Tuesday, September 15, 2015

MANIFESTO FOR THE POST OF GENERAL SECRETARY/EXECUTIVE MEMBER, KUTA, 2015

At the very outset I would like to thank the Returning Officer, KUTA elections, 2015, Prof. Mohammad Ayub for organizing this manifesto meet. I consider this a very prudent step aimed at giving the contestants for four main positions an opportunity to apprise members of this august body about their policies, programmes and plan of action. Our individual stand on various issues confronting the teaching community must always remain supreme to our personal rapport and relationships while we go for voting.  Sincerity of intent and sincerity of purpose is the most important trait that one must possess while seeking support.

Dear Colleagues, there is a considerable overlap in the issues highlighted by previous speakers since our issues will remain the same while our priorities may vary. While I fully support and endorse the stand taken by other contestants with regards issues concerning autonomy and freedom of this institution as a whole, viability and credibility of KUTA as an effective and vibrant association, issues concerning senior faculty and female faculty of the university like increase in the age of superannuation to 65, grant of post-retirement benefits like senior citizenship to the faculty, creation of women’s grievance cells, girls common rooms with washroom facilities in every department, equitable allocation of residential quarters, I strongly believe that it is the junior cadre that is suffering the most. Many of our junior colleagues are putting up a smile on their faces but are sulking and simmering with discontent deep inside due to stagnation. We need to address their issues on priority.

I have emailed an article of mine entitled, “half-baked regulations of UGC” to most of my colleagues in this university, in which I have made my stand clear vis-à-vis issues concerning UGC regulations of 2010, their second amendment, API score based performance assessment and its capping provision, use of impact factors for the quantitative assessment of teachers’ performance, salary packages and service length of university teachers etc. While we need to fight for their streamlining at the central level by joining hands with central associations like FEDCUTA, AIFUCTO etc, we need to address our local issues with a greater thrust. I believe UGC has already framed a committee to look into these issues and to suggest improvements in the same, there is every likelihood that API score may be scrapped in near future and assessment of teachers’ performance may be left to the discretion of individual Universities.

Under such circumstances we need to have a strong and vibrant KUTA that will make concerted efforts through sustained lobbying, persistent advocacy and logical interventions to settle things in the best interests of teachers as well as students. Misinterpretation of statutes at the local level has been a grave concern so far. We have witnessed how a large number of our colleagues suffered on account of misinterpretation of statues regarding counting of Ph.D teaching experience period while applying for the posts of Associate Professors. After three years of frustrating struggle the issue was resolved. Now it is the turn of capping of API scores which is being misinterpreted again. I alongwith some other colleagues apprised the university authorities outside KUTA about such misinterpretation way back in 2013 but nothing seems to have changed since then. Even today percent capping of API scores in various sub-categories of Category III of PBAS is being calculated with respect to the minimum score required for that post while it is abundantly clear from the second amendment document that percentage capping has to be calculated with respect to the cumulative or the total API score claimed by the candidate for all the sub-categories clubbed together. Thus it is not necessary to have a mandatory, minimum API score out of each sub-category like research papers, books, projects, conferences and research guidance as is evident from the second amendment document.

Friends I want to ask you all. Are we all so naïve and gullible to fall in the same ditch twice. Should we allow ourselves to undergo the same agony and traumatic experience of countless clarifications and counter-clarifications in this case again as we went through earlier or should we outrightly reject any such misinterpretation without allowing our careers to suffer on this account? Many teachers including me suffered irreversibly because their active teaching period while they were undergoing Ph.D. was not counted as teaching experience even though UGC clarification later made it amply clear that such period should have been counted. I don’t want my other colleagues to suffer on such account. That is my personal agenda for contesting this election which some of us are quite eager to know. But I can assure you that while I have this personal agenda, I have no hidden agenda whatsoever. 

I strongly believe that students must always remain at the core of our activities and endeavours. We owe a lot to our society too. We shouldn't give an impression at any point of time that we are against any kind of criteria based assessment of our performance or any kind of accountability measures. We must always welcome good things and not oppose for the heck of it. We must keep ourselves open to scrutiny provided the quantitative measures used to assess our performance are flexible, rational and just rather than rigid, harsh and impractical. 

My agenda is crystal clear. Let the teachers of this university not suffer on account of any clerical hassles, red tapism, misinterpretation and selective application of rules, regulations and statutes.  I won’t promise sky and moon, I would like to be practical. Let us change whatever is in our domain and whatever we can. With these words I request you all to vote and support my candidature for the post of General Secretary and Executive Member of KUTA. I pledge to dedicate myself to the cause of teaching community and do whatever I can to restore the dignity, legitimate rights and a free, fearless and honorable working environment for the teaching community of this University. The chaos, confusion, uncertainty of our future, fear of stagnation, frustration of becoming a victim of hegemony must not haunt us. We must be able to live and work freely and enjoy our work without any insecurities and uncertainties. It is only then that we can excel. I shall be looking forward to your vote and kind support in this noble endeavor.

