
• Quality Assurance
• Information to Prescribers
EDP Components Operative in
Maharashtra
(Municipal Corporation of Greater Mumbai)
Essential Drugs List
• Information to Prescribers
« Research & Monitoring
• Pooled Procurement
• Training in Rational Prescribing
Human Resource Development
EDP Components Operative in
Rajasthan
• Drug Policy
Essential Drugs List
• Training in Rational Prescribing
• Information to Prescribers
Human Resource Development
Activities in Other States
Besides Delhi, three other states, namely Maharashtra (Municipal Corporation of
Greater Mumbai), Rajasthan and Himachal Pradesh, are implementing the WHOIndia Essential Drugs Programme (WHO-India Programme) comprehensively.
Eight other states and union territories have been implementing some of the
components. These are Andhra Pradesh, Assam, Chandigarh, Madhya Pradesh,
Karnataka, Punjab, Tamil Nadu and West Bengal.
RAJASTHAN
Outstanding progress was made in Rajasthan in the field of RUD in 2000. This
progress can be summed up in the following manner:
1. Preparation and release of the Rajasthan State Essential Drugs List
(RSEDL) 2000: the Rajasthan Society for The Promotion of Rational Use
of Drugs (RSPRUD) prepared this list in consultation with senior state
government functionaries and was released by the Honourable Chief
Minister of Rajasthan, on the 3rd of February 2000 in the presence of the
Honourable Health Minister of the state, as well as members of the
RSPRUD.
A most significant aspect of the RSEDL is that the state government has
released it with certain mandatory guidelines, which have to be followed by
the State bureaucracy. The RSEDL 2000 guidelines are as follows:
(a) The doctors working under the State government shall only
prescribe and use medicines listed in the RSEDL 2000 as far as
possible.
(b) The RSEDL will benefit public servants, medicine relief cardholders
and pensioners, in the sense that the drugs included in the list would
be available to them free of cost. The Store Purchase Organisation
of the State medical and health departments will circulate an
approved rate contract for all the medicines listed in the RSEDL, on
the basis of which various institutions would procure medicines as
per their demands.
The State government has also appointed a committee to oversee
the implementation of the RSEDL, and has issued guidelines about
requests for alterations in the list.
12
2. Orientation programme on RUD for the faculty members of Zanana
Hospital, Jaipur: This programme was held on the 9th of May 2000 on the
request of the Professor and Head of the Gynaecology and Obstetrics
Department, SMS Medical College, Jaipur. The aim of the programme was
to sensitise faculty members of Zanana Hospital about rational drug use. It
was inaugurated by the Honourable Health Minister of Rajasthan and
presided over by the Secretary to the State government. The resource
persons were the President, Secretary and other senior members of the
RSPRUD.
Over fifty faculty members and resident doctors of Zanana Hospital
attended and appreciated the programme, which was given extensive media
coverage.
3. Workshops on rational prescribing for faculty members of medical
colleges at Jodhpur and Udaipur: Two workshops were held at Jodhpur
and Udaipur in the months of August 2000 and October 2000, respectively.
The objective of the two workshops was to sensitise faculty members of
various medical colleges in the two cities of Rajasthan to the use and
importance of essential drug lists. Mr. Rajendra Chaudhary, the Honourable
Health Minister of Rajasthan, inaugurated both programmes and stated that
all doctors should support the Essential Drugs Programme (EDP) in the
state, especially to help people living below the poverty line.
Both the workshops received wide coverage in the state newspapers and
television news channels, and encouraging feedback was received from
participating doctors. The resource persons for the two programmes were
senior programme participants from the Delhi Society for the Promotion
of Rational Use of Drugs (DSPRUD) and the Rajasthan Society for the
Promotion of Rational Use of Drugs, Jaipur (RSPRUD).
4. Inclusion of the RUD Sensitisation Module in the induction training
programme of state medical officers at the State Institute of Health
and Family Welfare (SIHFW), Jaipur: Induction training programmes
are organised for newly recruited doctors by the State government each
year, in which ten batches of thirty doctors each, take part. A one-day
training module on the rational use of drugs (RUD) has been included in
this induction programme, which was designed by a joint collaboration of
senior members of the DSPRUD, the RSPRUD and the organisers at the
SIHFW. The module focuses primarily on rational and irrational
prescribing and communication skills. Five such one-day modules were
conducted in the year 2000 and the response from the participants was very
encouraging. The contents and methods of presentation were well received.
13
5. RUD sensitisation module for doctors attending the in-service
training programme: Encouraged by the success of die one-day training
module on RUD at SIHFW, Jaipur, a similar one-day training module was
included in the in-service training of medical officers at the three regional
Health and Family Welfare Training Centres in the state of Rajasthan.
These centres are situated in Jaipur, Jodhpur and Ajmer, where the
government nominated thirty doctors for each of these two-week training
courses. Twenty such one-day modules have been completed in the year
2000 under the technical and financial support of the WHO-India
Programme.
The resource persons for this particular programme were active members
of the RSPRUD, and the response from the participants was extremely
positive.
6.
A prescription audit study for an antibiotic policy for teaching
hospitals: This study is being pursued by the Department of Microbiology,
SMS Medical College, Jaipur, under which an audit of prescriptions has
been done for five hundred patients (250 outpatients and 250 inpatients)
from the urology and general surgery departments. The drug susceptibilities
of the isolates are being studied.
The emerging resistance pattern of E. coli to common antibiotics found in
this study is quite alarming. The resistance of this organism to common
antibiotics is as follows: Ampicillin (100%), Chloramphenicol (94.4%), Cotrimoxazole (88.9%), Tetracycline (88.9%), Norfloxacin (83.3%) and
Ciprofloxacin (72.2%).
HIMACHAL PRADESH
The RUD Programme in Himachal Pradesh was formally inaugurated with a
sensitisation workshop at the State Institute of Health and Family Welfare,
Parimahal, Shimla, on the 10lh and 11th of November 1998. Following this, the
programme has witnessed continual progress in the implementation of its various
components.
" ' was formulated under the technical guidance of the WHOThe state drug policy
India Programme, adopted by the State Cabinet and released in August 1999. The
state Essential Drugs List was prepared, printed and released along with the drug
policy by Mr. J.P. Nadda, the Honourable Health Minister of Himachal Pradesh.
In accordance with the objectives laid down in the drug policy, two core
documents—the Standard Treatment Guidelines (STGs) and the Essential Drugs
Formulary (EDF)—were prepared, and these were released in November 2000 by
the Health Minister of the state.
The Publication of Standard Treatment Guidelines (STGs): This exhaustive
document offers guidelines for the treatment of commonly encountered ailments
in the outpatients departments of the various healthcare facilities under the
government of Himachal Pradesh. It also provides guidelines for the management
of medical emergencies. The STGs have been prepared with the technical and
financial support of the WHO-India Programme and the DSPRUD, and
published by the Department of Health and Family Welfare, Government of
Himachal Pradesh.
The morbidity pattern of the state at different levels of the healthcare system for
the last five years was obtained from statistical reports and analysed during the
Reproductive and Child Health (RCH) Training Workshop, conducted on the 6th
to the 8th of September 1999. An editorial committee was constituted with Dr.
S.K. Gupta as its convenor. The committee comprised twelve eminent experts in
the fields of medicine, surgery, paediatrics, obstetrics and gynaecology,
dermatology, ophthalmology, otorhinolaryngology and psychiatry. Sub
committees for different disciplines were formed and guidelines for treatment of
the commonly encountered disease conditions were written. The draft was
finalised and published after several in-depth discussions under the technical
guidance of Dr. Usha Gupta, Professor of Pharmacology, Maulana Azad Medical
College, New Delhi.
The publication of the Essential Drugs Formulary (EDF): In keeping with
the objectives laid down in the Himachal Pradesh drugs policy, this was the
second core document on RUD released in the year 2000. The Himachal Pradesh
EDF has been prepared along the lines of the Delhi state EDF. Published by the
Himachal Pradesh Society for the Promotion of Rational Use of Drugs
(HPSPRUD), Directorate of Health Services, Shimla, this document was released
by the Honourable Health Minister of Himachal Pradesh in November 2000, in
the presence of representatives from the WHO-India Programme and the
DSPRUD, as well as senior officials of the state health department.
In the preface to the formularv, both the state Chief Minister, Mr. Prem Kumar
Dhumal, and the Health Minister, Mr. J.P. Nadda, expressed the hope that the
formulary7 would provide objective information about drugs and therefore
maximise the use of the essential drugs list.
15
Dr. Usha Gupta once again provided technical assistance for die preparation of
the formulary as a DSPRUD consultant, while Dr. S.K. Gupta, Municipal Health
Officer, Sliimla, was the convenor of the formulary editorial committee. There
were eight members in this committee from various medical disciplines, under the
chairmanship of Dr. Sukh Ram Chauhan, Director, Health Services, Himachal
Pradesh.
Drug information in this manual is organised in therapeutic groups and lists the
category of the drug, its indications, contraindications, precautions to be taken,
side effects, drug interactions, usage in special circumstances like pregnancy,
lactation, hepatic and renal failure, and dosage instructions. The dosage has been
indicated in mg/kg of body weight in most of the cases. There are also additional
notes on the use of the drug wherever this is necessary. The information provided
is not necessarily the same as that inside the packages of the products. The drugs
have been listed in the same sequence as that of the EDL of Himachal Pradesh.
Included at the end of the formulary is a feedback form to invite any suggestions
for the inclusion/deletion of a drug(s). This has been done with the objective of
making this document an interactive one and encouraging active participation in
the decision-making process. A second edition of the formulary will be released in
two years time.
Training Programmes: Following the release of the RUD documents,
sensitisation courses on the concept of essential drugs are now being planned.
These courses will be held as a part of the various training programmes being
organised for health personnel by the state Health and Family Welfare
Department.
Training courses for drug store managers and pharmacists are also being proposed
under the Himachal Pradesh Essential Drugs Programme.
