Improving Primary Care Pharmaceutical Use
As mentioned above, there is only a single useful study of the impact of an essential drugs program on quality use of medicines. Since 1989, the Zimbabwe Essential Drugs Action Programme (ZEDAP) has conducted regular surveys of key indicators of drug supply management and use in public health facilities, and beginning in 1995, in the private sector as well.(ZEDAP 1996) These surveys, which provide a wealth of information about the status, strengths, and weaknesses of the national program over time, are the paradigm of how essential drugs programs could effectively monitor and evaluate its impact. Unfortunately, even in Zimbabwe, we have no estimate of the program=s total impact on use of medicines, since the annual surveys did not begin until after many activities had already been implemented. However, due to transitions in ZEDAP over time, we are able to estimate the value of the training component of the program on appropriate use.
In 1991, ZEDAP completed a phase of active implementation. In that year, the indicators from the national survey reflected quality of primary care drug use that ranked among the best in the world.(Hogerzeil 1993) In 1992, ZEDAP also shifted from independent management to full integration within the MOH, and donor support for many activities was reduced, including outreach education for MOH staff on principles of prescribing and use of the national standard treatment guidelines. The subsequent period has also been marked by difficult economic circumstances in Zimbabwe, increasing strain on health services because of a rising incidence of AIDS, and rapid transition in health personnel. Subsequent surveys through 1995 give us an indication of the effects of discontinuing active program implementation in this context on quality of use. For example, the number of drugs prescribed per patient rose by 26.9% between 1991 and 1995, and the percentage of patients treated according to STGs for gonorrhea declined by 41%.
Limitations of our analysis
This study suffers from a number of methodological limitations that are common to all literature reviews, and some which are unique to a review of developing country behavioral interventions. One limitation is the fact that, despite our intensive efforts, this collection of experiences is incomplete. There may be other studies on