Essential drugs save lives

8 World Health • SlstYear, No. 2, March-April 1998 Essential drugs save lives Drugs being prescribed in Nepal. Proper prescription practices help ensure that drugs ore used effectively. Photo W HO/) Schytte Economic recession and rising health care costs have led to demands in the industrialized countries for beffer value for money through the use of a smaller range of generic drugs. It is estimated that countries can save up to 50% of their drugs budget through establishing an essential drugs list. Millions of people in develop-ing countries - many of them children under five - die needlessly every year from diseases that could be easily treated with safe, inexpensive drugs. Millions more are prescribed inap- propriate, often expensive, drugs which deplete foreign currency reserves and prevent investment in other public health priority areas. Elsewhere, people resort to self- medication with over-the-counter antibiotics - cutting short the treat- ment and increasing the global spread of drug-resistant organisms. Today, more than a third of the world's population lack regular access to essential life-saving drugs. In Africa, where many of the poorest countries have no more than US$ 1 per capita to spend on drugs, fewer than half have access to the basic drugs they need. In some cases, essential drugs may be unavailable or unevenly distributed throughout the country. Even where there is no shortage of drugs - in the new mar- ket economies of east and central Europe, for example - they may remain beyond the pockets of most people. To make matters worse, drugs may be ineffective due to poor quality control or improper prescrib- ing. WHO estimates that at least a third of all countries have no effec- tive regulatory agency to control the quality, procurement, and appropri- ate use of drugs. More than 110 countries are signatories to WHO's Certification Scheme on the Quality of Pharmaceuticals moving in International Commerce, but many countries are not using the scheme to verify whether a supplier meets WHO requirements. Elsewhere, efforts to assist peo- ple affected by war and natural disasters are often hampered by misguided donations of inappropri- ate drugs - prompted, in some coun- tries , by commercial incentives to donate. Aid workers are often on the receiving end of unwanted, poor quality, or badly labelled drugs, already beyond their expiry date. In the aftermath of the Armenian earth- quake in 1988, it took 50 people six months to sort out the 5000 tonnes of drugs and medical supplies received. Eight per cent had already expired on arrival and 4% were destroyed by frost. Of the rest, only 30% were easy to identify and only 42% of any use in an emergency situation. More recently, during the war in the for- mer Yugoslavia, some drugs more than 50 years old were sent to Mostar and aid workers were faced with the task of disposing of 340 tonnes of expired drugs. But all this is steadily changing. Today, over 120 countries have developed national essential drugs lists and about 60 countries have adopted, or are now drawing up, comprehensive national drug poli- cies. The WHO Action Programme on Essential Drugs is currently helping over 60 countries to develop new strategies for the financing , supply management, rational use, and quality control of drugs. And in a major breakthrough in 1996, WHO issued guidelines for drug donations in emergencies - a voluntary agree- ment reached in collaboration with the major international agencies involved in humanitarian relief work. They include stipulations that, in future, all drug donations should be made in response to a clearly expressed need, that donated drugs should be clearly labelled and have a shelf-life of at least one year, and that they should be obtained from a reliable source and comply with World Health • 51 st Year, No. 2, Morch-April 1998 Checking the arrival of drugs in Papua New Guinea. A national drug policy is a key to controlling the supply, promotion and use of drugs. Photo WHO/E. Lauridsen quality standards in both the donor and the recipient country. In addition, all donated drugs - or their generic equivalents - should appear on the national list of essential drugs or on WHO's Model List of Essential Drugs. The Action Programme on Essential Drugs was established in 1981 to ensure that all people have access to high quality essential drugs, at an affordable price, and that drugs are appropriately prescribed and used. The first Model List of Essential Drugs was drawn up by WHO 20 years ago, in 1977. It com- prised 200 items, all with generic names and most no longer patented. It was designed for adaptation to the health needs of individual countries and comprised the essential drugs needed to ensure a reasonable level of health care for as many people as possible. The list has undergone minor changes over the years and currently contains about 300 drugs. It is revised every two years . In 1978, the Declaration of Alma-Ata identi- fied access to essential drugs as one of the basic elements of primary health care. However, the idea of essential drugs was never intended to be restricted to developing countries. Today, economic recession and rising health care costs have led to demands in the industrialized countries for better value for money through the use of a smaller range of generic drugs. In Australia, for example, a list of essential drugs approved for reimbursement through a health insurance scheme contains about the same number of drugs as Zimbabwe's essential drugs list. It is estimated that countries can save up to 50% of their drugs budget through establish- ing an essential drugs list. Daphne Fresle, Editor of WHO's Essential Drugs Monitor, says the concept is based on universal princi- ples of equity, common sense, and sound, evidence-based medicine. "Every recommended drug has a weight of scientific evidence behind it and is the best product a country can afford" , she points out. "This is good, evidence-based medicine - not cheap, inferior medicine. It is as valid for the treatment of cancer, cardiovascular diseases and meta- bolic disorders as it is for malaria, acute diarrhoea, and pneumonia." But there is a lot more to it than drawing up a list of essential drugs. A comprehensive national drugs policy requires the enactment of new legislation to control the supply, promotion, and use of drugs. A supply and distribution network must be established, together with systems for the selection, procurement, fi- nancing, quality control , safe storage, and distribution of essential drugs. 9 Education and training are needed - for medical students, doctors , and consumers - to ensure that drugs are both prescribed and used correctly. And monitoring systems must be put in place. Failure to halt the growing resistance to first-line antibiotics, caused by overprescribing and pa- tient misuse of drugs , will force governments to switch to more expensive alternatives instead. Today, three-quarters of the world 's population live in developing countries, but they represent less than 20% of the global drug market, now valued at over US$ 200 OOO million. Spending on drugs accounts for one- third to two-thirds of total health .care costs in developing countries and transitional economies, with 60-90% of drug costs paid for out-of-pocket by those least able to pay. The trends are not encouraging. The cost of new drugs is rising - fuelled by higher research and development costs and by intellectual property rights . At the same time there is a growing demand for essential drugs in developing countries: to treat opportunistic infections, including tuberculosis, in the millions of people infected with the AIDS virus, for example, and to treat chronic diseases associated with changing lifestyles and ageing. And all this is happening against a back- drop of increasing privatization of cash-strapped health services. WHO maintains that if the goal of health for all is to be achieved, the supply of essential drugs cannot be left to market forces. Dr Hiroshi Nakajima, WHO 's Director-General, points out that the concept of essen- tial drugs is driven by the need for equity and meeting real health needs. "National drugs policies and essen- tial drugs programmes are now, and in the foreseeable future , the best means we have of pursuing and eventually attaining the dual objec- tives of rational management of drug resources and better health for all." •