Beruflich Dokumente
Kultur Dokumente
an overview
Kathleen Holloway
Technical Briefing Seminar 2004
Essential Drugs and Medicines Policy
WHO Geneva
Objectives
Define rational use of medicines and identify the
magnitude of the problem
Understand the reasons underlying irrational use
correct drug
appropriate indication
appropriate drug considering efficacy, safety, suitability for the
patient, and cost
appropriate dosage, administration, duration
no contraindications
correct dispensing, including appropriate information for patients
patient adherence to treatment
WHO, Dept. Essential Drugs and Medicines Policy
1992/3
3/3
4/6
1994/5
10/3
16/6
1996/7
12/5
15/6
1998/9
12/5
14/7
2000/1
3/2
3/4
1994/5
1996/7
1998/9
2000/1
70
60
50
40
30
20
10
0
1990/1
1992/3
Africa
Asia
80
70
60
50
40
30
20
10
0
Nepal
% antibiotics
Yemen
% injections
Nigeria
% drugs
% cost
5
Pakistan
Bangladesh
Burkino Faso
Senegal
Angola
Tanzania
0
10
20
30
40
50
60
15
N e pa l
L.A M E R . & C A R .
E c ua do r
G ua t e m a la
E l S a lv a do r
J a m a ic a
E a s t e rn C a ribe a n
0%
10%
20%
30%
40%
50%
60%
0%
10%
20%
30%
40%
50%
60%
70%
10
11
13
8.65
48
% Px with antibiotics
9.5
% Px with injections
58
28.4
1.67
2.31
no.drug items/Px
0
10
20
30
dispensing doctors
40
50
60
70
non-dispensing doctors
12
improve
diagnosis
improve
intervention
2. DIAGNOSE
Identify Specific
Problems and Causes
(In-depth Quantitative
and Qualitative Studies)
3. TREAT
Design and Implement
Interventions
(Collect Data to
Measure Outcomes)
WHO, Dept. Essential Drugs and Medicines Policy
13
Scientific
Information
Influence
of Drug
Industry
Habits
Social &
Cultural
Factors
Treatment
Choices
Workload &
Staffing
Workplace
Intrinsic
Prior
Knowledge
Infrastructure
Relationships
With Peers
Societal
Economic &
Legal Factors
Authority &
Supervision
Workgroup
14
Managerial:
Guide clinical practice
Information systems/STGs
Drug supply / lab capacity
Use of
Medicines
Economic:
Offer incentives
Institutions
Providers and patients
Regulatory:
Restrict choices
Market or practice controls
Enforcement
15
Educational Strategies
Goal: to inform or persuade
Training for Providers
Undergraduate education
Continuing in-service medical education e.g. seminars, workshops
Face-to-face persuasive outreach e.g. academic detailing
Clinical supervision or consultation
Printed Materials
Clinical literature and newsletters
Formularies or therapeutics manuals
Persuasive print materials
Media-Based Approaches
Posters
Audio tapes, plays
Radio, television
WHO, Dept. Essential Drugs and Medicines Policy
16
17
60
Pre
Post
40
20
0
Intervention
Control
18
% of all C-sections
0.7
0.6
0.5
0.4
,
,
0.2
!!
!!
!,
!,
!
,
,
!!
Apr
Jul
84
Oct
!!
!
!
!
Cefazolin
recommended
Cefoxitin
not
recommended
,
,
, , ,
,
,
, , ,,
, ,
,
,
,
,,
!
!!
!!!!
!!
Jan
! !!
!
0.1
0
!
!
