Innovative Approaches to Increase Access to Medicines in Developing Countries

Logistics Management Information System (LMIS) for Health Commodities at Public Health Facilities in Amhara National Regional State of Ethiopia: A Data Quality Evaluation Survey

Introduction

Access to essential medicines is limited in developing countries mainly due to inefficiencies in health supply chain management, such as the absence of standard monitoring frameworks and poorly designed Logistics Management Information Systems (LMIS). Health supply chain managers need accurate and timely data for decision-making. However, routine health information systems suffer from poor data quality, reliance on paper-based reports, insufficient logistic formats, inadequate infrastructure, and limited human resources.

Objective

This study evaluates the data quality of LMIS for health commodities in public health facilities in the Amhara National Regional State of Ethiopia.

Methods

The study was conducted in Ethiopia's Amhara National Regional State. The study employed an institution-based concurrent mixed-methods design. Data collection involved 102 facilities selected through multi-stage stratified random sampling, adhering to sampling criteria set by USAID's Logistics Indicators Assessment Tool (LIAT). Data abstraction checklists were used to collect data.

Results

Of the seven tracer medicines selected to evaluate data quality, there was substantial variability in inventory accuracy rates. Inventory discrepancies were significant, highlighting potential issues with manual and digital record-keeping systems, with overall mean physical and electronic inventory accuracy rates of 74.7% and 70.6%, respectively. Additionally, the Report and Requisition Form (RRF) showed trends of timely submission, with the overall mean percentage completeness for the seven tracer medicines at 90.2%. However, the data quality experienced fluctuations, with the overall average percentage of legality (authorization of LMIS reports) and the accuracy of the RRF at 77.2% and 76%, respectively.

Conclusion and Recommendation

The evaluation of data quality revealed significant discrepancies in physical and electronic records, with notable fluctuations in completeness, legality, legibility, and accuracy within the health LMIS. To rectify these issues, robust data quality verification processes, clear guidelines, targeted interventions, strengthened monitoring systems, regular audits, and comprehensive training for health supply chain staff are needed.

Vaccine Logistics Management Information System at Public Health Facilities in Amhara Region, Ethiopia: A Performance Evaluation

OBJECTIVES

This study aimed to evaluate the performance of vaccine logistics management information systems at public health facilities in Amhara Region, Ethiopia.

METHODS

An institution-based concurrent explanatory mixed design was used at public health facilities in Amhara Region, Ethiopia. In total, 102 health facilities were selected using the multi-stage, stratified, random-sampling proportionate-to-size method. Data were collected using a structured data abstraction checklist from vaccine logistics management information system records. Additionally, experiences of Expanded Program for Immunization focal persons were gathered through interviewer-administered questionnaires.

RESULTS

Among the 102 health facilities surveyed, 99 (97.1%) provided vaccination services during the study period. On the day of the visit, the average availability and utilization rates of 15 vaccine logistics management information system forms were 44.1% and 40.5%, respectively. The mean inventory accuracy for tracer vaccines stood at 58.3% ± 45.1%. The overall average accuracy percentages for urban and rural vaccine request form reports were 73.4% and 69.6%, respectively.

CONCLUSIONS

The performance of vaccine logistics management information systems in these public health facilities was suboptimal. Key issues identified include inconsistent use of recording forms, shortages of reporting forms, lack of digitalization, poor data quality, and a shortage of qualified staff. These findings underscore the urgent need for standardization of the vaccine logistics management information system and enhancement of data quality.

Clinical characteristics, diagnosis, treatment and outcomes of patients living with HIV and co-infected with tuberculosis and histoplasmosis: a 5-y retrospective case series

BACKGROUND

In Latin America, tuberculosis (TB) and histoplasmosis are two of the most frequent opportunistic infections affecting people living with human immunodeficiency virus (HIV). However, there are limited data on the clinical characteristics and outcomes of patients with concurrent TB and histoplasmosis infections.

METHODS

This was a retrospective observational study to describe the clinical, epidemiological and laboratory characteristics and outcomes of 21 patients living with HIV (PLHIV) who were diagnosed with concurrent histoplasmosis and TB between 2017 and 2021 in Guatemala City, Guatemala.

RESULTS

Most patients were male and were newly diagnosed with HIV. All patients had advanced HIV disease (AHD). They presented with a median CD4 count of 20 cells/µl. The most common symptoms reported by the patients were fever, weight loss, cough and diarrhoea. Twelve patients died within 6 months of baseline evaluation, for a mortality rate of 57.1%.

CONCLUSIONS

PLHIV with concurrent TB and histoplasmosis infections are characterised by AHD, predominantly presenting with disseminated forms of these infections and with unspecific symptoms and signs. This evidence calls for early HIV and opportunistic infection screening and insights into the challenges and opportunities for the efficient diagnostic and therapeutic management of patients with AHD with concurrent histoplasmosis and TB infections.

