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Implementing National Drug Policies. What have we learned about this topic based on evidence?. NDPs are most successful when they include Implementation plan that involves all stakeholders, capacity development. E valuation and measurement as an integral part of the plan.
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What have we learned about this topic based on evidence? NDPs are most successful when they include • Implementation plan that involves all stakeholders, • capacity development. • Evaluation and measurement as an integral part of the plan. • “Keep telling the story” to all
Recommendations • Develop measurement systems (indicators/outcomes) • Identify small, ‘easy’ and potentially successful targets to address in early interventions • Talk to the Minister – and the media, and the health professionals, and the consumer. • Plan budgets and strategies to convert projects to programs • Plan a long term strategy to reinforce and renew political and professional support -
Key NDP research questions • What are the best /possible and sustainable data systems for measuring and monitoring policies in different settings? • What are effective strategies for converting policy into effective programs? • Using the media in NDP implementation: how, what for, what works (best), what doesn’t work? • Research into behaviour and attitudes of doctors, health professionals and consumers? • What strategies are effective in sustaining capacity development?
What have we learned about this topic? • Regulation without enforcement does not assure quality • There is little evidence of the impact of global and regional initiatives and tools (e.g. use of WHO Certification Scheme, GMP, GPP guidelines) on country efforts to assure the quality of essential medicines. • Despite having UN list of banned substances, many of these products are in the market.
Recommendations • Regulatory bodies, procurement agencies, and other national stakeholders should critically assess the performance of current operational quality assurance strategies. • WHO and development assistance agencies should support country initiatives to assure the quality of medicines, including strengthening enforcement. • The UN list of banned and restricted substances should be acted upon in all member states • Banning should be accompanied by suggested alternative treatments, be publicized, monitored; and drugs be recalled from the market.
Key regulatory research questions • How can different strategies contribute to assure quality, including combating counterfeit products? • Regional surveys of what, was done in the different countries to follow up decisions to include substances in the UN list of banned substances; and if nothing was done, why not. • Qualitative research as to why regulations are not enforced.
What knowledge do we currently have about this topic? • Inappropriate promotion continues to be very widespread • Compliance to, and awareness of WHO EC is generally poor • Voluntary guidelines and Self-regulation are rarely effective on their own • Many regulations exist that are not effectively enforced
Recommendations • Develop networking opportunities for regions • Report your research and experiences to the WHO/HAI drug promotion database • Enforce existing regulations and publicize enforcement actions • Develop and implement training/awareness programs for professionals and consumers
Recommendations (Cont.) • Every country needs to develop an effective and realistic strategy for controlling drug promotion • Develop and implement free access to good, unbiased drug and therapeutics information, both for professionals and the public • Develop funding mechanisms to monitor/enforce, possibly including a levy on promotional spending by the pharmaceutical industry • Educating children about medicines, and awareness of pharmaceutical promotion
Key promotion research questions • What is the extent and impact of drug promotion and regulation in developing countries? • What new tools are needed for improved monitoring and evaluation? • What is the impact of Internet drug promotion/sales? How can they be controlled? • What effect does drug promotion have on children’s perceptions of medicine taking?
What knowledge do we currently have about this topic? • Significant progress has occurred in this area. • Better communication between patients and providers can reduce injection overuse • Increased access to single use injection devices improves injection safety • Managerial approaches can improve injection practices
Recommendations • Combine interventions using various methods to improve effectiveness • Monitor injection use and injection safety using standardized indicators • Explore ways to test the Interactive Group Discussion approach in various other settings • Empower patients to express a preference for oral medications and demand single use injection equipment • Ensure injection device security
Key injection research questions • What financial incentives for prescribing injections can be identified to show how the problem could be addressed? • How can we study "positive deviants" who prescribe fewer injections? • Will the reduction of injection use in the formal, public sector drive patients to use the informal, private sector?
What have we learned about this topic? • DTCs need nurturing, members must be motivated to work and often need skills training (See new manual and existing course) • DTCs are an essential link between the National Drug Policy and the periphery • Process variables can show progress before outcome or impact effects can be detected
Recommendations • Establish clear hierarchy of responsibility for DTCs in the country • Establish national/ regional centres to support DTCs • Give DTC members protected time for their work • Develop institutional support for DTC, including influencing clinicians – locally relevant data, incentives for DTC members – food, training
Recommendations (Cont.) • Introduce culture and practice of DTCs into undergraduate education for medicine & pharmacy • Establish regular training for actual and potential DTC members • Employ and recognize clinical pharmacists and clinical pharmacologists in health service • Develop DTCs in private sector – in combination with other clinical meetings?
Key DTC research questions • What are the characteristics of a successful DTC? Including structure, process & outcome indicators for DTCs? • Can we evaluate the impact of DTCs on drug use & costs saved from improved use of drugs? • What are the influences of procurement factors, consumer pressure, and industry pressure on decisions of DTCs?
What have we learned about this topic? • Generic prescribing and substitution may be influenced by financing mechanisms. • A multi-method intervention can increase generic prescribing and reduce costs for the targeted therapeutic products. • Generic prescribing and generic substitution (generic dispensing) reduce costs but may not improve prescribing. • Drug quality must be assured to promote generic prescribing/substitution.
