Availability, prices and affordability of essential medicines for treatment of diabetes and hypertension in private pharmacies in Zambia

Access to essential medicines used in the management of noncommunicable diseases in Southern Ethiopia: Analysis using WHO/HAI methodology

Objectives

This study aims to assess access to essential medicines used in the management of noncommunicable diseases through analysis of the availability, prices, and affordability of these essential medicines in Arba Minch town, Gamo Zone, Southern Ethiopia.

Methods

A cross-sectional design was carried out using the World Health Organization/health action international methodology between 2 March and 2 May 2023, within public and private healthcare facilities located in Arba Minch town, Southern Ethiopia. The median price ratio served as a metric. Statistical tests like the Shapiro-Wilk and Kolmogorov-Smirnov were utilized to assess the normal distribution of price data. The Wilcoxon-Mann-Whitney U test was also employed to compare median buyer's prices (patient prices) between public and private healthcare institutions. Treatment affordability was determined by estimating the number of days' wages required by the lowest-paid government employee in Ethiopia to afford the prescribed medication regimen.

Results

Among 23 health facilities surveyed, the pooled availability of essential medicine used in the management of noncommunicable diseases was 18.7% (range: 0%-30.1%), with the public and private facilities contributing 16.3% and 38.3%, respectively. The overall percentage of availability originator brand versions was 1.1% for overall health sectors, 0.6% for public sectors, and 1.2% for private sectors. The overall percent availability of lowest price generics was 36.2% (range: 0%-26.2%; public: 32.0%; private: 37.1%). Only seven lowest price generics satisfied the World Health Organization target of 80% and above. The overall median price of lowest price generic medicines in private was two times higher than in public sectors. The top five median price scorers were amlodipine, furosemide, insulin, beclomethasone, and salbutamol. The Mann-Whitney U test showed that 11.6% of lowest price generics medicines had a statistically significant median price disparity between the public and private sectors (p < 0.05). The overall percent of unaffordability was found to be 100.0%, (public: 70.4; private: 100.0%).

Conclusions

This study revealed the limited availability and potential financial burdens on patients seeking essential noncommunicable disease medications. Limited availability suggests the need for better supply chain management and consistent stock availability. The price disparities and affordability challenges identified underscore the necessity for policy interventions such as price regulation and subsidized programs to ensure equitable access to essential noncommunicable disease medications in Arba Minch town, Southern Ethiopia.

Multiple cardiovascular risk factor care in 55 low- and middle-income countries: A cross-sectional analysis of nationally-representative, individual-level data from 280,783 adults

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009-2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40-69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8-66.4]) than those with hypertension only (47.4% [45.3-49.6]) or diabetes only (46.7% [44.1-49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8-41.8] using antihypertensive and 42.3% [95% CI: 39.4-45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1-27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4-18.8]), followed by diabetes (13.3% [10.7-15.8]) and hypertension-diabetes (6.6% [5.4-7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors.

Productivity-adjusted life-years and correlates of uncontrolled hypertension at two health facilities in Zambia

BACKGROUND

Hypertension has in the recent past surfaced as one of the conditions that has a significant impact on workforce productivity in emerging economies. Zambia is no different and has in the recent past recorded increasing cases. Despite the impact of hypertension being of great importance in regards to productivity, we have scarcity of data and studies on hypertension-related Productivity-Adjusted Life-Years (PALYs) in Zambia and Africa at large. This study assessed the impact of hypertension on PALYs lost and socioeconomic factors associated with nonadherence to antihypertensive medication (NATAM).

METHODS

This was a cross-sectional study of 198 participants from Livingstone University Teaching Hospital and Maramba Clinic situated in Livingstone, Zambia. Structured questionnaires were used to collect data. Productivity index multiplied by years lived was used to calculate PALYs and descriptive statistics were used to summarize sociodemographic, clinical and economic variables. Multivariable logistic regression was used to determine factors associated with NATAM.

RESULTS

The participants had a median age (interquartile range (IQR)) of 49 years (41, 59) and 60.1% (n = 119) were females while 39.9% (n = 79) were male. Our estimated PALYs lost per person due to hypertension were 0.2 (IQR 0.0, 2.7). Cumulative PALYs value lost due to the burden of hypertension was estimated to be at $871,239.58 in gross domestic product (GDP). The prevalence of NATAM was 48% (n = 95). The factors that were significantly associated with NATAM were age (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.90, 0.98), female sex (OR 2.52; 95%CI 1.18, 5.40), self-employment (OR 2.57; 95%CI 1.02, 6.45) and absenteeism from work (OR 3.60; 95%CI 1.16, 11.22).

