Standard Treatments
Session Guide
Standard Treatments
SESSION GUIDE
PURPOSE AND CONTENT
Experience has shown that even when drug supply is based on an essential drug list,
ample opportunity exists for ineffective, unsafe, or wasteful prescribing. Standard
treatments list the preferred drug and nondrug treatments for common health problems
experienced by people in a specific health system. As such, they represent one
approach to promoting therapeutic effective and economically efficient prescribing.
Standard treatments are currently used in the U.S., Europe, Latin America, Asia, Africa,
and the Western Pacific.
When implemented effectively, standard treatments offer advantages to patients (more
consistency, treatment efficacy); providers (gives an expert consensus, quality of care
standard, basis for monitoring); supply managers (makes demand more predictable,
allows prepacks); and health policy makers (provides focus for therapeutic integration of
special programs, promotes efficient use of funds). But effective implementation is
perhaps the greatest challenge in introducing standard treatments.
OBJECTIVES
This session will develop your ability to—
1. Recognize and convey to others the advantages and potential benefits of standard
treatments in promoting effective drug use.
2. Develop clinically effective, economically efficient, and locally appropriate standard
treatment protocols for priority health problems.
3. Prepare a plan to effectively implement standard treatments in your setting through
printed reference materials (manuals, posters, training materials); pre-service, inservice, and reinforcement training; and monitoring and supervision focused on the
priority health problems and their standard treatment.
PREPARATION
1. Read the Session Notes.
2. Read the Case Study, "A Second Edition? Standard Treatments in Pagalia." Look
carefully at the Questions to Consider both before and after reading the case.
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FURTHER READING
Treatment Guidelines and Formulary Manuals. In: Managing Drug Supply: The
Selection, Procurement, Distribution, and Use of Pharmaceuticals. 2nd ed., rev.,
and expanded. W. Hartford, Conn.: Kumarian Press; 1997:138-149.
INTERNET RESOURCES
Rational Drug Use in Rural Health Units of Uganda: Effect of National Standard
Treatment Guidelines on National Drug Use.
[www.who.ch/programmes/dap/ICIUM/posters/2f3_txt.html]
ICIUM POSTERS
2F-1. Improvement of prescribing practices after launching ARI project,
Choudhury SAR, Baqui QBOF,
2F-2. Effect of standard treatment guidelines with or without prescription audit on
prescribing for diarrhoea and acute respiratory infection in some
government health facilities of Bangladesh, Chowdhury AKA, Khan OF,
Matin MA, Khadiza B, Galib MA,
2F-4. Impact of pilot intervention (standard treatment guidelines, training) on
prescribing patterns in Dar es Salaam, Wiedenmayer K, Mtasiwa D,
Majapa N, Lorenz N,
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SESSION NOTES
INTRODUCTION
Local manuals are needed in every health system because of differing decisions about
drug choices and the patterns of illness within a country. Disease oriented manuals
are called standard treatment guidelines (STGs), treatment protocols, or prescribing
policies. Drug-oriented manuals are called Therapeutic Formularies.
The selection of drugs to be included on the essential drug list is based on the
prevalent pattern of illness and the standard treatments decided upon to treat these
conditions. Training, drug supply, assessment, and quality evaluation are based on
these standard treatments.
Thus developing and updating standard treatments are a very important part of any
essential drugs program and a basic component of any effort to improve rational use of
drugs.
This session will review the dangers of therapeutic anarchy, discuss the advantages of
standard treatments, and assess the impacts of standard treatments. The final part of
the session will review the development and implementation of standard treatments.
THE NEED: A SOLUTION TO THERAPEUTIC ANARCHY
Standard treatments have existed for as long as the art of healing has existed.
Traditional healers developed their standard set of cures and now pass them from
generation to generation. The history of early scientific medicine was one of identifying
patterns of signs and symptoms that revealed an underlying disease, assigning a name
to that disease, and searching for the effective remedy for it.
In this century, however, modern medicine has gone far beyond the stage where each
disease has but one treatment. Instead, each disease may have many acceptable
treatments. And if individual symptoms are treated without at least a working diagnosis,
the number of possible treatments can be endless.
