TY - JOUR
AU - Ofei, Francis, W
AB - Abstract Understanding how countries review their national standard treatment guidelines (STGs) and essential medicines list (EML) is important in the light of ever-changing trends in public health and evidence supporting the selection and use of medicines in disease management. This study examines the 2017 STGs and EML review process, the actors involved and how the list of medicines and disease conditions evolved between the last two editions. We examined expert committee reports, stakeholder engagement reports and the last two editions (2010, 2017) STGs and EML. The review process occurred in both bureaucratic and public arenas where various actors with varied power and interest engaged in ways to consolidate their influence with the use of evidence from research and practice. In the bureaucratic arena, a national medicines selection committee inaugurated by the Minister of Health assessed the 2010 edition through technical sessions considering the country’s disease burden, hierarchical healthcare structure and evidence on safety and efficacy and expert opinion. To build consensus and ensure credibility service providers, professional bodies and healthcare managers scrutinized the assessed guidelines and medicines list in public arenas. In such public arenas, technical discussions moved towards negotiations with emphasis on practicability of the policies. Updates in the 2017 guidelines involved the addition of 64 new disease conditions in the STG, with the EML including 153 additional medicines and excluding 56 medicines previously found in the 2010 EML. Furthermore, the level of care categorization for Level ‘A’ [i.e. community-based health planning and services (CHPS)] and Level ‘M’ (i.e. midwifery and CHPS with a midwife) evolved to reflect the current primary healthcare and community mobilization activities for healthcare delivery in Ghana. Ghana’s experience in using evidence from research and practice and engaging wide stakeholders can serve as lessons for other low and middle-income countries. Essential medicines list, evidence-based medicine, policy review process, standard treatment guidelines Key Messages Stakeholders within health systems space have varied interest and power to influence what gets on to or out of the national standard treatment guidelines (STGs) and essential medicines list (EML). Consensus building among stakeholders and agreement on what evidence from research and practice to use for selecting treatment options are critical for the STGs/EML review process. National STGs and EML policies are clinically relevant for service delivery at all levels of care and their timely review is therefore critical. Introduction Ghana first published its national treatment guidelines and medicines list policy in 1988 and since then the guidelines and medicines list have evolved. The Ghana National Drugs Programme (GNDP), a pharmaceutical policy unit of the Ministry of Health (MoH), coordinated the review process from 2000. The MoH published the 1988 edition titled ‘Essential Drugs List and National Formulary with Therapeutic Guidelines’ (Ministry of Health, 1988). Subsequently, two further editions of the documents with the same title were published in 1993 and 1996 (Ministry of Health, 1993, 1996). However, in the year 2000, the Essential Drugs List and National Formulary with Therapeutic Guidelines developed into two separate books titled Standard Treatment Guidelines (STGs) and Essential Medicines List (EML) (Ministry of Health, 2000a,b). Since then the GNDP has published the 2004, 2010 and 2017 STGs and EML editions (Ministry of Health, 2004a,c; 2010a,b; 2017a,c). Over the years, a national medicines selection committee (NMSC) of locally based specialists have provided technical support for the review processes towards publications of newer editions. In 1977 when World Health Organization (WHO) introduced the EML concept, less than a dozen countries had EML. Now, at least 135 countries have their own therapeutic manuals and formularies, which provide health professionals with up to date, accurate and unbiased advice on the rational use of medicines (WHO, 2007). The WHO essential medicine list is reviewed every 2 years. However, country-specific EML review period vary, e.g. Bhutan has 2007, 2009, 2011 and 2012 editions with an average review period of <2 years. Ethiopia has 2001, 2008, 2010 and 2015 editions with a 5-year review gap for the last two editions (WHO, 2019). WHO selection criteria for medicines have evolved with a change from experience-based to evidence-based approach (Laing et al., 2003). Countries may have specific criteria for medicines selection, and these may include elements of experience-based and evidence-based approaches. In Tanzania efficacy, safety, availability and affordability influenced selection decisions although these were largely based on experience rather than evidence (Mori et al., 2014). National medicines selection is important as it informs availability of essential medicines, medicines procurement, quality of care, treatment cost and access to medicines. In Ghana, healthcare providers use either the national STGs and/or EML as a guide to diagnose, prescribe medicines and manage common disease conditions. In addition, healthcare managers use the STGs and EML to guide treatment costing, development of institutional EMLs, procurement of medicines and National Health Insurance reimbursement at the three different levels of care delivery, namely, primary, secondary and tertiary. The EML confines circulation of essential medicines to specific and appropriate levels of care in Ghana. Healthcare providers deliver services through a hierarchy of hospitals, clinics, health centres, maternity homes and community-based health planning and services (CHPS) posts that reflect their human resources employed and capabilities to provide services (Ministry of Health, 2007). Due to the ever-changing trends in public health and evidence supporting the selection and use of medicines in disease management, regular evidence-based and transparent reviews of existing national STGs and EML is essential. This in turn requires timely use of evidence-based treatment recommendations by stakeholders and consensus building to ensure credibility and acceptance (World Health Organization, 2002; Sinclair et al., 2013; Perumal-Pillay and Suleman, 2017). Despite the importance of understanding how countries review and reconsider their national STGs and accompanying EML policies and use evidence from research and practice for the processes, documentation of this aspect has received little attention. The Ghanaian STGs/EML policy review process is not documented, and little information is available to stakeholders and policy change advocates who wish to understand how disease conditions and essential medicines are selected and how policymakers and advocates use evidence from practice and research to inform decisions. This article therefore aims to fill the gap and describes the review processes of how disease conditions and medicines get to be added or removed; the actors involved and their negotiations and use of evidence from research and practice in selecting common diseases treatment options and essential medicines for the 2017 edition of the STGs and EML for Ghana. Materials and methods Data collection and analysis This study employs a case study design that allows for in-depth investigation of complex and context-specific events such as the STGs/EML review process, within a real-life context. It allows the use of multiple sources of evidence and triangulation to provide data-rich explanation of a phenomenon (Yin, 2009). We present data drawing on our retrospective recollection of the review process as active participants and content analysis of the NMSC output, stakeholder meetings reports and the 2010 and 2017 STGs/EML editions. Disease conditions and medicines from the 2010 and 2017 STGs/EML editions were itemized and analysed to document how listed disease conditions and medicines evolved between the last two editions. Additionally, we purposively selected and studied all meeting reports, outputs and attendance of NMSC, management meetings, inauguration and publication launch and stakeholder engagement between 10 January 2014 and 4 October 2017 (Table 1) to trace and map the review process including specific timelines, activities, attendees and decisions. The inauguration and publication launch events as well as management group meetings were half-working day sessions while all other meetings were held for full working days. The data were then tabulated and systematically grouped based on different periods of the review process. The data were coded on four main themes: evidence, stakeholders, process and disease conditions. Evidence was categorized as being drawn from clinical experience and studies. Stakeholders categorized as practice, academia and management. Process categorized as STGs/EML pre-review, review and post-review processes. Under disease condition, there were two categories: 2010 disease conditions and 2017 disease conditions. Table 1 STGs and EML review process meetings reports and outputs Meetings reports Number of meeting reports/outputs Dates Inauguration of National Medicines Selection Committee report 1 10 June 2014 Management Group report 10 10 January 2014–17 February 2015 National Medicines Selection Committee Workshops report 7 24 February–11 June 2015 Stakeholder Consensus Workshop report 4 6 October 2015–13 September 2017 Evidence summaries group report 7 21 October 2015–8 January 2016 Editorial Committee output 40 November 2015–10 April 2017 Launch of STGs and EML report 1 4 October 2017 Meetings reports Number of meeting reports/outputs Dates Inauguration of National Medicines Selection Committee report 1 10 June 2014 Management Group report 10 10 January 2014–17 February 2015 National Medicines Selection Committee Workshops report 7 24 February–11 June 2015 Stakeholder Consensus Workshop report 4 6 October 2015–13 September 2017 Evidence summaries group report 7 21 October 2015–8 January 2016 Editorial Committee output 40 November 2015–10 April 2017 Launch of STGs and EML report 1 4 October 2017 Open in new tab Table 1 STGs and EML review process meetings reports and outputs Meetings reports Number of meeting reports/outputs Dates Inauguration of National Medicines Selection Committee report 1 10 June 2014 Management Group report 10 10 January 2014–17 February 2015 National Medicines Selection Committee Workshops report 7 24 February–11 June 2015 Stakeholder Consensus Workshop report 4 6 October 2015–13 September 2017 Evidence summaries group report 7 21 October 2015–8 January 2016 Editorial Committee output 40 November 2015–10 April 2017 Launch of STGs and EML report 1 4 October 2017 Meetings reports Number of meeting reports/outputs Dates Inauguration of National Medicines Selection Committee report 1 10 June 2014 Management Group report 10 10 January 2014–17 February 2015 National Medicines Selection Committee Workshops report 7 24 February–11 June 2015 Stakeholder Consensus Workshop report 4 6 October 2015–13 September 2017 Evidence summaries group report 7 21 October 2015–8 January 2016 Editorial Committee output 40 November 2015–10 April 2017 Launch of STGs and EML report 1 4 October 2017 Open in new tab Active participation and observation enable one to describe the setting observed, the activities that took place in that setting, the people who participated in those activities and better understand and capture the context within which people interacted (Patton, 2002). We drew on our experiences to interpret findings from the document analysis. Further analysis involved chronologically restructuring how the GNDP coordinated the review process, how the 2010 edition STGs and EML disease conditions and medicines evolved, and how various actors influenced the 2017 edition list of disease conditions and medicines with use of evidence and negotiations. We acknowledge the challenges involved in mapping the exact sequence of events and providing full explanations of events as they unfolded. To minimize this, we drew from varied meeting reports and outputs and our experiences of the review process. We present our analyses in three main stages: pre-review, review and post-review. Study limitations The in-depth personal engagement of a participant observer yields rich and ‘thick’ descriptive material and insights, but it is also its weakness. This is because, the participant’s view of the process may be clouded by their biases and sentiments and their influence on the processes may not be objectively assessed (Agyepong and Adjei, 2008). In addition, the challenge of recollecting information through active participation and observation is the ability to combine active participation and observation so as to become capable of understanding the review process as an insider while describing the process for an outsider (Patton, 2002; Robson, 2011). To minimize this weakness as noted by Agyepong and Adjei (2008), we provided no value judgments as to ‘good’ or ‘bad’, ‘success’ or ‘failure’ but rather focused on analysis and description. Results Pre-review stage The pre-review period included activities undertaken by the GNDP prior to assessing the 2010 STGs and EML. The Minister of Health in consultation with the GNDP and director pharmaceutical services nominated a chairperson to oversee technical discussion of the review process. A consultant physician and university academic with a background in internal medicine and therapeutics who had been a member of three previous STGs/EML expert committees and had previously directed the review process of the 2010 edition of the STGs/EML was nominated. The chairperson was to lead technical discussions related to treatment options and medicines selections based on local context, public health safety, efficacy, clinical and cost-effectiveness. STGs/EML management group With a chairperson in place, the GNDP constituted a management group to oversee day-to-day operations of the review process in January 2014. This comprised of the chairperson, GNDP technical officers (3), director pharmaceutical services and two representatives of the National Health Insurance Authority (NHIA) and a WHO country office representative. The NHIA representatives were included to guide align the STGs and EML to the national health insurance benefit package. The director pharmaceutical services represented the Minister of Health and were to ensure the STGs and EML alignment to national health strategies and plans. Finally, the WHO national programme officer for Essential Drugs and Medicines was included to provide technical guidelines on global best practices and lessons from other health systems as well as guidance on WHO model list of medicines and the WHO classification of antimicrobials. With the management group in place, the GNDP collated all disease review documents from the MoH, Ghana Health Service, Christian Health Association of Ghana to ascertain disease pattern of the country. The management group in turn recruited reviewers. Curriculum Vitae of review members with long history on the STGs/EML review committees were solicited and their availability assessed. New recruits recommended by existing reviewers and nominated by the management group were approached based on their expertise, years of experience and availability. In total, the management group recruited 40 local reviewers with expertise on the identified disease patterns to form the NMSC (Figure 1). Figure 1 Open in new tabDownload slide Composition of National Medicines Selection Committee. Figure 1 Open in new tabDownload slide Composition of National Medicines Selection Committee. To align the STGs/EML to existing public health programme treatment protocols, the GNDP collated current country-specific treatment protocols for expanded programme on immunization, eye care programme, buruli ulcer, national acquired immune deficiency syndrome/sexually transmitted infection control programme, national malaria control programme, national tuberculosis programme, national yaws eradication and reproductive health