CONCLUSIONS

Findings in our study highlight a high economic loss of PALYs due to hypertension with a potential to impact GDP negatively. We also found that NATAM reduced productivity and income among individuals of working age further impacting PALYs lost due to hypertension. The factors associated with NATAM were age, sex, employment status and absenteeism from work. This study underscores the need for interventions targeting young people, females, self-employed individuals, and absentees at work to improve adherence to antihypertensive drugs in order to reduce PALYs lost due to hypertension.

A desktop review of evaluation of implementation of national medicines policies in SADC countries

A national medicine policy (NMP), formerly referred to as a national drug policy (NDP) is a document that serves as a political commitment and guide for action by the government to provide safe, efficacious, quality assured, available, affordable and rationally used medicines. This is the first study to review the implemented components of the NMPs of the 16 South African Development Community (SADC) countries over the past ten years (2011-2021). Information published between 2011 and 2021 of each country such as pharmaceutical profiles, official government documents, WHO/HAI/World Bank datasets and research studies on the implemented components were appraised. Significant progress has been made by 16 SADC countries over the period 2011-2021 in implementing the NMP. The most commonly implemented components included the concept of essential medicines, pricing, and regulation. Though traditional and herbal medicines component is yet to be implemented by the majority. The pharmacist-patient ratio of 1:2300 was below the target for all countries, prompting the need to strengthen the pharmacy personnel in the healthcare systems. Medicine pricing, affordability, and availability studies are necessary to develop equitable pricing policies that will improve the accessibility of medicines in all countries and the SADC region. With the exception of the Republic of Tanzania, SADC countries need to urgently revise their NMPs, thus adopting progressive processes such as incorporating Health Technology Assessment (HTA) in the NMP. All SADC countries require a strong, internationalistic evaluation culture built-in their policy formulation. As the first study to investigate the implemented NMPs in the SADC region, it could serve as a springboard for the countries to address their common pharmaceutical challenges thus improving their readiness for universal health coverage (UHC). Future in-depth cross-country studies in the SADC region are necessary to comprehensively evaluate the implemented components of NMPs.

Implementing essential diagnostics-learning from essential medicines: A scoping review

The World Health Organization (WHO) model list of Essential In vitro Diagnostic (EDL) introduced in 2018 complements the established Essential Medicines List (EML) and improves its impact on advancing universal health coverage and better health outcomes. We conducted a scoping review of the literature on implementing the WHO essential lists in Africa to inform the implementation of the recently introduced EDL. We searched eight electronic databases for studies reporting on implementing the WHO EDL and EML in Africa. Two authors independently conducted study selection and data extraction, with disagreements resolved through discussion. We used the Supporting the Use of Research Evidence (SURE) framework to extract themes and synthesised findings using thematic content analysis. We used the Mixed Method Appraisal Tool (MMAT) version 2018 to assess the quality of included studies. We included 172 studies reporting on EDL and EML after screening 3,813 articles titles and abstracts and 1,545 full-text papers. Most (75%, n = 129) studies were purely quantitative in design, comprising descriptive cross-sectional designs (60%, n = 104), 15% (n = 26) were purely qualitative, and 10% (n = 17) had mixed-methods approaches. There were no qualitative or randomised experimental studies about EDL. The main barrier facing the EML and EDL was poorly equipped health facilities-including unavailability or stock-outs of essential in vitro diagnostics and medicines. Financial and non-financial incentives to health facilities and workers were key enablers in implementing the EML; however, their impact differed from one context to another. Only fifty-six (33%) of the included studies were of high quality. Poorly equipped and stocked health facilities remain an implementation barrier to essential diagnostics and medicines. Health system interventions such as financial and non-financial incentives to improve their availability can be applied in different contexts. More implementation study designs, such as experimental and qualitative studies, are required to evaluate the effectiveness of essential lists.

A national, multicentre web-based point prevalence survey of antimicrobial use in community healthcare centres across South Africa and the implications

OBJECTIVE

Up to 90% of antimicrobials globally are prescribed and dispensed in ambulatory care. However, there are considerable gaps regarding the extent and rationale for their use especially in low- and middle-income countries such as South Africa. Point prevalent surveys (PPS) are useful to determine current prescribing patterns, identify targets for quality improvement and evaluate the effectiveness of antimicrobial stewardship programmes (ASPs) within institutions. Consequently, the objective of this study was to undertake a PPS within community healthcare centers (CHCs) in South Africa given their importance to the public healthcare system. The findings will be used to provide guidance on future interventions to improve antimicrobial use in South Africa and wider.

