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Access chapter 4: Putting treatment into practice
   Last updated: 19.07.02
Summary
Chapter 4 of this handbook helps groups develop an understanding about:

  • Working out what material, financial and human resources are required for treatment work.

  • The role of drugs in HIV-related treatment and how to make the best use of them.

  • The importance of managing the different aspects of drug supply.

  • The importance of managing other aspects of work on HIV-related treatment - including money, transport and people.


4.1. Resources for HIV-related treatment work
When an assessment has been made and priorities have been decided, an organisation needs to consider the full range of resources that will be involved in providing HIV-related treatment. These resources can be divided into three main areas - material, financial and human.

Reliable supplies of material resources are vital for HIV-related treatment work. These include:

  • Drugs and other medical supplies, such as gloves, syringes and needles.

  • Laboratory and diagnostic tests, chemicals and equipment.

  • Support materials, such as notebooks, pens, furniture and fuel.

  • Maintenance materials for buildings and equipment.


The situation and type of work will determine what specific materials are necessary. It is important to think of what will be done and how it will be done - so that you can list exactly what will be needed.

The materials that are needed can be grouped under these headings:

  • Consumables - items such as drugs and dressings that need to be replaced regularly because they get quickly used up or have to be discarded after use.

  • Equipment - items such as scissors and blood pressure machines that need replacing when they are lost, damaged or stolen.

  • Capital - items such as buildings, vehicles and large equipment that should last a long time with proper maintenance.


These headings are useful because, in budgeting and accounting, items such as consumables are dealt with differently from capital items. Often, different sources of funding have to be found for different types of items.

Material resources for dispensing drugs
If drugs are to be dispensed, there should be an area for preparing and giving them out that is away from where people wait. This area should include:
  • Dispensing equipment, including counting aids and liquid measures.

  • A dispensing bench for counting tablets and recording the items being given out.

  • Space for the person dispensing the drugs to explain the medicines to patients.


There should also be a storage area for drugs that is dry, shaded from heat, and secured from theft. This should include:
  • Adequate shelving to make stock keeping easy and efficient.

  • A fridge for any drugs and vaccines that need to be stored below 15C.

  • A place to lock away valuable or easily misused drugs.


Financial resources and budgets
In terms of financial resources, groups need to work out their costs for materials and human resources in order to make a budget. A budget is an essential tool for managing money. It is a way of working out how much money will be spent over a period of time, usually one year. It includes what is spent (expenditure) and what is earned or received (income).

Preparing a budget for HIV-related treatment work
Questions to think about include:
  • How much money is needed to start up and continue the work?

  • Where will the money come from and how will it be accessed?

  • What will happen if funding is interrupted?

  • Should an NGO/CBO have more than one source of money?


Remember to include all of the possible items and to divide them into different headings - such as wages, transport, drugs, equipment and training. Make separate lists of “one off” capital items and recurring items (meaning those that come up frequently). This will help to identify ways of keeping costs as low as possible. If you do not know the exact price of an item, you can ask suppliers to provide estimates and then compare them. Budgets must be reviewed regularly – last year’s budget may not be appropriate for this year - for example if changes in prices or currency rates have occurred or if your work is expanding.

Developing a budget also helps to plan for sustainability. It helps in answering questions such as: How long can the work continue with the money that is available? When will more funding be needed and where will it come from? It is important for groups to be as self-sustaining as possible and to get funds from more than one source. It is also important to think about any costs that might be paid by local people as part of their contribution to improving access to HIV-related treatment. For example, a family might feed home care workers during a visit, or friends might bring food to patients in hospital.

Often, the money that a group receives will not be enough to pay for everything that is needed. In these cases, the VEN method can be used to show in a budget which items are vital, essential, and non-essential.

A group must also have good book-keeping and accounting systems to ensure that its money is well managed. These will provide proof to donors that the money is being managed and spent effectively and they help in planning future developments. The law usually requires that an independent person audits accounts regularly on a yearly basis.

