Decision criteria for selecting essential medicines and their connection to guidelines: an interpretive descriptive qualitative interview study

BACKGROUND AND OBJECTIVES

The World Health Organization Model List of Essential Medicines has led to at least 137 national lists. Essential medicines should be grounded in evidence-based guideline recommendations and explicit decision criteria. Essential medicines should be available, accessible, affordable, and the supporting evidence should be accompanied by a rating of the certainty one can place in it. Our objectives were to identify criteria and considerations that should be addressed in moving from a guideline recommendation regarding a medicine to the decision of whether to add, maintain, or remove a medicine from an essential medicines list. We also seek to explore opportunities to improve organizational processes to support evidence-based health decision-making more broadly.

METHODS

We conducted a qualitative study with semistructured interviews of key informant stakeholders in the development and use of guidelines and essential medicine lists (EMLs). We used an interpretive descriptive analysis approach and thematic analysis of interview transcripts in NVIVO v12.

RESULTS

We interviewed 16 key informants working at national and global levels across all WHO regions. We identified five themes: three descriptive/explanatory themes 1) EMLs and guidelines, the same, but different; 2) EMLs can drive price reductions and improve affordability and access; 3) Time lag and disconnect between guidelines and EMLs; and two prescriptive themes 4) An "evidence pipeline" could improve coordination between guidelines and EMLs; 5) Facilitating the link between the WHO Model List of Essential Medicines (WHO EML) and national EMLs could increase alignment.

CONCLUSION

We found significant overlap and opportunities for alignment between guideline and essential medicine decision processes. This finding presents opportunities for guideline and EML developers to enhance strategies for collaboration. Future research should assess and evaluate these strategies in practice to support the shared goal of guidelines and EMLs: improvements in health.

Access to cancer medication in public hospitals in a middle-income country: The view of stakeholder

BACKGROUND

Access to cancer medicines is a core component of comprehensive cancer care; as such, it is included in Mexico's public health insurance: Seguro Popular de Salud (SPS). Learning about stakeholders' experiences on processes and barriers influencing access to essential cancer medicines within healthcare facilities allows identifying needed policies to improve access to cancer care.

OBJECTIVE

The aim of this study was to obtain the insights of health professionals in public hospitals in Mexico on how SPS influences access to cancer medicines regarding medicine selection, financing, and procurement and supply systems. The purpose is to identify policy areas that need strengthening to improve access to cancer medicines.

METHODS

Semi-structured interviews were conducted with 67 health professionals from 21 public hospitals accredited by SPS across Mexico. A framework analysis was used with categories of analysis derived from the World Health Organization's Access framework.

RESULTS

Most stakeholders reported that the availability of listed cancer medicines was sufficient. However, cancer specialists reported that medicines coverage by SPS was restrictive covering only basic cancer care. Public hospitals followed SPS treatment protocols in selecting and prescribing cancer medicines but used different procurement procedures. When essential cancer medicines were unavailable (not listed or stocked-out), hospitals reported several strategies such as prescribing alternative therapies, resorting to direct purchases, and assisting patients in obtaining medicines elsewhere. Other reported barriers to access to treatment were: distance to health facilities, poor insurance coverage, and financial restrictions.

CONCLUSIONS

Health professionals have encountered benefits and challenges from the implementation of SPS influencing access to cancer medicines and care in Mexico, pointing to areas in which action is necessary. Finding the right balance between expanding the range and cost of cancer treatments covered by insurance and making basic cancer care available to all is a challenge faced by Mexico and other middle-income countries.

Availability, prices, and affordability of selected essential cancer medicines in a middle-income country - the case of Mexico

Background

More alternatives have become available for the diagnosis and treatment of cancer in low- and middle-income countries. Because of increasing demands, governments are now facing a problem of limited affordability and availability of essential cancer medicines. Yet, precise information about the access to these medicines is limited, and the methodology is not very well developed. We assessed the availability and affordability of essential cancer medicines in Mexico, and compared their prices against those in other countries of the region.

Methods

We surveyed 21 public hospitals and 19 private pharmacies in 8 states of Mexico. Data were collected on the availability and prices of 49 essential cancer medicines. Prices were compared against those in Chile, Peru, Brazil, Colombia and PAHO’s Strategic Fund.

Results

Of the various medicines, mean availability in public and private sector outlets was 61.2 and 67.5%, respectively. In the public sector, medicines covered by the public health insurance “People’s Health Insurance” were more available. Only seven (public sector) and five (private sector) out of the 49 medicines were considered affordable. Public sector procurement prices were 41% lower than in other countries of the region.

Conclusions

The availability of essential cancer medicines, in the public and private sector, falls below World Health Organization’s 80% target. The affordability remains suboptimal as well. A national health insurance scheme could serve as a mechanism to improve access to cancer medicines in the public sector. Comprehensive pricing policies are warranted to improve the affordability of cancer medicines in the private sector.

