Promoting rational use of medicines: a global perspective

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Promoting rational use of medicines a global
perspective

• Hans V. Hogerzeil, MD PhD FRCP Edin
• Director,
• Medicines Policy and Standards
• World Health Organization
• www.who.int/medicines

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The problem

• Increasing antimicrobial resistance
• 70-90 resistance to original 1st line
  antibiotics for dysentery (shigella), pneumonia
  (pneumococcal), gonorrhoea, and hospital
  infections (staph. aureus)
• Driven by over-use and inappropriate use of
  antimicrobials and poor infection control
• Over-use incorrect use medicines
• Over half of all prescriptions are inappropriate
  or incorrect
• Over half of all medicines are not taken
  correctly by patients
• One-third of the world's population does not have
  regular access to essential medicines

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The number of drugs per prescription varies from
1.3 to 4.3 per primary care encounter
Irrational use
Number of drugs per prescription
Source Managing Drug Supply, 1997
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Over-prescribing is costly- and spending on
child health is highly cost sensitive
Irrational use
Drugs are the largest health expenditure for poor
households
Source Azerbaijan - UNICEF-Bamako Technical
Report No. 35 Bangladesh 1995 - National
Accounts 1996/97 Mali (1986) - Diarra K and
Coulibaly S. Financing of recurrent health costs
in Mali. Health Policy and planning 1990,
5(2)126-138
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30 to 60 of PHC patients treated with
antibiotics- perhaps twice what is clinically
needed
Irrational use
of primary care patients receiving antibiotics
Source Quick et al, 1997, Managing Drug Supply
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Resistance to common pathogens is everywhere on
the rise - S. pneumonia
Irrational use
Summarized by WHO/GPV
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Up to 56 of primary care patients receive
injections - over 90 may be medically unnecessary
Irrational use

• 15 billion injections per year globally
• half are with unsterilized needle and syringe
• by age 2 children in some countrieshave received
  up to 20 injections

of primary care patients receiving injections
Source Quick et al, 1997, Managing Drug Supply
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Irrational use is a widespread hazard to health
other examples
Irrational use

• 25-75 antibiotics in teaching hospitals are
  inappropriate
• over 2/3 of antibiotics without prescription in
  many countries
• 90 of consumers buy 3-days supply of antibiotics
  or less
• Private providers in India use 80 different TB
  regimens
• 50 of people worldwide fail to take medicines
  correctly

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Injection use in Indonesia has been dramatically
reduced through a combination of interventions
Effective interventions
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Effective interventions
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Antimalarial treatment in Kenya has become more
prompt and appropriate through shopkeeper training
Effective interventions
Southern zone
Northern zone
Source Marsh et al, 2001
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Actions to improve use of medicinesconsider
effectiveness and feasibility
Effective interventions

• Recommended approaches
• Standard treatment guidelines
• Essential drugs list based on treatments of
  choice
• Hospital pharmacy and therapeutics committees
• Problem-based pharmacotherapy training
• Problem-based in-service and continuing education
• Promising approaches
• Interactive group process among providers and
  consumers
• Pharmacist and drug seller training
• Consumer involvement in public education

Source Laing, Hogerzeil and Ross-Degnanl, Health
Policy and Planning, 2001
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Trends in the use of medicines 1988-2003
Source WHO/PSM database 2004
Trends
naverage number of studies per year i.e. data
point
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Regional variation in prescribing 1990-2004
Trends
Source WHO/PSM database August 2004 Baseline
data covering all diseases and all ages
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Public/private diarrhoea treatment 1990-2004
Trends
Source WHO/PSM database 2004
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Variation in outpatient antibiotic use26
European countries, 2002
Source Goosens et al, Lancet, 2005 365
579-587 ESAC project.
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WHO data base 844 interventions in 204 sites18
evaluated with adequate study design
Source WHO/PSM database, ICIUM 2004
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2nd International Conference forImproving Use of
Medicineshttp//www.icium.org Chiang Mai,
Thailand, 2004,472 participants from 70
countries.

• Recommendations for countries to
• Implement national medicines programmes to
  improve medicines use in private and public
  sectors
• Long term with in-built monitoring system
• Scale up successful interventions
• Coordinated multi-faceted rather than single
  interventions
• Implement interventions to address community drug
  use
• School programs, and regulation of pharmaceutical
  promotion

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AMR recommendations from ICIUM

• Develop standard surveillance methodology for
  anti-microbial use and resistance, for community
  and hospitals
• Develop, implement, evaluate targeted
  multi-component interventions, adapted to health
  care system and regulation
• Focus on high priority areas to contain AMR such
  as
• Infection control, surgical prophylaxis, use by
  drug sellers
• Regulatory approaches to restrict use of some
  antimicrobials
• Incentives to prescribers and consumers
• Inclusion of AMR in graduate curricula and CME
• improved quality control of laboratories for AMR
  surveillance
• Develop surveillance systems and regulation to
  control non-human antimicrobial use

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Percentage of countries implementing national
policies to promote rational use and contain
resistance
Source pharmaceutical database WHO/TCM 2003
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What is WHO doing to promote rational use?

• Advocacy for the rational use of medicines (RUM)
• Essential Drug Monitor, effective drug info,
  meetings, ICIUM
• Model Formulary process
• Model List of Essential Medicines, Essential
  Medicines Library, WHO Model Formulary (five
  languages)
• Training programmes - about 250 participants/year
• Promoting rational use of drugs at primary health
  care, community levels and hospital levels (Drugs
  and Therapeutic Committees)
• WHO Global Strategy on antimicrobial resistance
• Operational research, advocacy for implementation
• Intervention research to promote RUM
• Identifying cost-effectiveness of interventions
  and policies
• Database to monitor trends in use and impact of
  interventions

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The WHO Essential Medicines Library, status 2005
Selection
WHO clusters
WHO/EDM
Summary of clinical guideline
Clinical guideline
RPS
WHO Model Formulary
WHO/EC, Cochrane, BMJ-CE
Reasons for inclusion Systematic reviews Key
references
WHO Model List
WHO/QSM
Statistics - ATC - DDD
MSH UNICEF MSF
Quality information - Basic quality tests -
Intern. Pharmacopoea - Reference standards
Link to price information
WCCs Oslo/Uppsala
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Conclusions

• AMR and irrational use of antimicrobials is a
  very serious global public health problem
• Much is known about how to improve rational use
  of medicines but much more policy implementation
  is needed at the national level
• Rational use could be greatly improved and
  resistance contained if a fraction of the
  resources spent on medicines were spent on
  improving use