BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH

CONCENTRATION PAPER COVER PAGE

 Abstract

The concept of Essential Drug Lists (EDL) is new for the Central Asian Republics (CARs) since there was no EDL in the Soviet Union and the Soviet System considered all registered drugs as essential. In the mid 90^th, the World Health Organization (WHO) introduced the EDL concept to the CARs as a tool to improve pharmaceutical supply. By now the countries have developed national essential drug lists and even revised them.

Comparison and discrepancies.

 I. Introduction

ACKNOWLEDGEMENT

I acknowledge Dr. Richard Laing of Boston University for his interest and support, and Associate Professor Lucy Honig of Boston University School of Public Health for commenting on writing and reviewing this paper. I also acknowledge Mrs. Tulip Schneider of the Massachusetts College of Pharmacy for her consultation on the comparative spreadsheet.

INTRODUCTION

The concept of Essential Drug Lists (EDL) is rather new for the Newly Independent States (NIS) since there was no EDL in the Soviet Union and the Soviet System considered all registered drugs as essential. Besides that, all the Republics lived under a central government located in Moscow and had limited autonomy on planning health budgets and on choices of pharmaceuticals.

The NIS became independent in the early 90s. Since then, the countries have been going through political, economical and social reforms, which have been associated with economic crises, political uncertainty and change of social structure. The Central Asian Republics (CARs), compared to other NIS, are in a more difficult situation economically. In the CARs, due to the budget constraints, health is not financed sufficiently. The countries can neither maintain the cumbersome health system inherited from the Soviet Union, nor to assure the basic medical supply to the health institutions due to the limited health budgets, and a scarce amount spent on pharmaceuticals.

In the mid 90s, the World Health Organization (WHO) introduced the EDL concept to the CARs as a tool to improve pharmaceutical supply. By now the countries have developed national essential drug lists and even revised them. Although health indicators and the economic situation are very similar among the CARs, the EDLs vary from country to country greatly. This raises the questions of whether they have made correct drug selections.

In this paper, I will compare the current EDLs of four former Soviet CARs, Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan, taking the WHO Model List as standard. By looking at the drugs selected by each of the four countries as essential I will analyze the national lists and highlight the main areas of disparities. In addition, I will discuss the value of the ED concept in relation to CARs.

This paper is designed to help public agencies such as governments and international organizations involved in the process of creating and revising national drug lists. The paper provides specific recommendations for the way forward to improve the Essential Drug Lists in the next two to three years.

Overview of EDL and Essential Drug Concept

It is well known that many transitional countries have limited resources and cannot afford to provide health care for their population at an affordable price. Spending the limited resources in the best possible effective and efficient way is a problem many countries struggle to solve.

Pharmaceuticals is one of the most expensive components of health care and may comprise up to 40 percent of the health budget in the developing countries [1]. Considering the fact that developing countries are not doing well economically, and consequently health budgets do not get a great deal of finances, one third of the health budget is a very limited amount indeed. It makes the proper use of the finances spent on pharmaceuticals crucial. In order to help countries to make the best use of the available finances for pharmaceuticals, the Essential Drug concept has been developed.

The 1975 World Health Assembly Report recognized the urgent problems of a lack of essential drugs in many countries [2]. It was the first step to developing the World Health Organization Model of EDL. Two years later, WHO proposed the first Model List of Essential Drugs, which contained 205 drugs [2]. Since 1977, the WHO list has been revised every second year, when some drugs are excluded and some others are added. According to Howard and Laing, in 1977 WHO EDL included 172 Essential drugs and 33 complementary drugs and by 1990 the numbers increased to 238 and 30 respectively [2]. They noted that, "analysis of the six lists produced between 1977 and 1990 shows an increase in the number of items from 205 to 268. 120 drugs have been added and 57 deleted" [2]. The tendency to increase the number of drugs in the WHO Model list continued throughout the next decade. The last edition of the WHO ED Model List from 1999 contains 306 active ingredients [3]. The list is divided into a main list and a complimentary list. Advances in the science of evidence-based decision-making, and the increasing link between essential medicines and guidelines for clinical health care are the main reasons the WHO Model list is revised [3], and perhaps these are the reasons for the constant increase of the numbers. By 1999, 156 member states developed an official national essential drug list, and 127 lists had been updated in the last five years [7].