Repurposing of Antifungal Drug Flucytosine/Flucytosine Cocrystals for Anticancer Activity against Prostate Cancer Targeting Apoptosis and Inflammatory Signaling Pathways

This study aimed to repurpose the antifungal drug flucytosine (FCN) for anticancer activity together with cocrystals of nutraceutical coformers sinapic acid (SNP) and syringic acid (SYA). The cocrystal screening experiments with SNP resulted in three cocrystal hydrate forms in which two are polymorphs, namely, FCN-SNP F-I and FCN-SNP F-II, and the third one with different stoichiometry in the asymmetric unit (1:2:1 ratio of FCN:SNP:H2O, FCN-SNP F-III). Cocrystallization with SYA resulted in two hydrated cocrystal polymorphs, namely, FCN-SYA F-I and FCN-SYA F-II. All the cocrystal polymorphs were obtained concomitantly during the slow evaporation method, and one of the polymorphs of each system was produced in bulk by the slurry method. The interaction energy and lattice energies of all cocrystal polymorphs were established using solid-state DFT calculations, and the outcomes correlated with the experimental results. Further, the in vitro cytotoxic activity of the cocrystals was determined against DU145 prostate cancer and the results showed that the FCN-based cocrystals (FCN-SNP F-III and FCN-SYA F-I) have excellent growth inhibitory activity at lower concentrations compared with parent FCN molecules. The prepared cocrystals induce apoptosis by generating oxidative stress and causing nuclear damage in prostate cancer cells. The Western blot analysis also depicted that the cocrystals downregulate the inflammatory markers such as NLRP3 and caspase-1 and upregulate the intrinsic apoptosis signaling pathway marker proteins, such as Bax, p53, and caspase-3. These findings suggest that the antifungal drug FCN can be repurposed for anticancer activity.

Treatment of highly virulent mammarenavirus infections-status quo and future directions

INTRODUCTION

Mammarenaviruses are negative-sense bisegmented enveloped RNA viruses that are endemic in Africa, the Americas, and Europe. Several are highly virulent, causing acute human diseases associated with high case fatality rates, and are considered to be significant with respect to public health impact or bioterrorism threat.

AREAS COVERED

This review summarizes the status quo of treatment development, starting with drugs that are in advanced stages of evaluation in early clinical trials, followed by promising candidate medical countermeasures emerging from bench analyses and investigational animal research.

EXPERT OPINION

Specific therapeutic treatments for diseases caused by mammarenaviruses remain limited to the off-label use of ribavirin and transfusion of convalescent sera. Progress in identifying novel candidate medical countermeasures against mammarenavirus infection has been slow in part because of the biosafety and biosecurity requirements. However, novel methodologies and tools have enabled increasingly efficient high-throughput molecular screens of regulatory-agency-approved small-molecule drugs and led to the identification of several compounds that could be repurposed for the treatment of infection with several mammarenaviruses. Unfortunately, most of them have not yet been evaluated in vivo. The most promising treatment under development is a monoclonal antibody cocktail that is protective against multiple lineages of the Lassa virus in nonhuman primate disease models.

Effectiveness of prime vendor system on availability of medicines and medical supplies in the selected public health facilities in Arusha district council

INTRODUCTION

The shortage of medicines and medical supplies remains to be a major issue that is facing public health facilities in Tanzania. This situation has been influenced by lack of consistency in the supply chain, increase in healthcare demand, poor regulatory system, insufficient funds, and lack of conducive infrastructure. Formerly, the Government initiatives such as engagement with the Prime Vendor System (PVS) demonstrated great assistance in getting rid of this challenge. Despite the operation of PVS, a recent shortage of medicines and medical supplies has been noticed.

OBJECTIVES

This study aimed to assess the effectiveness of PVS on the availability of medicine and medical supplies in the selected public health facilities in Arusha District Council.

METHODS

The study used a case study design with mixed research approach. The study involved 77 respondents which included 25 health facility in-charges, 50 patients, 1 District Pharmacist and 1 Prime Vendor. Questionnaires, interviews, and observation methods were used to collect data. Data collected covered a period of 2021-2022. Thematic analysis was used to analyze the qualitative data whereas descriptive analysis was used to analyze the quantitative data with the help of Excel and the Statistical Package for Social Sciences (SPSS) version 28.0.

RESULTS

The analysis indicates that PVS is not completely effective in supplying medicines and medical supplies due to its low capacity to conform to the orders placed by the public health facilities, a lack of supply competition, and a failure to adhere to contractual terms. Furthermore, at the time of data collection, the average availability of medicines and medical supplies at the selected public health facilities was 74.8%, while 80% of the selected public health facilities reported having a scarcity of medicines and medical supplies, and 92% of the interviewed patients reported having no full access to medicines.

CONCLUSION

Despite the shortcomings associated with the operation of the PVS, the system still seems to be very important for enhancing the availability of medicines and medical supplies once its effectiveness is strengthened. This study recommends a routine monitoring of PVS operations and timely interventions to reinforce an adherence to the contracted terms and improve PVS effectiveness.