METHODS

A PPS of antimicrobial consumption was undertaken among patients attending 18 CHCs in South Africa. A web-based application was used to record the utilization data, with utilization assessed against World Health Organization (WHO) and South African guidelines.

RESULTS

The overall prevalence of antimicrobial use amongst patients attending the CHCs was 21.5% (420 of 1958 patients). This included one or more antimicrobials per patient. The most frequently prescribed antimicrobials were amoxicillin (32.9%), isoniazide (11.3%) and a combination of rifampicin, isoniazid, pyrazinamide and ethambutol (Rifafour®) (10.5%), with the majority from the WHO Access list of antibiotics. There was high adherence to guidelines (93.4%). The most common indication for antibiotics were ear, nose and throat infections (22.8%), with no culture results recorded in patients' files.

CONCLUSIONS

It's encouraging to see high adherence to South African guidelines when antimicrobials were prescribed, with the majority taken from the WHO Access list. However, there were concerns with appreciable prescribing of antimicrobials for upper respiratory tract infections that are essentially viral in origin, and a lack of microbiological testing. The establishment of ASPs can help address identified concerns through designing and implementing appropriate interventions.

The Case for Integrating Health Systems to Manage Noncommunicable and Infectious Diseases in Low- and Middle-Income Countries: Lessons Learned From Zambia

Noncommunicable diseases (NCDs) are the leading cause of death in the world, and 80% of all NCD deaths occur in low- and middle-income countries (LMICs). The COVID-19 pandemic has demonstrated that patients with NCDs are at increased risk of becoming severely ill from the virus. Disproportionate investment in vertical health programs can result in health systems vulnerable to collapse when resources are strained, such as during pandemics. Although NCDs are largely preventable, globally there is underinvestment in efforts to address them. Integrating health systems to collectively address NCDs and infectious diseases through a wide range of services in a comprehensive manner reduces the economic burden of healthcare and strengthens the healthcare system. Health system resiliency is essential for health security. In this article, we provide an economically sound approach to incorporating NCDs into routine healthcare services in LMICs through improved alignment of institutions that support prevention and control of both NCDs and infectious diseases. Examples from Zambia's multisector interventions to develop and support a national NCD action plan can inform and encourage LMIC countries to invest in systems integration to reduce the social and economic burden of NCDs and infectious diseases.

Barriers to up-titrated antihypertensive strategies in 12 sub-Saharan African countries: the Multination Evaluation of hypertension in Sub-Saharan Africa Study

BACKGROUND

Sub-Saharan Africa (SSA) faces the highest rate of hypertension worldwide. The high burden of elevated blood pressure (BP) in black people has been emphasized. Guidelines recommend two or more antihypertensive medications to achieve a BP control. We aimed to identify factors associated with prescription of up-titrated antihypertensive strategies in Africa.

METHODS

We conducted a cross-sectional study on outpatient consultations for hypertension across 12 SSA countries. Collected data included socioeconomic status, antihypertensive drugs classes, BP measures, cardiovascular risk factors and complication of hypertension. We used ordinal logistic regression to assess factors associated with prescription of up-titrated strategies.

RESULTS

The study involved 2123 treated patients with hypertension. Patients received monotherapy in 36.3 vs. 25.9%, two-drug in 42.2 vs. 45% and three and more drugs strategies in 21.5 vs. 29.1% in low (LIC) and middle (MIC) income countries, respectively. Patients with sedentary lifestyle [OR 1.4 (1.11-1.77)], complication of hypertension [OR 2.4 (1.89-3.03)], former hypertension [OR 3.12 (2.3-4.26)], good adherence [OR 1.98 (1.47-2.66)], from MIC [OR 1.38 (1.10-1.74)] and living in urban areas [OR 1.52 (1.16-1.99)] were more likely to be treated with up-titrated strategies. Stratified analysis shows that in LIC, up-titrated strategies were less frequent in rural than in urban patients (P for trend <0.01) whereas such difference was not observed in MIC.

CONCLUSION

In this African setting, in addition to expected factors, up-titrated drug strategies were associated with country-level income, patient location and finally, the interplay between both in LIC. These results highlight the importance of developing policies that seek to make multiple drug classes accessible particularly in rural and LIC.

