The evidence on rational medicines use is clear: multiple interventions reinforce each other and must be repeated over time. WHO therefore continues to provide considerable training in promoting rational medicines use. In 2001, national and international training was provided to countries in the African, Eastern Mediterranean, European and Western Pacific regions.
The first Asian international training course on problem-based pharmacotherapy (organized jointly by the Philippine Society of Experimental and Clinical Pharmacology, and the WHO Collaborating Centre for Training in Pharmacology and Rational Drug Use at the University of Newcastle, Australia) was held in Manila. National workshops and courses on problem-based pharmacotherapy teaching were also held in China, Japan, Malaysia and Viet Nam. In the European region, the American International Health Alliance and Zdraveform-plus joined the Regional Office for Europe in providing rational medicines use training.
Efforts to promote hospital drugs and therapeutics committees (DTCs) also continued, especially in the Western Pacific, where the need for more effective DTCs had become evident. A meeting for hospital DTC members in the region was held in Penang, Malaysia. Organized by the WHO Collaborating Centre on Drug Information of the Universiti Sains Malaysia, with support from WHO, it was attended by 30 participants from 13 countries. Following the meeting, innovative rational medicines use strategies are now being implemented in a number of countries. Additionally, an international course on drugs and therapeutics committees was organized in Yogyakarta, Indonesia, by Management Sciences for Health and the WHO Collaborating Centre for Research and Training on Rational Drug Use (at Gadjah Mada University).
Figure 4 Too little too late: in six African countries 10-65% of sampled chloroquine tablets failed on content and 50-90% of sampled sulfadoxine/pyrimethamine tablets failed to dissolve
Elsewhere, in the African, South-East Asian and Western Pacific Regions, courses on medicines and therapeutics committees were organized in collaboration with Management Sciences for Health.
Other rational medicines use efforts focused on community medicines use. The international course on promoting rational medicines use in the community (held in Uganda), was well received. Developed and first tested in 2000, participants learned how to assess and remedy inappropriate medicines use in the community, including analysing what shapes medicines demand.
Traditional, and complementary and alternative medicine: does it work and is it safe?
Populations throughout Africa, Asia, and Central and South America, use traditional medicine (TM) to help meet their primary health care needs. As well as being accessible and affordable, it is also often part of a wider belief system, and as such considered integral to everyday life and well-being. At the same time, in Australia, Europe and North America, "complementary and alternative medicine" (CAM) is increasingly used in parallel to modern medicine, particularly for treating and managing chronic disease and conditions. Such widespread and growing use of TM/CAM is creating public health challenges, however, with respect to: policy; safety, efficacy and quality; access; and rational use.
In 2001, WHO responded to these challenges by developing a WHO Traditional Medicine Strategy for 2002-2005 (document reference: WHO/EDM/TRM/2002.1). It reviews the status of TM/CAM globally, and outlines WHO's own role and activities in TM/CAM. But more importantly, it provides a framework for action for WHO and its partners, to enable TM/CAM to play a far greater role in reducing excess mortality and morbidity, especially among impoverished populations. The strategy focuses on integrating TM/CAM with national health systems, as appropriate, by developing TM/CAM policies and programmes, and promoting the safety, efficacy and quality of TM/CAM by expanding the knowledge base on TM/CAM, and by providing guidance on regulatory and quality assurance standards.
Also in 2001, the Legal Status of Traditional Medicine and Complementary/Alternative Medicine (document reference: WHO/EDM/TRM/2001.2) was published and Volume III of the WHO Monographs on Selected Medicinal Plants finalized. Summarizing the legal status of TM/CAM in 123 countries, the former is a valuable guide for policymakers and legislators working to develop a legal framework in their country covering both the practice of TM/CAM and the quality assurance and appropriate use of TM/CAM products.
"...effective integration strategies will promote communication and mutual understanding among different medical systems, evaluate traditional medicine in its totality, integrate at both theoretical and clinical levels, ensure equitable distribution of resources between complementary and alternative medicine, provide a training and educational programme for both traditional and conventional medicine, and generate a drug policy that includes herbal medicines."