programmes. In addition, the GNDP collated relevant documents such as national health insurance benefits package, the WHO model list of essential medicines for both adults and children, submissions from stakeholders on inclusions and deletions to the EML as resources for the reviewers. To supplement funds from the Government of Ghana, the GNDP requested financial support from the European Union Commission, WHO and United Kingdom Department for International Development to compensate reviewers for their time and print copies of the STGs and EML. Conflict of interest, STGs format and terms of reference The management group developed conflict of interest form, terms of reference (TOR) and STGs outline format for the reviewers to facilitate the review process. All reviewers and persons closely involved in selecting treatment options and medicines disclosed any circumstance that could represent a potential conflict of interest at the beginning of all technical meetings. GNDP documented the conflict of interest forms and in case any interest was declared the reviewer would have been exempted from the meeting. However, no conflict of interest was declared during the review process. The TOR and criteria for medicine selection to guide the review process and functioning of the NMSC are summarized in Box 1. Box 1: Terms of reference for NMSC To review the diseases listed in the 2010 STG based on current trends in conditions of common occurrence in Ghana To review the medicines listed for the treatment of such diseases in the EML To recommend medicines for reimbursements in the National Health Insurance Medicines List through evidence for efficacy, safety and cost effectiveness. To define list of medicines for specialist care and programme drugs. To define a list of medicines for medical emergencies based on a defined list of emergency medical conditions Criteria for selection of essential medicines are: Drug selection should be based on the results of efficacy and safety evaluations obtained in controlled clinical trials and epidemiological studies, and on the performance in general use in a variety of medical settings. When several drugs are available for the same indication, only the drug and the pharmaceutical form that provides the more convenient benefit/risk ratio should be selected. When two or more drugs are therapeutically equivalent, the selection should fall on: The drug that has been more thoroughly investigated. The drug with the most favourable pharmacokinetic properties. The drug with the lowest cost, calculated on the basis of the whole course of treatment. The drug with which health workers are already familiar. The drug for which economically convenient manufacturing is available in the country. The drug which shows better stability at the available storage conditions. A fixed dose combination should be accepted only if clinical documentation justifies the concomitant use of more than one drug, and the combination provides a proven advantage over single compounds administered separately in therapeutic effect, safety patients’ compliance or cost. Evidence rating: NMSC members were to rate selected treatment options on the following basis. First, evidence rating A—requires at least one randomized control trial as part of a body of scientific literature of overall good quality and consistency addressing the specific recommendation. Second, evidence rating B—requires the availability of well-conducted clinical studies but no randomized clinical trials on the topic of recommendation. Third, evidence rating C—requires evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. To ensure uniformity in assessment and recommendations from NMSC members, the management group designed an outline format for the presentation of content on each disease condition. The outline included—Preamble; Causes; Symptoms; Signs; Investigations; Treatment objectives; Non-pharmacological treatment; Pharmacological treatment; first-line treatment; second-line treatment (where applicable); Evidence rating; Cautions/contraindication/alternative(s); Referral Criteria and Treatment summaries in the form of flowcharts or tables where possible. Review stage The GNDP placed a public announcement on 10 June 2014 in a national newspaper—The Ghanaian Daily Graphic—with a title ‘Committee to review essential medicines list’ (Appiah and Omaboe, 2014). The public announcement coincided with inauguration of the NMSC by the Minister of Health. The Minister tasked the committee to work with the GNDP to attain objectives of the review process. The review process is summarized in Figure 2. Figure 2 Open in new tabDownload slide STGs/EML review process. Figure 2 Open in new tabDownload slide STGs/EML review process. NMSC assignment and plenary sessions The management group in September 2014, assigned specific disease conditions from the 2010 edition STGs and priority disease conditions to NMSC members based on their expertise. NMSC members worked independently according to the pre-established STGs outline and criteria. To facilitate a plenary session and subject individual work to peer review, the management group further assigned NMSC members to specific groups (Table 2) based on clinical areas and cross-cutting disease conditions. A mix of expertise from child health, pharmacy, public health and policy, surgery and internal medicine constituted each group. Experts reported on disease conditions assigned and recommended new treatment options in their field using the agreed STGs outline format. Table 2 NMSC plenary grouping based on cross cutting diseases Group 1 Disorders of the Gastrointestinal Tract Disorders of the Liver Nutritional Disorders Haematological Disorders Malignancies Group 2 Childhood Immunisable Disease Problems of the Newborn General Emergency Antibiotics Prophylaxis in Survey Structured Approach to the Seriously Ill Child Group 3 Endocrine and Metabolic Disorders Obstetric Care and Obstetric Disorders Gynaecological Disorders Disorders of the Kidney and Genitourinary System Group 4 Eye Disorders Ear, Nose and Throat Disorders Oral and Dental Conditions General Management of Poisoning Group 5 Disorders of the Skin (Fungal Skin Infections, Viral Skin Infections, Non-Specific Skin Infections) Sexually Transmitted Infections Infectious Disease and Infections Disorders of the Musculoskeletal System Local Anaesthetic Agents Trauma and Injuries Management of Acute Pain Group 1 Disorders of the Gastrointestinal Tract Disorders of the Liver Nutritional Disorders Haematological Disorders Malignancies Group 2 Childhood Immunisable Disease Problems of the Newborn General Emergency Antibiotics Prophylaxis in Survey Structured Approach to the Seriously Ill Child Group 3 Endocrine and Metabolic Disorders Obstetric Care and Obstetric Disorders Gynaecological Disorders Disorders of the Kidney and Genitourinary System Group 4 Eye Disorders Ear, Nose and Throat Disorders Oral and Dental Conditions General Management of Poisoning Group 5 Disorders of the Skin (Fungal Skin Infections, Viral Skin Infections, Non-Specific Skin Infections) Sexually Transmitted Infections Infectious Disease and Infections Disorders of the Musculoskeletal System Local Anaesthetic Agents Trauma and Injuries Management of Acute Pain Open in new tab Table 2 NMSC plenary grouping based on cross cutting diseases Group 1 Disorders of the Gastrointestinal Tract Disorders of the Liver Nutritional Disorders Haematological Disorders Malignancies Group 2 Childhood Immunisable Disease Problems of the Newborn General Emergency Antibiotics Prophylaxis in Survey Structured Approach to the Seriously Ill Child Group 3 Endocrine and Metabolic Disorders Obstetric Care and Obstetric Disorders Gynaecological Disorders Disorders of the Kidney and Genitourinary System Group 4 Eye Disorders Ear, Nose and Throat Disorders Oral and Dental Conditions General Management of Poisoning Group 5 Disorders of the Skin (Fungal Skin Infections, Viral Skin Infections, Non-Specific Skin Infections) Sexually Transmitted Infections Infectious Disease and Infections Disorders of the Musculoskeletal System Local Anaesthetic Agents Trauma and Injuries Management of Acute Pain Group 1 Disorders of the Gastrointestinal Tract Disorders of the Liver Nutritional Disorders Haematological Disorders Malignancies Group 2 Childhood Immunisable Disease Problems of the Newborn General Emergency Antibiotics Prophylaxis in Survey Structured Approach to the Seriously Ill Child Group 3 Endocrine and Metabolic Disorders Obstetric Care and Obstetric Disorders Gynaecological Disorders Disorders of the Kidney and Genitourinary System Group 4 Eye Disorders Ear, Nose and Throat Disorders Oral and Dental Conditions General Management of Poisoning Group 5 Disorders of the Skin (Fungal Skin Infections, Viral Skin Infections, Non-Specific Skin Infections) Sexually Transmitted Infections Infectious Disease and Infections Disorders of the Musculoskeletal System Local Anaesthetic Agents Trauma and Injuries Management of Acute Pain Open in new tab During the first plenary session (24–27 February 2015), NMSC members peer-reviewed individual work to ensure practical relevance of treatment options, applicability to the Ghanaian healthcare service delivery system, best current evidence, consistency of recommendations, as well as uniformity based on agreed STGs outline format. NMSC members reviewed individual work as per assigned group and presented agreed evidence rating for proposed treatment options for disease conditions stated in the 2010 edition and new common disease conditions. The GNDP compiled inputs from the first plenary session and arranged the content in alphabetical order of ‘body systems’. The draft report was sent to NMSC members for further review of their individually assigned disease conditions. After, 3 months of individual work, the NMSC reconvened for a second plenary session (9–11 June 2015) to further peer review, build consensus on treatment options for the listed disease conditions and generate a draft STGs for a broader stakeholder engagement. During these technical workshops, reviewers discussed evidence rating from practice and scientific study, and decisions were made to suit the local country context in terms of efficacy, safety, cost, availability and use. Stakeholder engagement for draft STGs The GNDP organized a stakeholder meeting on 6 October 2015 with the objectives to consult stakeholders on the revised STGs, develop ownership amongst stakeholders and build consensus on the NMSC recommendations. To facilitate pre-reading and prior comments, the GNDP sent draft STGs copies to invited stakeholders 2 weeks before the meeting. The 62 participants are summarized in Figure 3 and their decisions in Box 2. Box 2: 6 October 2015 stakeholder meeting Labelling and classifying disease conditions. For example, juvenile rheumatoid arthritis was revised to juvenile idiopathic arthritis and gout moved from endocrine and metabolic disorders section to disorders of the musculoskeletal system section. Concomitant use of same class of medicine for pain relief. A service provider noted an increase use of the same class of analgesic in different formulation for pain relief, for example the concurrent use of oral, topical and injection diclofenac. To minimize this practice, a note—‘Different groups of drugs can be used together to treat pain. This increases the effectiveness of pain relief, as there is a limit to the dosage of each drug that can be given. This limits its effectiveness when used alone’. Recommended combinations include: (1) paracetamol and opioid (2) paracetamol and non-steroidal anti-inflammatory drug (NSAID) and (3) paracetamol and NSAID and opioid’—(Ministry of Health, 2017c) was include under management of pain section of the STGs. Clear difference between the causes of ‘acute diarrhoea’ and ‘chronic diarrhoea’ made as different pharmacological and non-pharmacological treatments were required. Stating dosage by age and weight in a consistent and uniform manner. Four clinical and child health pharmacists and a family physician were co-opted to align child specific dosage regimen by age and weight. GNDP set up 11-member editorial committee Figure 3 Open in new tabDownload slide Summary of key stakeholder engagements participants. Figure 3 Open in new tabDownload slide Summary of key stakeholder engagements participants. Evidence summaries group During feedback session of the NMSC and the stakeholders meeting, there were elements of contestation on weight of evidence to support treatment options. As a result, the chairperson and NMSC members decided to reconstitute an evidence summaries group to validate contested evidence presented to support a treatment option. An evidence summaries group previously trained by a specialist from Liverpool School of Tropical Medicine in the retrieval, appraisal and interpretation of systematic reviews (Sinclair et al., 2013) therefore supported the NMSC work. The evidence summaries group investigated conflicting issues over treatment options and weight of evidence for contested treatment options and reported to the NMSC. For example, the evidence summaries group provided information on use of Widal test in confirming typhoid fever. To prevent ambiguity a note—‘Diagnosis of typhoid fever is based on a strong clinical suspicion backed by; Blood cultures, positive during first 10 days of fever; Stool cultures, positive after 10th day up to 4th or 5th week; Urine cultures, positive during 2nd and 3rd week. The stated tests are superior to the Widal test, which is unreliable and rarely useful in confirming a diagnosis of typhoid fever’—was therefore included in the 2017 edition (Ministry of Health, 2017c). How the STGs content evolved Based on country-specific conditions of high prevalence and public health importance, the 2010 edition content evolved in terms of disease conditions. First, terms of some disease conditions presented in the 2010 edition were modified in the 2017 edition. For example, ‘Hepatitis’ revised as Acute Hepatitis and Chronic Hepatitis to reflect their different pharmacological and non-pharmacological treatments. Table 3 summarizes the disease conditions and ‘body systems’ revision. Finally, the 2017 edition incorporated 64 more disease conditions such as drug-resistant tuberculosis and topics such as ‘medicines use in the elderly and local anaesthetic agents’. Table 4 summarizes the new disease conditions and topics. Table 3 Disease conditions presented in the 2010 edition but modified for the 2017 edition 2010 Edition 2017 Edition Disorder of the Liver Hepatitis Disorder of the Liver Acute Hepatitis Chronic Hepatitis Eye Disorders Conjunctivitis Eye Disorders Neonatal conjunctivitis Haematological Disorders Multiple Myeloma Lymphoma Haematological Disorders Plasma Cell Myeloma Malignant Lymphoma Psychiatric disorders Alcoholism Psychiatric disorders Alcoholic Delirium Tremens Childhood Immunisable Diseases Hepatitis B Immunisable Diseases Hepatitis Disorder of the Cardiovascular System Cardiac Arrhythmias Rheumatic Fever Disorder of the Cardiovascular System Arrhythmias Acute Rheumatic Fever Disorder of the Central Nervous System Dizziness and Blackout Disorder of the Cardiovascular System Dizziness and Blackout Disorder of the Respiratory System Asthma Disorder of the Respiratory System Bronchial Asthma Common Malignancies Bladder Cancer Carcinoma of Prostate Disorder of the Kidney and Genitourinary Bladder Cancer Carcinoma of Prostate Common Malignancies Hepatocellular Carcinoma Disorder of Liver Hepatocellular Carcinoma Common Malignancies Carcinoma of the cervix Gynaecological Disorders Carcinoma of the cervix Endocrine and Metabolic Disorders Gout Disorder of Musculoskeletal System Gout Disorders of the Musculoskeletal System Juvenile Rheumatoid Arthritis Low Back Pain Disorders of the Musculoskeletal System Juvenile Idiopathic Arthritis Back pain General Emergencies Shock Trauma and Injuries Shock Oral and Dental Conditions Gingivitis Oral and Dental Conditions Acute Necrotizing Ulcerative Gingivitis 2010 Edition 2017 Edition Disorder of the Liver Hepatitis Disorder of the Liver Acute Hepatitis Chronic Hepatitis Eye