Session Guide - WHO archivesarchives.who.int/PRDUC2004/RDUCD/Acrobat_Files/SG_Acrobat_File… · The history of early scientific medicine was one of identifying patterns of signs

Session GuideStandard Treatments

STANDARD TREATMENTS SESSION GUIDE

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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. Standardtreatments list the preferred drug and non-drug treatments for common health problemsexperienced by people in a specific health system. As such, they represent oneapproach 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 (moreconsistency, treatment efficacy), providers (gives an expert consensus, quality of carestandard, basis for monitoring), supply managers (makes demand more predictable,allows prepacks), and health policy makers (provides focus for therapeutic integration ofspecial programs, promotes efficient use of funds). But effective implementation isperhaps the greatest challenge in introducing standard treatments.

OBJECTIVES[VA 1]To develop your ability to:

1. Recognize and convey to others the advantages and potential benefits ofstandard treatments in promoting effective drug use.

2. Develop clinically effective, economically efficient, and locally appropriatestandard treatment protocols for priority health problems.

3. Prepare a plan to effectively implement standard treatments in yoursetting through printed reference materials (manuals, posters, trainingmaterials); pre-service, in-service, and reinforcement training; andmonitoring and supervision focused on the priority health problems andtheir standard treatment.


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PREPARATION

1. Read the Session Notes.

2. Read the Case Study, "A Second Edition? Standard Treatments inPagalia." Look carefully at the Questions to Consider both before andafter reading the case.

FURTHER READING

1. Managing Drug Supply, 2, Chapter 11, Treatment Guidelines andFormulary Manuals, p. 138-149.

WEB PAGES

Rational Drug Use in Rural Health Units of Uganda: Effect of National StandardTreatment 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 onprescribing for diarrhoea and acute respiratory infection in somegovernment health facilities of Bangladesh, Chowdhury AKA, Khan OF,Matin MA, Khadiza B, Galib MA,

2F-4. Impact of pilot intervention (standard treatment guidelines, training) onprescribing patterns in Dar es Salaam, Wiedenmayer K. Mtasiwa D,Majapa N, Lorenz N,


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Standard Treatments

SESSION NOTES

INTRODUCTION

Local manuals are needed in every health system because of differing decisions aboutdrug choices and the patterns of illness within a country. Disease oriented manualsare called 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 theprevalent pattern of illness and the standard treatments decided upon to treat theseconditions. Training, drug supply, assessment and quality evaluation are based onthese standard treatments.

Thus developing and updating standard treatments are a very important part of anyessential drugs program and a basic component of any effort to improve rational use ofdrugs.[VA 2]This session will review the dangers of therapeutic anarchy, discuss the advantages ofstandard treatments, and assess the impacts of standard treatments. The final part ofthe session will review the development and implementation of standard treatments.

A. 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 fromgeneration to generation. The history of early scientific medicine was one of identifyingpatterns of signs and symptoms which revealed an underlying disease, assigning aname to that disease, and searching for the effective remedy for it.

In this century, however, modern medicine has gone far beyond the stage where eachdisease has but one treatment. Instead, each disease may have many acceptabletreatments. 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 careproviders learn about all of the treatments which could be used, instead of focusing onthe best treatment that should be used. Casual observation as well as more systematicstudy of prescribing practices frequently reveals a pattern of tremendous diversityamong prescribers in the treatment of even the most common conditions.


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Polypharmacy is one problem; for example, three, four, five, six, and sometimes moredrugs for acute viral gastroenteritis, for which only oral rehydration therapy is effective inreducing morbidity and mortality. Other common problems considered in greater detailelsewhere are incorrect drug choices, overdosing, underdosing, and choice of moreexpensive drugs when less expensive drugs would be equally or more effective.