The following definition by the WHO in a 1999 report best outlines the concept of essential drugs: "Essential drugs are those drugs that satisfy the health care needs of the majority of the population; they should therefore be available at all times in adequate amounts and in the appropriate dosage forms, and at a price that individuals and the community can afford" [4]. An EDL is intended to reflect public health relevance. In the WHO Model list, the WHO notes: "a list of essential drugs is a positive list, mainly intended to define priority drugs for public procurement and reimbursement, and for training of health personnel [5]. "The model list should be not only a model product, indicating the most cost-effective drugs for priority diseases, but also a model process, as an example for national and institutional committees" [6].

Having the list is not enough to be successful. Prioritization of the list and its harmonization with other key components of National Drug Policy is the factor essential to bring the list to life and bring benefits for the population. The Essential Drugs Concept has a great potential to improve health and literally save lives, but a key factor of its effectiveness is making essential drugs available, affordable, safe and properly used [8].

Since countries are not in the same political, economical and social situation and they have different geographical and climate conditions, the EDL developed by WHO is not a global standard. It is only a model list, which can be used by national institutions to develop national lists following the process applied by the WHO [5].

Process of Development of the WHO Model List

Selection is one of the key components of a National Drug Policy. An improved supply of drugs and lower costs are the rationale behind the selection [1]. The task of the selection process is to select and prioritize a limited number of pharmaceutical products from thousands available on the market.

Implementation of the ED concept starts with selection of drugs on the list. It is a very important and usually very complicated process. An expert committee of 14-24 members selects the WHO ED Model List. Selection is a complex issue and the committee considers multiple factors such as demographic situation, human and financial resources available, disease prevalence and health indicators [9]. The primary criteria for inclusion are accurate clinical data on safety and efficacy of the drug, its availability, cost and cost-effectiveness. Conditions of storage, and number of compounds in the drug are some other criteria to be paid close attention. (For more detailed information on the inclusion process see annex 1). Correct selection and purchase of pharmaceuticals improves the affordability and quality of health care to a wider proportion of the population. The process by which drugs are selected is extremely important and it is the base on which the ED concept is build. The selection process has to be consultative and transparent; the criteria have to be explicit and have to be linked to evidence-based clinical guidelines [9] (See annex 2).

According to WHO, selection of Essential Drugs is a two-step process [5]. Market approval is the first one. Market approval for new drugs is achieved if the drug proves to be effective, safe, and of good quality. But the market is usually not concerned with cost or need, and comparing new products with the existing ones is not a criteria for selection. Because of that, the second step based on comparison of efficacy and cost is conducted. It is needed first of all to prioritize drugs on the basis of need, efficacy and cost-effectiveness, as well as for developing procurement schemes and mechanisms to limit procurement and reimbursements to certain essential drugs. An evaluation based on a comparison between various drugs is needed [5].

Table 1. Population and health financing in Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan

Table 1 shows the differences between population and health financing in the four countries. In general, the situation in the former Soviet CARs has been deteriorating both economically and politically, and consequently health indicators have shown significant deterioration. The current average health expenditure is 3% GDP in countries of the former Soviet Union, which is almost two times less than the European Union average of 8.5% [10]. The CARs, except for Tajikistan, fit the average. The Health expenditure in Kazakhstan remains one of the lowest proportions in the WHO European Region [11], however it is the highest of the four CARs. In 1998, Kazakhstan’s estimated health expenditure was 3.5% of GDP. Pharmaceuticals accounted for about 10% of health expenditure in 1997, and 17.4% in 1995 [11]. The Kyrgyzstan public health care expenditure during the 1990s fluctuated between 3 and 4% of GDP. Of total health expenditure, pharmaceuticals have a share of 13% [10]. Another former Soviet country, Uzbekistan, showed a steady descending trend in public health care expenditure during the years of transition. In 1991 the country spent 6.0% of GDP for health care, which was a higher baseline compared to other Central Asian countries. The level decreased steadily to 3.0% of GDP in 1997 and slightly increased (3.3%) in 1998 [7]. About 10% of the health budget is spent on pharmaceuticals [7].

