2. WHO Essential Drugs and Medicines Policy
25 Years of Essential Medicines
Jonathan D. Quick, MD, MPH
Hans V. Hogerzeil, MD, PhD
WHO Essential Drugs and Medicines Policy
May 2002

3. Overview of the presentation
1. Achievements
2. Unfinished agenda
3. The selection of essential medicines
4. Promising developments

4. 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 > 10 years old.

5. Achievements
The essential drugs concept is nearly universal a floor, not a ceiling - applied differently in different settings
By Dec.1999:
156 countries with EDLS
1/3 within 2 years
3/4 within 5 years
National Essential Drugs List
< 5 years
(127)
> 5 years
(29)
No NEDL
(19)
Unknown
(16)
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.

6. Achievements
Treatment guidelines and formulary manuals put the essential drugs concept into clinical practice
 135 countries have treatment guidelines, formularies

7. Achievements
DAP’s role
Training in rational prescribing has expanded in universities throughout the world
Problem-based pharmacotherapy
In 18 languages
For medical students, clinical officers
Measurable improvement in prescribing
Now also: Teacher’s Guide to Good Prescribing

8. Achievements
The number of people with access to essential drugs has nearly doubled in 20 years
The poor have remained poor

9. Much has been achieved in 25 years...
...but…..

10. Unfinished agenda
Substandard drugs are common - over half are antibiotics, antimalarials, other anti-infectives
Percent breakdown cases of substandard drugs

11. Irrational use of drugs is a widespread hazard to health
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

12. Unfinished agenda
Financing, delivery, and other constraints still limit access to essential drugs
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)
Source: WHO/DAP (1998) 10 12

13. Example of challenge: New essential drugs are expensive
Selection
Example of challenge: New essential drugs are expensive
Antibiotics for gonorrhoea: x 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: $ /year; but 38 countries with a drug budget <$2 pp/year

14. The Essential Medicines Target
Selection
The Essential Medicines Target
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

15. List of common diseases and complaints
Selection
Clinical guidelines and a list of essential medicines lead to better prevention and care
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

16. History of the WHO Model List of Essential Drugs
Selection
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 history
of medicine, pharmacy and public health
Médecins sans Frontières, 2000

17. Use of the WHO Model List of Essential Drugs
Selection
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

18. Selection
The WHO Model List of Essential Medicines is a model 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

19. Summary of clinical guideline
WHO Essential Medicines Library Combining information from various partners
Selection
WHO clusters
WHO/EDM
Clinical guideline
Summary of 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

20. Practical implications of the access framework
Promising developments
Practical implications of the access framework
1. Rational
selection
4. Reliable
systems
2. Affordable
prices
3. Sustainable
financing
ACCESS TO
ESSENTIAL MEDICINES

21. Indicative price information promotes transparency and competition
Promising developments
Indicative price information promotes transparency and competition
MSH-WHO essential drugs price indicator
Drugs and diagnostics for HIV/AIDS
Pharmaceutical starting materials
Antiretroviral drugs in the Americas
AFRO Essential Drugs

22. Promising developments
Advocacy, corporate responsiveness and competition have reduced antiretroviral prices 95% in 3 years
UN Drug Access Initiative
Domestic production
Accelerated access initiative ??
Generic offers

23. Promising developments
Expanding drug financing options - increasing number of countries with drug benefits in health insurance
- Public funds
- Insurance
- Global fund
- Out-of-pocket
- Donations
Medicines covered by public health insurance (74)

24. Successful experiences with local supply systems and regional bulk procurement
E. Caribbean
Drug Service
Thailand, India: Pooled procurement
Gulf States
Guatemala:
Direct delivery
Mission for Essential Drugs
Northern Province, SA:
Contract distributor

25. The essential drugs concept - more valid than ever
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

26. Thank you
/ medicines