Transcript Poster presentation - WHO archives

COMPARATIVE ANALYSIS OF
SELECTED ESSENTIAL DRUG
LISTS
AZIZ JAFAROV/RICHARD LAING
Presenter Name: Aziz Jafarov
Authors: Jafarov A, Laing R
Institution: Boston University
Title: Development of Essential Drugs Lists in Four Central Asian Republics
(Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan): Comparison and
Discrepancies
Problem Statement: In the mid-1990s, the World Health Organization (WHO)
introduced the essential drugs list (EDL) concept to the Central Asian Republics
(CARs) as a tool to improve pharmaceutical supply. By now, all the CARs have
developed national essential drugs lists and have even revised them. Although
the health indicators are very similar among the CARs, the EDLs of
Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan vary considerably.
Objective: To compare the current EDLs of Kazakhstan, Kyrgyzstan,
Tajikistan, and Uzbekistan, using the WHO Model List as the standard. By
looking at the essential drugs selected by each of the four countries, the national
lists have been analyzed and the main disparities have been highlighted.
Design: Comparative study.
Outcome Measures: Number of drugs by list; number of drugs from WHO
Model List; alternative drugs; additional drugs; number of drugs per therapeutic
group by list; number of forms and doses.
Results: The number of drugs on the lists varies between 236 and 368. The
WHO Model List suggests an average of 1.9 doses and forms per drug, and the
WHO list usually includes two forms and doses, and only rarely three or more.
The national lists include up to 14 forms and doses for some of the drugs. For
the countries of interest, the average number of doses per drug ranges from 1.5
to 3.5. The cardiovascular drugs included vary widely among the four countries.
Of 27 cardiovascular drugs on the WHO Model List, Kyrgyzstan included 12,
Uzbekistan 10, Kazakhstan 14, and Tajikistan 18. The alternative and additional
drugs chosen also showed substantial variation. Uzbekistan’s health
professionals included the highest number of alternative and additional drugs
with 25, while Tajikistan included 6 and Kyrgyzstan only 4.
Conclusions: The EDLs of Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan
are very different. The number of essential drugs included, the drugs selected
for the national lists (particularly cardiovascular and gastroenterology drugs),
and the excessive number of forms and doses for Kyrgyzstan and Uzbekistan
make the EDLs controversial. At least some of these four countries require
revision of their EDLs, and the selection process needs to move from
experienced-based medicine toward evidence-based medicine.
Study Funding: Boston University
INRODUCTION/BACKGROUND
• Pharmaceuticals are one of the most expensive components of health
care and may comprise up to 40 percent of the health budget in
developing and transitional countries. The Essential Drug concept was
developed in order to help countries make best use of available
finances for pharmaceuticals. The 1975 World Health Assembly
Report recognized the urgent problems caused by lack of essential
drugs in many countries. This was the first step towards developing the
World Health Organization Model EDL. Two years later, WHO
proposed the first Model List of Essential Drugs. Since 1977, the
WHO list has been revised every second year, when some drugs are
excluded and some others are added. The latest edition of the WHO
ED Model List from 2002 contains 324 active ingredients.
• “Essential drugs 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 the appropriate dosage forms, and at
a price that individuals and the community can afford”
INRODUCTION/BACKGROUND
• Correct selection and purchase of pharmaceuticals aims to improve the
affordability and quality of health care to the population.
Implementation of the ED concept starts with selection of drugs to be
on the national EDLs. The primary criteria for inclusion are accurate
clinical data on safety and efficacy of the drug, its availability, cost and
cost-effectiveness. Ideally the selection process should be consultative
and transparent; the criteria should be explicit and linked to evidencebased clinical guidelines
• Since 1995, WHO/EURO has promoted the development of national
essential drug lists for all of these Central Asian countries. All
countries have developed such lists and it now appears timely to make
a critical review of the selections made.
METHOD
• The method used in this paper compares the existing Essential Drug
Lists of Kazakhstan, Kyrgyzstan, Uzbekistan, and Tajikistan with the
WHO Model EDL List. The WHO Model EDL includes the
International Nonproprietary Names (generic names) and the form and
doses recommended. The EDLs of the countries also have such
information. At the same time, the EDLs of some of the countries, in
addition to this information, includes trade names, which are the same
as brand names. The WHO Model EDL sorts the drugs into 27
therapeutic groups, with drugs identified as “core” or complementary.
For the purpose of this analysis, we have combined core and
complementary drugs into a single master list.
METHOD
• For this paper a comparative table has been developed and
the 1999 WHO Model EDL was taken as the standard.
