By Lillian Gitau 1 , John Kiambuthi 2 International Conference on Improving Use of Medicines

1. RECENT ADVANCES IN PROVISION OF PRIMARY HEALTH CARE BY MISSION ORGANIZATIONSTHEEFFECT OF AN EDUCATIONAL INTERVENTION ON USE OF ANTIBIOTICS IN THE TREATMENT OF ACUTE RESPIRATORY INFECTION AND MALARIA IN SIX MISSION HOSPITALS IN KENYA By Lillian Gitau1, John Kiambuthi2 International Conference on Improving Use of Medicines Chiang Mai, Thailand 2004 1 Centre for Drug Management and Policy /Sustainable Healthcare Enterprise Foundation (SHEF) 2 Mission for Essential Drugs & Supplies

2. Background and Setting • 40% of the worlds population living in more than 100 countries are exposed to the risk of malaria • 270 million are infected with the parasites, with 100 million deaths yearly • Acute respiratory infections (pneumonia) kills an estimated 4 million children yearly • In Kenya high infant mortality rates are attributed to ARI and malaria in children under five years 120 under five deaths per 1000 live birth • Malaria is the highest killer of children resulting in an estimated 34,000 deaths in under fives • Most of these deaths can be prevented using simple, affordable measures

3. Mission organizations provide 50% of the entire national serving 80% of the population. Objective of the mission sector provide affordable accessible healthcare Challenges finances personnel irrational use of drugs Promoting Rational Drug Use Established Pharmacy & Therapeutics Committees Essential Drug Lists Standard Treatment Guidelines Continuing Medical Education External training Background and Setting (continued)

4. Study Objectives • Objective: To assess the effectiveness of an educational program with supportive activities of Pharmacy and Therapeutic (P&TC) on prescribing for non-pneumonia ARI and malaria in children under five in six mission hospitalsin Kenya. • Specific Objectives: 1. To determine prescribing practices for non-pneumonia ARI and Malaria in children under five 2. To determine the effect of an educational and managerial intervention to improve prescribing of antibiotics for non-pneumonia ARI and malaria.

5. ARI Prescriber will use the approach to cough or difficult breathing clinical features to classify the disease. No pneumonia cough or cold is treated with supportive therapy and no antibiotics. Malaria 1st line treatment as per STG is SP combination 2nd line Amodiaquine Paracetamol Treatment of ARI and Malaria

6. Methods • Design: - Quasi Experimental design with comparison groups and a pre-post intervention study periods. - Use of quantitative and qualitative analytical methods. • Setting: Six mission hospitals in Central and Eastern provinces in Kenya. • Intervention: - An educational training on prescribing of non-pneumonia ARI and malaria - Support Pharmacy and Therapeutics Committees at each of the hospitals - Distribution of supporting educational materials

7. Quantitative Analysis - Outpatient clinics of 6 mission hospitals - Analysis of prescribing patterns for ARI and malaria 999 prescriptions for ARI cases 1465 prescriptions for malaria cases Qualitative Analysis Survey of 156 key informants - Exit interview of 120 caregivers - In-depth interview of 36 prescribers and P&TC members Methods (continued)

8. Results • Moderate changes observed in antibiotic and injection prescribing for ARI and malaria. • General use of antibiotics decreased by 2% after the intervention • General use of injections decreased from 22% baseline to 18% after the intervention • Overall prescriptions of generics for ARI and malaria increased by 13% • Generic prescribing for ARI improved by 11% (88% before Vs 99% after) • Generic prescribing for malaria improved by 14% (83% before Vs 97% after)

9. Results 4

12. Results (continued) Hospitals with an active P&TC committees had a better improvement in prescribing for ARI and malaria than those with non-active committees Smaller increases in treatment costs observed in hospitals with active P&TC. - For malaria: prescription costs increased by 41Ksh in hospitals with active P&TC compared to Ksh 110 in hospitals with inactive P&TC - For ARI: treatment costs increased by 26Ksh compared to 66Ksh in hospitals with inactive P&TC.

13. Summary and Conclusions • The intervention did result in improving the use of generics and in controlling increases in prescription costs. • Antibiotic use changed moderately, but less expensive antibiotics were being prescribed. • Smaller increase in treatment costs observed in intervention hospitals.

14. Education program and P&TC activities with adequate support in mission hospital settings can improve prescribing for ARI and malaria in children The role of P&TC needs to be reinforced and extended in the hospital settings to promote rational prescribing of medicines for childhood illnesses using the IMCI initiative Regular training of healthcare providers and P&TC activities supported by distribution of materials may yield a greater improvement in prescribing behavior. Educational programs supported by active P&TC may be more efficient in public health facilities where prescribing patterns also need improvement Government should consider the implementation of such initiatives throughout public health facilities in order to improve rational drug use in Kenya. Given the importance and the role of mission hospitals in Kenya, the Government should support those institutions in their initiatives. Considerations

15. Considerations (Continued) • Up scaling to include other educational and a managerial strategies • Use the sector to promote drug use in the community • Implement the IMCI strategy • Hospital drug use

16. Acknowledgment • The six mission hospitals • Technical support from Harvard Medical School and Boston University School of Public Health Center for International Health Development • Joint Initiative on Improving Use of Medicine under a grant from ARCH Thank you.