How and why pharmaceutical reforms contribute to universal health coverage through improving equitable access to medicines: a case of Ghana

Background

Examining how and why a country prioritizes and implements pharmaceutical reforms tends to show complex processes and myriad efforts made toward improving access to medicines. This study examines factors that enabled the prioritization and implementation of selected pharmaceutical reform items and how these factors contributed to improving equitable access to medicines and universal health coverage in Ghana.

Methods

An analytical framework was developed to identify variables to explore in answering the study questions and frame the analysis and presentation of findings. Documents analyzed included the National Medicines Policies, Health Sector Program of Work, and other health policies. Quantitative data were sourced from databases maintained by World Health Organization and the Institute for Health Metrics and Evaluation.

Results

The three main factors, evidence, financial and technical support, and alignment to national and global policies, influenced the prioritization and implementation of access to medicines reforms. The reforms targeted rational selection and use of medicines, medicine pricing, sustainable medicine financing, and regulatory and supply chain systems. Although there were limited quantitative data to quantify access to medicine policies" impact on universal health coverage, it can be reasonably assumed that, in Ghana, access to medicine policies has contributed to financial protection and improved access to quality health services.

Conclusion

Access to medicine policies targeted at promoting rational medicine selection and use, regulating medicine pricing and improving sustainable financing for medicines as well as the regulatory and supply chain systems arguably contributed to the attainment of UHC and must be sustained. Therefore, data collection and reporting indicators for access to medicines must be prioritized.

Global, regional and national availability of essential medicines for children, 2009-2020: a systematic review and meta-analysis

BACKGROUND

Access to essential medicines is a vital component of universal health coverage. The low availability of essential medicines for children (EMC) has led the World Health Organization (WHO) to issue a number of resolutions calling on member states on its improvement. But its global progress has been unclear. We aimed to systematically evaluate the progress of availability of EMC over the past decade across economic regions and countries.

METHODS

We searched eight databases from inception to December 2021 and reference lists to identify included studies. Two reviewers independently conducted literature screening, data extraction and quality evaluation. This study was registered with PROSPERO, CRD42022314003.

RESULTS

Overall, 22 cross-sectional studies covering 17 countries, 4 income groups were included. Globally, the average availability rates of EMC were 39.0% (95%CI: 35.5-42.5%) in 2009-2015 and 43.1% (95%CI: 40.1-46.2%) in 2016-2020. Based on the World Bank classification of economic regions, income was not proportional to availability. Nationally, the availability rate of EMC was reasonable and high (> 50%) in only 4 countries, and low or very low for the rest 13 countries. The availability rates of EMC in primary healthcare centers had increased, while that for other levels of hospitals slightly declined. The availability of original medicines decreased while that of generic medicines was stable. All drug categories had not achieved the high availability rate.

CONCLUSION

The availability rate of EMC was low globally, with slight increase in the last decade. Continuous monitoring and timely reporting of the availability of EMC are also needed to facilitate targets setting and inform relevant policy making.

A Pharmacoeconomic Outlook of the Biological Drugs Marketed in India: A Cost Variance Analysis

Introduction Biologic drugs are used to treat various illnesses like autoimmune diseases, cancers, hormonal irregularities, anemia, etc., and to prevent various diseases as vaccines. Though various biologic drugs are already available, they are still not within reach of the common man due to financial constraints. Through many search engines, studies evaluating the cost variation of different brands of biologics were investigated; however, only a few studies that address this problem were found. Hence, this study was planned with the objective of addressing the cost variation of various brands of biologic medicines available in the Indian market. Methods The website for the Current Index of Medical Specialties (CIMS) for India's location was used to obtain the prices of the different brands of biologic medicines in Indian National Rupee (INR) currency, which different manufacturers market with identical forms in strength and dosage. The percentage cost variation and cost ratio were calculated with the help of the minimum and maximum prices of various brands of biologic drugs. Results The prices of biologics belonging to six different classes that are available in 23 formulations were analyzed. The highest cost variability was shown by pegfilgrastim 6 mg at 1,022.92%, and the minimum-cost variation was shown by darbepoetin alfa 200 mcg at 13.07%. Conclusion Our research found a vast variance in the costs of various brands of biologic medicines in India. The government should address this cost variation problem by developing various policies, such as breaking the monopoly of manufacturers, providing tax incentives to nonprofit generic medicine manufacturers, and incorporating more biologic drugs under the protection of the Drugs Prices Control Order (DPCO).

Changes in launch delay and availability of pharmaceuticals in 30 European markets over the past two decades

BACKGROUND

The timing of the launch of a new drug is an important factor that determines access for patients. We evaluated patient access to pharmaceuticals in 30 European markets over the past two decades.

METHODS

Launch dates were extracted from the IQVIA (formerly IMS) database for 30 European countries for all pharmaceuticals launched internationally between 2000 and 2017. We defined launch delay as the difference between the first international launch date and the corresponding national launch date, and calculated these for each country in our sample over time. Additionally, we ranked countries according to their launch delays and looked at changes in the ranking order over time. Lastly, we determined the availability of new pharmaceuticals in each country, calculating this as the percentage of these pharmaceuticals that were available in each country during a pre-specified interval.