Substandard and falsified medical product recalls in Zambia from 2018 to 2021 and implications on the quality surveillance systems

Background

Substandard and falsified (SF) medical products are removed from circulation through a process called 'product recall' by medicines regulatory agencies. In Zambia, the Zambia Medicines Regulatory Authority (ZAMRA) is responsible for recalling SF medical products from the Zambian market through passive and active surveillance methods. This study aimed to describe the prevalence of recalls of SF medical products and to analyse the frequently recalled therapeutic categories, dosage forms, categories of defects that led to the recalls and their sources with respect to the country of the marketing authorisation holder (MAH) or manufacturer.

Methods

We conducted a descriptive cross-sectional review of the product recalls issued by ZAMRA between January 2018 and December 2021. A search for all medical product alerts and recalls issued by ZAMRA was carried out by reviewing the internal post-marketing surveillance database kept at ZAMRA headquarters. Data were extracted using a structured Excel database and analysed using Microsoft Excel.

Results

A total of 119 alerts were received during the review period, of which 83 (69.7%) were product recalls. Oral solid dosage forms were the most recalled dosage form (53%). Furthermore, the number of recalls increased in 2020 (44.6%) and 2021 (22.9%), with the majority (20.5%) of the recalled products being substandard products classified as antiseptics and disinfectants and were attributed to the high demand during the COVID-19 pandemic. Manufacturing laboratory control issues were the reason for product recall in almost half (47.4%) of the cases. Most of the products recalled originated from India (38.6%), followed by Zambia (25.3%). Only one suspected falsified product was recalled between 2018 and 2021. A total of 66 recalls of the 83 products were initiated by ZAMRA, with only 17 voluntarily by foreign MAHs. No product recall was initiated by the local representatives of foreign manufacturers or MAH.

Conclusion

The majority of the pharmaceutical product recalls in Zambia were substandard products. Manufacturing laboratory control issues lead to most recalls and require investigation of the root causes, preventive action, and strict compliance with the good manufacturing practices guidelines by manufacturers.

The availability of essential medicines for cardiovascular diseases at healthcare facilities in low- and middle-income countries: The case of Bangladesh

Long-term, often lifelong care for cardiovascular disease (CVD) patients requires consistent use of medicine; hence, the availability of essential medicine for CVD (EM-CVD) is vital for treatment, quality of life, and survival. We aimed to assess the availability of EM-CVD and explore healthcare facility (HCF) characteristics associated with the availability of those medicines in Bangladesh. This study utilized publicly available cross-sectional data from the 2014 and 2017 waves of the Bangladesh Health Facilities Survey (BHFS). The analysis included 204 facilities (84 from the 2014 BHFS and 120 from the 2017 BHFS) that provide CVD diagnosis and treatment services. The outcome variable "EM-CVD availability" was calculated as a counting score of the following tracer medicines: angiotensin-converting enzyme (ACE) inhibitors (enalapril), thiazide, beta-blockers (atenolol), calcium channel blockers (amlodipine and nifedipine), aspirin, and simvastatin/atorvastatin. A multivariable Poisson regression model was used to identify the HCF characteristics associated with EM-CVD availability. The number of Bangladeshi HCFs that provide CVD screening and treatment services increased just a little between 2014 and 2017 (from 5.4% to 7.9%). Since 2014, there has been an increase in the availability of calcium channel blockers (from 37.5% to 38.5%), aspirin (from 25.3% to 27.9%), and simvastatin/atorvastatin (from 8.0% to 30.7%), whereas there has been a decrease in the availability of ACE inhibitors (enalapril) (from 12.5% to 6.5%), thiazide (from 15.7% to 11.1%), and beta-blockers (from 42.5% to 32.5%). The likelihood of EM-CVD being available was higher among private and urban facilities than among public and rural facilities. Furthermore, facilities that had 24-hour staff coverage and performed quality assurance activities had a higher chance of having EM-CVD available than those that did not have 24-hour staff coverage and did not undertake quality assurance activities. Government authorities should think about a wide range of policy implications, such as putting more emphasis on public and rural facilities, making sure staff is available 24 hours a day, and performing quality assurance activities at facilities to make EM-CVD more available.

Blood pressure-lowering medicines implemented in 12 African countries: the cross-sectional multination EIGHT study

OBJECTIVE

In Africa, the number of patients with hypertension is expected to reach 216.8 million by 2030. Large-scale data on antihypertensive medications used in Sub-Saharan Africa (SSA) are scarce.Here, we describe antihypertensive drug strategies and identify treatment factors associated with blood pressure (BP) control in 12 Sub-Saharan countries.