[VA3]Standard treatments -- also known as standardtreatment schedules (STS); standard treatmentprotocols; therapeutic guidelines; and so forth --list the preferred drug and non-drug treatmentsfor common health problems experienced bypeople in a specific health system. Each drugtreatment should include for each health problemthe name, dosage form, strength, average dose(pediatric and adult), number of doses per day,and number of days of treatment. Otherinformation on diagnosis and advice to the patientmay also be included.

Standard treatments should consider both drugand non-drug treatments. "Reassurance," forexample, might be the proper standard treatmentfor a child who is shorter than other children of hisor her age, but who shows a normal growthcurve, no signs of malnutrition or chronic disease,and has shorter than average parents.

[VA 4]Health problems including specific diagnoses("malaria"), symptoms ("headache"), andpreventive health services (EPI immunizations,antenatal vitamin and mineral supplements) mayalso be included in such a manual.

Standard treatments are currently in use in partsof the U.S., Europe, Latin America, Asia, Africa,and the Western Pacific. Experience shows thateven the shortest essential drug list offers ampleopportunity to misuse drugs by improper treatmentof common problems. Thus, essential drugprograms are finding that the development ofstandard treatments is necessary fortherapeutically effective and economically efficient use of drugs.


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Standard treatments are used at different points of the therapeutic process. They maybe used for diagnosis, to decide on treatment and drug supply and to assist withadherence to the prescribed treatment. This will hopefully lead to the desired clinicaloutcome.[VA 5]

Figure 1STANDARD TREATMENTS IN THE THERAPEUTIC PROCESS

Rx

Signs &Symptoms

Treatment(Responses)

DrugSupply

Adherence(Compliance)

Clinical Outcome

Rx = focus of standard treatments

Rx

Rx

Rx

Diagnosis(Health

Problems)


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B. ADVANTAGES OF STANDARD TREATMENTS

Standard treatments offer a number of potential advantages for patients, healthproviders, supply managers, and health policy makers. Figure 1 illustrates the points inthe therapeutic process at which standard treatments can act. Potential benefits ofintroducing standard treatments include the following:

[VA6]

For Patients

• consistency among prescribers → reducedconfusion and increased compliance

• most effective treatments prescribed

• improved supply of drugs if drugs areprescribed only when needed.

For Providers

• gives expert consensus on most effective, economical treatment for aspecific setting

• provider can concentrate on correct diagnosis

• provide a standard to assess quality of care

• can also provide a simple basis for monitoring and supervision.

[VA7]

For Supply Management Staff

• performance standard for drug supply -- there should be sufficientquantities of drugs available for the most commonly treated problems atthe different levels of the health system

• facilitates pre-packaging of course-of-therapy quantities of commonlyprescribed items for common conditions

• drug demand more predictable, so forecasting more reliable.


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For Health Policy Makers

• provide a method to control costs by using drug funds more efficiently

• serve as a basis to assess and compare quality of care

• development and implementation of a single set of standard treatmentscan be a vehicle for integrating special programs (diarrhea diseasecontrol, acute respiratory infection, tuberculosis control, malaria, and soon) at the primary health care facilities.

Standard treatments do not take the thinking out of health care. Instead, they focus thethinking on other critical aspects of the therapeutic process: careful identification ofsigns and symptoms; correct diagnosis; and effective patient counseling on proper useof those few drugs or non-drug treatments that will truly benefit the patient.

Sometimes medical school faculty, consultant physicians, and other health careproviders oppose standard treatments, fearing they will lead to "cook book" medicineand loss of the "right to prescribe." This fear has proven largely unfounded; doctors inthe most prestigious medical institutions in developed and developing countries arewriting and promoting such handbooks.


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[VA8]C. KEY FEATURES OF STANDARD TREATMENTS

Standard treatments have been used for many years in some countries. Standardtreatments now exist for common illnesses of children, common adult illnesses, andobstetrics and gynecology. The existence of these treatments has reportedly had amajor impact on the consistency, effectiveness, and economy of prescribing. Keyfeatures of standard treatments, as they have been implemented for instance in PapuaNew Guinea, include:

• Simplicity -- The number of health problems is limited. For each healthproblem, a few key clinical diagnostics criteria are listed. Finally, drug anddosage information is clear and concise.