RESULTS

There was a clear trend towards a decrease in launch delays across all countries from 2000 (37.2 months) to 2017 (11.8 months). Over the entire observation period, the three fastest launching countries were the Netherlands, Sweden, and Germany, whereas the three slowest were Bosnia-Herzegovina, Serbia, and Turkey. Germany had the highest availability of new pharmaceuticals with 85.7%, followed by the United Kingdom (83.1%) and Norway (82.9%). Countries with the lowest availability of pharmaceuticals were Bosnia-Herzegovina, Serbia, and Latvia. Gross domestic product per capita was negatively correlated with launch delay (-0.67, p < 0.000) and positively correlated with the availability of pharmaceuticals (+ 0.19, p < 0.000).

CONCLUSION

Launch delay and the availability of pharmaceuticals varied substantially across all 30 European countries. Using countries with above-average availability and below-average launch delays as a benchmark, stakeholders may discuss or modify current pharmaceutical policy, if needed, to improve access to pharmaceutical care.

Increasing Societal Benefit From Cardiovascular Drugs

During the past few years, several innovative treatments for noncommunicable chronic disease have become available, including SGLT2i (sodium-glucose cotransporter-2 inhibitors), GLP-1a (glucagon-like-peptide 1 agonists), ARNI (angiotensin receptor-neprilysin inhibitors), and finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist. Each of these medications improves clinically relevant outcomes when added to existing therapies, and the indications for their use are rapidly expanding. Because existing drug regimens are already complex and costly, ensuring that society derives the maximal benefit from these new agents represents a major challenge. This Primer discusses how society can meet this challenge, which we address in terms of 5 principles: maximizing benefit, minimizing harm, optimizing uptake, increasing value for money, and ensuring equitable access. The Primer is most relevant for stakeholders in high-income countries, but the principles are broadly applicable to stakeholders in other settings, including low- and middle-income countries. We have focused the discussion on SGLT-2i, but the 5 principles herein could be used with reference to ARNI, finerenone, or any other health product.

Framing access to essential medicines in the context of Universal Health Coverage: a critical analysis of health sector strategic plans from eight countries in the WHO African region

BACKGROUND

Framing affects how issues are understood and portrayed. This profoundly shapes the construction of social problems and how policy options are considered. While access to essential medicines (ATM) in the World Health Organization (WHO) African Region is often framed as a societal problem, there is dominance of medical and technically oriented approaches to analyze and remedy the situation. Hence, the systematic application of social science approaches, such as framing theory, remains under-explored. Through a framing analysis of National Strategic Plans (NSPs) from eight countries, this study explores the applicability and potential usefulness of framing theory to analyze essential medicines policies.

METHODS

We inductively coded the relevant NSP textual fragments using the qualitative content analysis software ATLAS.ti.22. Benford and Snow's conceptualization of framing was used to organize the coded data into three frames: diagnostic (problems), prognostic (solutions) and motivational (values and ideological).

RESULTS

The following five diagnostic frames were dominant or in-frame: medicine unavailability, ineffective regulation, weak supply chain management, proliferation of counterfeit (substandard or falsified) medicines and use of poor quality medicines. Diagnostic frames related to financing, affordability, efficiency and corruption were given limited coverage or out of frame. Prognostic frames corresponded with how these problems were framed. Whilst Universal Health Coverage (UHC) and its guiding principles was the dominant motivational frame, we identified some frame discordance between the global discourse and national level policies.

CONCLUSIONS

Social science approaches such as framing analysis are applicable and useful to systematically analyze essential medicine aspects. By applying framing theory, we revealed that ATM aspects in the eight countries we analyzed are more often characterized in relation to availability at the expense of affordability which undermines UHC. We conclude that whilst UHC is a strong motivational frame to guide ATM aspects, it is insufficient to inform a comprehensive approach to address the problems related to ATM at country level. To effectively advance ATM, concerned actors need to realize such limitation and endeavor to gain a deeper understanding of how problems are framed and agendas are set at country level, the processes through which ideas and knowledge become policies, including the political demands, incentives and trade-offs facing decision-makers in selecting policy priorities.