Sample treatment budget
Budget for treatment programme, January 2002 to December 2002

Money coming in (income):
  • grant from donor 20 000

  • grant from government 20 000

  • miscellaneous sales 500

TOTAL 40 500

Money going out (expenditure):
  • salaries 10 000

  • rent of premises 6 000

  • purchase of drugs 11 000

  • other medical supplies 10 500

  • electricity 1 000

  • other expenses 2 000

TOTAL 40 500

Using VEN to make a budget
V = vital - meaning something that you can never do without.
E = essential - meaning something that you would normally always have.
N = non-essential - meaning something that is good to have, but that you can do without.

You should decide whether each item proposed for a budget is vital, essential or non-essential. It is important to make these decisions as a group - there may be different opinions!

If money is limited, most of it should be spent on vital items. If there is still some money left over, essential items can be bought. Do not purchase non-essential items until you are sure that you can get enough vital and essential supplies and have some money left over.

Human resources
A group also needs to consider its human resources. To deliver HIV-related treatment, an organisation needs people who can build and maintain helping relationships with people with HIV. They need to have an appropriate attitude, as well as the technical knowledge and skills to do their work effectively [see Chapter 2.1.B].

Examples of relevant technical knowledge and skills include:

  • Making a diagnosis.

  • Identifying the best drugs available.

  • Monitoring the effects of drugs.

  • Keeping up to date about new treatments.


In addition, the people in a group need to have organisational skills to support its treatment work. These include:

  • Accounting and administration.

  • Management and planning.

  • Purchasing and controlling stocks of drugs and other materials.

  • Fundraising and external relations.


Technical and organisational skills can be provided by a group through:

  • Building the skills and knowledge of existing staff and volunteers.

  • Recruiting and training new staff and volunteers with the right skills and knowledge.

  • Finding sources of skilled help and knowledge outside of the NGO/CBO.


To start with, an organisation will need to work out a list of the relevant skills, the time needed for each task, and any training that will be necessary. These will vary greatly according to the HIV-related treatment to be provided. For example, a hospital providing complex services for diagnosis and treatment will have very different requirements to a home based project using a few drugs and focusing on nursing care.

You will also need to be clear about when and where your services will be provided. Then, you can recruit people who are willing to work at certain times and in certain places. For example, will you provide services only during working hours or during evenings or weekends? Will you offer services in only one place, or will people have to travel to different places?

When these issues have been worked out, you can write clear job descriptions that say exactly what each person in the organisation is required to do, when they will do it, and who will be their manager.

Activity: Identifying resources
Aim: To identify the material, financial and people resources needed for different types of HIV-related treatment work.

Instructions:
1. Explain the aim of the activity.
2. Select three types of "typical" treatment activities carried out by local NGOs, CBOs and PLHA groups and the number of people that benefit from them. For example:
  • A community based DOTS programme - to benefit 100 people with TB.

  • A home care programme - to benefit 20 people with HIV.

  • A sexual health clinic - to benefit 200 people with STIs.

3. Divide participants into three groups.
4. Give each group one of the treatment activities and numbers of people. Ask them to identify the material, financial and human resources that would be required.
5. Ask participants to identify what organisations they would need to link with to get the resources for the treatment activity.
6. Ask participants to divide their material resources according to the VEN classification (of Vital, Essential, Non-essential).
7. Bring everybody back together and ask the groups to present their results. Encourage the participants to ask each other questions and to make comments.
8. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
  • How does the type of treatment affect the resources required?

  • How is the scale of resources affected by the number of people being reached?


Facilitators' notes:
  • Encourage participants to decide what is Vital, Essential and Non-essential based on the practical needs of their patients rather than on their own opinions.

  • Encourage participants to think of ways to reduce their costs, for example by making the best use of their existing resources rather than getting new ones.