Doctors, nurses, pharmacists, community health workers, and other health care
providers learn about all of the treatments that could be used, instead of focusing on
the best treatment that should be used. Casual observation, as well as more
systematic study of prescribing practices, frequently reveals a pattern of tremendous
diversity among prescribers in the treatment of even the most common conditions.
Polypharmacy is one problem; for example, three, four, five, six, and sometimes more
drugs for acute viral gastroenteritis, for which only oral rehydration therapy is effective in
reducing morbidity and mortality. Other common problems considered in greater detail
elsewhere are incorrect drug choices, overdosing, underdosing, and choice of more
expensive drugs when less expensive drugs would be equally or more effective.
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Standard treatments—also known as standard
treatment schedules (STS); standard treatment
protocols; therapeutic guidelines; and so forth—
list the preferred drug and nondrug treatments for
common health problems experienced by people
in a specific health system. Each drug treatment
should include for each health problem the name,
dosage form, strength, average dose (pediatric
and adult), number of doses per day, and number
of days of treatment. Other information on
diagnosis and advice to the patient may also be
included.
Standard treatments should consider both drug
and nondrug treatments. "Reassurance," for
example, might be the proper standard treatment
for a child who is shorter than other children of his
or her age, but who shows a normal growth
curve, no signs of malnutrition or chronic disease,
and has shorter than average parents.
Health problems including specific diagnoses
("malaria"), symptoms ("headache"), and
preventive health services (EPI immunizations,
antenatal vitamin and mineral supplements) may
also be included in such a manual.
Standard treatments are currently in use in parts
of the United States, Europe, Latin America, Asia,
Africa, and the Western Pacific. Experience
shows that even the shortest essential drug list
offers ample opportunity to misuse drugs by
improper treatment of common problems. Thus,
essential drug programs are finding that the
development of standard treatments is necessary
for therapeutically effective and economically
efficient use of drugs.
Standard treatments are used at different points of the therapeutic process. They may
be used to diagnose, decide on treatment and drug supply, and assist with adherence
to the prescribed treatment. This will hopefully lead to the desired clinical outcome.
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Figure 1. Standard Treatments in the Therapeutic Process
Signs &
Symptoms
Rx
Drug
Supply
Diagnosis
(Health
Problems)
Rx
Treatment
(Responses)
Rx
Adherence
(Compliance)
Rx
Clinical Outcome
Rx = focus of standard treatments
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ADVANTAGES OF STANDARD TREATMENTS
Standard treatments offer a number of potential advantages for patients, health
providers, supply managers, and health policy makers. Figure 1 illustrates the points in
the therapeutic process at which standard treatments can act. Potential benefits of
introducing standard treatments include the following:
For Patients
•
Consistency among prescribers leads to
reduced confusion and increased
compliance
•
Most effective treatments prescribed
•
Improved supply of drugs if drugs are
prescribed only when needed.
For Providers
•
Expert consensus given on most effective,
economical treatment for a specific setting
•
Provider can concentrate on correct
diagnosis
•
Provide a standard to assess quality of
care
•
Simple basis provided for monitoring and supervision.
For Supply Management Staff
•
Performance standard for drug supply, so that sufficient quantities of
drugs are available for the most commonly treated problems at the
different levels of the health system
•
Pre-packaging facilitated for course-of-therapy quantities of commonly
prescribed items for common conditions
•
Drug demand more predictable, so forecasting more reliable.
For Health Policy Makers
•
Method provided to control costs by using drug funds more efficiently
•
Basis available to assess and compare quality of care
•
Development and implementation of a single set of standard treatments
can be a vehicle for integrating special programs (diarrhea disease
control, acute respiratory infection, tuberculosis control, malaria, and so
on) at the primary health care facilities.
Standard treatments do not take the thinking out of health care. Instead, they focus the
thinking on other critical aspects of the therapeutic process: careful identification of
signs and symptoms; correct diagnosis; and effective patient counseling on proper use
of those few drugs or nondrug treatments that will truly benefit the patient.
Sometimes medical school faculty, consultant physicians, and other health care
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providers oppose standard treatments, fearing they will lead to "cook book" medicine
and loss of the "right to prescribe." This fear has proven largely unfounded; doctors in
the most prestigious medical institutions in developed and developing countries are
writing and promoting such handbooks.
