Improving Primary Care Pharmaceutical Use
Four training interventions had minimal or no impact. In an evaluation of an MOH training program, Ofori-Adjei (1996) found that traditional didactic, single-session, large group training had no impact on increasing the use of oral chloroquine or on improving standard dosing for malaria treatment; in subsequent focus groups with medical officers, the investigators found that the training had not addressed key issues such as misunderstandings about drug efficacy or patient preference for injections. Agunawela (1991) tested distributing unbiased information on appropriate antibiotic use with and without training seminars for prescribers; both interventions had small but non-significant positive effects. Bexell (1994) found that a single two-day, multi-method training workshop on ARI, malaria, and diarrhea was also associated with small, but non-significant improvements. The latter two interventions were more diffuse and broadly focused than the similar single issue training workshops described above that achieved greater effects.
The type of CHW training employed in most CCM interventions shares many characteristics with successful training interventions directed at other health providers: focus on a single health problem, multi-method training approach, practical skills-orientation, and usually multiple sessions over time. In addition, many interventions reinforced and intensified messages through concurrent community and health worker education, supervision, and drug supply management.
The CCM approach is clearly an effective strategy for reducing child mortality. Overall the ARI case management interventions reduced ARI-specific mortality in under-five children by a median of 25.7%; Sazawal and Black (1992), in a meta-analysis of both controlled and uncontrolled ARI CCM interventions, reported a reduction in all-cause mortality of 20%. Two other CCM interventions targeted diarrhea mortality. Based on time series, the Egypt National Control of Diarrheal Disease Program (Miller 1995) measured additional reductions in national diarrhea mortality attributable to the program interventions of 24.2% over 5 years. In the first reported CCM intervention, McCord (1978) reported reductions in combined diarrhea/ARI mortality in children under three of 46.3%, and reductions in case fatality from ARI and diarrhea of 79.0% and 56.3% respectively.