International Pharmaceutical Federation

Fédération internationale pharmaceutique

PO Box 84200, 2508 AE The Hague, The Netherlands

FIP STATEMENT OF PROFESSIONAL STANDARDS

Introduction

Adherence to long-term therapies for chronic diseases in developed countries averages only 50%. In
developing countries the rate is even lower, probably reflecting inequalities of access to appropriate
health care facilities, supervised by qualified health care professionals.

HIV/AIDS, tuberculosis and non-communicable diseases including mental health disorders, represented
54% of all illnesses world-wide in 2001 and are estimated to exceed 65% in the year 2020. Thus the
burden of illness is moving quite strongly towards chronic diseases. There is evidence that many patients
with chronic illnesses have difficulty in adhering to their recommended treatment regimens. Adherence
problems are observed whenever patient self-treatment is required, including for prevention. Poor
adherence results in poor health outcomes and increased health care costs. It has been estimated that
40% of cases of acute myocardial infarction or stroke are attributable to hypertension and yet studies
have shown that despite the availability of effective treatments, less than 25% of patients treated for
hypertension achieve optimal blood pressure.

Thus the cost to patients of non-adherence is avoidable illness, in some cases premature death. The cost
to health care systems of non-adherence is represented by medicines paid for but not taken plus
avoidable additional treatment. In the case of communicable diseases, non adherence may lead to the
development of resistance to medicines, making successful treatment much more difficult. Many
published papers testify to changes in costs following changes in adherence rates. Some studies show
that initial investments in interventions to improve adherence are fully recovered in a few years and
recurrent costs fully covered by savings.

There are, therefore, many reasons for seeking to improve adherence. The benefits include better health
outcomes and improved quality of life and improved safety for the patient, as well as cost savings for all
stakeholders. Indeed it has been stated that increasing the effectiveness of adherence interventions may
have a far greater impact on the health of the population than any improvement in specific medical
treatment.
There are a number of reasons why people do not adhere to long term
treatments, including:

• Insufficient resources to pay for the medicines they need.

• Personal experiences and beliefs about their medicines, or medicines in general.

• Problems with side effects, or other interference with their daily lives, especially peer group
pressure.

• Lack of information about their condition and the importance of treatment or of the need to
complete a course of treatment.

• Practical difficulties, such as access to a pharmacy and/or pharmacist, and/or the complexity of a
medication regimen.

• The influence of co-morbidities and physical and mental disabilities, especially depression, on
behaviour.

• Lack of understanding of the seriousness of the illness.

There is one further factor. Health professionals have tended to regard prescribed medicines and
medicines purchased without prescription as being quite distinct. This perception may have been
strengthened as new prescription medicines have become increasingly powerful and have been used for
illnesses that were previously not able to be treated successfully by medication. From the point of view
of the person presented with the need to take medication, no such distinction is made.

There has been little success to date in translating research knowledge about the reasons for non-
adherence into a successful strategy for improving the use of medicines. For all the reasons given above,
however, pharmacists and other health professionals providing services involving treatment with
medicines, should make every effort to assist patients who wish to do so, to improve adherence.

National and international organisations need to ensure that pharmacists provide high quality information
to motivate patients to appreciate the importance of their medication and make this the standard of
pharmacists’ practice world-wide.

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Approved by FIP Council in Sydney in September 2003
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Definition of “adherence”

There is a significant difference between “adherence” and “compliance”. The latter term implies that the
aim of prescribing is to get the patient to follow the orders of the physician. As the 2003 Report of the
World Health Organization on adherence makes clear “The main difference is that adherence requires
the patient’s agreement to the recommendations. We believe that patients should be active partners with
health professionals in their own care and that good communication between patient and health
professional is essential for an effective clinical practice.” The Medicines Partnership in the UK in its
publication “From compliance to concordance” also makes it clear that involving the patient as a partner
is very important as is the need for health professionals to treat one another as partners, each using their
individual skills to improve the patient’s participation. It is in this sense that the word “adherence” is
used in this statement.

If patients are full partners with the health professionals involved in their care, in all decisions about
taking medicines, they are more likely to follow the agreed regimen.

The “building blocks” to secure adherence, based on those suggested by the Medicines Partnership UK
in its publication “Make it a Medicines Partnership Project”, are attached as an annex.

In the light of the benefits better adherence to prescribed medication regimens would bring, the FIP
recommends that:

• Pharmacists, physicians and other healthcare professionals should regard patients as partners in all
decisions on treatments involving medication.
• Adherence should be recognised as an integral aspect of the whole process of clinical care and
hence a core subject in pharmacy, medical and nursing education and training at both basic
(undergraduate) and continuing phases.
• In each country, a research and development structure focusing on adherence should be established
to identify and address priorities, develop the necessary infrastructure to encourage a multi-
disciplinary approach, promote research and involve patients.
• Medicine-taking issues including cultural beliefs and lifestyle priorities should be incorporated in
patient records.
• All available opportunities should be taken to discuss issues relating to medication with patients.
• Pharmacists, physicians and nurses when they are involved directly with patients should ensure that
full and consistent information and advice is given to patients, the objective being to tailor that
information for each individual.
• Governments and third party payers should recognise the important benefits of adherence and
reflect that importance by incentives both for patients and in the remuneration structures for the
health professionals involved in the promotion of adherence.

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Approved by FIP Council in Sydney in September 2003
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• Governments and professional organisations should conduct public information campaigns on the
benefits of adherence and the need for people to participate fully in discussions with the relevant
health professionals to ensure maximum benefits from medication.
• Patients for whom medicines are prescribed should receive information verbally, reinforced by
readily understandable written information.
• National pharmaceutical organisations should encourage better adherence to chronic disease
medication regimens by:
o Developing and promoting pharmacy-based disease management programmes.
o Developing national guidelines on disease management that are evidence-based.
o Conducting surveys to monitor the success of pharmacy-based adherence programmes.
o Promoting documentation of adherence interventions by pharmacists.
o Encouraging patients to ensure that their medication record is complete.

See Attached document – Building Blocks

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Approved by FIP Council in Sydney in September 2003
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