Challenges with changing prescribing practices from CQ/SP to ACT in the private sector

Transcription

1 Challenges with changing prescribing practices from CQ/SP to ACT in the private sector A presentation at MMV Access Symposium Getting Antimalarials to Patients Kampala 9 th May 2007

2 Compiled by Dr James Tibenderana Drug Policy Change Specialist / Epidemiologist with the Malaria Consortium Implementation of this work was by The AFFORD project, a five year USAID funded health marketing initiative

3 Outline Why change? Factors influencing prescribers Ugandan experiences in training the private sector to promote rational use and demand The AFFORD project Challenges

4 good prescribing habits produce the optimal effects of the medicine and minimise any detrimental effects to the recipient bad prescribing habits produce poor treatment outcomes and can put the recipient s life at risk

5 Why change prescribing habits? Evidence from the public sector that prescriptions do not adhere to national guidelines (medicine, dosage) Adoption of ACTs as treatment for uncomplicated malaria has introduced new challenges (novel costly medicine with complex regimen versus familiar cheap and widespread CQ+SP) The need for impact on the malaria burden requires holistic approach to ACT access (public and private sector distribution, HBMF)

6 Factors that influence prescribers PERSONAL INFORMATION Prior Knowledge Scientific Information Habits, Perception Influence of Drug Industry Workload and Staffing CLINICAL PRACTICE Social and Cultural Economic and Legal SOCIETAL INSTITUTIONAL Infrastructure Relationship with Peers Authority and Supervision Source: MSH WORK GROUP

7 Factors that drive prescribing habits in the private sector Market forces Profitability Willingness of end user to pay cost-price and mark-up Willingness and financial capacity of provider to stock Physical availability of the medicine Supply chain has to be full producer/importer wholesaler pharmacy/retailer drug shop Consistently available; simple storage requirements

8 Factors that drive prescribing habits in the private sector Knowledge and Behaviour Awareness and preference End user and Prescriber Formulation and dosage regimen: pre-packs, fixed dose, pill burden, schedule, syrup for infants Peer pressure National guidelines Regulation Training and job aides Previous experiences End user and Prescriber Satisfaction Side effects

9 Ugandan experiences

10 Context Health care providers Public sector Health facility based Village Health teams Private-not-for-profit (PNFP) Private sector Private-for-profit (PFP) Pharmaceutical sector Public sector National Medical Stores Private sector Joint Medical Stores Local manufacturers Wholesalers Pharmacies Drug shops

11 Context Public and PNFP sector Coartem to be given free to users attending health facilities; National treatment policy in place PFP sector Experience with artemisinin monotherapies since ~1998 Various brands of ACTs licensed by NDA on the market Haphazard use of ACTs No clear professional guidelines on malaria case management Non ACT antimalarials prevail

12 Target population Prescription only medicine (POM) Doctors Clinical Officers Registered nurses Midwives Pharmacists Dispensers

13 Target population II next stage Over the counter medicine (OTC) Enrolled nurses Nursing assistants Nursing aids Community medicine distributors Drug shop owners / keepers

14 Tools for change Training / orientation Information, Education and Communication Behaviour Change Communication (BCC) Supervision and CME by professional bodies Promotion of multiple brands on the market: price by market forces and demand Marketing

15 Map of Uganda showing the distribution of districts covered in the AFFORD training SUDAN Kaabong Koboko Yumbe Moyo Kitgum Maracha Adjumani Arua DEMOCRATIC 3 rd Sept 06 to 10 th March 07 Amuru REPUBLIC CONGO Nebbi Gulu Oyam Pader Lira Abim Kotido Moroto Buliisa Masindi Apac Dokolo Amuria Katakwi Nakapiripirit 26 workshops Bundibugyo Hoima Kibaale Kiboga Nakaseke Nakasongola Luwero Amolatar Soroti Kumi Pallisa Kamuli Kaliro Kayunga Kaberamaido Namutumba Butaleja Budaka Iganga Tororo Mbale Kapchorwa Sironko Wanafwa Bukwa Kabarole Kyenjojo Kasese Kamwenge Sembabule Mubende Mityana Mpigi KAMPALA Wakiso Mukono Jinja Mayuge Bugiri Busia KENYA Ibanda Kiruhura Masaka Bushenyi Mbarara Kanungu Rukungiri Rakai Isingiro Ntungamo Kabale Kisoro RWANDA TANZANIA 75 districts of 81 represented Kalangala Key 2614 health workers trained Districts not trained

16 Proportion of cadres trained 25% 5% 17% 32% 15% 2% 2% 2% Doctors Pharmacists Laboratory Technologists Nurses Clinical Officers Dispensers Midwives Nursing assistants

17 Training / orientation Identified behaviour changes required Used clear messages (minimise ambiguity) Used competent trainers; familiar and respected Participatory approach including role plays Content focused on 3 main topics Mixture of cadres to simulate reality

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19 Training / orientation Professional bodies engaged from the onset contextual understanding (time is money; CME; patient satisfaction; behaviour changes); iterative approach to materials development based on feedback from trainers Exhibitors of ACTs and RDTs genuine suppliers and to get freebies for trial Tackling the numerous brands on the market promote MoH recommended; based on evidence

20 Challenges Training / orientation No clear documented evidence of what kind of training achieves behaviour change in resource poor settings Time consuming to address all topics yet time constraints in the private sector Expensive to train and produce good quality IEC materials

21 Challenges Training / orientation Training should be followed by practice but ACTs not popular yet Among end users and prescribers Reinforcement of behaviour change with follow up Difficult to do and get funds for Promoting the need for parasitological diagnosis Among >5 years (e.g. RDTs) Incremental cost to the end user (unless subsidised?)

22 Challenges Training / orientation Trainers? Getting there Trainees?

23 Challenges Changing from CQ+SP to ACTs Old habits die hard CQ+SP cheaper than ACTs CQ+SP readily available ACTs have complex dosages; pill burden Side effects of amodiaquine have tarnished AS+AQ combination Limitations of ACTs raise doubts - <5kg, 1 st trimester, food (cf CQ)

24 Challenges Changing from CQ+SP to ACTs Calibre of private providers that serve most rural areas do not concur with current national regulation Limited community awareness of ACTs NDA regulations about advertising versus IEC ; people should be given the power to make informed decisions

25 Acknowledgements Ministry of Health - NMCP, Health Promotion, NDA Training Secretariat and Training coordinator Professional Associations The 3,000 private practitioners that enthusiastically attended the training workshops The exhibitors that participated in the workshops USAID for funding The AFFORD project The AFFORD project for having the insight and courage to engage the private sector

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27 Thank you