Friday, September 11, 2015

Half-baked regulations of UGC and quantitative assessment of teachers' performance

University Grants Commission (UGC) was formally established in 1956 as a statutory body of the Government of India through UGC Act of 1956 for the purpose of disbursing grants to the universities and colleges besides determining, promoting and maintaining standards of teaching, examination and research in the institutions of higher learning. Academic institutions accept UGC regulations in toto and implement them in letter and spirit with a pre-conceived notion that the regulations have been framed by the most veteran experts in the field at the topmost level after threadbare discussions and after taking a kaleidoscopic view of the various segments of teaching and research community that are likely to be affected in a positive or negative manner by the regulations.

To a very large extent these regulations serve their actual purpose and achieve their objectives but in a huge number of cases these regulations prove counter-productive bringing a sense of dismay, frustration and dissuasion to those affected by their ill-effects. Negative effects are produced as a result of ambiguities and vagueness of many such regulations that many a times leads to misinterpretation of regulations and teachers working in colleges and universities have to bear the brunt of those disparities and discrepancies whose career is impacted adversely and irreversibly under such circumstances.

UGC Regulations, 2010

UGC Regulations of 2010 introduced for the first time Academic Performance Indicator (API) based scoring of teachers’ performance in teaching, research, publications and extension activities. While at the very onset, performance based assessment system (PBAS) introduced in these regulations was largely hailed as a step in the right direction towards enhancing standards of quality in higher education, a large number of teachers got adversely affected by several half-baked, vague and ambiguous provisions introduced in these regulations.

One such provision pertains to clause 3.9 of the UGC Regulations, 2010 that spells out the eligibility of Assistant Professors for the open posts of Associate Professors and the counting of period of Ph.D. research as teaching experience thereunder. It reads, “the period of time taken by candidates to acquire M.Phil. and/or Ph.D. degree shall not be considered as teaching/research experience to be claimed for appointment to the teaching positions”. This very clause adversely affected the prospects of promotion of a huge number of Assistant Professors across India whose plea was that “the period of time taken by the candidates to acquire M.Phil. and/or Ph.D. degree” should imply the period when an in-service teacher working on substantive basis in a university was on study leave for pursuing his research degree and not the period when he was actively teaching in his parent department while simultaneously pursuing his M.Phil. and/or Ph.D.

This plea of the affected lot in spite of being genuine was outrightly rejected by the authorities but was eventually endorsed by the UGC and directions were passed to the university authorities not to deduce active teaching period from the total experience gained by teachers while applying for the open posts of Associate Professors. However it took them almost three years of spine breaking, disheartening and frustrating struggle moving from door to door, table to table, one official to the other, explaining their grievance to them and seeking a just redressal of the same. In the mean time selection process continued unabated and many a teachers suffered setbacks since they were declared ineligible and were not called for interviews for these posts. Damage caused to them was irreversible that could not be undone even by UGC clarification later.

API score based performance assessment

When Performance-linked Assessment System (PBAS) based on API scores was announced by UGC in 2010, it was hailed by all academic circles as a concrete measure to arrest decline in the academic standards of higher education to some extent and infuse some semblance of accountability in measuring teaching and research performance of teachers quantitatively. However today it is widely believed that the PBAS based on API scores has done more harm than good to both teaching and research, because of which it should be scrapped altogether. The quantification of teachers’ performance using such stringent criteria has pushed teachers into a ‘rat race’ for gathering points for the sake of recruitment and promotion, and has forced them to mechanically turn into score building machines rather than concentrating on their basic responsibilities towards teaching and students.

The pressure of accumulating cut-off points within specified time frames has led to some sort of commercialization and mechanization of both teaching and research. This system by no means promotes any free and critical thinking among teachers.  So far it has had several negative consequences like proliferation of unhealthy and unfair practices such as substandard research, spurious publications, publication in paid journals, splitting one publication into two or more to get more points (salami publications), publishing books online on fast-track basis with sleazy publishers, outsourcing paper and book writing activities, to mention only a few, which has led to an overall degradation in quality standards of higher education. Ever since API scores were made mandatory, there has been a mushroom growth of hitherto unknown journals that are always on a prowl to persuade academicians to publish substandard research on payment basis to fetch them the required API scores.

Moreover there are stark discrepancies in API based assessment system too. While it envisages to accord points for publishing papers in journals, presenting papers in conferences, publishing books or book chapters and completing research projects, there is no allocation in category-III of PBAS for undertaking peer review of papers and books by teachers, for attending a conference or seminar without presenting a paper, for being a co-author in a paper that is presented in some conference, for chairing or co-chairing a scientific session during scientific meetings, for attending expert committee meetings or evaluating research projects submitted to funding agencies. These vital academic activities have been completing ignored while fixing API scores.

While calculating the API for joint publications by multiple authors, of the total score allotted to the relevant category of publication by the concerned teacher, the first/principal author and the corresponding author are supposed to equally share 60% of the total points and the remaining 40% are to be shared equally by all other authors. In case a paper has three authors and it carries a total of 10 points, as per this regulation 3 points each will go to the first and second author and the remaining 4 points will go to the third author who is neither the main researcher nor his supervisor but has contributed in some way in that research. Such irrational distribution of scores makes a mockery of this entire system and reflects the myopic vision of the people who have designed and developed it. 

