Improving Primary Care Pharmaceutical Use
pharmaceutical management for diarrhea and acute respiratory infection, the leading causes of child mortality in developing countries. (ADDR 1996, Sazawal 1992)
By 1995, an emphasis on appropriate use of medicines had begun to appear more systematically in international forums. For example, the WHO Expert Committee on National Drug Policies identified promotion of rational drug use as a priority component of national drug policies, including improved prescribing, objective drug information, and rational use by consumers.(WHO 1996) Late in 1995, an International Conference on National Medicinal Drug Policies was held in Sydney, Australia, fittingly the first developed country to adopt a national drug policy with a strong rational use component.(Australia DHHS 1997) The Sydney conference brought together prescribers, consumers, regulators, industry, and academics in a productive, non-confrontational manner to discuss the components of national drug policy, including quality use of medicines.(Saunders 1995, Laing 1995) At this meeting, the decision was made to organize an International Conference on Improving Use of Medicines in Thailand in 1997 in order to review the scientific evidence for the success of different interventions to improve use of medicines, and to establish an agenda for research and implementation in this area during the next decade.
Initial efforts to improve drug use were based on a simple rational actor model which assumed that problems in drug use stemmed from knowledge deficits among prescribers and consumers, and that education and training were appropriate strategies to improve drug use. This was the sole solution advocated by the 1985 Nairobi Conference. The result of this framework was a proliferation of document-oriented approaches like drug bulletins, manuals, and posters, as well as didactic lectures, seminars, and prescriber training sessions, carried out with a firm belief in their efficacy and little attention to measuring impact.
It soon became clear that the reasons for clinically inappropriate prescribing in the developing world were quite complex and multi-factorial, including perverse financial incentives, perceived patient demand, cultural misconceptions about drugs, extrapolating limited clinical experience, and the promotional practices of drug representatives.(Vance 1986, Fabricant 1987, Soumerai 1988) Two realizations developed: the need to understand