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CAMBODIA EXPERIENCE ON MTP
TO REDUCE INAPPROPRIATE
MEDICINE USE IN HOSPITALS
Sok Srun & Chroeng Sokhan
Ministry of Health, Kingdom of Cambodia
Abstract
Problem Statement: An indicator-based supervision and monitoring program had been conducted by the
Ministry of Health for years, aimed at improving prescribing practices in hospitals. However, the results did not
show significant improvement. A new approach was therefore implemented in 2002, using the Monitoring –
Training – Planning (MTP) method, a series of small-group discussions among managers and prescribers in
hospitals to solve problems in medicine use. MTP was first implemented in 2 stages, involving 13 pilot
hospitals.
Objectives: To evaluate the effectiveness of the MTP approach to reduce inappropriate medicine use in
specific disease problems as defined by each hospital. Indicators: % patients receiving IV fluids and %
patients receiving antibiotics (AB) after prescribers and managers participated in several MTP meetings.
Design: Pre and post MTP intervention without control.
Study Population: Patients with specific disease problems as defined by each hospital.
Intervention: An MTP Team was set up in each hospital, involving the managers and prescribers whose
prescribing practices showed a problem. Each team agreed on a priority disease problem, and arranged a
series of MTP monthly meetings. Prescribing surveys were conducted based on 30 cases per month, or all
cases if the number was <30 per month.
Outcome Measures: Reduction of % patients receiving inappropriate medicines, and when data were
available, reduction of medicine costs. Indicators: % patients receiving IV fluids and % patients receiving
antibiotics (AB) after prescribers and managers participated in several MTP meetings.
Results: Most pilot hospitals showed improvement in prescribing practices. Among them, Kandal Hospital
reduced AB use in normal delivery from 100% to 15% after 4 meetings. Kampong Cham Hospital reduced AB
use in post Caesarean surgery from 100% to 36% after 4 meetings and reduced AB post scrotal hernia
surgery from 100% to 33% after 3 meetings. No post-surgery complications were observed, and the hospital
reduced the average medicine cost from US$ 15.3 to US$ 6.1 per patient, saving US$ >2,000 per month on
medicine expenditure. At Seam Reap Hospital, the use of AB in the Traumatology Ward was reduced from
100% to 63%, and Oddar Meanchey Hospital reduced the use of IV fluids in normal delivery from 27% to zero,
and the use of AB from 23% to zero. At Battambang Hospital, the use of IV fluids in the maternity ward was
reduced from 70% to 0%, IV fluid use in the traumatology ward decreased from 70% to 0%, and the use of AB
in malaria decreased from 30% to 20%.
Conclusions: The MTP approach was effective in reducing inappropriate medicine use in hospitals, and the
achievements were sustainable. The preparation and evaluation workshops at the national level were
relatively costly, but the implementation cost in each hospital was quite low. After the successful
implementation in 13 hospitals, the MTP approach will be disseminated country-wide.
1- Background
 Previous indicator-based supervision and
monitoring program in Cambodia did not
show significant improvement.
 Inappropriate prescribing practices in health
facilities
 Intervention to improve prescribing is uneasy
to conduct, especially in private facilities
 Interventions needs to be incorporated in the
existing management system
2- Objective
 To discuss the problems of drug use in the
health care system
 To discuss the efforts in improving drug use
carried out so far
 To develop the innovative strategy for
rational drug use in the health care system.
3-Intervention Method (Stage 1)
 Select 6 pilot hospitals
 Assign 6 people of each hospital as Hospital MTP
Teams
 Training of MTP Teams on MTP process
 Schedule the meeting to:




define problems on drugs use
develop an innovative strategy to improve drug use
define target
monitor the implementation and evaluate the achievements
 National evaluation workshop
 Wider implementation (Stage 2) if Stage 1 is
successful
3-Self-monitoring vs MTP
Periodic evaluation at
MOH
SelfMonitoring
strategy
Indicator
Indicato
r
MTP
approach
Indicator
Indicato
r
M
T
P
M
T
P
Indicator
Indicator
Indicato
r
M
T
P
M
T
P
M
T
P
7- Summary
results of Stage 1
Health Facilities Priority problem
Intervention result
1-Kandal Hospital
-Use of AB in normal
delivery
-Reduction from 100% down to
15%(target 10%)
2-Kanpong Cham
Hospital
-Use of AB in postCaesarean surgery
-AB use post-scrotal
hernia surgery.
-Reduction from 100% down
36%(Target 10%)
-Reduction from 100% (target
10%)down to 33% in 3 meetings
-Average cost per patient
reduction from 15.3 to 6.1$
4-Result of Stage 1
Kandal RH:
Reduce AB use in normal delivery
% patients received oral antibiotics
100%
100%
Oral antibiotics
Target
80%
60%
55%
40%
32%
20%
10%
10%
10%
15%
10%
0%
1st meeting 2nd meeting 3rd meeting 4th meeting
4-Result of Stage 1
Kompong Cham:
Reduce AB use in post Caesarean surgery
% of patients receiving antibiotics
100%
100%
80%
87%
60%
58%
44%
41%
40%
20%
Post Caesarean surgery
Post Scrotal hernia surgery
Target
10%
10%
10%
36%
33%
10%
0%
1st meeting 2nd meeting 3rd meeting 4th meeting
Reduction of the average medicine cost per patient from 15.3 to US$ 6.1
(US$ 2000/month)
3-Intervention Method (Stage 2)
 Select … pilot hospitals
 Assign 6 people of each hospital as Hospital MTP
Teams
 Training of MTP Teams on MTP process
 Schedule the meeting to:




define problems on drugs use
develop an innovative strategy to improve drug use
define target
monitor the implementation and evaluate the achievements
 National evaluation workshop involving hospitals from
Stage 1
 Nation-wide implementation if Stage 2 is successful
7- Summary
results of Stage 2
Health Facilities Priority problem
Intervention result
1-Siem Reap
Hospital
-AB use in
Tromatology Ward
-Reduction from 100% down to
63% (target 50%)
2-Oddar Mean
Chhey Hospital
-Use of IV fluid in
normal delivery
-Reduction from 27% down to 0%
(target 0%)
3-Battambang
Hospital
-IV fluid use in
Maternity
-IV fluid use in
Traumatology
-AB use in Malaria
-Reduction from 70% down to
0%.(target 0%)
-Reduction from 70% down to 0%
(target 0%).
-Reduction from 30% down to
20%(target 0%)
8-Conclusion(1)
 Flexible approach, not time-consuming, not costly
to improve appropriate use of drugs in hospitals
 MTP is good for solving sensitive problems
 Encourage Hospital Technical Committees to
initiate activities in improving appropriate use of
drugs
 A comprehensive approach, a combination of adult
learning and managerial strategies.
 Involving stakeholders in hospital, the “negative”
consequences of rational drug use could be
discussed accordingly
8-Conclusion(2)




MTP can be implemented in both sector public and
private. With the supports from PHDs, MTP can be
used to solve drug use problems by themselves.
MTP can be extended nationwide. The “right people”
should be selected from each hospitals.
If MTP imlementation is conducted with monitoring,
supervision, and continuous training, MTP can
reduce the health care cost. The community will
participate and support this efforts
To reduce the prescribing problems and improve
RUD for healthcare workers and patients.