E-drug: Summary of ICIUM Conference
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Dear E-Druggers,
The summary of the First International Conference on Improving Use of
Medicines follows. Detailed recommendations for implementation and
action steps during the next five years that were produced by
conference participants will be available next week, and these will
also be distributed via E-Drug. When the materials from presentations
at the conference have been loaded on the WHO web site, we will send
the URL for those with web access.
Requests for research proposals focused on some of the priority
research topics identified at ICIUM will be appearing during the next
few months. We hope that many of you will participate in moving
forward the conference agenda in coming years.
Dennis Ross-Degnan
Harvard Medical School
on behalf of the ICIUM Scientific Committee
(drossdeg@warren.med.harvard.edu)
Chitr Sitthi-Amorn
Chulalongkorn University
on behalf of the ICIUM Organizing Committee
(chitr@chulkn.car.chula.ac.th)
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INTERNATIONAL CONFERENCE ON IMPROVING USE OF MEDICINES
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, Prof. 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.
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