Twenty-five years of essential medicines.

The twentieth century opened with only one widely available modern medicine: acetylsalicylic acid (aspirin). In the 1940s the first antibiotic, the first mass produced antimalarial, and the first antitubercular were introduced. The 1950s and 1960s saw the rapid introduction of oral contraceptives, medicines for diabetes, and then medicines for mental illness, many infectious diseases, cardiovascular diseases, and cancer. By the 1970s effective medicines--though not always ideal--existed for nearly every major illness. Yet for half the world's population, it was as if they were still living in the nineteenth century. For them, modern medicines were unavailable, unaffordable, of poor quality, or ineffective because not properly used. In 1975 the World Health Assembly introduced the concepts of "essential drugs" and "national drug policy", and they quickly became part of the global public health vocabulary. The Health Assembly was building on precedents set in Scandinavia, North America and some pioneering developing countries, such as Papua New Guinea, Peru, Sri Lanka, and the United Republic of Tanzania, in the hope that they would provide a way to begin closing the huge gap between those who were benefiing from the pharmaceutical harvest of the mid-1900s and those who were not. In October 1977, WHO produced the first Model List of Essential Drugs and in 1978 the Declaration of Alma-Ata identified "provision of essential drugs" as one of the eight elements of primary health care. According to the current WHO Expert Committee on the Selection and Use of Essential Medicines, "Essential medicines are those that satisfy the priority health needs of the population. They are selected with due regard to disease prevalence, evidence of efficacy and safety, and comparative cost-effectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms with assured quality, and at a price the individual and the community can afford. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility. " Thanks partly to the recognition and application of these principles, the situation has changed enormously since 1977. The following examples give some idea of the contrast. In 1977, perhaps a dozen countries had what would now be considered an essential medicines list or an essential drugs programme. Today, four out of five countries--at least 156 countries in total--have adopted national essential medicines lists. National lists are widely used for public procurement systems, reimbursement schemes, training, public education, and other national health activities. Most countries have recently updated their lists, and WHO has updated its own model list of essential medicines on average every two years for the 25 years. In 1977, the concept of a national drug policy was unknown to almost everyone. Today, over 100 countries have national drug policies in place or under development. These policies are being introduced at increasing speed in every region. More importantly, a growing number of countries are moving directly from policy to action. The national drug policy is increasingly serving as a framework within which interested parties can work for pharmaceutical sector reform within countries. In 1977, objective information on rational use of drugs was extremely limited, especially in developing countries. Today, at least 135 countries have their own therapeutic manuals and formularies, which provide health professionals with current, accurate and unbiased advice on the rational use of drugs. In addition, this year the WHO Model Formulary was launched. In 1977, medical training was often based on brand names, and little attention was given to systematic teaching about rational drug use. …