Therefore present API based PBAS seeks to promote a score-hunting attitude among teachers. It promotes mechanization rather than creativity. Teachers working in colleges and universities across the country are feeling stressed and subdued on account of flaws in UGC regulations particularly API based PBAS since these flaws are posing a serious threat to their academic progress and are demoralizing them besides leading to unhealthy competition in educational institutions.

Second amendment and capping of API scores

UGC brought in second amendment to the UGC Regulations of 2010 in June, 2013 only to add more ambiguity, confusion and chaos to the already existing vague regulations. This time UGC introduced capping to calculate the total API score claim of the applicants for direct recruitment as well as CAS (career advancement scheme) promotions under various sub-categories of Category III of PBAS (performance based assessment system). These sub-categories include research papers, books, research projects, research guidance, conference and seminar attendance.  However it clearly specified that the capping shall be calculated in relation to the total API score claimed by the candidates.

Publication in journals has a higher cap than the publication of books that may be favorable for science streams but not for other disciplines like humanities and languages. This leads to further discrepancies in the evaluation using a common yardstick for all streams across the board irrespective of whether the institute is primarily a teaching or a research centre, whether the centre is policy or practice oriented one, whether it is engaged in lab or field related work. Effectively, a teacher has to forego a lot of hard earned points in his own areas of strength due to the application of these caps. Furthermore going by the logic of these new Regulations, it is seldom possible for a newly recruited Assistant Professor to score a minimum percentage of API score in each sub-category within a short span of four years after his first appointment when he has hardly been approved as a research guide by the University BORS, thereby making it almost impossible for any new recruit to get his promotion as per the established timeline of UGC Regulations, 2010. Further it is not easy for the faculty members working in non-teaching departments and research centres to fulfill all the requirements as are laid down under the new amendment.

Ironically, research projects undertaken by the teachers have a higher cap and are placed above research guidance. This damages teachers' interests quite often since many a times funding agencies are running short of funds and can't approve project proposals of all the teachers evidenced by the fact that the new union government at the centre has slashed this budget by a whopping 20% for some unknown reasons. Further, the restriction of research supervision to one hour per student per week is detrimental to the academic interests of the research based institutions since that is just not enough to do justice with a scholar. Guidelines are also silent about the research guidance provided to the students for their M.Pharm./MBA/MCA/LLM dissertations. This is gross injustice to such supervisors who have to supervise several PG scholars every year for their year-long research projects that culminate in compilation of a dissertation and at the end of the day no weightage is given to these supervisors. This is quite discouraging and demoralizing for such supervisors moreso in light of the fact that in some of these subjects like M.Pharm. there is no M.Phil. and therefore PG dissertation is as good as M.Phil. dissertation. This anomaly needs to be rectified in its right earnest.

Second amendment notification clearly mentions that the capping shall be calculated in relation to the total API score claimed by the candidates. In one of the tables showing break-up percentage capping of various sub-categories, it clearly reads, “CAP AS % OF API CUMULATIVE SCORE IN APPLICATION”. It doesn’t say cap as % of API in each sub-category, it says cumulative score in the whole application meaning total API claim of the applicant in all sub-categories clubbed together. However once again it is being misinterpreted by many across India by taking the given cap as minimum and mandatory percentage of the API points required to be scored by the teachers in each sub-category of category-III whereas word “cap” clearly specifies it as a “ceiling” or the “maximum” of cumulative API score claimed by the applicant. Therefore in essence this amendment is meant to prevent the applicants from claiming a score under various sub-categories of Category III beyond a specified “Cap”, “Ceiling” or “Maximum” score. Thus most appropriate interpretation of the second amendment is to calculate caps in various sub-categories of category III in relation to the total API score claimed by the applicant in all the sub-categories clubbed together and to treat the cap as maximum limit of API score that an applicant can claim in each sub-category rather than the minimum or mandatory percentage that he has to score.

When the caps provided under Category I and II are not taken as minimum points required to be scored by the applicants there is no justification that under Category III they should be perceived as minimum percentage required to be scored. It is astonishing that in case of Category I and II UGC has directly used the words “maximum score” but in case of Category III it has used the word “capping” instead of “maximum” not realizing that even such words are liable to misinterpretation in Indian settings with a potential to compound the confusion to the detriment of the applicants. In order to avoid further damage to the careers of many a teachers on account of misinterpretation of this word, there is need to understand, interpret and implement the regulation in its true essence without leaving any room for miscalculation that has a potential to mar the prospects of promotion and growth of a vast number of teachers because going by the other interpretation of this statute, very few teachers would be able to fulfill the requirement and a large number of them would be left in lurch in spite of having an excellent total API score under all the three categories clubbed together.

