Strategies to promote rational drug use can be educational, managerial or regulatory. All parties need to be educated and encouraged to use drugs rationally; some managerial measures may help to ensure implementation; and regulations may be needed to enforce some of them, especially for the private sector.
Any strategy and intervention should be focused on a specific problem behaviour, and targeted at the people or facilities with an evident problem. Involving the target group in developing and implementing strategies is important for the success of the intervention.
A few very effective approaches are essential building blocks in efforts to promote rational prescribing.61 These are the development of clinical guidelines leading to essential drugs lists and formularies, and the establishment of drugs and therapeutics committees in major hospitals. These are discussed first.
Clinical guidelines and essential drugs lists
The starting point for most, if not all, interventions to promote rational drug use is nationally agreed clinical guidelines. These guidelines should cover the most common diseases and complaints, be differentiated for the different levels of health care, and be adapted to the competence of the health workers. Clinical guidelines define the desired prescribing behaviour and constitute the core of all educational, regulatory and managerial interventions. In addition they define the selection of essential drugs for the supply system, as expressed in the various lists of essential drugs.
Clinical guidelines indicate the most cost-effective therapeutic approach, on the basis of valid clinical evidence. Their impact is greatest if the end-users (prescribers and, to a certain extent, patients) are closely involved in the development.
WHO has defined recommended treatments for the most common diseases and complaints. Summaries of these guidelines and references to the full documents are available from the WHO Medicines web site http://www.who.int/medicines/
A variety of printed materials can be used to further promote rational prescribing. Drug bulletins provide summarized, comparative, independent and up-to-date information on selected drugs, and often include information about the cost of treatment. Providing balanced, independent drug information is particularly important in view of the volume of promotional material that is received by prescribers. However, experience has shown that printed information on its own has a limited impact. Printed materials are most useful when used with other, more interactive interventions, such as discussion groups, problem-based learning and prescription review.
Drugs and therapeutics committees
Drugs and therapeutics committees can play an important role in improving the efficiency of the pharmaceutical system, both nationally and at institutional levels. In addition to the national committee to coordinate development of the national clinical guidelines and the national essential drugs list, governments should therefore promote the establishment of such committees in all public and private hospitals.
Hospital drugs and therapeutics committees are vital structures for implementing comprehensive and coordinated rational drug use strategies in hospitals. They should be considered as an organizational keystone in the hospital pharmaceutical programme, which should be responsible for developing and coordinating all hospital policies related to pharmaceuticals (e.g. on the selection of standard treatments, hospital formularies and drug budgets). These committees should also be responsible for adapting the national clinical guidelines and essential drugs list to the needs of the hospital. They should also perform drug utilization studies and prescription reviews, and develop educational strategies to improve drug use and management. A WHO manual on the establishment and functions of drugs and therapeutics committees is being developed.