Example: Cambodia home based care
At a skills-building workshop, NGO/CBO participants identified what resources would be needed to provide home based care for 60 people with HIV. They also identified what other organisations they should link with to get the resources:

What resources are required?

Material resources:
  • Kit of essential drugs

  • Food

  • Motorbike, helmet and fuel

  • Raincoat


Financial resources:
  • Salaries for staff

  • Transport costs

  • Administration costs

  • Refreshments for meetings

  • Patient support funds


Human resources
  • Home care staff:

3 NGO staff
2 government staff
5 - 10 volunteers

What organisations should we link with?

For material resources:
  • Other NGOs

  • Government

  • National Centre for HIV/AIDS, Dermatology and STD Control


For financial resources:
  • Other NGOs

  • International donors

  • Local donors


For human resources:
  • Other NGOs

  • Health Centre

  • Community leaders

  • Government


The participants then used the VEN system to classify the material resources of the home care kit as vital, essential or non-essential:

Item (Classification)

Paracetamol 500mg tablets (E)
Oral rehydration salts (V)
Loperamide (E)
Primperan (metoclopramide) (N)
Nystatin suspension 25ml (V)
Potassium permanganate 10mg sachets (E)
Iodine solution 10%, 30ml vials (E)
Calamine lotion 500ml (N)
Benzyl benzoate 30ml (E)
Promethazine 100ml (N)
Multivitamins (N)
Plastic bags (E)
Cotton wool (E)
Plasters (E)
Micropore tape (E)
Safety pins (N)
Bandages (E)
Tweezers (E)
Scissors (E)
Cloths (N)
Gloves (V)
Household bleach (V)
Soap powder (E)
Condoms (V)

(Reference: Adapted from a workshop on "Access to HIV-Related Treatment," Khmer HIV/AIDS NGO Alliance and the International HIV/AIDS Alliance, Cambodia, May 2001)

4.2. Drugs for HIV-related treatment
Drugs are one of the most important material resources for HIV-related treatment work. With the right drugs, it is possible to treat diseases, reduce suffering and save lives. Without them, care can still be given, but many problems will continue or will get worse, and people will have less confidence that care, support and prevention are worthwhile.

Drugs can be very useful when they are made, stored and managed correctly and when they are used in the right way. Money is often wasted on drugs that are either inappropriate for the health problem in question, of poor quality, or badly managed. Drugs are not “magic”. There is not a drug to treat every illness and some drugs are more effective than others. Some drugs may seem more effective because of their name or packaging, but they may be no better than others, just more expensive. Drugs can also be ineffective and dangerous if they are used in the wrong way or for the wrong disease.

This Handbook focuses on drugs, but much of what is said applies to other medical supplies - such as dressings and syringes. Like drugs, adequate supplies of these items are needed for effective treatment. They must be of good quality, safe to use, and effective for the job. Many medical supplies also have expiry dates - which must be checked regularly. Medical supplies should be managed in the same way as drugs.

In this section we will focus on aspects of choosing and making the best use of drugs. Section 4.3 will then look at how to ensure the best quality and practical care of drugs for HIV-related treatment.

Some important questions to ask about drugs
Some important questions to ask about drugs:

Before obtaining any drugs, you need to think about:

  • Which drugs are needed for the type of treatment you want to provide?

  • Where will you obtain the drugs?

  • Do you have the right information to use drugs safely and effectively?

  • What quantity of each drug is needed?

  • Which supplier is best?

  • What are the dangers and benefits of donated drugs?

  • How should drugs be stored?

  • What is the best way to make use of the drugs?

  • How should drugs be given to the patient?


4.2.A. Managing HIV-related drugs
Drug management follows a well-recognised cycle of processes and events, whatever type of diseases or drugs are being considered. This is known as the drug management cycle:

Selection - Procurement - Distribution - Use - Selection ...