Legislating for universal access to medicines: a rights-based cross-national comparison of UHC laws in 16 countries

Universal health coverage (UHC) aims to ensure that all people have access to health services including essential medicines without risking financial hardship. Yet, in many low- and middle-income countries (LMICs) inadequate UHC fails to ensure universal access to medicines and protect the poor and vulnerable against catastrophic spending in the event of illness. A human rights approach to essential medicines in national UHC legislation could remedy these inequities. This study identifies and compares legal texts from national UHC legislation that promote universal access to medicines in the legislation of 16 mostly LMICs: Algeria, Chile, Colombia, Ghana, Indonesia, Jordan, Mexico, Morocco, Nigeria, Philippines, Rwanda, South Africa, Tanzania, Turkey, Tunisia and Uruguay. The assessment tool was developed based on WHO's policy guidelines for essential medicines and international human rights law; it consists of 12 principles in three domains: legal rights and obligations, good governance, and technical implementation. Relevant legislation was identified, mapped, collected and independently assessed by multi-disciplinary, multi-lingual teams. Legal rights and State obligations toward medicines are frequently codified in UHC law, while most good governance principles are less common. Some technical implementation principles are frequently embedded in national UHC law (i.e. pooled user contributions and financial coverage for the vulnerable), while others are infrequent (i.e. sufficient government financing) to almost absent (i.e. seeking international assistance and cooperation). Generally, upper-middle and high-income countries tended to embed explicit rights and obligations with clear boundaries, and universal mechanisms for accountability and redress in domestic law while less affluent countries took different approaches. This research presents national law makers with both a checklist and a wish list for legal reform for access to medicines, as well as examples of legal texts. It may support goal 7 of the WHO Medicines & Health Products Strategic Programme 2016-30 to develop model legislation for medicines reimbursement.

The Impact of Price Negotiations on Public Procurement Prices and Access to 8 Innovative Cancer Medicines in a Middle-Income Country: The Case of Mexico

BACKGROUND

To mitigate the effect of high prices, in 2008 Mexico established a commission that negotiates single procurement prices for patented medicines in the public sector.

OBJECTIVES

We assessed the possible effect of price negotiations on the prices of new essential cancer medicines in Mexico between 2010 and 2016 and on access to these new cancer medicines.

METHODS

We retrieved the public procurement prices and volume of 8 selected innovative cancer medicines in Mexico in addition to their maximum retail prices in the private sector. We calculated the median, interquartile (25%-75%) range, and maximum and minimum public procurement prices to analyze price changes and trends. We assessed changes between the maximum retail prices and the public procurement prices and changes in the volume procured from 2010 to 2016.

RESULTS

Between 2010 and 2016, the prices of selected patented cancer medicines in the public sector decreased by 40% to 85%, expressed in US dollars. When expressed in Mexican pesos, public prices for 5 medicines reduced and others remained stable, whereas prices increased in the private sector over the same period. Procurement prices were not uniform between and within public institutions. The volumes of selected cancer medicines supplied in the public sector increased over the years, suggesting better access.

CONCLUSION

Although direct causality is difficult to prove, the establishment of the negotiating commission seems to have led to reduced prices and possibly better access in the public sector. Medicine procurement by public hospitals should be monitored to ensure that negotiated prices benefit all institutions.

The right to health as the basis for universal health coverage: A cross-national analysis of national medicines policies of 71 countries

Persistent barriers to universal access to medicines are limited social protection in the event of illness, inadequate financing for essential medicines, frequent stock-outs in the public sector, and high prices in the private sector. We argue that greater coherence between human rights law, national medicines policies, and universal health coverage schemes can address these barriers. We present a cross-national content analysis of national medicines policies from 71 countries published between 1990-2016. The World Health Organization's (WHO) 2001 guidelines for developing and implementing a national medicines policy and all 71 national medicines policies were assessed on 12 principles, linking a health systems approach to essential medicines with international human rights law for medicines affordability and financing for vulnerable groups. National medicines policies most frequently contain measures for medicines selection and efficient spending/cost-effectiveness. Four principles (legal right to health; government financing; efficient spending; and financial protection of vulnerable populations) are significantly stronger in national medicines policies published after 2004 than before. Six principles have remained weak or absent: pooling user contributions, international cooperation, and four principles for good governance. Overall, South Africa (1996), Indonesia and South Sudan (2006), Philippines (2011-2016), Malaysia (2012), Somalia (2013), Afghanistan (2014), and Uganda (2015) include the most relevant texts and can be used as models for other settings. We conclude that WHO's 2001 guidelines have guided the content and language of many subsequent national medicines policies. WHO and national policy makers can use these principles and the practical examples identified in our study to further align national medicines policies with human rights law and with Target 3.8 for universal access to essential medicines in the Sustainable Development Goals.

Access to innovative cancer medicines in a middle-income country - the case of Mexico

BACKGROUND

Cancer has become the third cause of death in Mexico. Treatment for cancer is often complex and lengthy. New and better medicines enter the market at high prices, which may limit access. Like most Latin American countries, Mexico has an essential cancer medicines list that includes innovative medicines. Their accessibility and use in the public sector remains unknown. Therefore, we describe the use, as a proxy of access, of innovative and essential cancer medicines in the public sector in Mexico, by insurance institution, and by five regions between 2010 to 2016.

METHODS

We used drug utilization research methods to assess the use of eight patented cancer medicines. Through the national transparency platform, we obtained data on the quantities of these medicines used in all public health facilities and social health insurance institutions and recalculated those figures into defined daily dose (DDD) per 1000 population per year.

RESULTS

Overall, the use of all medicines increased over the years, especially for trastuzumab, rituximab and imatinib. The use of innovative medicines was higher per population covered in social health insurance institutions than in governmental facilities. Throughout the study period, the Central region (including Mexico City) has used more medicines per population than the other regions.

CONCLUSIONS

The use and access of some essential innovative cancer medicines has increased over the years, but remains unequal across insurance schemes and regions. Particularly, the Ministry of Health Insurance scheme and Northern and Western regions in the country would benefit from additional efforts to increase access to essential cancer medicines.

