update on selection, the eml, emlc and implementation

Update on selection, the EML, EMLC and implementation

Suzanne Hill

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?


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.


The ideal….

Treatment guidelines

Prescribing and use

measurement and evaluation

Essential medicines list

Procurement and supply systems


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


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.


Should lamotrigine be added to the Model List for the treatment of epilepsy , particularly in children?


GRADE example – lamotrigine in children?


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


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


The ideal….

treatment guidelines

Prescribing and use





And the problem with guidelines…

Non-communicable diseases, no guidelines (except mental health)

Dermatology – no department

Surgical care – no money to update


And then there is implementation…


Implementation….Comparison with 2009….

Ethiopia (2002)

Eritrea ?

Ghana (2004)

Kenya (2003)

Nigeria (2003)

Tanzania (2007)

Uganda (2001)

Zambia ?

Cameroun (2007)

Rwanda (2004)

Senegal (2003)


National processes

Repeated cycles of consultation

No use of evidence (notable exceptions)

Little use of WHO list

Limited linkages with the pharmaceutical sector


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


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


The ideal….

treatment guidelines

Prescribing and use





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)


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


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


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


What to do?


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


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!


No product, no program, no system, no outcome

update on selection, the eml, emlc and implementation

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