Many researchers in developing countries have described drug use as “irrational”, documenting cases of ineffective, unsuitable, suboptimal or unsafe prescribing, supply and/or consumption of pharmaceutical products. Drug use in these countries is influenced by many factors: health and drugs policy determines the legal frameworks for drug use and its regulation; the organisation and processes of healthcare provision affect access to professionals and drug therapy; and there are commonly big differences in the availability of drugs and services between regions (notably urban and rural areas). Provision and uptake of care are limited by financial constraints on the part of governments and individuals. Problems of access to objective product information, the role of the pharmaceutical industry in production and marketing, the prevalence of counterfeit products, and the difficulties of regulating professional practice and product quality are well recognised. In sub-Saharan Africa traditional and western medical practices commonly operate side by side: drugs are used in the context of local health beliefs, cultural traditions, and individuals’ perspectives and preferences regarding the appropriateness of different courses of action and drug use.

Interventions to promote safe and appropriate drug use are seen as a vital response to the health problems of developing countries. In 1981 the World Health Organisation set up its Action Programme on Essential Drugs to provide operational support and guidance to developing countries in the establishment of national drugs policies.¹ Over 80% of African countries now have national drugs programmes which initially focused on ensuring wider access to essential drugs. However, measures to improve drug use may be conceived at different levels and focus on any of a broad range of issues, from policy and regulation at a governmental level to prescribing practices and adherence rates at a practitioner/client level.

It is widely recognised, in industrialised as well as developing countries, that adherence to recommended medication regimens is often poor, potentially resulting in treatment failure. Boonstra and colleagues² in this issue of QSHC show how the quality in the processes of care—in this case, dispensing procedures and labelling of medicines—affects patient knowledge which is seen as a prerequisite for adherence to medication. In the measurement of patient knowledge of medication researchers generally focus on the name and purposes of the medication, the dose, frequency of dosing, duration of treatment, and sometimes side effects³ because these elements are viewed as essential for safe and appropriate use. Labelling that is both correct and includes the relevant dosage information is also believed to be important. Researchers are generally aware of the tenuous relationship between knowledge and medication-taking behaviour. It is acknowledged that adherence is influenced by many factors including access to care, affordability of medication, and information and beliefs regarding the need for treatment. However, a recent study in public health facilities in Ghana⁴ demonstrated a link between improved patient information and labelling and adherence rates.

The value of trained staff to the quality of the dispensing process is shown by Boonstra et al.² In many developing countries the more highly qualified professionals tend to be concentrated in the urban areas—for example, 837 of the 964 pharmacies in Ghana are in and around Accra and Kumasi, the country’s two largest cities.⁵ To obtain data representative of the different locations, Boonstra et al selected study sites that would reflect interregional differences in service provision. A more equitable distribution of trained staff across the country may be contingent on wider socioeconomic development, infrastructure, and amenities. However, Boonstra et al concluded that some training, even if limited, may lead to improvements in the quality of the prescribing and dispensing process and consequent outcomes regarding the safety and appropriateness of medication use.

Many researchers, especially social scientists, have described patterns of drug use in the context of local cultural traditions and health beliefs. Practices that may appear to western practitioners as irrational have sometimes been explained in terms of local perspectives and experiences of drug use. In terms of promoting more rational drug use, many of these researchers have highlighted the importance of ensuring that the design and delivery of health programmes take into account the health beliefs and perspectives of local people. In many African countries public sector health personnel (sometimes in comparison with private practitioners) have been perceived as relatively unapproachable, disinclined to spend time with clients, and unwilling to respond to their concerns and views. In their study in Botswana Boonstra et al² describe how family welfare educators—who were often members of the communities in which they worked—were sometimes referred to Botswana’s “barefoot doctors”. As such, they enjoyed the trust of their local communities despite their limited training, and thus could play a valuable healthcare role.

Boonstra et al also reported a mean dispensing counselling time of 25 seconds. As they point out, if this time was increased it would provide greater opportunity for providing relevant information and for ensuring that this was understood. As a person’s concerns and views regarding drug use are known to influence adherence, increased emphasis on the counselling component of the dispensing process would enable these perspectives to be identified and addressed.

In many developing countries public health facilities are only one of many sources of drugs. Local pharmacies, drug stores, chemical sellers, and drug peddlers are important suppliers of pharmaceuticals in many communities. However, despite the widely acknowledged pluralism in healthcare provision, interventions (and their assessment) to improve the quality and safety of drug use have generally focused on public sector care. Exclusion of private practitioners from programmes to improve drug use limits their potential coverage and effectiveness, and may also represent a lost opportunity on the part of health policy makers in achieving national or local health policy objectives.

To promote improvements in the quality of health care which meet specific policy objectives, indicators should be continually reviewed. Boonstra et al identify simple patient knowledge and labelling scores which, as measures of the quality of the processes of care (in this case prescribing and dispensing), would be expected to reflect improved outcomes—namely, safe and appropriate drug use.