Access to essential medicines in 195 countries: A human rights approach to sustainable development

In 2008 the UN Special Rapporteur on the Right to Health published 72 right to health indicators in 194 health systems. We present a follow-up report of eight indicators for access to medicines to serve as a reference point for progress towards SDG Target 3.8 on essential medicines. Data for these eight indicators in 2015 were collected and compared with the 2008 report. Between 2008 and 2015 we observed increased numbers of constitutions recognising access to medicines (7-13 countries), countries with a national medicine policy (118-122) and with a national list of essential medicines (78-107). Public spending on pharmaceuticals decreased or rose modestly in most of the 44 countries. Median availability of a basket of lowest-priced generics increased in the public (63%-70% n = 9 countries) and private (84%-92% n = 10) sectors. Median child immunisation rates remained constant for measles (around 90%) and improved for three doses of diphtheria-tetanus-pertussis (79%-86%). These eight indicators are useful and feasible, but should be further strengthened and expanded. Future monitoring exercises should use these indicators to screen progress and guide national governments' action to ensure universal access to essential medicines as part of the right to health.

Medicine procurement and the use of flexibilities in the Agreement on Trade-Related Aspects of Intellectual Property Rights, 2001-2016

Millions of people, particularly in low- and middle-income countries, lack access to effective pharmaceuticals, often because they are unaffordable. The 2001 Ministerial Conference of the World Trade Organization (WTO) adopted the Doha Declaration on the TRIPS (Trade-Related Aspects of Intellectual Property Rights) Agreement and Public Health. The declaration recognized the implications of intellectual property rights for both new medicine development and the price of medicines. The declaration outlined measures, known as TRIPS flexibilities, that WTO Members can take to ensure access to medicines for all. These measures include compulsory licensing of medicines patents and the least-developed countries pharmaceutical transition measure. The aim of this study was to document the use of TRIPS flexibilities to access lower-priced generic medicines between 2001 and 2016. Overall, 176 instances of the possible use of TRIPS flexibilities by 89 countries were identified: 100 (56.8%) involved compulsory licences or public noncommercial use licences and 40 (22.7%) involved the least-developed countries pharmaceutical transition measure. The remainder were: 1 case of parallel importation; 3 research exceptions; and 32 non-patent-related measures. Of the 176 instances, 152 (86.4%) were implemented. They covered products for treating 14 different diseases. However, 137 (77.8%) concerned medicines for human immunodeficiency virus infection and acquired immune deficiency syndrome or related diseases. The use of TRIPS flexibilities was found to be more frequent than is commonly assumed. Given the problems faced by countries today in procuring high-priced, patented medicines, the practical, legal pathway provided by TRIPS flexibilities for accessing lower-cost generic equivalents is increasingly important.

Policy approaches to improve availability and affordability of medicines in Mexico - an example of a middle income country

BACKGROUND

The World Health Organization recommends establishing and implementing a national pharmaceutical policy (NPP) to guarantee effective and equitable access to medicines. Mexico has implemented several policy approaches to regulate the pharmaceutical sector, but it has no formal NPP. This article describes the approach that the Mexican government has taken to improve availability and affordability of essential medicines.

METHODS

Descriptive policy analysis of public pharmaceutical policy proposals and health action plans on the basis of publicly available data and health progress reports, with a focus on availability and affordability of medicines.

RESULTS

The government has implemented pooled procurement, price negotiations, and an information platform in the public sector to improve affordability and availability. The government mainly reports on the savings that these strategies have generated in the public expenditure but their full impact on availability and affordability has not been assessed.

CONCLUSIONS

To increase availability and affordability of medicines in the public sector, the Mexican government has resorted on isolated strategies. In addition to efficient procurement, price negotiations and price information, other policy components and pricing interventions are needed. All these strategies should be included in a comprehensive NPP.

Impacts of a new insurance benefit with capitated provider payment on healthcare utilization, expenditure and quality of medication prescribing in China

OBJECTIVES

To assess a new Chinese insurance benefit with capitated provider payment for common diseases in outpatients.

METHODS

Longitudinal health insurance claims data, health administrative data and primary care facility data were used to assess trajectories in outpatient visits, inpatient admissions, expenditure per common disease outpatient (CD/OP) visit and prescribing indicators over time. We conducted segmented regression analyses of interrupted time series data to measure changes in level and trend overtime, and cross-sectional comparisons against external standards.

RESULTS

The number of total outpatient visits at 46 primary care facilities (on the CD/OP benefit as of July 2012) increased by 46 895 visits/month (P = 0.004, 95% CI: 15 795-77 994); the average number of CD/OP visits reached 1.84/year/enrollee in 2012; monthly inpatient admissions dropped from 6.4 (2009) to 4.3 (2012) per 1000 enrollees; the median total expenditure per CD/OP visit dropped by CNY 15.40 (P = 0.16, 95% CI: -36.95~6.15); injectable use dropped by 7.38% (P = 0.03, 95% CI: -14.08%~-0.68%); antibiotic use was not improved.

CONCLUSIONS

Zhuhai's new CD/OP benefit with capitated provider payment has expanded access to primary care, which may have led to a reduction in expensive specialist inpatient services for CD/OP benefit enrollees. Cost awareness was likely raised, and rapidly growing expenditures were contained. Although having been partially improved, inappropriate prescribing of antibiotics and injectables was still prevalent. More explicit incentives and specific quality of care targets must be incorporated into the capitated provider payment to promote scientifically sound and cost-effective care and treatment.

Achieving universal health coverage-the case of Zhuhai city

OBJECTIVE

Universal health coverage cannot be achieved without evidence from research, which requires national and international support. We hope that our careful documentation of one of China's local experience in designing and implementing the basic health insurance coverage, and our analysis of how it helped to achieve universal health coverage, will inform other systems in China as well as other relevant countries on their way to universal coverage.

