‘Every hospital should have its own EDL’

In 1999, for the first time in Maharashtra, the Municipal Corporation of Greater Mumbai (MCGM) came out with Essential Drugs List and Standard Treatment Guidelines (STGs) for outdoor patients. The MCGM has now completed work on STGs and EDL for indoor patients and will release the same for implementation in 162 dispensaries, 16 peripheral hospitals and 3 teaching hospitals in Mumbai. Dr Urmila Thatte, head, dept of clinical pharmacology and member of Drugs Therapeutic Committee (DTC), Nair Hospital spearheaded the MCGM taskforce on STGs and EDL. In a conversation with Soumya Viswanathan, Dr Thatte speaks on the protocol for preparing an Essential Drugs List, “a must for every hospital.”

What is the procedure for preparing standard treatment guidelines (STGs) and Essential Drugs List (EDL)?
The process of formulating a EDL is very crucial. In our exercise to prepare STGs and EDL for indoor patients, we followed the WHO guidelines.We collected morbidity data across 30 dispensaries, 16 peripheral hospitals and 2 teaching hospitals for two weeks. We studied the kind of patients, treatment given and morbidity. This work was done by different departments in these centres. Each department then suggested treatment guidelines (STGs) based on either local or international evidence. The list of drugs is then derived based on treatment guidelines. We could later on develop EDL specialitywise but as of now EDL would work across specialities.

What is the status of EDL in India?
National Essential Drug List has been in existence for last six years but was probably formulated the way WHO did a 25 years ago. It needs to be updated. As for states list, some states like Karnataka, Himachal Pradesh, Delhi, Rajasthan have EDL for outdoor patients. For indoor patients yes, Mumbai may be the first to have EDL. Delhi is also in the process of developing its list for indoor patients. In Mumbai, though EDL for outdoor patients was released in 1999 it is not being followed completely. It has yet to be implemented effectively. We found that only 40 per cent of doctors adhere to the guidelines that we brought out.

Since procuring drugs is an important function of DTC is the MCGM considering a revamp?
MCGM is in the process of changing the procurement process of drugs. What we have been following is a strict tendering process through which suppliers are selected for different drugs. But we don’t get the best price. At times, it so happens that the medicines don’t even reach the dispensaries because the order is small. Delhi state on the other hand has a pooled procurement process where one agency is appointed, which does the procurement for the whole state. Prices there are lower because of high volumes. We have a committee formed by representations from DTCs of the 3 teaching hospitals. Under the leadership of Asst Municipal Commissioner Shri SJ Kunte we have been developing standard operating procedures with extensive debate and discussions with all departments and experts involved in this activity.

How important is it for the private sector to implement STGs and EDL?
Last year we studied prescription practice for TB in private setup. It was shocking to find that inspite of the presence of WHO regimen for guidance, GPs were using irrational drug combinations. This only shows that private doctors must be targeted. Private practice also impacts public healthcare and resistance patterns. We now want to work on antimalarial and antibiotic misuse.

What is the main role of DTC?
We stress on rational and not fashionable prescription. There are numerous reasons for rampant misuse of drugs but there must be a change in the behaviour of doctors, patients and industry. For eg, in diarrhoea therapy, ORS is enough. Why do people use medicines? When you use medicines, you are open to adverse effects and therefore more medication. Abroad there is high incidence of hospitalization due to side effects because of irrational use of drugs.

What has the DTC at Nair done since its inception a year back?
We are training the teachers to teach the use of rational drugs for II MBBS students. We want to soon move to residents, GPs and IMA. We have trained the pharmacists too.

And a huge work is to select best drugs for the hospital. For eg, in the psychiatry dept, Dr Hemangee Dhavale, also member of DTC, studied drug patterns for outdoor patients.

Drugs were classified as typical and atypical. Atypical drug usage was around 20 per cent which the patient had to purchase from outside. Typical drugs were scheduled drugs, used 80 per cent of the times. What Dr Dhavale found was that inspite of higher cost per drug, atypical drugs brought down treatment costs because of fewer drugs required.

The aim was to convince the administration that newer anti-depressants can bring down the costs. Similarly we studied the pre-op antibiotic use, analgesic use and drug use in hypertension. We could thereby bring about a change in the hospital’s formulary.