Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data

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• 作者：Rasha Khatib ; PhD^a ; ^b ; Prof Martin McKee ; DSc^c ; Prof Harry Shannon ; PhD^d ; Clara Chow ; PhD^e ; Sumathy Rangarajan ; MSc^b ; Prof Koon Teo ; PhD^b ; Prof Li Wei ; PhD^f ; Prem Mony ; MD^g ; Viswanathan Mohan ; MD^h ; Rajeev Gupta ; PhDⁱ ; Rajesh Kumar ; MD^j ; Prof Krishnapillai Vijayakumar ; MD^k ; Prof Scott A Lear ; PhD^l ; Rafael Diaz ; MD^m ; Alvaro Avezum ; PhDⁿ ; Prof Patricio Lopez-Jaramillo ; PhD^o ; Fernando Lanas ; MD^p ; Prof Khalid Yusoff ; MD^q ; ^r ; Noorhassim Ismail ; MD^s ; Khawar Kazmi ; MBBS^t ; Prof Omar Rahman ; DSc^u ; Prof Annika Rosengren ; MD^v ; Nahed Monsef ; MD^w ; Prof Roya Kelishadi ; MD^x ; Prof Annamarie Kruger ; PhD^y ; Prof Thandi Puoane ; PhD^z ; Prof Andrzej Szuba ; PhD^aa ; Jephat Chifamba ; PhD^ab ; Ahmet Temizhan ; MD^ac ; Prof Gilles Dagenais ; MD^ad ; Prof Amiram Gafni ; PhD^d ; Prof Salim Yusuf ; DPhil^b ; ^{salim.yusuf@phri.ca" class="auth_mail" title="E-mail the corresponding author} ; for the PURE study investigators^&dagger ;
• 刊名：The Lancet
• 出版年：2016
• 出版时间：2-8 January 2016
• 年：2016
• 卷：387
• 期：10013
• 页码：61-69
• 全文大小：387 K

文摘

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.