Essential medicines list: The panacea for ill-treatment

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 Essential medicines list: 
The panacea for ill-treatment

Prof. Emeritus Lt Gen Mahmud Ahmad Akhtar
Former Surgeon General Pakistan Army/DGMS (IS)

Accessibility of health and as its integral part the medicines is a basic human right enshrined in the Pakistan’s constitution. The un-affordability of medicines is one of the key factor making it inaccessible. Equity in healthcare is basic and essential tenet of medical ethics, in fact the soul of the health-care. These principles have been the guiding force in the development of an essential drug list. Essential medicines concept was developed and evolved by the World Health Organization (WHO) to help developing low to middle income group countries lacking in scientific expertise and resources to solve their health problems by providing rational, affordable, cost effective medicines. First list of essential medicines was prepared in 1975 by the world’s top experts in the sciences of medicines, subsequently nineteen lists have been prepared, the last in April, 2015 revised and updated in September, 2015. The list contains medicines for prevention (vaccines etc.) treatment, investigations etc. of all disorders i.e. complete in every respect. The list is a model one allows every country to modify and add to it according to its own requirements and circumstances.

Pakistan’s 60% population i.e. over 120 million lives below the poverty line (i.e. unable even to afford two square meals) or at or just above the poverty line. Pakistan’s health budget is very meager-one of the lowest in the world - the portion meant for medicines is miniscule, therefore the dire need for rational affordable medicines.

Pakistan’s population can be divided into two broad categories. The majority living in the slums of the cities, rural areas, the worst affected living in places like Baluchistan, Fata, KPK Northern areas, Rural Sindh, Southern Punjab etc. About 90-95% - the real Pakistan the other 5-10% living in posh areas/gated communities in Karachi, Lahore, Islamabad etc. the elite.

This system is meant to solve the problems of 90-95% people living in real Pakistan. The Quaid in this speeches proclaimed raison-deter of making Pakistan to rescue the people inhabiting real Pakistan. This system has met huge success in the developing countries by improving health indicators, reducing morbidities and mortalities, reducing the burden of disease who adopted this system. Unfortunately Pakistan is the only developing country which did not adopt this system resulting in having one of the highest death toll in all the age groups in the world even in the SAARC. Taking an example, according to this world’s most prestigious medical journal, the Lancet’s recent publication, Pakistan has recorded the highest still birth rate (i.e. death of foetus after 3rd month of conception to delivery) in the world with 40 still births to 1000 deliveries, while the world’s average is 14 per 1,000. The Journal headlined that Pakistan is the most dangerous place for a woman to become pregnant. The Islamic Republic should have been the safest place for the daughters of Maa Hawa to become pregnant and to produce healthy children.  Not only there is loss of foetus but the highest maternal new born and infant mortality. “Riasat ho maa ki tarah”.

In the SAARC, Sri-lanka’s infant mortality rate is 08 per thousand, while Pakistan’s is 70 to 80, Nepal, Bhuttan, India below 36, while the newly-emerged BanglaDesh’s is 40 (declining) like-wise Pakistan’s maternal, newborn, children (below 05 years) etc. is the highest barring two to three Sub-Saharan countries. Pakistan’s life-span is 50 to 60, the shortest amongst the Saarc, Sri-lanka at 76 years, ours is even lower than the Bangladesh. Before BanglaDesh’s emergence, West Pakistan was far ahead. Likewise Pakistan also has high mortality due to non-communicable diseases like diabetes mellitus, hypertension, heart attacks, strokes etc.

The International agencies have reported that 45% children of Pakistan are suffering from stunting affecting their physical growth and more seriously from mental growth- jeopardizing not only their future but also the future of the Nation- children are the future of Nation.     

The definition of an essential medicine says everything. “Essential medicine is efficacious, safe, affordable/cost-effective which fulfills the needs of the large majority of a population.

Being efficacious and relatively safe, it provides rational and safe medicines. Iatrogenic diseases- the diseases caused by irrational use of medicines, one of the causes of fatalities even in the developed countries where the standards of education/medical practice are high, people are educated, therapeutic audits are done post-mortems are carried out to ascertain the causes of death, while in a country like Pakistan, where illiteracy is high, lack of professional education and poor accountability, the fatalities ought to be very high. In Pakistan lifesaving essential medicines are not available. On the other hand irrational medicines are flooding the markets, robbing the people of their health/life and meager financial resource of the patients and the debt- ridden country as the money is transferred out by the companies in foreign exchange. By providing affordable/cost effective rational essential medicines the people and the nation are protected. It is pertinent to point out that the high income countries pursuing Universal National health services use generic drugs like Essential Medicines. The other Saarc are also providing essential medicines to their people free of cost.

