- BATOOL JAFFER SULEIMAN, BRIAN GUNN*
* Dr Batool Jaffer Suleiman is Director, and Dr Brian Gunn is Specialist Clinical Pharmacist Officer, at the Directorate of Rational Drug Use. For further information contact: Ministry of Health, Undersecretary’s Office for Health Affairs, Directorate of Rational Drug Use, PO Box 393, Postal code 113, Muscat, Sultanate of Oman. Tel: + 566205, fax: + 562640.
ANY national drug policy should be concerned not only with the supply of safe, effective and appropriate drugs for the country but also with the way that they are prescribed and dispensed by health personnel. Patient demands and beliefs are other major factors influencing prescribing patterns. In recent years there has been growing concern in countries worldwide about the rising cost of health care, and of drug treatments in particular. The Sultanate of Oman is no exception, and policy-makers firmly believed that action had to be taken immediately to maximise the use of available health resources and to minimise waste. Oman took a bold new initiative by establishing a Directorate of Rational Drug Use, which came into being on 15 April 2000 as a result of a Ministerial Decree.
Oman’s population is 2.33 million (1999) in a country of about 312,000 sq km. Administratively, the country is split into 10 regions, with Muscat Region around the capital city the most densely populated. The Sultanate has a very progressive health system, which has grown dramatically over the past 30 years, and Oman recently had the distinction of receiving top ranking in the index of performance on the level of health in a WHO global review.1 Health services in the public sector are free, with patients paying only a minimum fee of 1 Rial (approximately US$ 2.59) for annual registration and 200 baisa (the equivalent of 52 cents) for each subsequent visit.
The Directorate reports to the Office of the Undersecretary for Health Affairs, and has been given the prime responsibility to research all aspects of irrational prescribing, dispensing and drug use (see figure 1). It is staffed full time by an Omani Director who is a clinical pharmacologist, a Senior Medical Officer, a Senior Clinical Pharmacist Officer and a Secretary. It is currently recruiting more staff.
Profiling prescribing practices
The Directorate began by undertaking baseline studies using the WHO core indicators for prescribing and dispensing.2 This is resulting in the creation of a quantitative and qualitative knowledge base about current practices across the nation (see figures 2 and 3). In addition to these core indicators, prescriptions are examined during the study process. Any prescription which appears to be irrational is put aside for review and patients’ case notes are examined where necessary. Finally these prescriptions are grouped and catalogued according to any specific problems found. As a result a profile of prescribing practices is rapidly accumulating.
Figure 1 Organizational position of the Directorate of RDU within Ministry of Health
To date most of the studies have been conducted in and around the capital, Muscat, at three levels of care, with data gathered from three major hospitals, one psychiatric hospital and three large health centres or polyclinics. Now the Directorate plans to extend these studies to all regions of the country. Preliminary site visits to some regions have revealed similar problems but also many unique issues need to be examined. It is hoped that the whole country will have been covered by the end of 2001. Once this has happened a group from the Directorate and key officials in the Ministry of Health will meet to discuss priorities and possible interventions. Further studies will be carried out to measure outcomes and the impact of such interventions.
Irrational drug use has many facets, and the Directorate is tackling the problems on a variety of fronts. High priority has been given to training and further education. Collaborative projects with the Medical School at Sultan Qaboos University and the Oman Institute for Assistant Pharmacists have been set up so that the principles of rational prescribing and drug use are included in the teaching. Lectures will be given by Directorate staff at each of the institutions on a variety of topics, including writing a legal and rational prescription, rational pharmacotherapy, the concept of P(ersonal)-drugs3, therapeutic objectives, the importance of generic prescribing, and public education and counselling.
Oman is not yet self-sufficient in the supply of health care professionals, and recruitment of physicians takes place from many countries around the region and from the Asian subcontinent. These physicians come with a wide range of backgrounds, experiences and practices. As part of a new initiative the Directorate is actively involved in the interview process and sets a separate examination paper as part of the overall recruitment examination. In addition it has been decided that the Directorate will begin an induction workshop for each batch of new physicians starting employment at the primary care level in the Sultanate. In this way new doctors will be introduced to the use of standard treatment guidelines and protocols, the Oman National Formulary and the Health Centre Formulary, as well as the major principles mentioned above.
Public education is another important sphere of activity for the Directorate. One of the physicians recruited to the Directorate already has a background of research into communication and promotional strategies for public education in rational drug use. It is hoped to extend these studies in a number of areas. One advantage is that Oman has a good infrastructure in place and there is widespread access to mass media. A knowledge, attitudes and practices (KAP) survey is planned for the near future.
Another area of influence for the Directorate is in the facilitation and monitoring of hospital or regional drug and therapeutics committees. It is anticipated that if these committees are well structured and meet regularly then much useful groundwork on rational prescribing, dispensing and drug use can be achieved. The committees’ structure is designed to allow maximum dialogue between pharmacists and prescribers and to allow for problem-solving and new initiatives to be generated, for example, the establishment of a local formulary.
Figure 2 Preliminary results from 2nd & 3rd level facilities, Muscat Region
Figure 3 Prescription analysis at primary care level, Muscat Region
Directorate staff have been actively involved in these committees centrally and regionally, and uniformly find great enthusiasm amongst the participants.
The Directorate plays a high profile role in workshops, seminars and conferences regionally and nationally. These gatherings provide the opportunity to present on key topics, and to raise awareness of the Directorate’s work.
In summary, Oman has been very proactive and forward-thinking in establishing the Directorate of Rational Drug Use. By giving responsibility to a single body it should be easier to study problems of irrational use and to make interventions as quickly as possible. It is now up to the Directorate to produce results. It is certain that many countries will be interested to learn the outcomes of the work carried out in Oman.
1. WHO. The world health report 2000. Health systems: improving performance. Annex 10. Geneva: World Health Organization; 2000. See on the Web at: http://filestore.who.int/~who/whr/2000/en/pdf/AnnexTable10.pdf (WHO carried out an analysis of the world’s health systems, using five performance indicators).
2. WHO. How to investigate drug use in health facilities. Geneva: World Health Organization; 1993. WHO/DAP/ 93.1.
3. WHO. Guide to good prescribing. Geneva: World Health Organization; 1994.