2. RATIONAL USE OF INJECTION: An Integrated Tool For Monitoring Injection Prescription in the Kingdom of CAMBODIA Dr Sok Srun Department of Hospitals, MoH. Kingdom of Cambodia

3. Background of Cambodia Location : Western Pacific region, bordering with Thailand, Lao PDR and Vietnam - Land area : 181 035 Km2 - Administration areas : 24 Provinces/Municipalities, 183 Districts, 1609 Communes & 13406 Villages - Population : 11.4 Million - Urban: 15,7% & Rural: 84.3% - Under 15: 43% & Over 65 : 3.5% - Growth rate : 2.5% - Crude birth rate : 3.8% - Total fertility rate : 5.3 - Religion : Buddhism 95% - GDP : USD 310 per Capita in 1999 - Adult Literacy Rate : 79.5% ( male:67.3% & female: 57% )

4. Health Facilities Health Facilities1995 Plan 2001 -Nat Hosp 8 8 8 -Prov.Hosp 23 24 24 -Dist.Ref Hosp 0 44 41 -(Former) Dist. Hosp164 - 112 -Health Centers 0 929 769 Hospital BedsPublic Private -National Hosp1926 500* -Provinces/Districts8490 NA

5. 1) Promote the rational use of injectables and oral antibiotics at public referral hospital level. 2) Monitor quantity and quality of injectable antibiotics and IV fluids prescription focusing on targeted diseases and using an integrated tool to promote RUD. 3) Evaluate the impact of RUD training on prescription behaviour and particularly the use of oral and injectable antibiotics and IV fluids. Objectives of the Tool

6. Methodology (1) Review of Patient files in 8 referral hospitals for targeted diseases and interventions. DATA COLLECTION: -Selection of 20 patient files per disease and intervention by randomization from the last 2 or 3 months. - Oral and injectable drug consumption focusing on 4 main diseases/interventions: (1) Severe malaria for adults; (2) ARI pediatric; (3) normal deliveries; (4) post operation in surgery -Percentage of patients with (1) injectable antibiotics only, (2) injectable plus oral antibiotics, and (3) IV fluid. -Calculation of the average duration of prescription of (1) injectable antibiotics only, (2) injection plus oral, and (3) IV fluid.

7. Methodology (2) DATA COLLECTION TEAM: Central Supervisor Team: Pharmacist supervisors (DoD & F) Medical doctors supervisor (DoH) Provincial Supervisor Team: Pharmacist from pharmacy office (PHD) Medical doctor from technical office (PHD) Pharmacists checked drug stock and drug consumption in hospital pharmacy. Medical doctors checked and analyzed patient files by using IPD check list.

8. Monitoring Tool

9. Field Implementation of the Tool 2 surveys using the tool were implemented: one in1999 and one in 2000 covered 8 referral hospitals, targeting the same diseases/interventions; After the 1999 survey, 9 meetings were organized to discuss treatment protocols among medical specialists, professors and national program managers (TB, malaria..) and to achieve therapeutic guidelines; From this group, 5 doctors from referral hospitals participated to the training of trainer sessions and became facilitators on RUD trainings; Before the 2000 survey, training on RUD were conducted on each referral hospital that had participated to the survey in 1999 and the new therapeutic guidelines and protocols were distributed to prescribers.

10. RESULTS (1) Percentage of patients with injectable antibiotics prescription only

11. RESULTS (2) Percentage of patients with antibiotics prescription (injectable and oral forms)

12. RESULTS (3) Average duration of injectable antibiotics prescription only

13. RESULTS (4) Average duration of antibiotherapy prescription (Injectable and oral forms)

14. RESULTS (5) Percentage of patients with IV fluid prescription

15. RESULTS (6) Average duration of IV fluid prescription

16. Conclusions Integrated Tool for Monitoring Injection Prescription: Useful for monitoring RUD in referral hospitals (quantitative and qualitative); Provision of 29 indicators to measure RUD; Promotion of rational IV free prescription (antibiotics); Good participation from prescribers to the survey and revision of guidelines and protocols; Impact on the reduction of injection prescription; Limited only to public sector.

17. Perspectives Extend the IPD training and MTP process. Train supervisors on RUD/Hosp management. Review the IPD training contents on RUD. Update the clinical & therapeutic guidelines. Develop human resources involved in RUD.