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.2In 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 this concern; World Health Organization (WHO) has designed standardized core prescribing and patient care indicators to evaluate the trends of drug use in outpatient settings of health facilities. Each core indicators have five components. The prescribing indicators include the degree of poly pharmacy, the percentage of drugs prescribed with generic name, the percentage of encounters with at least one antibiotic and injection and the percentage of drugs prescribed from EDL. Moreover, the patient care indicators include, average consultation time, average dispensing time, percentage of drugs actually dispensed and labelled as well as the percentage of patients' who know how to take the correct dosage. The recommended value of WHO for core prescribing indicators include: average number of drugs per encounter < 2 (1.4-1.8), percent encounters with antibiotics <30% (20-26.8%), and percent encounters with injection(s) < 25% (13.4-24.1%), whereas ideally adopted value for prescribing by generic name and from EDL is 100% each. Coming to the WHO patient care indicators, the average consultation time (>10 min), average dispensing time (>180 s), and the percentage of drugs actually dispensed, labelled and patient knowledge are all ideally 100% 6,7,8. These indicators measure the performance of prescribers and dispensers in key areas concerning rational drug use. The indicators assess prescribing, dispensing and patient use of drugs based on clinical encounters at healthcare facilities for the treatment of different illnesses. These indicator studies are less useful when used for inpatient care. These indicators can be used in dispensaries, health centres and hospitals in both public and private sector 9.

A cross-sectional study from 600 outpatient prescribing encounters from Eastern Ethiopia, using the WHO core prescribing indicators, found that average number of drugs prescribed per encounter was found to be (1.89). The percentage of encounters that contain at least one antibiotic and injection was 304 (50.67%) and 315 (59.16%), respectively. Besides, the percentage of drugs prescribed by generic name and from an Essential Drug List (EDL) of the country was 1055 (93.04%) and 1134 (100.00%), respectively.10Different previous studies conducted in Sudan in 2006, 2012, and 2014, concluded that as the values for the average number of medicines per prescription, injection prescribed and adherence to EML was indicative of irrationality for those studies.11,12,13 The study of 2012; included the largest population data to evaluate the prescribing behaviour in Sudan. From 7377 prescriptions analysed, the average number of drugs per prescription were 2.776 drugs, percentage of generics was 37.3%, percentage of antibiotics 54.3%, percentage of injections 38.6% and the percentage of drugs on the essential drug list (EDL) was 72.8%; the study concluded that the observed irrational prescribing behaviour necessitates the development of certain policies as well as practical and effective implementation mechanisms to promote rational prescribing.13

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. The objective of this study was to gather data on existing drug prescription and dispensing practices and to evaluate the prescribing and dispensing indicators against WHO standards for core drug use indicators. Hospital and community pharmacies from public and private sectors were contacted for carrying out this study survey.

The legality, validity, reliability and completeness of prescription papers have overwhelming influence on rational utilization of drugs throughout the globe. 14This study aimed to give an updated overview of rationality of prescription and dispensing practices through evaluation of WHO core drug use indicators in hospital and community pharmacies in Khartoum State- Sudan. Our study reports that the average number of drugs per prescription was found to be (3.98). The difference between hospital and community pharmacies was statistically significant P = 0.015 (Table 1). This value was higher than WHO standard which mandates the degree of poly-pharmacy be less than or equal to two (ideally, 1.6-1.8) in outpatient settings.9This is finding was higher than average numbers of drugs per prescription documented previously in Sudan (1.9, 2.776, 3) 11,12,13 and different parts of the world (2.4) in United States 15, (2.31) in India 16, (2.1) in west Ethiopia 17, (2.2) in Somali region of eastern Ethiopia 18, (2.3) in Pakistan 19, but less than Bangladesh (4.89) 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%) 11,21andconsistent 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 than twice the upper limit of the standard. Better injection prescribing practices were reported from several studies (5.7%, 28.50%, 17.18%, 28.3% 38.1% and 38.6%) in India 16, northwest Ethiopia 23, tertiary care hospital of Bangladesh 20, four selected hospitals of west Ethiopia 17 southern Ethiopia 25, and Sudan13 respectively. On the contrary, higher prevalence of injections was also reported in outpatient setting of Bahawal Victoria Hospital of Pakistan (98.0%)19. In developing countries, up to 56% of primary care patients receive injections. From this, over 90% may be medically unnecessary. Globally, 15 billion injections are given, but half of these injections do not use sterilized needle and syringe, which may result in transmission of potentially infectious diseases. Infections attributable to unsafe injection are hepatitis B (33%), hepatitis C (42%), and HIV (2%). 27,28 Overuse of injections may come from psychological dependence of both patients and healthcare professionals on injections for most diseases. Patients may assume that injections are more effective than any other agents.