• Credibility -- The treatments were initially developed for patients by themost respected clinicians in the country. Revisions based on actualexperience have further added to the credibility. Input from paramedicalstaff has been actively sought and acknowledged.

• Same standards for all levels -- Doctors and other health care providersuse the same standard treatments. The referral criteria differ, but the firstchoice treatment for a patient depends on the patient's diagnosis andcondition -- not on the prescriber. So if a patient attends a teachinghospital or a low level dispensary with a common condition the treatmentwill be exactly the same. If the patient does not respond to treatment theymay be referred to a higher level to receive the second line therapy whichwould be given in hospital.

• Drug supply based on standards -- The standard treatments arecoordinated with the supply of drugs. If changed circumstances require anew drug for the standard treatment, then the supply system responds.

• Introduced in pre-service training -- Standard treatment manuals aredistributed during pre-service training and their use becomes habit.

• Dynamic (regular updates) -- As bacterial resistance patterns change orother factors alter therapeutic preferences, the standards are revised toreflect current recommendations.

• Durable pocket manuals -- The standard treatments are published assmall, durable pocket manuals, which makes them convenient to carryand use.


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[VA 9]D. DEVELOPMENT OF STANDARD TREATMENTS

Experience from several countries suggests the following important considerations inthe development of standard treatments:

1. Target priority conditions2. Base on local disease factors3. Coordinate with special programs4. Use fewest drugs necessary5. Choose cost-effective treatments6. Use essential drug list drugs only7. Involve respected clinicians8. Consider patient perspective

In the interest of therapeutic and economic efficiency, standard treatments shouldtarget those conditions which contribute the most to rates of morbidity and mortality.Note that some conditions which contribute substantially to the number of patientstreated, and therefore to the total cost of drugs provided, contribute little to mortality.Skin conditions are a common example of this. Such problems may nevertheless bepriorities for the development of standard treatments precisely because they do absorba large percent of the drug budget.

In terms of selection of health problems, standard treatments fall into one of threecategories:[VA 10]

• Individual -- A standard treatment isprepared for only one problem or setof problems -- only diarrhea disease,only ARI, or only malaria.

• Selective --Standard treatments areprepared for a small number of highpriority problems, perhaps six totwelve. For example, a "package" oftreatments for diarrhea disease, ARI,antenatal care, immunizationscreening, malaria, and tuberculosis.

• Comprehensive --Standard treatmentsare prepared for 30, 50, 100, or evenmore common health problems. When published, such standard


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treatments become more like textbooks than basic references.Thenumber of treatments developed should be appropriate to the specificsituation. But individual treatments developed one-by-one may miss theopportunity to use the process to integrate several special programs. Atthe other extreme, comprehensive standard treatments risk overwhelminghealth workers with new information, thus reducing the chance that any ofthe standard treatments -- even those for common, high priority problems-- will be followed. There may be a place for targeting different levels ofthe health system with manuals containing differing amounts ofinformation.

Information on local disease patterns should also be considered. Seldom do PHCworkers have access to clinical laboratories. But results from surveys using availabledistrict, regional or national laboratory facilities can be used to make scientifically-basedselections of preferred drugs for certain types of diarrhea, ARI, malaria, tuberculosisand other infectious diseases. Dynamic standard treatments are periodically updatedto reflect changes in treatment patterns.

Development of standard treatments should aim at therapeutic integration throughcoordination with special programs such as diarrhea disease control, ARI, malaria, andso forth. PHC standard treatments should reinforce recommendations of specialprograms and, at the same time, PHC experience should be used by special programsin developing their treatment recommendations.

