Pros and cons of third amendment to UGC Regulations, 2010

On May 10^th, 2016 UGC published a Gazette Notification that promulgates third amendment to UGC Regulations of 2010 governing minimum qualifications for appointment of teachers and other academic staff in universities and colleges and measures for the maintenance of standards in higher education. Though third amendment mainly concerns changes in qualification for direct recruitment to the posts of Assistant Professors and exemption from the requirement of eligibility condition of NET/SLET/SET for recruitment subject to certain conditions for those candidates who completed their Ph.D. degrees prior to July 11, 2009, it also amended Academic Performance Indicators (API) for Career Advancement Scheme (CAS) promotions for Assistant Professors, Associate Professors and Professors and for direct recruitment of Associate Professors and Professors in universities and colleges.

Regulations governing recruitment of Assistant Professors

Several regulations passed by the UGC in the past have been contradictory and enigmatic with no logic or justification whatsoever. For example, to ensure and maintain the quality of Ph.Ds, UGC developed a set of regulations in 2009, and executed the same with retrospective effect. Consequently newly appointed Assistant Professors, having obtained their Ph.D. degrees before 2009 , who according to UGC rules were entitled to get several non-compoundable increments, were denied the same. They were asked to justify that their Ph.D was in accordance with UGC Regulations of 2009. One fails to understand how a Ph. D awarded in 2003 can comply with the regulations framed in 2009. While excellence and innovation need not be linked to perks, these kind of regulations definitely have a negative impact on the performance of those affected.

Similarly when UGC regulations 2009 were notified, it was mandated that only those holding Ph.D. degrees in accordance with standards set in 2009 are eligible for any fresh teaching posts. As per news reports, this rendered several thousand Ph.D. holders across India potentially ineligible for teaching jobs for the simple reason that when these people were pursuing their Ph.D. degrees, the rules setting new standards were not in place. Suddenly their Ph.Ds ran the risk of becoming invalid. Later UGC had to enforce the new rules prospectively to overcome this anomaly that had left large number of teaching faculty positions unfilled for quite a long time across India. These regulations had necessitated that even those applying for adhoc posts must hold Ph.Ds. It is common knowledge that adhoc posts are created by universities to attract teachers when they are unable to find suitable faculty meeting qualifications required for the regular posts. Now with Ph.D being stipulated for even adhoc posts, universities found it difficult to appoint any teachers for these positions, even on stop-gap basis.

UGC Regulations 2010 that mandated NET/SLET/SET for fresh recruitment as Assistant Professors in colleges and universities and necessitated Ph.D. degree completion in accordance with UGC Regulations of 2009 halted fresh appointments causing dearth of teaching faculty in educational institutions across India. Third amendment of May, 2016 sought to rectify this anomaly by laying down certain conditions for those candidates who completed their Ph.D. degrees prior to July 11, 2009 i.e., when UGC Regulations of 2009 were notified.  Third amendment of 2016 envisages that the candidates, who have been awarded a Ph. D. degree in accordance with UGC Regulations, 2009 or the subsequent Regulations if notified by the UGC, shall be exempted from the requirement of the minimum eligibility condition of NET/SLET/SET for appointment of Assistant Professor or equivalent positions in Universities/Colleges/Institutions. Further, the award of degrees to candidates registered for the M.Phil/Ph.D. programme prior to July 11, 2009, shall be governed by the provisions of then existing ordinances/by-laws/regulations of the institution awarding the degree and the Ph.D. candidates shall be exempted from the requirement of the minimum eligibility condition of NET/SLET/SET for recruitment and appointment as Assistant Professor or equivalent positions in Universities/Colleges/Institutions subject to the fulfillment of certain conditions like (a) Ph.D. degree of the candidate awarded in regular mode only (b) Evaluation of the Ph.D. thesis by at least two external examiners (c) Candidate had published two research papers out of which at least one in a refereed journal from out of his/her Ph.D. work (d) Candidate had presented two papers in seminars/conferences from out of his/her Ph.D. work (e) Open Ph.D. viva-voce of the candidate had been conducted. (a) to (e) as above are to be certified by the Vice- Chancellor/ Pro-Vice-Chancellor/ Dean (Academic Affairs).

