a cross - sectional retrospective study was carried out according to world health organization guidelines over 6  months and included 197 general practitioners ( gps ) and 19,700 prescriptions.this study revealed that the overall index of rational drug prescribing ( irdp ) indicator for gps was below the optimal prescribing practice level.we found disparities in the irdp between gps at different health facilities .
gps at national insurance fund facilities scored lower than those at state ministry of health facilities or other health facilities such as those owned by private interests , universities , and non - governmental organizations .
the irrational use of medicines is a major problem worldwide and represents the primary source of medical waste and harm .
the medicines component of the health services package is more variable and dynamic than other service components , particularly in terms of coverage , quality , and cost . in recent years
the overuse of medicines is diverse , and drug - prescribing indicators in developing countries are suboptimal , with core indicators varying between countries .
for instance , antibiotics and injectables are overused and generic medicines are underused in sudan .
the overuse of medicines not only leads to the development of drug resistance and wastes resources but also increases morbidity and mortality [ 3 , 4 ] .
thus , the appropriate use of medicines is an essential factor in the provision of quality health services , patient safety , and the rational use of health resources .
the world health organization ( who ) and the international network of rational use of drugs ( inrud ) have developed widely used core prescribing indicators to assess the prescribing quality of primary healthcare facilities and to enable comparisons between health facilities and prescribers . to our knowledge , no prescriber - based study has been conducted in sudan ; one study of the national health insurance fund ( nhif ) has been conducted in health facilities .
previous studies have been based on the facilities sampling method ( table  1 ) and have revealed antibiotic overuse [ 8 , 9 ] , underuse of generic medicines , and overprescribing of injectables .
other studies have revealed a relatively large average number of drugs per prescription and poor adherence to the essential medicines list ( eml ) .
these previous studies were conducted to investigate prescription patterns ; however , our study investigated the prescribing practices of general practitioners ( gps ) and used the largest sample and a unique study unit .
we used prescribing indicators as a benchmark among gps at primary healthcare centers ( phccs ) and as a baseline for regular assessment of prescribing quality . in sudan ,
the objective of this study was to use the who / inrud prescribing indicator to assess the quality of prescribing among gps at different types of phccs .
we used the assessment regimen created by who / inrud to evaluate prescribing performance according to the adopted standards to monitor the improvement of rationality in prescribing practice . before rational prescribing
can be promoted , the prescribing practices of those who provide 80  % of the services must be ascertained.table  1previous prescribing quality studies in sudanyeararealevelmean no .
drugs / prescription% of generic% of antibiotics% of injectable% from eml1991 n. provincephccs1.46363361996 kh statephccs1.9487322981998 kh statehospital and phccs2.1415929992004 kh stateteaching hospitals ( 2)1.9436510.52007 six statesphccs2.344.6662773.52010 kh statephccs243.271.813.792.72010 kh statefour pediatric hospitals249.381.33.52012 five nhif statesphccs2.654.2641499.32012 kh statehospitals and pharmacies2.837.354.338.672.8 
 eml essential medicines list , kh state khartoum state , n. province nile province , nhif national health insurance fund , phccs primary healthcare centers previous prescribing quality studies in sudan 
 eml essential medicines list , kh state khartoum state , n. province nile province , nhif national health insurance fund , phccs primary healthcare centers
the study was conducted in gezira state , which represents 27  % of nhif ; we targeted all gps ( 220 ) providing services for nhif subscribers at the primary healthcare level .
these gps provide services at three types of health facilities : ( 1 ) those owned by the nhif , ( 2 ) those owned by the state ministry of health ( smoh ) , and ( 3 ) those owned by others ( private interests , universities , and non - governmental organizations [ ngos ] ) .
insured patients pay 25  % of prescription costs , and pharmaceutical services are provided through a network of pharmacies owned by the nhif , smoh , and others .
we collected 100 prescriptions for each gp according to who / inrud guidelines for comparisons between prescribers .
the reference period of retrospective data collection was 6  months , representing the last quarter of 2014 and the first quarter of 2015 .
prescription collection was based on systematic random sampling , with an interval determined by dividing the gp s total prescriptions by 100 .
of the 220 gps , 197 ( 90  % ) had valid prescriptions over the 6  months , and the total valid number of observations was 19,700 prescriptions . trained technical professionals collected the data .
data were reviewed and entered twice in a microsoft excel spreadsheet before being exported to stata-12 for analysis .
the prescriptions data were transferred to who investigation format , checked again for accuracy , entered into an excel sheet , and individually checked once more for precision and completeness .
we used the who / inrud standard method for calculating prescribing indicators   ( table  2 ) .
