A/HRC/23/42 obligation to protect health also extends to safeguarding the public against the proliferation of irrational use of medicines, which results in wastage of scarce supplies and widespread health hazards. 58. Standard Treatment Guidelines (STGs) are invaluable for rational prescription of medicines, as they provide guidance on the most appropriate treatment options with respect to the local burden of disease. Unfamiliarity with STGs has been demonstrated in the instances of inappropriate use of antimicrobials for non-bacterial infections, over-use of injections where oral formulations are indicated and irrational combinations for fixed dose medications.81 Incorrect choice of medicines by physicians has been linked to higher levels of resistance, increased costs, morbidity and mortality in patients.82 As a good practice, prescribers and health-care workers should be regularly trained in STGs to promote rational prescribing to patients. Regularly updating, monitoring and evaluating the effectiveness of STGs promote adequate access to appropriate medicines. However, this has not been done in many countries, which is a challenge that States ought to overcome. 59. In many developing countries, pharmacies are the first point of contact for patients with the health-care system. Despite regulations restricting the sale of prescription medicines over-the-counter (OTC), in many developing countries this practice is rampant. In the case of antibiotics, unrestricted sale combined with irrational prescription have led to the public health threat of increased resistance to antibiotics.83 Countries with more restrictive antibiotic prescription have recorded relatively lower rates of resistance.84 Rational use of appropriate medicines requires strong enforcement of regulations by States. It also requires pharmacies and health centres to restrict OTC sale of medicines in accordance with law. 60. Numerous stakeholders perceive unethical commercial marketing and promotion of medicines by pharmaceutical companies as a serious concern. Billions of dollars are spent by the pharmaceutical industry on marketing through sales representatives, samples and advertising.85 Doctors are offered gifts under the pretext of continued medical education.86 Multinational pharmaceutical companies have been fined for promoting unapproved medicines,87 with little impact on their practices. Unethical promotion negatively affects the prescribing patterns of doctors, who would then tend to prescribe less rationally and to quickly adopt new medicines.88 Prescribers consequently obtain information on medicines from pharmaceutical companies,89 rather than consulting STGs. During the consultations, some States pointed to the existence of voluntary national industry codes to address 81 82 83 84 85 86 87 88 89 18 Promoting rational use of medicines: core components, WHO Policy Perspectives on Medicines, WHO (2002), p. 1. David H. Howard et al, The Global Impact of Drug Resistance, Clinical Infectious Diseases (2003), vol. 36, No. 1, pp. s4-10, p. s7. WHO, The evolving threat of antimicrobial resistance: Options for action (2012), pp. 38-39. H Goossens et al, Outpatient antibiotic use in Europe and association with resistance: a cross-national database study, ESAC Project Group, The Lancet (2005), vol. 365, pp. 579-587. WHO/HAI, Pauline Norris et al, Drug Promotion: what we know, what we have yet to learn: Review of materials in the WHO/HAI database on drug promotion (2005), p. 1. G Harris, Medical Marketing - Treatment by Incentive; As Doctor Writes Prescription, Drug Company Writes a Check, New York Times, 27 June 2004. Drug giant Glaxo pleads guilty, fined $3B for drug marketing, USA Today, 2 July 2012. Norris et al, Drug Promotion: what we know, what we have yet to learn: Review of materials in the WHO/HAI database on drug promotion (see Note 89 above), p. 38. Serhat Vancelik et al, “Impact of pharmaceutical promotion on prescribing decisions of general practitioners in Eastern Turkey”, BioMed Central Public Health, vol. 7, No. 122 (2007).