Tajikistan stands out among the countries of CAR, unfortunately, because it is in a more difficult situation. The country is recovering after civil war (1992-1997). In Tajikistan the scale of the health care financing collapse is dramatic. In 1990, the government health budget was about US $ 352 million or $69 per capita, but in 1998 the government spent only US $ 15,421 million or US $ 2.54 per capita [12], which comprises 1.2% of the country’s budget [13]. Sixteen percent of the health budget is spent on pharmaceuticals, which is US $ 0.49 per capita (1998). The amount does not allow even a basic supply [12]. Moreover, the health resources are not distributed equally per region. In 1998, state health funding per capita by region ranged from US $1.30 (Khatlon oblast) to US$ 3.48 (Dushanbe – capital city) [14].

Pharmaceuticals during the Soviet era.

While at Medical University in the former USSR and while employed at the pharmaceutical company "Tajikpharmacia", I learned that most of the drugs had been produced in the Soviet Union in pharmaceutical companies of the government. A smaller proportion was imported from socialistic countries like Hungary, Bulgaria, the former German Democratic Republic and some other countries. There was a pharmaceutical factory in each republic and in each major region of the country. Local factories manufactured most medicines that would have a short shelf life and would require special transportation conditions. There were Republican Planning Agencies in each of the former Soviet Republics to which the funds were distributed. Prior to distribution, the Central State Planning Agency estimated allocation of the funds for each republic. The republican level authorities had to follow or at least keep close to the estimations. The Republican Planning Agencies then distributed the funds among various ministries within republican governments. Republican Planning Agencies also had to monitor and evaluate the program expenditure and report them to the Central State Planning Agency.

During the Soviet Union era, a strictly centralized pharmaceutical system existed, and was financed and regulated through the federal government in Moscow. The republics had limited influence on the planning and the distribution of the pharmaceuticals. Many drugs were provided free or subsidized to the entire population. In hospitals, all the drugs were free, while primary care would offer prescriptions to the patients and the patients bought the prescribed drugs from a pharmacy. The prices for drugs were low and, in general, the population could easily afford the medicines. Certain groups of people like war veterans, the elderly, and children could get the prescribed medicines free or with significant discounts.

The Central government conducted special studies to forecast the need for drugs for every year. Based on the study results, the required amount of drugs was calculated and put on order to the pharmaceutical factories throughout the country, as well as to the partners in Eastern Europe and other importing partners. Most of the drugs used were generic and manufactured locally. The former Soviet Union had a limited list of medicines that could be used in the country.

Pharmaceuticals during the Post-Soviet era.

After the Soviet Union collapsed (December 1991), every NIS was forced to run the pharmaceutical sector on its own. At that point, all of the former Soviet countries had acute shortages in pharmaceutical supply, and concerns about the quality of the available drugs on the market. These conditions were created during so-called "perestroika", which was started in 1985 by the central government. During its last years, the Soviet system was not functioning well, since the central government was losing power. By the time the country collapsed, the economic situation was poor and the newly formed independent countries had to start from an unfavorable situation. Beside that, republics had limited experience in running their countries’ pharmaceutical industries on their own. Moreover, while part of the Soviet Union, the decisions had been made by the central government. Overall chaos in the countries had a significant negative impact on the pharmaceuticals market.

Central Asian Republics, as well as the other NIS, have had to contend with structural problems inherited from the Soviet system for the provision and distribution of pharmaceutical products [15]. Acute drug shortages, scarce financial resources, unadjusted regulation and legislation, and the absence of a comprehensive pricing and reimbursement schemes have sharpened the problems in pharmaceutical sector [15]. Most of the countries still are strongly in need of support from donor agencies to cope with shortages in drug supply. For instance, Tajikistan’s government relies on aid from external donors, and over 40% of pharmaceuticals is provided by donors in some areas and at present government drug expenditure (US $0.49 per capita in 1998) does not allow even a basic supply [16]. Other CARs also are in need of international donations.

