What medicines do we really need in Canada?

Canadians often express pride in our universal health system, which provides publicly-funded doctor and hospital services. We don’t have to worry about filing for bankruptcy to get care when we need it.

But when it comes to prescription medications, our health system comes up short.

That’s because most medications outside of the hospital setting aren’t covered by the health system. Canadians must rely on private drug insurance or pay for sometimes costly medications themselves. Some provinces offer prescription drug coverage to certain populations — low income citizens or seniors, for example — but still one in five Canadians report that a member of their household can’t afford medications.

That means many Canadians aren’t getting the medicine they need — and the consequences can be devastating.

So how can we make sure Canadians have better access to prescription medications? We could improve the health of Canadians by facilitating access to a carefully selected set of essential medicines.

The World Health Organization (WHO) has developed a model list of essential medicines designed to meet the core needs of people. It recommends that each nation adapt the list to local circumstances and facilitate access to the medications.

In a recent article in the Canadian Medical Association Journal Open, my colleagues and I adapt the WHO’s list based on Canadian guidelines and input from Canadian clinicians.

Hundreds of countries have essential medicines lists and we can learn from their successes and challenges. These include highincome countries like Sweden, which has more than a decade of good experience with its Wise List, middle-income countries like India and low income countries from Armenia to Zimbabwe.

In addition to providing patients with critical medications when they need them, an essential medicines list helps make sure patients are getting the right medicine.

How? More than 10,000 pharmaceutical products are approved for sale in Canada, and public formularies, which determine which medicines to fund for some groups (welfare recipients, people with disabilities and older adults), contain 3,000 to 5,000 medicines. That’s a lot of information to track.

With a short list of essential medicines, there’s less likelihood of error and confusion because patients, doctors and pharmacists only need to know about a small number of medicines.

Critics might argue an essential medicines list could limit choice and access to important new prescription medications. But we may not have as many choices as we think. Are we offered choice when there’s such an overwhelming list of products that health practitioners can’t possibly keep up? Prescribing decisions are too often based on the beliefs and habits of the health practitioner holding the pen — which might be based on the best available evidence but is often based on messages in pharmaceutical marketing campaigns.

When was the last time a doctor explained the pros and cons of each of the 11 ACE inhibitor blood pressure medicines and asked the patient which they would like to take? What would the doctor even say given that there are no important differences between the medicines?

Governments often have a tough time saying no to drug companies that have made a product similar to a previously-approved drug because they might be asked, “Why did you approve that company’s product but not ours?” So these me-too products proliferate and we end up with a large number of medications that do the same thing.

The people who can’t afford medicines now are forced to make difficult choices. Nobody should have to decide whether to pay the rent or buy food, or take a life-saving medication for high blood pressure, diabetes or HIV-AIDS. And that’s happening in Canada.

How can our governments afford to pay for essential medicines?

A short list of elite medicines could actually help us save money by focusing competition on fewer products, which we could purchase in larger quantities. Less could mean more bargaining power.

Prescription medicines only have their intended benefits when they’re accessible and prescribed appropriately. Developing a list of essential medicines in Canada and publicly funding them could promote progress on both fronts.