Each aspect of the drug management cycle must be carried out well so as to make sure that the next stage in the cycle will happen smoothly. Effective and efficient functioning of the whole cycle is necessary to ensure that access to good quality, appropriate and affordable drugs is possible for all who need them.

Selection of drugs according to need and affordability will only succeed if the procurement process – getting hold of good quality drugs at affordable prices - works well. When the drugs have been procured, they have to go through a distribution process to move them from the delivery point, such as a warehouse or clinic store, to the place where they can be provided to patients. The use of the drugs on patients provides information to help analyse what is needed and provide information to improve the selection – and so on, continuously around the drug management cycle.

It is, of course, important to support the management cycle with good organisation, information, human resources and financing so that each stage can feed smoothly into the next. The cycle will also be better supported if policies have been worked out locally and nationally about drugs and their management, for instance questions like: who decides which drugs are needed, what procedures are agreed for procurement, who is responsible for distribution, who may provide drugs to patients and what guidelines exist for the use of drugs?

Similarly, a good legal framework which supports the control of manufacture, distribution, prescribing and use of drugs will make it easier to ensure that drugs are provided safely and effectively.

4.2.B. The Essential Drugs concept
The Essential Drugs concept is an important tool for deciding what drugs are needed. It is based on the principle that a limited number of drugs will treat the majority of health problems for a given population. Many countries have an Essential Drugs List (EDL) that shows the names of these drugs. Such lists are usually based on a model list provided by the World Health Organisation.

An EDL is usually arranged according to types of disease, with drugs listed under each disease. In some countries the list also shows who may prescribe each drug and where they may use them. The national EDL should be available from the Ministry of Health, a pharmacist or government hospital.

New drugs are often expensive and there is limited experience in using them, so they might not be included in an EDL. However, some new drugs prove to be life saving or necessary for tackling serious public health problems and might be important enough to add to an EDL. If prices are high, most people will not have access to them. As time passes, new drugs should become cheaper and more accessible and there will be more experience to judge their safety and effectiveness. EDLs should be updated on a regular basis.

NGOs/CBOs providing treatment can make their own EDL, based on the national EDL or the WHO Model List of Essential Drugs. It should include only the drugs that are essential for the organisation’s specific work. In this way, an NGO/CBO can learn more about the effects and use of the drugs and ensure reliable supplies. The list should be reviewed at least once a year.

Essential Drugs Concept
Items on an EDL are selected according to their:

  • Efficacy – meaning that the drugs should be known to be effective and reliable.

  • Safety – meaning that the side effects are well-known and not dangerous in normal use.

  • Cost – meaning that it should be possible to obtain them within public health budgets and make them widely available to the people who need them.


It is important to note that “essential” includes an understanding of the social and economic conditions in which a drug is used, as well as its medical effects.

Essential Drugs List for NGOs/CBOs
An NGO/CBO involved in HIV-related treatment might include the following on their EDL:
  • Drugs for pain or fever, such as aspirin, paracetamol or morphine.

  • Drugs for infection, such as co-trimoxazole.

  • Drugs for diarrhoea, such as oral rehydration salts, charcoal tablets.

  • Drugs for skin problems, such as calamine lotion and promethazine tablets.

  • Drugs for nutrition problems, such as vitamins and iron.


Activity: Understanding Essential Drugs Lists
Aim: To raise awareness about the concept and use of Essential Drugs Lists (EDL).

Instructions:
NB. Before starting this activity, the facilitator needs to get a copy of the national EDL for each participant. If this is not available, copies of the World Health Organisation’s Model List of Essential Drugs can be used instead.
1. Explain the aim of the activity.
2. Present participants with the concept of Essential Drugs and the importance of having an EDL [see previous page].
3. Ask participants to brainstorm a list of drugs that are commonly used for HIV-related treatment in the local community.
4. Give participants a copy of the national EDL. Ask them to identify if the drugs that they have brainstormed are on the list.
5. If some of the drugs brainstormed by participants are not on the EDL, ask participants to discuss whether that is reasonable or whether the EDL should be changed. If they decide the latter, ask them how they would ensure that the change took place.
6. Facilitate a group discussion about what has been learned from the activity, based upon question such as:
  • What factors decide whether a drug should be on an EDL?