Disorders Conjunctivitis Eye Disorders Neonatal conjunctivitis Haematological Disorders Multiple Myeloma Lymphoma Haematological Disorders Plasma Cell Myeloma Malignant Lymphoma Psychiatric disorders Alcoholism Psychiatric disorders Alcoholic Delirium Tremens Childhood Immunisable Diseases Hepatitis B Immunisable Diseases Hepatitis Disorder of the Cardiovascular System Cardiac Arrhythmias Rheumatic Fever Disorder of the Cardiovascular System Arrhythmias Acute Rheumatic Fever Disorder of the Central Nervous System Dizziness and Blackout Disorder of the Cardiovascular System Dizziness and Blackout Disorder of the Respiratory System Asthma Disorder of the Respiratory System Bronchial Asthma Common Malignancies Bladder Cancer Carcinoma of Prostate Disorder of the Kidney and Genitourinary Bladder Cancer Carcinoma of Prostate Common Malignancies Hepatocellular Carcinoma Disorder of Liver Hepatocellular Carcinoma Common Malignancies Carcinoma of the cervix Gynaecological Disorders Carcinoma of the cervix Endocrine and Metabolic Disorders Gout Disorder of Musculoskeletal System Gout Disorders of the Musculoskeletal System Juvenile Rheumatoid Arthritis Low Back Pain Disorders of the Musculoskeletal System Juvenile Idiopathic Arthritis Back pain General Emergencies Shock Trauma and Injuries Shock Oral and Dental Conditions Gingivitis Oral and Dental Conditions Acute Necrotizing Ulcerative Gingivitis Open in new tab Table 3 Disease conditions presented in the 2010 edition but modified for the 2017 edition 2010 Edition 2017 Edition Disorder of the Liver Hepatitis Disorder of the Liver Acute Hepatitis Chronic Hepatitis Eye Disorders Conjunctivitis Eye Disorders Neonatal conjunctivitis Haematological Disorders Multiple Myeloma Lymphoma Haematological Disorders Plasma Cell Myeloma Malignant Lymphoma Psychiatric disorders Alcoholism Psychiatric disorders Alcoholic Delirium Tremens Childhood Immunisable Diseases Hepatitis B Immunisable Diseases Hepatitis Disorder of the Cardiovascular System Cardiac Arrhythmias Rheumatic Fever Disorder of the Cardiovascular System Arrhythmias Acute Rheumatic Fever Disorder of the Central Nervous System Dizziness and Blackout Disorder of the Cardiovascular System Dizziness and Blackout Disorder of the Respiratory System Asthma Disorder of the Respiratory System Bronchial Asthma Common Malignancies Bladder Cancer Carcinoma of Prostate Disorder of the Kidney and Genitourinary Bladder Cancer Carcinoma of Prostate Common Malignancies Hepatocellular Carcinoma Disorder of Liver Hepatocellular Carcinoma Common Malignancies Carcinoma of the cervix Gynaecological Disorders Carcinoma of the cervix Endocrine and Metabolic Disorders Gout Disorder of Musculoskeletal System Gout Disorders of the Musculoskeletal System Juvenile Rheumatoid Arthritis Low Back Pain Disorders of the Musculoskeletal System Juvenile Idiopathic Arthritis Back pain General Emergencies Shock Trauma and Injuries Shock Oral and Dental Conditions Gingivitis Oral and Dental Conditions Acute Necrotizing Ulcerative Gingivitis 2010 Edition 2017 Edition Disorder of the Liver Hepatitis Disorder of the Liver Acute Hepatitis Chronic Hepatitis Eye Disorders Conjunctivitis Eye Disorders Neonatal conjunctivitis Haematological Disorders Multiple Myeloma Lymphoma Haematological Disorders Plasma Cell Myeloma Malignant Lymphoma Psychiatric disorders Alcoholism Psychiatric disorders Alcoholic Delirium Tremens Childhood Immunisable Diseases Hepatitis B Immunisable Diseases Hepatitis Disorder of the Cardiovascular System Cardiac Arrhythmias Rheumatic Fever Disorder of the Cardiovascular System Arrhythmias Acute Rheumatic Fever Disorder of the Central Nervous System Dizziness and Blackout Disorder of the Cardiovascular System Dizziness and Blackout Disorder of the Respiratory System Asthma Disorder of the Respiratory System Bronchial Asthma Common Malignancies Bladder Cancer Carcinoma of Prostate Disorder of the Kidney and Genitourinary Bladder Cancer Carcinoma of Prostate Common Malignancies Hepatocellular Carcinoma Disorder of Liver Hepatocellular Carcinoma Common Malignancies Carcinoma of the cervix Gynaecological Disorders Carcinoma of the cervix Endocrine and Metabolic Disorders Gout Disorder of Musculoskeletal System Gout Disorders of the Musculoskeletal System Juvenile Rheumatoid Arthritis Low Back Pain Disorders of the Musculoskeletal System Juvenile Idiopathic Arthritis Back pain General Emergencies Shock Trauma and Injuries Shock Oral and Dental Conditions Gingivitis Oral and Dental Conditions Acute Necrotizing Ulcerative Gingivitis Open in new tab Table 4 New topics and disease conditions included in the 2017 edition 1. Disorders of the Gastrointestinal Tract Rotavirus Disease and Diarrhoea 2. Medicines Use in the Elderly Medicines use in the Elderly 3. Local Anaesthetic Agents Local Anaesthetic Agents 4. Immunisable Diseases Pneumococcal Disease Rotavirus Disease 5. Disorder of the Liver Vomiting Drugs and the Liver 6. Eye Disorders Exposure Keratopathy Strabismus Sickle-Cell Disease—Retinopathy Endocrine and metabolic disorders with eye complications 7. Disorders of the Musculoskeletal System Fibromyalgia Idiopathic inflammatory myopathies Management of the Hot Swollen Joint Pseudo-gout (chondrocalcinosis) 8. Gynaecological Disorders Abnormal Vaginal Discharge Acute Lower Abdominal Pain 9. Infectious Disease and Infestations Drug resistant tuberculosis Seasonal Malaria Chemoprevention 10. Obstetric Care and Obstetric Disorders Sickle-Cell Disease in Pregnancy Severe Pre-eclampsia and Imminent Eclampsia 11. Psychiatric Disorder Substance Use Disorders Autistic Spectrum Disorder 12. Ear, Nose and Throat Disorders Acute Epiglottitis 13. Structured Approach to the Seriously Ill Child Structured approach to the seriously ill child 14. Problems of the Newborn (Neonate) Retinoblastoma Wilms Tumour 15. Endocrine and Metabolic Disorders Diabetes in Pregnancy Treatment-Induced Hypoglycaemia 16. Sexually Transmitted Infections (STI) Mycoplasma genitalum STI-related Ano-rectal Related Syndromes Sexually Transmitted Infections in Children STI-related Neonatal Conjunctivitis (Opthalmia Neonatorum) 17. Management of Specific STI and STI Syndromes in Children STI-related Urethral Discharge Syndrome in Children STI-related Vaginal Discharge Syndromes in Children STI-related Lower Abdominal Pain or Pelvic Inflammatory Disease Syndrome in Children STI-related Genital Ulcer Syndrome in Children STI-related Ano-Rectal Related Syndromes in Children 18. Trauma and Injuries Abdominal Trauma Closed Fractures Open Fractures Dislocations Acute orthopaedic infections Cellulitis Chronic Osteomyelitis and Chronic Septic Arthritis Necrotizing Fasciitis Hand Infections Tuberculosis in orthopaedics Rickets and Osteomalacia Scurvy Osteoporosis Sickle-cell Vaso-occlusive Crisis Avascular Necrosis Osteogenesis Imperfecta 19. Oral and Dental Conditions Bacterial Endocarditis and Prophylaxis in Dentistry Acute Bacterial Sialoadenitis Ludwig’s Angina/Cervico-Facial Abscess Chronic Periodontal Infections Mouth Ulcers Odontogenic Infections Oral Squamous Cell Carcinoma Temporo-mandibular Joint dysfunction and masticatory muscle dysfunction Trigeminal Neuralgia 20. Disorders of the Kidney and Genitourinary System Anaemia in Chronic Kidney Disease Medicines and the Kidney Persistent or Recurrent Urethral Discharge Retention of Urine 1. Disorders of the Gastrointestinal Tract Rotavirus Disease and Diarrhoea 2. Medicines Use in the Elderly Medicines use in the Elderly 3. Local Anaesthetic Agents Local Anaesthetic Agents 4. Immunisable Diseases Pneumococcal Disease Rotavirus Disease 5. Disorder of the Liver Vomiting Drugs and the Liver 6. Eye Disorders Exposure Keratopathy Strabismus Sickle-Cell Disease—Retinopathy Endocrine and metabolic disorders with eye complications 7. Disorders of the Musculoskeletal System Fibromyalgia Idiopathic inflammatory myopathies Management of the Hot Swollen Joint Pseudo-gout (chondrocalcinosis) 8. Gynaecological Disorders Abnormal Vaginal Discharge Acute Lower Abdominal Pain 9. Infectious Disease and Infestations Drug resistant tuberculosis Seasonal Malaria Chemoprevention 10. Obstetric Care and Obstetric Disorders Sickle-Cell Disease in Pregnancy Severe Pre-eclampsia and Imminent Eclampsia 11. Psychiatric Disorder Substance Use Disorders Autistic Spectrum Disorder 12. Ear, Nose and Throat Disorders Acute Epiglottitis 13. Structured Approach to the Seriously Ill Child Structured approach to the seriously ill child 14. Problems of the Newborn (Neonate) Retinoblastoma Wilms Tumour 15. Endocrine and Metabolic Disorders Diabetes in Pregnancy Treatment-Induced Hypoglycaemia 16. Sexually Transmitted Infections (STI) Mycoplasma genitalum STI-related Ano-rectal Related Syndromes Sexually Transmitted Infections in Children STI-related Neonatal Conjunctivitis (Opthalmia Neonatorum) 17. Management of Specific STI and STI Syndromes in Children STI-related Urethral Discharge Syndrome in Children STI-related Vaginal Discharge Syndromes in Children STI-related Lower Abdominal Pain or Pelvic Inflammatory Disease Syndrome in Children STI-related Genital Ulcer Syndrome in Children STI-related Ano-Rectal Related Syndromes in Children 18. Trauma and Injuries Abdominal Trauma Closed Fractures Open Fractures Dislocations Acute orthopaedic infections Cellulitis Chronic Osteomyelitis and Chronic Septic Arthritis Necrotizing Fasciitis Hand Infections Tuberculosis in orthopaedics Rickets and Osteomalacia Scurvy Osteoporosis Sickle-cell Vaso-occlusive Crisis Avascular Necrosis Osteogenesis Imperfecta 19. Oral and Dental Conditions Bacterial Endocarditis and Prophylaxis in Dentistry Acute Bacterial Sialoadenitis Ludwig’s Angina/Cervico-Facial Abscess Chronic Periodontal Infections Mouth Ulcers Odontogenic Infections Oral Squamous Cell Carcinoma Temporo-mandibular Joint dysfunction and masticatory muscle dysfunction Trigeminal Neuralgia 20. Disorders of the Kidney and Genitourinary System Anaemia in Chronic Kidney Disease Medicines and the Kidney Persistent or Recurrent Urethral Discharge Retention of Urine Open in new tab Table 4 New topics and disease conditions included in the 2017 edition 1. Disorders of the Gastrointestinal Tract Rotavirus Disease and Diarrhoea 2. Medicines Use in the Elderly Medicines use in the Elderly 3. Local Anaesthetic Agents Local Anaesthetic Agents 4. Immunisable Diseases Pneumococcal Disease Rotavirus Disease 5. Disorder of the Liver Vomiting Drugs and the Liver 6. Eye Disorders Exposure Keratopathy Strabismus Sickle-Cell Disease—Retinopathy Endocrine and metabolic disorders with eye complications 7. Disorders of the Musculoskeletal System Fibromyalgia Idiopathic inflammatory myopathies Management of the Hot Swollen Joint Pseudo-gout (chondrocalcinosis) 8. Gynaecological Disorders Abnormal Vaginal Discharge Acute Lower Abdominal Pain 9. Infectious Disease and Infestations Drug resistant tuberculosis Seasonal Malaria Chemoprevention 10. Obstetric Care and Obstetric Disorders Sickle-Cell Disease in Pregnancy Severe Pre-eclampsia and Imminent Eclampsia 11. Psychiatric Disorder Substance Use Disorders Autistic Spectrum Disorder 12. Ear, Nose and Throat Disorders Acute Epiglottitis 13. Structured Approach to the Seriously Ill Child Structured approach to the seriously ill child 14. Problems of the Newborn (Neonate) Retinoblastoma Wilms Tumour 15. Endocrine and Metabolic Disorders Diabetes in Pregnancy Treatment-Induced Hypoglycaemia 16. Sexually Transmitted Infections (STI) Mycoplasma genitalum STI-related Ano-rectal Related Syndromes Sexually Transmitted Infections in Children STI-related Neonatal Conjunctivitis (Opthalmia Neonatorum) 17. Management of Specific STI and STI Syndromes in Children STI-related Urethral Discharge Syndrome in Children STI-related Vaginal Discharge Syndromes in Children STI-related Lower Abdominal Pain or Pelvic Inflammatory Disease Syndrome in Children STI-related Genital Ulcer Syndrome in Children STI-related Ano-Rectal Related Syndromes in Children 18. Trauma and Injuries Abdominal Trauma Closed Fractures Open Fractures Dislocations Acute orthopaedic infections Cellulitis Chronic Osteomyelitis and Chronic Septic Arthritis Necrotizing Fasciitis Hand Infections Tuberculosis in orthopaedics Rickets and Osteomalacia Scurvy Osteoporosis Sickle-cell Vaso-occlusive Crisis Avascular Necrosis Osteogenesis Imperfecta 19. Oral and Dental Conditions Bacterial Endocarditis and Prophylaxis in Dentistry Acute Bacterial Sialoadenitis Ludwig’s Angina/Cervico-Facial Abscess Chronic Periodontal Infections Mouth Ulcers Odontogenic Infections Oral Squamous Cell Carcinoma Temporo-mandibular Joint dysfunction and masticatory muscle dysfunction Trigeminal Neuralgia 20. Disorders of the Kidney and Genitourinary System Anaemia in Chronic Kidney Disease Medicines and the Kidney Persistent or Recurrent Urethral Discharge Retention of Urine 1. Disorders of the Gastrointestinal Tract Rotavirus Disease and Diarrhoea 2. Medicines Use in the Elderly Medicines use in the Elderly 3. Local Anaesthetic Agents Local Anaesthetic Agents 4. Immunisable Diseases Pneumococcal Disease Rotavirus Disease 5. Disorder of the Liver Vomiting Drugs and the Liver 6. Eye Disorders Exposure Keratopathy Strabismus Sickle-Cell Disease—Retinopathy Endocrine and metabolic disorders with eye complications 7. Disorders of the Musculoskeletal System Fibromyalgia Idiopathic inflammatory myopathies Management of the Hot Swollen Joint Pseudo-gout (chondrocalcinosis) 8. Gynaecological Disorders Abnormal Vaginal Discharge Acute Lower Abdominal Pain 9. Infectious Disease and Infestations Drug resistant tuberculosis Seasonal Malaria Chemoprevention 10. Obstetric Care and Obstetric Disorders Sickle-Cell Disease in Pregnancy Severe Pre-eclampsia and Imminent Eclampsia 11. Psychiatric Disorder Substance Use Disorders Autistic Spectrum Disorder 12. Ear, Nose and Throat Disorders Acute Epiglottitis 13. Structured Approach to the Seriously Ill Child Structured approach to the seriously ill child 14. Problems of the Newborn (Neonate) Retinoblastoma Wilms Tumour 15. Endocrine and Metabolic Disorders Diabetes in Pregnancy Treatment-Induced Hypoglycaemia 16. Sexually Transmitted Infections (STI) Mycoplasma genitalum STI-related Ano-rectal Related Syndromes Sexually Transmitted Infections in Children STI-related Neonatal Conjunctivitis (Opthalmia Neonatorum) 17. Management of Specific STI and STI Syndromes in Children STI-related Urethral Discharge Syndrome in Children STI-related Vaginal Discharge Syndromes in Children STI-related Lower Abdominal Pain or Pelvic Inflammatory Disease Syndrome in Children STI-related Genital Ulcer Syndrome in Children STI-related Ano-Rectal Related Syndromes in Children 18. Trauma and Injuries Abdominal Trauma Closed Fractures Open Fractures Dislocations Acute orthopaedic infections Cellulitis Chronic Osteomyelitis and Chronic Septic Arthritis Necrotizing Fasciitis Hand Infections Tuberculosis in orthopaedics Rickets and Osteomalacia Scurvy Osteoporosis Sickle-cell Vaso-occlusive Crisis Avascular Necrosis Osteogenesis Imperfecta 19. Oral and Dental Conditions Bacterial Endocarditis and Prophylaxis in Dentistry Acute Bacterial Sialoadenitis Ludwig’s Angina/Cervico-Facial Abscess Chronic Periodontal Infections Mouth Ulcers Odontogenic Infections Oral Squamous Cell Carcinoma Temporo-mandibular Joint dysfunction and masticatory muscle dysfunction Trigeminal Neuralgia 20. Disorders of the Kidney and Genitourinary System Anaemia in Chronic Kidney Disease Medicines and the Kidney Persistent or Recurrent Urethral Discharge Retention of Urine Open in new tab Essential medicines list The GNDP compiled a second draft of the STGs based on NMSC updated version and stakeholder consensus and generated a list of all essential medicines with their international non-proprietary names in line with practice, National Medicines Policy (Ministry of Health, 2004b) and level of care (Table 5). Due to new developments in terms of disease priorities, value for money and safety, efficacy and use of medicines, the 2017 EML increased by 153 medicines (Table 6) and 56 medicines (Table 7) that were listed in the 2010 EML excluded. Table 5 Level of care categorization for EML 2017 2017 Comment Level A—Community based Health Planning and Services (CHPS) The current categorization reflects primary healthcare and community mobilization activities for healthcare. 