The study clearly showed that there are some deficiencies in the quality of prescription writing. Majority of prescriptions (74.0%) don't contain diagnosis and the prescribers often omit writing the diagnosis on the prescription paper. Written dose and duration was missed in (22.0%) of prescription surveyed. A pervious study in Sudan 29, also found that the quality of drug prescribing among hospital doctors had serious deficiencies in comparison with studies done elsewhere.30,31 In the absence of diagnosis, the dispensers simply supply drugs without any know how about the condition to which the drug is going to be issued. However, prescribers have often used prescription in the wrong way. Missing the duration of therapy might result under therapy or over therapy.

Regarding the dispensing and patient care indicators, the average dispensing time was calculated to be 105 secs. The difference between hospital and community pharmacies was statistically significant at p = 0.02 (Table 2). (dispensing time = time when a patient reaches and leaves the pharmacy counter, waiting time not included). This value is below the WHO set point. Moreover, longer dispensing time was reported in different settings. For example, up to (152.3 s) in Ethiopia 33, (150 s) in Zimbabwe34 and (201 s) in Nigerian healthcare settings35. The duration of dispensing time ultimately affects the level of comprehension of patients towards the course of treatment, shorter dispensing time is insufficient to provide complete drug related information to the patients. The percentage of drugs actually dispensed were (55.99%), Figure 2 which shows lower percentage than the ideal WHO standard (100%). The percentage of dispensed drugs was found to be less than the average percent values reported at the tertiary care hospital in Ludhiana, India (100%)36, and Alexandria Egypt (95.5%) 37 However, an inadequate drug supply has its implications on patients’ health status and patient’s convenience and trust in health system. According to this study, the average percentage of drugs adequately labeled were (30.4%). In previous study in Sudan and India it was 37.6% 11 and 43.8% 38. These results have shown deviation from the ideal value of 100%. Labeling is one of the key indicators of good dispensing practice and by any means, adequate labeling ultimately promotes patient awareness about the regimen he/she takes and hence increases treatment adherence. According to our findings shown in Figure 2, (41.33%) of the patients had knowledge of correct dosage schedule for all prescribed 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. Patient’s knowledge of correct dosage is highly beneficial to avoid drug over use and abuse; and prevent adverse effects that harm patient’s health status. A good patient’s knowledge of correct dosage will definitely improve patient care and ultimately affect patients’ health and quality of life.

The large sample size of facilities surveyed, prescriptions and observations, add strength to the work. Data collection from 297 pharmacies was a challenge. The use of WHO core drug use indicators provides a lot of strength to the study. This study has a limitation that the prescription collection was made on only for 1 working day rather than over a long period. Also performing interviews inside the pharmacy facility might have motivated patients to give more positive responses than their real experience. Despite the aforementioned limitations, our study provides insight into the prevalence of irrational dispensing practices and uses of medicines in the capital of Sudan and revealed more worsen patterns of practices compared to previous results conducted in Sudan. Against our expectations, findings revealed that community pharmacies had better rational indicators in most of the encounters than hospital pharmacies. The findings of the present study highlight the importance of considering the monitoring of rational prescribing and dispensing to medicine especially antibiotics; and the value of antibiotic policies in restricting the use of antibiotic agents. A multi-faceted strategy that encompasses education, regulation, and increased financial support is needed at the national level in Sudan.

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.