Essential Medicine

Monday Seminar of Public Health Department Faculty of Medicine –Assiut University

Egypt

By: Alyaa Hassan Abo-Rahma

Demonstrator of Public Health and

Community Medicine

Faculty of Medicine- Al-Azhar University

Following the Second World War there was great growth in the development of new medicine products

1960s…… wide range of medicines was available including antibiotics, analgesics, antihistamines, sedatives, cardiovascular medicines as well as vitamin supplements and growth hormones with little control in many countries. Anything could be sold and bought by anyone who could afford it.

1960 !!!!The Thalidomide

Tragedy

By 1960, Thalidomide was marketed in 46 countries, with sales

nearly matching those of aspirin.

The drug was withdrawn from sale

According to the World Health Report (WHO, 2008) ‘nearly 30 000 children die every day from diseases that could easily have been treated if they had had access to essential

medicines.’

The birth of the essential

medicine concept

Begin as Idea In the Twenty-eighth WorId Health Assembly. in 1975 the Director-General reviewed: • The main drug problems facing the

developing countries. • Outlined possible new drug policies. • Referred to the experience gained in some

countries where schemes of basic or essential drugs implemented.

Identified the primary health care as the key to reach the goal

of Health for All

The concept of essential medicine was mentioned in one

of the ten points of the 1978 Alma Ata declaration .

VIIPrimary health care:

3. includes at least:

.…promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs.

1981……WHO established the Action Programme on Essential drugs to implement national drug policy.

1998…..WHO created the department of essential drugs and other medicines (EDM).

Definition Of Essential Medicine

Essential medicines, as defined by the  (WHO) are "those drugs that satisfy the health care needs of the majority of the population; they should therefore be available at all times in adequate amounts and in appropriate dosage forms, at a price the community can afford."

Criteria For The SelectionOf Essential Drugs

The choice of selection depends on:1- pattern of prevalent diseases. 2- Priority of health problems.2-the treatment facilities.3-the training and experience of the available personnel.4-the financial resources.

Each selected drug must be available in a form in which adequate quality, including bioavailability, can be assured; its stability under the anticipated conditions of storage and use must be established.

If two or more drugs appear to be approximately similar →→ the choice between them should be made on the basis of

In cost comparisons between drugs, the cost of the total treatment, and not only the unit cost of the drug, must be considered.

Relative Efficacy Safty Quality Availab-

ilityCost

Essential Medicine And Primary Health Care

1-The pattern of endemic disease: The prevalence of major endemic infections and parasitic diseases may vary from region to region within a country. Careful planning and epidemiological surveys are required to ensure that the most effective drugs are provided.

2- Existing systems of medicine: The establishment of primary health care services in developing countries should not result in abrupt disruption of prevailing cultural patterns in rural communities.

3- The national health infrastructure.the proximity and nature of the first referral facilities.

4-Training and supplies: The numbers of trained personnel. Workers with one or more years' training can do more than personnel reliant upon an intensive course of practical instruction lasting only a few weeks.

Components Of A National Drug Policy

(1) Identifying therapeutic needs in the community.(2) Selecting essential drugs for the different levels of the health care system.(3) Estimating quantities needed for the various drugs. (4) Improving drug supply and management, including procurement, storage, distribution, and the related training of personnel.

(5) Ensuring the proper use of essential drugs through the provision of appropriate information and training.(6) Providing education for health workers and the general public for the proper use of drugs;(7) Developing financing mechanisms to ensure the availabilityAnd equality in the health care system;(8) Strengthening local production of certain(9) Ensuring quality control

(10) Introducing proper legislation covering such matters as drug registration; proprietary and generic names; quality Assurance(11) Ensuring coordinated multi-sectoral action by all other sectors involved, such as education, planning, finance, industry, trade.(13) An evaluation process to assess the progress ofthe national drug policy implementation.

WHO LIST

Classified by their therapeutic action

WHO list

Drug information sheet-Generic name of each active substance.-Clinical information: (a) Indications (b) Dosage pharmacokinetic data:-average and range for adults and children:-special situations, e.g., renal, hepatic, cardiac.-Contraindications.-Precautions and warnings -Adverse effects - Drug interactions - Over dosage:-Pharmaceutical information:-Dosage forms.-Storage conditions and shelf-life (expiry date).-Pack sizes.- Legal category (narcotic or other controlled drug.-Name and address of manufacturer.

The 1st WHO Model List of Essential Medicines for Children was developed by a sub-committee in July 2007.

Is Vaccine Considered Essential Drugs?WHO's creation of the Expanded Program on Immunization (EPI) in the 1970s established a policy for selection and use of vaccines that the vast majority of developing countries adopted. Only three vaccines: HepB, yellow fever (YF), and Haemophilus influenzae type B (Hib) have been added since then, and the overall program directions remain largely intact.

