Rational Selection and Use of Essential Medicines

No country in the world has a national healthcare system, which offers unlimited access to all available medicines. National funds are limited and therefore rational selection must be central to any nation’s drug policy.

Rational selection involves governments selecting medicines, which will have the greatest impact on tackling the priority healthcare needs of their own country.  It aids in focussing healthcare professionals therapeutic decisions, improving training of healthcare professionals and increases public understanding of the available medicines. The national treatment guidelines, which are provided by the WHO, aim to enable healthcare professionals and patients to make informed decisions about appropriate treatment plans; and guide professionals when to use each intervention and in the correct dosages.

Rational Selection also helps to prevent unsafe and wasteful medication use, which continues to occur in many countries. Studies taken in teaching hospitals from developed and developing countries reveal that up to 75% of antibiotics prescription is inappropriate and 50% of patients worldwide fail to take medications properly [1]. 

Awareness of the key diseases impacting a nation and increasing healthcare professional education and awareness of the available medications, will not only increase a healthcare professionals ability to treat effectively and do less harm, but will also minimise the risks which are closely associated with irrational prescribing of medicines.

Affordable Prices

The price of essential medicines is considered to be one of the most important barriers to their universal access. In many high-income countries (HIC), pharmaceutical companies publicly fund over 70% of medicines. However for low and middle income countries (LMICS), 50-90% of medicines are paid for by the patients themselves even though drugs consume 25-65% of total public and private spending on health [2]. Therefore, impoverished individuals are the least likely to access the essential medicines they require due to having fewer capital resources or means of accessing treatment. Yet it is these individuals who are the most susceptible to requiring frequent administration of essential medicines.

“In developed countries a course of antibiotics to cure pneumonia can be brought for the equivalent of 2 or 3 hours’ wages. One year’s treatment for HIV infection comes to the equivalent of four to six month’s salary and the majority of drug costs are reimbursed. In developing countries a full course of antibiotics to cure a common pneumonia may cost one months’ wages. In many countries, one year’s HIV treatment – if it were purchased – would consume 30 years’ income. And the majority of households must buy their medicines with money from their own pockets.”

WHO press release WHA/13 1999

It is also essential, when considering affordable drug pricing, to remember all components of the price for generic and patented drugs. High mark-up costs imposed along the supply chain due to multiple middlemen, taxes of over 20%, pharmaceutical import duties of up to 65%, high distribution costs and pharmacy and seller charges drive prices up making the medicines less affordable.  A study in Malaysia found actual mark ups of 100%-140% for generic drugs [3]. In developing countries the purchasing price may be 2-5 times greater than the producer or importing price. Therefore, the WHO argues that rather than imposing a percentage mark up on medicines, charges at pharmacies that are based on fixed professional dispensary fees create better incentives for affordable dispensing. Also a reduction or elimination of duties and taxes for generic and patented essential medicines will aid in enabling price reductions [2].

Generation of a competitive market through the selling of generic pharmaceuticals is a great mechanism of reducing prices of essential medicines.  This has been demonstrated in Brazil and India. The annual cost per person for triple therapy in Africa has reduced by between 76%-95% through competition, advocacy and corporate responsiveness alone [3]. Expanding the use of generic drugs requires supportive government legislation and regulation. Furthermore, bulk purchases through procurement partnerships between regions and sub-regions can play an important role in securing a reliable supply of pharmaceuticals at reasonable prices.

Price information has also been shown to aid in price negotiations for locating new supply sources and in assessing the efficiency of local, sustainable procurement. Sustainable procurement is also dependant on sustainable financing.

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