the unit of analysis used was gp ( 100 prescriptions for each gp).table  2adjusted prescribing standards from who and inrud indicatorsprescribing indicatorsoptimal leveloptimal irdpmean medicines per prescription ( whether or not drugs dispensed)<2 1medicines prescribed by generic name ( % ) 100 1prescriptions with an antibiotic ( % ) 30 1prescriptions with an injectable dosage form ( % ) 10 1medicines prescribed from nhif gp s medicines list ( % ) 1001complementary indicator , average cost of prescription ( sdg)20.31 ( proxy) 
 inrud international network for the rational use of drugs , irdp index of rational drug prescribing , nhif national health insurance fund , sdg sudanese pound , who world health organization adjusted prescribing standards from who and inrud indicators 
 inrud international network for the rational use of drugs , irdp index of rational drug prescribing , nhif national health insurance fund , sdg sudanese pound , who world health organization to determine prescribing rationality and quality at the gp level , we used the index of rational drug prescribing ( irdp ) developed by yuxin and mingguang .
the irdp for each gp was calculated by compounding the indices of the five prescribing indicators .
the index of each prescribing indicator was calculated by dividing the optimal value by the achieved value for each
. moreover , for each type of health facility , the irdp was applied for comparison .
finally , we analyzed 19,690 prescriptions from 197 gps  ( 10 invalid prescriptions were excluded ) .
data at the gp level were clustered to represent the three types of health facilities .
data were reviewed and entered twice in a microsoft excel spreadsheet before being exported to stata-12 for analysis .
the prescriptions data were transferred to who investigation format , checked again for accuracy , entered into an excel sheet , and individually checked once more for precision and completeness .
we used the who / inrud standard method for calculating prescribing indicators   ( table  2 ) .
the unit of analysis used was gp ( 100 prescriptions for each gp).table  2adjusted prescribing standards from who and inrud indicatorsprescribing indicatorsoptimal leveloptimal irdpmean medicines per prescription ( whether or not drugs dispensed)<2 1medicines prescribed by generic name ( % ) 100 1prescriptions with an antibiotic ( % ) 30 1prescriptions with an injectable dosage form ( % ) 10 1medicines prescribed from nhif gp s medicines list ( % ) 1001complementary indicator , average cost of prescription ( sdg)20.31 ( proxy) 
 inrud international network for the rational use of drugs , irdp index of rational drug prescribing , nhif national health insurance fund , sdg sudanese pound , who world health organization adjusted prescribing standards from who and inrud indicators 
 inrud international network for the rational use of drugs , irdp index of rational drug prescribing , nhif national health insurance fund , sdg sudanese pound , who world health organization to determine prescribing rationality and quality at the gp level , we used the index of rational drug prescribing ( irdp ) developed by yuxin and mingguang .
the irdp for each gp was calculated by compounding the indices of the five prescribing indicators .
the index of each prescribing indicator was calculated by dividing the optimal value by the achieved value for each gp . moreover , for each type of health facility , the irdp was applied for comparison .
finally , we analyzed 19,690 prescriptions from 197 gps  ( 10 invalid prescriptions were excluded ) .
data at the gp level were clustered to represent the three types of health facilities .
the average number of medicines per prescription ( 2.55 : maximum 15 , minimum 1 ) indicated a poly - pharmacy pattern , with prescriptions involving antibiotics ( 54.71  % ) and injectable formulations ( 12.84  % ) .
a total of 81.19  % of the prescribed medicines were from the eml , and generics accounted for 46.34  % of prescriptions , which is some distance from the optimal required level of 100  % .
the average cost per prescription was 40.57 sudanese pounds ( sdgs ) ( table  3 ) .
values for nhif facilities were farther from the prescribing indicator standards than were smoh and other health facilities , except for the percentage of prescriptions containing antibiotics ( nhif 45.91 vs. smoh 57.24 vs. others 56.84  % ) ( table  3).table  3prescribing indicators and health facility typestype of health facility owner or operatorsmohnhifotheroverallnumber of gps1264328197average number of drugs per prescription2.442.972.42.55medicines prescribed by generic name ( % ) 48.9638.4749.2846.34prescriptions containing antibiotics ( % ) 57.2445.9156.8454.71prescriptions containing injectable formulations ( % ) 12.5515.589.9712.84drugs prescribed from gp s medicines list ( % ) 82.9772.6589.2781.19average cost of prescription ( sdgs)36.0759.5431.6940.57irdp3.463.083.753.39 
 gp general practitioner , irdp index of rational drug prescribing , nhif national health insurance fund , sdg sudanese pound , smoh state ministry of health prescribing indicators and health facility types 
 gp general practitioner , irdp index of rational drug prescribing , nhif national health insurance fund , sdg sudanese pound , smoh state ministry of health the correlation between gps and irdp was statistically significant at p  <  0.001 .
