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3b. Policy: Policy Interventions to Improve Rational Use of Medicines in LMIC
New Performance-Based Reward Strategy to Improve Pharmacy Practices, Financial Management, and Appropriate Medicines Use in the Public Sector in Uganda
1Management Sciences for Health, Uganda; 2Ministry of Health,Pharmacy Division, Uganda; 3National Drug Authorities. Uganda
Problem statement: Ensuring availability and appropriate use of essential medicines is crucial if limited resources are to be used optimally. Although training of health workers has been underway for a long time, taken since long, significant and sustainable improvements in availability and medicines management have not been achieved, and new interventions are needed. Increasingly, countries are finding it difficult to ensure sufficient funding for medicines; at the same time, the financial management (FM) capacity among pharmaceutical staff is weak. The use of a performance-based reward strategy (PBRS) has proven successful in strengthening vaccine management. The effect of capacitating pharmaceutical staff in FM and applying PBRS still needs to be assessed in regard to improving medicines management.
Objective: To assess impact of PBRS and FM in improving pharmacy practices (PP) and appropriate medicines use (AMU), implemented by trained medicines management supervisors (MMSs)
Design: A randomized longitudinal intervention study with randomization by districts; 25 indicators will be applied to assess good PP and AMU after educational, managerial, regulatory, and financial (reward) interventions were implemented. Data collection is undertaken as baseline at the initial facility visit, and several follow-up supervisory visits will also be made. Prior to each supervisory visit, performance will be assessed; this information will become part of the data along with the information collected during the visit. Supervisory visits are expected to continue for up to 2 years.
Setting: The study includes 45 intervention and 15 control districts with 1,482 public and 443 private not-for-profit, all-level health facilities; on average, 39 (11-105) facilities per district.
Intervention: The intervention districts are randomly assigned to 1 of 3 intervention groups: (1) supervision in supply chain management targeted at accreditation in good PP, (2) additional supervision in FM targeted at certification in good FM, and (3) additional stores computerization—all compared to a control group of facilities. Accreditation in good PP is undertaken by the national drug authority and harmonized with the licensing criteria applied in private sector pharmacies; 146 MMSs will be trained as district and health subdistrict supervisors. The reward system for MMSs comprises items such as motorbikes, computers, Internet access, personal training, and e-based learning, and for the facilities, accreditation, certification, technical manuals, continued education, and computerization, all with community involvement.
Policy: The strategy is built on the basis of the essential medicines concept with development of essential medicines, supplies, and the laboratory supplies list, classified according to health impact and importance in saving lives, which will guide procurement at all levels.
Outcome measures: The primary outcome measures included PP, FM, and AMU.
Results: Method description and baseline date available for ICIUM 2011. Results will only start to become available from mid 2011.
Funding source: United States Agency for International Development through Securing Ugandans’ Right to Essential Medicine (SURE) Program.
The Irrational Use of Drugs in Rural China: Evidences from Two Provinces
Center for Health Management & Policy, Shandong University, Peoples Republic of China
Problem statement: Irrational use of drugs is a severe problem in China. The overuse, under use, or misuse of drugs has resulted in wastage of scarce resources, poor-quality treatment, and unnecessary costs of health care.
Objectives: To evaluate the basic situation of rational use of drugs in rural China by studying the behavior and perception of health care providers and rural residents
Design: It was a policy evaluation study. A cross-sectional study was designed to evaluate the use of drugs in rural China.
Setting: This study was conducted in Shandong and Ningxia provinces. In each province, the public hospitals and rural community were the basic study sites.
Study population: In each province, 3 counties, 9 towns, and 18 villages were randomly sampled according to the economic level, and in each villages, 30 household were randomly sampled. In total, 13,481 rural residents were investigated. 3,000 prescriptions were randomly sampled and collected at county hospitals, township health centers, and village clinics. 49 health care providers from county, town, and village health institutions were interviewed.
Policies: The Ministry of Health has issued policies and carried out health promotion activities for improving the rational use of drugs in hospitals and communities, but the effects of these policies and activities on use of drugs, especially in the rural area in China, are unclear.
Outcome measure(s): Primarily, the behavior and perception of health care providers and rural residents on use of drugs were measured.
Results: The results showed that 75.3% and 66.2% of prescriptions sampled from the village clinics have antibiotics in Shandong and Ningxia, respectively, and the antibiotic utilization rate in the village clinics is significantly higher than that in county hospitals and township health centers (χ2=123.659, p＜0.001; χ2=12.735, p= 0.005). Accustomed prescription practices of rural health providers and economic incentives from selling drugs are the main reasons for the high antibiotic utilization; meanwhile over 50% of surveyed populations don’t know consequence of irrational use of antibiotics in the two provinces. Over 50% of prescriptions have the injections in the township health centers and village clinics, which is significantly higher than that in the county hospitals. Our study found that the rural patients actively require using the injections as they believe the effect of injections is better than oral drugs. 54.6% and 60% of the rural patients cannot comply with medical advice to take drugs in Shandong and Ningxia, respectively.
Conclusions: The policies and health promotions do not play certain roles in improving the rational use of medicines in rural China. Implementing trainings on the rational use of drugs and reforming the incentive mechanism for rural health providers are urgent and essential for improving the rational use of drugs in rural China.
Funding source(s): The study is part of a project entitled "Bringing Health Care to the Vulnerable: Developing Equitable and Sustainable Rural Health Insurance in China and Vietnam (RHINCAV)" funded by the European Commission (Specific Targeted Research Project).