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KEY FEATURES OF STANDARD TREATMENTS
Standard treatments have been used for many years in some countries. Standard
treatments now exist for common illnesses of children, common adult illnesses, and
obstetrics and gynecology. The existence of these treatments has reportedly had a
major impact on the consistency, effectiveness, and economy of prescribing. Key
features of standard treatments, as they have been implemented for instance in Papua
New Guinea, include:
 Simplicity: The number of health problems is limited. For each health problem, a
few key clinical diagnostics criteria are listed. Drug and dosage information is
clear and concise.
 Credibility: The treatments were initially developed for patients by the most
respected clinicians in the country. Revisions based on actual experience have
further added to the credibility. Input from paramedical staff has been actively
sought and acknowledged.
 Same standards for all levels: Doctors and other health care providers use the
same standard treatments. The referral criteria differ, but the first choice
treatment for a patient depends on the patient's diagnosis and condition not on
the prescriber. If a patient attends a teaching hospital or a low-level dispensary
with a common condition, the treatment will be exactly the same. If the patient
does not respond to treatment, he or she may be referred to a higher level to
receive the second line therapy, which would be given in hospital.
 Drug supply based on standards: The standard treatments are coordinated with
the supply of drugs. If changed circumstances require a new drug for the
standard treatment, then the supply system responds.
 Introduced in pre-service training: Standard treatment manuals are distributed
during pre-service training and their use becomes habit.
 Dynamic (regular updates): As bacterial resistance patterns change or other
factors alter therapeutic preferences, the standards are revised to reflect current
recommendations.
 Durable pocket manuals: The standard treatments are published as small,
durable pocket manuals, which makes them convenient to carry and use.
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DEVELOPMENT OF STANDARD TREATMENTS
Experience from several countries suggests the following important considerations in
the development of standard treatments:
1. Target priority conditions
2. Base on local disease factors
3. Coordinate with special programs
4. Use fewest drugs necessary
5. Choose cost-effective treatments
6. Use essential drug list drugs only
7. Involve respected clinicians
8. Consider patient perspective
In the interest of therapeutic and economic efficiency, standard treatments should
target those conditions that contribute the most morbidity and mortality rates. Note that
some conditions that contribute substantially to the number of patients treated, and
therefore to the total cost of drugs provided, contribute little to mortality. Skin conditions
are a common example. Such problems may nevertheless be priorities for the
development of standard treatments precisely because they do absorb a large percent
of the drug budget.
In terms of selection of health problems, standard treatments fall into one of three
categories:
•
Individual: Standard treatments are
prepared for only one problem or set
of problems, such as only diarrhea
disease, only ARI, or only malaria.
•
Selective: Standard treatments are
prepared for a small number of high
priority problems, perhaps six to
twelve. For example, a "package" of
treatments for diarrhea disease, ARI,
antenatal care, immunization
screening, malaria, and tuberculosis.
•
Comprehensive: Standard treatments
are prepared for 30, 50, 100, or even
more common health problems.
When published, such standard
treatments become more like
textbooks than basic references.
The number of treatments developed should be
appropriate to the specific situation. But individual treatments developed one by one
may miss the opportunity to use the process to integrate several special programs. At
the other extreme, comprehensive standard treatments risk overwhelming health
workers with new information, thus reducing the chance that any of the standard
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treatments -- even those for common, high priority problems -- will be followed. There
may be a place for targeting different levels of the health system with manuals
containing differing amounts of information.
Information on local disease patterns should also be considered. Seldom do PHC
workers have access to clinical laboratories. But results from surveys using available
district, regional, or national laboratory facilities can be used to make scientifically
based selections of preferred drugs for certain types of diarrhea, ARI, malaria,
tuberculosis, and other infectious diseases. Dynamic standard treatments are
periodically updated to reflect changes in treatment patterns.
Development of standard treatments should aim at therapeutic integration through
coordination with special programs such as diarrhea disease control, ARI, malaria, and
so forth. PHC standard treatments should reinforce recommendations of special
programs and, at the same time, PHC experience should be used by special programs
in developing their treatment recommendations.
Individual drug selections should, of course, be based on the principles of choosing the
fewest drugs necessary to effectively treat an individual condition, on choice of the most
cost-effective treatment, and on the essential drug list (if one exists). If an essential
drug list does not exist for the level of health care at which the treatments will be used,
then the process of producing standard treatments should also produce an essential
drug list.