Method

The method used in this paper compared the existing Essential Drug Lists of Kazakhstan [17], Kyrgyzstan [18], Uzbekistan [19], and Tajikistan [20] to the WHO EDL Model List from 1999 [21] (see spreadsheet annex 3). The WHO ED Model List includes two columns. In the first column, the International Nonproprietary Names (generic names) are given and the second column includes the form and doses recommended. The EDLs of Uzbekistan and Kyrgyzstan also have two similar columns. The EDLs of Tajikistan and Kazakhstan, in addition to two columns similar to the WHO Model List, include an additional column for trade names, which are the same as brand names. The WHO EDL Model list sorts the drugs into 27 therapeutic groups. The WHO list has the core list and a complementary one. From the lists I have analyzed, it was not clear if the four countries have sorted their lists into core and complementary lists.

For this paper a comparative table has been developed and the WHO Model EDL was taken as the standard. Five columns were created to sort out the molecules from the national lists sorted into three categories: 1) the molecule is also in the WHO Model EDL; 2) the molecule is from the same therapeutic group; and 3) the molecule is not included in the WHO Model List. There are two complimentary columns. One is to write down the number of the trade names mentioned in the national lists (in the case of Tajikistan and Kazakhstan) and the second is to indicate the number and form and doses for the molecules which are coming from the WHO Model EDL list. The table does not include the number of forms and doses for alternative and additional drugs.

Based on the spreadsheet, summary tables were developed for all the EDLs and WHO Model List, and some of the therapeutic groups to compare with the number of molecules from the WHO list, the number of alternative and additional drugs. Another summary table was developed to compare the number of the forms and doses for the molecules coming from WHO list per country.

General results

All four countries have developed and have already updated their EDL [17-20]. The lists have both similarities and differences. First of all they are not organized in the same format. The structure of Tajikistan and Kazakhstan EDLs is identical with the one from WHO. Uzbekistan and Kyrgyzstan have organized their lists differently (different therapeutic grouping, classification). The number of therapeutic groups, the number of drugs selected and included, and number of forms and doses also vary. The table of the comparative analysis is included as Annex 3.

SUMMARY

*Total number excludes brand names.

As can be seen in table 2, the numbers of molecules in the various lists vary between 236 and 368. Tajikistan’s EDL has the least number of molecules, 236, and Kazakhstan’s has the most, 368. The selected drugs are from both the WHO Model list and other sources. The numbers of drugs in EDLs that are adopted from the WHO EDL Model List are the following: Kazakhstan – 177, Kyrgyzstan – 146, Tajikistan – 200, and Uzbekistan – 136 (see annex 4-7).

The table above also reveals that Tajikistan has the least number of drugs in the list, 236, and has included the most number of drugs from the WHO Model Essential Drug Lists, 200, which comprises 85% of the drugs in the Tajik EDL (see annex 6). Uzbekistan has the second highest number of drugs among the four countries, 341, and the least number of drugs from WHO EDL Model List, 136 (40%). Additionally, it has more alternative and additional drugs, 205 (see annex 7). Kazakhstan’s EDL includes 177 (48%) molecules from the WHO EDL Model List, 61 alternative, and 130 additional molecules (see annex 4). Kyrgyzstan’s EDL includes 146 (51%) molecules from the WHO List and 141additional and alternative drugs (see annex 5).

Forms and dosage

The number of forms and dosage for each of the drugs of choice is listed on each EDL. They are important components. For most drugs, dozens of forms and doses are available in the market. The WHO Model EDL usually includes two, or rarely three or more forms and doses. The national lists are not consistent with the WHO Model List and include up to 14 forms and doses for some of the drugs. For instance, Kyrgyzstan has 5 forms in 14 doses of Paracetamol on the list. The table below compares the WHO list with some of the national lists for erytromycin in term of forms and doses.

Table 3. Forms and doses of erytromycin in WHO, Kazakhstan, Kyrgyzstan and Uzbekistan EDLs.

The table below illustrates a few other examples of variation of choices form the forms and doses for the selected drugs.

Table 4. Highlight of a few examples of forms and doses.

The WHO Model list suggests 594 forms and doses for 306 drugs, which makes an average of 1.9 doses and forms per drug. To compare, I take the average form and doses number for the drugs included in EDLs from the WHO Model list. Kazakhstan 435/177=2.5, Kyrgyzstan 521/146=3.5, Tajikistan 299/200=1.5, Uzbekistan 477/136=3.5.

Table 4. Number of forms and doses per drug.

