Improving Use of Medicines
- Where are we today?
Kathleen A Holloway
Regional Advisor Essential Drugs and Other Medicines
World Health Organisation, South East Asia
World Health
Organization
Regional Office for South-East Asia
A history
• Definition of rational use of drugs Nairobi 1985
– WHO Resolution WHA 39.27 endorses definition and recommends
strategy to promote rational use of drugs/medicines (RUM)
• INRUD formed in 1990
– WHO/INRUD indicators & training courses developed
• ICIUM 1 in 1997
– Experience of interventions mostly in public PHC shared
– Recommendations to (1) work on hospital DTCs & drug use
indicators, (2) community drug use & (3) impact of policies on use
• ICIUM 2 in 2004
– Experience in 25 areas of drug use shared
– Recommendations to (1) implement national programs to improve
use, (2) scale up successful interventions in sustainable way & (3)
implement interventions in the community
• Resolution WHA60.16 on rational use of medicines, 2007
– Incorporated major recommendations from ICIUM 2, but ….
– Lack of funds to implement recommendations
WHO Actions
• WHA60.16: Progress in rational use of medicines, 2007
– Urges Member States to “consider establishing and/or
strengthening…a full national programme &/or multidisciplinary
national body, involving civil society and professional bodies, to
monitor and promote the rational use of medicines”
• SEAR/RC64/R5: Nat. Essential Drug Policy & RUM, 2011
– Urges Member States to “establish or strengthen a dedicated
department/division/unit in the government, guided by a broad-based,
long-term, independent steering committee …to monitor medicines
use and coordinate strategies to promote rational use of medicines …
and to develop a roadmap for action based on a situational analysis”
• WHO activities 2007-2011 - with very limited funds
–
–
–
–
–
Promoting Essential Medicines Concept – EMLs, STGs
Supporting training on promoting RUM in community, PHC, hospitals
Monitoring (1) drug use in PHC & (2) drug policy implementation
Research on cost-effective interventions & evidence-based advocacy
Developing situational analysis tool for use by countries to identify
problems and solutions to inform national planning
WHO database on medicines use in
primary care 1990-2009
% guideline adherence
60
50
40
30
20
10
0
Irrational use
continues …
Children: diarrh treatment
70
60
50
40
30
<1992
'92-7
'98-03
'04-9
Africa (n=12,59,54,28)
L.America (n=2,15,11,1)
Europe/Mediterr (n=2,12,15,2)
Asia/Pacific (n=2,37,23,4)
ICIUM 2011: Abstracts 337 & 338
20
10
0
Private for Profit
Public
% diarrh. given ORS (n=8,69)
% diarrh. given ABs (n=6,58)
% diarrh. given anti-DDs (n=4,31)
Intervention impact: largest % change in any
medicines use outcome measured in each study
ICIUM 2011: Abstracts 337 & 338
Intervention type
No. studies Median impact 25,75th centiles
Printed materials
6
8%
4%, 10%
National policy
6
17%
4%, 23%
Economic strategies
8
13%
8%, 19%
Provider education
29
17%
9%, 22%
Consumer education
3
26%
13%, 27%
Provider+consumer ed
16
21%
11%, 24%
Provider supervision
26
18%
14%, 31%
Provider group process 9
36%
19%, 59%
Essential drug program 4
27%
22%, 40%
Community case mgt
10
33%
28%, 39%
Provider+consumer
educ & supervision
7
40%
18%, 54%
National policies in place to promote rational use
Source: MOH Pharmaceutical policy surveys 2003 & 2007
Drug use audit in last 2 years
National strategy to contain AMR
Antibiotic OTC non-availability
Public education on antibiotic use
DTCs in >half general hospitals
Drug Info Centre for prescribers
Obligatory CME for doctors
Med students trained on EML/STGs
STGs updated in last 2 years
EML updated in last 2 years
2007 (n>85)
0
2003 (n>90)
20
40
60
80
% countries implementing policies
100
Do countries with drug policies have better
use than those without?