Service length of College and University teachers

There is huge disparity and discrepancy in the service length as well as the salary packages as a teacher moves from Assistant Professor cadre to Associate Professor and then to Professor cadre. Lot of injustice is meted out to the junior cadre with a hike of just 1000 rupees from stage 1 to 2 and from stage 2 to 3 followed by a quantum leap of around 50 to 100% hike in the salary from stage 3 to 4 depending upon the service length of the aspirant. Till stage 3 salary gap is too narrow and beyond that it is too wide. Opposite of this is true in case of service length.

Career advancement scheme that is presently in vogue encompasses 12+3 formula as per which it takes around 12 to 16 years to move from Assistant Professor to the designation of an Associate Professor but only three years thereafter to become a Professor, which is totally inequitable, irrational and unjust. There is need to end this discriminative scheme and switch over to the more rational 9+6 formula or even better 9+3 scheme as the seventh pay commission formulates its recommendations in near future. This will bring some uniformity and remove discrimination and disparity in the scheme. Entire zeal, enthusiasm and motivation of an Assistant Professor gets killed by this unreasonable promotion system and it not only breeds inertia but corruption too. By incorporating API score based assessment and its capping, entire brunt is borne by the Assistant Professor for whom it becomes even more difficult even after 14 years to dream of becoming an Associate Professor since the parameters are very stringent that are only made worse by their misinterpretation.

In the year 2012, in a major policy decision, J&K government relaxed promotional norms of doctors working in the Medical Education Department. As per the amendment, promotions of doctors will follow 3+3+3 scheme instead of earlier 3+5+5 formula from the post of lecturer to assistant professor to associate professor to professor, thus reducing the total time span to become a professor from 13 to only 8 years. However in case of University teachers promotions are only getting delayed with every new regulation coming into force. Several expert committees at the central level have recommended reversal of this unreasonable formula of UGC.

Journal Impact Factors

Another faux pas of UGC has been the introduction of Impact Factors as means of evaluation of research activities of teachers. Impact factors were basically designed to assess the quality of a scientific journal by calculating the number of times the articles published in that particular journal were referenced or cited by others. Over the years it has been misused instead to assess the quality of the academicians. The impact factor is a flawed quantitative parameter as it is dependent on the number of times a paper is cited. A highly cited paper will push up the impact factor of a journal. No wonder journals that exclusively publish review articles rather than original research papers have much higher impact factors than other journals simply because they attract more number of citations.

There is another side to it. Take for instance a researcher who is working in a resource poor, under-developed setting where scientific, industrial, technological, economical or developmental concepts, processes and procedures that are old and sometimes even obsolete to the rest of the developed world, are still as good as innovations given their backwardness and slow pace of development. If such a researcher introduces such concepts at such a place with an aim of harnessing development, streamlining policies and procedures and organizing management activities, in different spheres, his work will hardly ever get published in a high impact journal given the redundancy and lack of novelty of his concepts in rest of the developed world even though his research and extension work might bring radical changes at his place of work much to the benefit and respite of millions of people inhabiting there. Further, the number of citations a research paper will get is dependent upon its life span that increases with an increase in the number of years after its publication. Thus, a far more reliable way to appropriately evaluate a research paper is through peer review by well-known experts in the field who can assess its standards. Let the research assessment go back to where it originally belongs, that is in the hands of peers and experts in that field.

The backlash against the journal impact factors is not restricted to India alone. It has led to the Declaration on Research Assessment (DORA) which was signed by members of the scientific community gathered at the annual meeting of the American Society for Cell Biology held on May 16, 2013. Specifically, the signatories have recommended that the journal impact factor should not be used as a measure of scientific success in funding, appointment and promotion consideration. Instead they recommend that the research should be evaluated on its own merits.

Anomaly and Revisit Committees

University Grants Commission itself has realized various flaws in their regulations after it received a flood of representations and complaints from teachers, researchers, colleges, universities, associations from across India since a very large number of teachers were getting adversely affected by them and their promotions were getting stuck for years together. Since 2010 UGC decided twice to scrap these regulations of 2010. Once during 489th meeting of the Commission in November, 2012 and then again during 497th full Commission meeting held on 10 Jan 2014, UGC decided to bring in third amendment calling for the rollout and revision of caps and forwarded it to the MHRD for approval on 23rd May, 2014. However the decision of UGC is still awaiting approval from MHRD even after a lapse of more than a year. It appears that at the eleventh hour some unknown force, most likely political in nature, prevails upon the union HRD ministry and gets the decisions revoked.

Many times UGC had to frame anomaly committees and revisit committees to examine the anomalies brought into its notice and revise the regulations. Though several anomalies with respect to pay scales and promotions have been removed by these committees, however no final decision has been made till date regarding revocation of these API scores even though recently a high power committee has been given two months time to decide on the matter while thousands of teachers continue to suffer on account of these anomalies and discrepancies across the country. Another committee has been constituted by the UGC on September 3rd, 2015 under the chairmanship of Prof. Arun Nigavekar, former Chairman, UGC with a view to attract, select and retain talented and meritorious faculty in colleges and universities who are otherwise getting disgruntled and disillusioned with the stringent and demoralizing UGC regulations and are leaving educational and research institutions for greener pastures abroad. This committee is at present inviting suggestions from all stake-holders on how API score based performance assessment could be improved and made more rational both at the entry point and during career advancement of teachers. Hope better sense prevails on them and they scrap this unjustified system altogether. In case they leave it to the discretion of the individual universities to decide the criteria of quantitative assessment of their teachers’ performance, then teachers at the institutional level have to play a proactive role and ensure that the criteria devised by the universities are prudent, practicable and pragmatic.

