A total of 297 pharmacies had been visited during the period from November 2018 to March 2019, in a rate of two pharmacies per day. (63%.0) were community pharmacies and (37%.0) were hospital pharmacies. Most of pharmacies (51.2%) were located in Khartoum city, (28.6%) in Omdurman city and (20.2%) in Khartoum North city. Majority of pharmacies (64.6%) had no health insurance services. Regarding type of facilities; (74.4%) were private pharmacies and (25.6%) were public pharmacies. The mean number of patients per day was 212.6, mean number of prescription per day was 181.8, mean number of patients aged <15y per day was 49.0 patients and >15y was 88.0 patients. Majority of visitors were male with mean number of 71.3.

The average number of drugs per encounter was 3.98 drugs. Hospital pharmacies had a higher (4.18±1.516) number of drugs prescribed than community pharmacies (3.87±1.331) with significance difference between mean of two types of pharmacies (P = 0.015). Both were higher than the WHO standard (1.6-1.8). The public facilities had higher mean number of drugs per prescription (4.06±1.413) than the private facility (3.96±1.407), but with no significant difference in mean between two types of facilities (P-value = 0.325). Khartoum North city had the highest mean number of drugs per one prescription (4.58±1.453), followed by Omdurman city (3.94±1.418) then Khartoum city (3.76±1.236) with significance difference between 3 cities (p-value = 0.001). Pharmacies with health insurance had higher mean number of drugs per one prescription (4.22±1.621), compared to (3.86±1.265) for pharmacies without health insurance (p-value <0.05).

The percentage of antibiotic per prescription was (53.7%). Antibiotic prescribing was much higher (54.0%) in the hospital pharmacies compared to (48.6 %) in community pharmacies but both are higher than the WHO standard of (20.0 - 26.8). The average percentage of injections per prescription at the facilities was found to be (57.6%). Injection use was very high (61.0%) in the hospital pharmacies compared to community pharmacy (53%.0). Overall injection use was higher than WHO standard of (13.4-24.1%). Table 1.

(Figure 1) shows that the percentage of prescription with written diagnosis was (26%.0) and the percentage of prescriptions with written dose was (78%.0), and again both indicators were less than WHO standard indicator (100%).

(Table 2) shows the details of dispensing indicators among facilities studied. The average dispensing time was (1.75) minutes (1.75 min and 1.76 min in public and private facilities respectively with no significance difference between two type of facilities (P =0.319). The hospital pharmacies had lower dispensing time of (1.47) minutes than community pharmacies (1.92) minutes with significance difference (P =0.002). The Percentage of drugs actually dispensed was (55.99%), hospital pharmacies were dispensed (64.0%) of the drugs that were prescribed compared with (51.0%) for community pharmacy. Regarding Patient-care indicators; the average adequacy of labelling of drugs was (30.4%). Proper labelling at hospital pharmacies was (65.0%) compared with (35.0%) in community pharmacies. The percentage of patients knowledgeable about the drug dosage was (41.3%). The knowledge by patients in community pharmacies was comparatively higher (44.2%) than hospital pharmacies (36.5%). The percentage of prescription dispensed after validation was (65.05%). Figure 2 shows the average of percentage patient care indicators compared to WHO standard:

The legality, validity, reliability and completeness of prescription papers have overwhelming influence on rational utilization of drugs throughout the globe. 14This study aimed to give an updated overview of rationality of prescription and dispensing practices through evaluation of WHO core drug use indicators in hospital and community pharmacies in Khartoum State- Sudan. Our study reports that the average number of drugs per prescription was found to be (3.98). The difference between hospital and community pharmacies was statistically significant P = 0.015 (Table 1). This value was higher than WHO standard which mandates the degree of poly-pharmacy be less than or equal to two (ideally, 1.6-1.8) in outpatient settings.9This is finding was higher than average numbers of drugs per prescription documented previously in Sudan (1.9, 2.776, 3) 11,12,13 and different parts of the world (2.4) in United States 15, (2.31) in India 16, (2.1) in west Ethiopia 17, (2.2) in Somali region of eastern Ethiopia 18, (2.3) in Pakistan 19, but less than Bangladesh (4.89) 20. The degree of poly-pharmacy seems unsafe in this study; it requires close monitoring to current prescribing practice. The higher degree of polypharmacy may result in greater risk of adverse drug reactions, drug-drug interactions and extravagancy prescribing.