• Data sources:
– WHO databases on pharmaceutical policy (as
reported by MOHs in 2003 & 2007) and
medicines use 2002 - 2008 from 58 countries
• Outcome:
– Difference in 12 medicine use indicators
between countries with policy & without policy,
expressed as % better (+) or % worse (-) use
• Analysis:
– Median of % better or worse use across all 12
indicators calculated for countries with policy as
compared to those without policy
– Linear regression of the number of policies
identified to “impact” on drug use positively vs
each drug use indicator in each country
ICIUM 2011:
Abstract 339
% better/worse drug use associated with policies
Policy (+ = better; - = worse)
Drug & Therapeutic Committees in > hosps
Composite
indicator
+ 21%
Indicator median
(25,75 percentiles)
+ 8%
(1,16)
Drugs free: <5years and all ages
+15 to 21% +10 to12% (3,18)
Undergrad nurse/doc training on EML/STG
+8 to 23%
Dedicated MOH unit on Rational Drug Use
+ 12%
+ 9%
(5,21)
National Drug Information Centre
+ 8%
+ 6%
(3,11)
Public education on Antibiotic use
+ 6%
+ 8%
(2,11)
National strategy to contain AMR
+18%
+ 5%
(3,16)
Ess.Med.List (EML) updated in last 2 years
+15%
+ 3%
(1,6)
Antibiotics available Over the Counter
-21%
- 9%
(-12,-2)
Drug sales revenue used for salaries
-12%
- 6%
(-12,-1)
Prescribing by staff of < 1 month training
-20%
- 2%
(-4,-1)
-8 to -20%
- 13%
(-16,-1)
Continuing Med. Education for health staff
ICIUM 2011: Abstract 339
+ 7 to 12% (4,19)
Correlation of AB use for viral upper respiratory
tract infection and number of policies
Nigeria
% viral URTI cases
treated with ABs
120
India
100
Brazil
Malaysia
80
60
China
40
20
Oman
0
R=-0.57
B=-3.24
P<0.001
0
5
10
Adjusted no. policies (out of 18)
ICIUM 2011: Abstract 339
15
20
♦ Country
Other progress
• European AMR containment strategies
– EARSS / ESAC surveillance, National coordination programs (Cars
2007), public education programs (Huttner et al 2010)
• Quantitative reviews intervention effectiveness
– IMCI (HPP 2010), Health Worker Performance (abstract 445)
• Development of a national situational analysis tool to inform
national planning to promote rational use of drugs
– SE Asian region (abstract 611), S.Africa (abstract 420)
• Development of monitoring tools, indicators and
intervention to improve adherence to ARVs
– Sub-Saharan Africa (abst. 505, 532, 542, 543, 544, 545, 817, 1121)
• Costing of irrational use
– Using WHO databases (abstracts 343, 358)
• Community-based surveillance of antibiotic use and AMR
– India & South Africa (abstracts 340, 341, 353, 354, 556, 582, 584)
Situational Analyses S. E. Asia 2010-2011
Sri Lanka, Bangladesh, Maldives, Bhutan, Indonesia, Nepal, Myanmar
• Few countries know what drugs they are using:
– Little monitoring of drug consumption or prescription audit
– Drug supply systems are mostly manual and inefficient with poor
quantification and stock management
• Most countries have multiple brands of the same drug:
– 500+ ‘brands’ of some drugs e.g. ABs, analgesics in some countries
– “We cannot limit the number of products for a particular molecule
registered because of complaints of the monopolies commission”
– “Having so many ‘brands’ makes it difficult to regulate the market
and convince doctors and patients to follow any EML”
– “We had to choose the lowest priced tender because of new
government financial rules even though we knew it may result in
non-delivery due to supplier default”
• Essential Drug Lists are generally not used:
– By public hospitals, the private sector or insurance companies
• Workshop to discuss issues and identify solutions:
– Greatly appreciated in all countries
Indonesian “puyer”: pulverizing 2 or
more (often 5-10) drugs into a powder
and then allocating doses by eye
Indian private practice: every 4th 'patient'
is a drug company representative
Nepal Health Worker Views
Auxiliary Health Worker (1 year
Funeral pyre in remote N. E. Nepal
trained paramedic in Health Post)
“For children under 5 years with
pneumonia I must give amoxy syrup
according to IMCI guidelines. Since
we are short of amoxy syrup & have
short-dated chloramphenicol syrup, I
am prescribing it to children of more
than 5 years with pneumonia in order
to use up the stock.”