Development of standard treatments must involve respected clinicians from all levels.
This might include leading professors from local medical schools as well as
experienced district medical officers and outstanding community health staff. In
Zimbabwe the "best and the brightest" field staff were invited to participate in the
revision.
Finally, the patient perspective must be considered. Issues of patient adherence to
treatment (compliance) and prevailing patient preferences must be weighed against
considerations of efficacy, safety, and cost.
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There are many examples of standard treatments available, some of which are listed in
Annex 1. The Australian guidelines are particularly useful in that they are revised
regularly. The text is available on computer diskette so that it can be easily adapted to
other settings, which is what Botswana did.
The address of the Australian group is:
Therapeutic Guidelines Ltd.
Chelsea House, 3rd Floor
55 Flemington Road
North Melbourne VIC 3051
Australia
phone: (61) 3 9329 1566
fax: (61) 3 9326 5632
The World Health Organization's Drug Action Programme in Geneva can also assist
with resource materials. [DAPmail@who.ch]
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IMPLEMENTATION OF STANDARD TREATMENTS
In terms of impact on prescribing and drug use patterns, the greatest weakness in past
efforts to introduce standard treatments has probably not been in the development of
reasonable standards, but in the effective implementation of the standards once they
have been developed. Prescribing patterns change slowly.
The following are important elements for a plan to implement standard treatments:
1. Printed reference materials
2. Official Launch
3. Initial training
4. Reinforcement training
5. Monitoring
6. Supervision
Printed reference materials can include manuals, posters, and training materials.
Depending on the number of treatments involved, printed references may be in the form
of wall charts, pocket handbooks, or larger "shelf-size" reference books.
Some people feel that wall charts provide a better reminder to health workers, are more
permanent, and help the patient better understand the treatment process. Others feel
that a handbook is more effective, provided it fits into the pocket, is durable, and is wellorganized. Pocketbooks can also include information about individual drugs or other
reference data.
The contents of pocket manuals can be organized in summary tables, in diagnostic and
treatment decision trees or flow charts, or simply in written text.
An official launch is very important. The Minister of Health, the leaders of professional
bodies, and leading clinicians should present the new guidelines at a public forum.
Ideally, the presentation should be covered by the press and broadcast media and
attended by representatives of health worker associations.
Initial training is also important. Ideally, standard treatments should be introduced
during formal pre-service training for doctors and other health care providers. Use of
the standard treatments and the reference manual or wall chart early in training
develops good habits for later clinical practice. This implies that examinations should
include questions on standard treatments.
The length of initial in-service training will depend on the number and complexity of
standard treatments. Training should specifically consider prescribers' inhibitions about
using standard treatments. Some may be afraid that "looking things up in front of the
patient" will detract from their credibility. Participants should therefore practice the use
of reference materials in actual patient care situations or in role plays.
Other prescribers may not appreciate how the treatments were prepared and at first
may not trust the treatments. Most importantly, if the standard treatments differ
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substantially from current practice (for example, fewer injections or fewer antibiotics
than currently prescribed), these differences should be identified and discussed.
Participants should be strongly encouraged to accept the standard treatments perhaps
even by signing a written agreement.
Especially for health care providers already in practice, reinforcement training during
the first six to twelve months after the initial training can play an important role in reemphasizing the importance of following standard treatments and allow an opportunity
to respond to questions that have arisen from attempts to apply the treatments.
Finally, the monitoring system and supervisory efforts should focus on the priority health
problems and standard treatments for these problems. Routine reports that focus on
high priority problems such as diarrhea disease and ARI can also include information
on treatment of these problems and, of great importance, on adequacy of supply for the
few drugs needed for these conditions.
CONCLUSION
The development of standard treatment guidelines can be a very useful early phase of
an essential drugs program. By involving prescribers in the production, review, and
revision of the materials, they can be co-opted into the guidelines.
Once the guidelines are produced, it is critical that they are implemented consistently by
role-model prescribers. Monitoring and supervision of the use of the guidelines are also
important.
Standard treatment guidelines can have considerable impact if they are developed,
promoted, and used in a sensible fashion. They can also be an expensive waste of
effort! With standard treatment guidelines, the process of production and
implementation and use is more important than the product.
