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
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
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
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
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.