Country Specific Approaches to Updating Essential Drugs and Formulary Lists1
Bhutan
A participatory approach was used to update the national essential drugs list (NEDL). A form was developed, and health workers at all levels were invited to propose additions and deletions to the national list. Suggestions were also requested for the level of use for each drug. The proposals were compiled by the essential drugs program coordinator for the National Selection Committee, which made the final decision. The current NEDL consists of 312 drugs and indicates their level of use.
Eastern Caribbean Drug Service (ECDS)
The ECDS is a group purchasing service for seven small Caribbean countries. Procurement is limited primarily to the ECDS Regional Core Formulary. Drugs are selected by the ECDS Technical Advisory Subcommittee (TAC), which consists of one member appointed by each participating country (generally the chief medical officer or a comparable ministry appointee) and the central stores managers from each country. The ECDS managing director and assistant managing director are nonvoting members of the TAC. The formulary list is subject to continual review. Changes are based on the evaluation and approval of written requests.
United States Public Health Service (USPHS)
Most drugs for the Oklahoma area of the USPHS are procured centrally, based on a formulary list. Each hospital in the area has a pharmacy and therapeutics committee that reviews drug needs and drug utilization for the hospital and its health centers. The formulary list is revised each year. Hospitals submit suggested additions and deletions to the area pharmacist, who compiles the suggestions. In a representative fashion, the chairpersons from each hospital pharmacy and therapeutics committee then meet at area headquarters to review and decide on the proposed revisions.
World Health Organization
Since publication of the first Model List of Essential Drugs in 1977, the list has been updated every two to four years, with revisions appearing in 1979, 1983,1985,1988,1990,1992, and 1995. The list is updated by an expert advisory committee that consists primarily of clinical pharmacologists and physicians. A major change that occurred with the 1985 list was the introduction of complementary drugs, which allowed substitution of therapeutic equivalents. Over the first fifteen years, the number of drugs on the list increased slightly, but most changes involved replacement of one preparation with a more therapeutically appropriate or cost-effective preparation. For example, amoxicillin replaced ampicillin, and doxycycline replaced tetracycline. Nevertheless, the list contains fewer than 300 active ingredients.
Zimbabwe
The first essential drugs list for Zimbabwe (EDLIZ) was produced in 1985. The list contained 581 formulations, 224 of which were allowed at the clinic level. As of 1994, the list had been revised three times and included 409 drugs and vaccines in 592 formulations. The number of formulations available at the clinic level had been decreased to 83, with an additional 259 for district hospitals (with some specialists), and another 154 for specialists' use only. Twenty-four drugs are featured in a supplementary list and can be imported without prior permission from the Ministry of Health for rare life-threatening conditions.
Revisions are carried out by the National Drug and Therapeutics Policy Advisory Committee (NDTPAC), which meets regularly. Its members include a professor from the Department of Pharmacy, University of Zimbabwe (UZ); a general practitioner; the clinical pharmacists, Department of Pharmacy, UZ; a professor from the national teaching hospital; the professor of clinical pharmacology, UZ; and the president of the national pharmacy association (private sector). The secretariat for the NDTPAC includes the director of pharmacy services, Ministry of Health and Child Welfare; the registrar, Drugs Control Council; the controller, Government Medical Stores; and the project coordinator, Zimbabwe Essential Drugs Programme.
The revision process is continual and takes about two years. It actually restarts as soon as a new list is issued. In this way, the merits of all new developments can be discussed and evaluated as soon as they arise. The committee has called on a panel of forty specialists for their views and contributions, and another eighty persons have been asked for comments and opinions. All medical disciplines, as well as pharmacists, buyers, and health economists, are represented, to arrive at the most economical choice with the widest possible coverage for medical conditions prevalent in Zimbabwe.