  • Why should NGOs/CBOs have their own EDL?


Facilitators’ notes:
  • Ensure that participants are clear about the concept of Essential Drugs right from the start of the activity before progressing to discussions of EDLs.

  • Encourage participants to think critically about why some HIV-related drugs that are essential to their work might not be on the national EDL. Also, encourage them to consider why some drugs on the national EDL might not be essential to their own work.


Example: fluconazole in Zambia
At a skills building workshop, NGO/CBO participants brainstormed a list of drugs that are used for HIV-related treatment in their local community. These included:

  • cotrimoxazole

  • nystatin

  • fluconazole


They then reviewed the national Zambian Essential Drugs List & the WHO Model List of Essential Drugs. The participants identified that fluconazole - one of the drugs they had listed - was not included on the national Zambian Essential Drugs List but was included on the WHO Model List of Essential Drugs.

The facilitator then led a group discussion about what had been learned from the activity. For example, participants agreed that NGOs/CBOs should advocate to their government for drugs like fluconazole- that are included on the WHO Model List of Essential Drugs, to be added to the Zambian Essential Drugs List.

(Reference: Adapted from the workshop on “Access to HIV-Related Treatment”, Catholic Dioceses of Ndola and the International HIV/AIDS Alliance, Zambia, April, 2001.)

4.2.C. Choosing the right drugs
It is vital to choose the right drugs for HIV-related treatment. Answering the following questions can help in making good decisions:

  • Will the drug make a difference to the health problem? Some drugs are more effective than others. Also, some conditions cannot be treated with drugs. For example, the common cold is caused by a virus for which no drug exists.

  • Is the drug safe? No drug is absolutely safe to use, although most are safe if used at the correct dose and for the correct amount of time. All drugs can cause some unwanted effects. For example, aspirin is good for relieving mild pain, but can also cause indigestion or bleeding in the stomach.

  • Where can you get information about the drug? Reliable information about drugs is very important for safe and effective treatment.

  • Are patients and their helpers able to follow the treatment regime? If it is too complicated to take the right drugs at the right time, or to deal with requirements for drugs to be taken with or without food or drink, treatment will fail. This is especially important if more than one drug is being used, for example with antiretroviral or TB combination treatments. Drug side effects can also prevent people from following a regime or completing it. Failing to follow and complete treatment for infections is a major cause of drug-resistant illnesses.

  • Can you get enough supplies of the drug? This is especially important if you want to provide a complete course of treatment, or to continue treatment indefinitely for long-lasting diseases. For example, antibiotics must be taken for a short but specific number of days, but antiretroviral drugs must be taken for much longer. Other drugs can be used only when needed for specific symptoms - such as paracetamol for mild pain. You will need to know how much of a drug a person needs and how many people need to be treated, in order to work out the full quantity required.

  • Can patients and treatment providers afford enough drugs to make treatment effective? Choosing the right drugs always involves questions about costs. If patients and their families have to pay for treatment in one way or another, they may fail to obtain enough of the right drugs. If treatment providers cannot afford the chosen drugs for the people they treat, they may have to restrict their work or lose credibility by not having drugs to offer their patients.


4.2.D. Drug names
It is important to know and remember the names of drugs, even when they are long or difficult to say. Calling a drug “the white tablets” or “the pink syrup” can lead to dangerous mistakes. Drugs that look the same may contain very different chemicals, and some that look different may actually be the same.

The name of a drug must appear clearly on the label. You should never accept a drug without a name. A person who cannot read should at least know that every drug has a name and that different drugs must not be mixed together or kept without a label. All drugs have at least one or two names. These include a:

  • Chemical name – meaning the scientific name of the drug chemical. This is mainly used by researchers, but is sometimes shortened and used by health workers instead of the generic or brand name.