Major drug use areas given major emphasis by WHO indicator studies are encounters with antibiotic(s) and injection(s). The percentage of encounters with antibiotics prescribed was found to be 53.7% which is too much higher than the upper limit of WHO standard, 30% (ideal range, 20-26.8%)9 This result was found to be less than pervious studies in Sudan (65.0%, 63.0%) 11,21andconsistent with other study (54.3%) 13. Values that are lower than this finding and closer to the WHO standard were reported from different areas of the globe including (30.3%) and (31.8%) in Indian healthcare settings 16,22, (29.14%) and (31.8%) in north and west Ethiopia respectively.23,24 However, several reports indicated that the prevalence of prescriptions containing antibiotics is even more than this finding. 25,26 The over-use of antibiotics is occurring internationally and leads to increase in adverse drug reactions and hospitalization, but also contributes significantly to an increase in antibiotic resistance and Sudan appears no different.

Coming to the injection prescribing practice, the prevalence of prescription containing injections was found to was higher than the admissible range (57.6%) compared to WHO criteria which is generally less than 25% (ideal range, 13.4-24.1%). This finding is more than twice the upper limit of the standard. Better injection prescribing practices were reported from several studies (5.7%, 28.50%, 17.18%, 28.3% 38.1% and 38.6%) in India 16, northwest Ethiopia 23, tertiary care hospital of Bangladesh 20, four selected hospitals of west Ethiopia 17 southern Ethiopia 25, and Sudan13 respectively. On the contrary, higher prevalence of injections was also reported in outpatient setting of Bahawal Victoria Hospital of Pakistan (98.0%)19. In developing countries, up to 56% of primary care patients receive injections. From this, over 90% may be medically unnecessary. Globally, 15 billion injections are given, but half of these injections do not use sterilized needle and syringe, which may result in transmission of potentially infectious diseases. Infections attributable to unsafe injection are hepatitis B (33%), hepatitis C (42%), and HIV (2%). 27,28 Overuse of injections may come from psychological dependence of both patients and healthcare professionals on injections for most diseases. Patients may assume that injections are more effective than any other agents.

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

Regarding the dispensing and patient care indicators, the average dispensing time was calculated to be 105 secs. The difference between hospital and community pharmacies was statistically significant at p = 0.02 (Table 2). (dispensing time = time when a patient reaches and leaves the pharmacy counter, waiting time not included). This value is below the WHO set point. Moreover, longer dispensing time was reported in different settings. For example, up to (152.3 s) in Ethiopia 33, (150 s) in Zimbabwe34 and (201 s) in Nigerian healthcare settings35. The duration of dispensing time ultimately affects the level of comprehension of patients towards the course of treatment, shorter dispensing time is insufficient to provide complete drug related information to the patients. The percentage of drugs actually dispensed were (55.99%), Figure 2 which shows lower percentage than the ideal WHO standard (100%). The percentage of dispensed drugs was found to be less than the average percent values reported at the tertiary care hospital in Ludhiana, India (100%)36, and Alexandria Egypt (95.5%) 37 However, an inadequate drug supply has its implications on patients health status and patient s convenience and trust in health system. According to this study, the average percentage of drugs adequately labeled were (30.4%). In previous study in Sudan and India it was 37.6% 11 and 43.8% 38. These results have shown deviation from the ideal value of 100%. Labeling is one of the key indicators of good dispensing practice and by any means, adequate labeling ultimately promotes patient awareness about the regimen he/she takes and hence increases treatment adherence. According to our findings shown in Figure 2, (41.33%) of the patients had knowledge of correct dosage schedule for all prescribed drugs. This is much lesser than the optimal value of 100 %. It was higher than that reported in Tanzania (37.9 %) 39 and Malawi (27 %) 40 but much lower than than that reported in KSA (79.3%) 41 Nigeria (93 %)42 and Egypt (94 %)37. Patient s knowledge of correct dosage is highly beneficial to avoid drug over use and abuse; and prevent adverse effects that harm patient s health status. A good patient s knowledge of correct dosage will definitely improve patient care and ultimately affect patients health and quality of life.

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