SETTING

Outpatient consultations for hypertension in urban tertiary cardiology centres of 29 hospitals from 17 cities across 12 SSA countries between January 2014 and November 2015.

PARTICIPANTS

Patients ≥18 years of age with hypertension were enrolled at any visit during outpatient consultations in the cardiology departments MAIN OUTCOME MEASURE: We collected BP levels, demographic characteristics and antihypertensive treatment use (including traditional medicine) of patients with hypertension attending outpatient visits. BP control was defined as seated office BP <140/90 mm Hg. We used logistic regression with a random effect on countries to assess factors of BP control.

RESULTS

Overall, 2198 hypertensive patients were included and a total of 96.6% (n=2123) were on antihypertensive medications. Among treated patients, 653 (30.8%) patients received a monotherapy by calcium channel blocker (n=324, 49.6%), renin-angiotensin system blocker (RAS) (n=126, 19.3%) or diuretic (n=122, 18.7%). Two-drug strategies were prescribed in 927 (43.6%) patients including mainly diuretics and RAS (n=327, 42% of two-drug strategies). Prescriptions of three-drugs or more were used in 543 (25.6%) patients. Overall, among treated patients, 1630 (76.7%) had uncontrolled BP, of whom 462 (28.3%) had BP levels ≥180/110 mm Hg, mainly in those on monotherapy. After adjustment for sociodemographic factors, the use of traditional medicine was the only factor significantly associated with uncontrolled BP (OR 1.72 (1.19 to 2.49) p<0.01).

CONCLUSION

Our study provided large-scale data on antihypertensive prescriptions in the African continent. Among patients declared adherent to drugs, poor BP control was significantly associated with the use of traditional medicine.

Availability, prices and affordability of essential medicines: A cross-sectional survey in Hanam province, Vietnam

OBJECTIVE

To measure medicines' prices, availability, and affordability in Hanam, Vietnam.

METHODS

The standardized methodology developed by the World Health Organization (WHO) and Health Action International was used to survey 30 essential medicines (EMs) in 30 public health facilities and 35 private medicine outlets in 2020. The availability of medicine was computed as the percentage of health facilities in which this medicine was found on the data-collection day. International reference prices (IRPs) from Management Sciences for Health (2015) were used to compute Median Price Ratio (MPR). The affordability of treatments for common diseases was computed as the number of days' wages of the lowest-paid unskilled government worker needed to purchase medicines prescribed at a standard dose. Statistic analysis was done using R software version 4.1.1.

RESULTS

The mean availability of originator brands (OBs) and lowest-priced generics (LPGs) was 0.7%, 63.2% in the public sector, and 13.7%, 47.9% in the private sector, respectively. In private medicine outlets, the mean availability of both OBs and LPGs in urban areas was significantly higher than that in rural areas (p = 0.0013 and 0.0306, respectively). In the public sector, LPGs' prices were nearly equal to their IRPs (median MPRs = 0.95). In the private medicine outlets, OBs were generally sold at 6.24 times their IRPs while this figure for LPGs was 1.65. The affordability of LPGs in both sectors was good for all conditions, with standard treatments costing a day's wage or less.

CONCLUSION

In both sectors, generic medicines were the predominant product type available. The availability of EMs was fairly high but still lower than WHO's benchmark. A national-scale study should be conducted to provide a comprehensive picture of the availability, prices, and affordability of EMs, thereby helping the government to identify the urgent priorities and improving access to EMs in Vietnam.

Evaluation of availability, price, and affordability of cardiovascular, diabetes, and global medicines in Abuja, Nigeria

OBJECTIVE

To assess the availability, price, and affordability of cardiovascular, diabetes, and global medicines in Abuja, Nigeria.

METHODS

A cross-sectional survey involving 27 private pharmacies, 13 public pharmacies, and 25 private hospital pharmacies in Abuja was conducted using the standardized World Health Organization/Health Action International methodology. The availability percentage for each pharmacy sector and each medicine was analyzed. The median price ratio (MPR) (ratio of the median price to the international reference prices) of the medicines were evaluated accordingly. Affordability was assessed by calculating the number of days' wages the lowest-paid unskilled government worker required to purchase a month worth of the standard treatment for a chronic condition.