,
,
,
,
,
,
0.3
Jan
Apr
Jul
85
Oct
Jan
Apr
Jul
Oct
86
19
Managerial strategies
Goal: to structure or guide decisions
Changes in selection, procurement, distribution to ensure
availability of essential drugs
Essential Drug Lists, morbidity-based quantification, kit systems
Dispensing strategies
course of treatment packaging, labelling, generic substitution
20
21
No. health
PrePostfacilities intervention intervention
Change
Control group
42
24.8%
29.9%
+5.1%
Dissemination of
guidelines
42
24.8%
32.3%
+7.5%
29
24.0%
52.0%
+28.0%
14
21.4%
55.2%
+33.8%
22
Fees (complete
drug courses)
2.9 2.9
(+/- 0)
2.9 2.0
(-0.9)
2.8 2.2
(-0.6)
% prescriptions
conforming to
STGs
23.5 26.3
(+2.7%)
31.5 45.0
(+13.5%)
31.2 47.7
(+16.5%)
Av.cost (NRs)
per prescription
24.3 33.0
(+8.7)
27.7 28.0
(+0.3)
25.6 24.0
(-1.6)
23
35.4
21
93
25.6
% Px with antibiotics
64.7
38
% Px with injections
72.8
2.1
5.3
no.drug items/Px
0
20
21 Bamako PHCs
40
60
80
100
12 non-Bamako PHCs
24
Tetracycline Use
19 (# prescriptions per 1,000 inhabitants)
4
30
20
19
99
19
98
19
97
0
19
96
0
19
95
10
94
Regulatory strategies
Goal: to restrict or limit decisions
Drug registration
Banning unsafe drugs - but beware unexpected results
substitution of a second inappropriate drug after banning a
first inappropriate or unsafe drug
Regulating the use of different drugs to different levels of
the health sector e.g.
licensing prescribers and drug outlets
scheduling drugs into prescription-only & over-the-counter
Regulating pharmaceutical promotional activities
26
Choosing an Intervention
A single educational strategy is often not effective and
does not have a sustainable impact
Printed materials alone are not effective
Combination of strategies, particularly of different types
(e.g. educational + managerial) always produces better
results than a single strategy
Focused small groups and face to face interactive
workshops have been shown to the effective
Audit and feedback, peer review, are very effective
Economic strategies are very powerful strategies to change
drug use but may be difficult to introduce
WHO, Dept. Essential Drugs and Medicines Policy
27
Moderate
Large
10
20
30
40
50
60
28
After
Workshop
80
60
AfterPeer
Review
(n = 20)
37/52
Study Physicians
Control Physicians
79/115
BaselineStage
(n = 20) 42/82
18-months
Follow-up
40
31/110
25/102
20/84
16/70
11/46
20
29
Intervention
given by:
Prescribers Baseline
%
Post
%
Change
%
"Experts" in 2 clinics
(San Jeronimo)
31
24.5
71.2
+46.7
"Leaders" in 18 clinics
(Coyoacan)
65
17.7
43.4
+ 25.6
"Coordinators" in 124
clinics (Tlaxcala)
157
24.7
31.2
+ 6.5
Source: Munoz, et al, unpub. (1993); Guiscafre, et al, Arch. Med. Res. (1995)
30
Proportion of visits
with injection
80%
60%
40%
20%
0%
1
11
13 15
17 19
21 23
25
Months
Comparison group
31
32
33
34
35
Summary of clinical
guideline
Reasons for
inclusion
Systematic reviews
Key references
Cost:
- per unit
- per treatment
- per month
- per case prevented
WHO Model
Formulary
WHO
Model List
Quality information:
- Basic quality tests
- Internat.
Pharmacopoea
- Reference standards
36
37
3 phases
(1) set up surveillance,
(2) develop, implement & evaluate interventions
(3) expand to other sites
WHO, Dept. Essential Drugs and Medicines Policy
38
Av.no.drugs / Px
100%
80%
No.drugs
60%
Antibiotics
40%
Injections
20%
0%
0
1
Months
8
39
40
ICIUM2004
2nd International conference for improving use of medicines
41
Child health
TB
Malaria
Impact of access on use
- Adult health
- HIV/Aids, STIs
- Antimicrobial resistance
42
Activity
Discuss in groups the following questions
Choose a major drug use problem in your country or project
Identify the causes underlying the problem
What are the main 1-2 strategies being undertaken to address
this problem?
Are these 1-2 strategies being evaluated? If so, how?
What should be the roles of government, NGOs, donors, and
WHO be in filling the gap in strategies/policies to address this
problem?
43