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Decisions on WHO's essential medicines need more scrutiny

Corrado Barbui & Marianna Purgato. Decisions on WHO's essential medicines need more scrutiny. BMJ 2014; 349 doi: (Published 31 July 2014)
Abstract / Summary: 
An informal article in this week's BMJ (2 August) looks at the WHO Essential Medicines List and how it is compiled and maintained.   'WHO suggests that essential medicines should be available within functioning health systems at all times, in adequate amounts, in the appropriate doses, with assured quality, and at a price the individual and the community can afford.'   The authors recognise that the list, first introduced in 1977, "has led to global acceptance of essential medicines as a powerful means to promote health equity'.   'The rules governing the process for inclusion on the list have changed substantially over time. Originally, the expert committee largely decided what should be included. But in 2002, in response to growing methodological concerns, a more systematic assessment of the evidence base was implemented.'   The authors identify 7 current problems with the current WHO procedure for inclusion of new medicines in the model list of essential medicines, and possible solutions to each:   1. Search strategy inconsistently reported, reasons for inclusion or exclusion of data not reported - Solution: A systematic search of the background evidence should be required and reported following the PRISMA or similar flowchart. The search strategy should be included in the application as an appendix   2. Target population, comparison groups, and outcomes of interest erratically reported - Solution: A PICO (population, intervention, comparisons, outcomes) format should be required. WHO could develop condition specific applications indicating the target population (new cases, non-responders, etc), the comparison groups (placebo, active comparators already included in the list, other active comparators), and the relevant outcomes (symptomatic, functional, short versus long term)   3. Quantitative summaries of overall treatment effect not systematically reported for each comparison and outcome - Solution: A tool such as GRADE should be required to report in a tabular format, for each outcome and comparison of interest, the number of studies and patients included, and the overall effect of the intervention   4. Quality of evidence erratically reported - Solution: A tool such as GRADE should be required to report, for each outcome and comparison of interest, the quality of the evidence base   5. Considerations not related to the evidence base inconsistently reported - Solution: WHO application form should include a box for considerations dealing with preferences, values, feasibility issues, and resource use   6. Conflicts of interest not clearly reported - Solution: WHO application form should include a box for reporting potential economic or intellectual competing interests   7. WHO expert committee narratively reports reasons for accepting or rejecting a medicine - Solution: WHO should develop a reporting template where judgments on the various aspects of the application are consistently and transparently reported.   Here is the citation: The full text is restricted-access.   The authors do not comment on child health, for which WHO produces a separate Model List of Essential Medicines for Children (2013). WHO also co-publishes The Interagency List of Essential Medicines for Reproductive Health (2006).  
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Corrado Barbui & Marianna Purgato

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