Stakeholders’ Perspectives Regarding Supply Chain System of Pharmaceuticals and Vaccines in Pakistan: A Qualitative Study

The present study was undertaken to assess the current supply chain system of pharmaceuticals and vaccines in Pakistan in terms of structure, process, and outcomes, as well as related barriers and solutions for an effective supply chain system. A qualitative study was designed to explore stakeholders’ perceptions selected using the snowball sampling technique. A semi-structured interview guide was used to interview these respondents at a convenient time and place. After data collection, recorded interviews were transcribed verbatim and subjected to thematic analysis. The results highlighted that the standard operating procedures (SOPs), checklists, and government guidelines were available at different levels, except for community pharmacies. Timely delivery of quality products and services along with market reputation, experience, and authorization were the key criteria used for supplier selection and evaluation. Good inventory management, financial models, effective coordination, training, and skill development programs were identified as key factors responsible for an efficient supply chain process. Availability of vaccines, their appropriate temperature monitoring, and transportation are also highly compromised in Pakistan. The results of the present study concluded that the current supply chain system in Pakistan is not up to the mark; major factors include poor forecasting and inventory control, delayed order placement, lack of training, inadequate involvement of professionally qualified staff, inadequate financing and procurement processes, and poor coordination and integration among all stakeholders.

Trends and Challenges in Access to Essential Medicines in Ethiopia and the Contributions of Local Pharmaceutical Production

Decades ago, the United Nations declared that access to essential medicines was a key element of universal human rights. Accordingly, member states have been striving to address this issue through strategic policies and programs. Strengthening local pharmaceutical production has been a pivotal strategy adopted by many developing countries including Ethiopia. The government of Ethiopia identified local pharmaceutical production as a key industrial sector and has been implementing a ten-years strategic plan to improve capabilities and attract investment. Such support is needed because local production could satisfy only 15 to 20% of the national demand, typically from a limited portfolio of medicines in conventional dosage forms. The increasing prevalence of chronic diseases has accentuated the need for a more sustainable supply to reduce reliance on imports and increase access to essential medicines. A full understanding of the structure, constraints and complexities of the Ethiopian pharmaceutical market structure is vital to direct effective policies, target most impactful investments and exploit opportunities for leapfrogging. Hence, the purpose of this review was to assess the trends and challenges in access to essential medicines and local pharmaceutical production in Ethiopia. Literature search through major databases and review of policy documents and performance reports from relevant sector institutions were made to extract information for the review.

Under the Umbrella of Clinical Pharmacology: Inflammatory Bowel Disease, Infliximab and Adalimumab, and a Bridge to an Era of Biosimilars

Monoclonal antibodies (MAbs) have revolutionized the treatment of many chronic inflammatory diseases, including inflammatory bowel disease (IBD). IBD is a term that comprises two quite similar, yet distinctive, disorders-Crohn's disease (CD) and ulcerative colitis (UC). Two blockbuster MAbs, infliximab (IFX) and adalimumab (ADL), transformed the pharmacological approach of treating CD and UC. However, due to the complex interplay of pharmacology and immunology, MAbs face challenges related to their immunogenicity, effectiveness, and safety. To ease the burden of IBD and other severe diseases, biosimilars have emerged as a cost-effective alternative to an originator product. According to the current knowledge, biosimilars of IFX and ADL in IBD patients are shown to be as safe and effective as their originators. The future of biosimilars, in general, is promising due to the potential of making the health care system more sustainable. However, their use is accompanied by misconceptions regarding their effectiveness and safety, as well as by controversy regarding their interchangeability. Hence, until a scientific consensus is achieved, scientific data on the long-term effectiveness and safety of biosimilars are needed.

TRIPS to Where? A Narrative Review of the Empirical Literature on Intellectual Property Licensing Models to Promote Global Diffusion of Essential Medicines

Governed through the World Trade Organization Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) since 1995, the current medical R&D system requires significant trade-offs between innovation and high monopoly prices for patented drugs that restrict patient access to medicines. Since its implementation, few amendments have been made to the original TRIPS agreement to allow low- and middle-income countries (LMICs) to facilitate access by generic manufacturers through flexible provisions, such as compulsory licensing and parallel import. Although a useful policy tool in theory, the routine use of TRIPS flexibilities in LMICs in the procurement of new essential medicines (EMs) is regarded as a 'last resort' due to strong political response in high-income countries (HICs) and new trade agreements' restrictions. In this context, access-oriented biomedical Public-Private Partnerships (PPPs) have emerged. More recently, leading multilateral health organizations have recommended different types of intellectual property (IP) interventions, voluntary biomedical patent pools, as strategies to reduce prices and increase the diffusion of novel EMs in LMICs. Nevertheless, the recent Ebola and COVID-19 outbreaks highlight growing concerns regarding the use of TRIPS flexibilities and the limited success of voluntary mechanisms in promoting access to medicines in the Global South amidst health crises. This review aims at describing the state-of-the-art empirical research on IP-related options and voluntary mechanisms applied by emerging PPPs to guarantee timely and affordable access to EM in LMICs and reflect on both models as access paradigms. Some suggestions are put forward for future research paths on the basis of these analyses and in response to contemporary debates on waiving key IP rights on COVID-19 therapies, diagnostics, and vaccines.

Pharmacies in informal settlements: a retrospective, cross-sectional household and health facility survey in four countries

BACKGROUND

Slums or informal settlements characterize most large cities in LMIC. Previous evidence suggests pharmacies may be the most frequently used source of primary care in LMICs but that pharmacy services are of variable quality. However, evidence on pharmacy use and availability is very limited for slum populations.