METHODS

The paper first presents the development of Zhuhai's basic health insurance system chronologically; then comprehensively describes the background and the key components of the common disease outpatient benefit package; followed by a comparison with the common practices of outpatient benefit package of other areas of China and four neighboring countries. It also summarizes the strengths and weakness of the package, and lists the remaining research questions for future studies.

RESULTS

The common disease outpatient benefit package of Zhuhai has helped to improve the universal health coverage of Zhuhai in the following aspects: securing all citizens' access to the common disease outpatient services under the basic health insurance coverage; containing the rapid growth of health expenditures; enhancing provider awareness of expenditure and encouraging cost-effective interventions through appropriate financial incentives; and shifting the focus from treatment to prevention and preventing the development of common diseases into serious conditions with high cost specialist services. The common disease outpatient benefit package greatly improved and strengthened the basic health insurance system through secured equal access to affordable outpatient care for common conditions.

CONCLUSION

Limited health resources are used more efficiently by pooling the risks and by implementing capitated provider payment, which enhances the cost awareness by health care providers, to improves efficiency and creates positive incentives for health professionals for using the most cost-effective health interventions.

Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration

Access to medicines and vaccines to prevent and treat non-communicable diseases (NCDs) is unacceptably low worldwide. In the 2011 UN political declaration on the prevention and control of NCDs, heads of government made several commitments related to access to essential medicines, technologies, and vaccines for such diseases. 30 years of experience with policies for essential medicines and 10 years of scaling up of HIV treatment have provided the knowledge needed to address barriers to long-term effective treatment and prevention of NCDs. More medicines can be acquired within existing budgets with efficient selection, procurement, and use of generic medicines. Furthermore, low-income and middle-income countries need to increase mobilisation of domestic resources to cater for the many patients with NCDs who do not have access to treatment. Existing initiatives for HIV treatment offer useful lessons that can enhance access to pharmaceutical management of NCDs and improve adherence to long-term treatment of chronic illness; policy makers should also address unacceptable inequities in access to controlled opioid analgesics. In addition to off-patent medicines, governments can promote access to new and future on-patent medicinal products through coherent and equitable health and trade policies, particularly those for intellectual property. Frequent conflicts of interest need to be identified and managed, and indicators and targets for access to NCD medicines should be used to monitor progress. Only with these approaches can a difference be made to the lives of hundreds of millions of current and future patients with NCDs.

Global aspects of drug development

About nine million children die every year before they reach the age of 5 years, of conditions largely amendable with existing medicines. Lack of medicines is not the single most important health problem of children, but work to provide children with better access to appropriate medicines is essential for achievement of the child health goals set. Taking into consideration the global aspect in the development of paediatric medicines the benefits of the regional paediatric initiatives can be spread worldwide. This chapter provides insights in the challenges and opportunities of developing paediatric medicines for health needs of children in the developing world. The Essential Medicines List for children first made available in 2008 serves as an example of the many tools available from WHO to improve children's access to the medicines they need.

Is access to essential medicines as part of the fulfilment of the right to health enforceable through the courts?

BACKGROUND

Most countries in the world have become States parties to one or more international human rights treaties, thus creating an obligation by the State to its people towards the realisation of the right to health, which includes access to essential medicines. But whether such access is enforceable in practice is unknown.

METHODS

We did a systematic search to identify completed court cases in low-income and middle-income countries in which individuals or groups had claimed access to essential medicines with reference to the right to health in general, or to specific human rights treaties ratified by the government. We identified and analysed 71 court cases from 12 countries in which access to essential medicines was claimed with reference to the right to health.

FINDINGS

In 59 cases, access to essential medicines as part of the fulfilment of the right to health could indeed be enforced through the courts, with most coming from Central and Latin America. Success was mainly linked to constitutional provisions on the right to health, supported by the human rights treaties. Other success factors were a link between the right to health and the right to life, and support by public-interest non-government organisations. Individual cases have generated entitlements across a population group, the right to health was not restricted by limitations in social security coverage, and government policies have successfully been challenged in court.

INTERPRETATION

Skilful litigation can help to ensure that governments fulfil their constitutional and international treaty obligations. Such assurances are especially valuable in countries in which social security systems are still being developed. However, redress mechanisms through the courts should be used as a last resort. Rather, policymakers should ensure that human rights standards guide their health policies and programmes from the outset.

Essential medicines and human rights: what can they learn from each other?

Most countries have acceded to at least one global or regional covenant or treaty confirming the right to health. After years of international discussions on human rights, many governments are now moving towards practical implementation of their commitments. A practical example may be of help to those governments who aim to translate their international treaty obligations into practice. WHO's Essential Medicines Programme is an example of how this transition from legal principles to practical implementation may be achieved. This programme has been consistent with human rights principles since its inception in the early 1980s, through its focus on equitable access to essential medicines. This paper provides a brief overview of what the international human rights instruments mention about access to essential medicines, and proposes five assessment questions and practical recommendations for governments. These recommendations cover the selection of essential medicines, participation in programme development, mechanisms for transparency and accountability, equitable access by vulnerable groups, and redress mechanisms.

Could the WHO model list of essential medicines do more for the safe and appropriate use of injections?

