An evaluation of the adequacy of Indian national and state Essential Medicines Lists (EMLs) for palliative care medical needs - a comparative analysis

Abstract

AbstractObjectivesEssential Medicines Lists (EMLs) guide the public sector procurement and supply of medications to impact access to adequate and appropriate palliative care drugs. This study evaluates the adequacy of India’s national and sub-national EMLs that can directly impact palliative care for 5.4 million patients.MethodsIn this qualitative document review, we compared Indian national, and state EMLs acquired from official government websites with the International Association for Hospice & Palliative Care (IAHPC) EML recommendations. We analysed data on the indication and formulation of drugs under the different categories of formulations present (all, some, and no), and drugs absent. Literature review and inputs from palliative care experts provided alternatives of absent medications to assess the adequacy of lists in managing the symptoms listed by IAPHC.ResultsWe analysed 3 national and 25 state lists for 33 recommended drugs. The Central Government Health Services list had the maximum availability of all formulations of drugs (16 [48%]) nationally. Among states and union territories, the Delhi EML was the closest to IAHPC with 17 (52%) drugs with all formulations present. Nagaland had the most incomplete EML with only 3 (9%) drugs with all formulations present. No EML had all the recommended formulations of morphine. In one national and sixteen state EMLs, oral morphine was absent.ConclusionWhile Indian EMLs lack drugs for palliative care when compared with the IAHPC EML, symptom management is adequate. There is a need for countries with limited resources to modify the IAPHC list for their settings.What is already known on this topicEssential Medicines Lists (EMLs) are instrumental in guiding public sector procurement of drugs. The implementation of EMLs is known to improve drug availability and prescription practices. The rising burden of people requiring end-of-life care globally necessitates the availability of appropriate drugs for the medical management of symptoms, which can be achieved through their inclusion in local EMLs.What this study addsThe national and sub-national EMLs of India do not fully adhere to the International Association for Hospice and Palliative Care (IAHPC) recommendations. However, they contain adequate drugs for the management of the listed symptoms. Additionally, the inclusion of various formulations of morphine remains a challenge to be addressed.How this study might affect research, practice or policyThis study highlights the need to develop a fit-for-purpose EML for palliative care, taking into account the geographical variations in palliative care needs, and resource constraints in healthcare delivery at the state and country level.