Implementation status of self-assessment/peer-group discussion program: a bottom-up approach of monitoring/supervision in improving quality of health services.

BACKGROUND: Monitoring/supervision is an essential component for improving the quality of health services including rational use of medicines. A new bottom-up approach of monitoring/supervision consisting of self-assessment/ peer-group discussion was found to be effective in improving prescribing practices. The new strategy significantly improved the prescribing practices based on standard treatment guidelines. The government has implemented it as a Program in primary health care services of Nepal. This article aims to share the implementation status of the self-assessment/peer-group discussion Program for improving the prescribing practices of common health problems and availability of drugs in the district health system. METHODS: Concurrent mixed research design was applied for data collection. The data were collected at different levels of health care system using in-depth interviews, participatory observations and documentary analysis. RESULTS: The Management Division, Department of Health Services implemented the Program in 2009-10 and the PHC Revitalization Division, DoHs is the implementation division since 2010-11. The Program comprised revision of participant's and trainer's manuals, training of trainers and prescribers, finalisation of health conditions and indicators, distribution of carbon copy prescription pads, and conduction of peer-group discussions.The Program was implemented in number of districts. CONCLUSIONS: The government made the policy decision to implement the Program for monitoring prescribing practices and the availability of free drugs in districts. However, it has covered only few districts and needs escalation to cover all 75 districts of the country.

Improving private drug sellers' practices for managing common health problems in Nepal.

BACKGROUND: In most Asian countries, 50 - 90% of pharmaceutical sales are made in private drug outlets, by personnel with some training in drugs but not for the treatment of common health problems. The objective of the study was to determine effects of focused training for private drug sellers to improve practices in treating acute respiratory infections and diarrhoea in children, and anaemia in pregnancy in Nepal. METHODS: Randomized controlled, four way nested design study incorporating four interventions for drug retailers in both hill and terai districts. One group received mailed printed educational materials followed by mailed feedback; a second received small group training followed by feedback; a third received small group training only; and a fourth, the control group, received no intervention. Surrogate customer method was used to assess practices. Outcomes were measured using multivariate linear regression. RESULTS: A significant increase in the asking of key history questions, recommendation ( prescribing by drug retailers) of cotrimoxazole, and advice-giving for pneumonia; a significant increase in ORS recommendation, and advice giving for diarrhoea including the avoidance of antidiarrhoeals; and a significant increase in asking key history questions and recommending appropriate products in pregnancy cases. CONCLUSIONS: Training intervention as well as training followed by practice feedback was effective in improving the management of common illnesses and pregnancy by private drug sellers.

Community intervention to improve knowledge and practices on commonly used drugs.

BACKGROUND: World Health Organisation (WHO) estimates that about half of all medicines are inappropriately prescribed, dispensed and sold and about half of all patients fail to take their medicines properly. OBJECTIVE: The overall objective of the study was improving use of medicines in the community by creating awareness among different target groups. MATERIALS AND METHODS: It was a pre-post comparison of intervention implemented at the community level in purposively selected Bhaktapur District of Kathmandu Valley, Nepal. The study was conducted in the private schools of the study district. Twelve schools were randomly selected. Thereafter, students from 6-9 grades were listed from the selected schools. Then 15% of the total students in each grade were randomly selected to get six students from each grade of the each school, totaling 288 students. The households of the selected students served as the sample households for the study. Thus, there were 288 households sampled for the study. The intervention and the targeted intermediary groups consisted of a. training of schools teachers b. training of journalists c. interactive discussions of trained school teachers with school children using key messages and c. communication of key messages through the local F.M. radio, newspaper/magazine. RESULTS: There was a significant increase in correct knowledge on action of antibiotics and excellent knowledge on the methods of administration of antibiotics of households after the intervention. Similarly, there was a significant increase in knowledge on cough as a disease and a significant decrease in the use of cough medicines after intervention. There was also a significant increase in excellent knowledge on the sources of vitamins and a significant decrease in the use of vitamin/tonics after the intervention. CONCLUSION: The participation of intermediary groups eg. school teachers, journalists and school children in the implementation of intervention were successful. The groups have fulfilled the commitments in implementing the plan of action. The key messages have effectively reached the households, and the knowledge and practices of the community members in drug use have improved.

An intervention improving prescribing practices and monitoring drugs availability in a district.

To improve the quality of health care in Nepal, supervision/ monitoring involving periodic visits by the district supervisor to health facilities (top-down approach) is in practice. It is not objectively implemented because of time and financial constraints and terrain of the country. To assess the effectiveness of a pre-tested strategy i.e. peer-group discussion with self-assessment piloted through the district health system in improving quality of care. A pre-post pilot study was conducted in 41 PHC facilities of Chitwan district of Central Nepal. The intervention included small-group training to prescribers followed by peer-group discussion with self-assessment data. It involved visit of in-charges from health facilities to district level regular meeting with self-assessment data on the treatment of four targeted health problems and also the availability of drugs of their health facilities as well as from health facilities which were under their supervision (bottom-up approach). In under-five children, there was a significant improvement in use of antimicrobials in diarrhoea, paracetamol alone and antibiotics in no pneumonia, and co-trimoxazole or amoxycillin alone or with paracetamol in pneumonia. The use of benzyl benzoate or gamma benzene hexachloride alone and antibiotics in scabies were also significantly improved. The peer-group discussion, a bottom-up approach of supervision/monitoring implemented through district health system improves the prescribing practices and availability of drugs in the district.

