An evaluation of South Africa's national drug policy: standard treatment guidelines/essential drugs list and its impact on rational drug prescribing at public hospital oupatient clinics: a case study of the Northern Province

During the years of apartheid, South Africa developed two health care systems, public and private, that were fragmented and segregated by race. The private health care system (almost exclusively white patients) was on the same level as the tertiary care in industrialised countries, while the public health care system (almost exclusively black and coloured) was similar to the primary health care systems in many developing countries. Even so, South Africa in 1996 was spending much more than any other African country on health care, 8.5% of the GDP per year (McIntyre 1995). The political tide turned in 1996 and with new governments came a new focus on equity of health care, access and services. Equity in health care and access are the main foci of health initiatives in South Africa. This research evaluated the impact of the National Drug Policy (1996), and the National Drug Programme (NDP). The NDP's key component is the Standard Treatment Guidelines/Essential Drugs List (STG/EDL) to be used in South Africa's public hospitals' outpatient clinics at all levels (primary, secondary, and tertiary). This study is a cross-sectional case study that evaluates the effectiveness of the implementation of this policy through strategies to encourage prescribers to use the STGIEDL as a regular part of their prescribing repertoire. The research techniques included a combination of quantitative analyses with a drug utilisation survey (DUS) that measured adherence to rational prescribing measures, and qualitative analyses in depth interviews with nurses, pharmacists, physicians and administrators. The results of both the drug utilisation survey of 1,204 prescriptions from eleven clinics and 20 interviews showed that there was little evidence of rational prescribing in public hospital clinics. Overall the prescribers at the clinic level did not adhere to the NDP and rational prescribing. The one major change observed was that the hospital clinic pharmacy would substitute most brand medicines for generic ones, unless the physician formally requests the brand drug. The one clinic that was the most adherent to the rational prescribing standard had a pharmacist who was enrolled in a rational prescribing and monitoring course. In addition, the manager pharmacist developed an EDP bulletin for all the staff and encouraged the use of the Standard Treatment Guidelines Essential Drugs list for all staff in the hospital clinic. In summary, this study shows that the major goals of the National Drug Policy (NDP), the rational prescribing of drugs and equity of access to health care and services, have note been reached. Even though there is some progress towards attaining these goals will require an effort of all stakeholders through enforceable legislation, allocated budgets, patient and prescriber education, and a bottom-up approach to policy implementation.