MAHARASHTRA
In this state, the Municipal Corporation of Greater Mumbai (MCGM) has taken
die inidative of implementing a programme of essential drugs in healthcare
facilities under its administrative control. The MCGM is a large administrative
body that caters to a population of around nine million people. Its health facilities
include a hundred and seventy-six health posts, a hundred and sixty-two
dispensaries, twenty maternity homes, sixteen peripheral hospitals, five specialist
hospitals and three teaching hospitals.
Besides the MCGM, work on RUD under the auspices of the WHO-India
16
Programme has also been initiated in the district of Pune. The Maharashtra
Institute of Medical Education and Research, Telegaon Dabhade, Dist. Pune has
prepared its own EDL and is propagating the concept of RUD through this list.
Anodier significant development is the introduction of the concept of RUD in
undergraduate medical curricula by the Maharashtra University of Health Sciences
(MUHS), Nasik in over thirty medical colleges under its control.
Some of die major projects undertaken in Maharashtra in the year 2000 are as
follows:
•
Preparation of Standard Treatment Guidelines (STGs) for indoor
patients: STGs for outdoor patients of the three levels of healthcare in the
MCGM were published. Following this, the coordinators of the programme
in Maharashtra commenced a similar programme for inpatients. Morbidity
data has been collected from three teaching hospitals and sixteen peripheral
hospitals. STGs for common conditions have been prepared and submitted
to the Drugs and Therapeutics Committee of the MCGM for suggestions
and modifications. Disease conditions have been categorised into twentyone different headings pertaining to the various specialities and super
specialities in hospitals under the MCGM.
Detailed information on specialised procedures like maintenance of central
venous pressure, correction of metabolic acidosis, mechanical ventilation
and several other procedures in adult and paediatric intensive care and
cardiac units has been provided.
•
A post-intervention study on adherence of doctors in the STGs and
the EDL in the outpatients’ departments: The STGs for outpatients
and the EDL have been distributed to all medical facilities under the
MCGM in 1999. This survey was done to observe adherence to STGs,
using tracer diseases in the departments of general medicine and paediatrics
of healthcare facilities.
Another objective was to find out the extent of change, if any, in
prescribing patterns in healthcare facilities in the course of one year.
A hundred and twenty prescriptions from each of the sixteen peripheral
hospitals and thirty randomly selected dispensaries were analysed for this
study. The analysis showed that adherence to STGs in the peripheral
hospitals varied from 16% to 59%, a variation that is below acceptable
levels. Similarly, in dispensaries, adherence to STGs was found to be poor,
varying from 17% to 60%. These figures confirm that it is not enough to
merely publish and distribute lists and guidelines to ensure adherence.
17
Training medical officers in the proper use of STGs is equally, if not more,
important, and this is now being planned. A post-intervention study will
follow to assess the impact of the training.
•
A pre-intervention drug use study at Pune: The aims of this study were
to measure drug use indicators in a representative group of medical
facilities in Dist. Pune and to compare the performance of individual
facilities. It was conducted over a period of six months, in which a total of
1729 prescriptions were studied and core drug use indicators were analysed.
On analysing the data, it was found that the general prescribing pattern in
primary healthcare facilities of Pune district was quite similar to the pattern
found in the medical facilities under the MCGM, Mumbai. For instance,
encounters with injections were found to be as high as 31%-36%, the
average consulting and dispensing time was very low, as was the percentage
of drugs labelled. An intervention is being planned.
•
A post-intervention study in the MCGM, Mumbai — Effects of
training on pharmacists: Training courses for pharmacists were
conducted in the MCGM Mumbai in 1999 in which a hundred and three
pharmacists participated. This survey was carried out to assess the effects
of training on the dispensing practices of these pharmacists.
The dispensaries under the MCGM were divided into two groups, namely
trained and untrained pharmacists. Twenty dispensaries from each group
were randomly selected. Core patient care indicators for a hundred and
twenty patients in each dispensary were assessed as per the
recommendations of the WHO.
The figures reveal that after training, there was a significant change in the
labelling of drugs dispensed to the patients, although this change was
expected to be higher. This implies that some other form of intervention at
the pharmacy level is required.
•
Treatment failure in tuberculosis—the causes of drug therapy
failures: The number of patients with multiple drug-resistant tuberculosis
has increased significantly in the last few years, particularly in crowded
metropolitan cities like Mumbai. One of the main reasons for this increase
is irrational drug prescribing by clinicians and lack of compliance by
patients. This study was carried out to look into the causes of this scenario.
Patients attending three types of healthcare facilities—DOTS centres,
tertiary care centres and private practitioners—were interviewed.
18
(a) Results found at DOTS centres: Out of die 258 DOTS centres in
Mumbai, forty-five were randomly selected and a total of 1708 patients \
from diese centres were interviewed to evaluate their knowledge on
anti-tuberculosis drug use. On analysis of die data collected, it was
found that the patients’ knowledge about the duration of treatment and
details of drug therapy was negligible. Hence, intervention at die
community level is essential in order to increase patient awareness on
this particular disease.
Other causes of patients not coming to DOTS centres for treatment
were socio-economic ones like homelessness, alcoholism, shifting for
treatment to private practitioners and to native places during summer
vacations. Another reason why patients do not come regularly to the
DOTS centres is die fact diat they cannot afford the frequent trips in
terms of costs of commuting.
(Ii) Results found at tertiary care centres: 240 cases of tuberculosis at
two tertiary care centres were studied. It was found that a high
percentage of patients had a fair understanding of the dosages of drugs,
duration of treatment and adverse drug effects. Wide variations were
found to exist in the treatment schedules offered to patients in both
pulmonary and extra pulmonary tuberculosis. Therefore, inten^ention is
necessary at the tertiary level to promote the proper prescribing of
medicines and to prevent a further increase in the development of drug
resistance.
(c) Results found at private healthcare facilities: An attempt was made
to examine the regimens followed by private practitioners for treating
tuberculosis in order to detect any potential deficiencies in die regimens
that could contribute to the development of drug resistant tuberculosis.
The results suggested the following: (i) Most of the practitioners
depended on criteria like weight gain and increased appetite for
assessing any improvement in tuberculosis, despite the availability of
good diagnostic laboratories; (ii) Only 28% of practitioners
recommended sputum examinations in diagnosis as well as a follow up
of the cases; (iii) Only 10% of practitioners recommended that the
decision regarding the treatment of non-responsive cases would be
based on a sensitivity report; and (iv) About 25% of practitioners would
add a single drug to supplement the existing treatment.
These findings suggest serious implications for the epidemiology of the
disease, and imply a need for immediate intervention measures.
19
•
Introduction of the concept of RUD in the undergraduate medical
curric^ilum: The Maharashtra University of Health Sciences (MUHS),
Nasik, has taken the first step in this direction, with the introduction of
wide curricular changes in the second MBBS study course. The need for
incorporating rational drug use at the undergraduate level arises due to
irrational prescribing, which is very prevalent, especially among young
doctors. The current courses in pharmacology tend to concentrate on a
drug-oriented approach, while the course in clinical medicine emphasises
primarily on diagnosis. As a result of this, the field of proper therapeutics,
i.e. accurate prescribing and communication skills, is neglected.
Hence, by inducting the concept of RUD into the second MBBS level, it is
expected that students will be able to rationally select drugs, learn to avoid
unnecessary drugs, and critically evaluate drug information.
The process of change was initiated in 1999 with a workshop at Nasik, in
which representatives of all the thirty-three medical colleges affiliated to the
MUHS were present. A committee was formed by the representatives of
the WHO-India Programme (Maharashtra unit) to finalise the changes to
be made in the curriculum. It is hoped that these changes will prove to be
trendsetters for other medical colleges in the country.
Programme for Interns: A programme termed ‘Shidori’ is being
conducted for interns at the GS Medical College, Mumbai, in wMch two
important aspects of RUD are being covered in a two-hour session. These
aspects are: (a) The concept of rational therapeutics; and (b) interaction
with medical representatives and ethics of drug promotion. The concept of
rational therapeutics includes, among other things, the ‘P-Drug’ concept..
Pharmacy Courses: Suitable interventions to include the concept of RUD
in teaching courses for pharmacists are being planned in Mumbai and Pune
district in the year 2001.
ANDHRA PRADESH
Activities in the southern coastal state of Andhra Pradesh commenced in July
1999 with a seminar on RUD at the Department of Health and Family Welfare,
Hyderabad. Drug procurement and supply in the state is partly funded by the
state government and partly by the World Bank.
A survey on the consumption of drugs in Andhra Pradesh was conducted as a
preparatory step towards a programme on the rational use of drugs. The
20
importance of the survey lies in the fact that Andhra Pradesh is a large state with a
total of 1,336 primary healthcare centres (PHCs), thirty-four area hospitals, ninety
seven community health centres (CHCs) and nineteen district hospitals. Moreover,
one single authority does not control these medical facilities. The PHCs function
under the supervision of the Directorate of Health Services, while the
Commissionerate of Medical Sciences looks after secondary care hospitals, and the
tertiary hospitals, by the Directorate of Medical Education. Hence, it was felt that
there was a great need to gauge accurately the pattern and extent of drug use in the
state. It was with this objective that a project entitled ‘ Drug Consumption Profile
in Rural and Urban Andhra Pradesh’ was started in the year 2000.
Drug Consumption Profile in Rural/Urban Andhra Pradesh: This project is
being carried out by the National Institute of Nutrition, Hyderabad with the
technical and financial assistance of the WHO-India Essential Drugs Programme
(WHO-India Programme).
The project began in June 2000, and is scheduled to be complete by May 2001.
The activities carried out under the project so far include identifying the health
facilities to be surveyed, recruitment of workers for the survey and finalisation of
the pro formae to be used. Sixteen PHCs, four CHCs and one district hospital,
located in different parts of the state, were selected as the sample for the survey.
A pilot survey for the same was carried out at the PHCs and CHCs in districts
near Hyderabad. On the basis of this pilot survey, the procedure was modified
several times and a final format for the study has now been agreed upon.
Data collection suffered a temporary setback in the year 2000 because of flash
floods and severe inundation. However, field investigators from Nizamabad,
Cuddapah and West Godavari districts are currently collecting the necessary
information in their respective areas, and the programme is now underway and
would be completed according to schedule.
