NTA Level 5 • Semester 1 • PST05105

Types of Interventions in Promoting Rational Medicines Use

Rational Use of Medicines • Source Session/Topic 8

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Session 8: Types of Interventions in Promoting Rational Medicines Use

Total Session Time: 120 minutes

Prerequisites

• None

Learning Tasks

By the end of this session students are expected to be able to:

• Give overview of national interventions in promoting rational

medicines use

• Identify types of national interventions in promoting rational

medicines use

• Explain national interventions in promoting rational medicines use

Resources Needed:

• Flip charts, marker pens, and masking tape

• Black/white board and chalk/whiteboard markers

SESSION OVERVIEW

SESSION CONTENTS

STEP 1: Presentation of Session Title and Learning Tasks (05 Minutes)

READ or ASK students to read the learning objectives and clarify

ASK students if they have any questions before continuing.

STEP 2: Introduction to National interventions in promoting rational

medicines use (15 Minutes)

• Subsequent are some of the major and supreme roles and strategies in

order to eliminate the irrational use of the medicines, the

contribution of WHO, Pharmaceutical personnel, prescribers and

government is important in this regard.

• Based on this evidence, WHO has developed recommendations for twelve

core national policies and structures that are needed to promote

rational use of medicines.

STEP 2: Types of National interventions in promoting rational medicines use

(30 minutes)

|Activity: Buzzing (15 minutes) |

|ASK students to pair up and buzz on the following question for 2 |

|minutes |

|What are the types of national interventions in promoting rational |

|medicines use? |

| |

|ALLOW few pairs to respond and let other pairs to add on points not |

|mentioned |

|WRITE their response on the flip chart/board |

|CLARIFY and SUMMARIZE by using the content below |

The following are twelve core national interventions to promote rational

use of medicines

• A mandated multi-disciplinary national body to coordinate medicine use

policies

• Clinical guidelines

• Essential medicines list based on treatments of choice

• Drugs and therapeutics committees in districts and hospitals

• Problem-based pharmacotherapy training in undergraduate curricula

• Continuing in-service medical education as a licensure requirement

• Supervision, audit and feedback

• Independent information on medicines

• Public education about medicines

• Avoidance of perverse financial incentives

• Appropriate and enforced regulation

• Sufficient government expenditure to ensure availability of medicines

and staff

STEP 3: Explanation of the Types of National Interventions in Promoting

Rational Medicines Use (60 minutes)

The following are the explanation for twelve National core interventions in

promoting rational medicines use

A mandated multi-disciplinary national body to coordinate medicine use

policies

• Many societal and health system factors, as well as professionals and

many others, contribute to how medicines are used.

• Therefore, a multi-disciplinary approach is needed to develop, implement

and evaluate interventions to promote more rational use of medicines.

• A national regulatory authority (RA) is the agency that develops and

implements most of the legislation and regulation on pharmaceuticals.

• Ensuring rational use will require many additional activities which will

need coordination with many stakeholders.

• Thus a national body is needed to coordinate policy and strategies at

national level, in both the public and private sectors.

• The form this body takes may vary with the country, but in all cases it

should involve government (ministry of health), the health professions,

academia, the RA, pharmaceutical industry, consumer groups and non-

governmental organizations involved in health care.

• The impact on medicine use is better if many interventions are

implemented together in a coordinated way, single interventions often

having little impact.

Clinical guidelines:

• Clinical guidelines i.e. standard treatment guidelines or prescribing

policies consist of systematically developed statements to help

prescribers make decisions about appropriate treatments for specific

clinical conditions.

• They provide a benchmark of satisfactory diagnosis and treatment against

which comparison of actual treatments can be made.

• They are a proven way to promote more rational use of medicines provided

they are:

o developed in a participatory way involving end-users;

o easy to read;

o introduced with an official launch, training and wide dissemination;

o Reinforced by prescription audit and feedback.

• Guidelines should be developed for each level of care ranging from

paramedical staff in primary health care clinics to specialist doctors in

tertiary referral hospitals, based on prevalent clinical conditions and

the skills of available prescribers.

• Evidence-based treatment recommendations and regular updating help to

ensure credibility and acceptance of the guidelines by practitioners.

• Sufficient resources are needed to reimburse all those who contribute to

the guidelines, and to cover the costs of printing, dissemination and

training.

Essential medicines list based on treatment of choice:

• Essential medicines are those that satisfy the priority health care needs

of the population.

• Using an essential medicines list (EML) makes medicine management easier

in all respects; procurement, storage and distribution are easier with

fewer items and prescribing and dispensing are easier for professionals

if they have to know about fewer items.

