INTRODUCTION:

According to data from the Central Statistics Agency of Indonesia in 2015, the number of foreign tourists who came to Indonesia was around 10.4 million people, there was an increase of around 8 million tourists from 2010, and it is known that around 40% of them made Bali as their main destination.^1,2 Nearly 8% of tourists visiting travel destinations in developing countries need access to health services during and after travelling. Health care financing in tourist areas is often more expensive than expected.

Based on data from the Association of British Insurers, the average health insurance claimed for medical tourism in 2011-2016 is around 1300 pounds, even mentioning that the bill for diagnoses such as dengue fever in Indonesia can up to 40,000 pounds.^3,4 The World Health Organization (WHO) estimates that more than half of the drugs used in the world are not prescribed correctly and many of them occur in health practices of developing countries where routine mechanisms for evaluating drug use have not been developed.^5,6

The use of drugs is said to be rational if the patient gets drugs that are in accordance with clinical needs, according to the dose and duration of administration, and the costs incurred for these drugs are fairly low for the patient and their community. The rational use of drugs aims to avoid drug-related problems.^7,8 A survey conducted at 8 hospitals in Ethiopia found an irrational pattern of prescribing, indicated by the high number of drugs prescribed per visit, injection prescribing, and antibiotic prescribed.⁹ Poor prescription can result in ineffective and unsafe therapy, exacerbate and prolong the disease, seriously endanger the patient and increase the cost of treatment.^10,11

Evaluation of drug use is necessary to promote rational drug prescribing in health care facilities.¹² Rational prescribing will create a better health service not only for the public, but also in the context of medical tourism, for foreign tourists who are also entitled to get optimal health service, but not burdensome services.¹³ So far there have been no studies evaluating the rationality of drug use in travel clinics. Therefore, this study can provide a little glimpse into the phenomenon of irrational prescribing that happen in the world of tourism medicine.

METHODS:

This study was a cross-sectional study of foreign travelers visiting 2 travel clinics in Bali. Data collection was carried out retrospectively. The data was collected based on medical records for foreign travelers between January-December 2019. The research was conducted in 2 travel clinics located in the Sanur Beach area, Bali. The samples of this study were all foreign travelers who received diagnoses and medicinal therapy at the clinic between January- December 2019 and had complete medical record data. Foreign travelers with unreadable medical record data were excluded. We used a total sampling method so that all patients who met the inclusion and exclusion criteria were assigned as samples in this study.

Before this research was carried out, this research protocol had obtained ethical feasibility from the Ethics Committee of the Faculty of Medicine and Health Sciences, Universitas Warmadewa No 122/Unwar/ FKIK/EC-KEPK/VI/2020. The research instrument used was a questionnaire to collect data that only contained the patient registration number and kept the patient's detailed identity secret. This questionnaire only contained patient information needed in the study such as age, gender, and origin of tourists, diagnoses and complications, therapeutical data used by patients including the name of the drug, the method of administration of the drug, and the amount of drug given.

Demographic data such as age, sex, and origin of tourists and clinical characteristics such as type of diagnosis, number of diagnoses, and complications are nominal variables that will be grouped into several categories to facilitate data analysis and presented in the form of frequency and percentage tables. Drug use was evaluated by following the WHO Prescribing Indicators, including the number of drugs per prescription sheet, the percentage of prescription drugs with generic names, the percentage of antibiotic prescriptions, the percentage of prescribed injections, and the percentage of drugs that were in accordance with the formulary. Drug use was said to be rational if all indicators were in accordance with WHO prescribing indicators whereas it was said to be irrational if it did not meet the indicators set by WHO.

RESULT:

Based on patient registers at the clinics during 2019, there were 284 tourists who visited and performed the treatment. Of the 284 patients, 64 patients were excluded as showed in picture 1, with details: 17 patients were domestic travelers and 47 patients did not receive drug therapy, so the number of samples in this study was 220 patients, with characteristic that can be seen in table 1.

Figure 1: Sample’s Flowchart

Table 1: Sample’sCharacteristics

S.No	Characteristic	n(%)n=220
1	OriginofTravelers
	-Asia	61(27,7)
	-EuropeAmerica	104(47,3)
	-Australia	55(25,0)
2	Age
	-<17 years old	34(15,5)
	-17-50 years old	103(46,8)
	->50 years old	83(37,7)
3	Gender
	-Male	86(39,1)
	-Female	134(60,9)
4	TypeofDiagnoses
	-Infectious	148(67,3)
	-Non-infectious	72(32,7)
5	NumberofDiagnoses
	-1	185(84,1)
	-2	35(15,9)
6	Complication
	-Yes	13(6,0)
	-No	207(94,0)

In table 1, it can be seen that the sample of this study was foreign travellers, with the largest number came from Europe America (47,3%). Most of the patients were adults aged 17-50 years (46,8%) and females (60,9%). Most of the diseases experienced were infectious diseases (67.3%). Only 6% of the sample had complications from their disease. Evaluation of drug use in the travel clinics was carried out using WHO prescribing indicators including the average number of drugs per recipe, the percentage of prescription drugs with generic names, the percentage of prescribing antibiotics, the percentage of prescription with injection preparations, and the percentage of drugs that were in accordance with the formulary, with the results as described in table 2. The total number of prescriptions obtained was 220 and the number of types of drugs in this study was 544. We found many polypharmacy events, low prescriptions with generic names (14,2%), not all prescriptions met national formulary (64,8%), high prescriptions of antibiotic (50,0%) and injection (29,1%).