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ANNEX 1
Publications Relevant to Development of Standard Treatments
WORLD HEALTH ORGANIZATION
Manual for Rural Health Workers: Diagnosis and
Treatment with Essential Drugs
Action Program on Essential Drugs, 1991
Respiratory Infections in Children: Management in Small
Hospitals, 1988
The Rational Use of Drugs in the Management of Acute
Diarrhea in Children, 1990
Control of Sexually Transmitted Diseases, 1985
Drugs used in anesthesia, 1989
Drugs used in parasitic diseases, 1990
Drugs used in mycobacterial diseases, 1991
The treatment and prevention of acute diarrhea, 1989
The management of diarrhea and use of oral rehydration
therapy, 1985
Management of severe and complicated malaria: a practical handbook, 1991
The New Emergency Health Kit, 1990
Available from:
World Health Organization
Publications Department
1211 Geneva 27
Switzerland
[www-pll.who.ch/programmes/pll/pll_index_frames.html]
MEDICINS SANS FRONTIERES
Clinical Guidelines: Diagnostic and Treatment Manual, 1990
Essential Drugs - drug information sheets, 1990
Gestes medico-chirurgicaux en situation d'isolement
(guidelines for surgical treatment, in French), 1989
Available from:
Médicins sans Frontières
Medical Dept.
8 rue Saint-Sabin
7554 Paris Cédex 11
France
[www.mgt.org/aboutus/expert/guidlist.htm]
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AUSTRALIA
Antibiotic Guidelines; 9th
Edition, 1997
Psychotropic Drug
Guidelines; 2nd Edition,
1993
Analgesic Guidelines; 2nd
Edition, 1992
Cardiovascular Drug
Guidelines; 1st Edition,
1996
Gastrointestinal Drug
Guidelines; 1st Edition,
1994
Neurology Guidelines, 1st
Edition, 1997
Analgesic Guidelines, 3rd
Edition,1997
Endocrinology Guidelines , 1st Edition, 1997
Available from:
Victorian Medical Postgraduate Foundation Inc.
Therapeutics Committee
"Chelsea House" 3rd Floor
55 Flemington Road
North Melbourne, VIC 3051
Australia
[www.csu.edu.au/faculty/health/conference/vmpf.htm]
email address: vmpf@vicnet.net.au
Past editions of these guidelines may be available for the cost of postage.
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BRITAIN
British National Formulary,
Available from:
British Medical Association/Royal Pharmaceutical
Society of Great Britain
Tavistock Square
London WC1H 9JP
England
EASTERN CARIBBEAN
Eastern Caribbean Regional Formulary and
Therapeutics Manual, 1991
Available from:
Eastern Caribbean Drug Service
PO Box 179, The Morne
Castries, Saint Lucia
West Indies
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KENYA
Kenya Manual for Rural Health Workers, 1986
Available from:
Ministry of Health
Nairobi, Kenya
Management Schedules for Dispensaries: A
Manual for Rural Health Workers, 1979
Therapeutic Guidelines: A Manual to Assist in
the Rational Purchase and Prescription of
Drugs, 1980
Available from:
African Medical and Research Foundation
PO Box 30125
Nairobi, Kenya
BHUTAN
Bhutan Standard Treatment Guide, 1989
Available from:
Bhutan Essential Drugs Programme
Ministry of Social Services,
Thimpu, Bhutan
UGANDA
Uganda Essential Drugs Manual,
1991
Available from:
Ministry of Health
Uganda Essential Drugs
Management Programme
Central Medical Stores
PO Box 16
Entebbe, Uganda
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ZIMBABWE
EDLIZ (Essential Drugs List
for Zimbabwe), 1994
A series of 15 modules on
clinical and management
topics are also available
Available from:
Zimbabwe Essential Drugs
Action Programme
Ministry of Health
Box 8168
Causeway, Harare
Zimbabwe
BOTSWANA
Botswana Treatment Guide, 1992
Available from:
National Standing Committee on Drugs
Ministry of Health
Gaborone, Botswana
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MALAWI
Standard Treatment Guidelines/
Available in both pocket and desktop
versions; 2nd edition, 1993
Malawi Prescriber’s Companion, 1993
Available from:
Malawi Essential Drugs Programme
PO Box 30390
Lilongwe 3, Malawi
TANZANIA
Standard Treatment Guidelines and The
National Essential Drug List for Tanzania,
1991
Available from:
Ministry of Health
Dar es Salaam
United Republic of Tanzania
PAHO
Development and Implementation of Drug Formularies, 1984. Scientific Publication
474.
