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Background: Irrational use of antibiotics is a global problem that may potentiate antimicrobial resistance. Objective: We assessed prescribing practices in Eswatini and the effect of a short intervention - prescription audit and feedback coupled with small group education on prescribing indicators. Methods: This was a pre-post intervention study using the World Health Organization/ International Network for the Rational Use of Drugs (WHO/INRUD) prescribing indicators at three time points: baseline, post-intervention, and post-follow-up. Baseline results were used to design a six-months’ unblinded intervention in 32 health facilities, randomly allocated to intervention (16) and control (16) arms. Prescribing patterns were assessed immediate post-intervention, and six months after the end of the intervention, through an audit of 100 randomly selected prescriptions from each facility. Comparison of WHO/INRUD prescribing indicators were carried out using intention to treat analysis at the two time points. Results: At baseline, in both intervention and control facilities, rational prescribing standards were only met by the average number of medicines per prescription and the percentage of prescriptions with injections. The use of antibiotics was above 50% in both intervention and control facilities. At the end of the follow-up period, there was a significant decrease in the use of antibiotics in intervention facilities, compared to control facilities (MD = -8·31, 95% CI = -15·74 - -0·89; p = 0·03). Conclusion: In a low-and-middle-income setting with a high prevalence of irrational prescribing practices, a prescription audit, feedback, and small group education intervention may have benefits in improving rational antibiotics prescribing. Funding Information: The Institute of Tropical Medicine (ITM) financially supported the conduct of this study through the School of Public Health at the University of the Western Cape. Declaration of Interests: None to declare. Ethics Approval Statement: Ethics clearance was granted by the University of the Western Cape Higher Degrees Committee (reference BM/16/4/2) and the National Health Research Review Board in Eswatini. Permission to access healthcare facilities was granted by the office of the Deputy Director Pharmaceutical Services in the Ministry of Health in Eswatini.

Background Costly prescription medicines with existing cheaper alternatives tend to be purchased by medically insured consumers of healthcare. In South Africa medical scheme members pay higher out-of-pocket payments for medicines than those without insurance. Aim This study explored reasons for co-payments among insured Pretoria medical scheme members purchasing prescription medicines at private retail pharmacies, despite being insured and protected against such payments. Setting The study took place in retail pharmacies in Pretoria, Gauteng Province, South Africa. Methods An exploratory qualitative study was performed. Semi-structured interviews were conducted among purposefully sampled medical scheme members (12) and nine key informants (six pharmacists and three regulators – one for the pharmaceutical industry, one for medical schemes and one for pharmacists). Three pharmacies (two corporate and one independent) each were identified from high and low socio-economic areas. Scheme members were interviewed immediately after having made a co-payment (eight) or no co-payment (four) from the selected pharmacies. Interviews were recorded, coded and organised into themes. Results Co-payments were deemed confusing, unpredictable and inconsistent between and within pharmacies. Members blamed schemes for causing co-payments. Six sampled pharmacies rarely stocked the lowest-priced medicines; instead, they dispensed medicines from manufacturers with whom they had a relationship. Corporate pharmacies were favoured compared to independents and brand loyalty superseded cost considerations. Medical scheme members did not understand how medical schemes’ function. Conclusion Unavailability of lowest-priced medicines at pharmacies contributes to co-payments. Consumer education about generics and expedited implementation of National Health Insurance could significantly reduce co-payments. Keywords co-payments; high socio-economic; low socio-economic; medical scheme; medicines pricing policy; National Health Insurance; pharmacist; prescribed minimum benefit; retail pharmacy; regulator.

South Africa’s transition towards a district-based health system (DHS) aims to offer health promotion and prevention services at community level, through re-engineered primary health care (PHC) ser...

BackgroundRational medicines use (RMU) is the prescribing/dispensing of good quality medicines to meet individual patient's clinical needs. Policy-makers, managers and frontline providers play critical roles in safeguarding medicine usage thus ensuring their rational use. This study investigated perspectives of key health system actors on prescribing practices and factors influencing these in Eswatini. Public sector healthcare service delivery is through health facilities (public sector, not-for-profit faith-based, industrial) and community-based care.MethodsA qualitative, exploratory study using semi-structured in-depth interviews with seven policymakers and managers, and 32 facility-based actors was conducted. Drawing on Social Practice Theory, material (health system context), competence (provider) and cultural (patient and provider) factors influencing prescribing practices were explored.ResultsParticipants were aged between 21-57years, had been practicing for 1-30 years, and were a mix of doctors, nurses, pharmacists and pharmacy-technicians. Factors contributing to irrational medicines use included: poor use of treatment guidelines, lack of RMU policies, poorly-functioning pharmaceutical and therapeutics committees, stock-outs of medicines, lack of pharmacy personnel in primary healthcare facilities, and restrictions of medicines by level of care. Provider-related factors included: knowledge, experience and practice ethic, symptomatic prescribing, high patient numbers. Patient-related factors included late presentation, language, and the need to be prescribed many medicines.ConclusionIn Eswatini, prescribing practices are influenced by the interaction of factors (health system, provider and patient) that span levels (facility, region, and policy-making) of the health system. Promoting RMU thus goes beyond the availability of guidelines and provider training and requires concerted efforts of multiple stakeholders.

Background. Diabetes constitutes a significant health problem in South Africa. Early detection and good management can prevent or delay complications, with national guidelines for diabetes treatment now available to facilitate this. However, problems are being encountered with their implementation and there is evidence that preventive care is still inadequate in South Africa.Community health workers (CHWs) are lay personnel employed to serve as a link between professional health care staff and the community. They visit homes and can be a powerful force for diabetes prevention and adherence to treatment regimens, given appropriate knowledge.Method. We conducted a study to evaluate the knowledge, beliefs and attitudes of a group of CHWs serving a poor urban area, using focus groups and personal interviews.Results. The CHWs did not have the requisite knowledge, attitudes and beliefs to make a positive impact on prevention and management of diabetes. For example, they cited eating sugar as a cause of diabetes...

Background. Community health workers (CHWs) are lay people trained to assist with health care in their communities. This study took place at two sites in Khayelitsha, a township in the Cape Peninsula, from 2000 to 2002.Objectives. To describe the process of developing an intervention programme for primary prevention of noncommunicable diseases (NCDs) in general and cardiovascular disease in particular, targeting CHWs.Method. Forty-four CHWs were assigned to either an intervention or a control group. The intervention group, living in Site C, received training on lifestyle modification with emphasis on healthy eating and physical activity, while the control group, living in Site B, did not receive any training until a year later. The process was undertaken in four stages. Stage 1 involved assessment of the CHWs' risk factors by obtaining anthropometric measurements. CHWs were interviewed and focus group discussions were held on the socio-cultural factors associated with body weight and body image, a...