Post on 06-Jan-2016
description
WHO/PSM
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
WHO/PSM
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
WHO/PSM
The number of drugs per prescription varies from 1.3 to 4.3 per primary care encounter
0.0 1.0 2.0 3.0 4.0 5.0
Ecuador
Guatemala
Eastern Caribean
El Salvador
J amaica
L.AMER. & CAR.
Yemen
Nepal
Indonesia
ASIA
Zimbabwe
Sudan
Tanzania
Uganda
Swaziland
Cameroon
Nigeria
Ghana
AFRICA
Number of drugs per prescriptionSource: Managing Drug Supply, 1997
Irrational use
WHO/PSM
Over-prescribing is costly- and spending on child health is highly cost sensitive
AzerbaijanDrugs61%
Fees, Other39%
Bangladesh
Drugs73%
Fees, Other27%
Mali
Fees, Other20%
Drugs80%
Source: Azerbaijan - UNICEF-Bamako Technical Report No. 35 ; Bangladesh 1995 - National Accounts 1996/97Mali (1986) - Diarra K and Coulibaly S. Financing of recurrent health costs in Mali. Health Policy and planning; 1990, 5(2);126-138
Drugs are the largest health expenditure for poor households
Irrational use
WHO/PSM
30 to 60 % of PHC patients treated with antibiotics- perhaps twice what is clinically needed
0% 10% 20% 30% 40% 50% 60% 70%
Guatemala
Jamaica
El Salvador
Eastern Caribean
L.AMER. & CAR.
Bangladesh
Nepal
Indonesia
ASIA
Zimbabwe
Tanzania
Ghana
Cameroon
Swaziland
Sudan
AFRICA
% of primary care patients receiving antibiotics
Source: Quick et al, 1997, Managing Drug Supply
Irrational use
WHO/PSM
Resistance to common pathogens is everywhere on the rise - S. pneumonia
0% 10% 20% 30% 40% 50% 60%
% prevelance of intermediate or high level resistance S. pneumoniae to pencillin, 1993-1997
Colombia
Ethiopia
Rwanda
Brasil
Egypt
Argentina
Saudi Arabia
Hong Kong
Japan
South Africa
Mexico
Summarized by WHO/GPV
Irrational use
WHO/PSM
Up to 56 % of primary care patients receive injections - over 90% may be medically unnecessary
0% 10% 20% 30% 40% 50% 60%
Eastern Caribean
J amaica
El Salvador
Guatemala
Ecuador
L.AMER. & CAR.
Nepal
Indonesia
Yemen
ASIA
Zimbabwe
Tanzania
Sudan
Nigeria
Cameroon
Ghana
AFRICA
% of primary care patients receiving injectionsSource: Quick et al, 1997, Managing Drug Supply
15 billion injections per year globally half are with unsterilized needle and
syringe by age 2 children in some countries
have received up to 20 injections
Irrational use
WHO/PSM
Injection use in Indonesia has been dramatically reduced through a combination of interventions
Effective interventions
Source: Santoso et al., 1996
0%
20%
40%
60%
80%
100%
1 3 5 7 9 11 13 15 17 19 21 23 25
Months
Pro
po
rtio
n o
f vi
sits
wit
h i
nje
ctio
n
Comparison group Interactive group discussion
Interactive group discussion (IGC group only) Seminar (both groups)
District-wide monitoring(both groups)
WHO/PSM
Review of 30 studies in developing countries Drug use improvements with various interventions
0
Improvement in outcome measure (%)
10 20 30 40 50 60
Large group training Small group training
Diarr. community case mgt
ARI community case mgt
Info/guidelines
Group process
Supervision/audit
EDP/Drug supply
Economic strategies
Minor Moderate Large
Source: Ross-Degnan et al, Plenary presentation, Conference on Improving the Use of Medicines, 1997, Chiang Mai, Thailand.
