Promoting rational use of medicines: a global perspective

1. 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

2. 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

3. Irrational use The number of drugs per prescription varies from 1.3 to 4.3 per primary care encounter Number of drugs per prescription Source: Managing Drug Supply, 1997

4. Irrational use Over-prescribing is costly- and spending on child health is highly cost sensitive 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

5. Irrational use 30 to 60 % of PHC patients treated with antibiotics- perhaps twice what is clinically needed % of primary care patients receiving antibiotics Source: Quick et al, 1997, Managing Drug Supply

6. Irrational use Resistance to common pathogens is everywhere on the rise - S. pneumonia Summarized by WHO/GPV

7. Irrational use Up to 56 % of primary care patients receive injections - over 90% may be medically unnecessary • 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

8. Interactive group discussion (IGC group only) Seminar (both groups) District-wide monitoring (both groups) Source: Santoso et al., 1996 Effective interventions Injection use in Indonesia has been dramatically reduced through a combination of interventions

9. Review of 30 studies in developing countries Drug use improvements with various interventions Minor Moderate Large 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 10 20 30 40 50 60 0 Improvement in outcome measure (%) Source: Ross-Degnan et al, Plenary presentation, Conference on Improving the Use of Medicines, 1997, Chiang Mai, Thailand. Effective interventions

10. Training Training Effective interventions Antimalarial treatment in Kenya has become more prompt and appropriate through shopkeeper training Southern zone Northern zone Source: Marsh et al, 2001

11. Effective interventions 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

12. Trends Trends in the use of medicines: 1988-2003 Source: WHO/PSM database 2004 n=average number of studies per year i.e. data point

13. Trends Regional variation in prescribing 1990-2004 Source: WHO/PSM database August 2004 Baseline data covering all diseases and all ages

14. Trends Public/private diarrhoea treatment: 1990-2004 Source: WHO/PSM database 2004

15. Variation in outpatient antibiotic use26 European countries, 2002 Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.

16. WHO data base: 844 interventions in 204 sites18% evaluated with adequate study design Source: WHO/PSM database, ICIUM 2004

17. 2nd International Conference forImproving Use of Medicineshttp://www.icium.orgChiang 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

18. 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

19. Percentage of countries implementing national policies to promote rational use and contain resistance Source: pharmaceutical database WHO/TCM 2003

20. 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

21. Selection The WHO Essential Medicines Library, status 2005 WHO clusters WHO/EDM Clinical guideline Summary of 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

23. 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