A national drug policy addressing the safe and appropriate use of injections is an important element to prevent overuse and unsafe use of injections. Because the World Health Organization World Health Organization Model List of Essential Medicines is a keystone of national drug policies, the authors examined the way it addresses injection practices. They reviewed the 11th World Health Organization Model List of Essential Medicines to collect information on (1) injectable medicines, (2) diluents, and (3) the recommendations regarding the procurement of injection devices. Of 306 active ingredients on the list, 135 (44%) are mentioned in injectable form. Of these, 41 (30%) need diluents for reconstitution. The list does not mention the need to procure appropriate diluents, injection devices, and safety boxes in quantities that match the quantities of injectable medicines. In addition, the list provides limited information that can be used to forecast the needs of injection devices to administer the injectable medicines that are included in the list. Future revisions of the World Health Organization Model List of Essential Medicines should attempt to reduce the number of injectable formulations on the basis of evidence. In addition, the list should specify that when injectable medicines are being supplied, diluents, single-use syringes, and safety boxes should be supplied. The volume of syringes needed for administration should be specified for each injectable medication on the list to facilitate the forecasting of the needs of injection devices.

The concept of essential medicines: lessons for rich countries

Rich countries should follow the lead of poor countries and adopt a more systematic way of controlling the cost of drugs

Prescription habits of dispensing and non-dispensing doctors in Zimbabwe

The number of dispensing doctors has increased in the last decade, but the implication of this trend on the quality of health care and drug use is unknown. We present a comparative drug utilization study of 29 dispensing doctors and 28 non-dispensing doctors in Zimbabwe based on standard indicators developed by the World Health Organization. Dispensing doctors prescribed significantly more drugs per patient than non-dispensing doctors (2.3 versus 1.7), injected more patients (28.4% versus 9.5%), and prescribed more antibiotics (0.72 versus 0.54) and mixtures (0.43 versus 0.25) per encounter. Dispensing doctors also spent significantly less time on each encounter (8.7 min versus 13.0 min) than their non-dispensing colleagues. The use of generic name, brand name and essential drugs did not differ significantly between the two groups of practitioners. Multivariate analyses controlling for gender, race, place of education, location of practice and patients seen per day showed that dispensing by doctors was associated with less clinically and economically appropriate prescribing. These findings suggest that the quality of health care--as related to drug use, patient safety and treatment cost--is lower with dispensing doctors than with non-dispensing doctors.

Can hysterosalpingocontrast-sonography replace hysterosalpingography in the assessment of tubal subfertility?

INTRODUCTION

Hysterosalpingo-contrastsonography (HyCoSy) is a new method for assessing tubal patency using transvaginal ultrasound. It is thought to have several advantages over conventional hysterosalpingography (HSG). We prospectively evaluated the performance of HyCoSy and HSG in the diagnosis of tubal pathology.

METHODS AND PATIENTS

One-hundred consecutive subfertile women underwent both HyCoSy and HSG in randomised order. Results of both tests were related to findings at laparoscopy with dye, which was used as the reference test. Each woman was asked to score the pain exsperienced at both procedures on a visual analogue scale.

RESULTS

When laparoscopy with dye was used as reference test, the likelihood ratios of HyCoSy were slightly inferior to those obtained for HSG. Since the performance of HyCoSy was dependent on experience, the results were recalculated omitting the 50 initial procedures from the analysis. In that calculation, results of HyCoSy and HSG were comparable. There were no differences in pain experienced during the procedure, as there appeared also to be no differences in patient preferences.

CONCLUSION

There appear to be no strong arguments either to replace HSG by HyCoSy, or to reject the use of HyCoSy. Both procedures can be used in the evaluation of tubal pathology.

[Pregnancy course and outcome in 2956 pregnancies after in-vitro fertilization in Netherlands]

OBJECTIVE

Description of the outcome of pregnancies after in vitro fertilisation (IVF) in Dutch IVF centers.

DESIGN

Descriptive, retrospective.

METHOD

Data were collected on IVF pregnancies in the period 1984-1992 from seven Dutch IVF centers.

RESULTS

The study comprised 2956 pregnancies. Five centres provided data on 2133 ongoing and non-ongoing pregnancies. More than 25% ended in a spontaneous abortion (22.3%) or ectopic pregnancy (3.6%). From the seven centres there were data available on 2311 ongoing pregnancies. Of these, 30.8% were multiple; preterm delivery occurred in 29.2%. The birth weight of 40.6% of 3173 neonates was lower than 2500 g and that of 10.1% lower than 1500 g. A birth weight under the 10th percentile of the national reference curve was found in 16.7% and under the 2.3rd percentile in 4.3% of cases. Perinatal mortality was 31.3 pro mille. In 1588 singleton pregnancies preterm birth occurred in 15.6%; 41.3% of the singletons weighed less than 2500 g, of which 3.6% less than 1500 g while 12.3% had a birth weight below the 10th percentile. The results of our study are similar to those of other major studies in the literature and are unfavourable compared with to Dutch reference values. This is mainly due to the high proportion of multiple pregnancies. However, we found indications of a slight disturbance of pregnancy in IVF singleton and twin pregnancies.

Intervention research in rational use of drugs: a review

Many studies have been done to document drug use patterns, and indicate that overprescribing, multi-drug prescribing, misuse of drugs, use of unnecessary expensive drugs and overuse of antibiotics and injections are the most common problems of irrational drug use by prescribers as well as consumers. Improving drug use would have important financial and public health benefits. Many efforts have been undertaken to improve drug use, but few evaluations have been done in this field. This article provides an overview of 50 intervention studies to improve drug use in developing countries. It highlights what type of interventions exist and what is known about their impact. It reveals that commonly used interventions, such as an essential drug list and standard treatment guidelines, have rarely been systematically evaluated so far. The majority of intervention studies are focused on prescribers in a public health setting, while irrational use of drugs is also widespread in the private sector. Furthermore, the magnitude of inappropriate drug use at community level is often overlooked and few interventions address drug use from a consumer's perspective. More research on different types of intervention strategies in various health care settings is needed to draw conclusions on the effectiveness of a specific intervention strategy. Also more research is needed on socio-cultural factors influencing the impact of drug use interventions, particularly from a user perspective. To enhance evaluative research, more technical support will be needed for researchers in developing countries. The design of available studies from developing countries is generally weak, only six of the 50 studies included in this overview were randomized controlled studies. In order to provide technical support and coordination of future intervention research the establishment of an international resource centre for drug use intervention research is recommended.