Tailpiece:

Nobody is against incorporation of quantitative or qualitative measures for assessing the performance of teachers but they need to be flexible, rational and just rather than stringent, impracticable, irrational and unjust. What kind of standards are these that are not only demoralizing the teaching community but inciting unhealthy competition, infighting, dissuasion and dissidence among teaching faculty. In this manner desired objectives of UGC regulations can never be achieved and these regulations will continue to prove counter-productive.

- Dr Geer Mohammad Ishaq

Monday, August 24, 2015

Drug utilization research for promoting rational use of medicines in Kashmiri population

Principal aim of drug utilization research is to facilitate safe, effective and rational use of drugs in populations. Without knowledge of how medicines are being prescribed and used, it is difficult to make necessary interventions for promoting rational drug use in the society. Therefore drug utilization studies are carried out to ensure that the drugs are prescribed, dispensed and used appropriately, in tune with established guidelines with a view to improve patient’s health related quality of life. Results of four drug utilization studies carried out by the authors over the past few years including drug utilization evaluation of statins in patients of diabetes mellitus at a tertiary care hospital; Evaluation of the prescribing patterns of anti-hypertensive drugs in patients of hypertension with associated co-morbidities at a tertiary care hospital; Drug utilization patterns and risk assessment for primary and secondary prevention of cardiovascular disease at a tertiary care hospital and drug utilization patterns and risk assessment for renal impairment patients at a tertiary care hospital shall be presented. Besides, aim and objectives of three more drug utilization studies to be taken up this year including drug utilization studies among neonatal and pediatric in-patients at a tertiary care hospital; drug utilization studies among geriatric patients at an internal medicine unit of a tertiary care hospital and Hospital and community-based drug utilization evaluation and assessment of the quality of pharmaceutical care among pregnant women of Kashmiri origin shall also be discussed. With the completion of these studies a baseline of vital information shall be generated on the overall drug utilization patterns among different categories of Kashmiri patients that shall very well serve the objectives of National Drug Utilization Programme launched by the Indian Council of Medical Research (ICMR) this year and improve the quality of drug use among the local population.

Community and hospital-based drug utilization study in Kashmiri population using WHO devised methodology


Introduction:

Essential medicines are one of the vital tools needed to improve and maintain health. However, for too many people throughout the world medicines are still unaffordable, unavailable, unsafe and improperly used. An estimated one-third of the world’s population lacks regular access to essential drugs, with this figure rising to over 50% in the poorest parts of Africa and Asia. When available, the medicines are often used incorrectly: around 50% of all medicines are prescribed, dispensed or sold inappropriately, while 50% of patients also fail to take their medicines appropriately. This often leads to problems such asineffective treatment, health risks, patient non-compliance, decreases the quality care of population andincreases morbidity and mortality besides leading to excessive spending onpharmaceuticals and wastage of financial resources by patients as well ashealth care system1. Published literature suggests that drug wastages may be dueto excessive and irrational prescribing and dispensing, or due to lack of controlupon the sales of prescription medications in the community pharmacies andpoor compliance of the patients.2-3 For these reasons,World Health Organization has evolved the concept of Drug Utilization Research (DUR)whose primary aim is to facilitate the rational use of drugs in populations.DUR involves study of marketing, distribution, prescription, dispensing and use of drugs in a society with special emphasis on the resulting medical, social and economic consequences4. DURstudies are a very important tool to obtain such information so that it helps in universal access to medicines and their rational use.

Novelty:

In the state of J&K, barring a couple of hospital based DUE studies by Jan et al5 and Tandon et al6, no community or hospital-based DUEstudies have been conducted. However newspaper reports suggest large scale use of medicines by the locals. Self-medication and over-the-counter dispensing of prescription drugs by mostly unqualified retail pharmacists seem to be rampant. There is acute paucity of literature about DUE studiesfrom J&K. Therefore there is need to conduct a study which can reveal the picture of how drugs are being prescribed, dispensed and used in households of our community as well as at primary/community health centres.

Applicability:

This study shall provide an idea about the present utilization practices of medicines in the community and associated hospitals, the problems encountered by people related to the medicine use including the channels through which people treat their ailments, obtain their medicines, medicine affordability and accessibility problems and the extent to  which rational drug use concept exists in the community. This study shallalso generate sufficient data for both state and centralgovernments which can then help in policy making for promoting universal access to medicines as well as their rational use since no such data is available from J&K at present.

