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 evidence-based 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

Country WHO Kazakhstan Kyrgyzstan Tajikistan Uzbekistan

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 evidence-based 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.