1. Improving the Rational Use of Medicines through the MTP approach in Referral Hospital Cambodia Antalya, Turkey November 14-18, 2011 Chroeng, Sokhan 1,2 ; Sau, Sokunna 3,2 ; Or, Oudamroath 1 ; Mfuko, William 3 1= Ministry of Health Department of Drugs & Food; 2= INRUD Cambodia; 3= Ministry of Health, Department of Hospital Services; WHO Cambodia

2. 2 Background In Cambodia, like in many developing countries, inappropriate use of medicines is a chronic problem which has resulted to a host of negative health impacts such as reduced quality of therapy, wastage of resources, risk of unwanted side effects and adverse medicine reactions, including psychosocial impacts which have, on the overall, lead to the loss of confidence in public health systems. The MTP approach, implementing in 2001 in Cambodia to improve rational use of medicines and therefore gradually reducing impacts of irrational use of medicines. The MTP approach has focused on referral hospital and is currently implemented in 64 provincial and national referral hospitals. Also 551 private sector drug outlets, including community pharmacies and licensed drug outlets have been trained and/or implementing the MTP method for improving the rational use of medicines

3. 3 Aim of the intervention To use of the monitoring training planning (MTP) approach to improve, on sustainable basis, prescriber’s skill in identification of and resolving irrational medicines use problems at provincial referral hospital through hospital drug therapeutic committees (DTC). The effectiveness of approach in reducing irrational use of medicines with indicators and target defined by DTC at provincial referral hospital is provided. Morning technical meeting

4. CAMBODIA IPD CHECKLIST4 Data the Comparison between 1 st and 2 nd survey The MOH-Cambodia pilot-tested the MTP implementation in 6 referral hospitals, focused on drug use problems in hospitalized patients Beginning August 2001,

5. 5 Method The approach follows the generic MTP methodology and therefore consists of: a monitoring component (M); an educational and problem solving component (Training); and a planning component (P) constituting of agreement on and pursuing the planned activities to achieve agreed targets. The MTP sessions are normally conducted once per month and each session does not exceed 2 hours. The DTC/MTP team usually solve drug use problem in about 2-4 monthly meeting cycles, depending on targeted problems. A decision to stop conducting the meeting takes place when the result have been achieved and accordingly they would move to another target drug use problem.

6. 6 Tools and outcome measures Tools Patient records/files The MTP team (comprised of about 6-8 staff) who are mostly members of the DTC The MTP methodology – which is well understood by all DTC members Agreed problems and ways to solve them, including baseline and targets to be attained Regular meetings, held on monthly basis, are used to track, monitor and review progress in attaining agreed outcomes/indicators Outcome measures Antibiotic (AB) use in:  post partum women;  elective surgery, including post-surgery (in Hernia cases); and  trauma cases (mainly road accidents); severe and non-severe malaria cases IV Fluid use in:  ICU ward;  post-operation (hernia & caesarian section); and  malaria; during delivery DTC members reviewing results of previouly planned activities to resolve drug problems

7. 7 Results - 1 No. Condition National Average BaselineTargetResults 1. Antibiotic use in post partum in women and elective surgery hernia 79% (Range: 50%-100%) 12% (Range: 10%-15%) 5% (Range: 0% - 13%) 2. I.V. fluids use 85% (Range: 80-90%) 23% (Range: 15%-30%) 27% (Range: 21%-33%) Figure 1: Reduction of inappropriate use of Antibiotics in post-partum in women, hernia and IV fluids in caesarean section and hernia These graphs indicate that prior to MTP interventions antibiotics and IV fluid use were high but gradually decreased with the number of MTP sessions: for example antibiotic (AB) use fell from 100% to nearly 5% by the 4 cycle of MTP implementation; and IV fluid use declined from 100% level to 10%.

8. 8 Results - 2 Figure 2: Reduction of inappropriate use of Antibiotics in post partum women ( r3, r4 & r5 ) Provincial HospitalBaselineTarget # of Review Cycles Result % Reduction K.Kong60%10%43% 95% Kg.Som100%15%40% 100% Takeo100%10%33% 97% M.Kiri91%10%411% 88% P.Penh50%10%46% 88% In five referral hospital, as shown in the data below (Figure 2), on the average 93.6% (range: 88%- 100%) reduction in inappropriate use of antibiotics in post-partum in women was achieved over a period of 4 months.