These simple calculations show another area of controversy in the EDLs. It will be very helpful for the procurement process to keep the number of forms essential to procure low. Having too many forms and doses, it is difficult to decide how much of which dose to purchase. Obviously too many forms and doses for most of the drugs is not essential. For instance, it is not essential to have 4 forms in 14 doses of paracetamol.

The EDL of Kazakhstan has a separate column named "Trade names", which is the same as brand names. For almost every generic name, a number of brand names are indicated. In some cases the brand names are more than 10. For instance, The NDL of Kazakhstan mentions 7 brand names for diazepam (valium, seduxen, relanium, bruzepam, sibazon, apaurin, diazepam), 11 trade names for ibuprofen (Advil, Apifen, Brufen, Bonifen, Dolgit, Apoibuprofen, Ipren, Motrin, Reumofen, Nurofen), and 14 for paracetamol. The NDL of Tajikistan has a similar column. It includes brand names for most of the drugs in the list. For example, 4 trade names are mentioned for diazepam (Valium, Seduxen, Relanium, Sibazon).

Summary

Cardiovascular diseases are one of the main causes of death in all of the four countries: 39.1% of the 0-64 population group in Uzbekistan [22], 33.9% in Kazakhstan [23] and 33.5% in Kyrgyzstan [24]. The inclusion of cardiovascular drugs in the EDL is well reasoned and definitely needed. The WHO EDL Model List includes 27 generic cardiovascular drugs. As can be seen in the summary table 5, Kazakhstan adopted 14 of them, Kyrgyzstan 12, Tajikistan 18 and Uzbekistan only 10 of them. The numbers of additional and alternative drugs also vary: Kazakhstan – 15, Kyrgyzstan – 4, Tajikistan – 6 and Uzbekistan – 25. The numbers of molecules of the additional drugs are different too. For instance, some of the molecules included in the Uzbek list are not present in any of other countries’ EDLs (see annex 8 for compete list of cardiovascular drugs for each of the countries).

Gastrointestinal drugs

The proportion of mortality caused by gastrointestinal diseases is substantial in the Central Asian Republics: 8.5% in Uzbekistan [22], 5% in Kazakhstan [23] and 8.7% in Kyrgyzstan [24]. The WHO EDL Model List includes 12 generic gastrointestinal drugs. Kazakhstan adopted 7 of them, Kyrgyzstan only 6, Tajikistan 11 and Uzbekistan 3. The numbers of additional and alternative drugs also vary: Kazakhstan – 16, Kyrgyzstan – 7, Tajikistan – 6, and Uzbekistan – 18 (see table 6). Besides the number of molecules, the additional drugs are also different. For instance, some of the molecules included in one country are not considered essential in others (see annex 9).

Table 6. Gastrointestinal drugs. Summary

DISCUSSION

The 1999 version of the WHO Model List consists of 306 drugs. The number of drugs in the four countries ranges from 236 to 368, including 136-200 drugs from the WHO Model List. Some of the WHO Model List drugs are not included in any of the national lists. Instead, the national lists include other drugs, which raises the issue of evidence-based selection.

Although the countries have similar disease indicators with about the same level of health financing, except for Tajikistan, the EDLs in the four countries vary substantially. This fact raises questions about the selection process of the essential drugs included in the national lists and perhaps to a certain extent questions if the drugs included in the WHO Model List are the right ones. The differences also show that the selection process was based on experience, and the selection depended on the people involved in the selection process. Either the WHO or the CARs (or both) did not make their choice based on evidence.

Tajikistan and Kazakhstan, in addition to the generic name column, included a column for brand name options. Brand names are associated with high cost, and because of that they cannot be the priority choice. Perhaps this column is included for educational purposes, because some categories of health professionals are not familiar with generic names. But inclusion of brand names for most of the drugs in the list can lead to misinterpretation, particularly in procurement and prescription practices of the health professionals. Since 1977, the WHO Model List has includes only generic names of drugs. There are hundreds of brand names for a generic drug available on the market. Including a brand name in the EDL limits the procurement option to that particular brand name, while inclusion of a generic name keeps the choice open, and the drugs can be purchased at the best available price in the market at any time. Brand names should be removed from the EDLs.

