The BMJ Today: Essential medicines, evidence, and influence

helen_macToday an Analysis article questions the quality of applications to the World Health Organization’s essential medicines list. The WHO essential medicines list is a skeletal formulary of medicines that all countries should consider making available. Although the list just covers the basics, the medicines included such as amoxicillin and haloperidol are taken seriously—to be a WHO essential medicine is a big deal.

Corrado Barbui and Marianna Purgato audited the quality of drug applications against the standards and evidence that WHO asks for. They focus on the quality of the evidence presented in the application. Overall, they are not impressed, and their audit leads to a discussion about how the applicants and WHO could raise standards. You can listen to Barbui setting out his concerns and solutions in a Podcast too.

Debate articles are the bread and butter of the Analysis section of The BMJ, and Barbui and Purgato’s evaluation provided a strong base for them to illustrate the problems and call for change. But even if the quality of prospective essential medicine applications were impeccable, would we have a perfect list?

Commentary by Colin Millard and colleagues suggests perhaps not. They take the example of misoprostol, which was included as an essential medicine in 2011 for the prevention of postpartum haemorrhage, following multiple unsuccessful applications. Little new evidence to show the efficacy of the drug compared to oxytocin accumulated. However, misoprostol has some practical advantages in lower resource settings because it is easier to store and has various routes of administration.

Although Millard and colleagues are bothered by evidence for misoprostol, the focus of their commentary lies elsewhere—with influence. They want to understand whether it was influence, in the absence of evidence, that led to the application finally being approved. The authors present a graph showing the number of organisations supporting applications for misoprostol and are concerned about the vested interest and positions of some of the organisations involved.

We hope that these complementary perspectives will give readers an insight into the processes that lie behind the list. And that they’ll spark debate about how the list might better serve patients around the globe in the future.

Helen Macdonald is the analysis editor, The BMJ.