Assessment of Prescribing and Dispensing Practices Based on WHO Core Prescribing Indicators in Hospital and Community Pharmacies in Khartoum State-Sudan

Rational drug management has become an increasingly important topic in order to make optimal use of the drug budget to offer health services of the highest possible standard. It is important that continuous assessment for rational prescribing and use of drug have to be carried. Objective of this study was to gather data on existing drug prescription and dispensing practices and to evaluate the prescribing and dispensing indicators as described by the WHO.


Introduction
A drug prescription is usually considered as the endpoint of a patient's visit to a certain healthcare setting. In most situations, it is an instruction that is formally written from a prescriber to a dispenser and is considered to be a medico-legal document that should be written legibly, accurately and completely. Although the prescription format may vary slightly from one country to another, most countries agree on the core elements that should be included in the prescription order during practice. 1 Dispensing is the process of preparing and giving medicine to a named person on the basis of a prescription. It involves the correct translation of the instructions of the prescriber and the accurate preparation and labelling of medicine for use by the patient. This process may take place in a community pharmacy setting, hospital, health centre, public or private clinic. Also, it can be carried out by many different kinds of people with a variety of training or background, but during dispensing process, patients' well-being and their drug-related needs are the primary concern of the pharmacist. 2 In Pharmacy practice, the missions of the hospital pharmacist ranges from simple dispensing to ensure rights of the patients. These missions also include being part of the medication management in hospitals, which encompasses the entire way in which medicines are selected, procured, delivered, prescribed, administered and reviewed. It also includes optimizing the contribution that medicines make to producing informed and desired outcomes; enhancing the safety and quality of all medicine related processes affecting patients; and ensures the 7 "rights" are respected: right patient, right dose, right route, right time, right drug with the right information and documentation. 3 Rational drug use can partly be achieved when there is a rational prescribing of drugs with generic or non-proprietary name, from an Essential Drugs List (EDL) of the healthcare setting (if any) or from the country at large. For drugs to be considered essential, they should meet the healthcare demands of the majority of the population in that catchment area. They are usually selected based on the prevailing disease condition, risk benefit and cost effectiveness ratio (pharmacoeconomic analysis), quality, patient compliance and acceptance. Drugs prescribed with generic name can also increase the availability and affordability of drugs elsewhere [4][5]  in Omdurman city and 20% in Khartoum North city.
Data from these pharmacies were collected by hospital pharmacy master candidate. The candidate stayed at each selected pharmacy for study at least complete shift (8 hours) to collect required data for each pharmacy.
Minimum 10 prescriptions had been reviewed and 10 patients had been interviewed from each pharmacy.

Sample Size
The pharmacies were stratified into either public or private hospital pharmacy and community pharmacy. Operational Definitions

Number of Drugs Prescribed
To quantify the degree of polypharmacy.

Number of Drugs Prescribed by Generics
To measure the tendency for prescribing by generic names.

Percentage of Drugs on EML
To measure the adherence to key strategies such as STG and EML.

Percentage of Patients Prescribed Antibiotics
Address its contribution to antimicrobial resistance.

Percentage of Injections Prescribed
To measure the overused costly and unsafe forms of drug.

Data Analysis
The  20 .
The degree of poly-pharmacy seems unsafe in this study; it requires close monitoring to current prescribing practice. The higher degree of polypharmacy may result in greater risk of adverse drug reactions, drug-drug interactions and extravagancy prescribing.
Major drug use areas given major emphasis by WHO indicator studies are encounters with antibiotic(s) and injection(s). The percentage of encounters with antibiotics prescribed was found to be 53.7% which is too much higher than the upper limit of WHO standard, 30% (ideal range, 20-26.8%) 9. This result was found to be less than pervious studies in Sudan (65.0%, 63.0%) 11,21 and consistent with other study (54.3%) 13 . Values that are lower than this finding and closer to the WHO standard were reported from different areas of the globe including (30.3%) and (31.8%) in Indian healthcare settings 16,22 , (29.14%) and (31.8%) in north and west Ethiopia respectively. 23-24 However, several reports indicated that the prevalence of prescriptions containing antibiotics is even more than this finding. [25][26] The over-use of antibiotics is occurring internationally and leads to increase in adverse drug reactions and hospitalization, but also contributes significantly to an increase in antibiotic resistance and Sudan appears no different.
Coming to the injection prescribing practice, the prevalence of prescription containing injections was found to was higher than the admissible range (57.6%) compared to WHO criteria which is generally less than 25% (ideal range, 13.4-24.1%). This finding is more  In previous study in Sudan and India it was 37.6% 11 and 43.8% 38  drugs. This is much lesser than the optimal value of 100 %. It was higher than that reported in Tanzania (37.9 %) 39 and Malawi (27 %) 40 but much lower than than that reported in KSA (79.3%) 41 Nigeria (93 %) 42 and Egypt (94 %) 37

Conclusion
The overall completeness and rationality of prescription was found suboptimal since some of the key components were missed. The degree of poly pharmacy was greater than of WHO criteria. However, inappropriate use of antibiotics and injections was highly noticeable. These two commonly overused and costly forms of drug therapy need to be regulated closely.
Labeling practice has been significantly poor. Several activities recommended to be useful and effective in promoting rational drug use. These are establishing drug and therapeutic committee; problem-based basic training in pharmacotherapy; targeted continuing education; availability, accessibility, and affordability of drugs of a good standard.