Promoting Rational Use of Injections within National Medicine Policies

1
Promoting Rational Use of Injections within
National Medicine Policies

• World Health OrganisationDept. Essential Drugs
  and Medicines PolicySafe Injection Global
  NetworkPhnom Penn October 2002

2
A National Medicines Policyoften not implemented
due to lack of political will and corruption

• Expresses the goals and objectives set by a
  government for the pharmaceutical sector and
  identifies the main strategies for achieving them
• specifies the roles of all stakeholders (public
  and private)
• specifies government aims, decisions
  commitments
• should be concerned with
• equitable access,
• ensuring drugs are of good quality, safety and
  efficacy,
• promoting correct use of drugs

3
Every country needs a national drug policy
because of

• medical reasons
• 25-40 of the world population has no access to
  drugs
• up to 50 of the worlds drugs may be used
  inappropriately
• substandard and counterfeit drugs are not
  infrequent
• cost reasons
• drugs are 20-40 of health budgets - antibiotics
  injections are most expensive
• the need for coordinated multiple interventions
• single interventions do not change behaviour
  long-term

4
Up to 56 of primary care patients receive
injections - gt 90 may be medically unnecessary

• 15 billion injections per year globally
• half are with unsterilized needle/syringe
• 2.3-4.7 million infections of hepatitis B/C and
  up to 160,000 infections of HIV per year
  associated with injections

of primary care patients receiving injections
Chart date from Quick et al, 1997, Managing Drug
Supply
5
drugs that are prescribed unnecessarilyestimate
d by a comparison of expected versus actual
prescriptionChalker HPP 1996, Hogerzeil et al
Lancet 1989, Isah et al 2000
6
Many Factors Influence Drug Use
Personal
Prior Knowledge
Scientific Information
Habits
Information
Social Cultural Factors
Influenceof Drug Industry
Societal
Economic Legal Factors
Workload Staffing
Workplace
Infrastructure Availability
Authority Supervision
Relationships With Peers
Workgroup
7
Changing a Drug Use ProblemAn Overview of the
Process
8
Impact of multiple interventions on injection use
in Indonesia
9
No.drugs
Antibiotics
Injections
Source Sisounthone B, WPRO-EDM Newsletter,
March 2002 1(1)4
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Reducing injectables in WHOs model EDL

• SIGN recognised frequency of injectables in 11th
  EDL
• nature of problem (plus consequences) is
  identified and presented to secretariat of model
  EDL (EDM)
• 136 out of 306 active ingredients are injectables
  
• 173 injectable formulations
• lt50 injectables had enough information to decide
  syringe size
• injectable ingredients listed
• problem presented to expert committee of model
  EDL
• expert committee agreed to
• review all injectables by the Cochrane
  Collaboration
• insert a statement in the 12th model EDL
• those who supply injectables should supply
  the necessary equipment to give them in a sterile
  way

11
Review of 30 studies in developing countries
size of drug use improvements with different
interventions
None/minor
Moderate
Large
Large group training
Small group training
Diarrhoea community case mgt
ARI community case mgt
Info/guidelines
Group process
Supervision/audit
EDP/Drug supply
Economic strategies

0
10
20
30
40
50
60
Improvement in outcome measure ()
Adapted from Ross-Degnan et al, Plenary
presentation, Conference on Improving the
Use of Medicines, 1997, Chiang
Mai, Thailand.
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12 national strategies to promote RUD

• 1. Mandated multi-disciplinary body to
  coordinate medicine use policies
• 2. Evidence-based standard treatment guidelines
• 3. Essential Drug Lists based on treatments of
  choice
• 4. Drug Therapeutic Committees in hospitals
• 5. Problem-based training in pharmacotherapy in
  under-grad. training
• 6. Continuing medical education as a licensure
  requirement
• 7. Supervision, audit and feedback
• 8. Independent drug information e.g bulletins,
  formularies
• 9. Public education about drugs
• 10. Avoidance of perverse financial incentives
• 11. Appropriate and enforced drug regulation
• 12. Sufficient govt. expenditure to ensure
  availability of drugs, equip, staff

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National policies to reduce unsafe inapprop.
injections

• A national task force a subcommittee of the NDP
  body - to assess unsafe inapprop. injections and
  plan action
• Select appropriate injectable drugs and equipment
• public sector EDL, market withdrawal of
  inappropriate injections
• increase availability of approp.injections (with
  enough equip) alternatives
• reduce availability of inappropriate injections
  through effective registration of drugs
  dispensing outlets, enforcing Px-only regulation
• Train healthcare workers and the public on
  approp. safe use
• Regulate and monitor promotional activities and
  material
• Establish functional drug and therapeutic
  committees
• Eliminate economic incentives encouraging
  injection over-use
• prescriber salaries from drug sales, especially
  expensive injections
• dispensing fees that are a of drug costs
• flat prescription fees