G. Bodeker. Lessons on integration from the developing world's experience. British Medical Journal, 2001, 322 164-167 (20 January).
Making the medicines evidence base more accessible
The concept of essential medicines was initiated by the World Health Assembly in 1975. It requested WHO to assist Member States by, "advising on the selection and procurement, at reasonable cost, of essential medicines of established quality corresponding to their national health needs." A WHO Expert Committee developed the first WHO Model List of Essential Medicines in 1977. Since then, the list has been revised every two years. Numerous studies have documented the impact of clinical guidelines and essential medicines lists on the availability and proper use of medicines within health care systems. A careful selection of a limited range of essential medicines results in a higher quality of care, better management of medicines, and more cost-effective use of health finance.
But in 1999, the relevant WHO Expert Committee recommended that the methods for updating and disseminating the Model List be revised. This was a response to advances in evidence-based decision-making, the increased need to link use of essential medicines to clinical guidelines, and the high cost of many new and effective medicines. An extensive consultation process followed. Revisions proposed ranged from development of a more transparent process for selecting medicines, to creation of a WHO Essential Medicines Library.
The WHO Essential Medicines Library will provide rapid access to information about medicines on the WHO Essential Medicines List
The WHO Essential Medicines Library is now being created and will contain not only information about how and why medicines are selected for the List, and links to WHO clinical guidelines, but also links to the WHO Model Formulary, price information services, and information on international nomenclature and quality standards.
Rational use efforts are also being targeted at pharmacists, given the considerable influence they can have on community medicines demand and use. The EuroPharm Forum Network of pharmaceutical associations and the Regional Office for Europe developed guidelines and model programmes for improving the performance of pharmacists in the areas of health promotion and management of chronic illness. Its Pharmacy-based Hypertension Management Model has now been tested and implemented in Estonia, Latvia, Lithuania, Portugal, Slovenia and Spain. Care provided by pharmacists includes screening for high blood pressure, regular blood pressure measurement and patient counseling. In Slovenia, Estonia, Lithuania and Spain, 10%, 27%, 57% and 64% respectively of individuals referred by their pharmacist to a doctor for investigation of elevated blood pressure were diagnosed with hypertension.
The Europharm Form Network also initiated an education campaign for patients - Questions to ask about your medicines - in Croatia, Estonia and Latvia through twinning arrangements with countries that are already implementing a similar campaign.
Other rational use activities focused on fighting the development of antimicrobial resistance (AMR). 2001 saw the launch of the WHO Global Strategy for the Containment of Antimicrobial Resistance. Summarizing evidence on interventions to promote rational use of antimicrobials, it aims to both persuade governments to take urgent action and to guide this action with expert technical and practical advice. A special issue of the Essential Drugs Monitor (Vol 28/29) in English, French, Spanish and Russian also raised awareness of the problem and what policy-makers, health care professionals, health advocates and members of the public can do to help tackle it.
Promoting rational medicines use in China: when evidence leads to policy change and impact
Xuan Wu Hospital
Beijing Multi Centre Study
In 2000, as part of the groundwork for developing a national drug policy, baseline data on rational medicines use were collected from a number of health facilities in Beijing, including Xuan Wu Hospital. Following analysis of the baseline data, intervention strategies involving printed materials on rational medicines use (particularly rational use of antibiotics), reference materials and poster displays on appropriate medicines use were identified. Additionally, since antibiotic use at Xuan Wu Hospital was notably high, active promotion of applications of guidelines on rational use of antibiotics was also recommended.
In 2001, after the above recommendations had been implemented, monitoring indicated that: specific strategies for facility-level interventions, targeting
• specific prescribing practices, are most appropriate since their impact can be measured accurately
• interventions are more effective if targeted at a clearly defined group and the facility can implement managerial interventions to improve medicines availability and use.
