The politics of essential medicines

What are Essential Medicines? What do they mean to a country and to communities all over the world? And more interestingly, can there be politics on this simple and innocuous list?

Essential Medicines, as per the World Health Organisation (WHO), are those that satisfy the priority health needs of most people in the community. They are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford.

Based on the health needs of the people, WHO prepared a list of Essential Medicines way back in 1977 and this list has been reviewed every two years by a group of eminent people in the field, chosen after duly ascertaining that they have no conflict of interest. This year, the list completes 40 years of existence.

The very fact that the list has been in existence for four decades is in itself a great achievement. It has withstood all the turbulent times and has proved to the world that what is really required for any country is a list of drugs that would meet most healthcare needs.

And above all, it has shown that many drugs that pharmaceutical companies unnecessarily promote for their own profit are not needed. For example, in India, the government acknowledges that 65% of medicines in the market are not essential. Fortunately, these unessential medicines do not find place in government hospitals.

Most want to know as to how many medicines are there in the list. The most recent 20th list of Essential Medicines, published by WHO in June 2017, has 433 drugs in it. And, as it gets revised every two years, this year the list has added 30 medicines for adults and 25 for children and also specifies nine already listed products for use for a new condition.

The 20th list has also many important and relevant interventions. It provides advice on which antibiotics to use for common infections and which to save for the most serious conditions, based on a thorough review of all essential antibiotics. All this is intended to optimise antibiotic use and reduce antibiotic resistance without restricting access. The list categorises antibiotics into three groups, the first being ‘access’, the second ‘watch’ and the third ‘reserve’. As this categorisation is based on scientific evidence, if these guidelines are followed by doctors while prescribing antibiotics then it will prevent antibiotic resistance. This is undoubtedly an important move towards good public health.

Global impact

Today, some 156 countries have, in principle, accepted the concept of Essential Medicines list and believe that it is an excellent public health tool. That is, four out of five countries all over the world believe this list because their governments know that making healthcare available to their citizens is of prime importance and buying these medicines takes up a major portion of their health budgets. Indeed, amongst several things that need to be put in place for healthcare to be delivered to people, an important policy intervention is that countries stick to the Essential Medicines list.

All this did not happen overnight and it took almost thirty years for the Essential Medicines list to become the global standard because most countries did not have a national drug policy. When the list was first announced in 1977, there were just half a dozen countries that showed interest in it, but over the years the confidence of countries in the list has increased substantially. Now, about a hundred countries have such a policy in place, in which the Essential Medicines list finds a prominent place.

In India, the Health Ministry brought out a revised list of Essential Medicines in 2015. Even several states in India have their own lists of Essential Medicines, including Karnataka, Tamil Nadu, Rajasthan, Kerala and several others. But the extent to which this list has been given its due and really used as an important tool in public health varies from state to state, as often the list is just catching dust in a few states.

Not many people are aware that this list came under heavy criticism from the US Pharmaceutical Manufacturers’ Association (PMA). In 1978, the PMA stated that “adoption of this recommendation could result in sub-optimal medical care and might reduce health standards already attained”. And as they have been arguing forever, they claimed that the list would discourage the drug industry from researching and developing new medicines.

The International Federation of Pharmaceutical Manufacturers (IFPMA), a global coalition of multinational drug manufacturers, passed a resolution stating that it had “serious reservations about the policies recommended” and the manner in which the policies “were represented and promoted by the WHO”. The impact of this resolution had its effect as the next edition of Essential Medicines was pared down. In fact, the WHO even stated that “Essential Medicines were meant for Third World countries only”. And it made no effort to “widely disseminate” the list.

However, over the years, the confidence of countries in the list improved and they did not succumb to the threats from the drug companies. Undoubtedly, much more needs to be done as a large number of people around the world still do not have access to Essential Medicines as well as we in India have. For that to happen, we need to revive the vision and commitment that existed 40 years ago.

(The writer is president, Drug Action Forum, Karnataka)