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