Effective interventions
WHO/PSM
Antimalarial treatment in Kenya has become more prompt and appropriate through shopkeeper training
% of surrogate shoppers
0%10%20%30%40%50%60%70%
1998 1999 2000 1998 1999 2000
Fevers treated with antimalarials Antimalarials given appropriately
Source: Marsh et al, 2001
Effective interventions
Southern zone Northern zone
Training Training
WHO/PSM
Actions to improve use of medicines:consider effectiveness and feasibility
• 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
Effective interventions
WHO/PSM
Trends in the use of medicines: 1988-2003 Source: WHO/PSM database 2004
0
10
20
30
40
50
60
88/9 90/1 92/3 94/5 96/7 97/8 00/1 02/3
Year
% p
ati
en
ts r
eceiv
ing
AB
/In
j
0
0.5
1
1.5
2
2.5
3
Av
. n
o.
dru
gs /
Px
% Px with AB (n=22) % Px with Inj (n=19) Av.no.drugs/Px (n=24)
n=average number of studies per year i.e. data point
Trends
WHO/PSM
Regional variation in prescribing 1990-2004
0
10
20
30
40
50
60
% Px with AB % Px with Inj % STG compliance
Asia Africa Lat. America
Source: WHO/PSM database August 2004
Baseline data covering all diseases and all ages
Trends
WHO/PSM
Public/private diarrhoea treatment: 1990-2004
0
10
20
30
40
50
60
70
ORS Antibiotics Antidiarrhoeals STGcompliance
% d
iarr
ho
ea c
ases t
reate
d
Private for profit Public
Source: WHO/PSM database 2004
Trends
WHO/PSM
0
5
10
15
20
25
30
35
FR GR LU PT IT BE SK HR PL IS IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL
DD
D p
er
1000 in
h. p
er
day
Variation in outpatient antibiotic use26 European countries, 2002
Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.
WHO/PSM
WHO data base: 844 interventions in 204 sites18% evaluated with adequate study design
38.3%
10.5%25.1%
7.6%
2.2%1.1%
7.2%
7.6% 0.4%Provider education
Consumer education
Printed materials
Supervision & audit
Community case mgt
Group process
Economic strategies
Essential drug prog
Regulation
Source: WHO/PSM database, ICIUM 2004
WHO/PSM
2nd International Conference forImproving Use of Medicines
http://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
WHO/PSM
AMR recommendations from ICIUM
1. Develop standard surveillance methodology for anti-microbial use and resistance, for community and hospitals
2. Develop, implement, evaluate targeted multi-component interventions, adapted to health care system and regulation
3. 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
4. Develop surveillance systems and regulation to control non-human antimicrobial use
WHO/PSM
Percentage of countries implementing national policies to promote rational use and contain resistance
0 10 20 30 40 50 60 70
STGs updated in last 5 years
EML for insurance reimbursement
Drug Info centre for prescribers
DTCs in most referral hospitals
Independent CME for prescribers
Drug use audit in last 5 years
AB public education in last 2 years
Px-only antibiotic (AB) availability
National Reference laboratory
National strategy to contain AMR
Source: pharmaceutical database WHO/TCM 2003
WHO/PSM
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
WHO/PSM
The WHO Essential Medicines Library, status 2005
WHOModel List
Summary of clinical guideline
Reasons for inclusionSystematic reviewsKey references
WHO Model Formulary
Link to price information
Quality information:- Basic quality tests- Intern. Pharmacopoea- Reference standards
Clinical guidelineRPS
WHO clusters
MSHUNICEF
MSF
WHO/QSM
WHO/EDM
WHO/EC, Cochrane, BMJ-CE
Statistics:- ATC- DDD
WCCs Oslo/Uppsala
Selection
WHO/PSM
Monitoring community cotrimoxazole resistance and use in Durban, S.Africa, 2002-3
0%5%
10%15%20%25%
10 11 12 1 2 3 4 5 6 7
% p
atie
nts
treat
ed
with
cot
ri
0%20%40%60%80%100%
% re
sist
ant
sput
um
isol
ates
PHC clinics Pharmacies Private Practitioners
H.influenzae resist. S.pneumoniae resist.
WHO/PSM
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