  • Generic name – meaning the name that is adapted from the chemical name and is shorter and easier to say. This is usually decided by the World Health Organisation and is also called the international non-proprietary name (INN)

  • Brand or proprietary name – meaning the name chosen by the producer of the drug. This is short and easy to remember - to encourage people to ask for the drug by that name. The same producer may have several different brand names for the same drug.


One way to reduce confusion about drug names is to use only generic names. For example, paracetamol is a generic name, but it also has very many brand names. Also, it is often combined with other drugs in many hundreds more brands for joint pains, fevers or coughs. A person might use two or three of these brands for different reasons and not realise that they are taking an overdose of paracetamol - which can cause serious liver damage.

Generic drugs are products that have only the generic name on the label. They are usually available if there is no valid patent (or legal “ownership”) on the drug. Mostly, there is little practical difference between using generic or branded versions of the same drug.

Branded or proprietary drugs are products that have a “brand” name. They are often advertised using this name – to encourage people to be loyal to that one company’s product. This can lead to people continuing to prescribe or ask for the brand even when cheaper generic products are available.

Generic drugs are usually cheaper than brand name drugs, often by a large amount. When a generic drug arrives on the market, there is usually competition between companies. This drives prices down and, sometimes, can even lead to the original drug becoming much cheaper.

Drug names
Generic and brand name products contain the same active drug, but have different names. For example:

Chemical name of drug: (12Z, 14E, 24E)-(2S, 16S, 17S, 18R, 19R, 20R, 21S, 22R, 23S)-1, 2-dihydro-5,6,9,17,19-pentahydroxy-23-methoxy-2,4,12,16,18,20,22-heptamethyl-8-(4-methylpiperazin-1-yliminomethyl)-1, 11, 13-trienimino) naptho [2,1-b]-furan-21-yl acetate

Generic name of drug: rifampicin

Brand name of drug: Rifadin, Rifampin, Rimactane

Some generic drugs are combined together in the same medicine. These combinations are often given a compound generic name, for example:

trimethoprim + sulphamethoxazole = co-trimoxazole
(generic name) + (generic name) = (compound generic name)

International generic names can vary slightly according to language. For example:

Generic name in English: amoxicillin
Generic name in French: amoxicilline
Generic name in Spanish: amoxicillina
Generic name in Latin: amoxicillinum

Activity: Types of drug names
Aim: To identify the different types of drug names involved in HIV-related treatments.

Instructions:
NB. Before starting this activity, the facilitator needs to collect together some examples of packets, containers or labels for drugs used in HIV-related treatment. These can be obtained from a treatment project or a pharmacy. You can have more than one example of the same drug, but, as a whole, they should represent a variety of types of drugs. You will need enough packets, containers or labels to give one to every pair of participants.
1. Explain the aim of the activity.
2. Present participants with definitions of generic and brand names of drugs [see previous page].
3. Ask participants to work in pairs.
4. Give one example of a packet, container or label for a drug to each pair. Ask them to look at it, and to identify the generic and brand names of the drug.
5. Ask each pair to exchange their packet, container or label with another pair so that they have a different drug. Ask them to look at it and to identify its generic and brand names.
6. Repeat the activity one more time.
7. Bring everybody back together and ask some of the pairs to present the generic and brand names of the drugs that they looked at. Check that they have identified the names correctly. Encourage the participants to ask each other questions and to make comments.
8. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
  • Is it easy to identify the generic and brand names of drugs?

  • How different are the generic and brand names of drugs?

  • Who might need to know the generic and brand names of drugs? Why?


Facilitator’s notes
  • The facilitator for this activity should be someone who is very familiar with the differences between generic and brand names of drugs, and who can offer clear and simple explanations to participants.