ASSAM
Activities in Assam started in the year 2000 at the Guwahati Medical College
Hospital, the premier teaching institution in the northeast region of the country.
To get the programme off the ground, consultants from the DSPRUD visited the
state in early 2000. The North Eastern Society for the Promotion of Rational Use
of Drugs (NESPRUD) was subsequently formed. A distinctive feature of this
society is that it is not confined to the state of Assam, but will be involved in the
21
cause and promotion of RUD in all the seven northeastern states of India. The
first activity undertaken by the society was the organisation of a workshop on
RUD in Guwahati.
Awareness workshop on RUD at the Guwahati Medical College: This
workshop was held on the 8th of April 2000. Resource persons from the
DSPRUD visited Guwahati to speak to the participants about the importance,
concept and advantages of rational drug use. The participants comprised faculty
members and paramedical staff of the Guwahati Medical College, clinicians,
medical students, senior health officials of the state government, representatives
from non-governmental organisations (NGOs) working in the field of health in
Assam and some members of the general public. The workshop was appreciated
not only by the participants, but also by the local newspapers and the regional
centre of Doordarshan, the national television network of India. Articles by the
NESPRUD on the subject of RUD were published in the local newspapers,
dealing with the prescription of inexpensive, safe and effective drugs to needy
patients. Besides this, Doordarshan, Guwahati telecast a discussion on the
promotion of RUD on the 11th of April 2000, in which both the President and
Secretary of the NESPRUD participated.
Preparation of an essential drugs list (EDL): Work on this project has just
begun and is likely to be taken up as a full-fledged activity in 2001. NESPRUD
members have started visiting all the member states. Two visits to the states of
Manipur and Meghalaya have been made with the objective of starting RUD
activities in 2001. In the first visit to Imphal, the capital of Manipur, on the 16th
of July 2000, the President, NESPRUD met the Professor and Head of the
Department of Pharmacology, Regional Institute of Medical Colleges, Imphal and
handed over core documents on RUD.
In die visit to Shillong, later in the year 2000, the executive body of the
NESPRUD met the Health Minister of Meghalaya, the Health Secretary, the
Director of Health Services of the state as well as the Director of the North East
Regional Indira Gandhi Post Graduate Institute of Medical Sciences, Shillong.
More such visits are being planned in the near future.
22
THE UNION TERRITORY OF CHANDIGARH
The major activities undertaken in the Union Territory of Chandigarh in 2000
were:
1. A workshop on the rational use of drugs (RUD): A
workshop on RUD was conducted at the Chandigarh Medical
College on the 29th and 30th of January 2000 with the objective of
educating faculty members on the importance of introducing the
concept of RUD in the medical curriculum. Experts from the
DSPRUD, New Delhi addressed the participants of the
workshop on this issue. The workshop was a follow up of the
‘Chandigarh Dialogue’, held in July 1999, in which the status of
the programmes in Chandigarh, Haryana, Himachal Pradesh and
Punjab were discussed.
2. A drug utilisation study at the Punjab University Health
Centre (PUHC), Chandigarh: The PUHC caters to the
medical needs of a population of about 2500. The centre has an
outpatients’ department that runs six days a week, and the drugs,
if available, are dispensed by a pharmacy. With a view to
streamline the availability of drugs, a drug utilisation study was
undertaken by a senior faculty member of the Institute of
Pharmaceutical Science, Punjab University, Chandigarh.
The purpose of the study was to assess the rational use of drugs
through prescription monitoring by observing the pattern of
drug prescribing and dispensing. Five hundred randomly selected
prescriptions were monitored over a period of six months.
Several parameters were taken into account, including
demography, drug related parameters (category of the drug, dose,
dosage form, frequency, duration, single or fixed combinations
of drugs and whether the drug generic or proprietary), and
patient-related parameters such as the time of consultation,
information provided by the prescriber/dispenser, the labeUing
of drugs dispensed and the patient’s understanding of drugs to
be taken.
23
The prescription auditing revealed the following:
(a) The types and categories of drugs prescribed were:
Generic (50.57%), branded (49.43%), individual (81.73%),
fixed dose combinations (18.27%), antibiotics (22.76%),
analgesics (21.76%), antihistaminic (12.56%), drugs for
gastrointestinal tract (9.47%), steroids (3.57%) and drugs for
CVS (3.16%).
(b) Dosage and diagnosis: Doses were mentioned for 19.28%
of the antibiotics prescribed. The diagnosis was written only
in 12.75% of the prescriptions monitored.
(c) Instructions on drug use: Written instructions on the
container were not given by the pharmacist for any of the
drugs dispensed; 85.51% of the prescribed drugs were
available from the PUHC pharmacy, of which 43.23% were
dispensed in loose envelopes (without labelling).
(d) Patients’ knowledge: Only 17.25% of the patients were
aware of the nature of the medication prescribed to them,
and 68.25% were aware of the medication schedule.
Follow up: The above observations were shared with the physicians and
pharmacists of the PUHC. The issues were related to administrative problems and
procurement and distribution of drugs. An intervention study has been initiated
and is in progress.
KARNATAKA
The RUD Programme in Karnataka was launched on the 20th of October 1999 at
a conference held in Bangalore, the capital of the state. Members of the state
health department and the Karnataka Medical Council (KMC) participated at this
conference. It was addressed by Professor Ranjit Roy Chaudhury, coordinator of
the WHO-India Programme. An interesting feature of the programme is that the
initiative has been taken by pharmacists rather than by doctors. The Karnataka
State Pharmacy Council (KSPC) has taken on the responsibility of introducing
RUD in the state and has formed an RUD committee for this purpose. The
President of the Karnataka State Branch (KSB) of the Indian Medical Association
(IMA) is a member of this committee.
A number of activities have started in the year 2000, such as the training of
doctors and pharmacists in RUD, the study of prescription trends in the state
hospitals and the preparation of an essential drugs list (EDL).
24
Given below is a brief account of the programme:
1. The inclusion of RUD as a module in quality care and ethical
practice workshops: These ongoing workshops were initiated at six
different places in Karnataka—Gulbarga, Belgaum, Kolar, Shimoga,
Mysore and Davanagere— by the government of Karnataka. One
workshop is held every month, and six hundred doctors working in
hospitals under the government of Karnataka have already participated in
these workshops in 2000. On the request of die RUD committee of the
KSPC, a module on RUD was included in the workshops.
2. Public education in RUD: Work on this aspect has been started by the
KSPC. A two-hour lecture-cum-discussion tided ‘Public Education in the
Rational Use of Drugs’ was held on the 24th of September 2000 at the
Banashankari Consumer Protection Society meeting, in which over fortytwo members of the public participated.
The KSPC has also established links with the Institute of Social Sciences,
Bangalore to publish articles on RUD in the Institute’s vernacular monthly
newsletter, the readership of which includes around 10,000 members of the
Panchayati Raj Institution.
3.
A training programme for doctors and pharmacists: The first training
programme was held on the 18th of October 2000, in which doctors and
pharmacists from eight project hospitals of the Karnataka Health Systems
Development Project (KHSDP) took part. The participants were sensitised
to the rational use of drugs and antibiotics, and measuring drug use
indicators in hospitals.
One doctor and one pharmacist from each of the participating hospitals
were selected to form a team to help promote the cause of RUD in their
hospitals.
4. Preparing an essential drugs list (EDL): The preparation of an EDL
has been initiated in consultation with clinicians from various disciplines. A
consolidated list has been prepared by referring to seven different EDLs,
such as the WHO EDL, Government of India EDL, the EDL for health
centres and sub-centres in Delhi, the EDL for Delhi hospitals, the
Karnataka Rate Contract EDL, the MCGM, Mumbai EDL and the Tamil
Nadu EDL. Morbidity data for Karnataka has also been collected.
25
5. A special feature on RUD in the Karnataka Medical Journal: This
journal is circulated amongst approximately 8000 doctors in the state of
Karnataka. A special feature on the rational use of drugs is being planned
for the journal, and is likely to be released sometime in 2001.
MADHYA PRADESH
The Madhya Pradesh Society for the Promotion of Rational Use of Drugs
(MPSPRUD) was formed in September 1999. Professor Ranjit Roy Chaudhury,
President of the DSPRUD, visited Gwalior on the 21st of April 2000 and a
programme has since been initiated:
1. A project for 10+2 level school children: This is a unique project for the
poor in rural and urban slums, where there is a complete absence of
healthcare facilities. Under this scheme, 10+2 level school children are
being trained in the use of a few important and commonly used drugs, to
be administered to members of the community in times of need. It is a
joint project involving several agencies and departments, led by the WHOIndia Programme in the state of Madhya Pradesh. The modalities of the
project are currently being worked out.
2. A workshop on the rational use of drugs (RUD) in reproductive and
child healthcare (RCH): This workshop was organised in Bhopal, the
capital of Madhya Pradesh, from the 28th to the 30th July 2000, jointly by
the DSPRUD and the Family Panning Association of India (FPAI) through
their Small Family by Choice Project (SFCP). The most significant aspect
of this workshop is that it was a specialised RUD effort—the first of its
kind by the WHO-India Essential Drugs Programme. Medical
professionals from the FPAI took part in this workshop. The importance
of this programme is that if rational prescribing is adopted in family
planning and RCH activities, it will enhance and promote the image and
concept of family planning in India.
Shri Digvijay Singh, the Honourable Chief Minister of Madhya Pradesh,
inaugurated the workshop. A team of gynaecologists and clinicians from
FPAI, Mumbai were also present, while Professor Roy Chaudhury,
coordinator of the WHO-India Programme and Dr. S.A. Dahanukar from
KEM hospital, Mumbai (on behalf of the DSPRUD) provided the expertise
in RUD. The sessions of the three-day meeting included the basic
principles of RUD, nutrition in pregnancy, management of complications
in pregnancy and labour (hypertension, eclampsia, antepartum and post26
partum haemorrhages), safe abortions, reproductive tract infections,
sexually-transmitted infections, pelvic inflammatory disease, care of the
neonate, choice of drugs in common conditions like malaria and
tuberculosis, with reference to pregnant and lactating women, and various
contraceptive techniques and devices.
