World Health Organization policy improves use of medicines

In this issue of PLOS Medicine, Kathleen Holloway from WHO and David Henry (University of Toronto, Canada) evaluated data on reported adherence to WHO essential medicines practices and measures of quality use of medicines from 56 low and middle income countries for 2002-2008. They compared the countries' government-reported implementation of 36 essential medicines policies with independent survey results for 10 validated indicators of quality use of medicines (QUM). They claim that the results provide the strongest evidence to date that WHO essential medicines policies are associated with improved medicines use.

Over-use and under-use of medications is a global public health problem with serious consequences, including antibiotic resistance, avoidable adverse drug events, and untreated and undertreated illnesses leading to hospitalization and death. Since 1977, the World Health Organisation (WHO) has advocated the concept of Essential Medicines and developed a range of policies to promote quality use of medicines. However, whether these policies lead to better medication usage has not been clear.
The authors first derived estimates of the impact of individual policies by comparing QUM in countries that did or did not report implementing them. Working with a list of the most effective policies (27-policy and 18-policy variables) and using a single composite indicator for QUM, the authors found that the more essential medicines policies reported, the higher the composite QUM indicator [(r) = 0.39 (95% CI 0.14 to 0.59), P=0.003]. When they stratified the countries by gross national income per capita,, they found that the 27-policy variable was significantly associated with QUM for those with a GNI below the median value of US$2333 [(r)=0.43 (95% CI 0.06, 0.69), P=0•023]; but not for those above the median value [(r)=0.22 (95% CI -0.15, 0.56), P=0.261]. Limitations of the study included substantial missing data, but imputation of missing data supported the main results, and that the adherence to essential medicines policies were reported by the countries rather than measured directly.

The authors state, "Our most important findings were 2-fold. First, some essential medicines policies—particularly the provision of undergraduate training in standard treatment guidelines to doctors and nurses, provision of free essential medicines, and having a ministry of health unit promoting QUM—were associated with improved medicines use. Second, there was a positive correlation between the number of medicines policies that countries reported implementing and the quality of their medicines use. This correlation was strongest and statistically significant in countries with national per capita wealth levels below the median of the study countries (US$2,333), underscoring the importance of essential medicines policies in low-income countries."
They conclude, "International support for the WHO, increasingly, is being channelled to vertical disease programmes (e.g., addressing AIDS, tuberculosis, and malaria) and away from horizontal programmes designed to support development and maintenance of health policies and standards. The medicines policies and data discussed here were developed and collected as part of the WHO core "normative" functions, which are now under threat. It is important that the critical role of the WHO is recognised and that these efforts are sustained and enhanced."

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