Individual drug selections should, of course, be based on the principles of choosing thefewest drugs necessary to effectively treat an individual condition, on choice of the mostcost-effective treatment, and on the essential drug list (if one exists). If an essentialdrug 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 essentialdrug list.

Development of standard treatments must involve respected clinicians from all levels. This might include leading professors from local medical schools as well asexperienced district medical officers and outstanding community health staff. InZimbabwe the "best and the brightest" field staff were invited to participate in therevision.

Finally, the patient perspective must be considered. Issues of patient adherence totreatment (compliance) and prevailing patient preferences must be weighed againstconsiderations of efficacy, safety, and cost.


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There are many examples of standard treatments available, some of which are listed inAnnex One. The Australian guidelines are particularly useful in that they are revisedregularly, and the text is available on computer diskette so that it can be easily adaptedto other settings, which is what Botswana did.

The address of the Australian group is:Therapeutic Guidelines Ltd.Chelsea House, 3rd Floor55 Flemington RoadNorth Melbourne VIC 3051Australiaphone: (61) 3 9329 1566fax: (61) 3 9326 5632

The World Health Organization's Drug Action Programme in Geneva can also assistwith resource materials. [[email protected]]


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[VA 11]E. IMPLEMENTATION OF STANDARD TREATMENTS

In terms of impact on prescribing and drug use patterns, the greatest weakness in pastefforts to introduce standard treatments has probably not been in the development ofreasonable standards, but in the effective implementation of the standards once theyhave been developed. Prescribing patterns change slowly.

The following are important elements for a plan to implement standard treatments:

1. Printed reference materials2. Official Launch3. Initial training4. Reinforcement training5. Monitoring6. Supervision

Printed reference materials can include manuals, posters, and training materials. Depending on the number of treatments involved, printed references may be in the formof wall charts, pocket handbooks, or larger "shelf-size" reference books.

Some people feel that wall charts provide a better reminder to health workers, are morepermanent, and help the patient better understand the treatment process. Others feelthat a handbook is more effective, provided it fits into the pocket, is durable, and is well-organized. Pocketbooks can also include information about individual drugs or otherreference data.

The contents of pocket manuals can be organized in summary tables, in diagnostic andtreatment decision trees or flow charts, or simply in written text.

An official launch is very important. The Minister of Health, the Chairmen ofprofessional bodies, leading clinicians should present the new guidelines at a publicforum. Ideally, the presentation should be covered by the press and broadcast mediaand attended by representatives of health worker associations.

Initial training is also important. Ideally, standard treatments should be introducedduring formal pre-service training for doctors as well as other health care providers. Use of the standard treatments and the reference manual or wall chart from early intraining develops good habits for later clinical practice. This implies that examinationsshould include questions on standard treatments.

The length of initial in-service training will depend on the number and complexity ofstandard treatments. Training should specifically consider prescribers' inhibitions aboutusing standard treatments. Some may be afraid that "looking things up in front of the


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patient" will detract from their credibility. Participants should therefore practice the useof reference materials in actual patient care situations or in role plays.

Other prescribers may not appreciate how the treatments were prepared and at firstmay not trust the treatments. Most importantly, if the standard treatments differsubstantially from current practice (for example, fewer injections or fewer antibioticsthan 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 duringthe first six to twelve months after the initial training can play an important role in re-emphasizing the importance of following standard treatments and allow an opportunityto respond to questions which have arisen from attempts to apply the treatments.

Finally, the monitoring system and supervisory efforts should focus on the priority healthproblems and standard treatments for these problems. Routine reports which focus onhigh priority problems such as diarrhea disease and ARI can also include informationon treatment of these problems and, of great importance, on adequacy of supply for thefew drugs needed for these conditions.

[VA 12]F. CONCLUSION

The development of standard treatment guidelines can be a very useful early phase ofan essential drugs program. By involving prescribers in the production, review, andrevision of the materials, they can be co-opted into the guidelines.