WHO national vaccine policy • Every eligible child must have equal access to

nationally adopted vaccines regardless of religion, caste, or economic status.

• Countries should strive toward financial Support for the national immunization program

Prescription and Rational Use of Drugs

the correct drug being given to the correct patient, for the correct indication, in the correct dosage, by the correct route of administration, for the correct duration of treatment.

Any error at any stage of this complex process can prevent the drug from being

effective.

Drug Quality• Storage:Temperature

Air, light• Deterioration:Color, Odour, Solubility.• Expiration:

• Limiting the use of injection: more cost• Limiting the use of syrup: incorrect dose• Shortest and least divided doses

The Essential Medicine Not Only Essential Drugs !!

But also essential equipment and supplies

A lot of information is available about essential drugs, and WHO

have produced model lists of essential drugs. Until recently, less information was available aboutmedical supplies and equipment,

despite the fact that there is a much wider range of different brands

Medical supplies and equipment

■ Supplies : Items that need to be replaced on a routine basis, including: disposable syringes and needles, items that are used within a short time, e.g. cotton wool, laboratory stains and tape; reusable items, e.g. catheters.

■ Equipment :Durable items that last for several years, e.g. beds, examination tables, sterilizers, microscopes.

Choosing equipment is often given little attention.Items can be inappropriate because they are technically unsuitable or incompatible with existing equipment, accessories or spare parts are not available, or because staff have not been trained to use them.

This can result in procurement of inappropriate equipment .

Quality Assurance

Definition :Planned and systematic actions that can be demonstrated to provide confidence that a product or services will fulfill the requirements for quality.

Importance

1-Ensure the ongoing quality, safety and effectiveness of medical devices2- Avoid medical device failures during critical medical procedures3-Improve clinical effectiveness and device availability4- Reduce patient and staff risk and improve patient confidence

Maintenance

Medical equipment should be maintained at a higher safety level than other types of equipment. Maintenance not only has a positive impact on the safety and effectiveness of healthcare technology, but also has two important economic benefits:1- It increases the lifetime of equipment and thus helps to save costs.2- It enhances the demand for health services.

Healthcare Equipment That Is Out Of Order Quickly Leads To A Decline In Demand, Which Will In Turn Reduce The Income And Quality Of Services Of The Health Facilities. The Hospital Will Lose Clients

CASE 1:a female aged 42, married with four children started taking T.B therapy in 2015 Though Anti T.B has improved her life, she still face huge difficulties adhering to the TTT.She has to travel 50 kilometers from her village to the nearest clinic every month. Mona starts her journey in the morning either on foot or if she is lucky, she finds a van which she pays an equivalent of 8USD to and fro.

Upon arrival at the clinic she usually waits for 5 to 6 hours and occasionally finds some food to eat which costs her nearly 0.5 USD.She finally see the doctor, who takes less than ten minutes to do routine check ups. Usually she gets no chance to ask questions, and too often the doctor is already overworked and moody.Furthermore, she may need to have liver tests and others investigations done, which cost a lot of money”.

Access means not only the availability of drugs at the health care institution, but also the ability of the patient to physically get them. Transport, meals, diagnostic tests and other related costs, act as barriers to access for many in the community. Furthermore adequate human resources to ensure patients receive adequate attention is a major factor in the success of treatment. Therefore though delivery of drugs and supply to the community is a major issue for the success of PHC, this must be accompanied by other supportive services.

Mr X a male aged 36, married with two children, diagnosed as urinary bladder carcinoma with bone metastasis this caused him severe pain that he could hardlysleep.He went to a public hospital where the doctor prescribed him a strong pain killer and advised him to visit a private clinic. He visited the clinic and he was in shock to find that the clinic belonged to the doctor who prescribed him the medicines in the public hospital.

“I was re-examined with some simple test and the doctor told me that I have to take the very pain killer he earlier prescribed.” He says. The price of the medicines was about 200$. He was forced to use the money he had reserved for rent since he was desperate.“After learning more about essential medicines, I discovered that the pain killer I was given at the private clinic was on the essential medicine drug list.” He says.

Drugs use IndicatorsCore drug use indicators :• Average number of drugs per patiant• Percentage of drugs prescribed by generic name• Percentage of patients with antibiotic

prescribed• Percentage of patients with injection prescribed• Percentage of drugs prescribed from essential

drug list

Patient care indicators:• Average consultation time• Patient knowledge of correct dosage• Percentage of drugs actually

dispensed• Average dispensing time.

The medicine situation

Accessibility : distance, quantity, quality, financial ((affordable )).Multiple source of supply :Governomental,NGOCorruption affect the selectionGood prescription writingSelf medication : challengeAffordable price

A non-functioning health care system can lead to unscrupulous practices. In addition a lack of understanding of what drugs are essential and therefore should be available at all times can be costly to the patients.

A primary health care system without medicines like

a river without water. (J. Escobal,2007)