Evaluation of a successful intervention for sustainability and effects in post research phase.

INTRODUCTION: Promoting appropriate use of drugs is an essential element in achieving quality of health and medical cares for patients and the community, and also to minimize financial burden. OBJECTIVE: The objective of this paper is to assess the successful intervention for sustainability and effects in post research phase. To address these problems, a variety of educational, managerial and regulatory strategies to improve prescribing have been tried in Nepal. When training is combined with a managerial intervention i.e. peer-group discussion, it results into improved changes in prescribing practices of paramedics in several practices. METHODOLOGY: A prospective, three-way design study consisting of small group training, small group training followed by peer-group discussion and control was conducted in three regions of Nepal including one hill and two terai (plains) districts from each region. The study included all health post from the sampled districts, making 80 health posts the study population. RESULTS: The study revealed the effectiveness of the peer-group discussion approach in improving the prescribing practices. An assessment to identify the sustainability of the strategy and its effect within the district healthcare system after the completion of the research phase was undertaken. The study found that peer-group discussion was discontinued in all targeted districts and the improved practices were not sustained after the completion of the research. Various reasons have been found for not continuing the effective intervention.

Can licensed drug sellers contribute to safe motherhood? A survey of the treatment of pregnancy-related anaemia in Nepal.

Iron-deficiency anaemia is a major cause of maternal mortality worldwide, contributing to perhaps one in five maternal deaths. According to the World Health Organization (WHO), maternal anaemia is most severe in southern Asia. Drug retail shops frequently serve as the public's first point of contact for medical care, even though many drug sellers have no training in the treatment of illness. In western Nepal, drug retailer treatment of anaemia in pregnancy was investigated using interviews, focus groups and simulated clients ('surrogates'). Research assistants posing as the husbands of anaemic pregnant women asked retailers for advice. In 112 retail shops studied, 71% of the study surrogates were recommended iron supplements for purchase. Drug recommendations often included vitamins, minerals and other ingredients not therapeutic for pregnancy-related anaemia. Retailers were found to take little case history. Fifty-seven per cent of retailers asked about the duration of the pregnancy; 40% asked no relevant questions. Advice about the drugs sold was infrequent and 59% of the surrogates received no advice of any kind other than a product recommendation. Knowledge of important referral criteria was also especially low. Although 66% of the retailers had some sort of formal training for work with pharmaceuticals, current training levels were not found to be associated with better knowledge or practice. A focused training intervention to improve retailer treatment of anaemia in pregnant women is recommended.

Drug retailer training: experiences from Nepal.

Sale of modern medicines by untrained peddlers, general merchants, and other drug sellers is common throughout the developing world. Drug sellers operating in the 'informal sector' are often the first source of health care outside the home. Reasons given by patients for using private drug sellers include expediency, convenience, efficacy of the medicines, dependability of supply, and reasonable cost. At the same time, self-medication through private drug sellers can be ineffective, wasteful, and at times distinctly harmful. Regulatory approaches to controlling drug selling in the informal sector, widely endorsed on paper through national drug control legislation, require a cadre of professional regulatory staff and enforcement mechanisms which are too often beyond the current economic and political reach of countries. In Nepal, where rugged terrain has limited infrastructure development, the doctor to population ratio is 1:23,000, utilization of government health services averages only 0.2 visits per person per year. Retail drug outlets outnumber health posts and health centers by a ratio of 4:1 and private drug sellers often offer the only access to modern medicine for much of the population. Community surveys have found that drug retailers are very often the first and only source of health care outside the home. Given the importance of retail drug outlets and the lack of trained pharmacists, the Department of Drug Administration in 1981 established a 45-hr course for drug retailers which emphasized practical training as well as formal teaching on pharmacology, ethics, storage of drugs, and legal issues. By the end of 1989, 4096 drug retailers had graduated from the course. Still run by the Ministry of Health Department of Drug Administration, the course has proven to be administratively feasible and has been quite popular with drug retailers. Initial reservations expressed by doctors and some pharmacists were soon overcome, and the course is now well accepted by professional groups. Because the course is offered in different locations, geographic coverage has also been very good despite Nepal's logistic constraints. The operating cost of the course averages about U.S. $18 per trainee. Informal evaluations have resulted in plans for refresher training more narrowly focused on safe dispensing and appropriate referral for a limited number of important public health problems. Since 50-90% of pharmaceutical expenditures typically pass through the informal private sector in developing countries, it is suggested that other countries consider focused drug retailer training as a response to the problems of manpower shortages and drug dispensing by unqualified staff.