• A national EML should be based upon national clinical guidelines.

• Medicine selection should be done by a central committee with an agreed

membership and using explicit, previously agreed criteria, based on

efficacy, safety, quality, cost and cost-effectiveness.

• EMLs should be regularly updated and their introduction accompanied by an

official launch, training and dissemination.

• Public sector procurement and distribution of medicines should be limited

primarily to those medicines on the EML, and it must be ensured that only

those health workers approved to use certain medicines are actually

supplied with them.

• Government activities in the pharmaceutical sector like quality

assurance, insurance reimbursement policies and training, should focus on

the EML.

• The WHO Model List of Essential Medicines can provide a starting point

for countries to develop their own national EML.

Drug and therapeutic committees in district and hospitals:

• A drugs and therapeutics committee (DTC), also called a pharmacy and

therapeutics committee, is a committee designated to ensure the safe and

effective use of medicines in the facility or area under its

jurisdiction.

• DTC committees are well-established in industrial countries as a

successful way of promoting more rational, cost-effective use of

medicines in hospitals.

• Governments encourage hospitals to have DTCs by making it an

accreditation requirement to various professional societies.

• DTC members should represent all the major specialties and the

administration; they should also be independent and declare any conflict

of interest.

• A senior doctor would usually be the chairperson and the chief

pharmacist, the secretary.

• Factors critical to success include: clear objectives; a firm mandate;

support by the senior hospital management; transparency; wide

representation; technical competence; a multidisciplinary approach; and

sufficient resources to implement the DTC’s decisions.

Problem-based training in pharmacotherapy in undergraduate curricula:

• The quality of basic training in pharmacotherapy for undergraduate

medical and paramedical students can significantly influence future

prescribing.

• Rational pharmacotherapy training, linked to clinical guidelines and

essential medicines lists, can help to establish good prescribing habits.

• Training is more successful if it is problem-based, concentrates on

common clinical conditions, takes into account students’ knowledge,

attitudes and skills, and is targeted to the students’ future prescribing

requirements.

• The Guide to Good Prescribing describes the problem-based approach, which

has been adopted in a number of medical schools.

Continuing in-service medical education as a licensure requirement:

• Continuing in-service medical education (CME) is a requirement for

licensure of health professionals in many industrialized countries.

• Continuing in-service medical education (CME) is a requirement for

licensure of health professionals in many countries.

• In many developing countries opportunities for CME are limited and there

is also no incentive since it is not required for continued licensure.

• CME is more effective if it is problem-based, targeted, involves

professional societies, universities and the ministry of health, and is

face-to-face.

• Printed materials that are unaccompanied by face-to-face interventions,

have been found to be ineffective in changing prescribing behaviour.

• CME need not be limited only to professional medical or paramedical

personnel, but may also include people in the informal sector such as

medicine retailers.

• Governments should therefore support efforts by university departments

and national professional associations to give independent CME.

Supervision, audit and feedback:

• Supervision is essential to ensure good quality of care. Supervision that

is supportive, educational and face-to- face, will be more effective and

better accepted by prescribers than simple inspection and punishment.

• Effective forms of supervision include prescription audit and feedback,

peer review and group processes.

• Prescription audit and feedback consists of analyzing prescription

appropriateness and then giving feedback.

• Prescribers may be told how their prescribing compares with accepted

guidelines or with that of their peers.

• In hospitals, such audit and feedback is known as drug use evaluation.

• Group process approaches amongst prescribers consist of health

professionals themselves identifying a medicine use problem and

developing, implementing and evaluating a strategy to correct the

problem.

• Community case management is a special type of supervised group process

involving community members in treating patients.

Independent medicine information

• Often, the only information about medicines that practitioners receive is

provided by the pharmaceutical industry and may be biased.

• Provision of independent (unbiased) information is therefore essential.

• Drug information centres (DICs) and drug bulletins are useful ways to

disseminate such information.

• Both may be run by government or a university teaching hospital or a

nongovernmental organization, under the supervision of a trained health

professional.

• Whoever runs the DIC or bulletin must

o Be independent of outside influences and disclose any financial or

other conflict of interest,

o Use evidence-based medicine and transparent deduction for all

recommendations made

The WHO Model Formulary provides independent information on all medicines

in the WHO Model List of Essential Medicines.

Public education about medicines:

• Without sufficient knowledge about the risks and benefits of using

medicines and when and how to use them, people will often not get the

expected clinical outcomes and may suffer adverse effects.

