Essential medicines are one of the most cost-effective ways of saving lives and improving health, and constitute 20-40% of health budgets in many developing countries. Increasing costs and lack of resources often result in public health systems being unable to procure sufficient medicines to meet patient demand. Despite this, medicines are often managed and used inefficiently and irrationally. This may be due to many factors, for example inadequate training of health staff, lack of continuing education and supervision, or lack of updated, reliable, unbiased drug information. Particular areas of inefficiency and drug use problems include:

• poor selection of medicines, without consideration for relative efficacy, cost-effectiveness or local availability

• inefficient procurement practices, resulting in non-availability, inadequate quality, wastage, or use of unecessarily expensive medicines

• prescribing not in accordance with standard treatment protocols

• poor dispensing practices resulting in medication errors, and patients’ lack of knowledge about dosing schedules

• patients not adhering to dosing schedules and treatment advice.

Inefficient use of medicines affects the safety and quality of therapeutic care and wastes resources. According to WHO (1985):

Rational drug use requires that the patients receive drugs appropriate to their clinical needs in doses that meet their individual requirements (right dose, right intervals and right duration). These drugs must be of acceptable quality, and available and affordable, at the lowest cost to patients and the community.

When the use of medicines is not in accordance with this definition, there are often undesirable health and/or economic outcomes. Such outcomes include insufficient therapeutic effect, adverse drug reactions, preventable side-effects and interactions from medicines, and increasing resistance of bacterial pathogens to antimicrobial medicines; these may all result in increased or prolonged hospital admissions, which are expensive.

Some inefficiencies result from lack of an effective forum that brings together pharmacists, clinicians and administrators to balance the demand for quality care with financial constraints. There may be tension between prescribers and financial managers about which medicines should be available for what problems. DTCs are a forum to bring together all stakeholders involved in decisions about drug use; they may exist at any level within the health-care system - at district level (overseeing primary health-care facilities), in hospitals, or at the national level. In developed countries hospital DTCs have been shown to be very effective in safeguarding and promoting efficient and rational use of medicines (Crawford and Santell 1994, Weekes and Brookes 1996) by, for example:

• establishing documented rules and policies for all aspects of drug management including the selection of formulary list medicines and agreement of treatment protocols

• conducting continuing education, audit and feedback, drug utilization review and monitoring of adverse drug reactions and medication errors.