Fault lines in API based performance assessment of teachers

From the very beginning there have been stark discrepancies in API based performance assessment system devised by the UGC in the year 2010. While it envisaged to accord API scores for publishing papers in journals, presenting papers in conferences, publishing books or book chapters and completing research projects, there was 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 by someone else, for chairing or co-chairing a scientific session during scientific meetings, for attending expert committee meetings or evaluating research projects submitted to funding agencies and for being appointed as a member of editorial and review boards of various journals. These vital academic activities had been blatantly ignored while fixing API scores. Though third amendment regulations of 2016 have made new API allocations for activities like winning a national or international award or fellowship, yet the all important activities mentioned above continue to remain unaccounted which is a gross injustice with teachers who spend considerable amount of their precious time in these significant academic activities. UGC had constituted an expert committee in September, 2015 under the chairmanship of Prof. Arun Nigavekar, former Chairman, UGC with a view to improve API score based performance assessment and make it more rational both at the entry point and during career advancement of teachers. It is very unfortunate that some of the ambiguities and discrepancies in API score allocation still persist after the recommendations of this committee have been notified in the official Gazette of India.

Under clause 3.9 of the UGC Regulations, 2010 it was specified that, “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. It took UGC six years to clear the ambiguity and confusion in this clause. While the original regulations were ratified by UGC in its 468^th meeting held on February 23, 2010, it was after six years and 44 meetings of the Commission when UGC in its 512^th Meeting held on February 4, 2016 issued a clarification that “the period of active service spent on pursuing Research Degree i.e. for acquiring Ph.D. degree simultaneously without taking any kind of leave may be counted as teaching experience for the purpose of direct recruitment/promotion to the post of Associate Professor and above”. During the interim period of six years a huge number of teachers across India suffered academically, mentally, financially for no fault of theirs and had to pay through their nose for the incompetence of policy makers at the helm of affairs.

UGC brought in second amendment to its 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 of API scores claimed by 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. Thankfully third amendment has scrapped this harsh provision of second amendment altogether that had done more harm than good to both teaching and research, much to the relief and respite of suffering university teachers whose promotions were held up for several years on this account. A good riddance indeed! Third amendment has retained only one ceiling under category III(E)ii for invited lectures and oral presentations. The API score under this sub-category has been restricted to 20% of the minimum score fixed for Category III for any assessment period. The quantification of teachers’ performance using such stringent criteria has actually 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.

Increase in weekly teaching workload

Previously UGC Regulations of 2010 had specified a workload of 16 hours per week involving direct teaching-learning process for Assistant Professors and 14 hours for Associate Professors and Professors. These Regulations had also specified that a minimum of 6 hours per week may be allocated to research activities of a teacher.  However third amendment of 2016 has specified a workload of 18 hours for Assistant Professors, 16 hours for Associate Professors and 14 hours for Professors in addition to 6 hours per week for tutorials, remedial classes, seminars, administrative responsibilities, innovation and updation of course contents for all the three categories of university teachers. This abrupt rise in workload seems to be neither reasonable nor justified. Third amendment of 2016 does not allocate 6 hours per week to research activities as envisaged in 2010 Regulations. However it is mentioned that those teachers who supervise the research of five or more Ph.D. students at a time shall be allowed a reduction of two hours per week in direct teaching hours.

It would have been preferable to allocate a specific time duration per week towards research activities irrespective of the number of Ph.D. scholars that a teacher is supervising at a time. 18/16/14 hours per week as envisaged in third amendment includes lectures/practicals/project supervision, wherein two hours of practicals/project supervision have to be treated as equivalent to only one hour of lecture. It is beyond one’s comprehension why two hours of actual contact/teaching-learning process during practicals or project supervision has to be reduced to only one hour. This kind of reduction is usually done for the calculation of number of credits in the choice-based credit system of teaching but not for calculating actual contact hours of teaching. Further it is not clear why the weekly teaching workload has been increased by two hours for Assistant and Associate Professors whereas the hours spent on examination duties such as invigilation, question paper setting, evaluation of answer scripts and tabulation of results are over and above the prescribed direct teaching hours and are an integral part of overall teaching workload of 40 hours per week as per the third amendment to UGC Regulations of 2010.