Table 2: Drug Evaluation Result Basedon WHO Prescribing Indicators

No	WHO Indicators	Prescribing	Number of Event	Result	WHO standard
1 Average number of drugs perrecipe			544	2.47 %	1.6-1.8
2. Percentage of prescription drugswith genericnames			74	14.2%	100%
3. Percentage of prescribing Antibiotics			110	50.0%	20.0-26.8%
4. Percentage of prescription With injection preparations			42	29.1 %	13.4-24.1%
5. Percentage of drugs Prescribed from national drug formulary			338	64.8%	100%

DISCUSSION:

A travel clinic is a clinic that is specifically intended for tourism medicine, which is also called a travel medicine clinic or tourism medical clinic. Despite their special nature, travel clinics can be established in an integrated manner with existing health institutions.^3,14 There is no clear data regarding the number of clinics or health services serving tourism medicine in Bali, but it was stated that there was 22 public health service in Bali which are included as Beach Tourism Health Centres because they were located along with the coastal tourism areas in Bali.¹⁵ Foreign tourists travel farther than domestic tourists, so they are more susceptible to contract a disease, especially infectious disease and seeking medical help before, after, and while travelling¹⁶. The high biodiversity of Indonesia makes the country one of the favourite travel destinations in the world.¹⁷Bali is the most famous destination in Indonesia with more than 1 million movements of foreign tourists, especially in Australia. In 2018, Indonesia became the country most visited by Australian citizens. Because Indonesia, especially Bali, has a tropical climate, so the risk of contracting infectious diseases is higher than non-infectious diseases. Diseases that were often reported to tourists after travelling from Bali included food and vector-borne disease, rabies, and trauma.¹⁸ In table 1, it can be seen that the sample of this study was foreign travelers, with the largest number came from Europe America (47,3%). Most of the patients were adults aged 17-50 years (46,8%) and females (60,9%). Most of the diseases experienced were infectious diseases (67.3%). Only 6% of the sample had complications from their disease.

Our results that can be seen in table 2 concluded that none of drug indicators met the WHO standards. The two travel clinics that were our data collection source belonged to private primary health care. In a study conducted in India at primary health care, it was found that the mean number of drugs administered per visit was 5,56 which indicates a fairly high presence of polypharmacy and a very low percentage of generic prescription drugs was only 4%.¹⁹ A study about prescription evaluation was also carried out in Gujarat India which aimed to compare the prescription patterns of public clinics and private clinics and found that prescribing drugs in government clinics were more rational than in private clinics.²⁰ Rational use of medicines defined as patients receive medications appropriate to their clinical needs, in dose that meet their requirements, for an adequate period, and at the lowest cost to them and their community.²¹ Polypharmacy are belong to irrational drug use due to higher chance of drug-drug interactions.^22,23

The purpose of this study was limited to evaluate the prescription at travel clinics in Bali and unfortunately, we did not do further analysis for searching out the cause of this irrational prescribing happened. The previous finding showed that there are several factors that influence the rationality of prescription including pharmaceutical regulations²⁴, price standards, the influence of drug companies²⁵, drugs innovation, and the decision of prescribers or doctors who prescribe drugs. Prescriber’s decision is the most crucial factor in this situation. Educational background, work situation, and other related matters can influence the quality of prescriptions made by prescribers.^26,27 A prescription is the reﬂection of prescribers' attitude towards the disease being treated and the type of health care system in the community.^28,29 Furthermore, this finding could attract policymakers for improving some regulations regarding the standard of prescription and the existence of medical tourism in Bali.

CONCLUSION:

This study showed that the phenomenon of irrational prescribing can occur in various health service providers, including travel clinics that practice medical tourism. Our evaluation found that the prescriptions at the two travel clinics in Bali were not in accordance with the standards set forth by WHO and were considered irrational to be addressed to patients. In this regard, improving public policy about this issue could be one point for the policymakers in developing medical tourism in Bali.

CONFLICT OF INTEREST:

The author(s) declared no potential conflicts of interest with respect to the research authorship, and/or publication of this article.

ACKNOWLEDGMENTS:

The author is grateful to Ministry of Research, Technology, and Higher Education for the grant given at 2020. Faculty of Medicine and Health Science, Universitas Warmadewa, Bali, Indonesia for the supports and facilitation given.

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Received on 15.09.2023 Modified on 30.10.2023

Research J. Pharm. and Tech 2024; 17(8):3881-3884.

DOI: 10.52711/0974-360X.2024.00602