Rasha Khatib1, Martin McKee2, Harry Shannon3, Clara Chow4, Sumathy Rangarajan5, Koon Teo5, Li Wei6, Prem Mony7, Viswanathan Mohan8, Rajeev Gupta9, Rajesh Kumar10, Krishnapillai Vijayakumar11, Scott A Lear12, Rafael Diaz13, Alvaro Avezum14, Patricio Lopez-Jaramillo15, Fernando Lanas16, Khalid Yusoff17, Noorhassim Ismail18, Khawar Kazmi19, Omar Rahman20, Annika Rosengren21, Nahed Monsef22, Roya Kelishadi23, Annamarie Kruger24, Thandi Puoane25, Andrzej Szuba26, Jephat Chifamba27, Ahmet Temizhan28, Gilles Dagenais29, Amiram Gafni3, Salim Yusuf30. 1. Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory, Hamilton, ON, Canada; Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada. 2. Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK. 3. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. 4. Westmead Hospital and The George Institute for Global Health, Sydney University, Sydney, NSW, Australia. 5. Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada. 6. National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China. 7. St John's Medical College and Research Institute, Bangalore, Karnataka, India. 8. Madras Diabetes Research Foundation, Chennai, India. 9. Fortis Escorts Hospitals, JLN Marg, Jaipur, India. 10. Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India. 11. Dr Somervell Memorial CSI Medical College, Thiruvananthapuram, Kerala, India. 12. Simon Fraser University, Faculty of Health Sciences, Burnaby, BC, Canada. 13. Estudios Clínicos Latinoamérica, Rosario, Santa Fe, Argentina. 14. Dante Pazzanese Institute of Cardiology, São Paulo, SP, Brazil. 15. Fundacion Oftalmologica de Santander, Floridablanca-Santander, Colombia. 16. Universidad de La Frontera, Temuco, Chile. 17. Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; UCSI University, Cheras, Selangor, Malaysia. 18. Department of Community Health, University Kebangsaan Malaysia Medical Centre, Wilayah Persekutuan, Kuala Lumpur, Malaysia. 19. Division of Cardiology, Department of Medicine, The Aga Khan University, Karachi, Pakistan. 20. Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh. 21. Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. 22. Consultant Family Medicine, Health Affairs Department, Primary Health Care Services Sector, Dubai Health Authority, Dubai, United Arab Emirates. 23. Research Department, Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. 24. Faculty of Health Science North-West University, Potchefstroom Campus, Potchefstroom, South Africa. 25. School of Public Health, University of the Western Cape, Bellville, Cape Town, South Africa. 26. Department of Internal Medicine, Wroclaw Medical University, Borowska, Wroclaw, Poland. 27. Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe. 28. Cardiology Department, Faculty of Medicine, Karabuk University, Karabuk, Turkey. 29. Laval University Heart and Lungs Institute, Quebec City, QC, Canada. 30. Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada. Electronic address: salim.yusuf@phri.ca.
Abstract
BACKGROUND: WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability. METHODS: We analysed information about availability and costs of cardiovascular disease medicines (aspirin, β blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry. FINDINGS: Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55). INTERPRETATION: Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO's targets of 50% use of key medicines by 2025. FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
BACKGROUND: WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability. METHODS: We analysed information about availability and costs of cardiovascular disease medicines (aspirin, β blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry. FINDINGS: Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55). INTERPRETATION: Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO's targets of 50% use of key medicines by 2025. FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
Authors: Emelia J Benjamin; Michael J Blaha; Stephanie E Chiuve; Mary Cushman; Sandeep R Das; Rajat Deo; Sarah D de Ferranti; James Floyd; Myriam Fornage; Cathleen Gillespie; Carmen R Isasi; Monik C Jiménez; Lori Chaffin Jordan; Suzanne E Judd; Daniel Lackland; Judith H Lichtman; Lynda Lisabeth; Simin Liu; Chris T Longenecker; Rachel H Mackey; Kunihiro Matsushita; Dariush Mozaffarian; Michael E Mussolino; Khurram Nasir; Robert W Neumar; Latha Palaniappan; Dilip K Pandey; Ravi R Thiagarajan; Mathew J Reeves; Matthew Ritchey; Carlos J Rodriguez; Gregory A Roth; Wayne D Rosamond; Comilla Sasson; Amytis Towfighi; Connie W Tsao; Melanie B Turner; Salim S Virani; Jenifer H Voeks; Joshua Z Willey; John T Wilkins; Jason Hy Wu; Heather M Alger; Sally S Wong; Paul Muntner Journal: Circulation Date: 2017-01-25 Impact factor: 29.690
Authors: Rimke Bijker; Nagalingeswaran Kumarasamy; Sasisopin Kiertiburanakul; Sanjay Pujari; Wilson Lam; Romanee Chaiwarith; Wing W Wong; Adeeba Kamarulzaman; Pacharee Kantipong; Anchalee Avihingsanon; Kinh V Nguyen; Junko Tanuma; Oon Tek Ng; Benedict Lh Sim; Tuti P Merati; Jun Y Choi; Rossana Ditangco; Evy Yunihastuti; Ly P Sun; Cuong D Do; Jeremy Ross; Matthew Law Journal: Antivir Ther Date: 2019
Authors: Valery L Feigin; Bo Norrving; Mary G George; Jennifer L Foltz; Gregory A Roth; George A Mensah Journal: Nat Rev Neurol Date: 2016-07-22 Impact factor: 42.937