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Essential Medicines and Policy Department  (EDM)

International Conferences on Improving Use of Medicines (ICIUM)


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Problem-based rational drug use train-the-trainers program: postgraduate

Orrell C., Kishuna A.




Seven billion rand (1.5 billion US dollars) will be spent on pharmaceuticals in South Africa in 1996. Most of these will be prescribed and dispensed, in the public sector, by nurses and other primary health care professionals who have been inadequately trained for the task. There is no comprehensive system in-service training in rational prescribing that addresses this need for human resource development and support.

A train-the-trainers programme has been developed to meet this need. It aims to provide prescribers at primary care level with training in prescribing medicines rationally, while building up a network of references and resources to support them further, with the intention of reducing ineffective, unsafe and expensive prescribing practices.

The programme is presently being implemented in district-based primary health care facilities in the public sector of two regions in South Africa, with national expansion planned. Prescribing nurses, pharmacists and doctors are included. Community nominated district-trainers are trained to teach the course to small groups of staff at facilities within their health district. Staff are trained in their own environment.

Initial training consists of four problem-based teaching modules which cover: principles of rational drug prescribing; dispensary management; practical use of standard treatment guidelines; and patient counselling. Staff are encouraged to make use of references and regional drug information centres.

Prescribing practices, prescription costs and health facility resources are analysed in a before-after study with no control group, by prospectively recording WHO-based drug use indicators from 30 sample prescriptions at each facility where the training occurs. Data regarding the facility's human and material resources is also collected. This data collection started in December 1996 in one region of KwaZulu-Natal, at 3 health facilities. Data collection will be repeated by the facility’s staff 3 months after the training and development of the support network. Outcomes will hopefully show an improvement in prescribing practices and a reduction in prescription costs.

The programme is part of a broader plan for supporting rational drug use, and it links with the Universities of Cape Town and Groningen's rational drug use training program for undergraduate therapeutics teachers, the South African National Drug Action Program, and the WHO Action Programme on Essential Drugs.



25% South Africa’s health expenditure is on drugs.
Most are dispensed and prescribed in public sector by staff less than adequately trained.


New Essential Drugs Program in April 1996: further increase in primary care prescriber responsibilities with no in-service training available.
No means of quantifying wastes or inefficiencies in the system.
Increasing awareness that drug prescribing and utilisation are a problem in primary care.

needs assessments conducted:

focus group discussions held with health care workers revealed these needs.

drug information

SE, CI, resistance
patient information

treatment guidelines

common conditions
easy access to information

Impetus and initial funds provided by Health Systems Trust



1. To create a system for the training and support of primary care health workers in the rational, cost effective and safe use of drugs.

this system must be based at the site-of-service, and provide in-service training.
it must create the structure of a seeding effect, so that the trainers will be selected, trained and supported at a district level; they will then participate actively in the training of the next level primary health care staff,
the teaching method must be clinically oriented and problem-based.
it must make maximum use of existing infrastructure.
it should support and strengthen the essential drugs programme and its implementation in South Africa;
it must be easily sustainable.

2. Every component of the system is to be linked to measurement, outcome analysis and research.

3. to establish and reinforce the principle of lifelong learning amongst the healthcare workers concerned.

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30.4% of prescriptions were considered adequate (i.e. contained the name and strength of the drug, dosing schedule and duration of treatment).

42.2% were correctly labelled (i.e. the patient’s name, the drug name, the dosing schedule and drug expiry date were all on the label).

13.5% of the prescriptions followed the Essential Drug Program Standard Treatment Guidelines (STAG) completely. 30.2% did not follow them at all. The level of adherence to the STGs did not influence the cost of the prescription.

25% of the patients had little or no knowledge of the drugs they had been given, nor of their dosing schedules.


The three facilities visited were well-staffed community health centres. There was adequate medicine supply.
Comparisons between clinics over time will be done once the 3 month set of data has been analysed.



It is cheaper to prescribe EDL drugs. Encouraging the use of generics may increase the use of EDL drugs, and is likely to lead to cheaper prescriptions.

Three month data will allow focus on the change in prescribing practices. These may relate to cost.

Presently these data cannot relate improved prescribing practices to better patient outcomes. Whether or nor the STG for a particular diagnosis was followed, had no bearing on the prescription cost.

Possible to analyse each facility separately and compare them, in terms of STG use, patient knowledge, labeling and so on, to each other and to themselves over time.

Such data, when collected on a larger scale, may provide a quantitative basis for local, or even policy, changes in staff training and dispensary practice.


Success factors
Appointment of dedicated primary care trainers to provide on-going in-service training. The demand for training is increasing. These trainers should be employed on a regional, if not a district, level. ACTIVE support is needed at provincial level to achieve this.
Staff need protected time for training purposes. Present staff have full clinical commitments.
Further support (financial, academic and administrative) for the present RMIC and for initiation of other Regional Medicines Information Centres is needed.
Continued development of electronic networks (e.g.. Healthlink), and training of staff in their use.


Rational prescribing cannot be taught in isolation. Efforts to prescribe rationally are undermined by drugs being out-of-date or unavailable, high patient numbers and patient demand. Improvements in staffing and all areas of pharmaceutical service are needed.

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2-day problem-based workshop for primary care prescribers has been created.
Principles based, encouraging self-directed learning to update and adapt existing knowledge of prescribing and dispensing.
Flexible program: to allow a shift in focus if needed.


Content: (see Training Manual)

Module One: Principles of rational drug prescribing, based on the Guide to Good Prescribing (WHO). Teaching occurs in small groups of 8-10 staff members, using relevant primary care clinical examples to illustrate and apply the prescribing process.

Module Two: Approach to application of standard therapeutic guidelines. Taught with module one.

Module Three: Principles of managing a dispensary.

Module Four: Points on dispensing. Both modules 3 and 4 are ideally taught in the dispensary of the health care facility.

All modules are applicable to prescribers. The last 2 would be important to any staff who dispense or provide patient information.


Drug use indicators

30 prescriptions collected at each facility. First collection: December 1996. Second collection: March 1997. Data from the first set are presented here.
The data were collected at a point when the patient carried both their prescription cards and their dispensed medications. Patient knowledge of the drugs dispensed was checked too.

sample indicators

Per facility:
Facility type (community centre/clinic/mobile)
Access to staff (prescribing sister/doctor/pharmacist)
Availability of unbiased drug information
Source and availability of medicines
Per prescription:
Number of drugs prescribed and dispensed
Number prescribed generically and on the Essential Drugs List
Compliance with Standard Treatment Guideline
Completeness of prescription
Adequacy of labelling









Mean no. of drugs per prescription





1.3 to 2.0

Mean cost per prescription






Mean cost per item





% drugs on EDL






% drugs prescribed by generic name






(Underlined = significantly different from others)

R= rand; R4.50 = US$1.00

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