Drugs on national EDLs were classified as being: 1) on the
WHO Model EDL; 2) From the same therapeutic group; or
3) Not included on the WHO Model List. The numbers of
the trade/brand names mentioned in the national lists (in
the case of Tajikistan and Kazakhstan) were collected. In
addition, drugs were compared with those in the WHO
Model EDL.
• Based on the spreadsheet, summary tables were developed
for all the EDLs and the WHO Model List and some of the
therapeutic groups in order to compare with the national
and the WHO list.
RESULTS/FORM AND DOSES
Kazakhstan Kyrgyzstan Tajikistan Uzbekistan
Country
WHO
Drug name
Form Dose Form Dose Form Dose Form Dose Form Dose
Ibuprofen
1
2
3
6
5
5
1
2
6
4
Rifampicin
1
2
2
6
2
6
1
2
4
4
Ciprofloxacin
1
1
2
6
4
7
1
2
4
6
Erytromycin
1
4
2
7
4
9
1
2
4
6
Aciclovir
1
2
4
5
5
6
0
0
4
3
Isosorbite
1
1
3
5
1
4
1
1
5
5
RESULTS/CARDIOVASCULAR DRUGS
Organization
Country
Number of drugs
From WHO ML
Other Drugs
Total number of
drugs
WHO 1999
27
0
27
Kazakhstan
14
15
29
Kyrgyzstan
12
4
16
Tajikistan
18
6
24
Uzbekistan
10
25
35
RESULTS/GASTROINTESTINAL DRUGS
Organization
Country
Number of drugs
from WHO Model
List
Other drugs
Total number of
drugs
WHO 1999
12
0
12
Kazakhstan
7
16
23
Kyrgyzstan
6
7
13
Tajikistan
11
6
17
Uzbekistan
3
18
21
RESULTS/DRUGS AFFECTING THE
BLOOD
Organization
Country
Number of drugs
From WHO ML
Other Drugs
Total number of
drugs
WHO 1999
14
0
14
Kazakhstan
7
18
25
Kyrgyzstan
6
12
18
Tajikistan
9
2
11
Uzbekistan
6
25
31
DISCUSSION
• The number of drugs in the four countries ranges from 236 to 369,
including 136-200 drugs from the WHO Model List. Some of the
WHO ML drugs are not included in any of the national lists. Instead,
the national lists include other drugs, which raise the issue of evidencebased selection.
• Although the countries have similar disease indicators with about the
same level of health financing, except for Tajikistan, the EDLs in the
four countries vary substantially. This fact raises questions about the
selection process of the essential drugs included in the national lists
and perhaps to a certain extent questions whether the drugs included in
the WHO Model List are the right ones.
• Choices of cardiovascular and gastrointestinal drugs are among the
most controversial among the countries. Why are the choices so
different?
DISCISSION
• The different choices made about cardiovascular drugs and
gastrointestinal drugs show that the countries do have their own
opinions and are not pressured by WHO and other health organizations
involved in the development and updating of the EDLs to conform to
the WHO Model EDL. This suggests that at least in some of the
countries, the selection may not be evidence-based.
• Some countries, in addition to the generic name column, included a
column for brand name options. Perhaps this column is included for
educational purposes, because some health professionals are not
familiar with generic names. But inclusion of brand names for most of
the drugs in the list can lead to misinterpretation, particularly in
procurement and prescription practices. Including a brand name in the
EDL limits the procurement option to that particular brand name.
• What is the right number of forms and doses for a drug? For most of
the drugs, WHO suggests two forms and dosages. For example,
compared to the WHO average of 1.9 dosages per drug, Kyrgyzstan
averages 3.6 and Uzbekistan 3.5. But the national lists of some of the
countries show much higher numbers. How necessary is it to have 14
forms and doses of paracetamol?
CONCLUSION
• There has been a significant effort by the countries to implement the
ED Concept. All of the four countries have developed and revised their
EDLs. The total number of drugs included in the national lists is
reasonable. Local institutions contributed to the process of the
development and revision of the lists, and there is knowledge and
interest in the ED concept. The number of essential drugs among the
four countries, the drugs selected for the national lists, and the
excessive number of forms and doses make the lists controversial.
• WHO is moving towards evidence-based medicine, and the
organization is still strongly involved in the process of developing and
revising the EDLs. Perhaps the EDL concept will bring benefits if the
WHO will develop comprehensive guidelines on evidence-based
selection and create a database on essential drugs. This will facilitate
the selection process in the countries, which are deficient in human
resources and have limited financial capacity.
• The EDLs of the countries are very different. At least some of their
selected drugs and the selection process itself require radical revision.