2010 edition categorized Level ‘A’ as Community Level M—Midwifery and CHPS with midwife Level ‘M’ category arose from the fact that some CHPS posts had midwives as well as community health officers with training in Integrated Management of Neonatal and Childhood Illness. 2010 edition categorized Level ‘M’ as Midwifery Level B1—Health centre without a doctor Same as 2010 edition Level B2—Health centre with a doctor Level C—District Hospital Level D—Regional/Teaching Hospital 2017 Comment Level A—Community based Health Planning and Services (CHPS) The current categorization reflects primary healthcare and community mobilization activities for healthcare. 2010 edition categorized Level ‘A’ as Community Level M—Midwifery and CHPS with midwife Level ‘M’ category arose from the fact that some CHPS posts had midwives as well as community health officers with training in Integrated Management of Neonatal and Childhood Illness. 2010 edition categorized Level ‘M’ as Midwifery Level B1—Health centre without a doctor Same as 2010 edition Level B2—Health centre with a doctor Level C—District Hospital Level D—Regional/Teaching Hospital Open in new tab Table 5 Level of care categorization for EML 2017 2017 Comment Level A—Community based Health Planning and Services (CHPS) The current categorization reflects primary healthcare and community mobilization activities for healthcare. 2010 edition categorized Level ‘A’ as Community Level M—Midwifery and CHPS with midwife Level ‘M’ category arose from the fact that some CHPS posts had midwives as well as community health officers with training in Integrated Management of Neonatal and Childhood Illness. 2010 edition categorized Level ‘M’ as Midwifery Level B1—Health centre without a doctor Same as 2010 edition Level B2—Health centre with a doctor Level C—District Hospital Level D—Regional/Teaching Hospital 2017 Comment Level A—Community based Health Planning and Services (CHPS) The current categorization reflects primary healthcare and community mobilization activities for healthcare. 2010 edition categorized Level ‘A’ as Community Level M—Midwifery and CHPS with midwife Level ‘M’ category arose from the fact that some CHPS posts had midwives as well as community health officers with training in Integrated Management of Neonatal and Childhood Illness. 2010 edition categorized Level ‘M’ as Midwifery Level B1—Health centre without a doctor Same as 2010 edition Level B2—Health centre with a doctor Level C—District Hospital Level D—Regional/Teaching Hospital Open in new tab Table 6 List of medicines added to the 2017 essential medicines list Name Dosage form Strength 1. Abatacept Injection 125 mg/ml 2. Actinomycin D Injection 10 mg/ml 3. Adalimumab Injection 10 mg/ml 4. Adapalene Cream/Gel 0.1% 5. Alendronate Tablet 70 mg 6. Alfuzocin Tablet 10 mg 7. Alprazolam Tablet 250 μg 8. Aluminium Hydroxide Tablet 500 mg 9. Anakinra Injection 150 mg/ml 10. Antacid containing (Aluminium Hydroxide, Magnesium Hydroxide, Simethicone, Calcium alginates) Mixture 11. Atazanavir Tablet 300 mg 12. Atomoxetine Tablet 10 mg, 25 mg, 40 mg 13. Azathioprine Injection 25 mg Tablet 25 mg 14. Belimumab Infusion 120 mg, 400 mg 15. Calcitonin Injection 100 units/ml 16. Capreomycin Injection 1 g 17. Carboplatin Injection 10 mg/ml 18. Cefixime Tablet 200 mg Suspension 20 mg/ml 19. Celecoxib Tablet 100 mg, 200 mg 20. Certolizumab Injection 200 mg/ml 21. Cervedilol Tablet 3.125 mg, 12.5 mg 22. Cetirizine Tablet 10 mg 23. Chloral Hydrate Tablet 707 mg Oral solution 28.66 mg/ml 24. Cholestyramine Oral powder 4 g 25. Cinnarizine Injection 15 mg 26. Citalopram Tablet 20 mg, 40 mg 27. Clobetasol Propionate Cream 0.05% 28. Clonazepam Hydrochloride Tablet 500 μg 29. Clonidine Tablet 25 μg, 100 μg 30. Clopidogrel Tablet 75 mg 31. Codeine containing cough preparations Syrup 32. Colchicine Tablet 500 μg 33. Copper Sulphate Stone 34. Cyclizine Injection 50 mg/ml Tablet 50 mg 35. Cyclobenzaprine Tablet 5 mg, 10 mg 36. Cycloserine Capsule 250 mg 37. Cyclosporine Injection 50 mg/ml Oral solution 100 mg/ml Tablet 10 mg, 25 mg 38. D-penicillamine Tablet 125 mg 39. Darbepoietin alfa Injection 250 μg 40. Denosumab Injection 60 mg/ml, 70 mg/ml 41. Desferrioxamine Injection 500 mg 42. Desmopressin Nasal spray 150 μg 43. Dextromethorphan containing cough preparations Syrup 44. Diloxanide Furoate Tablet 500 mg 45. Diphtheria Antitoxin Infusion 46. Doxorubucin Injection 2 mg/ml 47. Duloxetine Hydrochloride Tablet 20 mg, 30 mg 48. E45 Cream 49. Econazole Cream 1% 50. Entecavir Injection 50 μg/ml Tablet 500 μg 51. Epoietin beta Injection 2000 units, 10 000 units 52. Etanercept Injection 50 mg/ml 53. Ethanol Solution 10% 54. Ethionamide Tablet 500 mg 55. Ferric Sodium Gluconate complex Injection 62.5 mg elemental iron 56. Ferrous Gluconate Tablet 300 mg 57. Flupenthixol Decanoate Injection 20 mg/ml, 25 mg/ml 58. Fomepizole Injection 5 mg/ml 59. Fusidic Acid Cream 2% 60. Gabapentin Tablet 300 mg 61. Glycerol Suppository 1 g, 2 g, 4 g 62. Golimumab Injection 100 mg/ml 63. Guaifenesin containing experorant Syrup 64. Hydrochlorothiazide Tablet 12.5 mg, 25 mg 65. Hydroxychloroquine Tablet 200 mg 66. Hydroxymethyl Cellulose Eye drops 0.3% 67. Hypertonic Saline Injection 3% 68. Imiquimod Cream 5% 69. Indomethacin Tablet 25 mg, 75 mg 70. Infliximab Injection 100 mg 71. Intralipid Infusion 20% 72. Ipratropium Bromide Nebulizer 250 μg 73. Iron (III) Hydroxide Polymaltose Complex Suspension 100 mg elemental iron 74. Kanamycin Injection 500 mg/vial, 1 g/vial 75. Lamotrigine Dispersible tablet 25 mg Tablet 25 mg, 50 mg 76. Leflunomide Tablet 10 mg, 15 mg, 100 mg 77. Levofloxacin Tablet 500 mg 78. Malathoin Liquid 0.5% 79. Mefenamic Acid Tablet 500 mg 80. Melatonin Tablet modified release 2 mg 81. Methocarbamol Tablet 750 mg 82. Methoxy polyethylene glycol epoietin beta (pegylated form of Epo) Injection 100 μg/ml500 μg/ml 83. Methylprednisolone sodium succinate Infusion 500 mg, 1 g Methylprednisolone acetate Suspension for injection 40 mg/ml 84. Metoprolol Tartrate Tablet 50 mg, 100 mg 85. Miconazole + hydrocortisone Cream 2% + 1% 86. Milk of Magnesia Suspension 87. Minocycline Capsule modified release 100 mg 88. Mist. Potassium Citrate Solution 89. Mometasone Cream 0.1% 90. Montelukast Chewable tablet 4 mg, 5 mg Tablet 10 mg Granule 4 mg, 5 mg 91. Mupirocin Ointment 92. Mycophenolate mofetil Capsule 250 mg Injection 500 mg Suspension 200 mg/ml 93. Naproxen Tablet enteric coated 500 mg 94. Neomycin + Hydrocortisone Nasal drops 0.5% + 1.5% 95. Nitrous Oxide: Oxygen Inhalation 50: 50 96. Norfloxacin Tablet 400 mg 97. Oilatum Soap 98. Ondansetron Tablet 4 mg, 8 mg 99. Oxymetazoline Nasal spray 0.3% 100. Pamidronate Injection 6 mg/ml, 15 mg/ml 101. Pantoprazole Tablet 40 mg 102. Para-aminosalicylic acid Granule 4 mg 103. Paromomycin Suspension 125 mg/5 ml Capsule 250 mg 104. Pegylated inteferon alfa-2a Injection 180 μg/ml 105. Pegylated inteferon alfa-2b Powder for injection 50 μg, 80 μg 106. Permethrin Lotion 1% 107. Pneumococcal Conjugate Vaccine 13 (PCV13) Injection 108. Podophyllin Tincture of benzoin 10–25% 109. Podophylotoxin Solution 0.5% Cream 0.15% 110. Polygeline Infusion 3.5% 111. Polyvinyl Alcohol Eye drops 1.4%, 2% 112. Povidone Iodine Solution 10% 113. Pregabalin Tablet 50 mg, 100 mg 114. Probenecid Tablet 500 mg 115. Prostagladin E1 Injection 500 μg/ml Tablet 500 mg 116. Prothionamide Injection 250 mg 117. Purified Factor IX Injection 118. Purified Factor VIII Injection 119. Recombinant Factor IX Injection 120. Recombinant Factor VIII Injection 121. Ribavirin Tablet 200 mg, 400 mg 122. Rifaximin Tablet 200 mg, 550 mg 123. Rituximab Injection 10 mg/ml, 119.66 mg/ml 124. Salt-poor Human Albumin Solution 125. Saxagliptin Tablet 2.5 mg 126. Shea Butter Cream 127. Sildenafil Citrate Tablet 25 mg, 50 mg, 100 mg 128. Sitagliptin Tablet 25 mg 129. Sodium Aurothiomalate Injection 20 mg/ml, 100 mg/ml 130. Sodium Thiosulfate Injection 500 mg/ml 131. Strontium Ranelate Granule sachets 2 mg 132. Sulfasalazine Suspension 50 mg/ml Tablet 500 mg 133. Tacrolimus Injection 5 mg/ml Tablet 500 μg, 2 mg, 5 mg 134. Tadalafil Tablet 2.5 mg, 10 mg 135. Teriparatide Injection 20 μg 136. Tetracaine Hydrochloride Eye drops 0.5% 137. Tiotropium Bromide Inhaler (dry powder) 18 μg 138. Tizanidine Tablet 2 mg 139. Tocilizumab Injection 20 mg/ml, 180 mg/ml 140. Tofacitinib Tablet 5 mg, 11 mg 141. Tretinoin Gel 0.01% 142. Triamcinolone Injection 10 mg/ml, 40 mg/ml 143. Triazolam Tablet 125 μg, 250 μg 144. Trichloroacetic Acid Solution 80–90% 145. Valsartan Tablet 40 mg, 160 mg 146. Vancomycin Injection 500 mg 147. Verapamil Tablet 40 mg, 80 mg 148. Verdanafil Tablet 5 mg, 10 mg 149. Vildagliptin Tablet 50 mg 150. Vitamin B-Compound Injection (High potency) 151. Vitamin C Tablet 100 mg 152. Xylometazoline Nasal spray 0.1% 153. Zinc Oxide Cream United State Pharmacopeia Name Dosage form Strength 1. Abatacept Injection 125 mg/ml 2. Actinomycin D Injection 10 mg/ml 3. Adalimumab Injection 10 mg/ml 4. Adapalene Cream/Gel 0.1% 5. Alendronate Tablet 70 mg 6. Alfuzocin Tablet 10 mg 7. Alprazolam Tablet 250 μg 8. Aluminium Hydroxide Tablet 500 mg 9. Anakinra Injection 150 mg/ml 10. Antacid containing (Aluminium Hydroxide, Magnesium Hydroxide, Simethicone, Calcium alginates) Mixture 11. Atazanavir Tablet 300 mg 12. Atomoxetine Tablet 10 mg, 25 mg, 40 mg 13. Azathioprine Injection 25 mg Tablet 25 mg 14. Belimumab Infusion 120 mg, 400 mg 15. Calcitonin Injection 100 units/ml 16. Capreomycin Injection 1 g 17. Carboplatin Injection 10 mg/ml 18. Cefixime Tablet 200 mg Suspension 20 mg/ml 19. Celecoxib Tablet 100 mg, 200 mg 20. Certolizumab Injection 200 mg/ml 21. Cervedilol Tablet 3.125 mg, 12.5 mg 22. Cetirizine Tablet 10 mg 23. Chloral Hydrate Tablet 707 mg Oral solution 28.66 mg/ml 24. Cholestyramine Oral powder 4 g 25. Cinnarizine Injection 15 mg 26. Citalopram Tablet 20 mg, 40 mg 27. Clobetasol Propionate Cream 0.05% 28. Clonazepam Hydrochloride Tablet 500 μg 29. Clonidine Tablet 25 μg, 100 μg 30. Clopidogrel Tablet 75 mg 31. Codeine containing cough preparations Syrup 32. Colchicine Tablet 500 μg 33. Copper Sulphate Stone 34. Cyclizine Injection 50 mg/ml Tablet 50 mg 35. Cyclobenzaprine Tablet 5 mg, 10 mg 36. Cycloserine Capsule 250 mg 37. Cyclosporine Injection 50 mg/ml Oral solution 100 mg/ml Tablet 10 mg, 25 mg 38. D-penicillamine Tablet 125 mg 39. Darbepoietin alfa Injection 250 μg 40. Denosumab Injection 60 mg/ml, 70 mg/ml 41. Desferrioxamine Injection 500 mg 42. Desmopressin Nasal spray 150 μg 43. Dextromethorphan containing cough preparations Syrup 44. Diloxanide Furoate Tablet 500 mg 45. Diphtheria Antitoxin Infusion 46. Doxorubucin Injection 2 mg/ml 47. Duloxetine Hydrochloride Tablet 20 mg, 30 mg 48. E45 Cream 49. Econazole Cream 1% 50. Entecavir Injection 50 μg/ml Tablet 500 μg 51. Epoietin beta Injection 2000 units, 10 000 units 52. Etanercept Injection 50 mg/ml 53. Ethanol Solution 10% 54. Ethionamide Tablet 500 mg 55. Ferric Sodium Gluconate complex Injection 62.5 mg elemental iron 56. Ferrous Gluconate Tablet 300 mg 57. Flupenthixol Decanoate Injection 20 mg/ml, 25 mg/ml 58. Fomepizole Injection 5 mg/ml 59. Fusidic Acid Cream 2% 60. Gabapentin Tablet 300 mg 61. Glycerol Suppository 1 g, 2 g, 4 g 62. Golimumab Injection 100 mg/ml 63. Guaifenesin containing experorant Syrup 64. Hydrochlorothiazide Tablet 12.5 mg, 25 mg 65. Hydroxychloroquine Tablet 200 mg 66. Hydroxymethyl Cellulose Eye drops 0.3% 67. Hypertonic Saline Injection 3% 68. Imiquimod Cream 5% 69. Indomethacin Tablet 25 mg, 75 mg 70. Infliximab Injection 100 mg 71. Intralipid Infusion 20% 72. Ipratropium Bromide Nebulizer 250 μg 73. Iron (III) Hydroxide Polymaltose Complex Suspension 100 mg elemental iron 74. Kanamycin Injection 500 mg/vial, 1 g/vial 75. Lamotrigine Dispersible tablet 25 mg Tablet 25 mg, 50 mg 76. Leflunomide Tablet 10 mg, 15 mg, 100 mg 77. Levofloxacin Tablet 500 mg 78. Malathoin Liquid 0.5% 79. Mefenamic Acid Tablet 500 mg 80. Melatonin Tablet modified release 2 mg 81. Methocarbamol Tablet 750 mg 82. Methoxy polyethylene glycol epoietin beta (pegylated form of Epo) Injection 100 μg/ml500 μg/ml 83. Methylprednisolone sodium succinate Infusion 500 mg, 1 g Methylprednisolone acetate Suspension for injection 40 mg/ml 84. Metoprolol Tartrate Tablet 50 mg, 100 mg 85. Miconazole + hydrocortisone Cream 2% + 1% 86. Milk of Magnesia Suspension 87. Minocycline Capsule modified release 100 mg 88. Mist. Potassium Citrate Solution 89. Mometasone Cream 0.1% 90. Montelukast Chewable tablet 4 mg, 5 mg Tablet 10 mg Granule 4 mg, 5 mg 91. Mupirocin Ointment 92. Mycophenolate mofetil Capsule 250 mg Injection 500 mg Suspension 200 mg/ml 93. Naproxen Tablet enteric coated 500 mg 94. Neomycin + Hydrocortisone Nasal drops 0.5% + 1.5% 95. Nitrous Oxide: Oxygen Inhalation 50: 50 96. Norfloxacin Tablet 400 mg 97. Oilatum Soap 98. Ondansetron Tablet 4 mg, 8 mg 99. Oxymetazoline Nasal spray 0.3% 100. Pamidronate Injection 6 mg/ml, 15 mg/ml 101. Pantoprazole Tablet 40 mg 102. Para-aminosalicylic acid Granule 4 mg 103. Paromomycin Suspension 125 mg/5 ml Capsule 250 mg 104. Pegylated inteferon alfa-2a Injection 180 μg/ml 105. Pegylated inteferon alfa-2b Powder for injection 50 μg, 80 μg 106. Permethrin Lotion 1% 107. Pneumococcal Conjugate Vaccine 13 (PCV13) Injection 108. Podophyllin Tincture of benzoin 10–25% 109. Podophylotoxin Solution 0.5% Cream 0.15% 110. Polygeline Infusion 3.5% 111. Polyvinyl Alcohol Eye drops 1.4%, 2% 112. Povidone Iodine Solution 10% 113. Pregabalin Tablet 50 mg, 100 mg 114. Probenecid Tablet 500 mg 115. Prostagladin E1 Injection 500 μg/ml Tablet 500 mg 116. Prothionamide Injection 250 mg 117. Purified Factor IX Injection 118. Purified Factor VIII Injection 119. Recombinant Factor IX Injection 120. Recombinant Factor VIII Injection 121. Ribavirin Tablet 200 mg, 400 mg 122. Rifaximin Tablet 200 mg, 550 mg 123. Rituximab Injection 10 mg/ml, 119.66 mg/ml 124. Salt-poor Human Albumin Solution 125. Saxagliptin Tablet 2.5 mg 126. Shea Butter Cream 127. Sildenafil Citrate Tablet 25 mg, 50 mg, 100 mg 128. Sitagliptin Tablet 25 mg 129. Sodium Aurothiomalate Injection 20 mg/ml, 100 mg/ml 130. Sodium Thiosulfate Injection 500 mg/ml 131. Strontium Ranelate Granule sachets 2 mg 132. Sulfasalazine Suspension 50 mg/ml Tablet 500 mg 133. Tacrolimus Injection 5 mg/ml Tablet 500 μg, 2 mg, 5 mg 134. Tadalafil Tablet 2.5 mg, 10 mg 135. Teriparatide Injection 20 μg 136. Tetracaine Hydrochloride Eye drops 0.5% 137. Tiotropium Bromide Inhaler (dry powder) 18 μg 138. Tizanidine Tablet 2 mg 139. Tocilizumab Injection 20 mg/ml, 180 mg/ml 140. Tofacitinib Tablet 5 mg, 11 mg 141. Tretinoin Gel 0.01% 142. Triamcinolone Injection 10 mg/ml, 40 mg/ml 143. Triazolam Tablet 125 μg, 250 μg 144. Trichloroacetic Acid Solution 80–90% 145. Valsartan Tablet 40 mg, 160 mg 146. Vancomycin Injection 500 mg 147. Verapamil Tablet 40 mg, 80 mg 148. Verdanafil Tablet 5 mg, 10 mg 149. Vildagliptin Tablet 50 mg 150. Vitamin B-Compound Injection (High potency) 151. Vitamin C Tablet 100 mg 152. Xylometazoline Nasal spray 0.1% 153. Zinc Oxide Cream United State Pharmacopeia Open in new tab Table 6 List of medicines added to the 2017 essential medicines list Name Dosage form Strength 1. Abatacept Injection 125 mg/ml 2. Actinomycin D Injection 10 mg/ml 3. Adalimumab Injection 10 mg/ml 4. Adapalene Cream/Gel 0.1% 5. Alendronate Tablet 70 mg 6. Alfuzocin Tablet 10 mg 7. Alprazolam Tablet 250 μg 8. Aluminium Hydroxide Tablet 500 mg 9. Anakinra Injection 150 mg/ml 10. Antacid containing (Aluminium Hydroxide, Magnesium Hydroxide, Simethicone, Calcium alginates) Mixture 11. Atazanavir Tablet 300 mg 12. Atomoxetine Tablet 10 mg, 25 mg, 40 mg 13. Azathioprine Injection 25 mg Tablet 25 mg 14. Belimumab Infusion 120 mg, 400 mg 15. Calcitonin Injection 100 units/ml 16. Capreomycin Injection 1 g 17. Carboplatin Injection 10 mg/ml 18. Cefixime Tablet 200 mg Suspension 20 mg/ml 19. Celecoxib Tablet 100 mg, 200 mg 20. Certolizumab Injection 200 mg/ml 21. Cervedilol Tablet 3.125 mg, 12.5 mg 22. Cetirizine Tablet 10 mg 23. Chloral Hydrate