This week’s print issue of The Lancet (28 January) contains a 73-page Lancet Commission on Essential medicines for universal health coverage. It also contains five Comments on this subject.
Lancet Commission: Essential medicines for universal health coverage
Veronika J Wirtz et al.
The Lancet 2017; Volume 389, No. 10067, p403–476, 28 January 2017
DOI: http://dx.doi.org/10.1016/S0140-6736(16)31599-9
‘Appropriate use of medicines depends on behaviours of many stakeholders
- – Patients must take the medicines that are clinically appropriate for their illnesses, in the right doses and dosage forms, at the right time, and for the recommended duration. Patients and their caregivers require: knowledge about symptoms and information to decide when and where to seek care; convenient access to quality medicines at affordable costs; and knowledge, motivation, and skills to use the recommended medicines as directed.
- – Prescribers must prescribe clinically appropriate, cost-effective products. They require: diagnostic and therapeutic decision-making skills; up-to-date, evidence-based treatment guidelines that are consistent with medicines available and reimbursed in their systems; reliable, valid diagnostic tools in facilities; professionalism, training, time, and appropriate incentives to act in the interests of patients and caregivers…
- – Consumer organisations and pharmaceutical manufacturers provide information to health professionals, and in some settings directly to the public. They require: regulatory oversight to provide unbiased, evidence-based information.’
We know from WHO that ‘Globally, most prescribers receive most of their prescribing information from the pharmaceutical industry and in many countries this is the only information they receive.’ World Medicines Report, WHO, 2011. “Appropriate use of antibiotics [and other medicines] is only possible if healthcare workers and the public have access to reliable, unbiased information on medicines. Universal access to reliable information on medicines is readily achievable and should be a cornerstone of efforts to promote rational prescribing. There is an urgent need for concerted action.” WHO: http://www.who.int/rhem/didyouknow/essential_medicines/rational_antibiotic_use/en/
The causes of incoreect use of medicines are multifaceted and WHO advocates 12 key interventions accordingly:
- 1. Establishment of a multidisciplinary national body to coordinate policies on medicine use
- 2. Use of clinical guidelines
- 3. Development and use of national essential medicines list
- 4. Establishment of drug and therapeutics committees in districts and hospitals
- 5. Inclusion of problem-based pharmacotherapy training in undergraduate curricula
- 6. Continuing in-service medical education as a licensure requirement
- 7. Supervision, audit and feedback
- 8. Use of independent information on medicines
- 8. Public education about medicines
- 9. Avoidance of perverse financial incentives
- 10. Use of appropriate and enforced regulation
- 11. Sufficient government expenditure to ensure availability of medicines and staff.
http://www.who.int/medicines/areas/rational_use/en/
The Lancet Commission adds to our understanding but its recommendations are off-target. ‘The Commission proposes three recommendations to governments and the main public or private payers to operationalise this focus while implementing health system reforms toward UHC:
- 1. Governments and the main public or private payers should establish independent pharmaceutical analytics units (or equivalent)…
- 2. Pharmaceutical analytics units must collaborate with multiple stakeholders…
- 3. Engaged stakeholder groups, led by data produced by the pharmaceutical analytics unit, should identify and prioritise local medicines use problems, identify contributing factors across the system, and develop and implement sustainable, long-term, multifaceted interventions…
Arguably, the above can provide further data on the local and national causes of poor quality prescribing.
But let’s not forget the basics. Prescribers and users of medicines need access to reliable unbiased information, not only on individual, commonly used medicines but also on diagnostics and on appropriate selection of medicines (as given in formularies such as the BNF). ‘Globally, most prescribers receive most of their prescribing information from the pharmaceutical industry and in many countries this is the only information they receive.’ As for patients, we know that they are often given no information at all, or the information is in a language they do not understand.
The HIFA Project on Access to Information for Prescribers and Users of Medicines is currently exploring these issues, including a global literature review on the information needs of prescribers in LMICs. http://www.hifa.org/projects/prescribers-and-users-medicines We invite you to contribute.
Best wishes, Neil
Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa.org