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25 Years of Essential Medicines25 Years of Essential Medicines1977 - 20021977 - 2002
Jonathan D. Quick, MD, MPHHans V. Hogerzeil, MD, PhD
WHO Essential Drugs and Medicines PolicyMay 2002
2 25 years
Overview of the presentation
1. Achievements 1977 - 2002
2. Unfinished agenda
3. The selection of essential medicines
4. Promising developments
Overview
3 25 years
Cumulative number of national drug policies (NDPs)*
40
19
10
18
10 12
0
5
10
15
20
25
30
35
40
45
Africa Americas E.Med Europe S-E. Asia W. Pacific
1985 1990 1995 1999
National drug policies are being introduced at a growing pace in every region - guides for collective action
* Includes countries with current NDPs, draft policies or policies or policies > 10 years old.
Achievements
4 25 years
National Essential Drugs List
< 5 years (127)> 5 years (29)No NEDL (19)Unknown (16)
By Dec.1999:
156 countries with EDLS
1/3 within 2 years
3/4 within 5 years
The essential drugs concept is nearly universal a floor, not a ceiling - applied differently in different settings
Countries with an official selective list for training, supply, reimbursement or related health objectives. Some countries have selective state/provincial lists instead of or in addition to national lists.
Achievements
5 25 years
135 countries have treatment guidelines, formularies
Achievements
Treatment guidelines and formulary manuals put the essential drugs concept into clinical practice
6 25 years
Training in rational prescribing has expanded in universities throughout the world
DAP’s role
Problem-based pharmacotherapy In 18 languages For medical students,
clinical officers Measurable improvement in
prescribing Now also: Teacher’s Guide to
Good Prescribing
Achievements
7 25 years
Number of people (billions)
0
1
2
3
4
5
6
1977 1987 1997
No regularaccess
Regularaccess toessentialdrugs
The number of people with access to essential drugs has nearly doubled in 20 years
Achievements
The poor have remained poor
9 25 years
Incorrect amount
17%
No active ingredient
60%Other problems
7%
Incorrect ingredient
16%
Percent breakdown - 325 cases of substandard drugs
Substandard drugs are common - over half are antibiotics, antimalarials, other anti-infectives
Unfinished agenda
10 25 years
Unfinished agenda
Irrational use of drugs is a widespread hazard to health
Half of 102 countries surveyed regulate drug promotion By age 2 children in some areas have had > 20 injections 15 billion injections per year - half of them unsterile 25-75% of antibiotic prescriptions are inappropriate
11 25 years
Financing, delivery, and other constraints still limit access to essential drugs
Source: WHO/DAP (1998)
Percentage of population with regular access to essential drugs (1997)
1 = <50% (36)1 = <50% (36)2 = 50-80% (68)3 = 80-95% (33)4 = >95% (41)5 = No data available (1)
Unfinished agenda
12 25 years
Example of challenge:New essential drugs are expensive
Antibiotics for gonorrhoea: 50-90x price of penicillins
Antimalarial drugs: chloroquine $0.10 per treatment artemether-lumefantrine $2.50/pp (25x)atovaquone-proguanil $40/pp (400x)
Antituberculosis: $15 for DOTS vs $300 for MDR (20x)
Antiretrovirals: $300-600/year; but 38 countries with a drug budget <$2 pp/year
Selection
13 25 years
The Essential Medicines Target
S S
All the drugsin the world
Registered medicines
National list ofessential medicines
Levels of use
Supplementaryspecialistmedicines
CHWdispensary
Health center
Hospital
Referral hospital
Private sector
Selection
14 25 years
Clinical guidelines and a list of essential medicines lead to better prevention and care
Health Technology and Pharmaceuticals
List of common diseases and complaints
Training andSupervision
Financing and Supply of drugs
Treatment guidelines
Treatment choice
Preventionand care
Selection
Essential medicines list / National formulary
15 25 years
History of the WHO Model List of Essential Drugs
1977 First Model list published, ± 200 active substances List is revised every two years by WHO Expert Committee Last revision (April 2002) contains 325 active substances 2002 Revised procedures approved by WHO
The first list was a major breakthrough in the historyof medicine, pharmacy and public health
Médecins sans Frontières, 2000
Selection
16 25 years
Use of the WHO Model List of Essential Drugs
156 countries have a national list of essential drugs Major agencies (UNICEF, UNHCR, IDA) base their catalogue
on the WHO Model List Sub-sets of the Model List:
UN list of essential drugs for emergencies: 85 drugs New Emergency Health Kit: 55 drugs for 10,000 people/3m
Normative tools follow the Model List: WHO Model Formulary International Pharmacopoea Basic Quality Tests and reference standards
Selection
17 25 years
The WHO Model List of Essential Medicines is amodel product, model process and public health tool
Independent Membership of the Committee, careful consideration of conflict of interest
Transparent process, standard application, web review Link to evidence-based clinical guidelines Systematic review of comparative efficacy, safety, cost-
effectiveness and public health relevance Rapid dissemination, electronic access Regular review
Selection
18 25 years
WHO Essential Medicines LibraryCombining information from various partners
WHOModel List
Summary of clinical guideline
Reasons for inclusionSystematic reviewsKey references
WHO Model Formulary
Cost:- per unit- per treatment- per month- per case prevented
Quality information:- Basic quality tests- Intern. Pharmacopoea- Reference standards
Clinical guideline BNF
WHO clusters
MSHUNICEF
MSF
WHO/EDM
WHO/EDM
WHO/EC, Cochrane
Statistics:- ATC- DDD
WCCs Oslo/Uppsala
Selection
19 25 years
Practical implications of the access framework
1. Rational
selection
4. Reliable
systems
2. Affordable
prices
3. Sustainable
financing
ACCESS TO
ESSENTIAL MEDICINES
Promising developments
20 25 years
MSH-WHO essential drugs price indicator
Drugs and diagnostics for HIV/AIDS
Pharmaceutical starting materials
Antiretroviral drugs in the Americas
AFRO Essential Drugs
Indicative price information promotestransparency and competition
Promising developments
21 25 years
Indicative annual cost per person for triple therapy in Africa (US $)
$0
$2,000
$4,000
$6,000
$8,000
$10,000
1996 1997 1998 1999 2000 2001 2002
UN Drug Access Initiative
Domestic production
Accelerated access initiative
Generic offers
Advocacy, corporate responsiveness and competition have reduced antiretroviral prices 95% in 3 years
????
Promising developments
22 25 years
Medicines covered by public health insurance (74)
Expanding drug financing options - increasing number of countries with drug benefits in health insurance
- Public funds- Insurance- Global fund- Out-of-pocket- Donations
Promising developments
23 25 years
Successful experiences with local supply systems and regional bulk procurement
Guatemala:Direct delivery
Northern Province, SA:Contract distributor
Gulf StatesE. CaribbeanDrug Service
Mission for Essential Drugs
Thailand, India: Pooled procurement
24 25 years
Conclusion
The essential drugs concept -more valid than ever
Much has been achieved in 25 years
Yet the unfinished agenda is large - quality, access, use
The Model List of Essential Medicines remains a strong public health tool
There are promising developments for access - pricing, financing, supply systems and quality