NTK Chuc, NT Do, NT Binh, Larsson M, Chalker J, Falkenberg F, Diwan V & Tomson G.

1. IMPROVING PRIVATE PHARMACY PRACTICE: A MULTI INTERVANTION EXPERIMENT IN HANOI, VIETNAM NTK Chuc, NT Do, NT Binh, Larsson M, Chalker J, Falkenberg F, Diwan V & Tomson G.

2. IMPROVING PRIVATE PHARMACY PRACTICE: A MULTI INTERVANTION EXPERIMENT IN HANOI, VIETNAM . . CoP Hanoi Medical University . IHCAR, KI Torkel Falkenberg Mattias Larsson Göran Tomson . EC Funded Collaborative Project 1997-1999 LSHTM HSRI/MoH A multi- intervention approach to rationalise drug use through private pharmacies ERB3514PL950674

3. Background regardingdrug use Health sector reform • increasing reliance on market mechanisms • the role of the state is weakened • rapidly emerging and profitable health care Pharmaceutical sector • increasing reliance on market mechanisms • the role of the state is weakened • rapidly emerging and profitable health care • Drug shortage during the 70ies and 80ies • After Doi Moi increased availability of drugs • A drug policy adopted 1996 and Prescription regulation 1995 • Impaired implementation of regulations due to weak and not clearly defined sanctions for violations • Weak information support to the private pharmacy sector • Drug shortage during the 70ies and 80ies • After Doi Moi increased availability of drugs • A drug policy adopted 1996 and Prescription regulation 1995 • Impaired implementation of regulations due to weak and not clearly defined sanctions for violations • Weak information support to the private pharmacy sector Pharmaceutical sector Rational Use of Drugs

4. Background: Community antibiotic use, Bavi. Average duration of treatment: Ampicillin 3.2 days; Penicillin 2.5 days 78% of the antibiotics were obtained through private pharmacies without consulting a doctor. Larsson M, Kronvall G, NTK Chuc, Tomson G, falkenberg T. 1999

5. Background: Community antibiotic resistance,Bavi. H. influenzae S. pneumoniae Vancomycin Ciprofloxacin Gentamicin Ampicillin Antibiotic Penicillin V Erythromycin Trimetoprim/Sulfa Tetracycline Chloramphenicol 0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0 100,0 Percentage of resistant strains Larsson M, Kronvall G, NTK Chuc, Tomson G, falkenberg T. 1999

6. General objective of the research To evaluate a multi-intervention package including regulatory enforcement, education and peer influence in order to improve private pharmacy practice.

7. SCIENTIFIC DESIGN Ques t i onna i r e Ques t i onna i r e PEER- INFLUENCE ENFORCEMENT OF REGULATION EDUCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Intervention pharmacies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SCM 4 SCM 2 SCM 1 SCM 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Control pharmacies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Number of SCM encounters/ interviewers 600 / 60 600 600 / 60 600 2261/128 2/2000 1/1998

8. Methods to assessprivate pharmacy service: Questionnaire Simulated client methodology (SCM) to assess Knowledge to assess Practice A semi-structured questionnaire to assess how the pharmacy staff state how the will manage specific cases Mock patients present cases at the pharmacies buys the recommended drugs and note the Questions asked and Advice given.

9. Tracer conditions ARI: I have a (3,4,5) year old (daughter or son) who is coughing since two days. What should I buy? STD: My friend has a pain when peeing and have pus coming from their urethra for the last 3-4 days. Can you tell me how to assist him? Steroid request: My back is aching. Could I have 2, 3, 4 or 5 tablets of Prednisolonee please Antibiotic request: Could I have 2, 3, 4 or 5 tablets of Cephalexin

10. Intervention 1: Enforcement Regulation (ER) Information about the prescription and drug dispensing regulation Four Inspectors conducted 2 visits to each intervention pharmacy • Methods: • The regulations were explained and discussed, antibiotics and steroids were use as example. • Written documents including the regulations and a letter from Hanoi Health bureau was handed out.

11. Intervention 2: Education (E) • Development: • Pharmacy Treatment Guideline for ARI and STD • Question, Advice, Treatment (QAT) approach Conductors: Researchers + Experts visited the pharmacies twice Methods:Face to face education sessions with the pharmacy staff and provision of the material

12. GPP, ARI, STD Intervention 3: Peer Influence (PI) Organization:Five geographically based groups • Procedure: • A one-day seminar with the group leaders on GPP targeting the four tracer conditions. • Group meetings where the case management of clients visiting their pharmacies were discussed.

13. Results ARI Case Management Dispensing of antibiotics Practice Knowledege

14. Results STD Case Management Correct Symptomatic Treatment Knowledege Practice

15. Policy recommendations • Good knowledge is no guarantee for good practice • The messages should be designed so that profit can be maintained or increased. • Repetition of essential messages is crucial for change • Issues which are considered sensitive, such as condom use, are however harder to improve • Considering the high utilisation of private pharmacy service this will have a substantial effect on rational use of drugs.