INTRODUCTION
Standard Treatment Guidelines (STGs) have existed for as long as the art of healing has existed. Traditional
healers developed their standard set of cures and passed them from generation to generation by word of
mouth or in writings. In modern medicine, there is a definite thinking that there may be more than one treatment
modality available for many medical conditions. This leads to confusion and, in many cases, incorrect
treatment. Doctors, nurses, pharmacists, community health workers, and other health care providers, at times,
learn about all of the treatments that could be used, instead of focusing on the best treatment that should be
used. Casual observation, as well as more systematic study of prescribing practices, frequently reveals a
pattern of tremendous diversity among prescribers in the treatment of even the most common conditions.
Polypharmacy is one problem; for example, there are three, four, five, six, and sometimes more drugs
prescribed for acute viral gastroenteritis, for which only oral rehydration therapy is effective in reducing
morbidity and mortality. Other common problems are incorrect drug choices, overdosing, underdosing, and
choice of more expensive drugs when less expensive drugs would be equally or more effective.
Standard Treatment Guidelines also known as standard treatment schedules, standard treatment protocols,
therapeutic guidelines, and so forth list the preferred drug and non-drug treatments for common health
problems experienced by people in a specific health system. Each drug treatment should include for each
health problem the name, dosage form, strength, average dose (pediatric and adult), number of doses per day,
and number of days of treatment. Other information on diagnosis and advice to the patient may also be
included. Referral criteria from a lower level facility to a higher one are also an important aspect of Standard
Treatment Guidelines. Experience shows that even the shortest essential drug list or formulary list offers ample
opportunity to misuse drugs by improper treatment of common problems. Thus, essential drug programmes
are finding that the development of standard treatments is necessary for therapeutically effective and
economically efficient use of drugs. Standard treatments are used at different points of the therapeutic process.
They may be used to diagnose, decide on treatment and drug supply, and assist with adherence to the
prescribed treatment. The formulation of Standard Treatment Guidelines is a necessity for developing
countries so that maximum patients derive benefit from the scarce available resources.
Standard Treatment Guidelines in India have been developed for various diseases and ailments by clinical and
professional bodies for the treatment in their respective areas. Standard Treatment Guideline has been
defined as a systematically developed statement designed to assist practitioners and patients in
making decisions about appropriate health care for specific clinical circumstances. STGs are meant to
reflect expert consensus based on a review of current published scientific evidence of acceptable approaches
to diagnosis, management or prevention of specific conditions. In addition to supporting rational decision-
making, other important uses of STGs are:
· Provide standardized guidance to practitioners.
· Guiding allocation of resources for health care; and estimating cost of health services.
· Making specific decisions about what health care to reimburse, cover, or encourage and in evaluating the
decisions, actions, or performance of the primary users of guidelines.
In India, expertise in developing and implementing STGs exists only in the various pockets of health sector i.e.
either in specific diseases or for specific state or geographical or administrative boundaries but these were
never shared or reviewed and discussed at a common platform. It was therefore felt by the Ministry of Health &
Family Welfare Government of India & WHO Country Office, India that guidelines needed to be prepared with
the ultimate goal of providing a protocol for the health care system to follow that will produce improved patient
care and outcomes. Hence, a study was undertaken in this regard. It was decided to initially identify 35 medical
conditions for which no National Programme Guidelines exist & thereafter develop STGs on these select
conditions. The conditions were identified by the Ministry of Health & Family Welfare Government of India &
WHO Country Office, India in consultation with Heads of Departments of various specialties in Armed Forces
Medical College, Pune. As regards diseases covered under National Health Programmes, it was decided to
provide an abridged version of the Programme to the readers which focuses on the diagnostic & treatment
STANDARD TREATMENT GUIDELINES
modalities of the individual disease processes. The Programmes as received from the Ministry of Health &
Family Welfare were thus summarized into smaller versions & published in the second part of this document so
that readers can have access to them at one place itself.
It was decided that STGs would be developed for four Levels of Health care. The identified levels were in
conformity with the existing health care delivery system of the country. The levels are described in the section
on “How to use this book”. For the purpose of Standardization, all authors of STGs followed Indian Public
Health Standards (IPHS) guidelines issued by the Director General Health Services Government of India, for
assessing the facilities of diagnostics & drugs available at the second (PHC) & third level (CHC) of health care.
These STGs developed as a collaborative effort by various Departments of Armed Forces Medical College
were then sent to the Ministry of Health & Family Welfare Government of India for getting peer reviewed. The
comments of apex institutes like AIIMS, PGIMER Chandigarh, and NIMHANS among others were circulated to
the authors for incorporation in the STGs. Thereafter, one more peer review was conducted at an expert group
meeting held at AFMC on 26 Aug 07 wherein experts from all field representing apex institutions & professional
bodies were involved in a brain storming with the authors on the prepared STGs. The comments of the peers
were duly incorporated by the authors while preparing the final STGs as they appear in this document.
The contents are in two parts: Part I and Part II. The STGs for 35 conditions in Part I have been developed de
novo. The Standard Treatment Guidelines in Part I have been prepared by authors based on their experience &
after consulting standard textbooks in the varied specialties of medical sciences. Authors have attempted to put
themselves in the shoes of a doctor working with scarce resources especially at the Primary & Secondary level
of care while drafting these guidelines. To the extent possible, standard case definitions have been used in
drafting diagnostic, treatment & therapeutic modalities for each disease at the specified levels of health care.
However, it needs no emphasis that these are mere guidelines & do not attempt to take the place of textbooks.
Medicine, unlike most physical sciences, is not an exact science. Signs & Symptoms as well as responses to
treatment vary from one patient to another though the underlying disease pathology may be similar. For
treatment especially at the Tertiary Level wherein at most times the specialist is dealing with complications of
the disease rather than the basic health problem- a more detailed research is entailed before deciding the
modalities of treatment & this could vary from one institution to another. Moreover, with rapid strides in the field
of medicine, better diagnostic & treatment modalities could replace existing guidelines on the subject. The
guidelines in Part II are essentially summarization of guidelines published by Ministry of Health, Govt. of India
as part of National Health Programmes issued from time to time. Relevant information from the updated
documents has been incorporated into this book.
Costing of the disease management process at all four levels of health care was another aspect which has been
attempted. This exercise has probably been conducted for the first time in the country for the selected medical
conditions. This part of the Project was exclusively undertaken by the Ministry of Health & Family Welfare in
collaboration with the WHO Country Office, India. Armed Forces Medical College merely provided the inputs to
the Cost Accountant appointed by the MOHFW for this pioneering task. The costing sheets prepared for each of
the STGs form the concluding part of this document. This important part of this document would help in
estimating standard cost of health services covered by STGs which could be used for the purpose of health
insurance or any other provider payment mechanism followed in the country.
While it is hoped that the book may prove to be a concise and ready reference, it makes no pretension to being
anything more than an introduction to the important conditions; in no sense is it put forward as a complete
treatise. Readers are advised to check the most current information. It is the responsibility of the practitioner,
relying on his/her own experience and knowledge of the patient, to make diagnosis, to determine dosages and
the best treatment for each individual patient, and to take all appropriate safety precautions.
Col Rajvir Bhalwar
Col AK Jindal, YSM
Wg Cdr Rajesh Vaidya
STANDARD TREATMENT GUIDELINES