The workshop was given extensive news coverage in die local media.
3. A workshop on the rational use of drugs for private practitioners. This
sensitisation workshop, the second of its kind for private practitioners, was
organised at Gwalior, jointly by the WHOTndia Programme and the
Gwalior branch of the Indian Medical Association (IMA), on the 6th of
August 2000. More than a hundred and twenty private practitioners
participated in the workshop. Experts from the DSPRUD discussed the
principles of RUD at length.
4. Other activities in Madhya Pradesh: A drug policy for the state is on the
anvil and will be adopted by the State Assembly in the following year. The
publication of core documents for Madhya Pradesh is being planned. These
publications include an essential drugs list (EDL) for various levels of
healthcare and a set of standard treatment guideEnes (STGs). The WHOIndia Programme will provide financial support for these activities, and the
State government will be actively involved in the programme. This is
essential as these publications are to be officially circulated to all medical
facilities in the State.
A system to strengthen the quality assurance of drugs purchased by the
State government, by the inspection of pharmaceutical houses for good
manufacturing practices, is also being worked on.
PUNJAB
Drug procurement in Punjab is done by the Punjab Health Systems Corporation
(PHSC) and is funded by the World Bank. The PHSC has adopted the EDL for
Delhi hospitals for its purchases. However, drug purchasing is done in accordance
with the procurement guidelines laid down by the World Bank, such as pre
qualification criteria and GMP certificates.
An awareness symposium on the rational use of drugs (RUD): A major
activity in Punjab this year was a symposium on RUD at Ludhiana. This two-day
symposium was organised by the Department of Pharmacology, Christian Medical
College (CMC), Ludhiana on the 13th and 14th of November 2000. Doctors from
the college participated at the symposium. Dr. A.G. Thomas, Principal, CMC,
chaired the inaugural session. Dr. T.M. Jaison, Deputy Director, CMC and the
Civil Surgeon, Ludhiana were also present on the occasion. Dr. Thomas
appreciated the relevance of the theme of the symposium in the existing scenario
in India, where a large number of drugs can be bought over the counter, leading to
misuse of drugs. He also emphasised the need to observe rationality in drug
prescribing in terms of drug selection, number of drugs, dosage and toxicity.
The sessions of the symposium focused on the following themes:
(a) Types of irrationalities observed in prescriptions, leading to
therapeutic failures and iatrogenic disease
(b) The concept of essential drugs, the importance and advantages of an
essential drugs list (EDL)
(c) Guidelines for the safe use of drugs for the geriatric category
(d) A systematic approach to the proper selection of anti-hypertension
drugs
(e) The utilisation of antimicrobials to avoid drug resistance
(f) The critical evaluation of promotional literature on drugs
(g) The importance of communication skills for physicians.
The participants started the preparation of an EDL as a group activity. One of
the recommendations of the symposium was that a drug review committee should
be constituted, comprising health authorities, excise department officials, clinicians
and pharmacologists. The committee should also look into the real needs of the
patients and formulate guidelines on the procurement and prescription of safe,
effective and inexpensive drugs.
TAMIL NADU
In this southern state, where an independent essential drugs programme has been
in operation since 1994, the role of the WHO-India Programme has been to
provide technical assistance. The Tamil Nadu Medical Services Corporation
(TNMSC), in collaboration with DANIDA, is implementing the programme. The
State has its own EDL and Drug Formulary. The TNMSC has been successful in
ensuring the availability of essential drugs to a large percentage of the rural
population.
28
Most of the activities of the WHO-India Essential Drugs Programme in Tamil
Nadu are concentrated at the Christian Medical College (CMC), Vellore. The
assistance provided has mainly been in the form of organising seminars and
making training modules on RUD for medical officers and pharmacists,
conducting surveys on drug use in primary’ healthcare centres, and in the
establishment of a drug information centre.
WEST BENGAL
Although the World Bank is supporting the healthcare system in West Bengal, a
programme on the rational use of drugs was launched with technical and financial
assistance from the WHO-India Programme towards the end of 1998. It was felt
that in order to effectively introduce the programme in West Bengal, it was
important to have accurate information on the disease pattern in the community.
While in urban areas, it would be sufficient to gather data from the records of
morbidity and drug utilisation in government and private health institutions, it
would not be a suitable method in the case of rural areas due to lack of medical
institutions and, therefore, statistical records. Rather, a door-to-door survey of
morbidity and mortality, and attitudes of the rural community towards
professional healthcare is the only alternative. Hence, a project entitled ‘A Study
on Morbidity and Mortality in a Rural Community of West Bengal’ was carried out
in Bankura District. This study was undertaken by the Joypur Harajyoti Udyog
Society, Bankura, West Bengal. The main objectives of this study were:
•
•
•
•
To find out the point-prevalence rate of morbidity during different seasons
To examine the relative frequency of different diseases, both acute and
chronic in nature
To study the characteristics (age, gender and occupation) of patients
suffering from such diseases
To delineate the attitudes of the rural community’ towards professional
medical care in times of illness.
During the course of this study, one or two members from each of the 1500
families of panchayat areas of villages studied were questioned. A total of 1781
persons were surveyed, and study was carried out over a period of three months in
the summer, monsoon and winter seasons. A pre-designed and pre-tested semi
structured pro forma was used to conduct the door-tc-door survey. This was
done by' trained, non-medical investigators. To ensure qualitative data, a trained
medical supervisor monitored the investigators. It was found that around 32% of
the population was in the age group of forty years or below, and only 9.5% lived
29
in proper concrete houses. The most common diseases were found to be enteric
(40/o), followed by cough and cold (28%) and fever (11%). Forty-four percent of
persons did not seek professional medical care, while 19% went to health centres,
and 3%, to hospitals. In the case of pregnant women, 53% of the deliveries were
done at home, and 33%, in hospitals.
A complete assessment of the generated data is being made in order to plan
suitable intervention measures.
30
New States
The WHO-India Essential Drugs Programme (The WHOTndia Programme)
has constantly strived to include into its fold more and more states and spread
die programme of rational use of drugs (RUD) to benefit as much of the
Indian population as possible. This programme is being implemented in twelve
states, and it is its endeavour to spread its wings to reach out to those states
that have been hitherto untouched, and therefore, deprived of the merits and
value of the programme.
UTTAR PRADESH (U.P.)
Dr. Harsh Vardhan, former Health Minister of Delhi, held detailed discussions
with Mr. Ramapati Shastri, Health Minister, U.P. as an initial step in the
direction of launching the programme in the state of U.P. This was followed by
a visit to Lucknow, the state’s capital, by a senior consultant from the Delhi
Society for the Promotion of Rational Use of Drugs (DSPRUD). As a
consequence of this visit, a committee has been formed for the induction of
the programme in the state. The members of this committee include two senior
officials of the Health and Family Welfare Department and the Health
Secretary of the same. During the meetings of the DSRPUD representatives
with senior State health officials in Lucknow, strategies for the implementation
of the RUD programme were discussed.
Formulation of a drug policy: One of the priorities of the committee would be
to formulate a drug policy for U.P. Once the State Cabinet accepts this policy,
the other components of the programme on RUD can be initiated. The
political leadership in the state and bureaucrats in the health department are
eager to follow the ‘Delhi Model’ and have communicated this to the
representatives of the WHO-India Programme, New Delhi, who have assured
them of their support.
Assistance to the Sanjay Gandhi Post Graduate Institute of Medical Sciences
(SGPGIMS), Lucknow:_While the preparatory work at the level of the state
government is underway, assistance from the DSPRUD in the area of drug
purchase has been sought by the SGPGIMS, Lucknow, a premier medical
institution of U.P. This prestigious institute has an annual drug budget of
rupees sixty crores. In order to streamline the supply of essential medicines to
thousands of poor patients visiting the institute, the SGPGIMS would like to
use the EDL used by Delhi hospitals and also buy these medicines from the
31
v'
J
06983
___
same suppliers under foe same terms and conditions. They would also like to
adopt foe GMP inspection protocol followed in Delhi to ensure foe supply of
good quality medicines. The SGPGIMS has also expressed foe desire to apply
foe Delhi course content in foe training of pharmacy managers in their
hospitals.
GUJARAT
Activities in this state were initiated at foe beginning of foe year 2000, at a
meeting at New Delhi between foe President of foe DSPRUD and Mr. Ashok
Bhatt, former Health Minister, Gujarat, who had shown keen interest in foe
RUD programme. However, due to a political change in foe state, foe
launching of foe programme suffered a setback and foe proposed visit of foe
President, DSPRUD to Ahmedabad was postponed. Dr. Usha Gupta from foe
DSPRUD visited Gujarat later in the year and held meetings with senior state
health officials. At these meetings, foe Commissioner of Food and Drugs
Control Administration has been given foe responsibility of convening RUD
activities in foe state. A drug policy statement for Gujarat is being prepared
after which, it would need to be approved by foe State Cabinet
Assistance was provided by foe DSPRUD to non-governmental organisations
working in foe field of health in Gujarat last year, namely SEWA and Lo Cost,
to conduct workshops in foe state on RUD.
ORISSA & KERAT-A
Programmes on RUD in these two states are expected to commence in the
near future. Sensitisation workshops on rational drug use are being planned for
the year 2001. In the state of Orissa, the Health Secretary to the state
government has taken a keen interest in the planning process, and executive
members of the DSPRUD will be visiting foe two states to define and
implement foe plans.
32
Research Activities
The following research activities were taken up in different states under the
WHO-India Essential Drugs Programme in the year 2000:
DELHI
1. Impact of drug information on patients’ knowledge about drug use and
compliance
Investigators: Professor Ranjit Roy Chaudhury, Professor Usha Gupta,
Dr. Jeevan Jha and Dr. Sangeeta Sharma
The objective of the study was to provide verbal as well as written
information to patients on the drugs prescribed to them and to assess
the impact of this information on their knowledge and compliance about
drug use. This was a randomised and controlled clinical study carried out
at the Deen Dayal Upadhyay Hospital (DDU Hospital), New Delhi.