On May 26^th, 2016 Press Information Bureau, Govt. of India released a press note stating that the Union Ministry of Human Resource Development (MHRD) has reviewed the third amendment of UGC Regulations, 2010 and issued a direction to the UGC under Section 20(I) of the UGC Act, 1956 to keep the overall workload of Assistant Professor and Associate Professors/Professors unchanged and in accordance with earlier regulations i.e., not less than 40 hours a week for 180 teaching days. It also directed that the direct teaching –learning hours to be devoted by Assistant Professors (16 hours) and Associate Professors/Professors (14 hours) shall also remain unchanged. Thus MHRD has asked the UGC to roll back its amendment in relation to teaching workload within a span of just twenty days. That reflects poorly upon the amount of homework/critical appraisal done by UGC before bringing out new regulations. 

Third amendment regulations of 2016 seek to divide the actual number of hours spent by a teacher during an academic year under category-II in professional development, co-curricular and extension activities by a factor of 10. Thus in order to score the maximum permissible 45 API points under category-II, a teacher has to spend a total of 450 (45 x 10) hours in each academic year of 30-40 weeks duration on these activities that sums up to one and a half hour each day over and above his daily teaching, research and administrative workload as detailed under category-I of PBAS. Practically speaking isn’t it too taxing for a teacher to devote so much time daily to these activities? Something seems to be terribly wrong with the mathematics of API calculation. It is pertinent to mention that as per UGC Regulations of 2010, there have to be a minimum of 30 weeks of actual teaching in a 6-day week, another 12 weeks having been devoted to admissions, examinations, sports, cultural and co-curricular activities, another 8 weeks for vacations and 2 weeks attributed to public holidays. Since we avail a total of 10-12 weeks for summer and winter vacations during the year, we can use 40 weeks (totaling 280 hours) for activities listed in category-II that require a total of 450 hours during a year for maximum permissible API score of 45, given the fact that total number of hours devoted to these activities in a year has to be divided by 10.

Silent regulations

UGC regulations continue to remain silent about the research guidance provided to the students for their M.Pharm./MBA/MCA/LLM/M.Ed. dissertations. This is yet another 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. However one good change made in third amendment regulations of 2016 relates to increase in API score for each Ph.D. thesis submitted from 7 to 10 and for each thesis awarded from 10 to 15. This was a much needed change. But the API score awarded to a book chapter continues to be too meager. For a book chapter published in an international edition, API score is only 10 and for national edition score is only 5 and if there are two or more authors for the chapter, this score has to be shared equally among all of them. So what does each author get, peanuts?  Worst part is that earlier regulations in this regard had clearly mentioned that the score needs to be equally shared among all authors, but surprisingly third amendment has chosen to remain silent on that, leaving enough scope for yet another ambiguity and confusion. Even for the books per se, third amendment allocates an “API score of 30 per book for single author” in case of an international edition and “a score of 20 per book for single author” in case of a national edition. What happens if there are multiple authors in either case remains unclear and has to be eventually left to the whims of scissor-happy officials at the helm of individual universities. Instead of using the term “single author”, term “each author” should have been used.

Anomaly in distribution of API score among first, second and the remaining authors of a journal paper has also been rectified in the third amendment regulations of 2016. Now the first and principal/corresponding author/supervisor/mentor would share equally 70% of the total points and the remaining 30% would be shared equally by all other authors. However the paradoxical and needless practice of getting papers already published in reputed journals re-evaluated by the experts at the time of promotions from state 3 to 4 and stage 4 to 5 has still not been abolished which is a big omission since the papers that have already undergone rigorous process of peer review by reputed and well established journals hardly need to be revaluated again by the experts and this only leads to wastage of time and consequent delay in timely promotion of teachers, moreso when API score has already been allocated to published papers on the basis of indexing/peer review by referees/impact factors and other such parameters.