Diagnosis of ectopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

The combination of transvaginal sonography and serum hCG measurement is reliable in the diagnosis of ectopic pregnancy (EP) in spontaneous pregnancies. In patients who became pregnant through IVF-ET, transfer of multiple embryos after IVF could be responsible for the different performance of these tests. We evaluated the discriminative capacity of transvaginal sonography in combination with hCG measurement in the diagnosis of EP after IVF-ET.

DESIGN

Prospective cohort study.

SETTING AND PATIENT(S)

Consecutive patients, pregnant through IVF-ET, who presented with clinically suspected EP.

INTERVENTION(S)

Transvaginal sonography, serum hCG measurement at 6, 9, and 15 days after ET and after a negative transvaginal sonography.

MAIN OUTCOME MEASURE(S)

Ectopic pregnancy confirmed at laparoscopy.

RESULT(S)

Between September 1993 and May 1996, 86 women were included in the study, of whom 24 had an EP. Transvaginal sonography identified 46 intrauterine pregnancies and 5 EPs, but serum hCG could not diagnose EPs in patients in whom transvaginal sonography did not show a gestational sac. Serum hCG measurement 9 days after ET could identify pregnancy failure with 100% specificity at a cut-off value of 18 IU/L, but it could not identify patients with EP with enough certainty to justify immediate treatment.

CONCLUSION(S)

We recommend single serum hCG measurement 9 days after ET to discriminate between viable and nonviable pregnancies. Transvaginal sonography can be postponed until 5 weeks after ET, except for patients with abdominal pain and/or vaginal bleeding, or patients with a serum hCG level of < 18 IU/L.

A prospective, randomized, cross-over comparison of two methods of artificial insemination by donor on the incidence of conception: intracervical insemination by straw versus cervical cap

In a prospective, randomized study of insemination with donor semen, intracervical insemination by straw was compared with insemination using a cervical cap with an intracervical reservoir. A total of 91 patients completed 486 treatment cycles. There were no significant differences in age, parity, indication for insemination by donor, or method of cycle monitoring between women who became pregnant and those who did not conceive with either insemination method. In 236 standard intracervical insemination cycles, 14 patients became pregnant (5.9% per cycle), whereas 38 patients conceived in 250 cervical cap cycles (15.2% per cycle). Both the crude pregnancy rates and the cumulative pregnancy rates calculated by the Kaplan-Meier life-table method were significantly different (chi(2)-test, P < 0.001, and log-rank test, P < 0.005 respectively). Pregnancy rates in artificial insemination with cryopreserved donor semen may be improved by the use of a cervical cap when compared to cervical insemination by straw. The use of the cervical cap may prolong the exposure of the spermatozoa to the cervical mucus and prevent the backflow of semen into the vagina.

Guidelines for drug donations

Drug donations are usually given in response to acute emergencies, but they can also be part of development aid. Donations may be given directly by governments, by non-governmental organisations, as corporate donations (direct or through private voluntary organisations), or as private donations to single health facilities. Although there are legitimate differences between these donations, basic rules should apply to them all. This common core of "good donation practice" is the basis for new guidelines which have recently been issued by the World Health Organisation after consultation with all relevant United Nations agencies, the Red Cross, and other major international agencies active in humanitarian emergency relief. This article summarises the need for such guidelines, the development process, the core principles, and the guidelines themselves and gives practical advice to recipients and donor agencies.

Instability of (methyl)ergometrine in tropical climates: an overview

Parenteral ergometrine is widely used for the prevention and treatment of excessive uterine bleeding following birth. Unfortunately, in tropical climates it is often found to contain very little active ingredient: only 32 of 100 field samples from Bangladesh, Gambia, Malawi, Yemen and Zimbabwe contained 90-110% of the amount of active ingredient stated on the label, and 34 contained less than 60%. In this paper the results of nine studies, of which eight were initiated and coordinated by WHO, are reviewed to formulate answers to the following questions: (1) what is the extent of the problem of low potency of ergometrine in tropical climates; (2) is the problem due to instability or low initial quality, or both; (3) which practical measures can assure the quality of injectable ergometrine; and (4) are there any alternative drugs which are more stable? Injectable ergometrine is very unstable under tropical conditions and particularly if stored unrefrigerated and exposed to light, when it may loose up to 20% of its potency per month. However, there are differences between brands. Practical measures to assure the quality of injectable ergometrine therefore include a careful supplier selection and refrigerated storage. Ergometrine injection should always be protected from light until given to the patient. Loss of active ingredient can easily be detected by regular visual checks of the colour of the solution. Any discoloration implies that the solution contains less than 90% of the stated amount of active ingredient, and should not be used. Methylergometrine is no more stable than ergometrine. Parenteral oxytocin is more stable than both ergometrine and methylergometrine injection. Oral and buccal dosage forms are less stable than injections. In view of the better stability in tropical climates, similar cost, fewer side effects and comparative efficacy, parenteral oxytocin, rather than parenteral ergometrine, is the drug of choice in the prevention and treatment of postpartum haemorrhage.