METHODS

We conducted household, individual, and healthcare provider surveys and qualitative observations on pharmacies and pharmacy use in seven slum sites in four countries (Nigeria, Kenya, Pakistan, and Bangladesh). All pharmacies and up to 1200 households in each site were sampled. Adults and children were surveyed about their use of healthcare services and pharmacies were observed and their services, equipment, and stock documented.

RESULTS

We completed 7692 household and 7451 individual adults, 2633 individual child surveys, and 157 surveys of pharmacies located within the seven sites. Visit rates to pharmacies and drug sellers varied from 0.1 (Nigeria) to 3.0 (Bangladesh) visits per person-year, almost all of which were for new conditions. We found highly variable conditions in what constituted a "pharmacy" across the sites and most pharmacies did not employ a qualified pharmacist. Analgesics and antibiotics were widely available but other categories of medications, particularly those for chronic illness were often not available anywhere. The majority of pharmacies lacked basic equipment such as a thermometer and weighing scales.

CONCLUSIONS

Pharmacies are locally and widely available to residents of slums. However, the conditions of the facilities and availability of medicines were poor and prices relatively high. Pharmacies may represent a large untapped resource to improving access to primary care for the urban poor.

Bioequivalence Assessment of an Oral Fixed-Dose Formulation of Dutasteride-Tamsulosin 0.5 mg/0.4 mg: A Randomized, Single-Blind, Single-Dose, 2-Period Crossover Study in Mexican Population Under Fasted Conditions

The aim of the present study was to compare the bioavailability and to demonstrate the bioequivalence between a dutasteride-tamsulosin 0.5 mg/0.4 mg capsule formulation and the regulatory reference drug (Combodart®, GlaxoSmithKline). A randomized, single-blind, single-dose, 2-way crossover study under fasting conditions, with at least a 28-day washout period was carried out in healthy volunteers. Plasma concentrations of drugs were determined by high-performance liquid chromatography-tandem mass spectrometry. The pharmacokinetic analysis included maximum plasma concentration (C_max ), area under the plasma concentration-time curve (AUC) from time 0 to 72 hours, and AUC from baseline to infinity. The test formulation was considered bioequivalent if the geometric mean ratios (test/reference) were within the predetermined range of 80% to 125%. Safety and tolerability were evaluated by clinical assessment. The confidence intervals for the log-transformed test/reference ratios for dutasteride, C_max (95.4-109.2) and AUC from baseline to 72 hours (93.2-109.1), and for tamsulosin, C_max (101.9-119.8), AUC from baseline to the last quantifiable concentration (91.4-106.3) and AUC from baseline to infinity (90.9-103.3), were within the allowed limit specified by the regulatory authorities (80%-125%). In addition, both test and reference drugs were safe and tolerated. These results demonstrated the bioequivalence of test product (Dakart®) compared with Combodart®.

Essential list of medicinal products for rare diseases: recommendations from the IRDiRC Rare Disease Treatment Access Working Group

Background

Treatments are often unavailable for rare disease patients, especially in low-and-middle-income countries. Reasons for this include lack of financial support for therapies and onerous regulatory requirements for approval of drugs. Other barriers include lack of reimbursement, administrative infrastructure, and knowledge about diagnosis and drug treatment options. The International Rare Diseases Research Consortium set up the Rare Disease Treatment Access Working Group with the first objective to develop an essential list of medicinal products for rare diseases.

Results

The Working Group extracted 204 drugs for rare diseases in the FDA, EMA databases and/or China’s NMPA databases with approval and/or marketing authorization. The drugs were organized in seven disease categories: metabolic, neurologic, hematologic, anti-inflammatory, endocrine, pulmonary, and immunologic, plus a miscellaneous category.

Conclusions

The proposed list of essential medicinal products for rare diseases is intended to initiate discussion and collaboration among patient advocacy groups, health care providers, industry and government agencies to enhance access to appropriate medicines for all rare disease patients throughout the world.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01923-0.

The role of accountability in the performance of Jazia prime vendor system in Tanzania

Background

Access to safe, effective, quality and affordable essential medicines for all is a central component of Universal Health Coverage (UHC). However, the availability of quality medicines in peripheral healthcare facilities is often limited. Several countries have developed integrated complementary pharmaceutical supply systems to address the shortage of medicines. Nevertheless, there is little evidence on how accountability contributes to the performance of such complementary pharmaceutical supply systems in low-income settings. The current study analyses how accountability mechanisms contributed to the performance of Jazia Prime Vendor System (Jazia PVS) in Tanzania.

Methods

The study analysed financial, performance and procedure accountability as defined in Boven's accountability framework. We conducted 30 in-depth interviews (IDIs), seven group discussions (GD) and 14 focus group discussions (FGDs) in 2018 in four districts that implemented Jazia PVS. We used a deductive and inductive approach to develop the themes and framework analysis to summarize the data.

