Dialogues with Government Doctors and Policy Planners on Rational Therapeutics and Free medicines Scheme

Regular engagement and interactions with policy planners and medical practitioners can go a long way in paving way in promoting rational use of drugs and enhancing access to free medicines from public health facilities. Their engagement and participation in processes directed towards strengthening systems for ensuring availability of free medicines and rational use of drugs can help bring about better results in terms of adherence to norms and guidelines and improvement in prescription behavior and skills thus leading to increased access to medicines and better quality of health care. WHO defines rational use of drug as: "Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community." In simplest words, rational use means prescribing right drug, in adequate dose for the sufficient duration and appropriate to the clinical need of the patient at lowest cost. Common types of irrational use of medicines include: use of too many medicines per patient ("poly-pharmacy"); inappropriate use of antimicrobials, often in inadequate dosage, for non-bacterial infections; overuse of injections when oral formulations would be more appropriate; failure to prescribe in accordance with clinical guidelines; inappropriate self medication, often of prescription-only medicines; non-adherence to dosing regimes. Such irrational prescription practices have been found to be very rampant in India across both public and private medical practitioners and there are ample of factors which promote such prescribing behaviors among doctors. The factors may range right from gaps in drug procurement/supply systems to industry influences etc irrespective of the fact whether the state executes free medicines scheme or not. Whatever the factors be, it is crucial that these gaps are identified promptly and immediate remedial actions are taken to prevent/minimize them.

The overall objective of these dialogues thus held with state policy planners and medical practitioners was to bring about greater engagement of doctors and government health officials in endorsing and promoting rational use of drugs and rational prescription practices as a vital component of universal access to medicines.

Specific objectives of the dialogue were:

  • To position concept of free medicines, essential drugs and rational use of medicines as an integral part of universal access to health care
  • To identify primary barriers to implementation of strategies and policy guidelines for rational use of drugs
  • To identify new ways of implementing rational use of drugs especially within public health system and explore novel solutions to address barriers and build on existing strengths
  • To suggest how different stakeholders (government, medical practitioners, NGOs, community members etc) can collaborate to promote and monitor uptake of strategies for rational use of medicines.

The participants included senior state health officials (engaged in drug procurement/supply chain management, policy planners), senior district health officials (CM&HOs), doctors serving in different levels of public health care facilities. The dialogues were held in the states of Rajasthan, Uttarakhand and Madhya Pradesh to begin with, while in Odisha they are soon to happen.

Brief highlights from the dialogues held in different states are as below :

Uttararakhand (2nd December 2015, Dehradun) : Prayas and JSA Uttarakhand in collaboration with the Department of Health and Family Welfare, Govt. of Uttarakhand organised the dialogue with doctors and policy planners on "Institutionalizing Rational Use of Drugs and Provisioning of Essential and Life Saving Medicines Free to All"on 2nd December 2015 at Dehradun. The dialogue held at the conference hall of the office of Director General (Health), Uttarakhand had about 90 participants from all the 13 districts of the state. The program was Chaired by the Mission Director, NHM, Dr. Neeraj Kharwal and Co-chaired by the DG, Health, Dr. R.P. Bhatt. Participants from the districts included Chief Medical and Health Officers, Chief Medical Superintendents from district hospitals and base hospitals, District Program Managers NHM and pharmacists. Apart from the district teams, state team of officials involved in the planning and preparations of the free medicines scheme for Uttarakhand were also a part of the dialogue.

This dialogue was one of the first sensitisation workshops with the doctors around free medicines scheme and rational use of drugs as the state gets ready to implement the free medicines scheme. The major objective of the dialogue was thus to bring about greater engagement of doctors in endorsing and promoting free medicines scheme. The dialogue also attempted to explore and draw a list of wide range of factors that influence prescription writing behavior of doctors serving across different tiers of public health care system.

Rajasthan Medical Services Corporation (RMSC) was also requested to be a part of the dialogue to share Rajasthan experience with the participants. Dr. Rajesh Bharadiya, Medical Officer In-charge of Mukhya Mantri Nishulk Dawa Yojana of Udaipur district thus joined in the dialogue and oriented participants on how the state should go ahead with implementing the scheme taking lessons from Rajasthan. Dr. Rajesh Kakkar, Professor and Head, Dept. of Medicine, Himalayan Institute of Medical Sciences, Jolly Grant,Dehradun oriented participants on the role of doctors in ensuring success of free medicines scheme and motivated them to endorse rational prescription practices. During the day long interactions, participants came forward with their apprehensions and doubts about the quality and efficacy of generic drugs, sticking to the EDL and prescribing only by generic names, if the EDL would suffice their drug requirements, how would they deal with pressures from the patients who would initially be reluctant to use generic drugs etc. Their doubts and concerns were thoroughly discussed and general consensus was developed on how to deal with the challenges which lay ahead. A detailed report of the event is enclosed as Annexure-IV.

Madhya Pradesh (15th December 2015, Bhopal) : The dialogue in Madhya Pradesh was held with the Regional Jt. Directors, Chief Medical and Health Officers (CM & HOs), Civil Surgeons, Specialists Medicines (RMOs) of all districts with the objective to orient them on rational treatment and to make Sardar Vallabhbhai Patel Nishulk Aushadhi Vitran Yojna of M.P. Government a success. The dialogue was held on 15th December 2015 in the National Health Mission’s (NHM) conference hall and was chaired by the Mission Director, NHM. About 65 doctors participated in the day long workshop.

One of the highlights of the workshop was the case based clinical problem solving approach in which case scenarios of some ordinary and critical illnesses were discussed to understand how these can be treated from the medicines available within the state EDL. Almost, all case scenarios which the doctors wished to discuss had medicines available within the EDL barring a very few which were not available in the required forms. The session was facilitated by Rakesh Biswas who is the HOD Medicines in L.N. Medical College, Bhopal. Other guest facilitators were Dr. Ravi D'Souza (SOCHARA), Commissioner Health and the Mission Director NHM, MP.

Rajasthan (28th December 2015, Jaipur) : Similar to other states the program was held in collaboration with the Department of Health and FW, Govt. of Rajasthan at the Conference Hall of the Health Directorate in Jaipur. The participants included more than 70 young doctors from different districts of the state. Mr. Naveen Jain, MD NHM Chaired the inaugural session. Mr. Om Prakash Kasera, Managing Director, Rajasthan Medical Services Corporation (RMSC) and Dr. V.K.Mathur, Director, Reproductive and Child Health and other officials also joined in the event.

Unlike other states where the participants were senior Medical Officers, in Rajasthan the government was keen that the dialogue be held with young doctors who had just joined the department and were yet to receive some kind of orientation on free medicines scheme, rational use of drugs and using standard treatment protocols. The young doctors who were serving mostly at primary level of health care seemed extremely enthusiastic about understanding the concepts of rational use of drugs and standard treatment protocols. Towards the end of the dialogue it was very encouraging to see young doctors endorsing ethical treatment practices and committing themselves to sticking to them.