The First International Conference on Improving Use of Medicines (ICIUM)
The First International Conference on Improving Use of Medicines (ICIUM), held in Chiang Mai, Thailand, from April 1-4, 1997, identified progress in improving the use of medicines in developing countries over the last decade. Sounding an early theme that echoed throughout the conference, Professor Mark Nichter of the University of Arizona urged participants to pursue the "politics of the possible," finding issues and approaches that might allow individuals from many different professional backgrounds and perspectives to work together in interdisciplinary research and activities to improve use of medicines.
The Chiang Mai Conference was attended by 272 researchers, policymakers, and health managers from 46 countries representing a range of interests including universities, ministries of health, non-governmental agencies, consumer organizations, donors, and the pharmaceutical industry. International co-sponsors included the World Health Organization Action Programme on Essential Drugs (WHO/DAP), the International Network for Rational Use of Drugs, the United States Pharmacopeial Convention, and the Applied Research on Child Health Project. ICIUM was organized locally by a consortium that included the Thai Food and Drug Administration, the Thai Network for Rational Use of Drugs, Chulalongkorn University College of Public Health, and Chiang Mai University.
The objectives of ICIUM were to synthesize the evidence for success of different strategies to improve use of medicines in developing countries, to develop policy guidelines for implementing proven strategies, and to identify important directions for future research. Invited international teams of authors presented six critical reviews of experience from developing countries on improving pharmaceutical practice by health professionals, improving community drug use, and assessing economic and policy interventions on the use of drugs. Over 120 contributed papers on these themes were also presented; in an effort to create a resource base for work in this area, all contributed presentations were captured electronically, and they will be made available soon along with conference recommendations on the WHO/DAP web site.
The best evidence regarding successful interventions was in the area of primary care prescribing. Based on well-designed studies, clearly effective strategies included focused, problem-oriented, repeated training; supervision or self-monitoring using simple indicators; and peer group-oriented guideline development. Disseminating clinical guidelines or drug information without active implementation was clearly ineffective. Unfortunately, most experience to date has focused on the short- term impacts of public sector interventions to improve care for acute diarrhea or respiratory infections in children. Evidence of effectiveness is still scant regarding strategies to improve use of medicines in the private sector, for non-pediatric populations, and for chronic diseases.
Compared to primary care settings, there have been few reported interventions in hospitals in developing countries; this may be due in part to previous donor emphasis on reducing community mortality in children. Furthermore, with rare exception, the research designs in hospitals have been insufficient, usually uncontrolled pre-post designs. With ample evidence from developed countries of the potential for hospital interventions to improve use of medicines, ICIUM participants highlighted hospitals as a key area for future work. High priority was assigned to developing and testing a manual to guide the formation, activities, and impact monitoring of pharmacy and therapeutics committees, which were seen as a key component of implementing effective hospital policies.
Conference participants recognized the critical need to inform and empower consumers, who were the ultimate decision-makers in the use of medicines. Although consumer organizations and health educators have tried many educational approaches, few have been adequately evaluated and documented; all now recognize the need to critically assess the impact of their activities. However, it appears that interactive, contextualized programs, using a mix of communication channels, can be effective in improving community drug use. There is also evidence that the sales practices of retail drug sellers can be improved through targeted outreach education. Consumer education is currently a neglected area that requires sustained financial and technical support, and much greater advocacy.
Studies examining the impacts of common economic and pharmaceutical sector policies on use of medicines were conspicuously lacking. Of more than 50 countries with essential drugs programs, only Zimbabwe has measured in a valid way the impacts of its program on the use, rather than the supply, of medicines. The Zimbabwe strategy of regular public and private sector indicator surveys was highly endorsed as a model for all programs. Valid studies evaluating specific policy changes, such as the market withdrawal of drugs or the establishment of generic prescribing regulations, were rare; the use of time series to evaluate such policies was highly recommended. One clear policy lesson was the need to increase coordination among technical experts, consumer activists, and regulators in the enforcement of existing regulations. Given the importance of health sector reform, priority was also given to integrating this perspective in pharmaceutical policy studies, requiring multidisciplinary research and long-term capacity building.
There were repeated calls to extend indicator-based approaches for measuring and assessing drug use beyond the WHO standard methodology for problem identification.(1) Suggested indicators included not only more detailed measures of the adequacy of diagnosis, guideline compliance, quality of care, and cost, but also indicators of the appropriateness of inpatient drug use, the success of pharmacy and therapeutics committees, and the effectiveness of community-based programs.
The success of ICIUM will be measured by how broadly its recommendations are translated into action, both in institutionalizing successful strategies and in carrying out the priority research agenda to fill current gaps in experience. Dr Suwit Wibulpolprasert of the Thai Ministry of Public Health called the diverse stakeholders in attendance to work together to pursue this agenda not only through "open windows of opportunity" like development of GMP guidelines and educational activities to support them, but also through the more difficult terrain where their interests may conflict, the "forbidden windows," such as in implementing effective generic drug policies. Dr Alfredo Bengzon, former Secretary for Health in the Philippines, challenged researchers to become more active in the political process both to inform and motivate political leaders. Without this, even the best research would be of no value in improving people's health.
(1) WHO. How to investigate drug use in health facilities:
selected drug use indicators. Geneva: World Health Organization. 1993.