The essential medicines concept is an important tool for deciding which drugs are needed. It is based on the principle that a limited number of drugs (called essential medicines) will treat the majority of health problems for a given population.
An essential medicines list (EML) focuses on a small, carefully selected list of drugs. Obtaining, distributing and managing drugs can be more efficient and cost-effective when focused on a limited number of products. EMLs are usually based on treatment guidelines and local treatment needs. Prescribing can also be safer and more effective, because health workers and patients can become familiar with the effects and uses of a limited number of drugs. EMLs and treatment guidelines can be used as a basis for training health-care workers.
A Model list of essential medicines, developed by the World Health Organization (WHO), is arranged according to types of disease, with individual drugs listed under each disease. The model list provides an example of good practice of an EML and can be used to advocate a national EML. In some countries, the EML also shows who may prescribe each drug and where they may use them. The national EML should be available from the Ministry of Health, a pharmacist or government hospital.
New drugs are often expensive and, because they are new, there is limited experience in using them, so they may not be included in an EML. However, some new drugs prove to be lifesaving or necessary for tackling serious public health problems and might be important enough to add to an EML. If prices are high, most people will not have access to them. As time passes, new drugs should become cheaper and more accessible and there will be more experience to judge their safety and effectiveness. National EMLs should therefore be updated regularly - for instance, every year or two.
Essential medicines lists for NGOs/CBOs: Based on local treatment needs, NGOs/CBOs providing HIV/AIDS-related treatment can make their own EML, using the national EML or the WHO Model list of essential medicines as an example. If the NGO/CBO works mainly in the community, it should try to work in line with government guidelines and EMLs for primary health care. It should include only the drugs that are essential for the organization's specific work. In this way, NGO/CBO staff can learn more about the effects and use of the limited range of drugs and ensure that reliable supplies continue to be available.
An NGO/CBO involved in HIV/AIDS-related treatment might include the following on its EML:
• drugs for pain or fever, such as aspirin, paracetamol or morphine;
• drugs for infection, such as co-trimoxazole;
• drugs for diarrhoea, such as oral rehydration salts and charcoal tablets;
• drugs for skin problems, such as calamine lotion and promethazine tablets; and
• drugs for nutrition problems, such as vitamins and iron.
The list should be regularly monitored and formally reviewed at least once a year. Training for care and treatment should include training about the essential medicines concept and about the rational use of drugs. Systems will also be needed to record and monitor the use of drugs and ensure that adequate supplies are maintained.
Case study - Drug provision in Lusaka, Zambia
The Catholic Diocese of Lusaka developed a home-based care programme to coordinate the work of 35 community projects providing support, prevention, and pastoral and medical care to people living with HIV/AIDS. The diocese provided the necessary drugs, and training for their use, through its central office in the city.
Bulk drug supplies were distributed regularly to the projects. But this depended on using a standard list of drugs and other materials for treating common problems - an essential medicines list. This was developed by modifying government lists created for general community health care and including items that were particularly relevant to people living with HIV/AIDS. The programme manager also developed simple systems for ordering and recording the use of the drugs. She made sure that project workers understood the importance of keeping good records to get adequate quantities of the right drugs for their work.
But accurate records also allowed the managers to see how drugs were being used. They focused training sessions on needs for accurate diagnosis and rational prescribing. They were also able to highlight where something unusual was happening, such as high amounts of antibiotics being used. By coordinating the different records, they identified specific training needs and improved diagnostic and prescribing skills among the health workers. Patients benefited from these improvements in care and became more confident about dealing with their health needs.
Participatory group activity
To raise awareness about the concept and use of essential medicines lists (EMLs).
Before starting this activity, the facilitator needs to get a copy of the national EML for each participant. If this is not available, copies of the World Health Organization's Model list of essential medicines can be used instead.
1. Explain the aim of the activity.
2. Present participants with the concept of essential medicines and the importance of having an EML (see previous page).
3. Ask participants to brainstorm about a list of drugs that are commonly used for HIV/AIDS-related treatment in the local community.
4. Give participants a copy of the national EML. Ask them to identify if the drugs that they have brainstormed about are on the list.
5. If some of the drugs discussed by participants are not on the EML, ask participants to assess whether that is reasonable or whether the EML should be changed. If they decide on the latter, ask them how they would ensure that the change took place.
6. Facilitate a group discussion about what has been learned from the activity, based upon questions such as:
• What factors decide whether a drug should be on an EML?
• Why should NGOs/CBOs have their own EML?
• Ensure that participants are clear about the concept of essential medicines right from the start of the activity before progressing to discussions of EMLs.
• Encourage participants to think critically about why some HIV/AIDS-related drugs that are essential to their work might not be on the national EML. Also encourage them to consider why some drugs on the national EML might not be essential to their own work.
At a skills-building workshop, NGO/CBO participants brainstormed about a list of drugs used for HIV/AIDS-related treatment in their local community.
They then reviewed the national Zambian Essential Medicines List and the WHO Model list of essential medicines. The participants identified that fluconazole (one of the drugs they had listed) was not on the national Zambian list but was included in the WHO list.
The facilitator then led a group discussion about what had been learned from the activity. For example, participants agreed that NGOs/CBOs should advocate to their government that drugs such as fluconazole, which are included in the WHO Model list of essential medicines, be added to the Zambian Essential Medicines List.
Reference: Adapted from the workshop on access to HIV/AIDS-related treatment, Catholic Dioceses of Ndola and the International HIV/AIDS Alliance, Zambia, April, 2001.