Results

The study findings revealed that a number of accountability mechanisms implemented in conjunction with Jazia PVS contributed to the performance of Jazia PVS. These include inventory and financial auditing conducted by district pharmacists and the internal auditors, close monitoring of standard operating procedures by the prime vendor regional coordinating office and peer cascade coaching. Furthermore, the auditing activities allowed identifying challenges of delayed payment to the vendor and possible approaches for mitigation while peer cascade coaching played a crucial role in enabling staff at the primary facilities to improve skills to oversee and manage the medicines supply chain.

Conclusion

Financial, performance and procedure accountability measures played an important role for the successful performance of Jazia PVS in Tanzania. The study highlights the need for capacity building linked to financial and supply management at lower level health facilities, including health facility governing committees, which are responsible for priority-setting and decision-making at facility level.

Structure-Based Virtual Screening: From Classical to Artificial Intelligence

The drug development process is a major challenge in the pharmaceutical industry since it takes a substantial amount of time and money to move through all the phases of developing of a new drug. One extensively used method to minimize the cost and time for the drug development process is computer-aided drug design (CADD). CADD allows better focusing on experiments, which can reduce the time and cost involved in researching new drugs. In this context, structure-based virtual screening (SBVS) is robust and useful and is one of the most promising in silico techniques for drug design. SBVS attempts to predict the best interaction mode between two molecules to form a stable complex, and it uses scoring functions to estimate the force of non-covalent interactions between a ligand and molecular target. Thus, scoring functions are the main reason for the success or failure of SBVS software. Many software programs are used to perform SBVS, and since they use different algorithms, it is possible to obtain different results from different software using the same input. In the last decade, a new technique of SBVS called consensus virtual screening (CVS) has been used in some studies to increase the accuracy of SBVS and to reduce the false positives obtained in these experiments. An indispensable condition to be able to utilize SBVS is the availability of a 3D structure of the target protein. Some virtual databases, such as the Protein Data Bank, have been created to store the 3D structures of molecules. However, sometimes it is not possible to experimentally obtain the 3D structure. In this situation, the homology modeling methodology allows the prediction of the 3D structure of a protein from its amino acid sequence. This review presents an overview of the challenges involved in the use of CADD to perform SBVS, the areas where CADD tools support SBVS, a comparison between the most commonly used tools, and the techniques currently used in an attempt to reduce the time and cost in the drug development process. Finally, the final considerations demonstrate the importance of using SBVS in the drug development process.

Using Beatboxing for Creative Rehabilitation After Laryngectomy: Experiences From a Public Engagement Project

Laryngectomy is the surgical removal of the larynx (voice box), usually performed in patients with advanced stages of throat cancer. The psychosocial impact of losing the voice is significant, affecting a person’s professional and social life in a devastating way, and a proportion of this patient group subsequently must overcome depression (22–30%) and social isolation (40%). The profound changes to anatomical structures involved in voicing and articulation, as a result of surgery, radiotherapy or chemotherapy (separately or in combination with one another), introduce challenges faced in speech rehabilitation and voice production that complicate social reintegration and quality of life. After laryngectomy, breathing, voicing, articulation and tongue movement are major components in restoring communication. Regular exercise of the chest, neck and oropharyngeal muscles, in particular, is important in controlling these components and keeping the involved structures supple. It is, however, a difficult task for a speech therapist to keep the patient engaged and motivated to practice these exercises. We have adopted a multidisciplinary approach to explore the use of basic beatboxing techniques to create a wide variety of exercises that are seen as fun and interactive and that maximize the use of the structures important in alaryngeal phonation. We herein report on our empirical work in developing patients’ skills, particularly relating to voiced and unvoiced consonants to improve intelligibility. In collaboration with a professional beatboxing performer, we produced instructional online video materials to support patients working on their own and/or with support from speech therapists. Although the present paper is focused predominantly on introducing the structure of the conducted workshops, the rationale for their design and the final public engagement performance, we also include feedback from participants to commence the critical discourse about whether this type of activity could lead to systematic underlying research and robustly assessed interventions in the future. Based on this exploratory work, we conclude that the innovative approach that we employed was found to be engaging, useful, informative and motivating. We conclude by offering our views regarding the limitations of our work and the implications for future empirical research.

Combining retrosynthesis and mixed-integer optimization for minimizing the chemical inventory needed to realize a WHO essential medicines list

Retrosynthetic pathways suggestions are optimized to minimize the number of unique chemicals required to synthesize multiple products as would be useful for on-demand manufacturing.