What is the right number of forms and doses for a drug? For most of the drugs, WHO suggests two forms and doses. But the national lists of Kyrgyzstan and Uzbekistan show much higher numbers. There are even some extreme cases, when the countries indicate 10-14 doses of the various forms for a drug. How necessary is it for Kyrgyzstan to have 14 forms and doses of paracetamol? The countries need to make an effort to reduce the number of forms and doses. This multiplicity of dosage and forms can lead to procurement problems. We also can assume that either the national treatment guidelines have not been developed properly; or the treatment guidelines are not standardized or are not evidence based.

Choices of cardiovascular drugs are one of the most controversial among the countries. From 27 drugs included in the WHO Model List, Kyrgyzstan included 12, Uzbekistan 10, Kazakhstan – 14, and Tajikistan – 18. For alternative and additional drugs, the countries made very dissimilar selections. Uzbekistan’s health professionals included the most number of alternative and additional drugs - 25, while Tajikistan included 6, and Kyrgyzstan only 4. The physicians in the countries have very similar background in terms of education and training. The health indicators are also similar among the countries. Why are the choices so different?

The gastrointestinal drugs group is another clear example of discrepancies in the lists. Again the counties chose different drugs from those included in the WHO Model List as essential. From the 12 WHO Model List drugs, Kyrgyzstan found 6 as essential, Tajikistan chose 11 of them, Kazakhstan - 7, and Uzbekistan only 3.

The different choices made about cardiovascular drugs and gastrointestinal drugs show that the countries do have their own opinions and are not pressured by WHO and other health organizations involved in the development and updating of the EDLs to conform to the WHO Model EDL. This suggests that at least in some of the countries, the selection may not be evidence-based. It also says treatments preferred by medical professionals are different in different countries.

Correct selection is a key factor for an EDL to be successful. All the discrepancies described above are related to the selection process. There is a tendency to shift from experienced-based selection to evidence-based selection process in the WHO [3]. Countries would greatly benefit if the WHO would make the selection process within the organization transparent and would share its experience, resources and the methods used with them.

Ensuring transparency of the selection process and making available and accessible the results of the studies on drugs on-line would be an invaluable contribution to improve the selection process. To make the selection process comprehensive, clear and transparent, a few examples of the process of how a drug was selected for the WHO Model List could be published as guidelines on the selection process.

A good model list has a great value. But a good model list does not guarantee correct use. It is still a challenge for the WHO and governments to make right selections and appropriate use of essential drugs [2, 25].

Recommendations – The way forward

These recommendations below target public agencies such as governments and international organizations involved in the process of creating and revising EDLs:

CONCLUSION

There has been a significant effort by Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan to implement the Essential Drug Concept. All of the four former Soviet Central Asian countries developed and revised their EDLs. The total number of drugs included in the national lists is reasonable, except for the listing of brand names. Local institutions contributed to the process of the development and revision of the lists, and there is knowledge and interest in the concept. The number of essential drugs among the four countries, the drugs selected for the national lists, and the excessive number of forms and doses for Kyrgyzstan and Uzbekistan make the lists controversial. In addition, inclusion of the brand names in a separate column in Kazakhstan and Tajikistan EDLs creates room for misinterpretation and for bad procurement practices.

WHO is moving towards evidence-based medicine, and the organization is still strongly involved in the process of developing and revising the EDLs. Perhaps the EDL concept will bring benefits if the WHO will develop comprehensive guidelines on evidence-based selection and create a database on the drugs to facilitate the selection process in the countries, which are short in human resources and have limited financial capacity.

The EDLs of Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan are very different. At least some of these EDLs of the above countries require radical revision of the selected drugs and the selection process.