First, do no harm. How can we
ensure that drug misuse does not
contribute to untimely deaths?
Peon (untrained assistant in sub-HP)
“When doctor saab is not here I do
dressings and give out cetamol. For
young children I give cotrim.”
Challenges
• Lack of institutionalisation to promote RUM
– Often there is no unit in MOH doing monitoring or coordination of
interventions & policies to promote RUM
• Lack of investment & policy implementation
• Fragmentation of health systems, largely driven by donors
• Imbalance of drug information
– Most prescribers get their information only from drug company
representatives
• Lack of pharmaceutical public health experts
– Medicine issues are not taught in most public health degrees
– Public health has fragmented into sub-specialities with limited
pharmaceutical public health & general public health expertise
• Research needs
– How to develop national integrated health system approaches to
promote RUM & how to monitor policy implementation
– Impact of “non-health” (e.g. fiscal) policies on health & medicine use
The Reality
• Continued irrational use & lack of action to tackle it is
the biggest public health scandal of the 21st century
• Irrational use is bad news & nobody likes to hear about it
– Many countries are unwilling & most donors do not fund projects to
promote rational use of medicines
• WHO programs on promoting RUM
– Most international training & research stopped due to lack of funds
– Unless funds come, WHO's databases to monitor drug use,
intervention impact & pharmaceutical policy will be abandoned and
there will be no data for advocacy or another WHA Resolution
• Searching for funds for WHO post WHA60.16 (2007)
– Many proposals & letters of intent developed but not one accepted
– Donors not happy even to have RUM component in umbrella grant
– "We only deal with getting the drugs to the country, WHO should
deal with how the drugs are used"
– "This project would take too long & we need results in 3 years"
Ways Forward
• Develop contextualised national coordinated plans of
action based on a situational analysis
– WHO developing a tool but lacks funding
• Training & research in the pharmaceutical sector
– Schools of public health should teach about the pharmaceutical
sector, clinical pharmacology & pharmacy courses should teach
the skills of drug use monitoring, formulary management, DTCs
– Journals should publish much more on drug policy & use research
• Continue to monitor the situation and any progress:
– Drug use, intervention impact & pharmaceutical policy impact to
provide evidence for advocacy + another WHA Resolution
• Spend 5% of all medicines budget on promoting RUM
– All donors should contribute
• Move from research to activism for change and replace
competition with collaboration and cooperation
Continue the debate
We know what to do but we are not doing it, so we need
continued political pressure and debate
– WHA60.16 requires 2 yearly reporting to the WHA, so use the
opportunity to continue the debate & get another Resolution
– Lobby for national, regional, international multi-stakeholder
collaboration in development of the pharmaceutical sector e.g. ….
– All donors supplying medicines agree to allocate some of their funds
to monitoring use & promoting RUM (for ALL medicines)
– Pharma companies agree to limit & publicly declare their
promotional activities & stop all adverts promoting inappropriate use
For adoption of WHA 60.16, my sincere thanks go to:
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Member States
International Network for Rational Use of Drugs
WHO Colleagues
Networks and NGOs
– Essential Drug Project, UK; Ecumenical Pharmaceutical Network;
Health Action International; REACT: Action on Antibiotic Resistance