Methodology:

The study mainly comprises of two parts -the household part and the hospital part. In households the method of data collection will make use of a pre-validated, self-administered structured questionnaire. The study design will be a cross sectional baseline study based on the methods contained in WHO manual "How to investigate the use of medicines by consumers”7 and WHO methodology on Drug Utilization Research as outlined in WHO guide “Introduction to drug utilization research”8.

The structured household interview questionnaire will include  information on the socio-demographic data of interviewed households, their common chronic diseases, use of traditional remedies, medicines available on the day of the visit, their therapeutic uses and by whom they were used, various modalities through which people in the households treat and obtain their medicines and the reasons for choosing them, various storage places and practices of the stocked medicines, expiry dates of the stocked medicines, and the left-over medicines and how households deal with them, adequacy of labels for the stocked medicines, households' knowledge of the correct dosage regimen and route of administration of stocked medicines, the adherence of patients towards their prescribed medications using Morrisky’s patient adherence questionnaire9, approximate expenditure on healthcare services and its impact on the overall economy of the household, the Daily Defined Dose and Anatomical Therapeutic Classification of the prescribed drugs for chronic use etc.

Second part of the study shall be conducted in the primary/community health centers as well as the private retail pharmacists in the vicinity of the selected hospitals. This will involve the assessment of prescribing practices of the healthcare prescribers and dispensing practices of pharmacists. Data from a random sample of 20-25 prescription slips per facility shall be captured on the day of the facility visit to study prescribing practices, using WHO drug use indicators like number of medicines per prescription, medicines prescribed by generic name, medicines prescribed from essential medicines list, usage of antibiotics, injections, syrups, fixed dose combinations etc.

Knowledge, attitude and dispensing practices of pharmacists will also be ascertained using a pre-validated, structured questionnaire. This will include the information on qualification and experience of the retail pharmacists, overall drug dispensing and storage practices by retail pharmacists, involvement of pharmacist in patient counseling, promotional schemes from manufacturers, pharmacists’ knowledge and attitude about legal and rational drug use.

Selection of Districts, Households and Health Facilities:

Sampling of districts and health facilities shall be done in a systematic manner in accordance with PPS (probability proportional to size) approach so as to ensure that the findings are representative of the entire Kashmir province of Jammu and Kashmir state. Accordingly districts, households, retail chemists and study hospitals shall be sampled in such a manner so as to represent the whole geography of Kashmir province. In each of the 06 districts selected three blocks, one primary health centre or community health centre in each block, three retail chemists in each block and thirty households in each block shall be selected randomly for the data collection. Thus, data shall be collected from a total of 18 blocks, 18 primary/community health centres, 54 retail chemists and 540 households. 

Feasibility:

The health sector in Jammu and Kashmir is unique Indian state beset by many challenges. A combination of weak institutional capacity, limited access to modern equipment and infrastructure, and shortage of healthcare personnel has limited the effectiveness of health service delivery in the State. The healthcare system in J&K is primarily run by the State Government. The private sector plays a smaller part in health service delivery. The non-governmental sector is largely absent.We don’t have qualified and trained pharmacy graduates working as pharmacists either in government or in private sector. In government hospitals Medical Assistants with one year multi-purpose health worker type diploma in their hands are employed as pharmacists whereas in private sector matriculates with some experience in sale of medicines at a retail counter have been registered as pharmacists and granted drug sale licenses as per a redundant and obsolete piece of legislation known as the J&K Pharmacy Act, 2011 (samvat) that has been framed more than sixty years back and amended only once to include matriculates as registered pharmacists. Consequently patients are deprived of good counseling services on the use of medicines. On top of that patients largely prefer to consult these very Medical Assistants or so-called pharmacists over registered medical practitioners for choosing medicines and curing their ailments. However the reasons for and consequences of such a drug utilization pattern have not been documented anywhere in the literature.

Outcome:

Jammu and Kashmir government has drafted and approved its maiden state drug policy in the year 2012 that has several provisions related to promotion of rational use of medicines including pharmacovigilance activities and drug utilization research. However drug policy has not been implemented. There is paucity of literature on existing drug related problems in the community. Therefore this study will significantly improve implementation of the approved drug policy by generating data on various drug related problems existing in the community and documenting various prospects and challenges towards improving drug use. One such study sponsored by Public Health Foundation of India (PHFI), New Delhi has already been conducted by us in the year 2014 and report submitted to PHFI. This study is also feasible and viable in the local settings. Prior permission from government authorities shall be obtained before starting the study.

This study is expected to throw some light upon the below mentioned research questions:

ü  What are the most frequent categories of medicines being used by the surveyed households and by whom they are used?
ü  What are the preferences people rely on treating their ailments and obtaining medicines?
ü  What are the reasons for choosing the source of treatment (such as health facility, pharmacist, traditional healer, self-medication etc)?
ü  What are the alternate modes of treatment used by the patients?
ü  How far are patients adherent to the prescribed medications?
ü  How well versed are patients with their prescribed medications?
ü  What are the prescribing practices of healthcare prescribers in the primary care hospitals?
ü  What are the daily defined doses (DDD) per 1000 inhabitants on the basis of Anatomical therapeutic classes (ATC) of the prescribed drugs?
ü  What are the knowledge, attitude and dispensing practices of community/retail pharmacists?
ü  What is the overall satisfaction level of people towards the healthcare facilities and prescribed medications?
ü  What is the economic impact of healthcare expenditures in general and expenditures on medicine in particular on households?