  • Keep repeating the activity until every participant can confidently pick up a packet, container or label and quickly identify the appropriate generic and brand names.


Example: India
At a skills building workshop, NGO/CBO participants were given packets, containers and labels for drugs used in HIV-related treatment. After examining them, they identified the generic and brand names of the drugs. For example:

Generic name: paracetamol
Brand name: Panadol
Brand name: Crocin

Generic name: co-trimoxazole
Brand name: Bactrim
Brand name: Septran

Afterwards, the facilitator led a group discussion about what had been learned from the activity. For example, participants agreed that many people involved in HIV-related treatment – including people with HIV, home based care workers, and community volunteers – need a basic knowledge about the different names of drugs.

(Reference: Adapted from a workshop on “Access to HIV-Related Treatment,” India HIV/AIDS Alliance and the International HIV/AIDS Alliance, India, February 2001.)

4.2.E. Using drugs effectively
Rational drug use is another key concept that is important for an effective HIV-related treatment programme. It is about finding ways to make the best use of drugs - by prescribing them sensibly and taking into account all the information that you have about:

  • The health problems you are treating.

  • The facilities that are available.

  • The people who need the treatment.

  • The drugs that are available and accessible to them.

  • Their economic and social situations.

  • Their beliefs and practices with regard to drugs and treatments.


Rational drug use is supported by answering questions such as:

  • Is the drug really necessary?

  • Is the drug the correct one for the condition?

  • Is the drug suitable for the person, for example a child or pregnant woman?

  • Are the dose, frequency and length of treatment correct?

  • Are any other drugs being taken which might interfere with this one?

  • Is the drug likely to be available?

  • How expensive is the drug? Can you afford it?

  • How effective is the drug for this condition?


Irrational drug use – when drugs are not provided in a sensible way – can happen when:

  • A drug is used that is ineffective for the condition.

  • Wrong or insufficient advice is given to the patient about using the drug.

  • Too high or too low a dose of the drug is used.

  • The drug is given for too long a time.

  • The drug is given for too short a time.

  • Too many drugs are given at the same time, with similar or conflicting effects or causing increased risk of side effects.


Ways to encourage rational drug use include ensuring:

  • Appropriate and independent information: Unbiased and accessible information about drugs encourages rational drug use. The information should be written by people who do not have financial interests in the things they are writing about and the information should be in language that people understand. Budgets for treatment work should always include some money for buying up-to-date reference books and information about drugs. Old information about drugs can be dangerous because it does not include recent updates about drug safety or about new drugs.


  • Training of health workers: In addition to having good information, health workers need training to help to provide effective treatment. All health workers need to keep up to date with the latest information on new drugs, new diseases and new ways of dealing with all kinds of health problems. Planning for HIV-related treatment work should always include training to keep people up to date and to refresh their understanding of good practice and the role of drugs in treatment. An NGO/CBO must ensure that sources of information are kept up to date and that time and funds are available to allow workers to access new updates.


  • Consistent drug supply: Rational drug use will only be possible if the necessary drugs are continuously available and accessible. If not, it is difficult to encourage rational prescribing and the use of an Essential Drugs List. For example, many countries suffer from interrupted supplies of TB drugs. This affects treatment and prevention of TB and encourages the disease to become resistant to drugs. It also discourages patients and health workers, and wastes money and medicines. If this happens, treatment is likely to fail, and expensive alternative drugs will be needed to overcome drug resistant bacteria.


  • Understanding views and beliefs about drugs: What people believe about the drugs they are taking is a very important part of any treatment. If people think their drugs will not work, they are less likely to start taking them or to use them correctly. It is vital to find out what people know and think about drugs, for example through discussions with community groups. You might have to change how drugs are prescribed or provide education for community members to improve their understanding about drugs and the way they are used.


Activity: Rational Drug Use
Aim: To raise awareness about the importance of rational drug use.