• Governments have a responsibility to ensure both the quality of

medicines and the quality of the information about medicines available to

consumers. This will require:

o Ensuring that over-the-counter medicines are sold with adequate

labelling and instructions that are accurate, legible, and easily

understood by laypersons.

o The information should include the medicine name, indications, contra-

indications, dosages, drug interactions, and warnings concerning

unsafe use or storage.

o Monitoring and regulating advertising, which may adversely influence

consumers as well as prescribers, and which may occur through

television, radio, newspapers and the internet.

o Running targeted public education campaigns, which take into account

cultural beliefs and the influence of social factors.

Education about the use of medicines may be introduced into the health

education component of school curricula or into adult education programmes,

such as literacy courses.

Avoidance of perverse financial incentives:

Financial incentives may strongly promote rational or irrational use.

Examples include:

o Prescribers who earn money from the sale of medicines like dispensing

doctors will prescribe more medicines, and more expensive medicines, than

prescribers who do not; therefore the health system should be organized

so that prescribers do not dispense or sell medicines.

Patients prefer medicines that are free or reimbursed, If only essential

medicines are provided free by government or reimbursed through insurance,

patients will pressure prescribers to prescribe only essential medicines.

If medicines are only reimbursed when the prescription conforms to clinical

guidelines, there may be an even stronger pressure on prescribers to

prescribe rationally.

Appropriate and enforced regulation

o Regulation of the activities of all actors involved in the use of

medicines is critical to ensuring rational use

o If regulations have any effect, they must be enforced, and the

regulatory authority must be sufficiently funded and backed up by the

judiciary.

Regulatory measures to support rational use of medicines:

|Activity: Small Group Discussion ( 15 minutes) |

|DIVIDE students into small manageable groups |

|ASK students to discuss on the following question |

|What are regulatory measures to support rational use of medicines |

|ALLOW students to discuss for 10 minutes |

|ALLOW few groups to present and the rest to add points not mentioned |

|CLARIFY and SUMMARIZE by using the contents below |

The following are regulatory measures to support rational use of medicines

• Registration of medicines to ensure that only safe efficacious

medicines of good quality are available in the market and that

unsafe non-efficacious medicines are banned;

• Limiting prescription of medicines by level of prescriber; this

includes limiting certain medicines to being available only with a

prescription and not available over-the-counter;

• Setting educational standards for health professionals and

developing and enforcing codes of conduct; this requires the

cooperation of the professional societies and universities;

• Licensing of health professionals – doctors, nurses, paramedics – to

ensure that all practitioners have the necessary competence with

regard to diagnosis, prescribing and dispensing;

• Licensing of medicine outlets – retail shops, wholesalers – to

ensure that all supply outlets maintain the necessary stocking and

dispensing standards;

• Monitoring and regulating medicine promotion to ensure that it is

ethical and unbiased. All promotional claims should be reliable,

accurate, truthful, informative, balanced, up-to-date, capable of

substantiation and in good taste.

i. Sufficient government expenditure to ensure availability of medicines

and staff:

• Lack of essential medicines leads to the use of nonessential

medicines, and lack of appropriately trained personnel leads to

irrational prescribing by untrained personnel.

• Without sufficient competent personnel and finances, it is

impossible to carry out any of the core components of a national

programme to promote rational use of medicines.

• Governments are responsible for investing the necessary funds to

ensure that all public health facilities have sufficient,

appropriately trained health professionals and enough essential

medicines at affordable prices for all the population, with specific

provisions for the poor and disadvantaged.

• Achieving these will require limiting government procurement and

supply to essential medicines only, and investing in adequate

training, supervision and health staff salaries.

STEP 6: Key Points (05minutes)

• Monitoring medicine use and using the collected information to

develop, implement and evaluate strategies to change inappropriate

medicine use behaviour are fundamental to any national programme to

promote rational use of medicines.

• A mandated multi-disciplinary national body to coordinate all

activities and sufficient government funding are critical to success.

• Without sufficient competent personnel and finances, it is impossible

to carry out any of the core components of a national programme to

promote rational use of medicines.

STEP 7: Evaluation (05minutes)

• List five national interventions in promoting rational medicines use

• What are the regulatory measures to support rational use of medicines

References:

World Health Organization (2001).How to Develop and Implement a National

DrugPolicy.2nd ed. Geneva.

World Health Organization, (1985).The Rational Use of Drugs.Report of the

Conference of Experts. Geneva:

Grand AL1, Hogerzeil HV2, and Haaijer-Ruskamp FM3,(1999), Intervention

research in rational use of drugs: a review. HEALTH POLICY AND PLANNING;

14(2): 89–102. Oxford University Press

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