References:

1.       WHO (2002). Promoting rational use of medicines: core components. WHO Policy Perspectives on Medicines, No.5. Geneva, World Health Organization.
2.       Potter M. Medication compliance - a factor in the drug wastage problem. Nurs times. 1981; 77 (suppl 5):17-20.
3.       Nasser AN. Prescribing patterns in primary health care in Saudi Arabia. DICP. 1991; 25:90-93.
4.       Serradell J, Bjornson DC &Hartzema AG. Drug Utilization Study Methodologies: National and International Perspectives. Drug Intelligence and Clinical Pharmacy. 1987; 21(12, December):994-1001.
5.       Jan A et al. Drug Utilization At SKIMS–A Tertiary Care Hospital.JK- Practitioner 2013;18(1-2):35-40.
6.       Tandon R et al. Antihypertensive drug prescription patterns, rationality, and adherence to Joint National Committee-7 hypertension treatment guidelines among Indian postmenopausal women. J Midlife Health. 2014; 5(2): 78–83.
7.       Chetley A, Hardon A, Hodgkin A, Haaland A, Fresle D. How to investigate the use of medicines by consumers.(WHO/PSM/PAR/2007.2) Geneva: World Health Organization, 2007.
8.       WHO. Introduction to drug utilization research/WHO International Working Group for Drug Statistics Methodology, WHO Collaborating Centre for Drug Statistics Methodology, WHO Collaborating Centre for Drug Utilization Research and Clinical Pharmacological Services 2003. 
9.    Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care1986;24:67-74.

Hospital and community-based drug utilization evaluation and assessment of the quality of pharmaceutical care among pregnant women of Kashmiri origin

Pregnancy is a special physiological condition where drug treatment presents a special concern because the physiology of pregnancy affects the pharmacokinetics of medications used and certain medications can reach the fetus and cause harm. Careful consideration of the benefits to the mother and the risks to the foetus is required while prescribing drugs during pregnancy and lactation. The use of drugs during pregnancy calls for special attention because in this case in addition to the mother, the health and life of her unborn child is also at stake. 
 
Due to ethical constraints whenever a new drug hits market, it is almost never tested in pregnant women and hence its effect on the fetus and newborn remains uncertain. Most of the drugs therefore are labelled as ‘not to be used in pregnancy'. These constraints put pregnant women and their physicians in a difficult situation worldwide. Furthermore in case of unplanned pregnancies most of the fetuses are exposed to drugs before even being aware of pregnancy.
 
World Health Organization (WHO) has reported that 50% of all medicines are prescribed, dispensed or sold inappropriately, while 50% of patients also fail to take their medicines appropriately. This often leads to problems such as ineffective treatment, health risks, patient non-compliance, decreases the quality care of population and increases morbidity and mortality besides leading to excessive spending on pharmaceuticals and wastage of financial resources by patients as well as health care system. For these reasons, WHO has evolved the concept of Drug Utilization Evaluation (DUE) whose primary aim is to facilitate the rational use of drugs in populations.
 
Methodology:
 
The study design will be a cross sectional baseline study based on the methods contained in WHO manual "How to investigate the use of medicines by consumers” and WHO methodology on Drug Utilization Research as outlined in WHO guide "Introduction to drug utilization research." Study will be conducted at all the three levels of primary, secondary and tertiary care hospitals including both government and private antenatal clinics. Study units shall include a leading government, tertiary care gynecological hospital based at Srinagar, the capital city of J&K state, few community health centres and primary health centres spread across Kashmir valley and a few private antenatal clinics. Sampling of health facilities shall be done on the basis of their geographical distribution in accordance with PPS (probability proportional to size) approach so as to ensure that the findings are representative of the entire Kashmir province. 
 
Data shall be collected using a self-administered, pre-designed and pre-tested questionnaire after obtaining necessary ethical clearance. Pregnant women reporting at study units during the study period shall be interviewed in local language, after obtaining their informed consent. Their statements shall be corroborated with the written records and medicines that are available with them. All prescriptions during the study period shall be audited for drug utilization and cost analysis. Information shall be collected and analyzed for various study parameters including demographic and anthropometric details, duration of pregnancy, family per capita income per month, number of antenatal visits, self-medication practices, number of drugs used, number of herbal/homeopathic drugs used etc. All drugs used during the first (first 12 weeks), second (13th to 24th week) and third (24th week onwards) trimester of pregnancy shall be classified into category-A, category-B, category-C, category-D and category-X, as per the classification for drug use during pregnancy, given by the US Food and Drug Administration (FDA). ATC-DDD classification of drugs as prescribed by WHO shall be used wherever necessary. 
 