The sample size of the intervention and control groups was a hundred
patients each.
Leaflets in colloquial Hindi with information on drugs prescribed to
them, and about primary indicators (purpose, dose, frequency and
duration of treatment) and supplementary indicators (adverse effects,
precautions, missed doses and future appointments) of drug use were
prepared and distributed amongst patients in the intervention group. In
addition, pharmacists and young medical students briefed them on the
drugs on a one-to-one basis.
The results of the study showed that as a result of the information
provided to the patients in the intervention group, their knowledge of
drugs had improved remarkably, almost twofold on primary indicators
and threefold on supplementary indicators.
2. The impact of educational intervention on the prescribing behaviour of
physicians, especially on the extent of antibiotic use in acute respiratory
infection (ARI) and acute diarrhoea at primary healthcare centres in
Delhi:
Investigators: Professor Ranjit Roy Chaudhury, Dr. Sangeeta Sharma,
Dr. Usha Gupta and Dr. J.S. Bapna.
33
ARI and acute diarrhoea were selected for this study because antibiotics
are particularly misused in these two conditions. The aims of the study
and the method adopted for it have already been discussed in Chapter
One (Activities in the State of Delhi) of this report. The findings show
that antibiotics were employed in 80%-100% of the cases of acute
diarrhoea in the pre-intervention phase. Although there was a decline in
this figure in the post-intervention phase, more in some health facilities
than others, it was felt that one educational intervention was not
sufficient for changing prescribing behaviour.
X. Cost analysis for treatment of mild hypertension and mild chronic
bronchial asthma:
Investigators: Professor Ranjit Roy Chaudhury, Dr. Anita Kotwani and
Dr. Usha Gupta
The aim of this study was to examine the pattern and cost of drug use in
the conditions of mild hypertension and chronic bronchial asthma. A
hundred randomly selected prescriptions for each of these conditions
were collected from the outpatients’ departments of three hospitals
under the government of Delhi. A detailed pro forma was used to collect
this data, the analysis of which is underway.
T The effect of rational prescribing on the cost of therapy in acute
respiratory infection (ARI) and acute diarrhoea:
Investigators: Dr. Rajkumari Gulati, Dr. Sangeeta Sharma, Professor
Ranjit Roy Chaudhury, Dr. Usha Gupta and Dr. J.S. Bapna.
The objective of the project was to study the cost of therapy in ARI and
acute diarrhoea, with and without the use of standard treatment
guidelines (STGs) and pooled procurement. Thirty prescriptions for
each of these conditions were collected from each of the twenty-five
randomly selected health facilities under the Delhi government. The
health facilities were divided into study and control groups, and STGs
were introduced into the study groups during interventional workshops.
The results suggested significant savings in the cost of treatment as a
result of the adoption of the pooled procurement system. Adopting a
pooled procurement system of medicines, rather than the buying of
medicines from the market enhances the extent of savings. ARI and
diarrhoea are two common diseases in India, and the saving in the cost
of therapy in these two conditions would have a greater impact
34
on the healthcare budget. This study demonstrates that the savings in the cost of
therapy in these two conditions is over 100% as compared to the minimum cost
at which the drug is available in a retail centre. The results of the study are
summarized as follows:
1. a) The cost of therapy in diarrhoea calculated as per the STGs (if followed
completely) would be Rs.l 1.20.
b) In control health facilities, the average cost of therapy in diarrhoea was
Rs. 17.82 and Rs. 15.97 respectively in both the pre intervention and post
intervention periods.
c) In study health facilities, the average cost of therapy in diarrhoea was
Rs. 13.88 and Rs. 14.42 respectively in the pre intervention and post
intervention periods.
d) In diarrhoea the cost of therapy at retail prices was nearly 106-135%
more than when the prices were calculated at CPA rates.
2. a) In ARI, the cost of therapy as per STGs, if followed, was calculated to
be Rs.4.75
b) In control health facilities, the average cost of therapy was found to be
Rs.9.56 and Rs. 10.19 respectively in the pre intervention and post
intervention periods.
c) In study health facilities, the average cost of therapy was found to be
decreased from Rs.9.31 to Rs.8.29 following intervention.
d) When a comparison was made between the two modes of procurement
of drugs (for the cost therapy of ARI) - CPA and Retail sector - it was
observed that the cost was nearly 80% more at retail sector rates than at
Pooled procurement rates (CPA).
The average cost of therapy in diarrhoea did not reduce following intervention.
This probably could be due to the fact that there is not much of a difference
between the cost of therapy as per STGs (Rs.l 1.20) and cost of therapy in practice
in health facilities. The average cost of therapy in ARI decreased following
intervention though not significantly. The cost of therapy in ARI would further
35
reduce by nearly 100% if STGs are implemented successfully. In diarrhoea, the
CPA system of procurement of medicines reduces the cost of therapy by 106135%. In ARI, the CPA system of procurement of medicines reduces the cost of
therapy by nearly eighty percent.
RAJASTHAN
5. A prescription audit study for an antibiotic policy in teaching hospitals
Investigators: Dr. Sad Pathak, Department of Microbiology, SMS
Medical College, Jaipur.
In this project, the prescriptions of five hundred patients (250 inpatients
and 250 outpatients) from the Departments of Urology and General
Surgery, SMS Medical College are being studied, and the drug
susceptibilities of the bacterial isolates are being analysed.
The results show an alarming pattern of antibiotic resistance amongst
the common pathogens. As an example, the resistance pattern of E.coli
is indicated in the table below:
The emerging resistance pattern of E.coli to common antibiotics
in patients from the Urology Department of SMS Medical College, Jaipur.
Percentage resistance
Ampicillin
Chloramphenicol 94.4%
Co-trimoxazole 88.9%
100%
Percentage resistance
Tetracycline
Norfloxacin
Ciprofloxacin
88.9%
83.3%
72.2%
MAHARASHTRA
6. A post-intervention study of the adherence of doctors to standard
treatment guidelines (STGs) and essential drugs lists (EDLs) in the
outpatients’ departments
Investigators: Dr. S.A. Dahanukar and Dr. Drmila Thatte
36
The purpose of this study was to assess the adherence of doctors to the STGs and
EDLs of the outpatients’ departments of the healthcare facilities under the
MCGM, Mumbai. The adherence of doctors in the departments of general
medicine and paediatrics was studied using prescriptions issued for certain tracer
diseases. 1 he outpatients STGs and EDL have already been distributed in 1999.
A hundred and twenty prescriptions were analysed for each of the sixteen
peripheral hospitals and thirty randomly selected dispensaries under the MCGM.
The analysis revealed that the adherence to STGs in the peripheral hospitals varied
from 16%-59%, a range below the acceptable level of adherence. In dispensaries,
too, the level of adherence to STGs was found to be low, varying from 17%-60%.
These figures confirm that in addition to printing and distributing written
information, the training of medical professionals in the proper use of STGs is
essential.
7. A pre-intervention drug use study at Pune
Investigators: Dr. V.A. Pandit, Department of Pharmacology, Bharati
Vidyapeeth, Pune.
The objectives of this study were to measure drug use indicators in a
representative group of medical facilities in District Pune, and to compare
the performance of individual facilities. The study was conducted over a
period of six months, during which 1729 prescriptions, and core drug use
indicators, were analysed.
On the analysis of the data acquired, it was found that the general
prescribing pattern in the primary healthcare centres of Dist. Pune was
similar to the pattern found in the medical facilities under the MCGM,
Mumbai. For instance, encounters with injections amounted to 31%-36%,
the average consulting times and the percentage of drugs labelled were very
low. Intervention is being planned.
8. A post-intervention study at the MCGM, Mumbai—the effect of
training on pharmacists
Investigators: Dr. S.A. Dahanukar, Dr. Urmila Thatte and others.
Training courses for pharmacists were conducted at the MCGM, Mumbai
in 1999, in which a hundred and three pharmacists trained. This survey was
37
carried out to assess the effects of training on the dispensing practices of
these pharmacists.
The dispensaries under the MCGM were divided into two groups,
namely trained and untrained pharmacists. Twenty dispensaries from
each group were randomly selected. Core patient care indicators for a
hundred and twenty patients in each dispensary were assessed as per the
WHO recommendations.
The figures reveal that after training, there was a significant change in the labelling
of drugs dispensed to the patients, although this change was expected to be
higher. This implies that some other form of intervention at the pharmacy level is
required.
9. Treatment failure in tuberculosis—the causes of drug therapy
failures
Investigators: Dr. S.A. Dahanukar, Dr. Urmila Thatte and others.
The aim of this study was to assess the reasons behind the rapidly
increasing incidence of drug resistant tuberculosis, especially irrational
drug prescriptions by physicians and lack of compliance by patients.
Patients attending three types of healthcare facilities—DOTS centres,
tertiary care centres and private practitioners—were interviewed for this
study and the results are as follows:
DOTS centres: Out of the 258 DOTS centres in Mumbai, forty-five were
randomly selected and a total of 1708 patients from these centres were
interviewed to evaluate their knowledge on anti-tuberculosis drug use. On
analysis of the data collected, it was found that the patients’ knowledge
about the duration of treatment and details of drug therapy was negligible.
Hence, intervention at the community level is essential in order to increase
patient awareness on tliis particular disease.
Other causes of patients defaulting from DOTS centres for
treatment were socio-economic ones like homelessness, alcoholism,
shifting for treatment to private practitioners and to native places
during summer vacations. Another reason why patients do not come
regularly to the DOTS centres is the fact that they cannot afford the
frequent trips in terms of costs of commuting.
38
Tertiary care centres: 240 cases of tuberculosis at two tertiary care centres
were studied. It was found that a high percentage of patients had a fair
understanding on the dosages of drugs, duration of treatment and adverse
drug effects. Wide variations were found to exist in the treatment schedules
offered to patients in both pulmonary and extra pulmonary tuberculosis.
Therefore, intervention is necessary at the tertiary level to promote the
proper prescribing of medicines and to prevent a further increase in the
development of drug resistance.