the optimal index is 5 ; however , the overall irdp score for gps was 3.39 ( range 2.14.8 ) .
the prescribing quality indices revealed that prescribing practice was nowhere near the optimal index of 5 , with nhif facilities having a lower index ( 3.08 ) than smoh facilities ( 3.46 ) and health facilities owned by others ( 3.75 ) ( table  3 ) .
the objectives of this study were to use the who / inrud prescribing indicator to assess the quality of prescribing among gps at different types of phccs .
we conducted a cross - sectional retrospective study over 6  months that involved 197 gps with valid prescriptions , representing 90  % of the total study population ( 220 ) .
the study revealed that the mean number of medications per prescription was 2.55    1.32 drugs , which represents poly - pharmacy according to the benchmark we applied of more than two drugs .
the mean number of drug prescriptions was 2.55 ; this was much closer to the 2.6 found by a study conducted in nhif facilities in 2012 in five other states .
the mean number of drugs per prescription was higher than most previously reported sudanese studies when we excluded the studies by mustafa   and mahmoud et al . , who reported 2.6 and 2.8 drugs per prescription , respectively ( table  1).when compared with other developing countries , the mean number of drugs per prescription in sudan ( 2.55 ) was less than in mali ( 3.2 ) , yemen ( 3.0 ) , uganda ( 2.9 ) , thailand ( 2.85 ) , and pakistan ( 2.7 ) [ 1923 ] .
however , gps in sudan prescribed a higher mean number of drugs per prescription than those in india ( 2.4 ) , tanzania ( 2.2 ) , saudi arabia ( 2.08 ) , and malaysia ( 2.0 ) [ 2427 ] .
collectively , nhif facilities had a higher mean number of medications than other facilities ( table  3 ) . the major implications of poly - pharmacy are additional avoidable costs and an increased probability of adverse drug reactions .
a limitation of the study was that inter - country comparisons were not adjusted according to the prevalence of chronic diseases in the population .
the percentage of generic medicines prescribed was 46.34  % , which is considerably lower than the standard of 100  % .
the calculated percentage represents a severe underuse of generic medicines that was also lower than the middle eastern mediterranean region s average use of generics ( 57.1  % ) .
this result is consistent with previous studies conducted in different districts in sudan ( table  1 ) . when compared with those of neighboring countries , the percentage of generic drugs per prescription in sudan ( 46.34  % ) was lower than in egypt ( 95.4  % ) , ethiopia ( 99.16  % ) , mali ( 70.4  % ) , uganda ( 91.3  % ) , and yemen ( 67.1  % ) [ 1921 , 29 , 30 ] .
however , the percentage of generic drugs prescribed was remarkably higher in sudan than in bahrain ( 14.3  % ) and jordan ( 5.1  % ) [ 29 , 30 ] .
gps in nhif facilities prescribed considerably fewer generics ( 38.47  % ) than those in smoh ( 48.96  % ) and other facilities ( 49.28  % ) .
the implications of low generic use are primarily the wastage of scarce health resources and a decrease in access to pharmaceuticals because of an affordability barrier .
the percentage of prescriptions containing antibiotics was 54.71  % , a considerably high result according to the who guideline benchmark of 30  % antibiotic use .
it was consistent with percentages assessed previously in other states of sudan ( table  1 ) .
the percentage in the who eastern mediterranean region was 53.6  % , slightly less than found for sudan in the current study .
the use of antibiotics was lower in nhif facilities ( 45.91  % ) than in smoh ( 57.24  % ) and other facilities ( 56.84  % ) .
antibiotic overuse can have a devastating impact in terms of the development of multi - drug - resistant bacteria , which can lead to unmanageable infectious diseases .
the percentage of prescriptions containing injections was 12.84  % , which is considered relatively over the optimal level , although no strict standard exists , as the who benchmark is < 10  % .
the average prevalence of injection use in the eastern mediterranean region is higher ( 27.1  % ) .
studies conducted in sudan reveal progress in the rational use of injections ( table  1 ) .
this reduction is attributable to a new malaria management protocol that focuses strongly on ingestible formulations rather than injection , which was the initial dominant medication formulation .
the overall percentage of medications prescribed from the eml was 81.19  % , whereas the prescribing quality indicator standard is 100  % .