This time UGC has decided to notify its own list of refereed journals and publishers with a view to fix the API scores in a more reliable manner and leave no scope for score allocation to papers published in paid substandard journals that have particularly surfaced in huge numbers after API based assessment system came to the fore or to books published by sleazy publishers. But how comprehensive and inclusive the list shall be and how much time UGC will take to notify the list remains to be one of the biggest dilemmas of third amendment since any inordinate delay in its notification could potentially impede the process of final settlement of pending as well as fresh promotion cases of teachers. Hope none of the quality journals or standard publishers are left out in the process. Collecting feedback about teaching quality from students who have put in more than 75% attendance in each course as envisaged in the third amendment is a welcome step, however any likelihood of confounding bias in such evaluation needs to be scientifically and systematically removed before incorporating that feedback in the performance assessment of teachers during their promotions. Furthermore earlier thrust on research at the cost of teaching has also been rectified and equal weightage has been accorded to teaching and research activities in the third amendment. Other modalities of UGC Regulations, 2010 and their fall-outs on the quality standards of higher education have already been discussed in detail in an earlier article by this author in this very newspaper.

Conclusion

API based performance assessment system seeks to promote a score-hunting attitude among teachers. It promotes mechanization rather than creativity. Nobody is against performance-based appraisal but this should not come at the cost of teaching, which has to be the primary focus. Teachers working in colleges and universities  all over India are feeling stressed and subdued on account of flaws in UGC regulations particularly API based assessment system since these flaws are posing a serious threat to their academic progress and are demoralizing them besides leading to unhealthy competition in educational institutions. 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. MHRD, UGC and the universities need to take all possible measures, initiatives and urgent steps to rectify the errors in UGC regulations, remove all ambiguities, discrepancies, anomalies and confusions in them so that they do not become an unnecessary hurdle in the promotion of teachers. UGC Regulations, 2010 on the whole need to overhauled altogether.

(Author teaches at the Dept of Pharmaceutical Sciences, University of Kashmir and can be reached at ishaqgeer@gmail.com Views expressed are his own)

Drug utilization evaluation of anti-microbials in ambulatory care and community households - a multicentric study

Introduction:

The widespread inappropriate use of antibiotics is considered as one of the important causes of the development of antibiotic resistance [1-4]. It is estimated that 20-50% of all antibiotics use is inappropriate, resulting in an increased risk of side effects, higher costs and higher rates of AMR in community pathogens [5]. Around 25 percent of ADRs are caused by antimicrobial medicines. Antimicrobials constitute about 20 to 40 percent of a hospital’s medicine budget and can lead to significant, unnecessary health care costs if not carefully managed. A crucial strategy to control antibiotic resistance is to reduce the excessive and inappropriate use of antibiotics in practice. One such strategy involves the detailed surveillance of antibiotic use in both hospitals as well as community to guide and control antibiotic overuse and misuse.

However, the antibiotic usage patterns and the problem of AMR has received relatively little recognition in developing countries like India and the ability to undertake extensive surveillance is lacking in resource-constrained settings [5].There is acute paucity of literature on antibiotic utilization patterns in developing countries like India where antibiotics can be obtained easily from private retail pharmacies without prescriptions and pharmacists also advise and dispense antibiotics to patients [6]. This tri-centric study is an attempt to analyze the situation on ground vis-a-vis antibiotic prescribing and utilization patterns in out-patient departments of government hospitals, private clinics and community households with an aim of identifying the gaps, barriers, prospects and challenges towards enhancing their rational use and minimizing emergence of antibiotic resistance.

Novelty:

There is dearth of literature published on DUE of anti-microbials from India as a whole. In the state of J&K, barring a couple of hospital based DUE studies by Jan et al [1] and Tandon et al [2], no community or hospital-based DUE studies have been conducted at all. However newspaper reports suggest large scale use of medicines including anti-microbials 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 studies from J&K. Therefore there is need to conduct a study which can reveal the picture of how anti-microbials are being prescribed, dispensed and used at primary, secondary and tertiary care hospitals. Christian Medical College (CMC), Vellore and Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh have already been designated as nodal centres in the ICMR’s antimicrobial surveillance programme launched in early 2014 to work on antibiotic resistance and its mechanization for developing a policy to minimize microbial resistance due to Gram +ve and Gram -ve bacteria. Through the present study they will be able to scale up and further evaluate drug utilization patterns in their affiliate hospitals and catchment areas and substantiate the antimicrobial resistance data.