Instructions:
1. Explain the aim of the activity.
2. Read out the following case study to participants:

“A woman has had mild diarrhoea – with loose stools, but no blood or mucus – for two days. She goes to see a health worker who prescribes the following medication - Co-trimoxazole 2 tablets twice a day for 5 days; Tetracycline 250mg 1 capsule daily for 3 days; Vitamin B injection.”

3. Ask participants to identify why this prescription is not an example of rational drug use. Encourage the participants to ask each other questions and to make comments.
4. Ask participants what would be a more rational prescription for the health problem. Correct any inaccurate suggestions.
5. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
  • What could be the consequences if drugs are prescribed irrationally?

  • Who needs to have at least basic knowledge about rational drug use? Why?


Facilitators' notes:
  • The facilitator for this activity should be someone who is very familiar with rational drug use and confident about information relating to the specific case study. This will help to ensure that they provide clear and accurate information to the participants. [NB. The example below provides the correct advice on the rational prescription].

  • Remember that the aim of the activity is to build awareness about rational drug use, rather than build medical knowledge. Therefore, make sure that the activity does not become too technical or intimidating for participants who lack detailed knowledge about drugs or treatment.


Example: rational treatment of mild diarrhoea
At a skills building workshop, NGO/CBO participants studied the following case study:

A woman has had mild diarrhoea – with loose stools, but no blood or mucus – for two days. She goes to see a health worker who prescribes the following medication:
Co-trimoxazole 2 tablets twice a day for 5 days; Tetracycline 250mg 1 capsule daily for 3 days; Vitamin B injection.

They then identified why this prescription is an example of irrational drug use:
  • The most important treatment for diarrhoea has been forgotten – drinking plenty of fluid and using oral rehydration solution to stop dehydration.

  • The woman only has mild diarrhoea and is not passing blood or mucus, so she probably does not need an antibiotic. She definitely does not need two different types of antibiotics (co-trimoxazole and tetracycline).

  • The prescription does not specify the strength of the tablets to be used. If an antibiotic were needed, co-trimoxazole would be suitable in the correct dose, but not if the woman is already taking it for long-term prevention of HIV-related opportunistic infections.

  • Tetracycline can be used for diarrhoea, but is not usually the first choice. Doxycycline is more useful. Also, the usual adult dose of tetracycline is 250-500mg 3-4 times a day, for at least 5 days. A 3-day course of one 250mg tablet a day is unlikely to work and could cause the woman to build resistance to the drug.

  • An injection of vitamin B is unnecessary. Injections can be dangerous, especially if unclean needles are used. Vitamin B injections should only be given if there are specific symptoms of vitamin deficiency.


Participants identified that a rational prescription would involve giving the woman the correct advice (based upon hearing a detailed history of the problem). It would focus on helping her to improve her situation rather than waste time and money on unnecessary drugs. It would include:

  • Advice that mild diarrhoea usually clears up in a few days without drugs.

  • Advice to drink plenty of fluids and oral rehydration solution.

  • Advice on how to make and use oral rehydration solution.

  • Advice about preventing diarrhoea through better hygiene and safer water.

  • Advice to come back if the diarrhoea does not improve after two more days.


The facilitator then led a discussion about what had been learned from the activity. For example, participants agreed that rational drug use is vital for both the good health of the person and the reputation and resources of the NGO/CBO.

(Reference: Adapted from a workshop on “Access to HIV-Related Treatment,” India HIV/AIDS Alliance and the International HIV/AIDS Alliance, India, February 2001.)

Source: Access to Treatment Handbook
This is an extract from Mobilising NGOs, CBOs and PLHA groups for improving access to HIV/AIDS-related treatment: a handbook of information, tools and other resources, developed by the International HIV/AIDS Alliance with support from the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), published in this form in June 2002.

To view the whole publication follow this link.

To download this section, complete with graphics, in pdf format (which requires Adobe Acrobat software to read it) follow this link (file size 517 Kbytes).