Improving access to, and use of, essential medicines in SEAR Kathleen A Holloway Regional Adviser Essential Medicines WHO/SEARO March 2016 | RA-EDM Presentation | March 31, 2016
Drug availability in public sector: - S. E. Asia Country % Avail % drug Av. no. % prescr- Pharmacists *data from MOH Key Ess stock- drugs / ibed drugs always avail. N=10-20 drugs out patient dispensed above PHCs Bangladesh 2014 43-75 9-52 1.8-2.3 65-96 No Bhutan 2015 94-98 2-5 1.9-2.8 96-100 Yes DPR Korea 2012 - - 1.3-2.6 - ? Rajasthan 2013 - - 3.3-4.1 92-100 ? Karnataka 2013 89 24 3.2-3.6 92-100 No Indonesia 2011 - - 2.6-3.3 91-99 No Maldives 2014 - 6-21 3.0-3.4 87-90 No Myanmar 2014 59-80 18-24 2.2-3.3 - No Nepal 2014 68-82 21-38 2.3-2.8 78-93 No Sri Lanka 2015 72-79 3-7 2.8-3.6 92-99 No Thailand 2015 69-97 1-9 2.8-3.6 100 Yes | Timor-Leste 2015 RA-EDM Presentation | March 31, 2016 54-77 9-41 2.3-2.6 94-99 No
Causes of stock-out Bhutan: stock-out due to simultaneous policy changes – Regulation on non-importation of unregistered drugs enforced, – Anti-corruption Task Force, Audit Commission, & Min. of Finance misunderstanding about higher prices for better supplier criteria – “Encouraged” local wholesalers by 3-year tenders & higher default rates – For some products: no bids, no supplier & stock-out – Resolved after situational analysis & 2 nd policy meeting Sri Lanka: stock-out due to quality problems – NRA registration process weak - few qual. staff, not following SOP – registration with the NRA is the only quality criteria in govt. purchase – 800 samples tested last year with 30% failure rate leading to withdrawal of 12 products overall and several batches every month & therefore stock-out – New NMRA established, & new e-LMIS introduced to monitor consumption | RA-EDM Presentation | March 31, 2016
Unexpected consequences of price control for essential medicines India: – different formulations and combinations manufactured to escape price control. • Irrational combinations • Paracetamol 650mg instead of 500mg • Labelling insufficient to alert public to dangers Bangladesh: – National Essential Medicines List not revised (due to industry pressure according to respondents) • Only 209 medicines in the EML and so hospitals have to procure non-EML drugs | RA-EDM Presentation | March 31, 2016
Public PHC AB use & stewardship – S.E. Asia Country % OPD % URTI Nat AMR DTCs ABs Pub educ. N=10-20 given given strategy most OTC on ABs in AB AB hos. last 2 yrs Bangladesh 2014 19-54 59-60 No No Yes No Bhutan 2015 33-49 26-42 No Rf hos Yes No DPR Korea 2012 18-51 58-81 No No Yes Not on AB Rajasthan 2013 53-67 81-100 No Yes Yes No Karnataka 2013 23-45 67-78 No No Yes No Indonesia 2011 34-55 72 2011 Yes Yes Yes Maldives 2014 15-34 33-48 No No Yes No Myanmar 2014 34-53 73-96 No No Yes No Nepal 2014 40-48 63-71 2001 Rf hos Yes No Sri Lanka 2015 45-67 47-85 No Yes Yes Not on AB Thailand 2015 11-14 20-52 2011 Yes Yes Not on AB Timor-Leste 2015 33-50 46-66 No No Yes No | RA-EDM Presentation | March 31, 2016
Public PHC antibiotic use – S.E. Asia Country % OPD given AB % URTI given AB Policies implemented (10-20 between 2010-12 and 2010- 2014- 2010- 2014- facilities/ 2014-15 2012 2015 2012 2015 country) Bangladesh 34-74 19-54 - 59-60 No monitoring, no DTCs, no updated EML or STG Bhutan 31-34 33-49 - 26-42 Some monitoring & CME, updated EML & STGs Maldives 35-43 15-34 - 33-48 Decreased availability Myanmar 27-56 34-53 72-100 73-96 Increased availability Nepal 21-54 40-48 72-74 63-71 NGO RUM project in a few districts Sri Lanka 49 45-67 - 47-85 DTCs just started Thailand 23-45 11-14 54-62 20-52 Monitoring, updated EML, DTCs, AB Smart use proj. | Timor-Leste RA-EDM Presentation | March 31, 2016 42-75 33-50 69-88 46-66 Decreased availability
Health worker views Nurse in Timor-Leste – I order double what I need because they only send half what I order. HP in Charge (Senior AHW) in Nepal – For children under 5 years with pneumonia I must give amoxycillin according to the IMCI guidelines. Since we are short of amoxycillin and have short-dated chloramphenicol syrup, I am prescribing chloramphenicol syrup to children of more than 5 years with pneumonia in order to use up the stock. Pharmacy Technician in Bhutan – There is a lot of irrational prescribing by doctors but it is very difficult to give any feedback. Doctor in Bangladesh – How can I make a proper diagnosis in one minute ? | RA-EDM Presentation | March 31, 2016
Role of pharmacists Pharmacists are needed to: – to manage the medicines supply system at all levels of the health sector – To undertake the monitoring of medicines use Pharmacists in the public sector were: – Lacking at some levels of the health sector in Bangladesh, Karnataka (India), Indonesia, Myanmar, Maldives, Nepal, Sri Lanka, Timor-Leste – Present in Thailand and Bhutan where medicines management is significantly better | RA-EDM Presentation | March 31, 2016
Summary Access to medicines depends on many health system issues – Monitoring of many things • Availability, prices, compliance with essential medicines list, prescribing, dispensing, quality of medicines, regulation enforcement and policy implementation – Coherent coordinated policy making at the centre between different departments of MOH and also Ministries of Finance, Trade, Industry – Adequate procurement policies and regulation to ensure medicines quality – Adequate human resources, especially pharmacists, and a functional logistic management information system – Implementation of policies to promote appropriate use of medicines | RA-EDM Presentation | March 31, 2016
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