Managerial strategies are also important in promoting rational use and in discouraging waste. The most important strategies are discussed below. In all cases, a careful analysis of the underlying problem, extensive discussions with all staff involved, a careful introduction, and intensive supervision and follow-up help to ensure maximum impact of the strategies. In some cases, unexpected negative effects may be the result.

Standard treatments, essential drugs lists, dispensing standards

As mentioned in Section 9.4, clinical guidelines should be used to define institutional or national essential drugs lists, and these should be used to guide drug procurement and reimbursement. Adherence to the clinical guidelines should also be promoted by involving the end-users in their development, by introduction and training in their use, through supervision and medical audit. Other possibilities are the introduction of standardized or structured prescription forms, for example for antibiotic prophylaxis, and the use of standardized course-of-therapy packages.

Some managerial interventions do not work. For example, a rule to limit prescriptions to a maximum of three drug items can easily be evaded by writing two prescriptions for one patient; and a rule to have consultants countersign certain expensive prescriptions can be circumvented by pre-signed empty prescription sheets.

Financial incentives

There is very little hard evidence on the impact of financial incentives. On theoretical grounds it can be assumed that the removal of perverse incentives should lead to better prescribing, but unintended effects are very common.

The combination of prescribing and dispensing functions in one professional usually leads to overprescribing, as there is a financial incentive to sell more or more expensive drugs. It is therefore recommended that these two functions are separated as much as possible, except in rural areas where there is insufficient market for separate pharmacies. Such a measure usually meets with strong opposition by dispensing doctors (who may earn a considerable part of their income by selling drugs) and by pharmacists (who may earn a considerable part of their income by selling drugs without prescription). In both cases the total remuneration of these professionals has to be reviewed, and systems of professional fees (consultation fee, dispensing fee) need to be introduced. Similarly, a percentage mark-up for a pharmacist creates an incentive to sell more expensive drugs. A flat dispensing fee, irrespective of the price of the drug, would remove this incentive but may lead to a price increase of the cheaper drugs. Financial incentives should always be planned and evaluated very carefully.