Main objective of the study shall be as under: 
 
Ø  To evaluate the prescribing patterns of doctors among the pregnant women presenting to antenatal clinics of a gynecological hospital, primary and community health centres and those reporting at private gynecological clinics.
Ø  To ascertain the choice, strength, dosage forms and duration of treatments prescribed to the pregnant women at study units and stratify them as per WHO ATC/DDD methodology wherever applicable.
Ø  To perform cost analysis of drugs prescribed to pregnant women.
Ø  To evaluate the prescribing patterns using WHO drug use indicators among the study population.
Ø  To evaluate the pharmaceutical care services including patient counseling, drug information and pharmacovigilance services available to patients at the study hospital.
Ø  To assess prescribing practices of the prescribers and dispensing practices of pharmacists.
Ø  To assess the use of traditional remedies by the pregnant women.
Ø  To evaluate the adherence of patients towards their prescribed medications using Morrisky’s patient adherence questionnaire.
 
Data from a random sample of prescription slips shall be captured on the day of the facility visit (roughly 20-25 slips per facility). Prior consent of the respective medical heads of the facilities shall be sought in addition to the oral consent of the patients. Analysis of prescription slips is required to contribute towards understanding the level and pattern of irrational prescription practices, if any.
 
Feasibility:
 
Information on the use of drugs during pregnancy is scarce and rather anecdotal. Careful consideration of the benefit to the mother and the risk to the fetus is required when prescribing drugs during pregnancy. Total avoidance of pharmacological treatment in pregnancy is not possible and may be dangerous because some women enter pregnancy with medical conditions that require ongoing and episodic treatment (e.g. asthma, epilepsy, hypertension). Also during pregnancy new medical problems can develop and old ones can be exacerbated (e.g. migraine, headache) requiring pharmacological therapy. The fact that certain drugs given during pregnancy may prove harmful to the unborn child is one of the classical problems in medical treatment.
 
Drug utilization studies on pregnant women focus on the potential teratogenic effects traditionally. However drugs can influence foetus during entire time of pregnancy. Furthermore toxic manifestations of intra uterine drug exposure may not be revealed many years after the time of birth. The potential long term consequences of intra uterine exposure to drugs emphasise the importance of studying drug exposure during pregnancy and prolonging follow up beyond the time of birth.
 
The health sector in Jammu and Kashmir is unique Indian state beset by many challenges. A combination of weak institutional capacity, limited access to modern equipment and infrastructure, and shortage of healthcare personnel has limited the effectiveness of health service delivery in the State. Patients are deprived of good pharmaceutical care services on the use of medicines like patient counseling services, drug information services, adverse drug reaction monitoring services etc due to non-availability of qualified clinical pharmacists in either government or private sector. However the reasons for and consequences of such a drug utilization pattern have not been documented anywhere in the literature.

Thursday, May 21, 2015

Drug utilization evaluation among geriatric patients at a tertiary care hospital

Background: The elderly population is one of the most rapidly increasing populations in the world. Inter-individual differences in age related pharmacokinetic and pharmacodynamic changes as well as co-morbid conditions have to be considered while prescribing medicines in elderly population. This population is vulnerable to many diseases and drug related problems. There are various problems with medicine treatment in elderly population like inappropriate prescribing is more likely to occur in elderly patients since they may receive several drugs simultaneously on account of chronic diseases and/or multiple health problems and polypharmacy, altered drug response, adverse drug reactions (ADRs) and patient non-compliance.
Need for the Study: The elderly population is increasing rapidly worldwide. Their growth rate (1.9%) is higher than general population (1.2%). At present, India is the third country after China and USA with large elderly population in the world. Elderly population has special problems related to health, social support, and economic security. Their healthcare need differs from the younger people. Though elderly are reported to be responsible for half the total drug usage, less than 5% of randomized control trials have been designed for them. Therefore, data available from younger subjects are used to guide prescribing in elderly. Physiological and pharmacological variations in elderly population include decreased total body mass, blood flow to various organs, immunity, and nervous functions; down- or up regulation of various receptors; and disturbance in first pass metabolism, bioavailability, metabolism, and excretion. Presence of co-morbidities in elderly people require use of multiple medications which increase the irrational prescription, use of inappropriate medications, noncompliance, economic burden, adverse drug reactions (ADRs), and drug interactions.  The overall incidence of ADR is two to three times higher and most of them are potentially avoidable in elderly patients. These hurdles in pharmacotherapy can be overcome by periodic evaluation of drug utilization and optimizing prescribing pattern by forming prescription guidelines for geriatric patients. Drug utilization research is an important tool to analyze the use of drugs with special emphasis on medical, social, and economic consequences in a society.
Objective: Main aim of this study is to evaluate the drug utilization patterns among geriatric in-patientsat a tertiary care hospital.
Setting and Method: A prospective, cross-sectional, observational study would be conducted among geriatricpatients admitted to the General Medicine ward during an eight month period at a tertiary care hospital.
Main Outcome Measures: Drug utilization patterns in geriatric patients, dose adjustments, patient counselling needs, pharmaco-economic evaluation of prescribed medication, physicians’ adherence to guidelines, patient compliance to prescribed medication.