Tablet 707 mg Oral solution 28.66 mg/ml 24. Cholestyramine Oral powder 4 g 25. Cinnarizine Injection 15 mg 26. Citalopram Tablet 20 mg, 40 mg 27. Clobetasol Propionate Cream 0.05% 28. Clonazepam Hydrochloride Tablet 500 μg 29. Clonidine Tablet 25 μg, 100 μg 30. Clopidogrel Tablet 75 mg 31. Codeine containing cough preparations Syrup 32. Colchicine Tablet 500 μg 33. Copper Sulphate Stone 34. Cyclizine Injection 50 mg/ml Tablet 50 mg 35. Cyclobenzaprine Tablet 5 mg, 10 mg 36. Cycloserine Capsule 250 mg 37. Cyclosporine Injection 50 mg/ml Oral solution 100 mg/ml Tablet 10 mg, 25 mg 38. D-penicillamine Tablet 125 mg 39. Darbepoietin alfa Injection 250 μg 40. Denosumab Injection 60 mg/ml, 70 mg/ml 41. Desferrioxamine Injection 500 mg 42. Desmopressin Nasal spray 150 μg 43. Dextromethorphan containing cough preparations Syrup 44. Diloxanide Furoate Tablet 500 mg 45. Diphtheria Antitoxin Infusion 46. Doxorubucin Injection 2 mg/ml 47. Duloxetine Hydrochloride Tablet 20 mg, 30 mg 48. E45 Cream 49. Econazole Cream 1% 50. Entecavir Injection 50 μg/ml Tablet 500 μg 51. Epoietin beta Injection 2000 units, 10 000 units 52. Etanercept Injection 50 mg/ml 53. Ethanol Solution 10% 54. Ethionamide Tablet 500 mg 55. Ferric Sodium Gluconate complex Injection 62.5 mg elemental iron 56. Ferrous Gluconate Tablet 300 mg 57. Flupenthixol Decanoate Injection 20 mg/ml, 25 mg/ml 58. Fomepizole Injection 5 mg/ml 59. Fusidic Acid Cream 2% 60. Gabapentin Tablet 300 mg 61. Glycerol Suppository 1 g, 2 g, 4 g 62. Golimumab Injection 100 mg/ml 63. Guaifenesin containing experorant Syrup 64. Hydrochlorothiazide Tablet 12.5 mg, 25 mg 65. Hydroxychloroquine Tablet 200 mg 66. Hydroxymethyl Cellulose Eye drops 0.3% 67. Hypertonic Saline Injection 3% 68. Imiquimod Cream 5% 69. Indomethacin Tablet 25 mg, 75 mg 70. Infliximab Injection 100 mg 71. Intralipid Infusion 20% 72. Ipratropium Bromide Nebulizer 250 μg 73. Iron (III) Hydroxide Polymaltose Complex Suspension 100 mg elemental iron 74. Kanamycin Injection 500 mg/vial, 1 g/vial 75. Lamotrigine Dispersible tablet 25 mg Tablet 25 mg, 50 mg 76. Leflunomide Tablet 10 mg, 15 mg, 100 mg 77. Levofloxacin Tablet 500 mg 78. Malathoin Liquid 0.5% 79. Mefenamic Acid Tablet 500 mg 80. Melatonin Tablet modified release 2 mg 81. Methocarbamol Tablet 750 mg 82. Methoxy polyethylene glycol epoietin beta (pegylated form of Epo) Injection 100 μg/ml500 μg/ml 83. Methylprednisolone sodium succinate Infusion 500 mg, 1 g Methylprednisolone acetate Suspension for injection 40 mg/ml 84. Metoprolol Tartrate Tablet 50 mg, 100 mg 85. Miconazole + hydrocortisone Cream 2% + 1% 86. Milk of Magnesia Suspension 87. Minocycline Capsule modified release 100 mg 88. Mist. Potassium Citrate Solution 89. Mometasone Cream 0.1% 90. Montelukast Chewable tablet 4 mg, 5 mg Tablet 10 mg Granule 4 mg, 5 mg 91. Mupirocin Ointment 92. Mycophenolate mofetil Capsule 250 mg Injection 500 mg Suspension 200 mg/ml 93. Naproxen Tablet enteric coated 500 mg 94. Neomycin + Hydrocortisone Nasal drops 0.5% + 1.5% 95. Nitrous Oxide: Oxygen Inhalation 50: 50 96. Norfloxacin Tablet 400 mg 97. Oilatum Soap 98. Ondansetron Tablet 4 mg, 8 mg 99. Oxymetazoline Nasal spray 0.3% 100. Pamidronate Injection 6 mg/ml, 15 mg/ml 101. Pantoprazole Tablet 40 mg 102. Para-aminosalicylic acid Granule 4 mg 103. Paromomycin Suspension 125 mg/5 ml Capsule 250 mg 104. Pegylated inteferon alfa-2a Injection 180 μg/ml 105. Pegylated inteferon alfa-2b Powder for injection 50 μg, 80 μg 106. Permethrin Lotion 1% 107. Pneumococcal Conjugate Vaccine 13 (PCV13) Injection 108. Podophyllin Tincture of benzoin 10–25% 109. Podophylotoxin Solution 0.5% Cream 0.15% 110. Polygeline Infusion 3.5% 111. Polyvinyl Alcohol Eye drops 1.4%, 2% 112. Povidone Iodine Solution 10% 113. Pregabalin Tablet 50 mg, 100 mg 114. Probenecid Tablet 500 mg 115. Prostagladin E1 Injection 500 μg/ml Tablet 500 mg 116. Prothionamide Injection 250 mg 117. Purified Factor IX Injection 118. Purified Factor VIII Injection 119. Recombinant Factor IX Injection 120. Recombinant Factor VIII Injection 121. Ribavirin Tablet 200 mg, 400 mg 122. Rifaximin Tablet 200 mg, 550 mg 123. Rituximab Injection 10 mg/ml, 119.66 mg/ml 124. Salt-poor Human Albumin Solution 125. Saxagliptin Tablet 2.5 mg 126. Shea Butter Cream 127. Sildenafil Citrate Tablet 25 mg, 50 mg, 100 mg 128. Sitagliptin Tablet 25 mg 129. Sodium Aurothiomalate Injection 20 mg/ml, 100 mg/ml 130. Sodium Thiosulfate Injection 500 mg/ml 131. Strontium Ranelate Granule sachets 2 mg 132. Sulfasalazine Suspension 50 mg/ml Tablet 500 mg 133. Tacrolimus Injection 5 mg/ml Tablet 500 μg, 2 mg, 5 mg 134. Tadalafil Tablet 2.5 mg, 10 mg 135. Teriparatide Injection 20 μg 136. Tetracaine Hydrochloride Eye drops 0.5% 137. Tiotropium Bromide Inhaler (dry powder) 18 μg 138. Tizanidine Tablet 2 mg 139. Tocilizumab Injection 20 mg/ml, 180 mg/ml 140. Tofacitinib Tablet 5 mg, 11 mg 141. Tretinoin Gel 0.01% 142. Triamcinolone Injection 10 mg/ml, 40 mg/ml 143. Triazolam Tablet 125 μg, 250 μg 144. Trichloroacetic Acid Solution 80–90% 145. Valsartan Tablet 40 mg, 160 mg 146. Vancomycin Injection 500 mg 147. Verapamil Tablet 40 mg, 80 mg 148. Verdanafil Tablet 5 mg, 10 mg 149. Vildagliptin Tablet 50 mg 150. Vitamin B-Compound Injection (High potency) 151. Vitamin C Tablet 100 mg 152. Xylometazoline Nasal spray 0.1% 153. Zinc Oxide Cream United State Pharmacopeia Name Dosage form Strength 1. Abatacept Injection 125 mg/ml 2. Actinomycin D Injection 10 mg/ml 3. Adalimumab Injection 10 mg/ml 4. Adapalene Cream/Gel 0.1% 5. Alendronate Tablet 70 mg 6. Alfuzocin Tablet 10 mg 7. Alprazolam Tablet 250 μg 8. Aluminium Hydroxide Tablet 500 mg 9. Anakinra Injection 150 mg/ml 10. Antacid containing (Aluminium Hydroxide, Magnesium Hydroxide, Simethicone, Calcium alginates) Mixture 11. Atazanavir Tablet 300 mg 12. Atomoxetine Tablet 10 mg, 25 mg, 40 mg 13. Azathioprine Injection 25 mg Tablet 25 mg 14. Belimumab Infusion 120 mg, 400 mg 15. Calcitonin Injection 100 units/ml 16. Capreomycin Injection 1 g 17. Carboplatin Injection 10 mg/ml 18. Cefixime Tablet 200 mg Suspension 20 mg/ml 19. Celecoxib Tablet 100 mg, 200 mg 20. Certolizumab Injection 200 mg/ml 21. Cervedilol Tablet 3.125 mg, 12.5 mg 22. Cetirizine Tablet 10 mg 23. Chloral Hydrate Tablet 707 mg Oral solution 28.66 mg/ml 24. Cholestyramine Oral powder 4 g 25. Cinnarizine Injection 15 mg 26. Citalopram Tablet 20 mg, 40 mg 27. Clobetasol Propionate Cream 0.05% 28. Clonazepam Hydrochloride Tablet 500 μg 29. Clonidine Tablet 25 μg, 100 μg 30. Clopidogrel Tablet 75 mg 31. Codeine containing cough preparations Syrup 32. Colchicine Tablet 500 μg 33. Copper Sulphate Stone 34. Cyclizine Injection 50 mg/ml Tablet 50 mg 35. Cyclobenzaprine Tablet 5 mg, 10 mg 36. Cycloserine Capsule 250 mg 37. Cyclosporine Injection 50 mg/ml Oral solution 100 mg/ml Tablet 10 mg, 25 mg 38. D-penicillamine Tablet 125 mg 39. Darbepoietin alfa Injection 250 μg 40. Denosumab Injection 60 mg/ml, 70 mg/ml 41. Desferrioxamine Injection 500 mg 42. Desmopressin Nasal spray 150 μg 43. Dextromethorphan containing cough preparations Syrup 44. Diloxanide Furoate Tablet 500 mg 45. Diphtheria Antitoxin Infusion 46. Doxorubucin Injection 2 mg/ml 47. Duloxetine Hydrochloride Tablet 20 mg, 30 mg 48. E45 Cream 49. Econazole Cream 1% 50. Entecavir Injection 50 μg/ml Tablet 500 μg 51. Epoietin beta Injection 2000 units, 10 000 units 52. Etanercept Injection 50 mg/ml 53. Ethanol Solution 10% 54. Ethionamide Tablet 500 mg 55. Ferric Sodium Gluconate complex Injection 62.5 mg elemental iron 56. Ferrous Gluconate Tablet 300 mg 57. Flupenthixol Decanoate Injection 20 mg/ml, 25 mg/ml 58. Fomepizole Injection 5 mg/ml 59. Fusidic Acid Cream 2% 60. Gabapentin Tablet 300 mg 61. Glycerol Suppository 1 g, 2 g, 4 g 62. Golimumab Injection 100 mg/ml 63. Guaifenesin containing experorant Syrup 64. Hydrochlorothiazide Tablet 12.5 mg, 25 mg 65. Hydroxychloroquine Tablet 200 mg 66. Hydroxymethyl Cellulose Eye drops 0.3% 67. Hypertonic Saline Injection 3% 68. Imiquimod Cream 5% 69. Indomethacin Tablet 25 mg, 75 mg 70. Infliximab Injection 100 mg 71. Intralipid Infusion 20% 72. Ipratropium Bromide Nebulizer 250 μg 73. Iron (III) Hydroxide Polymaltose Complex Suspension 100 mg elemental iron 74. Kanamycin Injection 500 mg/vial, 1 g/vial 75. Lamotrigine Dispersible tablet 25 mg Tablet 25 mg, 50 mg 76. Leflunomide Tablet 10 mg, 15 mg, 100 mg 77. Levofloxacin Tablet 500 mg 78. Malathoin Liquid 0.5% 79. Mefenamic Acid Tablet 500 mg 80. Melatonin Tablet modified release 2 mg 81. Methocarbamol Tablet 750 mg 82. Methoxy polyethylene glycol epoietin beta (pegylated form of Epo) Injection 100 μg/ml500 μg/ml 83. Methylprednisolone sodium succinate Infusion 500 mg, 1 g Methylprednisolone acetate Suspension for injection 40 mg/ml 84. Metoprolol Tartrate Tablet 50 mg, 100 mg 85. Miconazole + hydrocortisone Cream 2% + 1% 86. Milk of Magnesia Suspension 87. Minocycline Capsule modified release 100 mg 88. Mist. Potassium Citrate Solution 89. Mometasone Cream 0.1% 90. Montelukast Chewable tablet 4 mg, 5 mg Tablet 10 mg Granule 4 mg, 5 mg 91. Mupirocin Ointment 92. Mycophenolate mofetil Capsule 250 mg Injection 500 mg Suspension 200 mg/ml 93. Naproxen Tablet enteric coated 500 mg 94. Neomycin + Hydrocortisone Nasal drops 0.5% + 1.5% 95. Nitrous Oxide: Oxygen Inhalation 50: 50 96. Norfloxacin Tablet 400 mg 97. Oilatum Soap 98. Ondansetron Tablet 4 mg, 8 mg 99. Oxymetazoline Nasal spray 0.3% 100. Pamidronate Injection 6 mg/ml, 15 mg/ml 101. Pantoprazole Tablet 40 mg 102. Para-aminosalicylic acid Granule 4 mg 103. Paromomycin Suspension 125 mg/5 ml Capsule 250 mg 104. Pegylated inteferon alfa-2a Injection 180 μg/ml 105. Pegylated inteferon alfa-2b Powder for injection 50 μg, 80 μg 106. Permethrin Lotion 1% 107. Pneumococcal Conjugate Vaccine 13 (PCV13) Injection 108. Podophyllin Tincture of benzoin 10–25% 109. Podophylotoxin Solution 0.5% Cream 0.15% 110. Polygeline Infusion 3.5% 111. Polyvinyl Alcohol Eye drops 1.4%, 2% 112. Povidone Iodine Solution 10% 113. Pregabalin Tablet 50 mg, 100 mg 114. Probenecid Tablet 500 mg 115. Prostagladin E1 Injection 500 μg/ml Tablet 500 mg 116. Prothionamide Injection 250 mg 117. Purified Factor IX Injection 118. Purified Factor VIII Injection 119. Recombinant Factor IX Injection 120. Recombinant Factor VIII Injection 121. Ribavirin Tablet 200 mg, 400 mg 122. Rifaximin Tablet 200 mg, 550 mg 123. Rituximab Injection 10 mg/ml, 119.66 mg/ml 124. Salt-poor Human Albumin Solution 125. Saxagliptin Tablet 2.5 mg 126. Shea Butter Cream 127. Sildenafil Citrate Tablet 25 mg, 50 mg, 100 mg 128. Sitagliptin Tablet 25 mg 129. Sodium Aurothiomalate Injection 20 mg/ml, 100 mg/ml 130. Sodium Thiosulfate Injection 500 mg/ml 131. Strontium Ranelate Granule sachets 2 mg 132. Sulfasalazine Suspension 50 mg/ml Tablet 500 mg 133. Tacrolimus Injection 5 mg/ml Tablet 500 μg, 2 mg, 5 mg 134. Tadalafil Tablet 2.5 mg, 10 mg 135. Teriparatide Injection 20 μg 136. Tetracaine Hydrochloride Eye drops 0.5% 137. Tiotropium Bromide Inhaler (dry powder) 18 μg 138. Tizanidine Tablet 2 mg 139. Tocilizumab Injection 20 mg/ml, 180 mg/ml 140. Tofacitinib Tablet 5 mg, 11 mg 141. Tretinoin Gel 0.01% 142. Triamcinolone Injection 10 mg/ml, 40 mg/ml 143. Triazolam Tablet 125 μg, 250 μg 144. Trichloroacetic Acid Solution 80–90% 145. Valsartan Tablet 40 mg, 160 mg 146. Vancomycin Injection 500 mg 147. Verapamil Tablet 40 mg, 80 mg 148. Verdanafil Tablet 5 mg, 10 mg 149. Vildagliptin Tablet 50 mg 150. Vitamin B-Compound Injection (High potency) 151. Vitamin C Tablet 100 mg 152. Xylometazoline Nasal spray 0.1% 153. Zinc Oxide Cream United State Pharmacopeia Open in new tab Table 7 List of medicines absent in 2017 essential medicines list Name Dosage Form Strength 1. 5-Fluorouracil Injection 50 mg/ml 2. 6-Mercaptopurine Tablet 50 mg 3. Atenolol +  Hydrochlorothiazide Tablet 100 mg + 25 mg 4. Atracurium Injection 10 mg/ml 5. Bleomycin Injection 15 units 6. Busulphan Tablet 2 mg 7. Calcium Carbonate Tablet 500 mg 8. Capecitabine Tablet 500 mg 9. Cefaclor Capsule 250 mg, 500 mg Suspension 125 mg/5 ml 250 mg/5 ml 10. Chlorambucil Tablet 11. Crisantaspase Injection 10 000 units 12. Crotamiton Lotion 10% 13. Cyclopentolate Eye drops 0.5%, 1%, 2% 14. Cytarabine Injection 100 mg 15. Dacarbazine Injection 100 mg 16. Daunorubicine Injection 50 mg 17. Didanosine Capsule 200 mg Oral solution 10 mg/ml Tablet 100 mg, 150 mg 18. Docetaxel Injection 20 mg/0.5 ml 19. Edrophonium Injection 10 mg/ml 20. Ergotamine Tartrate Tablet 1 mg, 2 mg 21. Estramustine Phosphate Capsule 140 mg, 280 mg 22. Ferrous Sulphate +  Folic Acid Tablet 60 mg + 250 μg 23. Fluvastatin Capsule 20 mg 24. Folinic Acid Injection 15 mg Tablet 15 mg 25. Gelatin Infusion (Succinylated Gelatin) 26. Gentian Violet Paint 27. Halothane Inhalation 250 ml 28. Imatinib Tablet 100 mg, 400 mg 29. Indinavir Tablet 400 mg 30. Isoflurane Inhalation 100 ml 31. Ketorolac Injection 30 mg/ml 32. Lindane Lotion 1% 33. Lodoxamide Eye drops 0.1% 34. Mercurochrome Solution 35. Methylcellulose Eye drops 1% 36. Mitoxantrone Injection 2 mg/ml 37. Natamycin Eye drops 5% 38. Nelfinavir Tablet 250 mg 39. Neomycin Tablet 500 mg 40. Neostigmine Injection 0.5 mg/ml, 2.5 mg/ml 41. Noradrenaline (Norepinephrine) Injection 1 mg/ml (1:1000) 42. Pancuronium Bromide Injection 2 mg/ml 43. Procarbazine Tablet 50 mg 44. Propofol Injection 10 mg/ml 45. Protamine Sulphate Injection 10 mg/ml 46. Ritonavir Capsule 100 mg 47. Rocuronium Injection 10 mg/ml 48. Rose Bengal Minims Solution 1% 49. Rosiglitazone Tablet 4 mg 50. Saquinavir Capsule 300 mg 51. Stavudine Capsule 15 mg, 20 mg, 30 mg, 40 mg Oral solution 1 mg/ml 52. Streptokinase Injection 100 000 units 250 000 units 750 000 units 53. Suxamethonium Succinylcholine Injection 50 mg/ml 54. Tirofiban Infusion 250 μg/ml 55. Tuberculin (Purified Protein Derivative) Injection 20 units/ml 56. Vecuronium Bromide Injection 10 mg Name Dosage Form Strength 1. 5-Fluorouracil Injection 50 mg/ml 2. 6-Mercaptopurine Tablet 50 mg 3. Atenolol +  Hydrochlorothiazide Tablet 100 mg + 25 mg 4. Atracurium Injection 10 mg/ml 5. Bleomycin Injection 15 units 6. Busulphan Tablet 2 mg 7. Calcium Carbonate Tablet 500 mg 8. Capecitabine Tablet 500 mg 9. Cefaclor Capsule 250 mg, 500 mg Suspension 125 mg/5 ml 250 mg/5 ml 10. Chlorambucil Tablet 11. Crisantaspase Injection 10 000 units 12. Crotamiton Lotion 10% 13. Cyclopentolate Eye drops 0.5%, 1%, 2% 14. Cytarabine Injection 100 mg 15. Dacarbazine Injection 100 mg 16. Daunorubicine Injection 50 mg 17. Didanosine Capsule 200 mg Oral solution 10 mg/ml Tablet 100 mg, 150 mg 18. Docetaxel Injection 20 mg/0.5 ml 19. Edrophonium Injection 10 mg/ml 20. Ergotamine Tartrate Tablet 1 mg, 2 mg 21. Estramustine Phosphate Capsule 140 mg, 280 mg 22. Ferrous Sulphate +  Folic Acid Tablet 60 mg + 250 μg 23. Fluvastatin Capsule 20 mg 24. Folinic Acid Injection 15 mg Tablet 15 mg 25. Gelatin Infusion (Succinylated Gelatin) 26. Gentian Violet Paint 27. Halothane Inhalation 250 ml 28. Imatinib Tablet 100 mg, 400 mg 29. Indinavir Tablet 400 mg 30. Isoflurane Inhalation 100 ml 31. Ketorolac Injection 30 mg/ml 32. Lindane Lotion 1% 33. Lodoxamide Eye drops 0.1% 34. Mercurochrome Solution 35. Methylcellulose Eye drops 1% 36. Mitoxantrone Injection 2 mg/ml 37. Natamycin Eye drops 5% 38. Nelfinavir Tablet 250 mg 39. Neomycin Tablet 500 mg 40. Neostigmine Injection 0.5 mg/ml, 2.5 mg/ml 41. Noradrenaline (Norepinephrine) Injection 1 mg/ml (1:1000) 42. Pancuronium Bromide Injection 2 mg/ml 43. Procarbazine Tablet 50 mg 44. Propofol Injection 10 mg/ml 45. Protamine Sulphate Injection 10 mg/ml 46. Ritonavir Capsule 100 mg 47. Rocuronium Injection 10 mg/ml 48. Rose Bengal Minims Solution 1% 49. Rosiglitazone Tablet 4 mg 50. Saquinavir Capsule 300 mg 51. Stavudine Capsule 15 mg, 20 mg, 30 mg, 40 mg Oral solution 1 mg/ml 52. Streptokinase Injection 100 000 units 250 000 units 750 000 units 53. Suxamethonium Succinylcholine Injection 50 mg/ml 54. Tirofiban Infusion 250 μg/ml 55. Tuberculin (Purified Protein Derivative) Injection 20 units/ml 56. Vecuronium Bromide Injection 10 mg Open in new tab Table 7 List of medicines absent in 2017 essential medicines list Name Dosage Form Strength 1. 5-Fluorouracil Injection 50 mg/ml 2. 