Progesterone alone versus progesterone combined with HCG as luteal support in GnRHa/HMG induced IVF cycles: a randomized clinical trial

Two different regimens of luteal support in gonadotrophin hormone-releasing hormone (GnRH) analogue/human menopausal gonadotrophin (GnRHa/HMG)-induced in-vitro fertilization cycle (IVF) were compared in a randomized clinical trial. After embryo transfer, either vaginal progesterone alone was administered (n = 89, P group), or a combination of vaginal progesterone and human chorionic gonadotrophin (n = 87, P/HCG group). The primary aim of this study was to assess the effect of the different regimens of luteal support on the pregnancy rate. The secondary aim was to compare oestradiol and progesterone concentrations in the luteal phase between the two groups, and assess their effect on the pregnancy rate. A clinical pregnancy rate of 15% was found in the P/HCG group in comparison with 26% in the P group (odds ratio 0.49; 99% confidence interval: 0.18-1.3). The luteal serum oestradiol and progesterone values in the P/HCG group were significantly higher when compared with the P group on the 6th, 9th and 12th day after oocyte retrieval (Wilcoxon P < 0.001). In accordance with the high oestradiol concentrations, more cases of ovarian hyperstimulation syndrome (OHSS) were found in the P/HCG group. Oestradiol values on the 9th day after oocyte retrieval, presumably the day of implantation, appeared to be higher in women who did not become clinically pregnant. We conclude that vaginal progesterone alone provides sufficient luteal support in GnRHa/HMG induced IVF cycles. The combination of vaginal progesterone and HCG as luteal support leads to significant high luteal oestradiol and progesterone concentrations. But a high concentration of oestradiol seems to have a deleterious effect on the implantation process, resulting in a low pregnancy rate.

Socio-economic characteristics of artificial insemination donor (AID) couples compared with matched population controls

Socio-economic characteristics like education, occupation and religion may play a role when choosing or refraining from treatment by artificial insemination by donor (AID). From a cohort of 189 AID-patients, the socio-economic characteristics were established from the notes and a questionnaire that was sent to all patients to complete the available data. The response rate to the questionnaire was 83.6% (158 women). Data were compared with population controls that were matched for age and region. AID patients in this study had significantly lower educational and/or occupational levels than matched population controls and were significantly more religious.

Impact of a short course in pharmacotherapy for undergraduate medical students: an international randomised controlled study

Irrational prescribing is a habit which is difficult to cure. However, prevention is possible and for this reason the WHO Action Programme on Essential Drugs aims to improve the teaching of pharmacotherapy to medical students. The impact of a short problem-based training course in pharmacotherapy, using a WHO manual on the principles of rational prescribing, was measured in an international multi-centre randomised controlled study of 219 undergraduate medical students in Groningen (Netherlands), Kathmandu (Nepal), Lagos (Nigeria), Newcastle (Australia), New Delhi (India), San Francisco (USA), and Yogyakarta (Japan). The manual and the course presented the students, who were about to enter the clinical phase of their studies, with a normative model for pharmacotherapeutic reasoning in which they were taught to generate a "standard" pharmacotherapeutic approach to common disorders, resulting in a set of first-choice drugs called P(ersonal)-drugs. The students were then taught how to apply this set of P-drugs to specific patient problems on the symptomatic treatment of pain, using a six-step problem-solving routine. The impact of the course was measured by tests before training, immediately after, and six months later. After the course, students from the study group performed significantly better than controls in all patient problems presented (p < 0.05). The students not only remembered how to solve old problems, but they could also apply their skills to new problems. Both retention and transfer effect were maintained at least six months after the training session in all seven medical schools. In view of the impossibility of teaching students all basic knowledge on the thousands of drugs available, this approach seems to be an efficient way of teaching rational prescribing. However, the method should be accompanied by a change in teaching methods away from the habit of transferring knowledge about the drugs towards problem-based teaching of therapeutic reasoning.

Essential drugs for ration kits in developing countries

Since the early 1980s drug ration kits have been used to improve the supply of essential drugs to rural health facilities in developing countries. This paper evaluates some of the experiences with kit systems in Angola, Bhutan, Democratic Yemen, Guinea-Conakry, Kenya, Mozambique, Sudan, Tanzania, Uganda and Zambia in relation to the selection of drugs for the kits and their quantities and cost. Data were collected through a review of published papers, annual reports and programme evaluations, by questionnaires among field staff and interviews with key experts. In comparing the 10 programmes, 21 drugs can be identified that are used in at least two-thirds of all kits. This list may be useful for evaluation and planning purposes. Six drugs (ORS, chloroquine and 4 antibiotics) usually account for over 60% of the cost of the kit. Careful monitoring of the price and quantities of these 6 drugs can therefore be very cost-effective. In the absence of reliable data on morbidity and drug needs in the initial phases of a kit system, the median drug quantities in kits from these 10 countries may serve as a starting point. Accumulating surpluses are sometimes perceived as a serious disadvantage of kit systems, ORS, benzylbenzoate solution and iron tablets are the three drugs that have most frequently accumulated. These drugs are relatively cheap and usually have a long shelf-life; in most programmes they have been successfully redistributed to other health facilities while the kit content was being adapted. The overall financial loss due to accumulation of surpluses is therefore limited. Most programmes have reached a stable kit content within two years.

