Factors impacting prescription practice in primary healthcare setting in India: A case study in Rajasthan

A.BackgroundWe present a case of prescription practices in the Indian state of Rajasthan to demonstrate the effect of provider and system level factors, and their interactions on good prescription practices. We have presented two major dimensions of good prescription practice; first, completeness of prescription, a measure of adequacy; and second, appropriateness of prescription, a measure of quality of care (QoC). MethodWe used mixed method to audit 2801 prescriptions, selected from 24 rural and 7 urban government Primary Health Centres (PHCs) of Rajasthan, India. The findings represent analysis of 97% of the selected prescriptions that were considered legible. The selected prescriptions ensure represent variance in patient categories, seasonality and number of OPD foot fall across days in a week. Semi-structured in-depth interviews, followed by Focused Group Discussion (FGD) with providers was undertaken to obtain insights about facilitators and barriers to good prescription practices. We compared descriptive statistics across quintiles on adequacy indicators to understand variations around provider and system level factors; multilevel logistic regression model was used to obtain the adjusted effect. To assess appropriateness of quality of care (QoC), we evaluated 783 prescriptions that had adequate information to compare factors impacting QoC across quintiles. Finally, findings from the FGD was used to substantiate findings from the quantitative analysis. ResultWe found that prescription practices are outcomes of both provider and system level factors, and their interactions. The documentation of patient complaint, examination findings largely depends on system level factors; 59% and 38%, respectively. The treatment adequacy is largely associated with patient category. Ownership compliance of the doctors, measured in terms of their signature in the prescriptions, emerged as an important factor determining both adequacy and accuracy of prescriptions. We also found that treatment appropriateness, measured in terms of QoC, depends on both provider and system level factors. A conducive environment and trained provider are more likely to provide adequate and appropriate treatment. It is also observed that higher patient load is not a counter-productive to treatment appropriateness. Out of 783 legible prescriptions that were assessed for its appropriateness, only 36% were found inappropriate in terms of their documented justification for the treatment advised. ConclusionThere is a need to focus on provider and system level factors to improve prescription practices in primary health care (PHC). We recommend that institutional strengthening at systemic and provider level using innovative ways; such as task shifting to nurses as physician assistants, and reducing administrative activities of physicians to enhance focus on clinical work can propel better prescription practice.