6-Mercaptopurine Tablet 50 mg 3. Atenolol +  Hydrochlorothiazide Tablet 100 mg + 25 mg 4. Atracurium Injection 10 mg/ml 5. Bleomycin Injection 15 units 6. Busulphan Tablet 2 mg 7. Calcium Carbonate Tablet 500 mg 8. Capecitabine Tablet 500 mg 9. Cefaclor Capsule 250 mg, 500 mg Suspension 125 mg/5 ml 250 mg/5 ml 10. Chlorambucil Tablet 11. Crisantaspase Injection 10 000 units 12. Crotamiton Lotion 10% 13. Cyclopentolate Eye drops 0.5%, 1%, 2% 14. Cytarabine Injection 100 mg 15. Dacarbazine Injection 100 mg 16. Daunorubicine Injection 50 mg 17. Didanosine Capsule 200 mg Oral solution 10 mg/ml Tablet 100 mg, 150 mg 18. Docetaxel Injection 20 mg/0.5 ml 19. Edrophonium Injection 10 mg/ml 20. Ergotamine Tartrate Tablet 1 mg, 2 mg 21. Estramustine Phosphate Capsule 140 mg, 280 mg 22. Ferrous Sulphate +  Folic Acid Tablet 60 mg + 250 μg 23. Fluvastatin Capsule 20 mg 24. Folinic Acid Injection 15 mg Tablet 15 mg 25. Gelatin Infusion (Succinylated Gelatin) 26. Gentian Violet Paint 27. Halothane Inhalation 250 ml 28. Imatinib Tablet 100 mg, 400 mg 29. Indinavir Tablet 400 mg 30. Isoflurane Inhalation 100 ml 31. Ketorolac Injection 30 mg/ml 32. Lindane Lotion 1% 33. Lodoxamide Eye drops 0.1% 34. Mercurochrome Solution 35. Methylcellulose Eye drops 1% 36. Mitoxantrone Injection 2 mg/ml 37. Natamycin Eye drops 5% 38. Nelfinavir Tablet 250 mg 39. Neomycin Tablet 500 mg 40. Neostigmine Injection 0.5 mg/ml, 2.5 mg/ml 41. Noradrenaline (Norepinephrine) Injection 1 mg/ml (1:1000) 42. Pancuronium Bromide Injection 2 mg/ml 43. Procarbazine Tablet 50 mg 44. Propofol Injection 10 mg/ml 45. Protamine Sulphate Injection 10 mg/ml 46. Ritonavir Capsule 100 mg 47. Rocuronium Injection 10 mg/ml 48. Rose Bengal Minims Solution 1% 49. Rosiglitazone Tablet 4 mg 50. Saquinavir Capsule 300 mg 51. Stavudine Capsule 15 mg, 20 mg, 30 mg, 40 mg Oral solution 1 mg/ml 52. Streptokinase Injection 100 000 units 250 000 units 750 000 units 53. Suxamethonium Succinylcholine Injection 50 mg/ml 54. Tirofiban Infusion 250 μg/ml 55. Tuberculin (Purified Protein Derivative) Injection 20 units/ml 56. Vecuronium Bromide Injection 10 mg Name Dosage Form Strength 1. 5-Fluorouracil Injection 50 mg/ml 2. 6-Mercaptopurine Tablet 50 mg 3. Atenolol +  Hydrochlorothiazide Tablet 100 mg + 25 mg 4. Atracurium Injection 10 mg/ml 5. Bleomycin Injection 15 units 6. Busulphan Tablet 2 mg 7. Calcium Carbonate Tablet 500 mg 8. Capecitabine Tablet 500 mg 9. Cefaclor Capsule 250 mg, 500 mg Suspension 125 mg/5 ml 250 mg/5 ml 10. Chlorambucil Tablet 11. Crisantaspase Injection 10 000 units 12. Crotamiton Lotion 10% 13. Cyclopentolate Eye drops 0.5%, 1%, 2% 14. Cytarabine Injection 100 mg 15. Dacarbazine Injection 100 mg 16. Daunorubicine Injection 50 mg 17. Didanosine Capsule 200 mg Oral solution 10 mg/ml Tablet 100 mg, 150 mg 18. Docetaxel Injection 20 mg/0.5 ml 19. Edrophonium Injection 10 mg/ml 20. Ergotamine Tartrate Tablet 1 mg, 2 mg 21. Estramustine Phosphate Capsule 140 mg, 280 mg 22. Ferrous Sulphate +  Folic Acid Tablet 60 mg + 250 μg 23. Fluvastatin Capsule 20 mg 24. Folinic Acid Injection 15 mg Tablet 15 mg 25. Gelatin Infusion (Succinylated Gelatin) 26. Gentian Violet Paint 27. Halothane Inhalation 250 ml 28. Imatinib Tablet 100 mg, 400 mg 29. Indinavir Tablet 400 mg 30. Isoflurane Inhalation 100 ml 31. Ketorolac Injection 30 mg/ml 32. Lindane Lotion 1% 33. Lodoxamide Eye drops 0.1% 34. Mercurochrome Solution 35. Methylcellulose Eye drops 1% 36. Mitoxantrone Injection 2 mg/ml 37. Natamycin Eye drops 5% 38. Nelfinavir Tablet 250 mg 39. Neomycin Tablet 500 mg 40. Neostigmine Injection 0.5 mg/ml, 2.5 mg/ml 41. Noradrenaline (Norepinephrine) Injection 1 mg/ml (1:1000) 42. Pancuronium Bromide Injection 2 mg/ml 43. Procarbazine Tablet 50 mg 44. Propofol Injection 10 mg/ml 45. Protamine Sulphate Injection 10 mg/ml 46. Ritonavir Capsule 100 mg 47. Rocuronium Injection 10 mg/ml 48. Rose Bengal Minims Solution 1% 49. Rosiglitazone Tablet 4 mg 50. Saquinavir Capsule 300 mg 51. Stavudine Capsule 15 mg, 20 mg, 30 mg, 40 mg Oral solution 1 mg/ml 52. Streptokinase Injection 100 000 units 250 000 units 750 000 units 53. Suxamethonium Succinylcholine Injection 50 mg/ml 54. Tirofiban Infusion 250 μg/ml 55. Tuberculin (Purified Protein Derivative) Injection 20 units/ml 56. Vecuronium Bromide Injection 10 mg Open in new tab Stakeholder engagement for the second draft STGs and accompanying EML The GNDP organized a stakeholder meeting for the draft STGs and EML 10 January 2017 to build consensus, ownership and legitimize the outcome. A broader stakeholder of 95 participants (Figure 3) subjected the second draft STGs and accompanying EML to further review. Since the EML informs the NHIA medicines list, public procurement and use at different levels of care, discussions on EML attracted large participants. During the meeting, service providers contested some proposed level of care and requested changes (summarized in Table 8). At stakeholder engagements, the NMSC and GNDP did not exert their influence on service providers and stakeholders rather collective decisions were made based on information from research and practice adapted to reflect Ghana’s healthcare structure needs. Table 8 Request for medicines recategorization by stakeholders during the review process Request for medicines recategorizations approved at the second stakeholders meeting (10 January 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Injection Dexamethasone 4 mg/ml C M A service provider noted that with the provision of equipment for obstetric ultrasound scanning at health centres and some CHPS posts to estimate gestational age and eligibility for Dexamethasone 4 mg/ml injection, Dexamethasone injection be moved to a lower level Midwives at health centres and CHPS can administer Injection Metronidazole 5 mg/ml B2 B1 Service providers advocated use of Metronidazole 5 mg/ml injection at lower healthcare delivery level for pre-referral treatment of pre-term labour Injection Magnesium Sulphate 50% C M In order to facilitate pre-referral treatment of severe pre-eclampsia and eclampsia, Ma Injection Calcium Gluconate 100 mg/ml C B2 As a safety measure for Magnesium Sulphate toxicity Health centres with doctors to manage Magnesium Sulphate toxicity Gel Chlorhexidine Gluconate 4% M A To allow access at the lowest healthcare level for other medical procedures Request for medicines recategorization approved during negotiations with Physician Assistants (9 March 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Tablet Bendroflumethiazide 5 mg B2 B1 To improve access to healthcare and medicines especially in the rural areas. Allow physician assistants to management more disease conditions Physician assistants are to refer patients to higher level health facilities if necessary Tablet Metformin 500 mg Tablet Glibenclamide 5 mg Injection Metronidazole 5 mg/ml Tablet Griseofulvin 125 mg, 500 mg Some medicines for managing chronic conditions such as diabetes (e.g. Metformin 500 mg tablet, Glibenclamide 5 mg tablet) and hypertension (e.g. Bendroflumethiazide 5 mg tablet) moved from Level B2 to Level B1 to improve access to medicines. In addition, some antibiotics categorized by WHO as ‘ACCESS’ group (World Health Organization, 2017) such as Amoxicillin + Clavulanic Acid and Benzyl Penicillin moved from Level B2 to Level B1 Capsule Tetracycline 250 mg Injection Benzyl Penicillin 1 MU, 5 MU Injection Amoxicillin + Clavulanic Acid 500 mg + 100 mg Tablet Amoxicillin + Clavulanic Acid 250 mg + 125 mg 500 mg + 125 mg Suspension amoxicillin + clavulanic acid 250 mg + 62.5 mg 400 mg + 57 mg Tablet Prednisolone 5 mg Tablet Omeprazole 40 mg D B1 Tablet Methyldopa 250 mg B2 M Clotrimazole Pessary 100 mg Suspension Nystatin 100 000 IU/ml Clotrimazole Cream 1%, 2% B2 A Tablet Cetirizine 10 mg Not listed A Request for medicines recategorization denied during negotiations with Physician Assistants (9 March 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Injection Artesunate 60 mg B2 B2 To improve access to healthcare and medicines especially in the rural areas. Allow physician assistants to management more disease conditions. Physician assistants are to refer patients to higher level health facilities if necessary Injection Artemether 80 mg/ml Injection Quinine 300 mg/ml Infusion Ciprofloxacin 2 mg/ml Antibiotics such as injections Ciprofloxacin and Ceftriaxone maintained Levels B2 and Level C respectively, because Ciprofloxacin and Ceftriaxone categorized by WHO as ‘WATCH’ group (World Health Organization, 2017) must be guarded against potential misuse and abuse Tablet Lisinopril 2.5 mg, 5 mg, 10 mg Injection Aminophylline 250 mg/10 ml Tablet Amlodipine 5 mg, 10 mg Tablet Propranolol 10 mg, 40 mg, 80 mg Tablet Atenolol 25 mg, 50 mg, Tablet Atenolol 100 mg C B2 Suspension Cefuroxime 125 mg/5 ml Injection Cefuroxime 750 mg, 1.50 mg Tablet Cefuroxime 125 mg, 250 mg Capsule Azithromycin 250 mg C C Injection Ceftriaxone 250 mg, 1 g, 2 g Request for medicines recategorization approved during negotiations with NHIA (13 September 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Tablet Nifedipine 10 mg, 20 mg (slow release) B2 B2 Under section 11.1 of draft EML 2017 Anti-anginal Drugs, these medicines with the same strengths and formulation are classified as B2 but under section 11.3 Anti-hypertensive Drugs, these same medicines are classified as M Nifedipine under section 11.3 moved to Level B2. Methyldopa categorized for Level M can be used at that level of care Tablet Calcium 500 mg Not stated B2 In the draft EML 2017, both Tablet Calcium 500 mg and Calcium + Vitamin D were categorized as M Calcium supplement is indicated for Rheumatoid Arthritis in the 2017 STG. Calcium 500 mg is moved to Level ‘B2’ for orthopaedic cases while Calcium + Vitamin D is maintained at Level M Tablet Calcium 97 mg + Vitamin D 10 μg C M The Calcium Tablet is more expensive (0.50 GHC/tablet) than the Calcium + Vitamin D (0.05 GHC/tablet). Providers, including the maternity homes tend to bill the NHIA with the price for Calcium 500 mg for antenatal care, however, they may have supplied the Calcium + Vitamin D Request for medicines recategorization denied during negotiations with NHIA (13 September 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Gel Diclofenac 1% A/M M The draft EML 2017 categorized Diclofenac 1% gel as B1. The livelihood of most indigenous people is farming, and other heavy duty works. Diclofenac gel would be very useful in alleviating the aches. It should be made available at the lowest level (which is level A) since they are found in the deprived areas. Moved to Level M (Midwifery and CHPS post with a midwife) Tablet Co-Trimoxazole 400 mg + 80 mg B1 A Looking at the adverse effects of Co-trimoxazole, one may wonder if health personnel at Level A could be able to handle the potential side effects. Adverse effects include seizure, hyperkalaemia, agranulocytosis, hyponatraemia, immune hypersensitive reaction, and Stevens-Johnson syndrome. Recommend recategorization to B1 Maintain at Level A. Decision is based on recommendations from the Ministry of HealthCo-trimoxazole is used at CHPS posts for reproductive interventions Pessary Clotrimazole 100 mg B2/M M Recommend recategorization to A. To cater for patients with candidiasis in the deprived areas where the only health facility within the closest proximity is a CHPS post Currently, Level M includes CHPS posts with Midwife. For this reason, Clotrimazole pessary is maintained at Level M Shampoo Selenium Sulphide 2.5% C C Recommend Levels A or M. Skin infections like Tinea Versicolor, Dandruff and Seborrhoea are usually predominant in the deprived areas where health issues pertaining to personal hygiene and sanitation are high Selenium Sulphide is maintained at Level C. Another antifungal such as Nystatin cream is available at Level M Injection Anti-Snake Serum (West African Polyvalent) 1500 IU/ml B1 B1 Deprived areas have recorded high rates of snake attacks and bites. Anti-snake serum can be very useful at level A to reduce mortality, which may arise due to inability of patients to get to the higher level of care when that facility is far. Health personnel in the lower levels can be trained to prescribe and administer. Storage equipment should be provided as well Appropriate use and storage facility are important. The current level of care—B1 will have storage facilities and expertise to administer the serum. Anti-snake maintained at Level B1 Injection Pethidine 50 mg/ml B2 B2 The injectable opioids on the list (e.g. pethidine and morphine injection) at Level B2 should be reviewed upwards to Level C. These injectable medicines have the potential to affect breathing, so patients need to be monitored Pethidine maintained at Level B2 (Health Centre with a doctor) Request for medicines recategorizations approved at the second stakeholders meeting (10 January 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Injection Dexamethasone 4 mg/ml C M A service provider noted that with the provision of equipment for obstetric ultrasound scanning at health centres and some CHPS posts to estimate gestational age and eligibility for Dexamethasone 4 mg/ml injection, Dexamethasone injection be moved to a lower level Midwives at health centres and CHPS can administer Injection Metronidazole 5 mg/ml B2 B1 Service providers advocated use of Metronidazole 5 mg/ml injection at lower healthcare delivery level for pre-referral treatment of pre-term labour Injection Magnesium Sulphate 50% C M In order to facilitate pre-referral treatment of severe pre-eclampsia and eclampsia, Ma Injection Calcium Gluconate 100 mg/ml C B2 As a safety measure for Magnesium Sulphate toxicity Health centres with doctors to manage Magnesium Sulphate toxicity Gel Chlorhexidine Gluconate 4% M A To allow access at the lowest healthcare level for other medical procedures Request for medicines recategorization approved during negotiations with Physician Assistants (9 March 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Tablet Bendroflumethiazide 5 mg B2 B1 To improve access to healthcare and medicines especially in the rural areas. Allow physician assistants to management more disease conditions Physician assistants are to refer patients to higher level health facilities if necessary Tablet Metformin 500 mg Tablet Glibenclamide 5 mg Injection Metronidazole 5 mg/ml Tablet Griseofulvin 125 mg, 500 mg Some medicines for managing chronic conditions such as diabetes (e.g. Metformin 500 mg tablet, Glibenclamide 5 mg tablet) and hypertension (e.g. Bendroflumethiazide 5 mg tablet) moved from Level B2 to Level B1 to improve access to medicines. In addition, some antibiotics categorized by WHO as ‘ACCESS’ group (World Health Organization, 2017) such as Amoxicillin + Clavulanic Acid and Benzyl Penicillin moved from Level B2 to Level B1 Capsule Tetracycline 250 mg Injection Benzyl Penicillin 1 MU, 5 MU Injection Amoxicillin + Clavulanic Acid 500 mg + 100 mg Tablet Amoxicillin + Clavulanic Acid 250 mg + 125 mg 500 mg + 125 mg Suspension amoxicillin + clavulanic acid 250 mg + 62.5 mg 400 mg + 57 mg Tablet Prednisolone 5 mg Tablet Omeprazole 40 mg D B1 Tablet Methyldopa 250 mg B2 M Clotrimazole Pessary 100 mg Suspension Nystatin 100 000 IU/ml Clotrimazole Cream 1%, 2% B2 A Tablet Cetirizine 10 mg Not listed A Request for medicines recategorization denied during negotiations with Physician Assistants (9 March 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Injection Artesunate 60 mg B2 B2 To improve access to healthcare and medicines especially in the rural areas. Allow physician assistants to management more disease conditions. Physician assistants are to refer patients to higher level health facilities if necessary Injection Artemether 80 mg/ml Injection Quinine 300 mg/ml Infusion Ciprofloxacin 2 mg/ml Antibiotics such as injections Ciprofloxacin and Ceftriaxone maintained Levels B2 and Level C respectively, because Ciprofloxacin and Ceftriaxone categorized by WHO as ‘WATCH’ group (World Health Organization, 2017) must be guarded against potential misuse and abuse Tablet Lisinopril 2.5 mg, 5 mg, 10 mg Injection Aminophylline 250 mg/10 ml Tablet Amlodipine 5 mg, 10 mg Tablet Propranolol 10 mg, 40 mg, 80 mg Tablet Atenolol 25 mg, 50 mg, Tablet Atenolol 