At independence, most African countries operated policies of free health care for all. With the economic problems experienced in most African countries in the 1970s, this option was no longer feasible. With the introduction of the essential drug concept in the early 1970s and the publication of the first WHO model list of essential drugs, it became increasingly clear that the scarce financial resources needed to be cautiously used in order to contain the increasing drug costs and ensure sustained availability and accessibility of essential drugs. Such drugs are considered necessary and vital for the health needs of the population; they should be available at all times, in the proper dosage forms and at affordable costs.

Based on methodology used by the WHO, Member States have developed their own national essential drug lists which are supposed to be reviewed regularly in order to improve drug supply. In 1987 the Bamako Initiative was launched to involve communities in financing and managing their health care needs; the essential drug component became a core and prominent issue of this initiative. The drugs, delivery system and service delivery must be efficiently managed, supervised and monitored.

Despite the availability of numerous tools on the management of drugs, none of these specifically targets the health centre level, particularly the health workers employed at this level who have no formal training in drug management. This prompted the WHO Regional Office for Africa to start developing this manual in 1996.

A consultant prepared the preliminary draft and was later joined by five other consultants to complete and re-write certain sections of the manual. The first complete draft was then reviewed by the WHO/AFRO Division of Health Services and Systems Development. Following this review, the manual was field-tested for a period of one week in each of the following Member States: Malawi in October 1999, The Gambia in August 2000 and Lesotho in October 2000. The consultants who prepared the manual also acted as trainers in this exercise. Some members of local pharmaceutical departments in these countries also helped with the training.

The main purpose of the field-testing was to ascertain the suitability of the material for teaching drug management to health workers who are given the responsibility of managing drugs, particularly at the health centre or other similar level. Most of these health workers have had no formal training in drug management.

The field-testing involved conventional classroom teaching methodology. A group of health care personnel (15), mainly nurses and medical assistants working at the health centre, were the trainees at each site. The exercise lasted 5 days.

From the field-testing in the three countries, it was accepted that the manual is suitable for use in the training of people handling drugs at the health centre or equivalent (e.g. clinics, lower cadre attached to pharmacy depots and stores). The teaching should, however, be adapted to the background of the students and should last for 8-10 days. The teaching should also be relevant to the drug supply system operating in the individual country. If possible, local trainers should be used after an initial orientation period. A minimum of two and a maximum of three trainers per training session of 20 trainees are recommended.

The training should start by the administration of a pre-test and end with the administration of a post-test and a training session evaluation. An outline based on the various chapters of the manual should be prepared prior to the training. The training should include a one-day field visit to a health centre and any other higher-level health facility. Trainers and any additional local facilitators should have a pre-training meeting aimed at sharing the various chapters among themselves and discussing how to specifically handle the technical issues in the various chapters.

Annexes to this present manual include proposed pre-test and post-test questions, a training outline, evaluation form and a field visit checklist. These were used during the field-testing of the manual as well as during the first training sessions in Malawi and Lesotho in 2001, and in Gambia in 2002. These can be used in any training session, but appropriate changes need to be made for any specific local training needs. Comparative pre-test and post-test results from the field-testing exercises in Malawi, Gambia and Lesotho are also attached.

It should be noted, however, that while the pre-test and post-test include attitude questions, it is the opinion of the authors that the content of the manual is factual and the design of the training does not adequately cater for influencing or modifying the attitude of health workers towards patients in the exercise of health-care duties. While attempts should be made to emphasize the importance of a correct attitude towards the patient, it is felt that this should be dealt with during the super vision process, without excluding the possibility of organizing special training or briefing sessions on attitude.