WHO essential medicines policies and use in developing and transitional countries: an analysis of reported policy implementation and medicines use surveys

Abstract

Background: Suboptimal medicine use is a global public health problem. For 35 years the World Health Organization (WHO) has promoted essential medicines policies to improve quality use of medicines (QUM), but evidence of their effectiveness is lacking, and uptake by countries remains low. Our objective was to determine whether WHO essential medicines policies are associated with better QUM.

Methods and findings: We compared results from independently conducted medicines use surveys in countries that did versus did not report implementation of WHO essential medicines policies. We extracted survey data on ten validated QUM indicators and 36 self-reported policy implementation variables from WHO databases for 2002-2008. We calculated the average difference (as percent) for the QUM indicators between countries reporting versus not reporting implementation of specific policies. Policies associated with positive effects were included in a regression of a composite QUM score on total numbers of implemented policies. Data were available for 56 countries. Twenty-seven policies were associated with better use of at least two percentage points. Eighteen policies were associated with significantly better use (unadjusted p<0.05), of which four were associated with positive differences of 10% or more: undergraduate training of doctors in standard treatment guidelines, undergraduate training of nurses in standard treatment guidelines, the ministry of health having a unit promoting rational use of medicines, and provision of essential medicines free at point of care to all patients. In regression analyses national wealth was positively associated with the composite QUM score and the number of policies reported as being implemented in that country. There was a positive correlation between the number of policies (out of the 27 policies with an effect size of 2% or more) that countries reported implementing and the composite QUM score (r=0.39, 95% CI 0.14 to 0.59, p=0.003). This correlation weakened but remained significant after inclusion of national wealth in multiple linear regression analyses. Multiple policies were more strongly associated with the QUM score in the 28 countries with gross national income per capita below the median value (US$2,333) (r=0.43, 95% CI 0.06 to 0.69, p=0.023) than in the 28 countries with values above the median (r=0.22, 95% CI -0.15 to 0.56, p=0.261). The main limitations of the study are the reliance on self-report of policy implementation and measures of medicine use from small surveys. While the data can be used to explore the association of essential medicines policies with medicine use, they cannot be used to compare or benchmark individual country performance.

Conclusions: WHO essential medicines policies are associated with improved QUM, particularly in low-income countries. Please see later in the article for the Editors' Summary.

Figure 1. Differences in quality use of medicines between countries that did versus did not report implementation of specific medicine policies.

The figure presents the weighted mean (and 95% confidence interval) of differences (in percent) across ten selected QUM measures. ^∧Joint regulation by government and industry as opposed to government regulation only. CME, continuing medical education; DTC, drug and therapeutics committee; EML, essential medicines list; NMP, national medicines policy; STG, standard treatment guidelines.

Figure 2. Correlation between the number of policies that countries reported implementing (out of 27) and a composite measure of quality use of medicines in 56 countries.

Details of calculation of the composite QUM measure are provided in the Methods. B Faso, Burkina Faso; DR Congo, Democratic Republic of the Congo; Laos, Lao People's Democratic Republic; S Africa, South Africa; Serbia Montenegro, Serbia and Montenegro.

Figure 3. Correlation between number of implemented policies and percentage of cases of acute diarrhoeal illness treated with oral rehydration solution.

DR Congo, Democratic Republic of the Congo; Laos, Lao People's Democratic Republic; ORS, oral rehydration solution.

Figure 4. Correlation between number of implemented policies and percentage of cases of acute upper respiratory tract infection treated with antibiotics.

DR Congo, Democratic Republic of the Congo; Laos, Lao People's Democratic Republic; URTI, acute upper respiratory tract infection.