Applicability:

Aim of this study is to determine the prescribing practices and utilization patterns of antimicrobials in private retail pharmacy outlets and out-patient departments at all the three levels of healthcare viz., primary, secondary and tertiary care and assess rationality of treatment for Upper Respiratory Tract Infections (URTI). This tri-centric study on antimicrobial utilization patterns will evolve a holistic picture about the overall utilization patterns of antimicrobials and identify gaps in literature, stumbling blocks in rational prescribing and barriers in appropriate use of antibiotics. This study will assess and document statutory frameworks required for equitable access and rational use of antibiotics at state level and tertiary care level hospitals. It will identify the problem areas vis-a-vis utilization of anti-microbials and thereby help in devising suitable strategies for necessary interventions required to enhance their rational use.

Methodology:

The study shall be conducted in catchment areas and affiliated hospitals of three study centers namely University of Kashmir, Srinagar, Christian Medical College (CMC), Vellore and Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. Healthcare facilities at all the three level of care viz., primary, secondary and tertiary care shall be selected on PPS (Probability proportional to size) based approach alongside private pharmacy retail outlets.

Phase-I of the study shall include drug utilization evaluation in ambulatory care of government hospitals and in private retail pharmacy outlets. 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].

Objectives of the study are as follows:

1. To determine the extent and nature of antibiotic use, including FDCs, in prescriptions at retail dispensing pharmacist for community and OPD setting of primary, secondary and tertiary care in J&K, Chandigarh and Vellore (TN).
2. Evaluation of prescriptions for rationality of the antibiotic use in URTIs with pharmacist collecting additional patient data.
3. To see the availability and extent of adherence to standard treatment guidelines (STG) for URTIs.
4. To determine the proportion of cost of a prescription attributed to antimicrobials.
5. Determine availability of antibiotic policy in the tertiary care and district hospitals and assess the level of adherence to the same.
6. To correlate the patterns of DDDs of antibiotics with antibiograms wherever available.
7. To formulate effective intervention strategies to address antimicrobial use related problems.

Selection of districts, health facilities and community households:

Sampling of districts and health facilities from within the states 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 state. Selection of districts shall be done using economic and geographical criteria to capture maximum diversity. Steps in selection of districts involve ranking of districts on the bases of per capita Gross District Domestic Product (GDDP). Districts with equal intervals shall be selected taking first, last and the state capital. All levels of health facilities within India’s 3 tier public health system will be sampled, i.e., medical colleges (MC) at tertiary care level, district (DH) and sub-district hospitals (SDH) at secondary care level, community health centres (CHCs) and primary health centres (PHCs) at primary level. From each district one DH, 2 CHCs or SDHs (whichever are available) and 3 PHCs shall be randomly chosen for the study on the basis of capture diversity and geographical distribution intact. One Medical College or tertiary care hospital and one private hospital shall also be included from each study centre. Additionally ten community household and ten private clinicians practicing at a clinic willing to participate in the study would also be included randomly from each district.

Training of Field Workers

Data collectors/field workers/pharmacists would be trained over 1-2 days for collection of relevant data and addressing issues of confidentiality. Specifically, necessary skills would be imparted for the aspect of determination of rationality of antimicrobials prescribed/used for upper respiratory tract infections. Wherever possible algorithms will be made available for URTIs in order to help them determine the need and rationale of antimicrobials.

Data collection:

Trained data collectors (pharmacy practitioners or clinical pharmacologists) shall collect antibiotic use data by conducting exiting interviews with all patients receiving an antibiotic on leaving the medical facility. The patients will be interviewed at the attending pharmacy after they fill their prescription without the knowledge of prescribing physicians. This would avoid any bias on part of the prescribing physicians regarding their prescribing habits in relation to anti-microbials. However in hospitals where all prescriptions are filled within hospital premises and only negligible or none of the prescriptions go to retailers for dispensing, prescriptions will be audited within OPDs adjacent to consultation chambers of the prescribers. A pre-designed proforma shall be used to collect data regarding the diagnosis, name of the prescribed antibiotic/s, dose, dosage form, duration of treatment, number of units of antibiotic dispensed or purchased etc. The prescriptions will also be analyzed for various WHO drug use indicators. All the data collected shall be entered either into MS-Excel spreadsheets or any other suitable software that can also be used to process, code, clean and analyze the data.

