Table 3.

Medicine Policy variables with information on how a policy was judged to be present or not

Policies recommended to improve medicines usea		Criteria to determine whether a policy was adopted (implemented or partially implemented) in a country
National structures, medicines policies and monitoring
1	National MOH unit on promoting rational use of medicines	Policy was marked “yes” if there was any unit, even if very small and consisting of only 1–2 persons, or an executive committee with responsibility for promoting quality use of medicines.
2	Presence of a Drug and Therapeutic Committee (DTC) in most referral hospitals	Policy was marked “yes” if more than half of referral hospitals visited had a DTC which had met in the last year (even if not very active) and there was an MOH mandate for DTCs.
3	National strategy to contain antimicrobial resistance	Policy was marked “yes” if there was any policy document endorsed by MOH on AMR containment.
4	Presence of National Drug Information Centre	Policy was marked “yes” if any national drug information centre existed, even if the centre was not very active and did not offer 24-hour emergency information.
5	Prescription audit in the last 2 years	Policy was marked “yes” even if the audit had only been undertaken in the health facilities of some districts, but including at least one of the districts visited during the situational analysis.
Educational policies
6	Undergraduate training of prescribers on the National Essential Medicines List (EML)	Policy was marked “yes” even if only some training institutions included the EML in the curriculum.
7	Undergraduate training of prescribers on the National Standard Treatment Guidelines (STGs)	Policy was marked “yes” even if only some training institutions included the STG in the curriculum.
8	Continuing medical education (CME) of prescribers by MOH	Policy was marked as “yes” even if only some prescribers received CME on general prescribing in adults and/or children. The Antibiotic SMART Use program in Thailand, INRUD training activities in Nepal and the training activities of the National Institute of Health (INS) in Timor-Leste are examples of CME by the MOH [21, 37].
9	Public education on medicines use in last 2 years	Policy was marked “yes” if any district populations had received public education.
Managerial Policies
10	National Essential Medicines List updated in the last 2 years	Was not hypothesized to influence antibiotic use.
11	National Standard Treatment Guidelines updated in the last 2 years	Policy was marked” yes” if there was any kind of officially published book containing national treatment guidelines, but not for disease protocols on posters or pamphlets.
12	National Standard Treatment Guidelines (STGs) found in some health facilities (indicator of STG implementation).	Policy was marked “yes” if the national STGs (published book) were observed in more than two facilities visited.
13	National Formulary available	Policy was marked “yes” if any national formulary was observed in any facility.
14	Generic prescribing policy in public sector	Policy was marked “yes” if there was any initiative described to encourage generic prescribing. Was not hypothesized to influence antibiotic use.
15	Generic substitution in public sector	Policy was marked “yes” if generic substitution was both legal and seen to occur. Was not hypothesized to influence antibiotic use.
16	Prescriber workload low or moderate	Low/moderate workload defined as less than 60 patients per prescriber per day, as reported by prescribers or as observed in patient registers.
Supply system
17	Public sector procurement limited to only EML medicines	Policy was marked “yes” if public sector procurement limited to EML medicines was reported at the central level and observed at the health facilities visited. Indicator of implementation of the EML.
18	No medicines stock-out problems reported in the health facilities visited	Policy was marked “yes” if health workers at the facilities visited stated that there were no stock-out problems. Indicator of the quality of the supply system which may impact on use.
Economic Policies
19	NO Drug sales revenue used to supplement prescriber income	Policy was marked “no” if prescribers were observed selling drugs in the public sector, as was the case in one country in 1 year.
20	No registration or consultation fee	All countries stated that they dispensed drugs free of charge to all patients in public facilities if medicines were available, but some charged registration or consultation fees which could be perceived by patients as payment for treatment.
21	No user fee or copayment at the point of care	Although all countries officially dispensed drugs free of charge in public facilities, some types of facility, generally hospitals, charged a user fee or co-payment for drugs at the point of care.
Regulatory policies
22	Systemic antibiotics generally not available over-the-counter (OTC)	Systemic antibiotics could be got OTC in all countries but were generally unavailable in Bhutan and DPR Korea where the private sector is very small, and effort is made to enforce the drug schedules.
23	Regulation of advertisements for OTC drugs medicines	No countries were monitoring all drug promotional activities, but some did monitor advertising of OTC drugs.
Human resource policies
24	Prescribing by doctors (as opposed to other staff) in public primary care	Policy was marked “yes” if doctors were observed to be prescribing in the primary care facilities visited. Where doctors were not prescribing paramedical staff or nurses generally prescribed, although in one country unqualified staff sometimes prescribed.
25	No prescribing by staff with less than 1 month’s training in public primary care	Policy was marked “yes” if no unqualified staff were observed to prescribe.

^aIncludes all the policy questions, hypothesised to act on the quality of medicines use, as hypothesised elsewhere [16, 17] and found in the situational analysis reports [21]