Private healthcare facilities: An attempt was made to examine the regimens
followed by private practitioners for treating tuberculosis in order to detect
any potential deficiencies in the regimens that could contribute to the
development of drug resistant tuberculosis. The results suggested the
following: (i) Most of the practitioners depended on criteria like weight gain
and increased appetite for assessing any improvement in tuberculosis,
despite the availability of good diagnostic laboratories; (ii) Only 28% of
practitioners recommended sputum examinations in diagnosis as well as a
follow up of the cases; (iii) Only 10% of practitioners recommended that
the decision regarding the treatment of non-responsive cases would be
based on a sensitivity report; and (iv) About 25% of practitioners would
add a single drug to supplement the existing treatment.
These findings suggest serious implications for the epidemiology of the
disease, and imply a need for immediate intervention measures.
ANDHRA PRADESH
10. A drug composition profile in rural urban Andhra Pradesh
Investigators: Dr. Kamala Krishnaswamy and Dr. B. Dinesh Kumar
(National Institute of Nutrition, Hyderabad) and others.
A study on the consumption of drugs in Andhra Pradesh was conducted
as a preparatory step towards a programme on the rational use of drugs.
The project began in June 2000, and is scheduled to be complete in May
2001. The activities carried out under the project so far include
identifying the health facilities to be surveyed, recruitment of workers for
the survey and finalisation of the pro formae to be used. Sixteen primary
healthcare centres (PHCs), four community health centres (CHCs) and
one district hospital, located in different parts of the state, were selected
as the sample for the survey.
39
A pilot survey for the same was carried out at the PHCs and CHCs in districts
near Hyderabad. On the basis of this pilot survey, the procedure was modified
several times and a final format for the study has now been agreed upon.
Data collection suffered a temporary setback in the year 2000 because of flash
floods and severe inundation. However, field investigators from Nizamabad,
Cuddapah and West Godavari districts are currently collecting the necessary’
information in their respective areas, and the programme is now underway and
would be completed according to schedule.
UNION TERRITORY OF CHANDIGARH
11 (PUHC) ti^ati°n StUdy 31 thC Pun,ab Univer8ity Health Centre
Investigators: Dr. S.K. Kulkami (Professor of Pharmacology, Institute of
Pharmaceutical Sciences, Punjab University, Chandigarh)
The PUHC caters to the medical needs of a population of about 2500.
The centre has an outpatients’ department that runs six days a week, and
the drugs, if available, are dispensed by a pharmacy. With a view to’
streamlining the availability of drugs, a drug utilisation study was
undertaken.
The purpose of this study was to assess the rational use of drugs through
prescription monitoring by observing the pattern of drug prescribing and
dispensing. Five hundred randomly selected prescriptions were
monitored over a period of six months. Several parameters were taken
into account, including demography, drug related parameters (category
of the drug, dose, dosage form, frequency, duration, single or fixed
combinations of drugs and whether the drug generic or proprietary), and
patient-related parameters such as the time of consultation, information
provided by the prescriber/dispenser, the labelling of drugs dispensed
and the patient’s understanding of drugs to be taken.
The prescription auditing revealed the following:
(a) The types and categories of drugs prescribed were: Generic (50.57%),
branded (49.43%), individual (81.73%), fixed dose
CO1mbinations (18.27%), antibiotics (22.76%), analgesics (21.76%),
40
(b) antihistaminic (12.56%), drugs for gastrointestinal tract (9.47%),
steroids (3.57%) and drugs for CVS (3.16%)
(c) Dosage and diagnosis: Doses were mentioned for 19.28% of the
antibiotics prescribed. The diagnosis was written only in 12.75% of
the prescriptions monitored.
(d) Instructions on drug use: Written instructions on the container were
not given by the pharmacist for any of the drugs dispensed; 85.51%
of the prescribed drugs were available from the PUHC pharmacy, of
which 43.23% were dispensed in loose envelopes (without labelling).
{e)Patients knowledge: Only 17.25% of the patients were aware of the
nature of the medication prescribed to them, and 68.25% were aware
of the medication schedule.
Followup: The above observations were shared with the physicians and
pharmacists of the PUHC. The issues were related to administrative
problems and procurement and distribution of drugs. An intervention
study has been initiated and is in progress.
WEST BENGAI.
12. A study on morlbidity and mortality in a rural community of West
Bengal
Investigators: The Joypur Harajyoti Udyog Society, Bankura District.
Although die World Bank is supporting the healthcare system in West Bengal,
a programme on the rational use of drugs was launched with technical and
financial assistance from the WHO-India Essential Drugs Programme towards
the end of 1998. It was felt that in order to effectively introduce the WhoIndia Programme in West Bengal, it was important to have accurate
information on the disease pattern in the community. While in urban areas, it
would be sufficient to gather data from the records of morbidity and drug ’
utilisation in government and private health institutions, it would not be a
suitable method in the case of rural areas due to lack of medical institutions
and, therefore, statistical records. Rather, a door-to-door survey of morbidity
and mortality, and attitudes of the rural community towards professional
healthcare is the only alternative. Hence, a project entitled ‘A Study on
Morbidity and Mortality in a Rural Community of West Bengal’ was carried out
in Bankura District. This study was undertaken by the Joypur Harajyoti
41
Udyog Society, Bankura, West Bengal. The main objectives of this study were:
• To find out the point-prevalence rate of morbidity during different
seasons
To examine the relative frequency of different diseases, both acute and
chronic in nature
• To study the characteristics (age, gender and occupation) of patients
suffering from such diseases
• To delineate the attitudes of the rural community towards professional
medical care in times of illness.
During the course of this study, one or two members from each of the 1500
families of panchayat areas of villages studied were questioned. A total of 1781
persons were surveyed, and study was carried out over a period of three
months in the summer, monsoon and winter seasons. A pre-designed and pre
tested semi-structured pro forma was used to conduct the door-to-door survey.
This was done by trained, non-medical investigators. To ensure qualitative data,
a trained medical supervisor monitored the investigators. It was found that
around 32% of the population was in the age group of forty years or below,
and only 9.5% lived in proper concrete houses. The most common diseases
. were found to be enteric (40%), foflowed by cough and cold (28%) and fever
(11 /o). Forty-four percent of persons did not seek professional medical care,
while 19% went to health centres, and 3%, to hospitals. In the case of pregn’ant
women, 53% of the deliveries were done at home, and 33%, in hospitals.
A complete assessment of the generated data is being made in order to plan
suitable intervention measures.
42
Activities in the Area of
Human Resource Development
The WHO-India Essential Drugs Programme has devoted a large amount of
resources for training doctors and paramedical staff in the rational use of drufts.
Following is a documentation of the training programmes held in the year 2000
in different states of the country:
DELHI
1. Training programme for healthcare professionals in the rational use of
drugs at the Deen Dayal Upadhyay (DDU) Hospital, New Delhi.
2. Training programme for drugstore managers working in hospitals under
the government of the National Capital Territory of Delhi at the
Institute of Human Behaviour and Allied Sciences (IHBAS), Shahadra.
3. Educational intervention on the prescribing behaviour of physicians,
especially the extent of antibiotic use in acute respiratory infection (ARI)
and acute diarrhoea, in the primary healthcare centres of Delhi.
4. Educational intervention on prescribing amongst private practitioners at
the IHBAS, in collaboration with the Delhi Medical Council (DMC).
RAJASTHAN
5. Orientation programme on the rational use of drugs for the facultv
members of Zanana Hospital, Jaipur.
6. A workshop on rational prescribing for faculty members of the medical
colleges of Jodhpur.
7. A workshop on rational prescribing for faculty members of the medical
colleges of Udaipur.
43
8. Inclusion of a one-day sensitisation module on the rational use of drugs
into the induction training programme for state medical professionals at
the State Institute of Health and Family Welfare (SIHFW), Jaipur.
9. Inclusion of a one-day sensitisation module on the rational use <of drugs
for doctors into the in-service training of medical professionals at the
regional Health and Family Welfare Training Centres of Rajasthan.
MAHARASHTRA
10. Introduction of the concept of rational use of drugs into the
undergraduate curriculum of the medical colleges under the Maharashtra
University of Health Sciences (MUHS), Nasik.
LL Programme on rational use of drugs, termed Shidori, for interns at the
GS Medical College, Mumbai.
ASSAM
12. Sensitisation workshop on the rational use of drugs at the Guwahati
Medical College.
CHANDIGARH
13. Sensitisation workshop on the rational use of drugs at the Chandigarh
Medical College.
KARNATAKA
14. The inclusion of rational drug use as a topic into the quality care and
ethical practice workshops in the state of Karnataka.
15. Training programme in the rational use of drugs for doctors and
pharmacists from eight project hospitals of the Karnataka Health
Systems and Development project.
44
MADHYA PRADESH
16. Workshop on the rational use of drugs for private practitioners at
Gwalior.
17. Workshop on the rational use of drugs in reproductive and child
healthcare (RCH) in Bhopal.
PUNJAB
18. Symposium titled Awareness of Rational Drug Use’ held at the Christian
Medical College, Ludhiana.
While details of these programmes have already been discussed in Chapter Two
(Activities in Other States) of this report, the contents of the one-day training
modules on the rational use of drugs are indicated in overleaf.
45
One-day Training Module on the Rational Use of Drugs
Inducted into Training Courses for Doctors
Irrational Prescribing
•
•
•
•
•
•
Concept of Rational Use of Drugs
Evaluation of the components of irrational prescribing behaviour
Identification of the effects of irrational prescribing
Introduction of group tasks, using actual irrational prescriptions
Components of an ideal prescription with group task
Plenary discussions
Rational Prescribing
•
•
•
•
Concept of Essential Drugs
Enumeration of the steps involved in the rational use of drugs
Formulation of a method of selecting a rational drug (P-Drug concept)
Group Task: Writing prescriptions for conditions commonly encountered
in primary healthcare centres
•
Plenary discussions
Communication Skills
•
•
Effective communication with patients to improve patient compliance
Effective communication with the regulatory agency, with special
emphasis on poor quality drugs available in the market
•
Critical evaluation of a new drug formulation
•
Role play
46
A Focus on New Activities
The WHO-India Essential Drugs Programme ventured into new spheres of
work in the year 2000:
•
Introduction of the concept of rational use of drugs (RUD) into large
public sector organisations spending large amounts of money to provide
medical facilities to thousands of their employees, for example, the
Indian Railways.