RESULTS

The availability of cardiovascular (CV) medicines ranged from 28.4% (in private hospital pharmacies) to 59.9% (in private pharmacies). There was mixed variability in the mean availability of Originator Brands (OBs) and Lowest Priced Generics (LPGs) anti-diabetic drugs with the highest availability being OBs 36% and LPGs 40.2%, in private pharmacies and public pharmacies, respectively. The availability of global drugs ranged from 49.7% in private hospitals to 68.8% in private pharmacies. Two cardiovascular and four global medicines had greater than 80% availability across the pharmaceutical sectors. The median price ratio for OBs and LPGs was 9.60 and 1.72 for procurement, it was 8.08 and 2.60 in private pharmacies, 13.56 and 2.66 in public hospitals, and 16.38 and 7.89 in private hospitals. The percentage markup on LPG was 49.4% in public hospitals, 51.4% in private pharmacies, and 323% in private hospitals. Only nine medicines in both public hospitals and private pharmacies and two in the private hospital pharmacies required less than the daily wage of the lowest-paid government worker.

CONCLUSION

The availability of cardiovascular, diabetes, and global medicines was below 80% across the different pharmaceutical sectors in Abuja and the medicines were unaffordable. Although the prices were generally exorbitant, private pharmacies offered the best options in terms of availability, pricing, and affordability of medicines. Therefore, the results of this study emphasize the pertinence of enforcing policies that facilitate the availability, pricing, and affordability of cardiovascular, diabetes, and global medicines.

Availability, pricing and affordability of essential medicines in Eastern Ethiopia: a comprehensive analysis using WHO/HAI methodology

Background

Access to essential medicines is a universal human right and availability and affordability are the preconditions for it. In line with the sustainable development goals, World Health Organization (WHO) has outlined a framework that assists the policy makers to improve access to essential medicines for universal health coverage by 2030. However, the availability and affordability of essential medicines remains suboptimal in several low-income countries. Therefore, this study was designed to investigate the availability, pricing and affordability of essential medicines in eastern Ethiopia.

Methods

A cross-sectional study design was employed to conduct this study. Public and private health facilities found in Eastern Ethiopia and which fulfilled criteria set forth by WHO/Health Action International (HAI) guideline and essential medicines listed on WHO/HAI guideline and essential medicine list of Ethiopia were included. Accordingly, 60 medicine outlets were selected based on the WHO/HAI standardized sampling methodology. A standardized data collection tools developed by WHO/HAI, with necessary modifications, was employed to collect the data. Median Price Ratio (MPR) was computed as a ratio of median local buyers’ price to international buyers’ reference price. The Mann–Whitney U test was employed to compare the median buyers’ price between public and private health facilities. Kruskal–Wallis test was also run to explore the median price difference among all facilities. Treatment affordability was calculated based on the number of days of wage of the lowest-paid government employee of Ethiopia required to purchase the prescribed regimen.

Results

The overall percent availability of originator brand (OB) versions of essential medicines was found to be 3.6% (range: 0.0–31.7%), with the public and private sectors contributing 1.43% and 5.50%, respectively. The overall percent availability of lowest price generics (LPGs) was 46.97% (range: 1.7–93.3%) (Public: 42.5%; private: 50.8%). Only eight LPGs (16.0%) met the WHO target of 80%. The Mann–Whitney U test indicated that 64% drugs showed statistically significant median price difference between public and private settings (p < 0.05). The MPR value indicated that the median buyers’ price of drugs in private sector were more than four times the international reference price in 30% of drugs. The percentage of unaffordable medicine were 72.09 and 91.84% for public and private facilities, respectively, with 79.17% of the medicines were unaffordable when both settings were combined.

Conclusion

Only 16% of the surveyed medicines surpassed the WHO cut-off point of 80%. Nearly one-third of drugs in the private sector had a price of more than four times compared to the international reference prices. Moreover, four out of five drugs were found unaffordable when both settings were combined, demanded several days of wage of lowest paid government employee. This finding calls a prompt action from stakeholders to devise a strategy that help promote the access of essential medicines and rescue the struggling healthcare system of Ethiopia.