1. Management Sciences for Health, 1997. Managing Drug Supply, Second edition, 1997:122.
2. Howard N. J., Laing R. O.. Changes in the World Health Organization essential drug list. Lancet 1991; 338: 743-45.
3. World Health Organization. Procedure for updating WHO’s Model List of Essential Medicines, Report by Secretariat, Document EB109/8, December 7, 2001, http://www.who.int/medicines/organization/par/edl/procedures.shtml., Accessed April 20,2002.
4. World Health Organization. The Use of Essential Drugs, Ninth Report of the WHO Expert Committee, Nov. 1999. Geneva, WHO: 2000. Technical Report Series, No. 895.
5. World Health Organization. The WHO Model List of Essential Drugs, WHO Department of Essential Drugs and Medicines Policy. Prepared by: Dr. Hans V. Hogerzeil, WHO/EDM/PAR, September 4, 2000.
6. World Health Organization. Revised procedures for updating the WHO Model List of Essential Drugs: a summary of proposals and process. EXECUTIVE BOARD 108^th Session, EB108/INF.DOC./2, May 19, 2001.
7. World Health Organization, Updating and disseminating the WHO Model List of Essential Drugs: the way forward (Revised version, September 10, 2001), Department of Essential Drugs and Medicines Policy (EDM), Geneva.
8. World Health Organization. Highlights of the year 2000 in Essential Drugs and Medicines Policy, Geneva: WHO, 2001:1.
9. World Health Organization. How to develop and implement a national drug policy, Second edition. Updates and replaces, Guidelines for Developing National Drug Policy, 1988. http://www.euro.who.int/document/e67903.pdf. Accessed December 5, 2001.
10. World Health Organization. European Observatory on Health Care System, Health Care Systems in Transition, Kygryzstan, http://www.euro.who.int/document/e69818.pdf. Accessed January 22, 2002.
11. World Health Organization. European Observatory on Health Care System, Health Care Systems in Transition, Kazakhstan, http://www.euro.who.int/document. Accessed February 15, 2002.
12. World Health Organization. The definition and selection process for an EDL, WHO Department of Essential Drugs and Medicines Policy, Technical Briefing Paper, Prepared by: Dr Hans V. Hogerzeil, WHO/EDM/PAR, October 27, 2000.
13. World Health Organization. Regional office for Europe. Country information: Tajikistan. http://www.euro.who.int/document/obs/Tajikistan.pdf. Accessed on March 27, 2002.
14. Thompson, R. Financial and economic analysis of the health sector in Tajikistan 1999. York: Center for Health Economics, University of York, 1999.
15. European Observatory on Health Care Systems, Lithuania, www.observatory.dk. Accessed January 20, 2002
16. European Observatory on Health Care System, Health Care Systems in Transition, Tajikistan, http://www.euro.who.int/document/e69820.pdf, accessed January 22, 2002
17. Agency on Public Health. Essential Drug List of the Republic of Kazakhstan, November 06, 2001.
18. Essential Drug List of the Republic of Kyrgyzstan, Approved by the Government of the Kyrgyz Republic, 10.10.2001
19. Minister of Health of the Republic of Uzbekistan. Essential Drug List of the Uzbekistan Republic, May 18, 2001.
20. Ministry of Health of the Republic of Tajikistan, Essential Drug List of Tajikistan, Dushanbe, April 6, 1998
21. World Health Organization. WHO Model List of Essential Drugs, 1999, http://www.who.int/medicines/organization/par/edl/infedl11alpha.html, accessed on January 5, 2002.
22. Highlights on Health in Uzbekistan, htpp://www.euro.who.int/document/e71959.pdf. Accessed on March 12, 2002
23. Highlights on Health in Kazakhstan, htpp://www.euro.who.int/document/e72497.pdf. Accessed on March 7, 2002
24. Highlights on Health in Kyrgyzstan, htpp://www.euro.who.int/document/e72499.pdf. Accessed on February 7, 2002
25. Laing R. O., Hogerzeil H, Ross-Degnan D. Ten Recommendations to improve use of medicines in developing countries. Health Policy and Planning 16 (1) 13-20 2001,

http://dcc2.bumc .bu.edu/richardl/hpp10.pdf




Annexes

Annex 1-2

The seven steps from development of a new drug to inclusion on the WHO Model List of Essential Drugs

and

Selection criteria used by WHO Expert Committee on the Use Essential Drugs

Annex 3, 8 and 9

Comparative Table of EDLs of former Soviet Central Asian Countries

Cardiovascular drugs by country

Gastrointestinal drugs by country

Annex 4-7

Items on WHO Model list, Alternative drugs and Additional Drugs by Country



This paper is also available as a Word Document and the Annexes are available as Word and Excel files

   Word Document   Annex 1-2   Annex 3,8&9  Annex 4-7

   Word Document   Annex 1-2   Annex 3,8&9  Annex 4-7