Printed material alone has little effect...

Irrational prescribing, dispensing and patient use of drugs is a global problem. Numerous studies both from developed and developing countries describe a pattern that includes polypharmacy, use of drugs that are not related to diagnosis, unnecessarily costly drugs, inappropriate use of antibiotics, indiscriminate use of injections, irrational selfmedication with under- and overdosing, use of drugs with unproven efficacy and safety, incorrect administration, dosage, duration etc. Irrational drug use leads to reduced quality of therapy and waste of resources.

The problem is worsened by a global shift from public to private sector which, especially in countries without proper regulation results in even worse indiscriminate and irrational use of drugs due to business interests and ignorance. Factors underlying irrational drug use include various actors:

• Patients: misinformation, misconceptions
• Prescribers: lack of education and training, heavy patient load, pressure to prescribe
• Drug supply system: inefficient management, unavailability of drugs
• Health care system: informal prescribers, nonessential drugs on the market etc

In 1985 the WHO convened a conference in Nairobi, Kenia, on Rational Drug Use which was followed in 1997 by the International Conference on Improving the Use of Drugs in Chiang Mai, Thailand. Significant efforts have since been undertaken to improve drug use practices. Various strategies and interventions have been used to promote better prescribing: education and communication include training and print-only material; managerial interventions include standard treatment guidelines and selection of drugs; regulatory interventions include prescribing control by level of use and banning of unsafe and doubtful drugs.

Drug utilization research concerning impact of interventions has found that face-to-face education focussed on a few prescribing problems as well as standard treatment guidelines plus education is effective but that printed materials alone or unfocussed education is ineffective. Clearly effective interventions include problem oriented, repeated and participatory training, supervision and peer-group oriented guideline development.

Assuring drug supply and rational drug use in Dar es Salaam

The performance and quality of health services everywhere critically depends on the availability and proper use of drugs. One of the outputs of the Dar es Salaam Urban Health Project (DUHP) supported by the Swiss Tropical Institute STI is assurance of drug availability and rational drug use in Government health facilities in Dar es Salaam. Since April 1992 the City Council health facilities have been supplied with essential drugs financed with decreasing contributions by the Swiss government.

Availability of essential drugs is futile if not followed by rational drug use. A drug use indicator study in Dar es Salaam public health facilities revealed overprescribing of antibiotics and injections as well as nonadherence to National Standard Treatment Guidelines (STG). Based on the findings of the baseline study, interventions were selected (development of new STG, training) with the aim to improve prescribing, hence performance and quality of health services. Good quality of care reduces suffering, gains the confidence of patients in the health care system, the willingness to pay for services and thus enhances the sustainability of a drug supply system. Treatment guidelines are used to optimize limited resources and to guide practitioners towards clinical paths known to have good outcomes. The process of elaborating and implementing STG has been shown to be critically important for success of the intervention.

Re-defining Standard Treatment Guidelines

The National STG were associated with insufficient involvement of health providers, poor dissemination and lack of training. New STG for Dar es Salaam were launched with the objective to improve the process of guideline elaboration and implementation and to measure impact of the intervention.

The STG program was a collaborative effort by medical and pharmacy staff. Active collaboration of targeted prescribers of all cadres was sought. The National STG were used as a basis while format and contents were updated, improved and made more user-friendly. The draft was distributed to local reviewers. 20 health facilities selected by systematic random sampling were randomly paired into intervention and control facilities. An introductory workshop was conducted for 25 prescribers from the intervention group followed by continuing education. Coordination and approval was sought from the Ministry of Health. For sustainability the manuals were printed in Dar es Salaam. Prescribing indicators and adherence to STG were measured before and after the intervention.

Shift focus from guideline development to guideline integration

In a pre-post design analysis, compliance with STG norms improved significantly after the intervention in all health facilities.

The process of participatory and monitored STG elaboration and implementation with training had a positive effect on prescribing patterns of all prescribers, i.e. better compliance with STG. However, number of antibiotics and injections prescribed did not change by the intervention. This behaviour is deeply ingrained and rooted in socio-cultural conditions. A major finding is that development of guidelines alone is not sufficient for behavioural change. An active elaboration and implementation strategy is important.

To assume ownership of treatment guidelines, practitioners must be involved in the process of elaboration. Printed material has little effect on prescribing behaviour but needs to be accompanied by training. To be effective, training must be focussed, participative, repeated and ongoing, take place in small groups and it must be followed by supportive supervision. It is of paramount importance to shift focus from STG development to guideline integration.

Karin Wiedenmayer is a Clinical Pharmacist and works at the Support Center for International Health at the Swiss Tropical Institute. The Swiss Tropical Institute is the executing agency for the DUHP, Tanzania, financed by the Swiss Agency for Development and Cooperation.