Once the guidelines are produced, it is critical that they are implemented consistently byrole-model prescribers. Monitoring and supervision of the use of the guidelines are alsoimportant.

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 ofeffort! With standard treatment guidelines, the process of production andimplementation and use is more important than the product .


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Annex 1

PUBLICATIONS RELEVANT TO DEVELOPMENT OFSTANDARD TREATMENTS

WORLD HEALTH ORGANIZATION

Manual for Rural Health Workers: Diagnosis andTreatment with Essential DrugsAction Program on Essential Drugs, 1991Respiratory Infections in Children: Management in SmallHospitals, 1988The Rational Use of Drugs in the Management of AcuteDiarrhea in Children, 1990Control of Sexually Transmitted Diseases, 1985Drugs used in anesthesia, 1989 Drugs used in parasitic diseases, 1990Drugs used in mycobacterial diseases, 1991The treatment and prevention of acute diarrhea, 1989The management of diarrhea and use of oral rehydrationtherapy, 1985Management of severe and complicated malaria: a practical handbook, 1991The New Emergency Health Kit, 1990

Available from: World Health OrganizationPublications Department1211 Geneva 27Switzerland

[www-pll.who.ch/programmes/pll/pll_index_frames.html]

MÉDICINS SANS FRONTIERES

Clinical Guidelines: Diagnostic and Treatment Manual, 1990Essential Drugs - drug information sheets, 1990Gestes medico-chirurgicaux en situation d'isolement(guidelines for surgical treatment, in French), 1989

Available from:Médicins sans FrontièresMedical Dept.8 rue Saint-Sabin7554 Paris Cédex 11France


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[www.mgt.org/aboutus/expert/guidlist.htm]

AUSTRALIA

Antibiotic Guidelines; 9thEdition, 1997Psychotropic DrugGuidelines; 2nd Edition,1993Analgesic Guidelines; 2ndEdition, 1992Cardiovascular DrugGuidelines; 1st Edition,1996Gastrointestinal DrugGuidelines; 1st Edition,1994Neurology Guidelines 1st

Edition1997Analgesic Guidelines 3rd

Edition1997Endocrinology Guidelines 1st Edition 1997

Available from:Victorian Medical Postgraduate Foundation Inc.Therapeutics Committee"Chelsea House" 3rd Floor55 Flemington RoadNorth Melbourne, VIC 3051Australia

[www.csu.edu.au/faculty/health/conference/vmpf.htm]email address: [email protected]

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 PharmaceuticalSociety of Great BritainTavistock SquareLondon WC1H 9JPEngland

EASTERN CARIBBEAN

Eastern Caribbean Regional Formulary andTherapeutics Manual, 1991

Available from:Eastern Caribbean Drug ServicePO Box 179, The MorneCastries, Saint LuciaWest Indies


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KENYA

Kenya Manual for rural health workers, 1986

Available from:Ministry of HealthNairobi, KenyaManagement Schedules for Dispensaries: AManual for Rural Health Workers, 1979

Therapeutic Guidelines: A Manual to Assist inthe Rational Purchase and Prescription ofDrugs, 1980

Available from:African Medical and Research FoundationPO Box 30125Nairobi, Kenya

BHUTAN

Bhutan Standard Treatment Guide, 1989

Available from:Bhutan Essential Drugs ProgrammeMinistry of Social Services, Thimpu, Bhutan

UGANDA

Uganda Essential Drugs Manual,1991

Available from:Ministry of HealthUganda Essential DrugsManagement ProgrammeCentral Medical StoresPO Box 16Entebbe, Uganda


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ZIMBABWE

EDLIZ (Essential Drugs Listfor Zimbabwe), 1994[zimbcomp]A series of 15 modules onclinical and managementtopics are also available

Available from:Zimbabwe Essential DrugsAction ProgrammeMinistry of HealthBox 8168Causeway, HarareZimbabwe