Available from:
Pan American Health Organization/World Health Organization
525 23rd Street, N.W.
Washington, DC 20037
USA
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NEPAL
Nepalese National Formulary 1997
Available from:
Department of Drug Administration
Bijulbizar, Naya Baneshwor
Katmandu Nepal
Fax: (977-1) 244927
E-mail: dda@npl.healthnet.org
JAMAICA
Jamaica National Formulary, 1997
Available from:
Pharmaceutical Services Division
Ministry of Health,
Kingston 5, Jamaica
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ACTIVITY 1
Case Study: A Second Edition?
Standard Treatements in Pagalia
RATIONALE
Designing and implementing standard treatments that truly improve prescribing
practices is challenging. It requires an understanding of the issues involved in each
step of the process. It also requires sufficient commitment, cooperation, financial
resources, and effort.
This case study is intended to stimulate thinking and discussion about some of the
critical issues in the effective introduction of standard treatments in a health care
system.
QUESTIONS TO CONSIDER
1.
How were the Standard Treatments developed and implemented?
2.
How have the Treatments affected prescribing thus far?
3.
Should a second edition of the Standard Treatments be prepared at this
time? Is it the best use of time and money?
4.
What should be done? What should be proposed to Mr. Domingo at the
next meeting?
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A SECOND EDITION?
STANDARD TREATMENTS IN PAGALIA
ONE MORNING, MID-1998
Dr. Pedro, the Director of Health Services, sat patiently, only half listening to Dr.
Karma's animated review of the new Essential Drug component of the Health Financing
Project. The characteristic twinkle in Dr. Pedro's eye remained, despite the fact that he
had heard this same introduction at least twice before this month. The essential drug
component of the project was to achieve "therapeutic and economic efficiencies" that
would help the Ministry make maternal and child health services more widely available
and more effective.
Mr. Joko from Planning and Mrs. Soma from the Pharmaceuticals Directorate were also
at the meeting, along with several of their assistants. Dr. Pedro thought the assistants
seemed particularly taken with Dr. Karma's energetic presentation. "So, my friends,"
Dr. Karma announced, "by next Monday we must present Mr. Domingo [the project
officer for the major sponsoring donor] with a first year workplan for improving drug use.
Your thoughts, please."
HEALTH STATUS AND HEALTH CARE IN PAGALIA
While Mr. Joko raised a few points regarding recent negotiations with the donor, Dr.
Pedro reflected on the current health situation in the country. From his position in the
Ministry, Dr. Pedro felt he had a good grasp of needs at the health center level.
Pagalia is divided into 10 provinces and 80 districts. Health care is considered a central
responsibility, so national authorities play a major role in health care policy. Pagalia's
population of over 20 million receives primary health care services from a network of
nearly 300 health centers and 2,300 sub-centers. In addition, there is a small hospital
in nearly every district and over 15 provincial general and specialty hospitals. UNICEF
estimated that last year almost 120,000 Pagalians died -- one-half of whom under age
5. The infant mortality rate is believed to have dropped below 85 deaths per 1000 live
births. As expected, the leading causes of death among the under-five age group were
diarrhea disease, ARI, neonatal tetanus, measles, and other immunizable diseases. In
terms of health center attendances, Mr. Joko's staff in Planning had recently completed
a study that showed ARI accounted for 36 percent of under-five illness visits; skin
disease, 17 percent; and diarrhea disease, 15 percent. For adults, ARI accounted for
18 percent of attendances, skin diseases, 18 percent; anemia and nutritional
deficiencies, 10 percent; and diarrhea disease 6, percent. Although many health
centers have doctors assigned to them, a recent study from one province indicated that
only about one in four patients sees a doctor. The rest are diagnosed and treated by
nurses and paramedics.
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PUBLICATION OF THE STANDARD TREATMENT
After Mr. Joko finished his questioning, Dr. Pedro began the discussion of methods to
improve drug use patterns: "The only solution is the dissemination of standard
treatments. Standard treatments will straighten everything out." He went on to
describe the process which led two years ago to the publication of Standard Treatments
for Health Centers.