eml adherence seems high ; however , in actuality , this figure is misleading because the best achievement in core prescribing indicators was this indicator worldwide . according to the who prescribing database , on average , the middle eastern mediterranean region s percentage of medicines prescribed from the eml was 90.8  % .
previous studies in sudan have often found this prescribing core indicator to be higher than observed in this study ( table  1 ) .
interestingly , we found eml adherence was lower in nhif facilities ( 72.65  % ) than in smoh ( 82.97  % ) and other facilities ( 89.27  % ) .
a total of 197 gps reported an irdp of 2.14.88 , which is relatively low compared with other neighboring countries . for instance , ten health facilities in saudi arabia reported an irdp of 4.375 . in egypt ,
the same processes were conducted in ten phccs and revealed high irdp rankings , ranging from 3.92 to 4.88 . although the irdp was not high , it was higher than the 3.32 reported in china .
the index values for nhif facilities ( 3.08 ) were lower than for smoh ( 3.46 ) and other ( 3.75 ) facilities ( table  3 ) .
the current study revealed that the average prescription cost was 40.57 sdg , almost double the proxy 20.31 sdg .
a study conducted in five states in 2012 reported an average prescription cost of 20.5 sdg , almost half that observed in the current study .
the primary cause of the cost increase is attributed to the devaluation of the national currency , particularly over the last 4  years . when comparing average costs with those in other countries , proper economic adjustment of currency values is essential .
prescriptions from nhif facilities cost more than those from other facilities , with the average prescription costing 59.54 sdg ( nhif ) , 36.07 ( smoh ) , and 31.69 sdg ( other facilities ) .
these disparities were attributed to the relatively high percentage of patients with chronic diseases in nhif facilities ( 36  % ) , with smoh facilities having fewer such patients ( 18  % ) .
the authors consider the main cause of the observed suboptimal prescription quality to be low adherence to prescribing guidelines .
nhif facilities performed worse  than other facilities ,  which could be attributed to the accountability of non - nhif facilities ( all services provided by these facilities are reimbursed according to adherence to regulations ) , while the nhif facilities have not been subjected to that review .
appropriate medicine use is essential to the provision of quality health services , patient safety , and the rational use of health resources .
the present study used the largest sample to date and a unique study unit to investigate prescribing rationality among gps at different types of health facilities providing health services for insured patients in gezira state , sudan .
the study revealed that the overall irdp score for gps was less than optimal and characterized by significant disparities between gps at different health facilities , with nhif facilities receiving a lower index .
further studies should be conducted to determine the factors causing the considerable discrepancies ( 2.14.88 irdp ) between gps at health facilities owned by the nhif , the smoh , and others ( private interests , universities , and ngos ) .
the opinions expressed by the authors do not necessarily reflect the opinions of the chulalongkorn university , thailand , or the national health insurance fund , sudan .
 backgroundthe appropriate use of medicines is essential for the provision of quality health services , patient safety , and the rational use of health resources . in sudan , 
 general practitioners ( gps ) provide 80  % of insured patients health services . 
 pharmaceutical service costs have been increasing since 2010.objectiveswe aimed to use the world health organization ( who ) and international network for the rational use of drugs prescribing indicators to assess prescription quality among gps in different types of primary healthcare centers ( phccs ) within the national health insurance fund ( nhif ) in gezira state , sudan.methodwe followed established who guidelines to conduct a cross - sectional retrospective study . 
 the study was carried out over 6  months and involved 197 gps with valid prescriptions , representing 90  % of the total study population of 220 gps . 
 we collected a systematic random sample of 100 prescriptions for each gp and used stata 12 to analyze the 19,700 prescriptions.resultsthe mean    standard deviation number of medications was 2.55    1.32 per patient ; 46.32  % of drugs prescribed were generics ; 54.71  % of prescriptions were for antibiotics and 12.84  % were for injectable formulations ; and 81.19  % of prescribed medicines were from the nhif medicines list . 
 the overall index of rational drug prescribing ( irdp ) indicator was 3.39 , and the average cost per prescription was 40.57 sudanese pounds ( sdg ) . disregarding prescriptions for antibiotics , 
 the prescribing quality of gps in nhif facilities was farther from optimal prescribing practice than those in state ministry of health - owned facilities and facilities owned by private groups , universities , and non - governmental organizations.conclusionthe present study provides strong evidence of irrational prescribing practice among gps , with significant disparities , particularly in terms of antibiotic overuse , generic drug underuse , and adherence to the nhif medicines list . 
Key Points
Introduction
Materials and Methods
Data Analysis
Results
Discussion
Conclusion
Conflict of interest
Funding