BOTSWANA

Botswana Antibiotic Guidelines, 1989

Available from:National Standing Committee on DrugsMinistry of HealthGaborone, Botswana


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MALAWI

Standard Treatment Guidelines/Available in both pocket and desktopversionsMalawi National Formulary, 1990

Available from:Ministry of HealthPO Box 30377Lilongwe 3, Malawi

TANZANIA

Standard Treatment Guidelines and TheNational Essential Drug List for Tanzania,1991

Available from:Ministry of HealthDar es SalaamUnited Republic of Tanzania

PAHO

Development and Implementation of Drug Formularies, 1984. Scientific Publication474.

Available from:Pan American Health Organization World Health Organization525 Twenty-Third Street, N.W.Washington, DC 20037


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NEPAL

Nepalese National Formulary 1997

Available from:Department of Drug AdministrationBijulbizar, Naya BaneshworKatmandu NepalFax (977-1) 244927e-mail [email protected]

JAMAICA

Jamaican National Formulary 1997

Available from:Pharmaceutical Services DivisionMinistry of Health,Kingston 5, Jamaica.


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Activity One

CASE STUDY: A SECOND EDITION?STANDARD TREATMENTS IN PAGALIA

Rationale

Designing and implementing standard treatments which truly improve prescribingpractices is challenging. It requires an understanding of the issues involved in eachstep of the process. It also requires sufficient commitment, cooperation, financialresources, and effort.

This case study is intended to stimulate thinking and discussion about some of thecritical issues in the effective introduction of standard treatments in a health caresystem.

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 thistime? Is it the best use of time and money?

4. What should be done? What should be proposed to Mr. Domingo at thenext 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 FinancingProject. The characteristic twinkle in Dr. Pedro's eye remained, despite the fact that hehad heard this same introduction at least twice before this month. The essential drugcomponent of the project was to achieve "therapeutic and economic efficiencies" whichwould help the Ministry make maternal and child health services more widely availableand more effective.

Mr. Joko from Planning and Mrs. Soma from the Pharmaceuticals Directorate were alsoat the meeting along with several of their assistants. Dr. Pedro thought the assistantsseemed particularly taken with Dr. Karma's energetic presentation. "So, my friends,"Dr. Karma announced, "by next Monday we must present Mr. Domingo [the projectofficer for the major sponsoring donor], with a first year workplan for improving druguse. 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 theMinistry, 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 centralresponsibility, so national authorities play a major role in health care policy. Pagalia'spopulation of over 20 million receives primary health care services from a network ofnearly 300 health centers and 2,300 sub-centers. In addition, there is a small hospitalin nearly every district and over 15 provincial general and specialty hospitals. UNICEFestimated that last year almost 120,000 Pagalians died -- one-half of whom were underage 5. The infant mortality rate is believed to have dropped below 85 deaths per 1000live births. As expected, the leading causes of death among the under-five age groupwere diarrhea disease, ARI, neonatal tetanus, measles, and other immunizablediseases. In terms of health center attendances, Mr. Joko's staff in Planning hadrecently completed a study that showed ARI accounted for 36 % of under-5 illnessvisits; skin disease 17 %; and diarrhea disease 15 %. For adults, ARI accounted for 18% of attendances, skin diseases 18 %, anemia and nutritional deficiencies 10 %, anddiarrhea disease 6 %. Although many health centers have doctors assigned to them, arecent study from one province indicated that only about one in 4 patients sees adoctor. 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 toimprove drug use patterns. "The only solution is the dissemination of standardtreatments. Standard treatments will straighten everything out." He went on todescribe the process which led two years ago to the publication of Standard Treatmentsfor Health Centers.

The essential drug list had been developed in 1991, and in 1993 concern about druguse led to the beginning of work on standard treatments. A committee consisting offour doctors from Preventive Health Services, another person from the Ministry, threepeople from the Faculty of Medicine, and one outside member began work in earneston the project. In early 1996 the Standard Treatments for Health Centers werepublished.