100 mg C B2 Suspension Cefuroxime 125 mg/5 ml Injection Cefuroxime 750 mg, 1.50 mg Tablet Cefuroxime 125 mg, 250 mg Capsule Azithromycin 250 mg C C Injection Ceftriaxone 250 mg, 1 g, 2 g Request for medicines recategorization approved during negotiations with NHIA (13 September 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Tablet Nifedipine 10 mg, 20 mg (slow release) B2 B2 Under section 11.1 of draft EML 2017 Anti-anginal Drugs, these medicines with the same strengths and formulation are classified as B2 but under section 11.3 Anti-hypertensive Drugs, these same medicines are classified as M Nifedipine under section 11.3 moved to Level B2. Methyldopa categorized for Level M can be used at that level of care Tablet Calcium 500 mg Not stated B2 In the draft EML 2017, both Tablet Calcium 500 mg and Calcium + Vitamin D were categorized as M Calcium supplement is indicated for Rheumatoid Arthritis in the 2017 STG. Calcium 500 mg is moved to Level ‘B2’ for orthopaedic cases while Calcium + Vitamin D is maintained at Level M Tablet Calcium 97 mg + Vitamin D 10 μg C M The Calcium Tablet is more expensive (0.50 GHC/tablet) than the Calcium + Vitamin D (0.05 GHC/tablet). Providers, including the maternity homes tend to bill the NHIA with the price for Calcium 500 mg for antenatal care, however, they may have supplied the Calcium + Vitamin D Request for medicines recategorization denied during negotiations with NHIA (13 September 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Gel Diclofenac 1% A/M M The draft EML 2017 categorized Diclofenac 1% gel as B1. The livelihood of most indigenous people is farming, and other heavy duty works. Diclofenac gel would be very useful in alleviating the aches. It should be made available at the lowest level (which is level A) since they are found in the deprived areas. Moved to Level M (Midwifery and CHPS post with a midwife) Tablet Co-Trimoxazole 400 mg + 80 mg B1 A Looking at the adverse effects of Co-trimoxazole, one may wonder if health personnel at Level A could be able to handle the potential side effects. Adverse effects include seizure, hyperkalaemia, agranulocytosis, hyponatraemia, immune hypersensitive reaction, and Stevens-Johnson syndrome. Recommend recategorization to B1 Maintain at Level A. Decision is based on recommendations from the Ministry of HealthCo-trimoxazole is used at CHPS posts for reproductive interventions Pessary Clotrimazole 100 mg B2/M M Recommend recategorization to A. To cater for patients with candidiasis in the deprived areas where the only health facility within the closest proximity is a CHPS post Currently, Level M includes CHPS posts with Midwife. For this reason, Clotrimazole pessary is maintained at Level M Shampoo Selenium Sulphide 2.5% C C Recommend Levels A or M. Skin infections like Tinea Versicolor, Dandruff and Seborrhoea are usually predominant in the deprived areas where health issues pertaining to personal hygiene and sanitation are high Selenium Sulphide is maintained at Level C. Another antifungal such as Nystatin cream is available at Level M Injection Anti-Snake Serum (West African Polyvalent) 1500 IU/ml B1 B1 Deprived areas have recorded high rates of snake attacks and bites. Anti-snake serum can be very useful at level A to reduce mortality, which may arise due to inability of patients to get to the higher level of care when that facility is far. Health personnel in the lower levels can be trained to prescribe and administer. Storage equipment should be provided as well Appropriate use and storage facility are important. The current level of care—B1 will have storage facilities and expertise to administer the serum. Anti-snake maintained at Level B1 Injection Pethidine 50 mg/ml B2 B2 The injectable opioids on the list (e.g. pethidine and morphine injection) at Level B2 should be reviewed upwards to Level C. These injectable medicines have the potential to affect breathing, so patients need to be monitored Pethidine maintained at Level B2 (Health Centre with a doctor) Open in new tab Table 8 Request for medicines recategorization by stakeholders during the review process Request for medicines recategorizations approved at the second stakeholders meeting (10 January 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Injection Dexamethasone 4 mg/ml C M A service provider noted that with the provision of equipment for obstetric ultrasound scanning at health centres and some CHPS posts to estimate gestational age and eligibility for Dexamethasone 4 mg/ml injection, Dexamethasone injection be moved to a lower level Midwives at health centres and CHPS can administer Injection Metronidazole 5 mg/ml B2 B1 Service providers advocated use of Metronidazole 5 mg/ml injection at lower healthcare delivery level for pre-referral treatment of pre-term labour Injection Magnesium Sulphate 50% C M In order to facilitate pre-referral treatment of severe pre-eclampsia and eclampsia, Ma Injection Calcium Gluconate 100 mg/ml C B2 As a safety measure for Magnesium Sulphate toxicity Health centres with doctors to manage Magnesium Sulphate toxicity Gel Chlorhexidine Gluconate 4% M A To allow access at the lowest healthcare level for other medical procedures Request for medicines recategorization approved during negotiations with Physician Assistants (9 March 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Tablet Bendroflumethiazide 5 mg B2 B1 To improve access to healthcare and medicines especially in the rural areas. Allow physician assistants to management more disease conditions Physician assistants are to refer patients to higher level health facilities if necessary Tablet Metformin 500 mg Tablet Glibenclamide 5 mg Injection Metronidazole 5 mg/ml Tablet Griseofulvin 125 mg, 500 mg Some medicines for managing chronic conditions such as diabetes (e.g. Metformin 500 mg tablet, Glibenclamide 5 mg tablet) and hypertension (e.g. Bendroflumethiazide 5 mg tablet) moved from Level B2 to Level B1 to improve access to medicines. In addition, some antibiotics categorized by WHO as ‘ACCESS’ group (World Health Organization, 2017) such as Amoxicillin + Clavulanic Acid and Benzyl Penicillin moved from Level B2 to Level B1 Capsule Tetracycline 250 mg Injection Benzyl Penicillin 1 MU, 5 MU Injection Amoxicillin + Clavulanic Acid 500 mg + 100 mg Tablet Amoxicillin + Clavulanic Acid 250 mg + 125 mg 500 mg + 125 mg Suspension amoxicillin + clavulanic acid 250 mg + 62.5 mg 400 mg + 57 mg Tablet Prednisolone 5 mg Tablet Omeprazole 40 mg D B1 Tablet Methyldopa 250 mg B2 M Clotrimazole Pessary 100 mg Suspension Nystatin 100 000 IU/ml Clotrimazole Cream 1%, 2% B2 A Tablet Cetirizine 10 mg Not listed A Request for medicines recategorization denied during negotiations with Physician Assistants (9 March 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Injection Artesunate 60 mg B2 B2 To improve access to healthcare and medicines especially in the rural areas. Allow physician assistants to management more disease conditions. Physician assistants are to refer patients to higher level health facilities if necessary Injection Artemether 80 mg/ml Injection Quinine 300 mg/ml Infusion Ciprofloxacin 2 mg/ml Antibiotics such as injections Ciprofloxacin and Ceftriaxone maintained Levels B2 and Level C respectively, because Ciprofloxacin and Ceftriaxone categorized by WHO as ‘WATCH’ group (World Health Organization, 2017) must be guarded against potential misuse and abuse Tablet Lisinopril 2.5 mg, 5 mg, 10 mg Injection Aminophylline 250 mg/10 ml Tablet Amlodipine 5 mg, 10 mg Tablet Propranolol 10 mg, 40 mg, 80 mg Tablet Atenolol 25 mg, 50 mg, Tablet Atenolol 100 mg C B2 Suspension Cefuroxime 125 mg/5 ml Injection Cefuroxime 750 mg, 1.50 mg Tablet Cefuroxime 125 mg, 250 mg Capsule Azithromycin 250 mg C C Injection Ceftriaxone 250 mg, 1 g, 2 g Request for medicines recategorization approved during negotiations with NHIA (13 September 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Tablet Nifedipine 10 mg, 20 mg (slow release) B2 B2 Under section 11.1 of draft EML 2017 Anti-anginal Drugs, these medicines with the same strengths and formulation are classified as B2 but under section 11.3 Anti-hypertensive Drugs, these same medicines are classified as M Nifedipine under section 11.3 moved to Level B2. Methyldopa categorized for Level M can be used at that level of care Tablet Calcium 500 mg Not stated B2 In the draft EML 2017, both Tablet Calcium 500 mg and Calcium + Vitamin D were categorized as M Calcium supplement is indicated for Rheumatoid Arthritis in the 2017 STG. Calcium 500 mg is moved to Level ‘B2’ for orthopaedic cases while Calcium + Vitamin D is maintained at Level M Tablet Calcium 97 mg + Vitamin D 10 μg C M The Calcium Tablet is more expensive (0.50 GHC/tablet) than the Calcium + Vitamin D (0.05 GHC/tablet). Providers, including the maternity homes tend to bill the NHIA with the price for Calcium 500 mg for antenatal care, however, they may have supplied the Calcium + Vitamin D Request for medicines recategorization denied during negotiations with NHIA (13 September 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Gel Diclofenac 1% A/M M The draft EML 2017 categorized Diclofenac 1% gel as B1. The livelihood of most indigenous people is farming, and other heavy duty works. Diclofenac gel would be very useful in alleviating the aches. It should be made available at the lowest level (which is level A) since they are found in the deprived areas. Moved to Level M (Midwifery and CHPS post with a midwife) Tablet Co-Trimoxazole 400 mg + 80 mg B1 A Looking at the adverse effects of Co-trimoxazole, one may wonder if health personnel at Level A could be able to handle the potential side effects. Adverse effects include seizure, hyperkalaemia, agranulocytosis, hyponatraemia, immune hypersensitive reaction, and Stevens-Johnson syndrome. Recommend recategorization to B1 Maintain at Level A. Decision is based on recommendations from the Ministry of HealthCo-trimoxazole is used at CHPS posts for reproductive interventions Pessary Clotrimazole 100 mg B2/M M Recommend recategorization to A. To cater for patients with candidiasis in the deprived areas where the only health facility within the closest proximity is a CHPS post Currently, Level M includes CHPS posts with Midwife. For this reason, Clotrimazole pessary is maintained at Level M Shampoo Selenium Sulphide 2.5% C C Recommend Levels A or M. Skin infections like Tinea Versicolor, Dandruff and Seborrhoea are usually predominant in the deprived areas where health issues pertaining to personal hygiene and sanitation are high Selenium Sulphide is maintained at Level C. Another antifungal such as Nystatin cream is available at Level M Injection Anti-Snake Serum (West African Polyvalent) 1500 IU/ml B1 B1 Deprived areas have recorded high rates of snake attacks and bites. Anti-snake serum can be very useful at level A to reduce mortality, which may arise due to inability of patients to get to the higher level of care when that facility is far. Health personnel in the lower levels can be trained to prescribe and administer. Storage equipment should be provided as well Appropriate use and storage facility are important. The current level of care—B1 will have storage facilities and expertise to administer the serum. Anti-snake maintained at Level B1 Injection Pethidine 50 mg/ml B2 B2 The injectable opioids on the list (e.g. pethidine and morphine injection) at Level B2 should be reviewed upwards to Level C. These injectable medicines have the potential to affect breathing, so patients need to be monitored Pethidine maintained at Level B2 (Health Centre with a doctor) Request for medicines recategorizations approved at the second stakeholders meeting (10 January 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Injection Dexamethasone 4 mg/ml C M A service provider noted that with the provision of equipment for obstetric ultrasound scanning at health centres and some CHPS posts to estimate gestational age and eligibility for Dexamethasone 4 mg/ml injection, Dexamethasone injection be moved to a lower level Midwives at health centres and CHPS can administer Injection Metronidazole 5 mg/ml B2 B1 Service providers advocated use of Metronidazole 5 mg/ml injection at lower healthcare delivery level for pre-referral treatment of pre-term labour Injection Magnesium Sulphate 50% C M In order to facilitate pre-referral treatment of severe pre-eclampsia and eclampsia, Ma Injection Calcium Gluconate 100 mg/ml C B2 As a safety measure for Magnesium Sulphate toxicity Health centres with doctors to manage Magnesium Sulphate toxicity Gel Chlorhexidine Gluconate 4% M A To allow access at the lowest healthcare level for other medical procedures Request for medicines recategorization approved during negotiations with Physician Assistants (9 March 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Tablet Bendroflumethiazide 5 mg B2 B1 To improve access to healthcare and medicines especially in the rural areas. Allow physician assistants to management more disease conditions Physician assistants are to refer patients to higher level health facilities if necessary Tablet Metformin 500 mg Tablet Glibenclamide 5 mg Injection Metronidazole 5 mg/ml Tablet Griseofulvin 125 mg, 500 mg Some medicines for managing chronic conditions such as diabetes (e.g. Metformin 500 mg tablet, Glibenclamide 5 mg tablet) and hypertension (e.g. Bendroflumethiazide 5 mg tablet) moved from Level B2 to Level B1 to improve access to medicines. In addition, some antibiotics categorized by WHO as ‘ACCESS’ group (World Health Organization, 2017) such as Amoxicillin + Clavulanic Acid and Benzyl Penicillin moved from Level B2 to Level B1 Capsule Tetracycline 250 mg Injection Benzyl Penicillin 1 MU, 5 MU Injection Amoxicillin + Clavulanic Acid 500 mg + 100 mg Tablet Amoxicillin + Clavulanic Acid 250 mg + 125 mg 500 mg + 125 mg Suspension amoxicillin + clavulanic acid 250 mg + 62.5 mg 400 mg + 57 mg Tablet Prednisolone 5 mg Tablet Omeprazole 40 mg D B1 Tablet Methyldopa 250 mg B2 M Clotrimazole Pessary 100 mg Suspension Nystatin 100 000 IU/ml Clotrimazole Cream 1%, 2% B2 A Tablet Cetirizine 10 mg Not listed A Request for medicines recategorization denied during negotiations with Physician Assistants (9 March 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Injection Artesunate 60 mg B2 B2 To improve access to healthcare and medicines especially in the rural areas. Allow physician assistants to management more disease conditions. Physician assistants are to refer patients to higher level health facilities if necessary Injection Artemether 80 mg/ml Injection Quinine 300 mg/ml Infusion Ciprofloxacin 2 mg/ml Antibiotics such as injections Ciprofloxacin and Ceftriaxone maintained Levels B2 and Level C respectively, because Ciprofloxacin and Ceftriaxone categorized by WHO as ‘WATCH’ group (World Health Organization, 2017) must be guarded against potential misuse and abuse Tablet Lisinopril 2.5 mg, 5 mg, 10 mg Injection Aminophylline 250 mg/10 ml Tablet Amlodipine 5 mg, 10 mg Tablet Propranolol 10 mg, 40 mg, 80 mg Tablet Atenolol 25 mg, 50 mg, Tablet Atenolol 100 mg C B2 Suspension Cefuroxime 125 mg/5 ml Injection Cefuroxime 750 mg, 1.50 mg Tablet Cefuroxime 125 mg, 250 mg Capsule Azithromycin 250 mg C C Injection Ceftriaxone 250 mg, 1 g, 2 g Request for medicines recategorization approved during negotiations with NHIA (13 September 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Tablet Nifedipine 10 mg, 20 mg (slow release) B2 B2 Under section 11.1 of draft EML 2017 Anti-anginal Drugs, these medicines with the same strengths and formulation are classified as B2 but under section 11.3 Anti-hypertensive Drugs, these same medicines are classified as M Nifedipine under section 11.3 moved to Level B2. Methyldopa categorized for Level M can be used at that level of care Tablet Calcium 500 mg Not stated B2 In the draft EML 2017, both Tablet Calcium 500 mg and Calcium + Vitamin D were categorized as M Calcium supplement is indicated for Rheumatoid Arthritis in the 2017 STG. Calcium 500 mg is moved to Level ‘B2’ for orthopaedic cases while Calcium + Vitamin D is maintained at Level M Tablet Calcium 97 mg + Vitamin D 10 μg C M The Calcium