The Essential Drug list provides affordable/cost effective medicines which are within the reach of common people, therefore, saving lives. As an example every woman needs folic acid 400 microgram’s before conceiving and throughout the pregnancy to protect the fetus. Four hundred microgram folic acid costs, only a few paisas. This preparation is not available while non-essential medicines containing enormous quantity of unneeded folic acid and many other un-necessary constituent costing in rupees are available in the market - the common people unable to afford.

The result is that Pakistan has the highest still birth toll in the world. The other major cause of Pakistan’s highest infant, maternal, child (before 05 years) mortality and stunting of children is “Iron deficiency anemia”. The essential/rational iron preparation providing cost effective iron preparation is ferrous sulphate 120mg tablet, costing only a few paisas. This is not available while tablets containing unneeded amounts of iron and other harmful ingredients costing a tablet up to Rs.10/- and many sold as supplements costing Rs.20 to 30 are available depriving the common people of treatment resulting in high morbidities and mortality tolls in all the age group. All patients getting anti TB treatment need pyridoxine 10mg tablet to counteract the toxic effects of INH tablet costing only a few paisas, is not available, while expensive even harmful irrational preparation are sold depriving the common people of treatment.

Vitamin C, only 50 mg tablet is needed which is not available, while expensive preparations containing hundreds of mgs of vitamin C, with calcium and many other ingredients are sold causing hazards like renal stones etc.

Vitamin B12 -the rational preparation is hydroxyl-cobalamin one mg injection costing Rs 2 only is not available rather ousted from the market by corrupt measures, while irrational methyl-cobalamin preparation not recommended by any authentic Drug Regulatory Authority like BNF, PDA etc. and authentic scientific books of medicine/journals is sold up to Rs.100/- per mg injection. Furthermore the companies have been granted unchecked advertisement claiming it’s uses practically for ailments of all systems, has deprived people of their meager financial resources and the poor country billions in foreign exchange. Many companies and individuals have amassed billions of rupees at the cost of National.

It is pertinent to point out that one ampoule of injection Neurobion containing 1000 microgram B12, + 200 mg vitamin B1+ 200 mg vitamin B6 costs Rs.12.50 (three vitamins), while methyl-cobalamine a single inferior ingredient is priced up to Rs.100- an example of terrible corruption.

Poor children are deficient of vitamin A. Its deficiency is a cause of blindness and Pneumonias. Pneumonia is a major cans of children’s deaths. Essential preparation of Vit A is not available, while extremely expensive preparations are sold.

Lifesaving anti-bacterial medicines Penicillin V is the first line inexpensive antibiotic to treat common simple infections, is not available.

Lifesaving anti-staphylococcal, Penicillins, Cloxacillin/Flucloxacillin etc. are not available, while the substitute injections cost thousands of Rupees are beyond the reach of people. Nitro-furadantin costing rupee one a tab, first-line medicine to treat urinary tract infections is not available, sold in the black market for Rs.60 to Rs.250 a tablet is unaffordable to the common people. Furthermore, due to non-availability of many first line and second line anti-bacterial medicines people prefer the use of the 3rd line IV preparations costing thousands of rupees causing loss of meagre available funds also causing the hazard of increase bacterial resistance in Pakistan.  The list is endless.

Essential medicines system also helps in eradicating corruption. As an example Atorva-statin “Lipitor” brand 10mg costs Rs.66/- while many brands including multinational’s cost only Rs.6.50 to Rs.10. Quality is easily checked by doing blood lipid level tests. Likewise anti-hypertensive medicines efficacy is easily checked by measuring blood pressure even by the patients. The purchases of expensive brands provide kickbacks to doctors and purchasing officials- the cause of burgeoning corruption.

The author used essential medicines system successfully in the Armed Forces, while serving as the Director General Medicine and the Surgeon General, Pakistan Army. Prior to its introduction there used to be scarcity of medicines. With this system not only the patients were provided medicines throughout the year but also medical appliances were purchased out of the allotted drug budget.

Pakistan has also made many essential drug lists, the first one was done in 1987, then 1989, 1994 and 1996 under my chairmanship and later many updated but never implemented. The Governments of Pakistan made National and International commitments to implement the essential medicine system.

The implementation is very simple to do. It is to buy and use essential medicines in the public health care institutions. It will create market for essential medicines. These will be used in the medical and public sector, teaching institutions: will spread it to the private sector. It is recommended that the irrational, harmful drugs should be deregistered. The only medicines contained in the essential list or approved by the Drug Regulatory Authorities of the progressive countries like UK, USA, European Union, Nordic countries etc. should be registered. The irrational expensive medicines not approved by the scientifically advanced countries like UK, USA, Canada, Australia, New Zealand, European Union, Nordic countries etc. should be deregistered. In it lies the resolution of Pakistan’s medicine problems- the saving of lives of people- the mitigation of sufferings of people of Pakistan i.e. saving the lives of the people. 

In conclusion, the Essential Medicines list is a panacea for the country’s therapeutic problems. The list is available. The implementation is simple i.e. to introduce it in the public sector health care institutions.

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