•
Inclusion of private practitioners into the RUD programme. This is
essential because a sizeable percentage of the population does not visit
public health facilities and depends largely on general and specialist
private medical practitioners.
•
Programmes on RUD in specific areas of healthcare such as
reproductive and child health, cardiology and control of tuberculosis to
make the concept of rational use of drugs more focused.
•
Patient education programmes on the rational use of drugs. This is
imperative for the improvement of patients’ compliance and knowledge
about drugs.
• A focus on pharmacists should be an integral part of the RUD
programme, as they bridge the gap between the busy practitioner and the
patient. Taking their importance into consideration, the programme was
extended to include pharmacists last year.
• The WHO-India Programme broadened its horizons further to include
the field of traditional and herbal medicine into its realm. Practitioners
employing traditional systems of medicine offer treatment to millions of
patients living in the rural are^s of the country, who have little access to
modern medical facilities. The condition of such patients can be
improved considerably with the rational use of traditional, locally
available medicines.
Given the importance of work in the areas listed above, greater attention will
be paid to these activities in year 2001. A brief survey of the work done in these
areas so far is as follows:
47
1. The Indian Railways RUD Programme: An extensive programme to
launch the rational use of drugs for the Indian Railways has been
planned. It will cover all aspects of RUD—development of an
essential drugs list (EDL) for various levels of healthcare, the
procurement of drugs, quality control, rational prescribing and
patient compliance. It is expected that with the implementation of
the programme, the Indian Railways would be able to purchase more
drugs within the same budget.
Meeting with railway officials: The first meeting to discuss the railways
project was held at the DSPRUD office in New Delhi on the 20th of
November 2000. Dr. M.L. Gaur, Medical Director of the Jagjivanram
Hospital, Mumbai Central and Dr. Usha Krishna, consultant obstetrician
and gynaecologist at the same hospital represented the Western Railways
at this meeting. Professor Ranjit Roy Chaudhury, President, DSPRUD,
Mr. R. Parameswar, Vice-President, DSPRUD, Dr. Usha Gupta and Dr.
Uma Tekur were also present at the meeting. It was decided that initially,
the RUD project would be launched at the Jagjivanram Hospital and a
few other smaller railway hospitals in Mumbai. A second meeting has
been scheduled to be held in January 2001 in Mumbai to give definite
shape to the programme. It was decided that at this meeting, about forty
persons from the railways would take part. These would include railway
officials, pharmacists, medical consultants and specialists.
The advantages of having an RUD programme and the prevailing
conditions in the medical set-up would be discussed and an action plan
would be drawn up.
2. Inclusion of private medical practitioners in the RUD programme: In
order to have a comprehensive programme in RUD, the importance
of involving private practitioners cannot be overlooked. In keeping
with this view, two seminars for the orientation of private
practitioners to RUD were held in Delhi and Gwalior in March and
August 2000 respectively. The two seminars have been discussed in
detail in Chapter Two of this report.
3. Specialised RUD programmes: The first specialised workshop of the
WHO-India Programme was held at Bhopal in July 2000. It focused
on the importance of applying the concept of RUD to the specialised
area of reproductive and child health (RCH). Details of this
workshop are given in Chapter Two (Activities in Other States) of
48
the report. Several specialised workshops of this kind are being planned
in the areas of cardiology7, intensive care, nephrology, dermatology,
ophthalmology and oncology.
4. Patient education in RUD: This important component of die
programme has been focused on in this year. The first educational
and interventional study was conducted at the Deen Dayal Upadhyay
Hospital, New Delhi in early 2000. Patient awareness of drug use was
also assessed during the course of a drug use study conducted at the
Punjab University Medical Clinic, Chandigarh. A study into the
causes of the development of drug resistant tuberculosis in
Maharashtra also sheds some light on patients’ knowledge. These
studies are discussed at length in the respective state categories in the
report. Intervention measures to promote patient education are
underway.
5. The rational use of drugs in traditional medicine: The
Department of Indian Systems of Medicine and Homeopathy
(DISMH), Government of India published a list of essential herbal
drugs. Professor Ranjit Roy Chaudhury, Coordinator, Who-India
Essential Drugs Programme, was the technical consultant for this
important task.
A meeting on HTV/AIDS and traditional medicine was organised in
November 2000 at the India International Centre, New Delhi by the
DSPRUD. Eminent persons from the field of traditional medicine,
representatives from the DISMH, Government of India and several
prominent persons from different fields participated in this Journey
to Dialogue’.
49
Services to Other Agencies
The Delhi Society for the Promotion of Rational Use of Drugs (DSPRUD) has
been actively involved in implementing the programme of rational use of drugs
all over India. It has advised the government at the central, as well as the state,
level on various areas related to drugs. The technical expertise of the society
has been recognised and appreciated, as a result of which, it has been receiving
requests for assistance from national and international agencies. Recently,
requests have been received from Danish International Development
Assistance (DANIDA), the World Bank, the World Health Organisation and
the Ministry of Health and Family Welfare, Government of India.
□ .The Ministry of Health and Family Welfare, Government of India has
requested the DSPRUD to conduct a study on ‘The Quality Audit of Drug kit
A and B under the Reproductive and Child Health Project’. These kits are to be
procured with the financial assistance of the World Bank.
□ DANIDA is supporting the Basic Health Services Programme in the state of
Madhya Pradesh. It has sought the help of the DSPRUD to draft a drug policy
for this large province. Senior consultants from the society visited Bhopal for
this purpose. A draft drug policy statement has been prepared in consultation
with senior health officials and is awaiting approval by the State Cabinet.
The World Bank requested assistance from the DSPRUD in monitoring
drug policy indicators in Tamil Nadu (a state in south India) and Uttar Pradesh
(a large state in north India). The World Bank is providing financial aid to
medical services in these two states.
□ The World Health Organisation has asked the society to provide technical
assistance in carrying out the quality assurance of anti-tuberculosis drugs being
purchased by the WHO. These drugs will be supplied to the Ministry of
Health, Government of India for the National Tuberculosis Control
Programme in India. The DSPRUD has also been assisting the WHO in other
areas, such as the scrutiny of the essential drugs lists (EDLs) of Orissa and
Uttar Pradesh, organising a programme in India for a delegation of healthcare
professionals who were sent by the WHO representative office in Myanmar to
New Delhi. This delegation was here to study the various components of tire
RUD programme being implemented by the society in a number of states.
They were briefed on EDLs, the pooled procurement system and other aspects
of the programme. A visit was arranged for them to Jaipur to have a look at the
activities being carried out in the state of Rajasthan.
50
Dr. Kathy Holloway, Medical Officer, Department of Essential Drugs and
Medicines Policy (EDM) - WHO Geneva came to India on a visit in May 2000.
The purpose of her visit was to initiate projects on the rational use of
antibiotics by the community. A meeting was held at the DSPRUD office on
May 31, 2000, to discuss projects with members of the DSPRUD. Dr. Urmila
Thatte and Dr. Dilip from Mumbai also came to participate at the meeting. A
group was identified, to start work on a project entitled “Health seeking
behaviour and impact of educational intervention on rational antibiotic use in
ARI in Indian urban slums”.
51
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Conclusion
I he Delhi Society for the Promotion of Rational Use of Drugs (DSPRUD), has
in the year 2000, progressed steadily in the implementation of the WHO-India
Essential Drugs Programme. It has maintained a healthy collaboration with the
political leadership, the bureaucracy and a large number of technical experts,
which is of paramount importance in a programme of this magnitude.
The society, has been, since its inception, been implementing the programme
of rational use of drugs in India. Slowly but surely, the programme spread to as
many as twelve Indian states by the end of the year. However, besides moving
on to cover new territory, the society has endeavoured to consolidate existing
programmes to strengthen and enrich them.
In addition to building up the programme, the society has initiated new
activities, such as providing its services to other national and international
agencies in the field of drugs, activities in the area of human resource
development of the programme, a programme on RUD for the Indian Railways
and the rational use of traditional medicines. However, it is hoped that the
programme will continue to scale greater heights and achieve much more in its
future endeavours.
The WHO-India Programme would like to thank the Essential Drugs and
Other Medicines (EDM) of the World Health Organisation, Geneva for all its
support and guidance.
52
The WHO-India Essential Drugs Programme:
Coordinators & Participants
The WHO-India Programme in Rational Use of Drugs owes its
its resounding
resounding
success to the collective effort, enthusiasm and sincere involvement of persons
in its various activities in the different states of India:
Professor Ranjit Roy Chaudhury
National Coordinator of the WHO-India Programme (Honorary)
Emeritus Scientist, National Institute of Immunology, New Delhi
President, Delhi Society for the Promotion of Rational Use of Drugs (DSPRUD)
ANDHRA PRADESH
Professor M.U.R. Naidu (State Coordinator)
Professor & Head, Department of Clinical Pharmacology and Therapeutics,
Nizam’s Institute of Medical Science, Panjagutta, Hyderabad
Dr. Kamala Krishnaswamy,
Director, National Institute of Nutrition, Hyderabad
Dr. B. Dinesh Kumar
Research Officer, Department of Pharmacology, National Institute of Nutrition,
Hyderabad
Dr. P.V. Rao, Joint Commissioner (General),
Andhra Pradesh Vaidya Vidhana Parishad, Hyderabad
Mr. M. Nagarjuna
Secretary, Health and Family Welfare, Government of Andhra Pradesh,
Hyderabad
ASSAM
Dr. A. Deka (State Coordinator)
Professor of Pharmacology, Guwahati Medical College
Dr. S. Chakravarty, Secretary - North East Society for
Promotion of Rational Use of Drugs,
Department of Pharmacology, Guwahati Medical College
53
Dr. Bezbarua
Professor of Pharmacology, Guwahati Medical College
Dr. P.K. Ojha, Vice President, North East Society for
Promotion of Rational Use of Drugs,
Professor of Pharmacology, Guwahati Medical College
DELHI
Professor Ranjit Roy Chaudhury
President, DSPRUD
Mr. R. Parameswar
Vice President, DSPRUD
Former Deputy Comptroller and Auditor of India
Professor J.S. Bapna
Secretary, DSPRUD
Director, Institute of Human Behaviour and Allied Sciences (IHBAS), Delhi.
