Update on selection, the EML, EMLC and implementation Suzanne Hill November 2009 Essential Medicines...
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Transcript of Update on selection, the EML, EMLC and implementation Suzanne Hill November 2009 Essential Medicines...
Update on selection, the EML, EMLC and implementation
Suzanne Hill
November 2009
Essential Medicines & Pharmaceutical Policies
Essential Medicines & Pharmaceutical Policies
Quick quiz
What is an essential medicines list?
Why bother?
How does WHO produce the Model List?
What do countries do with it?
Essential Medicines & Pharmaceutical Policies
The essential drugs concept is nearly universal
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.
Essential Medicines & Pharmaceutical Policies
The ideal….
Treatment guidelines
Prescribing and use
measurement and evaluation
Essential medicines list
Procurement and supply systems
Essential Medicines & Pharmaceutical Policies
Currently…WHO Model List
16th EML – now lists all medicines that are OK for adults AND children, age restrictions, formulations
2nd EMLc – children's medicines, age restrictions, neonates
Evidence based
Transparent
Declarations of interest
Essential Medicines & Pharmaceutical Policies
Essential Medicines & Pharmaceutical Policies
Using evidence…..
Should dihydroartemisin-piperaquine be In the WHO treatment guidelines? On the Model List?
Sinclair D, Zani B, Donegan S, Olliaro P, Garner P. Artemisinin-based combination therapy for treating uncomplicated malaria. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007483. DOI: 10.1002/14651858.CD007483.pub2.
Essential Medicines & Pharmaceutical Policies
Essential Medicines & Pharmaceutical Policies
Essential Medicines & Pharmaceutical Policies
Essential Medicines & Pharmaceutical Policies
Should lamotrigine be added to the Model List for the treatment of epilepsy , particularly in children?
Essential Medicines & Pharmaceutical Policies
GRADE example – lamotrigine in children?
Essential Medicines & Pharmaceutical Policies
The tyranny of evidence…
Using GRADE – not easy for observational studies (eg safety) Getting evidence -
Palliative care – GOBSAT paper from 2007, no advance Neonates – comprehensive review, we know what doesn't exist Data on doses, especially in small children - regulatory
approval as proxy?
Getting applications Artesunate+amodiquine Cytotoxics for children
Cost-effectiveness
Essential Medicines & Pharmaceutical Policies
Discrepancies…and difficulties to explain…
Section 8.4, palliative care No medicines listed for grown-ups Long list for children
Section 28 – ENT medicines, children only
Salts/actives – still need to be sorted
Probably too many liquids
Essential Medicines & Pharmaceutical Policies
Essential Medicines & Pharmaceutical Policies
The ideal….
treatment guidelines
Prescribing and use
measurement and evaluation
Essential medicines list
Procurement and supply systems
Essential Medicines & Pharmaceutical Policies
And the problem with guidelines…
Non-communicable diseases, no guidelines (except mental health)
Dermatology – no department
Surgical care – no money to update
Essential Medicines & Pharmaceutical Policies
And then there is implementation…
Essential Medicines & Pharmaceutical Policies
Implementation….Comparison with 2009….
Ethiopia (2002)
Eritrea ?
Ghana (2004)
Kenya (2003)
Nigeria (2003)
Tanzania (2007)
Uganda (2001)
Zambia ?
Cameroun (2007)
Rwanda (2004)
Senegal (2003)
Essential Medicines & Pharmaceutical Policies
National processes
Repeated cycles of consultation
No use of evidence (notable exceptions)
Little use of WHO list
Limited linkages with the pharmaceutical sector
Essential Medicines & Pharmaceutical Policies
Content of national lists
Model EML changes not reflected - Chronic disease Analgesics Deletion of symptomatic treatments (eg cough syrups) Harmonisation with treatment guidelines – eg HIV, malaria,
TB Psychotherapeutic medicines (eg substance abuse) Age appropriate dosage forms Medicines for neonates
Essential Medicines & Pharmaceutical Policies
Medicines of note
Adult/general ether Pethidine/fentanyl/
pentazocine Ipecacuanha Clonidine, hydralazine,
methyldopa, reserpine Antitussives Ergotamine (migraine) Pralidoxime antimalarials
Maternal & Child Zinc sulphate Salbutamol (oral, tocolytic) Various contraceptives Caffeine citrate Oral ergometrine Aminophylline/ theophylline
Essential Medicines & Pharmaceutical Policies
The ideal….
