CHAPTER # 02

ESSENTIAL MEDICINES LIST

Contents
Iftikhar Ahmmad
Session: 2009-14
Definition and introduction
Essential characteristics of EML
General concept
Categories of medicines
Selection criteria and steps involved
Uses of EML
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CHAPTER # 02 ESSENTIAL MEDICINE LIST
Definition:
WHO define essential medicines as
Essential medicines are those that satisfy the health care needs of majority of the population.
They should therefore be available at all times in adequate amount and in the appropriate dosage
forms.
After the Second World War the development of medicines like antibiotics brought a revolution
in the medical care. The effectiveness of these new pharmaceuticals and intensive marketing
efforts combined to catalyze wide spread use of modern medicine. However, by 1970s it had
become clear that developing nations were not even meeting the basic needs of their people for
essential life-saving and health promoting medicines. As a result gradually a number of countries
started concentrating on the development of a basic list of reliable medicines to meet the most
vital basic needs of their people.
A World Health Organization (WHO) Committee of Experts met in 1977 to determine the
number of medicines, which were actually needed to ensure a reasonable level of health care for
as many people as possible. Consequently, the first Model List of Essential Medicines was
finalized in the same year. This list is being updated regularly after every two years by the WHO
i.e to add new effective drugs and to exclude the obsolete drugs. The Model List of Essential
medicines provide guidelines, about concept, contents and process, to the member countries to
make their own EML called National Essential Medicine List.
Currently, 156 countries have their NEML.
EML is also prepared by UNICEF, High Commission for Refugees and NGOs.
NEML of Pakistan
The National Essential medicines List (NEML) of Pakistan was first prepared in 1994 in
consultation with relevant experts. The list was previously reviewed in 1995, 2000 and 2003.
The present list is the fourth revision (revised in 2007) containing 335 medicines of different
pharmacological classes.
Words in parenthesis represent health care settings.
(P)- Primary health care setting e.g BHU, RHC.
(S)- Secondary health care setting e.g DHQ
(T)- Tertiary health care setting e.g Shaukat Khanum Memorial Cancer Hospital etc.
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Essential Characteristics of Essential Medicines List
1. In vivo efficacy data.
Only those drugs should be selected which have well established in vivo efficacy data.
2. In vitro stability data.
There is variation in the environmental conditions, so the drugs should be tested for
stability and then selected.
3. Available at affordable price.
The drugs should be available at low price, must be cost effective or economic.
4. Must have disease prevalence.
The drugs must have disease selection prevalence i.e. there are certain diseases which are
common in certain area. So drugs should be selected according to the disease prevalence.
5. Appropriate dosage form.
The drug must be available all the time in appropriate dosage form.
6. EML Must is prepared by every country and W.H.O model list will act as reference.
General Concept
1. Major factors
i. W.H.O motto i.e. health for all.
ii. Limited approach of population to the quality medicine.
iii. Limited funds used/specified by the government.
2. Minor Factors
i. Ease of management for limited selective medicine.
ii. Ease of practice by health profession.
iii. Improve patient compliance.
iv. Ease of procurement, transport, storage and dispensing.
v. Major purchase by limited funds.
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Categories of Medicines in EML:
In EML medicines are divided into two categories:
i. Core medicines
The core list presents a list of minimum medicine needs for a basic health
care system, listing the most efficacious, safe and costeffective medicines for
priority conditions. Priority conditions are selected on the basis of current and
estimated future public health relevance , and potential for safe and cost-effective
treatment.
ii. Complementary medicines
The complementary list presents essential medicines for priority diseases, for
which specialized diagnostic or monitoring facilities, and/or specialist medical
care, and/or specialist training are needed.
Selection Criteria for EML
It includes:
i. Scientific Justification
ii. Unbiased selection
iii. Need based selection
i. Scientific Justification:
Those drugs are included in EML which have in vitro stability as well as in vivo
efficacy i.e. pharmacokinetic and pharmacodynamics considerations. Collectively,
these are termed as Scientific Justification.
ii. Unbiased selection:
Selection should be unbiased.
To avoid bias, drugs should be included by their generic names.
iii. Need based:
Disease prevalence is different in urban and rural areas i.e. certain disease may be
more common in an urban area and less common in rural area and vice versa, so
drugs should be included in NEML according to disease prevalence in an area.
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Selection steps:
1. Establishment of committee
2. Selection of drugs
1. Establishment of committee:
Committee of experts is established which then considers the criteria for including of
drugs in EML. Preferably, the country own experts should be included in the committee.
If in any country experts are not available, assistance may be taken from W.H.O.
The experts include;
a. Experts in clinical medicine.
b. Experts in clinical pharmacology.
c. Experts in physical sciences.
2. Selection of drugs:
The committee will select drugs on the basis of:
d. Scientific justification
e. Epidemiology
f. Cost effectiveness
Drugs should be selected on the basis of generic names.
Regulation, implementation and facilitation to ensure quality production of
pharmaceutical product are the responsibility of government.
Among therapeutic equivalents, drug selection is based on benefits/risk ratio. Among
drugs sharing same risk/benefit ratio, selection is done on:
i. Highly evaluated scientific data.
ii. Feasible pharmacokinetic in the patient.
iii. Select the drug to be manufactured, transported and stored by the local firm.
iv. Cost effectiveness.
There are certain drugs which are available in fixed combination ratio e.g. anti T.B drugs.
Following parameters are used for selection of such drugs;
i. In vivo/in vitro no unwanted effects of combine drugs.
ii. Proven efficacy.
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Uses of EML:
i. Health
- Equality of provision of effective drugs for the majority of population.
- Cost effectiveness.
ii. Health Professional
There are three important health professional: Physician, pharmacist and nurse.
The major focus of all these three is patient.
Physician is assisted by drugs in EML, making the prescription more rationale.
Pharmacist has more scope to get excellence on limited number of drugs.
Nurse has the convenience to ensure proper storage, administration and dose because
of limited number of drugs.
Major focus: Patient Compliance is improved if number of drugs is limited.
iii. Economical
The burden on the government is decreased and so more drugs can be purchased with
in limited funds.
iv. Facilitation
NGOs, semi government and international organization can be attracted to make the
required drugs available.
v. Diseases
EML contain drugs for both communicable and non-communicable diseases.
vi. Reviewing
EML drugs must be reviewed every two years.