9. 9 Results - 3 Figure 3A: Reduction of inappropriate Use of Antibiotics in elective surgery (post-partum & hernia) ( r3, r4 & r5 ) Provincial HospitalBaselineTarget # of Review Cycles Result % Reduction Takeo (hernia) 100%10%30% 100% Takeo (post-partum) 100%12%45% 95% Reduction of inappropriate Use of antibiotics in elective surgery (post-partum & hernia)

10. 10 Results - 4 Figure 4: Reduction of inappropriate Use of IV fluids Provincial HospitalBaselineTarget # of Review Cycles Result % Reduction Kep (post-partum women) 90%30%333% 63% St. Treng (road accidents) 80%15%421% 74% In two referral hospital (Kep and St. Treng), as shown in Figure 4 below, the inappropriate use of IV fluids (in post-partum and road accidents) was reduced on the average by 69% (range: 63%-74%) over a period of 4 months.

11. 11 Results - 5 Figure 5: Reduction of inappropriate Use of IV fluids (ICU, caesarian, hernia and post-operation) Provincial HospitalBaselineTarget # of Review Cycles Result % Reduction Kampot (ICU)90%20%312% 87% Svay Rieng (ceasar, hernia)100%10%30% 100% Kratie (post-operation) 53%10%434% 36% Reduction of nearly 74% (range: 36%-100%) in inappropriate use of IV fluids in patient at ICU, assisted birth (caesarian section), hernia and post operation was achieved over a period of 3 months.

12. 12 2 nd Cycle: Patient Files QIV- 2007 -Total case: 22 Goiter s  No AB : 16  With AB: 06 -Appropriate: 4 -Inappropriate: 2 9% -Result: 9% Our target is 15% and the result is 9%, so we hope that in the 3 rd cycle (Q1 2008), we will able to reduce it to 0%. 1st Cycle: Patient Files QIII- 2007 -Total case: 27 Goiters No AB : 11 With AB: 16 -Appropriate: 13 -Inappropriate: 3 18% -Result: 18% In our target, we want to reduce the inappropriate use of AB to 20% in the 1st cycle. But as a result, we could reduce it to 18% in the 1st cycle. So, we plan to reduce it to 15% in the 2nd cycle. The priority problems were found by DTC/MTP from Q3 2007-Q4 2007 to Q1 2008 CAMBODIA JAPAN Friendship Mongkulborey hospital % of patients receiving Antibiotic Surgery Elective

13. 13 National Workshop on Evaluation of the MTP activities to improve Rational Use of Medicines in Referral Hospital, Preah Sihanouk Province 24-25 Dec,2009 Dr. Chroeng Sokhan,Coordinator of the Cambodia Inrud Group, President of the Pharmacist Association of Cambodia and Deputy-Director of the Department of Drugs and Food delivers a speech during the National Workshop on MTP Evaluation. Sihanouk Province, 14-25 Dec, 2009. Dr. Dy Bun Chem Director of Siem Reap Provincial Health Department delivers the opening remark of the Training on Rational Use of Antimalaria Drugs in the Private Sector. At his left : Pharmacist Ly Vannak, Chief of Drugs Technical Bureau of PHD Siem Reap. At his right: Dr. Sau Sokuna, Deputy-Director of the Hospital Department, Coordinator for the Rational Use of Drugs Project to conduct MTP activities in the Public and Private Sector Drug Sellers participants to the Training on Rational Use of Drugs funded by Global Fund. Siem Reap,16-17 August 2009

14. 14 Summary The MTP approach: is a flexible approach, not time consuming and least costly approach to improving the rational use of medicines in hospital settings encourages dialogue between hospital staff and the DTCs to initiate activities in identifying drug use problems and agreeing on activities to resolve them is a comprehensive approach, which include adult leaning theories can be implemented both in the public and private sectors In Cambodia, the approach has facilitated rapid national expansion with relatively modest investments and has saved providers time to attend to their day to day responsibilities without disrupting essential services to patients.

15. Policy implication & Conclusions Results from this intervention: show that the MTP is a practical and easy method to use to improve the rational use of medicines; and can be used to support expansion of the MTP approach to cover all health facilities in the country. Sufficient funding is needed to support DTC training and regular meetings to reflect on drug use problems and to find solutions for them. Group Photo the National Workshop on MTP evaluation for improving Rational Use of Medicines and Anti malaria Drug in Referral Hospitals, 6-10 December, 2010 Kampong Cham Province, GF R. 6 RUD- DDF/MTP Anti malaria phase 2.

16. Thank You