Mapping the selection, availability, price and affordability of essential medicines for mental health conditions at a global level

Updating the WHO Model Lists of Essential Medicines to promote global access to the most cost-effective and safe medicines for mental disorders

Since 1977, the WHO Model Lists of Essential Medicines (EML) have been a benchmark to guide the procurement of medicines at the national level, especially in low-income and middle-income countries. Aiming to include the most effective, safe, and cost-effective medicines for priority conditions, WHO updates the EML for adults and the EML for children every 2 years. Over the past 45 years, updates to the EML mental health section have been infrequent, in most cases with additions of individual medicines. A comprehensive revision of the entire section has never been attempted. With the aim of increasing the use of the WHO EML to expand the selection of the most effective and safe medicines for mental disorders, a series of evidence-based applications were submitted to the WHO Expert Committee on the Selection and Use of Essential Medicines in 2022, recommending a substantial revision of the entire mental health section. In this Health Policy, we summarise the recommended update and the evidence justifying it. We also discuss challenges in the update process, suggesting possible solutions. The requested comprehensive revision of the WHO EML mental health section aligns the list with the latest evidence. The revision offers an opportunity for countries to promote access to the most effective, safe, and cost-effective medicines for mental disorders, contributing to universal health coverage and global mental health equity.

Availability, price, and affordability of antiseizure medicines in Addis Ababa, Ethiopia

OBJECTIVE

Up to 70% of people living with epilepsy could become seizure-free with the appropriate use of antiseizure medicines. However, three quarters of people with epilepsy living in low-income countries do not get the treatment they need and also do not access antiseizure medicines. The purpose of this study was to assess the availability, price, and affordability of antiseizure medicines in Addis Ababa, Ethiopia.

METHODS

A cross-sectional study was done in selected pharmacies using a questioner developed after the modification of World Health Organization/Health Action International methodology. Data on the availability and price of lowest-priced generics and originator brand antiseizure medicines from essential medicines list in Ethiopia were collected from seven public sectors, five private sectors, and seven other sectors (five Kenema Public Community and two Red Cross Pharmacies) in Addis Ababa between 09 May and 31 2022. The data were analyzed using the modified World Health Organization/Health Action International workbook part I excel sheet. Descriptive results were reported in text and table format.

RESULTS

The overall availability of lowest-priced generics medication was 52%. The availability of lowest-priced generics was 62.86%, 30%, 55%, and 50% in public, private, Red Cross, and Kenema Public Community Pharmacies, respectively. The median price ratio in the public, private, Red Cross, and Kenema Public Community Pharmacy was 1.45, 3.72, 1.46, and 1.7, respectively. All the medications were unaffordable. Patients may be required to pay more than 6-month wage to purchase standard treatment for 1 month only.

SIGNIFICANCE

The overall availability of antiseizure medicines was lower than the WHO target for noncommunicable diseases. All the available medicines were unaffordable.

Availability, Price and Affordability of Psychotropic Medicines in Addis Ababa, Ethiopia

Background

Access to affordable, quality-assured essential medicines is crucial to reduce the burden of disease. However, one third of the world's population lacks regular access to essential medicines. The purpose of this study was to assess the availability, price, and affordability of medicines for mental disorders in Addis Ababa, Ethiopia.

Methods

A cross-sectional study was done in selected pharmacies after modification of a WHO/HAI methodology developed questionnaire. Data on the availability and price of 28 lowest priced generics and originator brand essential psychotropic medicines were collected from seven public sectors, five private sectors, and seven other sectors (five Kenema Public Community Pharmacies and two Red Cross Pharmacies) in Addis Ababa between May 9 and May 31, 2022. The data were analyzed using the developed WHO/HAI workbook part I Excel sheet. Descriptive results were reported in text and table format.

Results

The overall availability of lowest-priced generics medication was 41.69%. The availability of lowest-priced generics and originator brand medication was 54.68% and 1.7% in the public pharmacies; 24.14% and 0.0% in private pharmacies; 43% and 0.0% in Red Cross Pharmacies; and 42% and 3.2% in Kenema Public Community Pharmacies. The median price ratio in the public, private, Red Cross, and Kenema Public Community pharmacies was 1.26, 3.72, 1.65, and 1.59, respectively. Most of the medications were unaffordable. A patient could be required to pay up to 73 days wages to purchase a standard treatment for 1 month.

Conclusion

The availability of psychotropic medicines was lower than the WHO target for non-communicable diseases and most of the available medicines were unaffordable.

The new World Mental Health Report: Believing impossible things

OBJECTIVE

We examine whether the recent World Health Organization (WHO) report on global mental health uses severity of illness as a criterion in priority setting for resource allocation.

CONCLUSIONS

The WHO does not prioritise severity in the recent landmark World Mental Health Report. It recommends instead the insuperable task of scaling-up interventions for broadly defined mental health conditions, including milder distress, amongst over a billion people, with the majority living in low- and middle-income countries. Schizophrenia, the most severe and disabling of all psychiatric illnesses, is relatively neglected in the WHO report, and the disability associated with bipolar disorder is underestimated. This is inconsistent with the ethical principle of vertical equity, where the most severe illnesses should receive the greatest priority. The global mental health movement must refocus on deinstitutionalisation, and ensure adequate community and general hospital treatment for severe illnesses, especially the 24 million people with schizophrenia.

Clozapine haematological monitoring for neutropenia: a global perspective

AIMS

Clozapine is licensed for treatment-resistant psychosis and remains underutilised. This may berelated to the stringent haematological monitoring requirements that are mandatory in most countries. We aimed to compare guidelines internationally and develop a novel Stringency Index. We hypothesised that the most stringent countries would have increased healthcare costs and reduced prescription rates.

METHOD

We conducted a literature review and survey of guidelines internationally. Guideline identification involved a literature review and consultation with clinical academics. We focused on the haematological monitoring parameters, frequency and thresholds for discontinuation and rechallenge after suspected clozapine-induced neutropenia. In addition, indicators reflecting monitoring guideline stringency were scored and visualised using a choropleth map. We developed a Stringency Index with an international panel of clozapine experts, through a modified-Delphi-survey. The Stringency Index was compared to health expenditure per-capita and clozapine prescription per 100 000 persons.

RESULTS

One hundred twocountries were included, from Europe (n = 35), Asia (n = 24), Africa (n = 20), South America (n = 11), North America (n = 7) and Oceania and Australia (n = 5). Guidelines differed in frequency of haematological monitoring and discontinuation thresholds. Overall, 5% of included countries had explicit guidelines for clozapine-rechallenge and 40% explicitly prohibited clozapine-rechallenge. Furthermore, 7% of included countries had modified discontinuation thresholds for benign ethnic neutropenia. None of the guidelines specified how long haematological monitoring should continue. The most stringent guidelines were in Europe, and the least stringent were in Africa and South America. There was a positive association (r = 0.43, p < 0.001) between a country's Stringency Index and healthcare expenditure per capita.

CONCLUSIONS

Recommendations on how haematological function should be monitored in patients treated with clozapine vary considerably between countries. It would be useful to standardise guidelines on haematological monitoring worldwide.