Trainer's Guide
    Standard Treatments

The intention of this session is to introduce participants to Standard Treatment Guidelines (STG's) and to move their understanding of these manuals from the product to the process. The key learning objective of this session is to persuade participants of the importance of the process in producing these STG's. Too often these are produced and not used because the end users were either not involved or do not respect or accept the process that was used to produce the materials. A key activity in this session is the case study. Time must be made to ensure that this case is adequately discussed.

First Component

Introduction, and Description of Standard Treatment Guidelines

This component gives an overview of what Standard Treatment Guidelines are. It highlights the variation, which may occur in levels of the guidelines and the fact that guidelines may include the elements of diagnosis. The various points at which STG's can be used in the therapeutic process are highlighted in VA5.

Second Component

Advantages and Key Features of Standard Treatment Guidelines

This component stresses that there are advantages for patients, for providers, for supply management staff and for health policy makers. This component is a good opportunity to discuss the common attitudes about STG's. It is worth confronting the common complaint about STG's that they amount to "cook book medicine." The point should be made that there are benefits to everybody in terms of quality of service, and cost control. But the point should be made that in any system even if cost is not a factor there is a need for STGs for a quality reason. Point out that every prescriber has an informal set of treatment guidelines in their head; these can only be improved by critical review. When discussing the key features point out that simplicity has benefits for all. Stress that credibility is paramount. If a prescriber or a patient does not believe that this is the best advice they will ignore the guidelines. The point about same standards for all is very important from a health system standpoint. If a patient receives a different treatment at a hospital OPD than what is received at a primary care unit, they will assume that the treatment is better at the hospital. This will encourage them to bypass the primary care facility and clog up the referral facility. While a patient may receive a wider range of drugs at a hospital, the initial treatment should be the same as what the patient would receive at the primary care facility.

The issue of drug supply being related to standard treatment guidelines may be difficult for prescribers to understand. Point out that the procurement period for drugs in developing countries is often quite long and that any change in STG may cause a change in demand for various drugs. Also point out that if drugs are supplied which are not needed and shortages occur a prescriber may prescribe a drug not on the guidelines just to give something!

The introduction of these STG's into preservice training must be stressed. The students to be targeted should include medical students, pharmacy students, nursing students and all others who may be involved in prescribing or dispensing. Point out that these students often learn from textbooks that may be outdated or written for other countries. Recognize that this will mean that extra copies will need to be printed to be distributed to the training schools. The resistance of teachers to use these materials may be counteracted by involving such people in the development and review of the draft materials.

The issue of regular review is a difficult issue. While ideally the guidelines showed be reviewed frequently in practice the work to undertake a review is demanding. Thus the more complex the guidelines the less frequently they may be revised. This inevitably has an effect on the adequacy of the guidelines. Thus it is always a compromise between the ideal and the practical, in much the same way sample size determination is a compromise. Durability is often forgotten and is worth mentioning.

Third Component

Case Study Standard Treatments in Pagalia: A Second edition?

This case study can be used at this stage of the session or at the end of the session. If it is used at this time it is important to leave enough time at the end (about one hour) to finish the session. The case is rather a long one and participants should be encouraged to read it in advance so that they can spend time on the discussion. If they have not read the case study it may be useful to read it aloud though this takes time. When it comes to debriefing the discussion get one group to present the results for a question, discuss those issues and then move on to the next question with a different group. The key point of this case study is that the process of production and implementation determines the outcome of how the guidelines are used!

Fourth Component

Developing and Implementing Standard Treatment Guidelines

When discussing how STG's are developed discuss each step in detail. Point out that when selecting which conditions to address there are advantages and disadvantages in being either too selective or too comprehensive. If the guideline is for an individual condition the guideline will not be used often unless the condition is very common. If the guidelines are too comprehensive they will be very long; difficult to use and may end up having very small type if the intention is to keep the manual pocket sized.

The importance of local disease factors being addressed cannot be over stressed. People use the manual to deal with problems they face in their work. Use local examples to point out that local conditions or factors may affect how a condition is treated. The importance of involving vertical programs needs to be discussed. Point out that such programs may be keen to participate if asked and that they may even contribute to printing costs if they are involved early enough in the process. By stressing the use of the fewest drugs necessary there are many benefits not least to the supply system. The issue of cost effectiveness can also be discussed with examples. If a treatment reduces hospital stay but increases drug costs is this a cost-effective treatment? In most cases it will be. Using essential drugs only in STG's may mean that the EDL may need to change as the result of the discussions around the development of STG's. The involvement of respected clinicians is very important to assure the credibility of the guidelines. But it can be difficult as these individuals are often busy and may be unwilling to give their time. On one occasion I (RL) made an appointment with diabetes specialist in his outpatient's clinic to get 15 minutes of his time. During this time it was possible to review a chapter of the guidelines and assure his support. Considering the patient's perspective is important though difficult, as they are often not involved in this process. You can ask - Should they be involved? If so for what guidelines and how?

When discussing the implementation of the guidelines stress how importance of adequate planning and preparation. Stress that printing enough copies before the launch is important. Having an official launch ideally with the Minister of Health or leading professionals is ver important to assure the credibility of the guidelines. Point out that briefing the Minister is very important to assure that he understands the concepts behind the guidelines and expresses his support for the guidelines at every level. The initial training should focus on a few conditions where changes have occurred. The reinforcement training should ideally be focussed on those facilities which have not used the guidelines or expressed difficulties in their use. Monitoring can be undertaken in different ways. The easiest way is to monitor drug consumption of key drugs that are expected to change in usage rated once the guidelines are used. Another way is to audit treatment records. Another method could be the use of surrogate patients. Training supervisors to carry and use the STG's is important. Once workers realize that they are protected from criticism if they can say, "This is the treatment in the STG's!" they will use the guidelines.

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