Improving Primary Care Pharmaceutical Use
strategies: training in dispensing skills with and without supervisory follow-up (Kafle 1995a); and dissemination of guidelines with or without prescription audit and review (Chowdhury 1996). One study (classified as predominantly a training intervention above) also contrasted simple dissemination of guidelines versus focused training in the use of those guidelines with or without subsequent supervisory visits (Kafuko 1994). One African study examined the impact of requiring a prescription from a clinical officer or MD (rather than a nurse) for the dispensing of antibiotics, combined with monthly audit and personal feedback on level of antibiotic use.(Van der Hoek 1996) Finally Sunartono and colleagues (1995) examined the long-term impact of facility-level self-monitoring and staff discussion using indicators.
The final category of interventions in this review includes essential drugs programs and other drug supply programs developed to increase access to safe and effective drugs. Since improving the initiation of WHO/DAP in the early 1970s, over 50 countries have implemented essential drugs programs. These programs typically accompany improvements in supply with a variety of interventions to improve drug management and use, including essential drugs lists, treatment guidelines, staff training, cost recovery, or supervisory systems. The key question of interest for our review is the impact of these combined interventions on quality of drug use.
It is noteworthy that we could identify only 7 studies that have examined the impact of essential drugs programs on the use of medicines, and only a single program which employed a time series evaluation design that allows valid inference about the program's impacts.(ZEDAP 1995) The other studies that tried to evaluate the impact of essential drugs programs either failed to include a comparison group, or measured differences between study and comparison areas only after the program had been implemented.
Target providers, health problems, and practices
The interventions included in this review targeted a broad range of primary health care providers. For the most part, these interventions have focused on one or two health problems, although some studies have addressed practices (e.g. antibiotic use) that are relevant to a range of different health problems.
Physician practices were targeted in 34 (57.6%) of the 59 reported studies, while the practices of nurses,