The Standard Treatments for 100 conditions were included in the manual along withinformation on drug interactions, growth curves, and other reference information. Themanual included, for each health problem, key diagnostic features and recommendedtreatments.

The Treatments were published in a compact, but not quite pocket-sized manual with aglossy green cover which bore the Ministry logo. The manuals eventually were sent toall health centers. Since schools of medicine and other health education institutions fallgenerally outside the control of the Ministry of Health, little effort was made to havedirect contact with these educational programs.

"However," concluded Dr. Pedro, "since publishing the Standard Treatments for HealthCenters, the CDD Program (Control of Diarrhea Disease), the ARI Program, and the TB(tuberculosis) program have all changed their treatment recommendations. Clearlywhat is needed to promote proper drug use is to revise, reprint, and redistribute theStandard Treatments."

HEALTH CENTER TREATMENT PATTERNS --1997.

Mrs. Soma, from Pharmaceuticals, had been quiet up to this point, but Dr. Pedro's lastcomment troubled her. Politely, but firmly she began: "I'm not quite so sure thatrevising and redistributing the Standard Treatments is the answer." She then went onto briefly review two surveys which she and her colleagues at Pharmaceuticals hadrecently carried out.

The first study, in which Mr. Joko's staff had also been quite active, took last year's drugorder and compared it to a rough estimate of what would have been needed if thedisease pattern reported by the monitoring group at Preventive Health Services hadbeen treated according to Dr. Pedro's standards.


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"Look here," said Mrs. Soma, "your standard treatments would have the health centerstaff using large amounts of procaine penicillin, oral penicillin, and co-trimoxazole, whilelast year they ordered almost none of those antibiotics. Your treatments would have cutback on tetracycline, ampicillin, chloramphenicol, some of the injectibles, and otherpopular drugs." The drug names meant nothing to Mr. Joko, but he understood that thestandard treatments implied quite different consumption patterns than current practice.

Now in full stride, Mrs. Soma moved on to the second study, which her group hadcompleted only last week. "The Standard Treatments were sent out in 1996. We havejust completed a survey of 2500 patient cards from six randomly selected districts inEast Kalija province." In the treatment of common gastroenteritis (omitting cases ofdysentery or suspected cholera), for which Dr. Pedro's group recommended onlyrehydration, the average patient was getting over three drugs. Virtually every patientwas getting an antibiotic. More vitamins and minerals were being prescribed that oralrehydration salts. Antibiotics used for the under-fives alone included oxytetracyclineinjection, tetracycline capsules, metronidazole, trisulfa, tetracycline syrup, ampicillinsyrup, chloramphenicol suspension, and procaine penicillin injection. Some of thedrugs recommended in the standard treatments are not available.

Similarly, for influenza and acute upper respiratory infections, Dr. Pedro's group hadrecommended paracetamol for fever and aches, antihistamines for congestion, and acough medicine. Yet, nearly every patient got an antibiotic. This was supplemented byan average of two other types of drugs. The range of different antibiotics prescribedwas 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 clearlysensed her feeling that bright green Standard Treatments for Health Centers had notachieved 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 lesscompelled to support Dr. Pedro's plan to simply revise, reprint, and redistribute theStandard Treatments. The meeting continued another 15 minutes. Mr. Joko raisedsome procedural questions, and Dr. Pedro asked the group's opinion about the designand color of the cover.

Dr. Karma, always the diplomat, suggested that the project perhaps could support bothDr. Pedro's revision of the Standard Treatments and another series of studies bySoma's group. He asked the group members to accompany him to the meeting withMr. Domingo to propose how best the treatment guidelines could be revised andimplemented.

Documents

Session Guide - WHO archivesarchives.who.int/PRDUC2004/RDUCD/Acrobat_Files/SG_Acrobat_File… · The history of early scientific medicine was one of identifying patterns of signs