Tablet is more expensive (0.50 GHC/tablet) than the Calcium + Vitamin D (0.05 GHC/tablet). Providers, including the maternity homes tend to bill the NHIA with the price for Calcium 500 mg for antenatal care, however, they may have supplied the Calcium + Vitamin D Request for medicines recategorization denied during negotiations with NHIA (13 September 2017) Medicines Level of care categorization, 2010 Level of care categorization, 2017 Motivator and rationale for request Comment Gel Diclofenac 1% A/M M The draft EML 2017 categorized Diclofenac 1% gel as B1. The livelihood of most indigenous people is farming, and other heavy duty works. Diclofenac gel would be very useful in alleviating the aches. It should be made available at the lowest level (which is level A) since they are found in the deprived areas. Moved to Level M (Midwifery and CHPS post with a midwife) Tablet Co-Trimoxazole 400 mg + 80 mg B1 A Looking at the adverse effects of Co-trimoxazole, one may wonder if health personnel at Level A could be able to handle the potential side effects. Adverse effects include seizure, hyperkalaemia, agranulocytosis, hyponatraemia, immune hypersensitive reaction, and Stevens-Johnson syndrome. Recommend recategorization to B1 Maintain at Level A. Decision is based on recommendations from the Ministry of HealthCo-trimoxazole is used at CHPS posts for reproductive interventions Pessary Clotrimazole 100 mg B2/M M Recommend recategorization to A. To cater for patients with candidiasis in the deprived areas where the only health facility within the closest proximity is a CHPS post Currently, Level M includes CHPS posts with Midwife. For this reason, Clotrimazole pessary is maintained at Level M Shampoo Selenium Sulphide 2.5% C C Recommend Levels A or M. Skin infections like Tinea Versicolor, Dandruff and Seborrhoea are usually predominant in the deprived areas where health issues pertaining to personal hygiene and sanitation are high Selenium Sulphide is maintained at Level C. Another antifungal such as Nystatin cream is available at Level M Injection Anti-Snake Serum (West African Polyvalent) 1500 IU/ml B1 B1 Deprived areas have recorded high rates of snake attacks and bites. Anti-snake serum can be very useful at level A to reduce mortality, which may arise due to inability of patients to get to the higher level of care when that facility is far. Health personnel in the lower levels can be trained to prescribe and administer. Storage equipment should be provided as well Appropriate use and storage facility are important. The current level of care—B1 will have storage facilities and expertise to administer the serum. Anti-snake maintained at Level B1 Injection Pethidine 50 mg/ml B2 B2 The injectable opioids on the list (e.g. pethidine and morphine injection) at Level B2 should be reviewed upwards to Level C. These injectable medicines have the potential to affect breathing, so patients need to be monitored Pethidine maintained at Level B2 (Health Centre with a doctor) Open in new tab Negotiations with an interest group and institution After the stakeholder meeting in January 2017, the GNDP and NMSC further negotiated with an organized professional health group and representatives of the NHIA who sought to consolidate their influence and preserve their interest. First, the Ghana Physician Assistants Association requested a meeting with the GNDP to negotiate an increase in the number of medicines allowed at their level of care (Level B1). The physician assistants group representatives could not attend the January 2017 stakeholder meeting but later made suggestions to the GNDP for consideration. At the meeting on 9 March 2017, the physician assistants argued that as trained prescribers, they usually manage health centres in the rural areas and current EML places limits on their service delivery capabilities. Taking into account the hierarchical structure of the health system and the gatekeeper system where lower levels health facilities are to provide basic primary care and refer clients to higher level if necessary, the NMSC made some concessions. Table 8 summarizes the physician assistant’s request and NMSC decisions. The NHIA provider payment directorate recommended few changes to the final draft EML and requested a meeting with the GNDP officials to discuss their concerns. The NHIA concerns related to management of possible side effects, reimbursement cost and access to essential medicines especially in hard to reach areas usually served by CHPS posts (Table 8). Post-review stage The editorial committee proofread the draft STGs and EML to ensure standardized format and accuracy. The NMSC members then signed off the edited STGs and EML for ministerial approval. As per the national procurement law (Act 663), the GNDP sought invoices for three publishing companies. The procurement and supplies directorate of the MoH awarded a contract to Yamens Press Limited to print copies of the STGs and EML. The Minister of Health officially launched the documents on 4 October 2017 in Accra. During the launch, the chairperson proposed creation of a ‘standing committee’ or technical advisory committee in selected institutions to constantly evaluate and disseminate new data in between major national STGs and EML review process and advocated for adherence to the guidelines and essential medicines policies. In addition, the chair asked government and development partners to provide funds for STGs/EML review promptly to avoid rather long process because of insufficient funds and sporadic funding arrangement. The NMSC dissolved after the Minister of Health launched the published 2017 STGs and accompanying EML. Discussion The Ghanaian national STGs and accompanying EML review process is predominately evidence-based drawing on information provided by the NMSC, evidence summaries group and GNDP, and then adapted to reflect Ghana’s healthcare structure needs as informed by experts, stakeholders, service providers and professional groups. The review process involved actors with varied power sources who in different arenas influenced the process and how the content of the previous edition evolved. The review process occurred between bureaucratic (committee plenary sessions, management group meetings) and public arenas (stakeholder engagements) (Grindle and Thomas, 1991) where varied actors whether NMSC members or service providers influenced decisions. In the bureaucratic arena, the NMSC chair and members, evidence summaries group and GNDP reviewed the 2010 edition STGs/EML and considered the country’s disease burden, public health relevance, hierarchical health service delivery and evidence from research and practice on the safety, efficacy and cost-effectiveness of the treatment options. To build consensus and ensure credibility and acceptance (World Health Organization, 2002), treatment options and list of essential medicines generated from the STGs were subjected to discussions in public arenas. During these stakeholder engagements, whether organized as part of the scheduled review process or a request by specific groups such as the physician assistants group, service providers subjected the recommended treatment options and medicines list to further scrutiny. Service providers considered their experience from practice and how the new guidelines would impact their practice. In such public arenas, technical discussions move towards negotiations between the policymakers and implementers with emphasis on effect of changing health service delivery in terms of tasking shifting and continuous training of health professional to provide additional care and the practicability of the policy. Therefore, training of health professionals to provide reproductive healthcare at the lowest level of care (i.e. CHPS posts) and challenges of irrational use of medicines such as the concomitant use of same class of medicine for pain relief were some issues that influenced medicines categorization and notes for treatment options, respectively. Additionally, medicines for specific treatment options aligned to levels of care within the Ghanaian hierarchical health system. Aligning treatment options and medicines to level of care according to the National Medicines Policy (Ministry of Health, 2017b) aims to promote responsible use of medicines and encourage referral and adherence to the gatekeeper system where lower levels health facilities are to provide basic primary care and refer clients to higher levels if necessary. The categorization of medicines for ‘Level A’ and ‘Level M’ evolved to reflect national strategic plan for reproductive health and human resources training at the lowest level of the health system (Ministry of Health, 2016a,b). One may question whether findings and description of the Ghanaian process of reviewing its 2010 STGs/EML are generalizable. However, when you look at other studies (Laing et al., 2003; Mori et al., 2014; Perumal-Pillay and Suleman, 2017; Osorio-de-Castro et al., 2018), there are fundamental similarities and context-specific difference in how STGs/EML policies are reviewed. The review process of EML for Ghana, South Africa, Brazil, Tanzania and the WHO model list has similarities in the following aspects. One, the medicine selection expert members are multidisciplinary and are appointed or inaugurated or established by a higher authority such as the Minister of Health, MoH or Director General in the case of WHO. Two, all expert members declare potential conflict of interest during the review process. Three, evidence-based considerations on safety, efficacy, cost-effectiveness as well as expert opinions and experiences influenced medicines selection. Although the approach and level of evidence from research and practice may differ, there are some evidence-based considerations. Finally, the recommended medicine lists of the expert members are subjected to stakeholder comments and scrutiny and this is to accommodate different stakeholder perspectives (Laing et al., 2003; Mori et al., 2014; Perumal-Pillay and Suleman, 2017; Osorio-de-Castro et al., 2018). The review process in Ghana differs from South Africa in terms of expert members’ nomination. In South Africa, a notice of call for nomination is advertised at provincial and departmental levels, department of health intranet, national department of health internal and external webpages and in newspapers. Criteria for selection include a practitioner in a public sector hospital with an expertise in one of the following: internal medicine, psychiatry, pharmacology, public health, rational use of medicines, evidence-based medicines, health economics and bioethics. Field, capacity and geographical mix in provincial representation of each individual is considered (Perumal-Pillay and Suleman, 2017). While in Ghana, nominations are not widely advertised rather Curriculum Vitae of pervious experts are solicited and the management group on recommendations from existing NMSC members nominates new experts based on their availability and expertise on the country’s disease pattern and emerging public health trends. Additionally, the national EML committee of South Africa has four subcommittees, which are the technical review committees for primary healthcare, adult hospital level, paediatric hospital level and tertiary/quaternary level. These subcommittees undertake literature review and critical appraisal of evidence for the review of STGs/EML for those levels and make recommendations to the national committee. In Ghana, the GNDP and evidence summaries group support the NMSC with literature review and critical appraisal of evidence. Furthermore, the NMSC categorizes the national essential medicines according to the different levels of care of the healthcare system. The WHO publishes clear explanations and evidence for decisions (Laing et al., 2003), similarly in Brazil electronically submitted inclusion proposal for evaluation are made public on the MoH website (Osorio-de-Castro et al., 2018) and this transparency approach is yet to be adopted by Ghana. Additionally, the WHO EML does not necessarily generate from its treatments guidelines because of the apparent disconnect between selection decisions made by WHO expert committees and those made by WHO expert creating treatment guidelines (Laing et al., 2003). However, there are measures by the WHO to coordinate the timing of publication of both WHO guidelines and EML to minimize unintended delays and improve consistency and alignment (World Health Organization, 2017). In Ghana, the national EML reflects treatment guidelines recommended in the STGs to promote access to medicine at all levels of care (Ministry of Health, 2017a,c). Challenges The Ghanaian review process had challenges. Since 1988, when Ghana’s first Essential Drugs List and National Formulary with Therapeutic Guidelines was published, the average period for the next edition is ∼5 years and this is more than twice the National Medicines Policy recommended review period of 2 years (Ministry of Health, 1988, 2004b). The WHO model list of essential medicines, which serves as a guide for the development of national and institutional essential medicine lists is updated and revised every 2 years by the WHO expert committee on selection and use of medicines (World Health Organization, 2002). Additionally, the review process is long due to insufficient funds, intermittent funding flow to the GNDP and securing the availability of potential NMSC members. Lessons learnt and way forward STGs serve as one of the means by which quality of care can be provided for patients seeking healthcare as it documents well-established methods of prevention, diagnosis and treatment of common diseases seen in health facilities. The research provides information to service providers and policy change advocates on how reviewers and participating stakeholders interact and discuss issues relating to disease conditions and medicines in Ghana. Selection of medicines in Ghana which engages all relevant stakeholders to arrive at a medicines list that address a majority of common medical conditions affecting the majority of the population is critical given that medicines are categorized on level of care for use and access. The use of multidisciplinary reviewers and varied stakeholders lends to legitimacy and acceptance of the STGs/EML. Although the STGs and EML guide diagnosis, institutional medicines list, public procurement and the NHIA medicines list and benefit package tariff, there is little information on actual use of the STGs in health facilities in Ghana and its impact on rational use of medicines indicators. Studies are therefore required to assess the extent to which service providers use the treatment options stipulated in the STGs and adhere to the EML. In the future, an NMSC ‘standing committee’ with clear selection criteria and process, sustained financial support for the review process, evidence-centred database and publicizing the review process are necessary. A future consideration that will potentially increase access, reduce printing costs and allow for a ‘living’ continually updated STGs/EML is to make the STGs/EML available in an electronic format. Conclusions The Ghanaian national STGs and EML review processes are complex and based on evidence and consensus. The NMSC members, evidence summaries group and GNDP influenced the review process and content within bureaucratic arenas through mainly technical discussions. When drafts STGs/EML recommended by the NMSC were subjected to stakeholder discussions, service providers and professional groups influenced the process and content within a public arena mainly through negotiations and consensus building. 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Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Use of evidence and negotiation in the review of national standard treatment guidelines and essential medicines list: experience from Ghana
JF - Health Policy and Planning
DO - 10.1093/heapol/czz107
DA - 2019-11-01
UR - https://www.deepdyve.com/lp/oxford-university-press/use-of-evidence-and-negotiation-in-the-review-of-national-standard-mExj4xS5JA
SP - ii104
VL - 34
IS - Supplement_2
DP - DeepDyve
ER -