treatment guidelines
Prescribing and use
measurement and evaluation
Essential medicines list
Procurement and supply systems
Essential Medicines & Pharmaceutical Policies
Medicines included in survey (n=22)
Albendazole chewable tabs 200mg (2), suspension 100mg/5ml 20ml
Amoxicillin suspension 125mg/5ml 100ml
Artemether+lumefantrine tablet 20mg + 120mg (16 tabs)
Beclometasone inhaler 50mcg/dose 200doses
Ceftriaxone injection 1 gram, 250mg
Co-trimoxazole suspension 200mg + 40mg/5ml 100ml
Isoniazid tablets 100mg 1000 tablets
Mebendazole chewable tabs 100mg (6), syrup 100mg/5ml 30ml
Nevirapine syrup 50mg/5ml 100ml
Nystatin drops 100,000 IU/ml 30mls
ORS packet for 1 litre or 500mls
Paracetamol syrup 120mg/5ml 100ml
Rifampicin syrup 100mg/5ml 200ml
Salbutamol inhaler 100mcg/dose 200 doses, spacer device for inhaler
Vitamin A 100,000IU(30mg) 1000 capsules, liquid 50,000IU/ml 30
Zinc dispersible tablets 20mg (100)
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Proportion of survey medicines in EML, STGs and Central Medical Stores (CMS)
01020304050
60708090
100
% o
f med
icin
es a
vaila
ble
EML STG CMS #1
Essential Medicines & Pharmaceutical Policies
Proportion of survey medicines in EML, STGs, Central Medical Stores and NGO Stores
0
10
20
30
40
50
60
70
80
90
100
% o
f m
ed
icin
es
av
aila
ble
EML STG CMS NGO
Essential Medicines & Pharmaceutical Policies
Paediatric medicine availability, 2006
0
10
20
30
40
50
60
70
80
90
100
amox
icillin AL
Ceftriax
one
cotri
mORS
Vit A zinc
%
% facilities with medicinesavailable
% countries with medicines inEMl/STG
Essential Medicines & Pharmaceutical Policies
What to do?
Essential Medicines & Pharmaceutical Policies
Fishbone Diagram identifying requirements for the use of Magnesium Sulphate in a health facility
Use of MgSO4
MgSO4 is registered in the
country
Appears in NEDL
Licensed for use in pre-eclampsia and eclampsia
STGs for MgSO4 exist
Health facility has translated
STG into suitable local
protocol
MgSO4 supplied to
health facility
Suitable procurement
procedure is in place
Women have access to antenatal care
Pre-eclampsia and eclampsia correctly
diagnosed
Equipment and supplies available to diagnose pre-
eclampsia
Trained staff available to administer
MgSO4
Health professionals
aware that MgSO4 is the
first line treatment for severe pre-
eclampsia and eclampsia
Staff are trained to
use MgSO4
Equipment and supplies available to administer
MgSO4
Essential Medicines & Pharmaceutical Policies
Essential Medicines & Pharmaceutical Policies
What to do?
Better communication Can the web site be content based rather than function?
Better dissemination Needs money
Problem-based approach to implementation work with disease/condition groups Think about the pharmaceutical sector, not technical skills
Not just selection!
Essential Medicines & Pharmaceutical Policies
No product, no program, no system, no outcome
Essential Medicines & Pharmaceutical Policies