Bafoussam Baptist health center is a health unit under the Cameroon Baptist Convention Health Services, one of the many health centers in the western Region of Cameroon. Created in 1999 the health center has grown in staff and infrastructure from eight staff in 1999 to about one hundred and forty staff as of August 2018.The patient turn-out has drastically increase too from about fifteen patients per day to about one hundred and sixty outpatient daily and an inpatient of about twenty. There are four screeners trained to carry consultation and three medical doctors with added training on some key elements in nursing practice. This work force is guided by internal policies and one of the tool is to promote health equity as well as the respect of treatment guideline as a way of providing quality services in line with the essential drug guidelines (WHO, 1977). Bafoussam like some of the institutions of the CBCHS, being in an urban area the challenge has been the non respect of treatment guideline and formulary first due to the fact that the doctors are very new in the system and secondly because they are carried of this formulary by medical delegates. The key challenge is therefore irrational prescription that leads to poor quantification and hence expiry. Furthermore products are being introduced into the systems which are finally not used by the doctors who finally may change their jobs inflicting higher expenditure on health care. There is therefore need to impact on education to health personnel on the importance of a treatment guideline and formulary to improve drug availability and reduce expiry as well as lowering cost of health care.
Institutions of health in Cameroon under the ministry of health have organized themselves in a bit to develop their treatment guidelines and protocol to assist medical personnel to remain within the confines of these treatment guidelines to provide adequate health care to its population. In the Cameroon Baptist convention (CBC) treatment guidelines have been developed but there have been great challenge staying within the confines of this protocol. Though this it is a vital tool in the management of clients and determining the quantities of commodities to be purchased the non use or application is likely one of the causes of poor supply and distribution of drugs and medical supply. The high rate of doctor’s turnover and the poor implementation of the use of treatment guideline have also contributed to high expiry of drug and lost (CBCHS CP Bulletin, 2016).
Most of the causes of disability and death in low to medium income countries can be prevented or treated with safe, effective and affordable essential medicines if effective pharmaceutical supply chain management system will ensure that essential medicines are available and accessible to the patient base on the essential drug concept. Rational drug use is an aspect of health care where patients receive medications appropriately to their clinical needs, in doses that will meet their own individual requirements, for adequate length of time and at acceptable and at affordable cost WHO (1985). The CBCHS treatment guideline has not been revised since 2011 though it is highly used to educate the newly recruited nurses to screen patient. The non revision for such long a time and the lack of a formal curriculum to teach this to doctors and nurses lead to difficulty in its applicability.
Therefore promoting appropriate use of drugs through the implementation of the available treatment guidelines in health care systems is a pre-requisite not only because of the financial reasons with which policy makers and managers are usually concern. This implies that rational drug use is also essential element in achieving quality of health and medical care. According to WHO policy prospective on medicine (2002) 50% of drugs are prescribed, dispensed, or sold inappropriately and that 50% of patients who are prescribed drugs take the drugs inappropriately. This means that there is great need for effective education, training and supervision of prescribers and dispenser as well as patients on the use of medicine. The CBC has faced a lot of challenges in ensuring the availability of essential drugs in adequate quantities and quality even with the creation of a central pharmacy and the recent creation of the Drug Revolving Fund in the CBC with the main objective of improving on rational drug use among all stakeholders. According to the report Issued and in conformity with September 2002 World Health Organization Geneva observation, erratic prescription habits including polypharmacy, overuse of injections when oral medications are available and feasible, inappropriate use of antibiotics often in inadequate doses and dosage and sometimes for non bacterial infections, the non use of treatment guidelines, and exhaustive inappropriate self-medication were key issues that affect rational drug use. Currently the quest for specialisation services has not been envisaged in the drawing up of the formulary adding to the fact that rational prescription remains a dilemma in the CBC.
Clinical practice guidelines like may be the case with the CBCHS, serve as an educational resource for physicians to improve their knowledge of disease management and optimize patient outcomes in clinical practice. These guidelines synthesize available evidence-based information with expert opinion to develop consensus recommendations for health care providers.
Rational drug use has been well recognized as an important part of health policy and the term rational drug use in this to the context of this discussion is limited to the medical therapeutic view accepted at the WHO conference of 1985 in Nairobi. Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost to them and their community (WHO, 1985). For the consumer, the rationality of using a drug is based on the (re)interpretation of its value for daily life, influenced by cultural perceptions and economic conditions. People may only buy a few antibiotic capsules because they cannot afford more or they may spend money on analgesics to relieve their misery, while good food and rest would have been better for their health.
