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Essential Medicines and Policy Department  (EDM)

International Conferences on Improving Use of Medicines (ICIUM)


Strengthening curative care at PHC level in Mozambique, 1996

(On-the-job training in clinical procedures/diagnosis & rational prescribing)

Chambule J.; Chonguiça MC; Ferruccio V; Machatine G; Valigy IV - MoH Mozambique

This component of vital importance was reactivated in 1996. A coordinating task force on PHC (Gabinete de Coordenação dos Cuidados de Saúde Primários) was set up within the National Directorate of Health, including EDP, CDD, ARI, STDs and MCH staff. The objective was to support the provinces and districts in evaluating curative care at primary health care (PHC) level, on-the-job training and promotion of rational use of drugs. Its goal was to put together expertise and initiatives from vertical programs, in a integrated, comprehensive and long-term effort to enhance health workers' skills and improve standards of curative care.

Checklists tools and training modules were produced. Activities were conducted as full cycle in each province including:

1) evaluation of health units;

2) discussion of results and training;

3 integration of CDD, ARI, Malaria, STDs at provincial level;

4) diffusion of EDP manuals. The cycle was conducted in Gaza, Nampula, Manica, Inhambane, Sofala, Zambezia and Maputo provinces.

Prescribing practices were analyzed through 100 randomly selected prescriptions from 46 health centres, chosen among the major drug consumers. A new global index (rational prescription rate) was also calculated, defined as the percentage of prescriptions showing less than three drugs. In addition over-prescribing was assessed by looking at antibiotic-antimalaria associations, and other abnormal dosage association. The team observed and evaluated 20 child and 20 adult out-patient contacts in every health unit.

Reasonable standards of drug prescription, but low quality of clinical attendance were the main findings. Direct observation of clinical practice revealed that most medications were not appropriate, even when the prescriptions were classified as formally "correct". Many clinical workers prescribed after quickly questioning patients on main symptoms, and ignoring any clinical examinations. There was almost no counseling to patients on drug usage, treatment aims, possible side effects, or guidelines on home hygiene. Conversely, prescriptions were made routinely, as an unavoidable, full purpose procedure for every symptom and condition. The results were processed and were used to tailor on-the-job training, to improve the use of drugs and clinical procedures. National drug policy and its applications (such as the National Formulary, shore procurement of drugs, distribution system and the Essential Drugs Programme (EDP) have contributed to the satisfactory standard of drug prescription. Didactic, training and evaluation tools, were produced while the training activities were conducted in the provinces.

The main conclusions and recommendations were:

1) Prescription is just a step of the clinical process; therefore, its evaluation is unable to grasp the quality standard of the entire clinical procedure. At least in Mozambique, good prescription results are due to the existence of a drug health policy, and not to drug consciousness or clinical competence of the prescriber.

2) Efforts have to be made to pursue a systematic "problem-oriented" on-the-job training, using the evaluations critical results as the focal educational points.

3) Vertical programs (such as WHO's CDD, ARI, malaria, etc.) must be integrated, when strengthening general clinical competence is at stake.

4) Use of auxiliary services (i.e., laboratories) has to be rationalized: non-specific and useless requests must be avoided, sensible analyses must always be asked for.

5) High and middle level health cadres should spend more time supervising and up-grading lower level clinical health workers (responsible for about 95% of the total out-patient contacts), rather than treating patients.

6) Health workers have to be educated that not all illnesses necessarily require drug treatment, and that many sicknesses are self limited and benign; besides, a general education programme has to be launched for the public.

7) Efforts have to be made in the initial training to improve clinical practice and to apply the standard clinical procedures suggested by the Ministry of Health for the most common diseases.


Problem statement

In 1995 the standard treatment guidelines were reviewed by the Ministry of Health (MoH). Based on this, a coordinating task force was created within the MoH and included representatives from WHO's EDP, CDD, ARI, STDs and MCH programmes. The task force was charged to examine inefficiencies in their programs and how to improve the quality of care.



Obtain baseline data on clinical practices at the PHC level.

Provide on-site training in evaluation techniques and new standard treatment guidelines, including rational drug use.



Evaluation of prescriptions from health centres.

Direct observation of out-patient contacts.

Provide checklists tools and training modules for on-site training.



Most prescriptions followed the National Drug Policy guidelines, but they were not clinically appropriate.

Prescribing at the PHC level occurs mostly on the basis of symptomology, not clinical evidence.

Patients receive no counseling on appropriate drug use, treatment goals, or possible side effects.



In Mozambique, the national drug policy contributes to "correct" prescribing but not "appropriate" prescribing.

Vertical programmes should be integrated to improve general clinical competence.