Promoting rational prescribing: an international perspective

Irrational prescribing is a global problem. Rational prescribing cannot be defined without a method of measurement and a reference standard. The former is now available but the latter needs further development. Proven effective interventions to promote rational prescribing in developed countries are treatment protocols based on wide consultation and consensus, properly introduced and with a possibility of feedback; face-to-face education focussed on a particular prescribing problem in selected individuals; structured order forms; and focussed educational campaigns. Essential drugs lists are probably effective when based on consensus and used within a comprehensive educational programme. Printed materials alone are not effective. In most cases the usefulness of such strategies in developing countries has not been proven and should be studied. Medical education in clinical pharmacology and pharmacotherapy should be based on the practical needs of future prescribes, should include the principles of rational therapeutics and problem solving, and should immunize the students against the influences they are likely to encounter in their professional life, such as patient pressure, drug promotion and irrational prescribing by peers. Within the scope of a national formulary, specialist departments in teaching hospitals should define prescribing policies as the basis for prescribing, teaching, examinations and medical audit.

Substance use in pregnancy: do we care?

Two cohorts of substance-using women were compared retrospectively. From 1969 to 1979 a very high perinatal mortality rate (PMR 9.8%) was found among 92 polydrug-using women (1 twin excluded). Preterm delivery occurred in 25% of all pregnancies and in 30% of the children birth weight was below the 10th percentile. Nineteen women using heroin only had a worse fetal outcome (PMR 32%, preterm delivery in 47%, birth weight < 10th percentile in 42%). These results led to a strict surveillance system. In the period 1980-1989, 240 women (4 twins excluded) delivered after 16 weeks. Total fetal loss decreased to 2.1% and PMR to 0.4%, which was similar to results in controls. However, 22% of the women still delivered before 37 weeks and 27% delivered a child < 10th percentile. Methadone-using women were able to halve their dosage during pregnancy and 16 were detoxified. Multivariate analysis within the substance users of the second cohort showed that the neonatal abstinence syndrome, but not the (registered) amount of opiates used, was related to a lower birth weight. Not coping with prenatal care was related to a shorter pregnancy length. Multivariate analysis, including the controls, showed a significant relation of birth weight (345 g lower) with substance use. Also, head circumference was 0.8 cm smaller. Length of pregnancy however was related to smoking. This study shows that it is difficult to make substance users attend prenatal care, but also that women coping with prenatal care reduce substance intake. Opiate use might be responsible for lower birth weight, although not in a clear dose-response relationship, whereas lifestyle, as represented by not coping with prenatal care and the quantity of cigarette smoking, shortens the length of pregnancy.

Thyroid function and thyroid size in normal pregnant women living in an iodine replete area

OBJECTIVE

The interpretation of the changes in thyroid hormone concentrations during normal pregnancy is a matter of debate involving, in some geographical regions, enhanced thyroid activity in early pregnancy and a hypothyroid state in the third trimester. A clinically detectable increase in thyroid size has been found in areas of mild iodine deficiency ('goitre of pregnancy'), but not in iodine replete areas.

DESIGN

A prospective study. We have studied thyroid size and function in normal pregnant women living in an iodine replete area.

PATIENTS

Healthy women before and during a normal pregnancy resulting from artificial insemination (n = 10) and other women during the normal menstrual cycle (n = 11), in the iodine replete area of Amsterdam.

MEASUREMENTS

Thyroid volume was measured by ultrasonography. Plasma T4, free T3, free reverse T3, TSH, thyroxine binding globulin, hCG, progesterone and thyroid autoantibodies were measured.

RESULTS

Thyroid volume did not change during pregnancy (data given before pregnancy and during 1st, 2nd and 3rd trimesters, respectively: 10.3 +/- 5.1, 10.6 +/- 4.4, 9.6 +/- 3.8 and 9.4 +/- 3.0 ml, NS). Free T4 and free T3 levels declined during pregnancy (13.7 +/- 2.0, 13.5 +/- 4.1, 11.2 +/- 2.8, 10.2 +/- 1.6 pmol/l, P = 0.005; 4.55 +/- 0.63, 4.64 +/- 0.88, 3.72 +/- 0.67 and 4.01 +/- 0.75 pmol/l, P = 0.003), whereas free reverse T3 levels increased during pregnancy (0.16 +/- 0.04, 0.19 +/- 0.07, 0.14 +/- 0.03 and 0.20 +/- 0.07 pmol/l, P = 0.001). Thyroglobulin levels remained unchanged. Thyroid hormones and thyroid volume did not differ between follicular and luteal phases of the menstrual cycle.

CONCLUSION

Thyroid volume does not increase during pregnancy in iodine-replete areas. The decrease in free T4 and free T3 and the increase in free reverse T3 concentrations during pregnancy resemble the changes in thyroid hormones seen in non-thyroidal illness. This could be a physiological adaptation enabling energy conservation during the high metabolic demands of pregnancy.

Treatment of interstitial pregnancy with methotrexate: report of an unsuccessful case

Until now, the traditional management of interstitial pregnancy has been surgical. Lately, we have advocated conservative treatment with methotrexate as an option for infertility patients. This is the first publication of a rupture with abundant intra-abdominal bleeding during systemic treatment with methotrexate of a patient with an interstitial pregnancy. Signs of therapy failure are discussed.

Field tests for rational drug use in twelve developing countries

Increasing efforts are being made to improve drug-use practices and prescribing behaviour in developing countries. An essential tool for such work is an objective and standard method of assessment. We present here a set of drug-use indicators produced and tested in twelve developing countries. We describe practical applications, which include the use of indicators to increase awareness among prescribers in Malawi and Bangladesh, to identify priorities for action (eg, polypharmacy in Indonesia and Nigeria, overuse of injections in Uganda, Sudan, and Nigeria, and low percentage of patients who understood the dosage schedule in Malawi), and to quantify the impact of interventions in Yemen, Uganda, Sudan, and Zimbabwe.