Professor Usha Gupta
Treasurer, DSPRUD
Proffessor of Pharmacology, Maulana Azad Medical College, New Delhi
Dr. Uma Tekur
Professor of Pharmacology, Maulana Azad Medical College, New Delhi
Dr. Sangeeta Sharma
Assistant Professor, Department Neuropsycho Pharmacology, Institute of
Human Behaviour and Allied Sciences (IHBAS), Delhi
Dr. Rajkumari Gulati
Assistant Professor, Department Neuropsycho Pharmacology, Institute of
Human Behaviour and Allied Sciences (IHBAS), Delhi
Dr. Jeevan Jha
Medical Superintendent, Deen Dayal Upadhyay Hospital, New Delhi
Dr. P.R. Pabrai
Former Director, Drug Testing Laboratories, Ghaziabad, U.P.
54
Dr. R.N. Baishya
Director, Health Services, Government of the National Capital Territory (NCT)
of Delhi.
Dr. Abha Dhalla
Chief Medical Officer, CPA Cell, Directorate of Health Services, Government of
the NCT of Delhi.
Dr. Prafull Seth
Former President, Indian Pharmaceutical Association of India, New Delhi
Dr. Gopal Sachdev
Professor of Medicine, (LNJP) Hospital, New Delhi
Dr. Anita Kotwani
Assistant Professor of Pharmacology, Maulana Azad Medical College, New Delhi
Dr. N.R. Biswas
Assistant Professor of Ocular Pharmacology, Rajendra Prasad Eye Centre, All
India Institute of Medical Sciences (AIIMS), New Delhi
Dr. Shanthi Pal
Department of Pharmacology, Jamia Hamdard, New Delhi
Dr. G.R. Sethi
Professor of Paediatrics, LNJP Hospital, New Delhi
Dr. C.D. Tripathi
Professor of Pharmacology, Maulana Azad Medical College, New Delhi
Mr. M. Rajan
Consultant, Human Resource Development, DSPRUD, New Delhi
Dr. J.N. Gupta,
Documentation Consultant, DSPRUD, New Delhi
Ms. P.R. Kumar
Media Advisor, New Delhi
HIMACHAL PRADESH
Mr. J.P. Nadda (State Coordinator)
Health Minister, Himachal Pradesh
55
Dr. Sukh Ram Chauhan
Director, Health Services, Shimla, Himachal Pradesh
Dr. S.K. Gupta
Municipal Health Officer State Institute of Health and Family Welfare,
Parimahal, Shimla
Mr. B.M. Nanta,
Additional Secretary Health, Govt, of Himachal Pradesh
Dr. Manju Behal
Faculty Member
State Institute of Health and Family Welfare,
Parimahal, Shimla
Mr. S.K. Dash
Managing Director
Himachal Pradesh State Civil Supplies Corporation Ltd.
Shimla
Mr. Daler Singh Kanwar
Drugs Comptroller
Government of Himachal Pradesh
KARNATAKA
Mr. D.A. Gundurao (State Coordinator)
President, Karnataka State Pharmacy Council
Bangalore
Ms. Sunitha Srinivas
Deputy Director, Drug Information Centre
Karnataka State Pharmacy Council
Bangalore
Dr. G.V. Satyavati
Former Director General
Indian Council of Medical Research
Bangalore
Dr. B.G. Nagavi
Principal, JSS Mahavidya Peeth
College of Pharmacy
Mysore
56
MADHYA PRADESH
Dr. O.N. Kaul (State Coordinator)
Principal
Health and Family Welfare Training Centre
Gwalior
Dr. Manorama Shrivastava
Trustee,
Dr. Phatak Child And Mother Welfare Society
Gwalior
Dr. Gurdeep Singh
Advisor,
DANIDA Assisted M.P. Basic Health Programme
Bhopal
Dr. Jaspal Singh Vaseer, Director,
Swasthya Sampada,
Health Resource Centre,
Bhopal
MAHARASHTRA
Dr. S.A. Dahanukar (State Coordinator)
Professor and Head, Department of Pharmacology and Therapeutics
Seth GS Medical College
Mumbai
Dr. Urmila Thatte
Associate Professor
Department of Pharmacology and Therapeutics
Seth GS Medical College
Mumbai
Dr. N.N. Rege
Associate Professor
Department of Pharmacology and Therapeutics
Seth GS Medical College
Mumbai
57
Dr. Kalpana Apte
Assistant Director, Medical
Family Planning Association of India
Mumbai
Dr. Viraj Rajadhyaksha
Post Graduate Student
Department of Pharmacology and Therapeutics
Seth GS Medical College
Mumbai
Dr. Rajeev Chavda
Post Graduate Student
Department of Pharmacology and Therapeutics
Seth GS Medical College
Mumbai
Dr. R.P. Soonawala
Consultant Gynaecologist,
Family Planning Association of India,
Mumbai
Dr. Usha Krishna
Consultant Gynaecologist and Obstetrician
Family Planning Association of India,
Mumbai
Dr. M.L. Gaur,
Chief Medical Director,
Western Railways,
Mumbai
Dr. S.P. Kharey
Chief Medical Director
Western Railways
Mumbai
Dr. S.S. Gangoly
Professor of Medicine
Maharashtra Institute of Medical Education and Research
Talegaon General Hospital
Pune
58
Dr. V.A. Pandit, Associate Professor,
Department of Pharmacology
Bharati Vidyapeeth Deemed University Medical College
Pune
PUNJAB
Dr. AP. Dadhich
Professor and Head, Department of Pharmacology
Christian Medical College
Ludhiana
Dr. Anoop Agarwal
Professor, Department of Pharmacology
Christian Medical College
Ludhiana
RAJASTHAN
Professor P.C. Dandiya (State Coordinator 1)
President, Rajasthan Society for the Promotion of Rational Use of Drugs
Jaipur
Professor Rameshwar Sharma (State Coordinator 2)
Vice President, Rajasthan Society for the Promotion of Rational Use of Drugs
Jaipur
Dr. Ram Lubhaya, Secretary Health, Govt, of Rajasthan,
Executive Member, Rajasthan Society for the Promotion of Rational Use of
Drugs,
Jaipur
Dr. Kunal Kothari
Professor of Medicine
SMS Medical College
Jaipur
59
Professor Jyotsna Bhargava
Assistant Professor of Pharmacology
SMS Medical College
Jaipur
Dr. Mukul Mathur
Associate Professor, Department of Pharmacology
SMS Medical College
Jaipur
Mr. N.K. Gurbani, Head,
Department of Pharmacology
Public Health Training Institute
Jaipur
Dr. Sati Pathak
Professor and Head, Department of Microbiology
SMS Medical College
Jaipur
Dr. M.L. Aseri
Professor and Head, Department of Pharmacology
JLM Medical College
Ajmer
Dr. B.K. Jain
Professor and Head, Department of Pharmacology
Sardar Patel Medical College
Bikaner
Jodhpur
TAMIL NADU
Professor R. Murali (State Coordinator)
Head, Department of Community Medicine
Kilpauk Medical College
Chennai
Dr. Molly Thomas
Professor and Head, Department of Pharmacology
Christian Medical College
Vellore
60
Dr. Kurien Thomas
Professor of Medicine and Joint Director, Clinical Epidemiology Unit,
Christian Medical College
Vellore
UNION TERRITORY OF CHANDIGARH
Dr. V.K. Kak (State Coordinator)
Former Principal
Government Medical College
Chandigarh
Dr. V.K. Bhargava
Professor and Head, Department of Pharmacology
Post Graduate Institute of Medical Education and Research
Chandigarh
Dr. N.K. Goel
Professor and Head, Department of Pharmacology
Government Medical College
Chandigarh
Dr. C.S. Gautam
Reader, Department of Pharmacology
Government Medical College
Chandigarh
Dr. S.K. Kulkarni
Professor of Pharmacology
University Institute of Pharmaceutical Sciences
Punjab University, Chandigarh
Dr. Ratinder Jhaj
Senior Lecturer, Department of Pharmacology
Government Medical College
Chandigarh
Dr. Roma Uppal
Former Professor of Pharmacology
Post Graduate Institute of Medical Education and Research
Chandigarh
61
WEST BENGAL
Dr. Gouri Pada Dutta (State Coordinator 1)
Deputy Chairman
State Planning Board, Government of West Bengal
Kolkata
Dr. P.K. Sarkar (State Coordinator 2)
Director
Institute of Tropical Diseases
Kolkata
Mr. Avik Bandyopadhyay
Pharmacist
Udaynarayanpur
Howrah
Dr. Pinaki Sarkar,
Drug Information Centre,
Foundation of Health Action,
Kolkata
Delhi Society for the Promotion of Rational Use of Drugs:
Management and Administration
Ms. A. Banerji
Adminstrative Manager
Delhi Society for the Promotion of Rational Use of Drugs
Mr. S. Khanna
Executive Secretary
Delhi Society for the Promotion of Rational Use of Drugs
Mr. P.J. Sekharan
Personal Secretary
Delhi Society for the Promotion of Rational Use of Drugs
Mr. R.K. Rathi
Delhi Society for the Promotion of Rational Use of Drug
Mr. J. Gandhi
Financial Controller
Delhi Society for the Promotion of Rational Use of Drugs
62
Ms. J. Nag,
Informatics Officer,
Delhi Society for the Promotion of Rational Use of Drugs
Mr. J.S. Negi
Office Assistant
Delhi Society for the Promotion of Rational Use of Drugs
Mr. S. Hussain
Documentation Assistant
Delhi Society for the Promotion of Rational Use of Drugs
63
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