KARACHI: An excessive and irrational drug use across the health sector in Pakistan is creating resistance to frontline antibiotics used to control infections, says an official report.
The recent report said that antimicrobial resistance resulted from irrational use of drugs and showed that a high level of resistance to ampicillin, cotrimoxazole, chloramphenicol and erythromycin had long since been established in Karachi. “The results are alarming as these are the frontline antibiotics for control of infections,” it said.
The report said the irrational drug use was rampant despite the fact that Pakistan was one of the first countries to introduce the World Health Organisation’s (WHO) essential medicines programme.
The report pointed out low checks on registration and marketing of drugs and said there were 1,100-1,200 registered molecules and about 76,000-88,000 registered products in Pakistan, which was one of the highest in the developing world.“
Unnecessary number of registrations is due to both low quality checks required for registration and reportedly high influence of pharmaceutical industry. This contributes to irrational use of drugs with availability of excessive number of originator brands at different dosages and prices,” it said.
Moreover there was ‘almost no restriction’ on health providers interacting with industry. A visit by industry representatives to general practitioners “is alarmingly often the only source of treatment information, underscoring lack of in-service training, however, information provided is questionable”.
The report quoted a study saying some 18 per cent of sales advertisements “have unjustified or misleading claims” while another study showed that only 15 per cent of claims in promotional brochures met the WHO criteria for optimal drug information.
It quoted a study conducted previously by a private consultant saying self-medication and drugs purchased over the counter from medical stores of “questionable quality” was rampant.
“Although there are no national figures on self-medication, available studies indicate that in at least 51 per cent of ailments medicines are purchased over the counter through self-prescription. There is little restriction over type of medication that can be purchased and quality of drug stores is poor,” it said.
WHO defines the essential drugs as “those that satisfy the healthcare needs of majority of population; they should therefore be available at all times in adequate amounts and in appropriate dosage forms at a price the community can afford.”
However, the recent official report said the prescriptions by non-qualified practitioners as well as self-medication by patients were common in Pakistan.
To authenticate its contention, a previous study conducted in Karachi said potent drugs such as antibiotics, psychotropic, narcotics, anti-cancer therapy and harmones were frequently misused due to inappropriate prescriptions by quacks who mostly operated in remote rural areas of Sindh.
Estimates of the Pakistan Medical Association showed that there were more than 600,000 quacks operating across the country, of whom one-third were in Sindh and of them most were in Karachi.
At present, there is no official legal mechanism, through which authorities could monitor and take action against fake doctors.
The recent study, however, held the licensed practitioners responsible as well for recommending high level of inappropriate prescriptions to their patients. “Many qualified medical practitioners frequently prescribe inappropriately even for endemic problems,” it said.
In Karachi, it said, appropriate therapy for hypertension in elderly people was given by only 35 per cent of general practitioners (GPs). There were frequent variations from the recommended tuberculosis treatment with only 50 per cent of GPs being able to prescribe TB drugs in correct doses or correct duration.
Similarly, the treatment for psychiatric and paediatric illnesses did not correlate to diagnosis in 25 per cent of cases and doses of drugs were inappropriate in 31pc prescriptions.
Moreover, GPs in 76.5pc of patient encounters also dispense drug formulations of unknown composition, commonly known as ‘mixtures’, made in their own drug dispensing corner – a practice, which is not open to monitoring.
The report also highlighted a high number of drugs per prescription and rampant use of injections. The average number of drugs prescribed per patient is three or more in Pakistan as compared to an average of two to three in low- and middle-income countries, and over 70pc of patients are prescribed antibiotics.
Across Pakistan, 2.75 drugs per prescription are reported from basic health units and rural health centres, which is close to the average of 2.79 at teaching hospitals, showing low rationality at lower tiers.
The number of drugs prescribed is higher in the private sector with an average of 4.5 medicines per prescription in urban Sindh with over-prescriptions of antimicrobials, vitamins or minerals and injections.
“Pakistan is globally among the countries with the highest rate of injection usage with over 60 per cent of patient encounters involving an injection and mostly administered by private providers including quacks,” said the report.
“This is a dangerous trend as syringes are re-used amongst different patients, and are improperly disposed and sterilisation practices are not followed for injecting, with clear linkage shown to blood borne diseases such as hepatitis B,C and HIV.”