Prescription audit:

In order to study prescription practices of anti-infectives in public health facilities, a prescription audit will also be undertaken at the healthcare facilities. Data from a random sample of prescription slips will be captured on the days of the facility visit as per WHO recommendation of 600 encounters (20 facilities and 30 patients/prescriptions per facility) for each survey. Prior consent of the respective medical heads of the facilities shall be sought as well as oral consent of the patients. Analysis of prescription slips would contribute to understanding the level and patterns of prescribing of anti-microbials. Consumption of antimicrobial drugs would be determined in terms of total number of DDDs using the WHO ATC/DDD system [13]. The Anatomical Therapeutic Chemical (ATC) classification and the Defined Daily Dose (DDD), ATC/DDD measurement units shall be assigned to the data.

Assessing rational use of Anti-microbials:

The rationality behind antibiotic use would be assessed by collecting information on availability of a hospital Essential Medicines list or formulary system; existence of a hospital drugs and therapeutics committee and infection control committee; availability, updation and dissemination of any standard treatment guidelines (STGs) related to the use of antibiotics in the hospital; whether doctors consult STGs available; availability of suitable diagnostic methods for diagnosing infectious diseases; magnitude of patient load in the hospital (high patient load can decrease consultation time resulting in erratic diagnosis and treatment); percentage of patients sent for microbial lab investigations; percentage of patients to whom antibiotics are prescribed empirically and reasons for empirical treatment. Reasons for non-adherence to STGs and recommendations on improving antibiotic use shall be sought from prescribing doctors. A suitable questionnaire would obtain relevant information from the prescribers.

Workshop for dissemination of results and devising intervention strategies

At the end of first year, workshop for dissemination of results to the practitioners involved in providing the information will be undertaken for creating awareness among stakeholders and devising suitable interventional strategies in consultation with all stakeholders towards ensuring rational use of antimicrobials that in turn shall be implemented during second phase of the study.

Feasibility:

Two of the study centres namely PGIMER, Chandigarh and CMC, Vellore are already part of a national study on estimation of Drug Resistance Index of antimicrobials. This study would scale up the national programme further and supplement data obtained on drug resistance surveillance programme. Furthermore, 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. 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:

This study shall be able to generate baseline data on the nature, magnitude and extent of antibiotic prescribing, choice of the antibiotics, their dosage, frequency, duration, cost, disease conditions for which they have been prescribed, availability of Standard Treatment Guidelines, any deviations from the standard treatment guidelines etc across three study centres, one each in Srinagar (J&K), Chandigarh and Vellore (TN). This study will explore various policy options in accordance with the findings. Governments at the central and state level, hospital administrators, policy makers and ministries of health can use the research data for devising policies and strategies for enhancing rational use of antibiotics and for curbing the menace of antimicrobial resistance that is seriously limiting their effectiveness and use. In the second phase of the study interventions devised after due consultation with all stakeholders shall be implemented and their effectiveness evaluated for their subsequent translation into policy and practice.

References:

1. Jan A et al. Drug Utilization At SKIMS–A Tertiary Care Hospital.JK- Practitioner 2013;18(1-2):35-40.

2. 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.

3. 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.

4. 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.

5. WHO (2002). Promoting rational use of medicines: core components. WHO Policy Perspectives on Medicines, No.5. Geneva, World Health Organization.

6. Potter M. Medication compliance - a factor in the drug wastage problem. Nurs times. 1981; 77 (suppl 5):17-20.

7. Nasser AN. Prescribing patterns in primary health care in Saudi Arabia. DICP. 1991; 25:90-93.

8. 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. 

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.

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 489^th meeting of the Commission in November, 2012 and then again during 497^th 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 23^rd 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 3^rd, 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

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.