The Current Situation Regarding Long-Acting Insulin Analogues Including Biosimilars Among African, Asian, European, and South American Countries; Findings and Implications for the Future

Background: Diabetes mellitus rates continue to rise, which coupled with increasing costs of associated complications has appreciably increased global expenditure in recent years. The risk of complications are enhanced by poor glycaemic control including hypoglycaemia. Long-acting insulin analogues were developed to reduce hypoglycaemia and improve adherence. Their considerably higher costs though have impacted their funding and use. Biosimilars can help reduce medicine costs. However, their introduction has been affected by a number of factors. These include the originator company dropping its price as well as promoting patented higher strength 300 IU/ml insulin glargine. There can also be concerns with different devices between the manufacturers. Objective: To assess current utilisation rates for insulins, especially long-acting insulin analogues, and the rationale for patterns seen, across multiple countries to inform strategies to enhance future utilisation of long-acting insulin analogue biosimilars to benefit all key stakeholders. Our approach: Multiple approaches including assessing the utilisation, expenditure and prices of insulins, including biosimilar insulin glargine, across multiple continents and countries. Results: There was considerable variation in the use of long-acting insulin analogues as a percentage of all insulins prescribed and dispensed across countries and continents. This ranged from limited use of long-acting insulin analogues among African countries compared to routine funding and use across Europe in view of their perceived benefits. Increasing use was also seen among Asian countries including Bangladesh and India for similar reasons. However, concerns with costs and value limited their use across Africa, Brazil and Pakistan. There was though limited use of biosimilar insulin glargine 100 IU/ml compared with other recent biosimilars especially among European countries and Korea. This was principally driven by small price differences in reality between the originator and biosimilars coupled with increasing use of the patented 300 IU/ml formulation. A number of activities were identified to enhance future biosimilar use. These included only reimbursing biosimilar long-acting insulin analogues, introducing prescribing targets and increasing competition among manufacturers including stimulating local production. Conclusions: There are concerns with the availability and use of insulin glargine biosimilars despite lower costs. This can be addressed by multiple activities.

Appropriateness and affordability of prescriptions to diabetic patients attending a tertiary hospital in Eastern Uganda: A retrospective cross-sectional study

Background

Irrational prescription of drugs can lead to high cost of treatment thus limiting access to essential medicines. We assessed the affordability and appropriateness of prescriptions written for diabetic patients in Eastern Uganda.

Methods

We collected secondary data from the health management information system registers of patients who attended the outpatient medical clinic at Mbale regional referral hospital from January 2019 to December 2019. The average cost of the prescriptions was calculated and adjusted odds ratios for predictors for unaffordability estimated using logistic regression. Computed scores for indicators of rational drug prescription were used to assess the extent of rational prescribing.

Results

The median cost per prescription was USD 11.34 (IQR 8.1, 20.2). Majority of the diabetic patients (n = 2462; 94.3%, 95% CI: 93.3–95.1%) could not afford the prescribed drugs. Predictors for unaffordability were if a prescription contained: ≥ 4 medicines (AOR = 12.45; 95% CI: 3.9–39.7); an injectable (AOR = 5.47; 95%CI: 1.47–20.32) and a diagnosis of diabetes mellitus with other comorbidities (AOR = 3.36; 95%CI: 1.95–5.78). Having no antidiabetic drug prescribed was protective for non-affordability (AOR = 0.38; 95%CI: 0.24–0.61). The average number of drugs per prescription was 2.8. The percentage prescription of drugs by generic name and from the essential medicine and health supplies list of Uganda were (6160/7461; 82.6%, 96% CI: 81.7%-83.4%) and (6092/7461; 81.7%, 95% CI: 80.8%-82.5%) respectively against WHO standard of 100%.

Conclusion

The majority of diabetic patients (94.3%) in Eastern Uganda cannot afford to buy prescribed medicines. The government should therefore ensure that essential medicines are readily accessible in public health facilities.

The Nexus Between Adherence to Recommended Lifestyle Behaviors and Blood Pressure Control in Hypertensive Patients at Mutare Provincial Hospital, Zimbabwe: A Cross-Sectional Study

PURPOSE

To determine the association between the achievement of blood pressure (BP) control and adherence to recommended lifestyle behaviors among hypertensive patients seen at Mutare Provincial Hospital, Zimbabwe.

PATIENTS AND METHODS

A cross-sectional study was conducted using BP readings from three consecutive months. A structured interviewer-administered and pretested questionnaire with components derived from the World Health Organization Stepwise Survey was employed to extract information from 350 purposively selected participants. Measurement of BP was based on the Eighth Joint National Committee Guidelines. Bivariate and multivariate logistic regression analyses were computed using the SPSS package.