Financial Impact of Judicious Use of Medicine in Primary Care
NPS:Better Choices, Better Health, Australia
Problem statement: Many policies and guidelines have been developed to promote the judicious use of medicines. Funding large-scale programs to implement these policies remains challenging. NPS has worked at the national level to address quality use of medicine in the last 12 years.
Objectives: To assess the financial impact of NPS programs on expenditures by the Australian Pharmaceutical Benefit Scheme (PBS) between 2007 and 2009
Design: Time series modeling was used to assess the association between general practitioner (GP) participation in NPS programs and PBS expenditures, controlled for underlying trends, seasonality, autocorrelation, and medicine price changes. PBS monthly time trends over 1999–2009 in utilization of antithrombotics, antihypertensives, analgesics, antidepressants, and proton pump inhibitors (PPI) were analyzed.
Setting: Primary care
Study population: All Australians entitled to PBS subsidies
Intervention(s): The interventions aimed at GPs included educational visits, case studies, clinical audits, and group discussions. Key messages relevant to reducing suboptimal use of medicines included the following: (1) reserve clopidogrel for those unable to take aspirin; (2) avoid fixed-dose combination products in the initiation of antihypertensives; (3) limit the role of tramadol for mild to moderate pain management; (4) use psychological therapies as first-line treatments in mild depression; and (5) step down the dosage of PPIs to intermittent, symptom-driven therapy.
Policy: Evidence-based prescribing
Outcome measure(s): Difference in PBS expenditure on targeted medicines attributable to the intervention
Results: The GP participation rates were between 29% (5,956) and 52% (8,358) of all GPs. We found a significant correlation between GP participation and decreased PBS expenditures on targeted medicines (p <0.0001 to <0.05). We noted a significant increase in the effect of interventions in the initial period following implementation. For example, the annual PBS expenditure saving on antidepressants increased from 7% in 2008 to 12% in 2009 (last GP enrollment in May 2008); however, 2 years after implementation, the PPI program showed signs of waning. Annual cost savings decreased from 13% in 2008 to 12% in 2009 (last GP enrollment in April 2007). Overall, we estimate a mean annual PBS expenditure reduction of 16% (AU $18.4 million) per program per drug group attributable to NPS interventions.
Conclusions: Comprehensive programs in primary care can reduce inappropriate prescribing and lead to substantial national cost savings. Program for some drug groups may need refresher interventions every 2–3 years to sustain the impact.
Funding source(s): NPS is funded by the Australian Government Department of Health and Ageing.
Effects of Listing and Delisting in National Essential Medicine List on Utilization Patterns
1Faculty of Social Sciences and Humanities, Mahidol University, Thailand; 2Pharmacy division, Phramongkutklao Hospital, Thailand
Problem statement: The National Essential Medicine List (NEML) has been a major policy instrument that the Thai Government has employed to regulate the use of medicines in government health facilities since 1982. Recent changes made in the 2008 NEML, from the previous 2004 edition, include addition and deletion of a number of medicines.
Objectives: This study examines the effects of NEML listing and delisting on utilization patterns and compares delisted drugs with remaining or added medicines and, where applicable, “non-essential” medicines (NEM; not listed in both NEML editions) in the same pharmacological category.
Methodology: Comparisons were made on 3 groups of medicines: (1) statins: Atorvastatin (delisted), Simvastatin (listed 2004 and 2008), and Rosuvastatin (NEM); (2) ACEIs and AIIAs: Enalapril and Losartan (listed 2004 and 2008) and Valsartan (delisted); and (3) antiepileptics: valproic acid (listed 2004 and 2008), Gabapentin (indication changed), and Levetiracetam (added 2008). Outpatient electronic dispensing databases from 9 government hospitals were used. Segmented regression analysis of interrupted time-series data was employed. The number of patients prescribed each of the medicines 14 months before and 10 months after the policy change were traced. This comprises a total of 24 months of time-series data points, with 130,287 patients in this dataset prescribed the statins, 85,349 patients prescribed the ACEIs and AIIAs, and 31,739 patients prescribed the antiepileptics. Comparisons of the percentages of patients in the 3 major health insurance schemes prescribed the delisted medicines were also conducted.
Results: Time-series plots of the number of patients prescribed each studied medicine per month exhibit no apparent change in the utilization patterns for all the items before and after the switch from 2004 to 2008 NEML. The statistical analyses of the listed, delisted, and non-listed medicines showed no significant difference before and after the introduction of the 2008 NEML. Further examination of utilization patterns among beneficiaries of the 3 major health insurance schemes revealed differences in the percentage of patients in different groups being prescribed these medicines. Before the new NEML, Atorvastatin was prescribed to 31.5%, 3.8%, and 0.6% of patients in the Civil Service Medical Benefits Scheme, Social Security Scheme, and the 30-Baht Scheme, respectively. After the new NEML, these numbers changed only slightly to 31.1%, 3.3%, and 0.6%. Similar discrepancies among schemes were also found in the prescribing patterns of Losartan, Valsartan, and Gabapentin.
Conclusion: No statistical significant changes in the utilization patterns of the listed, delisted, and non-listed medicines occurred after the introduction of the 2008 NEML. Discrepancies in utilization were found among patients in different health insurance systems. It appears that health insurance policy exerts greater influence on utilization patterns than essential medicine policy.
Funding source: Information not provided