The Availability and Affordability of Selected Essential Medicines for Chronic Diseases in Six Low- and Middle-Income countries/Disponibilite et Accessibilite Economique Dans Six Pays a Revenu Faible Ou Moyen D'une Serie De Medicaments Essentiels, Destines a Traiter Des Maladies chroniques/Disponibilidad Y Asequibilidad De Algunos Medicamentos Esenciales Para Las Enfermedades Cronicas En Seis Paises De Ingresos Bajos Y Medios

Introduction Globally, approximately 35 million deaths (60% of all deaths) are attributable to chronic diseases each year, with more than 30 million deaths (52% of all deaths) due to cardiovascular disease (accounting for 30% of all deaths), cancer (13% of all deaths), chronic respiratory disease (7% of all deaths) and diabetes (2% of all deaths). (1) The global burden of disease resulting from all non-communicable conditions, (1) which includes premature death and disability, is 49%; 80% of these deaths occur in low- and middle-income countries. (1,2) Medicines represent a substantial proportion of the economic costs of treating chronic diseases in these countries. For example, in Latin America and the Caribbean it is estimated that medicine costs account for 44% of the direct medical costs of diabetes. (3) Further, in low- and middle-income countries 50-90% of the population have to pay for medicines themselves, (4) rendering treatment unaffordable for many. A significant proportion of chronic disease morbidity and mortality can be prevented if medications are made accessible and affordable. In patients with a high risk of cardiovascular disease, aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering medicines reduce the risk of future vascular events by about a quarter each. When used together, these medicines have the potential to reduce the relative risk by 75% and substantially reduce the recurrence of cardiovascular events. (5) Similarly, making cost-effective treatments available to patients with asthma and diabetes may lead to substantial reductions in morbidity and mortality. (6-9) Several studies have examined the availability, price and affordability of essential medicines, however none have focused specifically on medicines used to treat chronic diseases. (10-13) Little data exist on whether patients have access to affordable medicines for chronic diseases in low- and middle-income countries. A health-care facility-based study of practice patterns used for the secondary prevention of cardiovascular disease in 10 low- and middle-income countries looked at the proportion of patients with coronary heart disease and patients with cerebrovascular disease receiving medicine. (14) The proportion of coronary heart disease patients receiving aspirin was 81.2%; for beta-blockers it was 48.1%; for ACE inhibitors it was 39.8%; and for statins it was 29.8%. The proportions for patients with cerebrovascular disease were: 70.6% for aspirin; 22.8% for beta-blockers; 37.8% for ACE inhibitors; and 14.1% for statins. There are many reasons why medicines are not used more often. These include poor availability, a lack of affordability, poor prescribing practices and a lack of patient adherence. (14) Thus, despite the availability of cost-effective interventions, gaps in the treatment of chronic diseases persist. WHO is therefore initiating a global initiative to improve the care of chronic diseases in low- and middle-income countries. (15) As part of the initiative's preliminary activities, a survey of selected medicines used to treat chronic diseases was undertaken in selected countries to determine: * whether medicines were available, affordable and how much they cost; * whether there were variations in availability, price or affordability between the public and private sectors and between innovator brands (that is, the product that receives marketing authorization first, which is usually the patented version of the medicine) and generic equivalents; and * the contribution that mark-ups, taxes and other costs add to the final price of medicine. Our general hypothesis was that the essential medicines used to treat chronic diseases in low- and middle-income countries have limited availability and may not be affordable. Methods The survey was conducted in three low-middle income countries (Brazil, only in Rio Grande do Sul state; Pakistan and Sri Lanka) and three low-income countries (Bangladesh, Malawi and Nepal). …