Impacts of intellectual property provisions in trade treaties on access to medicine in low and middle income countries: a systematic review

BACKGROUND

We present a systematic review describing ex-ante and ex-post evaluations of the impacts of intellectual property provisions in trade treaties on access to medicine in low and middle income countries. These evaluations focused on multilateral and bilateral trade agreements. We ascertained which IP provisions impacting access to medicines were the focus of these evaluations. We provide a further research agenda related to investigating the effect of trade agreement's intellectual property provisions on access to medicines. We followed systematic review guidelines with 7 different databases to identify post-2000 ex ante and ex post evaluations of trade treaties on access to medicines in low and middle-income countries. We included only quantitative ex-ante studies that used structural modeling and simulations to derive quantitative predictions and ex-post studies that utilized empirical data and econometric techniques to quantify the effects of intellectual property provisions in free trade agreements on host country's pharmaceutical industry. The search strategy identified 744 titles after removal of duplicates. We identified 14 studies that fulfilled all eligibility; 7 studies are ex-ante and 7 are ex-post. The studies looked at medicine price and cost, affordability, welfare effects and speed of medicine market launch. Changes in intellectual property policy due to the implementation of trade agreements affect price, medicines expenditure and sales, consumer welfare, and ultimately the affordability, of medicines. The direction and magnitude of the price effects differ between ex-ante and ex-post studies. Further, the reported impacts of policy changes due to trade agreements on medicine access seem clearly multifactorial.

CONCLUSION

Both ex ante and ex post methods have advantages and limitations and, on balance, both types report, for the most part, an increase in price and a decrease in consumer welfare with imposition of intellectual property protection in trade agreements. The main differences between these studies are in the magnitude of the changes. There is a gap in our empirical understanding of the mechanisms through which such changes affect access to medicines and which outcomes relevant to access are most affected by which type of changes in intellectual property policy and law.

Qualitative formative implementation research to inform introduction of a new essential medicine

BACKGROUND

The launch of novel pharmaceuticals in the developing world faces significant barriers that can delay or ultimately inhibit uptake. Implementation research can provide an understanding of factors influencing the introduction and scale up of a new product and thus can inform implementation strategy development.

OBJECTIVE

This study explored the factors likely to influence introduction of a novel oxytocin formulation for the prevention of postpartum hemorrhage in Ethiopia.

METHODS

Qualitative research methods were used to assess barriers and enablers associated with pre-determined domains: regulatory approval, pricing, supply and demand side advocacy, policy inclusion, end-user training and drug supply. Data were collected through focus group discussions and in-depth interviews with community members, healthcare providers and key informants. Verbatim transcripts were translated to English and analyzed using a thematic content framework.

RESULTS

Approval from stringent regulatory bodies was an enabler for gaining national regulatory approval. Purchasers (government and patients) expressed price sensitivity but would be willing to pay a price comparable to or higher than current alternatives if improved quality is delivered. Endorsement from the World Health Organization was described as critical for national policy inclusion. Supply side advocacy should be directed towards the Ministry of Health, which is receptive to advice from reputable agencies with whom they have an existing relationship. Demand side advocacy should be delivered through existing health system channels such as Ministry of Health authorities (for healthcare workers) and community health workers (for community members). The requirement to purchase the product directly from a single manufacturer was highlighted as a potential barrier for entry into the local supply chain.

CONCLUSION

This study highlighted several barriers and enablers associated with the introduction of a new drug product into the health system of Ethiopia. An advanced understanding of these influences can inform the design of locally-appropriate implementation strategies.

Global Acceptance of Biosimilars: Importance of Regulatory Consistency, Education, and Trust

Globally, biosimilars are expected to have a key role in improving patient access to biological therapies and addressing concerns regarding the escalating cost of health care. Indeed, in Europe, increased use of biologics and reduced drug prices have been observed after the introduction of biosimilars. Recently, several monoclonal antibody biosimilars of anticancer therapies have been approved, and numerous others are in various stages of clinical development. Biosimilars are authorized via a regulatory pathway separate from that used for generic drugs; they are also regulated separately from novel biologics. Biosimilar approval pathways in many major regulatory regions worldwide are, to a broad degree, scientifically aligned. However, owing to regional differences in health care priorities, policies, and resources, some important regulatory inconsistencies are evident. Acceptance of biosimilars by health care systems, health care professionals, and patients will be a key factor in the uptake of these therapies, and such regulatory variations could contribute to confusion and diminished confidence regarding the quality, efficacy, and reliability of these agents. Furthermore, the need for manufacturers to account for regulatory inconsistencies introduces inefficiencies and delays into biosimilar development programs. These issues should be addressed if biosimilars are to attain their maximal global potential. This review summarizes the evolution of the global biosimilar landscape and provides examples of inconsistencies between regulatory requirements in different regions. In addition, we review ongoing efforts to improve regulatory alignment and highlight the importance of education as a crucial factor in generating trust in, and acceptance of, biosimilars on a worldwide scale.

IMPLICATIONS FOR PRACTICE

Biosimilars of monoclonal antibody anticancer therapies are beginning to emerge, and more are likely to become available for clinical use in the near future. The extent to which biosimilars can contribute to cancer care will depend on their level of acceptance by health care systems, health care professionals, and patients. A better understanding of the regulatory basis for the approval of biosimilars may enhance confidence and trust in these agents. In order to have informed discussions about treatment choices with their patients, oncologists should familiarize themselves with the biosimilar paradigm.