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
Overview
Overview of the presentation
1. Achievements 1977 - 2002
2. Unfinished agenda
3. The selection of essential medicines
4. Promising developments
2 25 years
Achievements
National drug policies are being introduced at a growing
pace in every region - guides for collective action
45
40
40
Cumulative number of national drug
policies (NDPs)*
35
30
25
19
20
15
18
10
10
12
10
5
0
Africa
Americas
1985
E.Med
1990
Europe
1995
S-E. Asia W. Pacific
1999
* Includes countries with current NDPs, draft policies or policies or policies > 10 years old.
3 25 years
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.
4 25 years
Achievements
Treatment guidelines and formulary manuals put the
essential drugs concept into clinical practice
 135 countries have treatment guidelines, formularies
5 25 years
DAP’s role
Achievements
Training in rational prescribing has expanded in
universities throughout the world





6 25 years
Problem-based pharmacotherapy
In 18 languages
For medical students,
clinical officers
Measurable improvement in
prescribing
Now also: Teacher’s Guide to
Good Prescribing
Achievements
The number of people with access to essential drugs
has nearly doubled in 20 years
The poor have
remained poor
Number of people (billions)
6
5
No regular
access
4
3
Regular
access to
essential
drugs
2
1
0
1977
7 25 years
1987
1997
Much has been achieved in 25 years...
...but…..
8 25 years
Unfinished agenda
Substandard drugs are common - over half are
antibiotics, antimalarials, other anti-infectives
Percent breakdown - 325 cases
of substandard drugs
Incorrect
ingredient
16%
Incorrect
amount
17%
Other
problems
7%
9 25 years
No active
ingredient
60%
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
10 25 years
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%
1 = <50%
2 = 50-80%
3 = 80-95%
4 = >95%
5 = No data available
11 25 years
Source: WHO/DAP (1998)
(36)
(36)
(68)
(33)
(41)
(1)
Selection
Example of challenge:
New essential drugs are expensive
Antibiotics for gonorrhoea:
Antimalarial drugs:
Antituberculosis:
Antiretrovirals:
12 25 years
50-90x price of penicillins
chloroquine $0.10 per treatment
artemether-lumefantrine $2.50/pp (25x)
atovaquone-proguanil $40/pp (400x)
$15 for DOTS vs $300 for MDR (20x)
$300-600/year; but 38 countries with
a drug budget <$2 pp/year
Selection
The Essential Medicines Target
National list of
essential medicines
Registered medicines
All the drugs
in the world
Levels of use
S
CHW
S
dispensary
Health center
Hospital
Referral hospital
Private sector
13 25 years
Supplementary
specialist
medicines
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
14 25 years
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
15 25 years
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:



Normative tools follow the Model List:



16 25 years
UN list of essential drugs for emergencies: 85 drugs
New Emergency Health Kit: 55 drugs for 10,000 people/3m
WHO Model Formulary
International Pharmacopoea
Basic Quality Tests and reference standards
Selection
The WHO Model List of Essential Medicines is a
model product, model process and public health tool






17 25 years
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, costeffectiveness and public health relevance
Rapid dissemination, electronic access
Regular review
Selection
WHO Essential Medicines Library
Combining information from various partners
WHO clusters
Clinical
guideline
WHO/EC, Cochrane
Reasons for inclusion
Systematic reviews
Key references
WHO/EDM
Summary of clinical guideline
BNF
WHO Model
Formulary
WHO
Model List
WHO/EDM
MSH
Cost:
UNICEF - per unit
- per treatment
MSF
- per month
- per case prevented
18 25 years
Statistics:
- ATC
- DDD
WCCs
Oslo/Uppsala
Quality information:
- Basic quality tests
- Intern. Pharmacopoea
- Reference standards
Promising developments
Practical implications of the access framework
1. Rational
selection
3. Sustainable
financing
ACCESS TO
ESSENTIAL MEDICINES
2. Affordable
prices
19 25 years
4. Reliable
systems
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
20 25 years
Promising developments
Advocacy, corporate responsiveness and competition
have reduced antiretroviral prices 95% in 3 years
Indicative annual cost per person for triple therapy in
Africa (US $)
$10,000
$8,000
UN Drug Access Initiative
$6,000
$4,000
Domestic production
$2,000
Accelerated access initiative
??
Generic offers
$0
1996
21 25 years
1997
1998
1999
2000
2001
2002
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)
22 25 years
Successful experiences with local supply systems and
regional bulk procurement
E. Caribbean
Drug Service
Guatemala:
Direct delivery
Northern Province, SA:
Contract distributor
23 25 years
Gulf States
Thailand, India:
Pooled procurement
Mission for
Essential Drugs
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
24 25 years
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