Prof. Dr. Shyam P Lohani

Medicines are a vital component of patient care throughout the world. Access to medicines is fundamental human rights. However, medicines are not easily available across the globe. World
Health Organisation (WHO, 2002) defines essential medicines (EMs) as products that satisfy the priority healthcare needs of the population. Those products should be accessible in the health facilities at all times in sufficient amounts and available at affordable prices. As of 2016, over 155 countries across the world have prepared their own lists of national essential medicines based on the WHO model list (Wikipedia, 2020). Essential Medicines List (EML) provides an important document to all the countries around the globe, especially those that lack the capacity to perform evidence-based appraisals of drug procurement, for developing their formularies and national essential medicine list specific to suit their local needs based on disease prevalence. The recently updated EML includes a total of 460 products that are deemed necessary to address key public health priorities and needs of a population at large (WHO, 2019).

Process
There are wide variations among the countries in terms of the number of drugs in their national essential medicines list and Gross Domestic Product (GDP). With many exceptions, countries with a smaller GDP have a fewer number of medicines in the lists of essential medicines. No countries have included all the drugs listed in the WHO EML in their list of essential drugs. Among Southeast Asian countries, the Maldives has 535 products in the list followed by Pakistan (373 items), India (367 items), Sri Lanka (318 items) and Nepal (300 items), while Bangladesh has the least number of drugs (187 items) in the national essential medicines list (WHO Bulletin, 2019). However, the recently revised national list of essential medicines of Nepal contains 359 medicines (DDA, 2016).
The preparation of the essential medicines list begins with the identification of common diseases at different levels of health care in a particular country. The process mainly involves thorough discussion and acceptance among many experts in a multidisciplinary team. The selection of drugs should depend on many criteria such as disease prevalence, safety, and efficacy, level of health care, availability, prescribing practices, cost-effectiveness and desirable pharmacokinetic profile for patient use. The selected drugs should be harmonised with the standard treatment schedule in use at the primary care centers.
Nepal faces a double burden of diseases, both communicable and non-communicable. National list of essential medicines covers most of the diseases prevalent in the country. However, the coverage for non-communicable diseases in the list still is not sufficient. It is advised to include more drugs on the list to manage those conditions. Premature deaths from NCD have a great economic burden more so to the countries having a low and middle income. The direct and indirect cost incurred due to NCD puts a substantial burden on the family, community and the country.
The Government of Nepal started a free drug scheme from the fiscal year 2006/7 to provide essential drugs to the patients receiving services from government healthcare facilities. It started with 40 drugs and now the list of free drugs includes 70 products from 2015. The pharmaceutical inventory management is crucial for making medicines available all the time at an affordable price to the users. It also helps in preventing product stock out and reduces the costs of holding inventory. Accurate and updated stock records are crucial for proper inventory management since they are the key to future forecasts. The appropriate inventory ultimately helps to fulfill patient satisfaction which is an important determinant of quality of healthcare at the government health facilities. There have been limited numbers of researches, particularly on the availability of free medicines in healthcare facilities in Nepal. The problem of stock-out was found to be worrisome, especially in the mountain region, due to geographical isolation, road condition, and transportation difficulties.
The unavailability of medicines at the public health facilities due to frequent stock-outs leads patients to purchase medicines at the private pharmacies. The out of pocket expenditure against total health expenditure in Nepal stands at around 49 per cent which is huge considering the per capita income of Nepali people. The out of pocket expense incurred by the patients will lead them to poverty. People often blame public health facilities for frequent shortages of medicines, thus the patient’s satisfaction over the services of health care facilities is poor. The vicious cycles of unavailability of medicines such as poor satisfaction of services at the public health facilities and out of pocket expenditure have a negative impact on the government’s efforts for universal health coverage among its population.

Way forward
There is a need for a comprehensive study on the availability of essential medicines at public health facilities and the clients’ satisfaction with the health services in Nepal. The existing system of procurement of medicines needs to be improved. The inventory management and distribution of medicines at the healthcare facilities should be carried out by pharmacists. Another pertinent issue is the expiry of medicines supplied to the health facilities due mainly to the short expiry period while purchasing and not following the first expiry first out policy. The right diagnosis will have meaning only when patients get the right medicines at the right time at the public health facilities. The availability and accessibility of medicines at public health facilities thus is an important determinant of the quality of healthcare and would be useful for increasing healthcare coverage.

(Prof. Lohani is the Founder and Academic Director of Nobel College and can be reached at lohanis@gmail.com)