RESULTS

The mean age of the 350 participants was 67±11.38 years. Males made up 35% of the participants and BP control was achieved in 41.4% of the patients. Only 5.1% of the participants reported adherence to all the recommended lifestyle behaviors. Low adherence rates were reported for diet, medication, and physical activity. Bivariate analysis showed that participants who adhered to antihypertensive treatment and alcohol recommendations had reduced odds of having uncontrolled hypertension, while consuming deep-fat fried foods ≥3 times a week was associated with higher odds of uncontrolled BP (p<0.1). Logistic regression analysis revealed that participants who ate traditional whole-grain "sadza" or porridge were more likely to have controlled BP [adjusted odds ratio (AOR): 1.6; 95% confidence interval (CI): 1.0-2.5] while those who did not add salt at the table had reduced odds of having uncontrolled BP by 40% (AOR: 0.6; 95% CI: 0.4-0.9).

CONCLUSION

Overall, adherence to the recommended lifestyle behaviors which are known to be effective in controlling BP in Mutare was poor. Health workers should include comprehensive health education messages on the importance of compliance with dietary, medication, and physical exercise recommendations when counseling patients. The intervention crafting process should focus on identifying enablers of the recommended lifestyle behaviors in the community and the health delivery system.

Prices, Availability and Affordability of Medicines with Value-Added Tax Exemption: A Cross-Sectional Survey in the Philippines

BACKGROUND

Developing countries, such as the Philippines, started implementing policies to improve access to medicines, which is a vital step toward universal healthcare coverage. This study aimed to evaluate the prices, availability and affordability of prescribed medicines for diabetes, hypercholesterolemia and hypertension with the exemption of 12% value-added tax in the Philippines.

METHODS

The prices and availability of 50 medicines were collected in August 2019 from 36 public and 42 private medicine outlets in six regions of the Philippines, following a modified methodology developed by the World Health Organization and Health Action International. Availability is reported as the percentage of outlets in which the surveyed medicine was found at the time of visit. Medicine prices are expressed as median unit prices (MUPs) in Philippine Peso. Affordability is calculated based on the number of days' wages required for the lowest-paid unskilled government worker to purchase a monthly treatment.

RESULTS

The mean availability of surveyed medicines was low in both public and private sectors, with 1.3% for originator brands (OBs) and 25.0% for lowest-priced generics (LPGs) in public outlets, and 34.7% and 35.4% in private outlets, respectively. The MUP of medicines were higher in private outlets, and OBs have higher unit price compared to the generic equivalents. Treatments with OBs were unaffordable, except for gliclazide, but the affordability of most LPGs is generally good.

CONCLUSION

Access to medicines in both sectors was affected by low availability. High prices of OBs influenced the affordability of medicines even with tax exemption. A review of policies and regulations should be initiated for a better access to medicines in the Philippines.

Pharmacotherapy for hypertension in Sub-Saharan Africa: a systematic review and network meta-analysis

BACKGROUND

The highest burden of hypertension is found in Sub-Saharan Africa (SSA) with a threefold greater mortality from stroke and other associated diseases. Ethnicity is known to influence the response to antihypertensives, especially in black populations living in North America and Europe. We sought to outline the impact of all commonly used pharmacological agents on both blood pressure reduction and cardiovascular morbidity and mortality in SSA.

METHODS

We used similar criteria to previous large meta-analyses of blood pressure agents but restricted results to populations in SSA. Quality of evidence was assessed using a risk of bias tool. Network meta-analysis with random effects was used to compare the effects across interventions and meta-regression to explore participant heterogeneity.

RESULTS

Thirty-two studies of 2860 participants were identified. Most were small studies from single, urban centres. Compared with placebo, any pharmacotherapy lowered SBP/DBP by 8.51/8.04 mmHg, and calcium channel blockers (CCBs) were the most efficacious first-line agent with 18.46/11.6 mmHg reduction. Fewer studies assessing combination therapy were available, but there was a trend towards superiority for CCBs plus ACE inhibitors or diuretics compared to other combinations. No studies examined the effect of antihypertensive therapy on morbidity or mortality outcomes.

CONCLUSION

Evidence broadly supports current guidelines and provides a clear rationale for promoting CCBs as first-line agents and early initiation of combination therapy. However, there is a clear requirement for more evidence to provide a nuanced understanding of stroke and other cardiovascular disease prevention amongst diverse populations on the continent.

TRIAL REGISTRATION

PROSPERO, CRD42019122490. This review was registered in January 2019.

Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future

BACKGROUND

Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa.

METHODOLOGY

Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa.

RESULTS

Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care.

CONCLUSION

There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.