Interventions for improved prescribing and dispensing of medicines in Nepal, Thailand and Vietnam

Abstract: Background: To find successful interventions to improve drug use, especially antibiotics, is a pressing need in low income countries. The objectives of the research are to explore current practice and knowledge of practitioners in the public and private sectors in resource poor countries, and experiment with different interventions to improve practices in the prescribing and dispensing of medicine. Designs: I: Post intervention, with control. II: Pre post intervention and time series with rolling control. III: Baseline comparison of data from questionnaires and simulated client method (SCM). IV and V: Randomized controlled trial. Settings: Public primary health care facilities (PHC) in 2 hill districts in Nepal (I) and in Hai Phong Province, Vietnam (II). Private pharmacies in Hanoi (III-V) and Bangkok (V). Study Population: I: A 25 % sample of all prescriptions issued in a year by all PHC facilities in the two districts. II: Monthly random collection of 30 prescriptions from all 217 facilities. III: 60 randomly selected private pharmacies as measured by 5 simulated client visits (SCM) and a semi structured questionnaire per pharmacy. IV: Pre post questionnaires to 34 randomly selected matched pairs of pharmacies. V: The intervention and control pharmacies that had all 5 simulated client visits for each condition at each phase in Hanoi and Bangkok. Interventions: I: An assured drug supply scheme with a prescription charge. II: Incentives, controls and the education of providers, patients and communities. IV-V: Multi-faceted interventions with regulatory enforcement, faceto face education and peer influence. Outcome Measures: Attendance (I), items per prescription and % prescriptions containing antibiotics (I & II), % antibiotics prescribed with an adequate dose (II). Correct questions, advice and treatment for managing a case of a sexually transmitted disease (STD) (III, IV), acute respiratory infection (ARI) (IV), and antibiotic and steroid requests (IV and V). Results: In the intervention groups: I: Attendance fell 18% the first year and recovered over 3 years. Items per prescription were 2.5 (1.7 in control and 1.4 calculated needed values). 61 % of prescriptions contained antibiotics (37% in control and 27% calculated needed value). II: The per cent of prescriptions with antibiotics decreased from 68% to 45% and the per cent with an adequate dose, increased from 30% to 93%. III: 74% of drug sellers said they would refer a case of STD to a doctor but only 16% did. None gave correct treatment. Few asked relevant questions and gave relevant advice. IV: After the interventions more drug sellers in the intervention group stated they would ask about the health of the partner (p=0.03) and advise on condom use (p=0.01) and partner notification (p=0.04): For ARI, in the intervention group, more say they would ask questions about fever (p=0.01) and fewer would give antibiotics (p=0.02). Fewer would sell low dose antibiotics without a prescription (p=0.02). V: In Hanoi fewer in the intervention group sold antibiotics (p=0125) and steroids (p <0.0001) and more asked questions and gave advice. In Bangkok there were no changes. Conclusions: The prescribing and dispensing of antibiotics is a major problem in all the locations studied. Studies presented here show that improvements are possible to achieve both in the public and private sectors in most resource poor settings but vary with location. Major problems remain. Comprehensive, tailored, interventions have to be developed for each location including both consumers and their providers. Isolated examples of successful small scale interventions are no longer enough. Indicators as both assessment and managerial tools are central to this endeavour.