Though drugs are not the only therapeutic interventions in healthcare that provide a desirable health level, rational use of them plays an important role in the efficacy and sufficiency of therapeutic interventions. Rational drug utilization means that each client receives the right medicine, in an adequate dose for an adequate duration, with appropriate information and follow-up treatment, and at an affordable cost (WHO, 1977). Irrational prescription may include are over- and under-prescribing, polypharmacy, no indicated drug prescription, unreasonable use of expensive medicines and inappropriate use of antibiotics (Sadeghian GH et al., 2013). In addition to high cost of treatment, inappropriate prescribing causes ineffective, unsafe treatment, exacerbation or prolongation of illness, distress, and harm to the patient and implies a hidden cost to health care in terms of stock management. Similarly in Cameroon Like other countries, inappropriate use of drugs due to irrational prescription practices is a common problem and requires being concisely controlled (Gholamreza-Sepehri, Meimandi MS 2005)
Due to the high cost of inappropriate use of drugs, developing countries face more problems because of the limited economic resources and lack of organized drug policy (Kshirsagar MJ et al., 1998). In order to improve the prescription quality and rational prescription pattern promotion there is an inevitable need to investigate the factors that affect doctors’ prescription patterns. Defining drug prescription and consumption pattern provides advantageous feedback to prescribers in order to improve their prescribing behavior. Prescription analyzing studies will help the policymakers to set the priorities to promote the rational use of medicines nationwide.
The concepts of “essential drugs” and “national drug policy”, were introduced in 1975 by the World Health Assembly quickly became part of the global public health vocabulary. In October 1977, the first model list of Essential Drugs where produced and in 1978 the Declaration of Alma-Ata identified “provision of essential drugs” as one of the eight elements of primary health care. “Essential medicines are those that satisfy the priority health needs of the population according to the current WHO Expert Committee on the Selection and Use of Essential Medicines which are selected with due regard to disease prevalence, evidence of efficacy and safety, and comparative cost-effectiveness and availability. Essential medicines are intended therefore to be available within the context of functioning health systems at all times in adequate amounts at desired levels of health care as per protocol, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility.” The following examples give some idea of the contrast. In 1977, the concept of a national drug policy was unknown to almost everyone. Today, over 100 countries have national drug policies in place or under development which are being introduced at increasing speed in every region. More importantly, a growing number of countries are moving directly from policy to action.
COPE training will be undertaken to identify the real need of the institution that affect the smooth use of treatment guidelines to improve on the care management of patient following the recent transformation and will lead to training. This training will focus mainly on the patient’s rights and staff needs in relation to health care management for the first part while barriers to effective use of guidelines are handled also. The staff will deliberate on the seven client rights and three provider’s needs (Engendered Health 2002). Grol R(2001)observes that guideline recommendations into everyday practice requires changes in the attitudes and behaviour of health professionals and a certain adaptation of the structural environment which could involves logistic supply services and motivation. Although behaviour can be modified even in the absence of changes in knowledge and attitude, behavioural modifications based on such changes are more permanent. Looking at the “Knowledge-Attitude- Behaviour Framework”, physicians have to be aware of a guideline and need to have some knowledge of its content which could only be achieved through education. Obviously, knowledge influences attitudes, and attitudes affect practice behaviour. Therefore, implementation strategies should be focused on the improvement of knowledge and attitudes in order to improve the uptake of guidelines in clinical practice. This education will be well achieved using the health belief model that best addresses the individual’s perceptions of the threat posed by a health irrational drug use (susceptibility, severity), the benefits of avoiding the threat, and factors influencing the decision to act (barriers, cues to action, and self-efficacy).
In-service education program, workshops, seminars will carry information on medicines and drug therapy which is constantly changing. The DTC is responsible for ensuring that all staff receive up-to-date information. In addition, educational programs can be used to address medicine use problems that have been identified by the DTC and the COPE exercise (Guide to good prescribing: a practical manual (WHO 1994). Large group meetings (more than 15 participants) can be effective as well as small group meetings (less than 15 participants) wherever possible; the teaching will be problem-based. Influencing opinion leaders has been shown to influence prescribing habits significantly. Drug newsletters can be a valuable component in providing drug information and can be published monthly, quarterly or at longer intervals and should provide staff with unbiased and accurate information about drug therapy.