The essential drug list had been developed in 1991. In 1993 concern about drug use
led to the beginning of work on standard treatments. A committee consisting of four
doctors from Preventive Health Services, another person from the Ministry, three
people from the Faculty of Medicine, and one outside member began work in earnest
on the project. In early 1996 the Standard Treatments for Health Centers were
published.
The Standard Treatments for 100 conditions were included in the manual along with
information on drug interactions, growth curves, and other reference information. The
manual included, for each health problem, key diagnostic features and recommended
treatments.
The Treatments were published in a compact, but not quite pocket-sized manual with a
glossy green cover with the Ministry logo. The manuals eventually were sent to all
health centers. Since schools of medicine and other health education institutions fall
generally outside the control of the Ministry of Health, little effort was made to have
direct contact with these educational programs.
"However," concluded Dr. Pedro, "since publishing the Standard Treatments for Health
Centers, the CDD Program (Control of Diarrhea Disease), the ARI Program, and the TB
(tuberculosis) program have all changed their treatment recommendations. Clearly
what is needed to promote proper drug use is to revise, reprint, and redistribute the
Standard Treatments."
HEALTH CENTER TREATMENT PATTERNS—1997
Mrs. Soma, from Pharmaceuticals, had been quiet up to this point, but Dr. Pedro's last
comment troubled her. Politely, but firmly she began: "I'm not quite so sure that
revising and redistributing the Standard Treatments is the answer." She then went on
to briefly review two surveys that she and her colleagues at Pharmaceuticals had
recently carried out.
The first study, in which Mr. Joko's staff had also been quite active, took last year's drug
order and compared it to a rough estimate of what would have been needed if the
disease pattern reported by the monitoring group at Preventive Health Services had
been treated according to Dr. Pedro's standards.
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"Look here," said Mrs. Soma, "your standard treatments would have the health center
staff using large amounts of procaine penicillin, oral penicillin, and co-trimoxazole, while
last year they ordered almost none of those antibiotics. Your treatments would have cut
back on tetracycline, ampicillin, chloramphenicol, some of the injectibles, and other
popular drugs." The drug names meant nothing to Mr. Joko, but he understood that the
standard treatments implied quite different consumption patterns than current practice.
Now in full stride, Mrs. Soma moved on to the second study, which her group had
completed only last week. "The Standard Treatments were sent out in 1996. We have
just completed a survey of 2500 patient cards from six randomly selected districts in
East Kalija province." In the treatment of common gastroenteritis (omitting cases of
dysentery or suspected cholera), for which Dr. Pedro's group recommended only
rehydration, the average patient was getting over three drugs. Virtually every patient
was getting an antibiotic. More vitamins and minerals were being prescribed that oral
rehydration salts. Antibiotics used for the under-fives alone included oxytetracycline
injection, tetracycline capsules, metronidazole, trisulfa, tetracycline syrup, ampicillin
syrup, chloramphenicol suspension, and procaine penicillin injection. Some of the
drugs recommended in the standard treatments are not available.
Similarly, for influenza and acute upper respiratory infections, Dr. Pedro's group had
recommended paracetamol for fever and aches, antihistamines for congestion, and a
cough medicine. Yet, nearly every patient got an antibiotic. This was supplemented by
an average of two other types of drugs. The range of different antibiotics prescribed
was again quite impressive, at least a dozen by Mrs. Soma's tally.
Mr. Joko was again mystified by most of Mrs. Soma's drug names, but he clearly
sensed her feeling that bright green Standard Treatments for Health Centers had not
achieved their purpose. The twinkle in Dr. Pedro's eye was beginning to fade.
A SECOND EDITION?
Having shared the results of the directorate's studies, Mrs. Soma somehow felt less
compelled to support Dr. Pedro's plan to simply revise, reprint, and redistribute the
Standard Treatments. The meeting continued another 15 minutes. Mr. Joko raised
some procedural questions, and Dr. Pedro asked the group's opinion about the design
and color of the cover.
Dr. Karma, always the diplomat, suggested that the project perhaps could support both
Dr. Pedro's revision of the Standard Treatments and another series of studies by
Soma's group. He asked the group members to accompany him to the meeting with
Mr. Domingo to propose how best the treatment guidelines could be revised and
implemented.
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