WHO and national lists of essential medicines in Mexico, Central and South America, and the Caribbean: are they adequate to promote paediatric endocrinology and diabetes care? | BMJ Global Health

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WHO and national lists of essential medicines in Mexico, Central and South America, and the Caribbean: are they adequate to promote paediatric endocrinology and diabetes care?

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Essential Medicines List: a good start, but just a start
Julia E. von Oettingen, Marie-Eve Robinson, Daphne Cloutier, Guy Van Vliet and Eddy Jean-Baptiste
Published on: 13 June 2018

Published on: 13 June 2018
Essential Medicines List: a good start, but just a start
- Julia E. von Oettingen, Pediatric Endocrinologist McGill University Health Centre
- Other Contributors:
  Marie-Eve Robinson, Pediatrician
  
  Daphne Cloutier, Pediatrician
  
  Guy Van Vliet, Pediatric Endocrinologist
  
  Eddy Jean-Baptiste, Endocrinologist
The comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.

However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML,...
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The comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.

However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML, while the safer antithyroid medication, methimazole, is not.

The Pediatric Endocrinology Education Program for Haiti, supported by the Pediatric Endocrine Society and the European Society for Pediatric Endocrinology, aims to introduce pediatric endocrine care to a country where no pediatric endocrinologist currently practices. Unpublished data from teleconsultations as part of this program demonstrate that the majority of children diagnosed with endocrine disorders do not have access to the medications they need – even if these are listed on the national EML. For example, hydrocortisone and fludrocortisone, essential medications for children with adrenal insufficiency, are on Haiti’s EML but were unavailable despite extensive searches. Even inexpensive medications such as levothyroxine and routine supplements such as calcium carbonate and vitamin D2/D3 are often difficult to find and calcitriol is entirely unavailable. The list of inaccessible medications is long, including vital medications such as growth hormone and diazoxide for neonatal hypoglycemia.

Maybe most reflective of the alarming situation is access to insulin. While listed on all EMLs, the reality of children who are diagnosed with diabetes is different. The Kay Mackenson Clinic, a center for children with chronic diseases in Haiti, recently assessed the availability of insulin in Haiti and showed that close to one third of patients do not have access to insulin at the time of diagnosis and close to half lack access to insulin after they are discharged from the hospital following initial diagnosis (5). Further, long-acting and ultra-short acting insulin analogs, mainstay of therapy for intensive diabetes control, are virtually inaccessible.
Inequities in access to essential medications in pediatric endocrinology remain unacceptable. The comparison of EMLs by Rowlands et al should stimulate further research into actual accessibility, including its predictors and barriers.

References:
1. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19:127–140.
2. van Mourik MS, Cameron A, Ewen M, Laing RO. Availability, price and affordability of cardiovascular medicines: a comparison across 36 countries using WHO/HAI data
3. http://www.worldbank.org/en/country/haiti/overview
4. http://www.fda.gov/Drugs/DrugSafety/ucm209023.htm
5. von Oettingen J, Carolan E, Jean-Baptise E, Larco N, Larco P, Ogle G, Lorgeat V, Mascary M, Bonnell R, Carpenter C. (2016). Health care delivery gaps affect children with new onset diabetes in
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Conflict of Interest:
None declared.
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