OUTCOME AND ALTERNATIVE STRATEGIES
Outcome and anticipation is that at the end of a training exercise the staff will remain cautious on the importance of the standard treatment guideline and treatment protocol to better manage the minimal resources and as Griffiths (1972) puts it, “Health education attempts to close the gap between what is known about optimum health practice and that which is actually practiced.” Similarly, Simonds (1976) defined health education as aimed at “bringing about behavioral changes in individuals, groups, and larger populations from behaviors that are presumed to be detrimental to health, to behaviors that are conducive to present and future health.” It is evident that each definitions emphasized voluntary, informed behavior changes and as Green (1980) will put it, health education as “any combination of learning experiences designed to facilitate voluntary adaptations of behavior conducive to health”. Standard treatment guidelines (STGs), clinical policies, treatment protocols or best-practice guidelines, structured approaches to diagnosis and therapy have considerable potential to promote rational drug use which also has a big bearing on logistic issues as far as stock management and inventory control is concern. The CBC has developed its own treatment protocol which takes its reflection from the national treatment guideline. With the over increasing search for better job satisfaction, the rate of doctors turn over which remain significantly high has caused some challenges in the respect of the use of available protocol and treatment guideline. Normally during intake of doctors they go through an orientation period of about three months to be familiar with the system and how it function but due to the motivation sometimes from medical delegates who parade the corridors of the consultation rooms, the stay to this guide seems not to be feasible. There is great need for collaboration and training therefore to move everyone in one direction and five main modules can be generated to cover the educational series: the essential drugs concept and its implications; drug formularies; treatment guidelines for common diseases; drug control, drug policy (including patents) and drug promotion and inventory management. The training and education of health personnel need to be more intentional because there is a huge barrier to break which will be resistance obviously due to many reasons and relevant strategies will be put in place to enforce the change. Rimer, et al., (2001) remarks that there is increasing emphasis on identifying evidence-based interventions and disseminating them widely while Derryberry (1960) noted that “health education . . . requires careful and thorough consideration of the present knowledge, attitudes, goals, perceptions, social status, power structure, cultural traditions, and other aspects of whatever public is to be addressed. The populations of the west region believe that health is expensive meaning that if a prescription is not expensive, then it will not be effective. While Bafoussam Baptist health center base her guidelines on the essential drug concept and have in their formulary generic drugs and become difficult for doctors to remain in the confine of the formulary. This constitutes a barrier as doctors will want to satisfy their clients by prescribing branded drugs.
THEORIES AND CHANGE PROCESS
Personal factors which can include factors related to physicians’ knowledge and attitudes which are closely linked to any behavioural change and are prerequisites for any meaningful change as it can turn to be the main barriers to implementation and adherence to guidelines. Similarly lack of awareness and lack of familiarity with the guideline and its recommendations posses a big challenge. When it comes to attitudes, the main barriers to be considered can involve the lack of agreement, self-efficacy, skills, outcome expectancy and motivation from both employee and clients. In this context, the derived strategies for guideline implementation mainly will focus on dissemination strategies and educational. In general active learning from experts as opinion leaders (Knob A, 2010) and continuing education (Burgers et al.,2009) needs to be emphasized as they are a useful tools for improving physicians’ knowledge. Regarding the improvement of physicians’ attitudes, (individualized) audit and feedback are considered to be effective strategies (Bowers et al., 2005). Periodic continuous education needs to be organized either as ward conferences and case discussions. Normalization Process Theory, an implementation theory, will be used in. Other theories, Social Cognitive Theory, Adult Learning Theory, Social Learning Theory
CHANGE MANAGEMENT APPROACH/ALTERNATIVES
Implementation of clinical practice guidelines in the CBCHS will require a pull strategy focused on creating a demand for guideline implementation and include professional organization endorsement, quality measures based on guideline-related outcomes, and guideline-based performance objectives. In this direction, a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills are highly required. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources especially, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice where a leadership structure is setup to manage the change. In addition to physicians, education must be directed at non-physician clinicians, office staff, and administrators who also are responsible for guideline implementation. To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities either globally or departmentally that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving during education.