WHO Essential Drugs Strategy

1
25 Years of Essential Medicines 1977 - 2002
Jonathan D. Quick, MD, MPH Hans V. Hogerzeil, MD,
PhD WHO Essential Drugs and Medicines Policy May
2002
2
Overview of the presentation
Overview

• 1. Achievements 1977 - 2002
• 2. Unfinished agenda
• 3. The selection of essential medicines
• 4. Promising developments

3
National drug policies are being introduced at a
growing pace in every region - guides for
collective action
Achievements
Includes countries with current NDPs, draft
policies or policies or policies gt 10 years old.
4
The essential drugs concept is nearly universal
a floor, not a ceiling - applied differently in
different settings
Achievements
By Dec.1999 156 countries with EDLS 1/3 within
2 years 3/4 within 5 years
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.
5
Treatment guidelines and formulary manuals put
the essential drugs concept into clinical practice
Achievements
? 135 countries have treatment guidelines,
formularies
6
Training in rational prescribing has expanded in
universities throughout the world
Achievements
DAPs role

• Problem-based pharmacotherapy
• In 18 languages
• For medical students, clinical officers
• Measurable improvement in prescribing
• Now also Teachers Guide to Good Prescribing

7
The number of people with access to essential
drugs has nearly doubled in 20 years
Achievements
8
Much has been achieved in 25 years...

• ...but..

9
Substandard drugs are common - over half are
antibiotics, antimalarials, other anti-infectives
Unfinished agenda
Percent breakdown - 325 cases of substandard
drugs
10
Irrational use of drugs is a widespread hazard to
health
Unfinished agenda

• Half of 102 countries surveyed regulate drug
  promotion
• By age 2 children in some areas have had gt 20
  injections
• 15 billion injections per year - half of them
  unsterile
• 25-75 of antibiotic prescriptions are
  inappropriate

11
Financing, delivery, and other constraints still
limit access to essential drugs
Unfinished agenda
Percentage of population with regular access to
essential drugs (1997)
Source WHO/DAP (1998)
12
Example of challengeNew essential drugs are
expensive
Selection

• 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 lt2 pp/year

13
The Essential Medicines Target
Selection
National list of essential medicines
Registered medicines
All the drugs in the world
Levels of use
CHW
S
S
dispensary
Health center
Supplementary specialist medicines
Hospital
Referral hospital
Private sector
14
Clinical guidelines and a list of essential
medicines lead to better prevention and care
Selection
List of common diseases and complaints
Treatment choice
Treatment guidelines
Essential medicines list / National formulary
Training and Supervision
Financing and Supply of drugs
Prevention and care
Health Technology and Pharmaceuticals
15
History of the WHO Model List of Essential Drugs
Selection

• 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
history of medicine, pharmacy and public health

Médecins sans Frontières, 2000
16
Use of the WHO Model List of Essential Drugs
Selection

• 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

17
The WHO Model List of Essential Medicines is
amodel product, model process and public health
tool
Selection

• 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

18
WHO Essential Medicines LibraryCombining
information from various partners
Selection
WHO clusters
WHO/EDM
Summary of clinical guideline
Clinical guideline
BNF
WHO Model Formulary
WHO/EC, Cochrane
Reasons for inclusion Systematic reviews Key
references
WHO Model List
WHO/EDM
MSH UNICEF MSF
Cost - per unit - per treatment - per month -
per case prevented
Statistics - ATC - DDD
Quality information - Basic quality tests -
Intern. Pharmacopoea - Reference standards
WCCs Oslo/Uppsala
19
Practical implications of the access framework
Promising developments
20
Indicative price information promotestransparency
and competition
Promising developments

• MSH-WHO essential drugs price indicator
• Drugs and diagnostics for HIV/AIDS
• Pharmaceutical starting materials
• Antiretroviral drugs in the Americas
• AFRO Essential Drugs

21
Advocacy, corporate responsiveness and
competition have reduced antiretroviral prices
95 in 3 years
Promising developments
??
22
Expanding drug financing options - increasing
number of countries with drug benefits in health
insurance
Promising developments
- Public funds - Insurance - Global fund -
Out-of-pocket - Donations
23
Successful experiences with local supply systems
and regional bulk procurement
24
The essential drugs concept -more valid than ever
Conclusion

• 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