Recommendations • Disseminate findings on impact of generic prescribing and generic substitution policies. • Create incentives through the financing mechanisms to enable generic prescribing and generic substitution. • Every hospital should design and implement comprehensive approaches that include appropriate formulary, generic prescribing and substitution policies.
Key generic prescribing research questions • What works to promote generic prescribing and generic substitution policies? • What are the effects on health outcomes of cost-containment interventions? • How can the impact of educational interventions for generic prescribing be sustained?
Procurement and Hospital Economics (combined)
What knowledge do we currently have about these topics? • Knowledge must be shared with all stakeholders – health providers, politicians, warehouse workers. • All procurement interventions must be self-sustainable. • Training is not the only intervention to improve procurement systems • Simple economic indicators can be developed for each facility. Should be used for trend monitoring. • A matrix of ABC and VED (vital, essential, and desirable) can be an effective monitoring and management tool for each facility • Available information technology is fine for performing procurement management
Recommendations • Develop case studies of effective procurement management • Develop a good procurement manual, handbook, and training (such as how to use ABC/VED data) • Need a new periodicals for procurement and supply management of pharmaceuticals • Focus on training and staffing levels, for effective procurement management • Develop financial management indicators that relate to health outcomes.
Key procurement and economics research questions • After supervision, what are the best interventions to improve procurement? • What financial incentives improve procurement performance? • What is the goal of Quality Control in the procurement system? • How has decentralization and the HIV/AIDS and TB epidemics impacted drug supply management systems? • How can forecasting beimproved? • How do we measure and value the rational use of drugs in hospitals? • What is the impact of stock outs on rational use?
Innovative Public & Private Sector Strategies to Improve Drug Use in Primary Care
What knowledge do we currently have about this topic? • Private systems need to be competitive and profitable to be sustainable • Buy-in/consensus of stakeholders is critical to program development
Recommendations • Develop programs/interventions based on consensus building of stakeholders • Develop information systems to support decision making in private care initiatives • Explore IT/communications strategies to support pharmaceutical management and improved drug use • Increase focus on quality of care aspects of private sector initiatives
Key public-private innovation research questions • What can be done using incentives to improve the quality of care in the private sector? • How can the issue of commercial competition, which may decrease the quality of service, be addressed?
Microeconomic Issues in Drug use: User fees and Physician incentives
What have we learned about this topic • Dispensing doctors or prescribing dispensers perform less well • Self regulation does not work • Fee structure influences medicines use and prescribing, cost, quality of care, availability, and cost effectiveness • Regulations have been effective in reducing antibiotic use.
Recommendations • Need for agreed indicators to monitor and evaluate RDU, pharmacy practices and care to monitor the effect of for-profit dispensing and other financial incentives • WHO should develop guidelines and take a position on the issue of prescribing and dispensing (for profit) by the same person.
Key microeconomics research questions • What are the determinants of prescriber behavior? • What guides the patient in their choice of services? • How do pharmacy practice and quality of care for dispensers and prescribing dispensers differ and change among countries? • What interventions are effective to improve use through changing physician fees and financial incentives?
What have we learned about this topic? • Alternative drug distribution channels have a role in improving access and RUD • To be viable these alternative channels need active effective supervision, good financial management, motivated staff, active DTC & technical training • In some cases financial incentives may cause adverse effect on RUD
Recommendations • An informed community is essential which means that community education and involvement are mandatory • These systems should be part of the overall health system and not parallel or separate • Regulatory and policy framework should be balanced with reality • Private providers such as itinerant drug sellers may be brought into system
Key RDF research questions • Can the performance of itinerant drug sellers be improved? • How do the different drug distribution schemes affect equity? • How will improved access affect use of drugs?
What knowledge do we currently have about this topic? • An area of considerable progress since ICIUM1 • Prices vary greatly • Almost all developed countries have some form of “price mechanism” • WHO/HAI methodology is a major advance
Recommendations • All countries should do a WHO/HAI pricing survey though this methodology needs to be extended. • A drug pricing network--involve pricing directorates, health insurance groups, researchers and activists--should be established. Submit a grant proposal for a 2 day meeting of collaborators
Recommendations(cont.) • Survey public sector procurement systems to evaluate efficiency, cost, best practices. • All countries should develop price monitoring systems • In order to encourage the uptake of generic medicines, develop mechanisms for QC to provide confidence for all
Key pricing research questions • What pricing policies and mechanisms are used and what are their features? • Impact of pricing policies on: use, health outcomes & access by level and sector
What have we learned about this topic? • Health insurance scheme can be established in resource-poor settings. • HIS can use leverage with various stakeholders to promote rational use of medicines-- through reimbursement policies tied into treatment guidelines, provider accreditation, contracts with pharmaceutical companies. • Claims data can help us understand medication use, cost, and outcomes • USE AVAILABLE DATA NOW.
Recommendations • Start implementing drug benefits in a systematic manner with continuous monitoring and evaluation. • Develop standardized coding & IT system from the beginning. • Develop capacity to enable people to routinely use insurance data for monitoring, evaluation, evidence-based decision-making. • Develop network to share experiences • Develop manual and training modules on using claim data for monitoring drug use and cost.