Following further collection of baseline data in 2001, WHO recommended that:
• the Chinese Ministry of Health develop and promote educational, supervisory and managerial strategies to improve medicines use
• the medicines reimbursement list and use of China's Essential Medicines List be synchronized in order to promote rational medicines use among prescribers
• the impact of rational medicines use interventions be monitored regularly.
Activities carried out in 2001 to implement the above recommendations included:
• a national course on promoting rational medicines use
• local courses on promoting rational medicines use
• development and implementation of research proposals
• pilot-testing of national antimicrobial standard treatment guidelines
• consultative meeting with the Ministry of Health, the State Drug Administration, the State Planning Commission and other stakeholders to review and synchronize the medicines reimbursement list and China's Essential Medicines List.
The results of all the above activities indicate that national policies for improving rational medicines use in China can be:
• readily developed if data and evidence are presented to stakeholders
• readily adopted or adapted, and enforced, through directives from national level.
Improving rational medicines use in Laos
Monitoring, Training and Planning (MTR) is a simple managerial tool that can be used to make cumulative improvements to prescribing practices. The strategy covers:
• monitoring: identifying and measuring problems
• training: identifying the underlying causes of the problems and finding solutions (i.e. searching for relevant information or providing training)
• planning: targeting the levels of improvement after implementing a solution.
The idea is that a group (such as a group of providers, prescribers or dispensers) meets to identify specific medicines use problems. Medicines use indicators are then used to measure their extent. The group then explores possible underlying factors and agrees on how to tackle them. The level of improvement for the next period is agreed upon. Before the next meeting, information is collected using the indicators to see whether the targeted improvement has been achieved. The group again discusses the problem and how further improvements can be achieved.
The figure - based on average data from 5 regional hospitals - shows the impact of MTR implementation on rational medicines use in Laos. Use of antibiotics and injections declined. By the 4th month, however, a trend towards pre-MTP levels can be seen, indicating the need to further reinforce and sustain the MTR programme.
Source: Presentation of Dr Bouathong Sisounthone at intercountry meeting for hospital drugs and therapeutics committees, Penang, Malaysia, October 2001.
Table 1 - Principal impediments to ensuring availability of opioid analgesics for palliative care
• Concern about addiction to opioids
• Insufficient training about opioids for health-care providers
• Restrictive laws relating to manufacture, prescribing and dispensing
• Reluctance of health care providers to use opioids due to concerns about legal sanctions
• Reluctance of health care providers to stock opioids due to concerns about theft or robbery
• Burden of regulatory requirements
• Potential for diversion
Source: Assuring Availability of Opioid Analgesics for Palliative Care Report on a WHO Workshop, Budapest, Hungary 25-27 February 2002 Document reference EUR/02/5037079.
Work to promote use of four-drug fixed-dose combination (4FDC) anti-TB medicines also aims in part at reducing AMR. Widespread use of these medicines would not only reduce the risk of the emergence of drug-resistant TB, however. It would also simplify TB treatment, minimize TB prescription errors, and increase patient adherence to treatment regimens. Inadvertent medication errors and adverse medicines reactions would also decrease. Medicines management would improve, too, since procurement, distribution and dispensing/handling are all easier with fewer items, that share a single expiry date. Clinical evidence to support use of 4FDC anti-TB medicines was collected. And guidance for national TB programme managers on use of these medicines was developed.
Conversely, other rational use activities focused on how to increase use of a medicine. WHO launched a report, Achieving Balance in National Opioids Control Policy (document reference: WHO/EDM/QSM/2000.4) in 2000, to advocate balanced control approaches. This was in response to concern that overemphasis of the dependence-producing characteristics of opioid analgesics was leading to excessive fear of addiction, under-use for legitimate medical purposes, and unduly restrictive regulations on distribution and use of these medicines (see Table 1). Regulatory barriers to access to opioid analgesics have since been lowered in several countries, including China, India, Italy and Mexico.