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Lancet. 2016 Jan 2;387(10013):61-9. doi: 10.1016/S0140-6736(15)00469-9. Epub 2015 Oct 20.

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.

Collaborators (367)

Yusuf S, Rangarajan S, Teo KK, Chow CK, O'Donnell M, Mente A, Leong D, Smyth A, Joseph P, Islam S, Zhang M, Hu W, Wong G, Lee S, Casanova A, Dyal L, Dehghan M, DeJesus J, Lewis G, Mackie P, Chin S, Farago L, Zarate M, Kay I, Agapay D, Solano R, Ramacham S, Kandy N, Rimac J, Trottier S, ElSheikh W, Mustaha M, Tongana T, Aoucheva N, Swallow J, Ramezani E, Aoucheva N, Aliberti A, Lindeman J, Diaz R, Orlandini A, Linetsky B, Toscanelli S, Casaccia G, Maini Cuneo JM, Rahman O, Yusuf R, Azad AK, Rabbani KA, Cherry HM, Mannan A, Hassan I, Talukdar AT, Tooheen RB, Khan MU, Sintaha M, Choudhury T, Haque R, Parvin S, Avezum A, Oliveira GB, Marcilio CS, Mattos AC, Teo K, Yusuf S, Dejesus J, Agapay D, Tongana T, Solano R, Kay I, Trottier S, Rimac J, Elsheikh W, Heldman L, Ramezani E, Dagenais G, Poirier P, Turbide G, Auger D, LeBlanc De Bluts A, Proulx MC, Cayer M, Bonneville N, Lear S, Gasevic D, Corber E, de Jong V, Vukmirovich I, Wielgosz A, Fodor G, Pipe A, Shane A, Lanas F, Seron P, Martinez S, Valdebenito A, Oliveros M, Wei L, Lisheng L, Chunming C, Xingyu W, Wenhua Z, Hongye Z, Xuan J, Bo H, Yi S, Jian B, Xiuwen Z, Xiaohong C, Tao C, Hui C, Xiaohong C, Qing D, Xiaoru C, Qing D, Xinye H, Bo H, Xuan J, Jian L, Juan L, Xu L, Bing R, Yi S, Wei W, Yang W, Jun Y, Yi Z, Hongye Z, Xiuwen Z, Manlu Z, Fanghong L, Jianfang W, Yindong L, Yan H, Liangqing Z, Baoxia G, Xiaoyang L, Shiying Z, Rongwen B, Xiuzhen T, Dong L, Di C, Jianguo W, Yize X, Tianlu L, Peng Z, Changlin D, Ning L, Xiaolan M, Yuqing Y, Rensheng L, Minfan F, Jing H, Yu L, Xiaojie X, Qiang Z, Lopez-Jaramillo P, Camacho Lopez PA, Garcia R, Jurado LJ, Gómez Arbeláez D, Arguello JF, Dueñas R, Silva S, Pradilla LP, Ramirez F, Molina DI, Cure-Cure C, Perez M, Hernandez E, Arcos E, Fernandez S, Narvaez C, Sotomayor A, Garcia H, Sanchez G, David T, Rico A, Mony P, Vaz M, Bharathi AV, Swaminathan S, Shankar K, Kurpad AV, Jayachitra KG, Kumar N, Hospital HA, Mohan V, Deepa M, Parthiban K, Anitha M, Hemavathy S, Rahulashankiruthiyayan T, Anitha D, Sridevi K, Gupta R, Panwar RB, Mohan I, Rastogi P, Rastogi S, Bhargava R, Kumar R, Thakur JS, Patro B, Lakshmi PV, Mahajan R, Chaudary P, Raman Kutty V, Vijayakumar K, Ajayan K, Rajasree G, Renjini AR, Deepu A, Sandhya B, Asha S, Soumya HS, Kelishadi R, Bahonar A, Mohammadifard N, Heidari H, Yusoff K, Ismail TS, Ng KK, Devi A, Nasir NM, Yasin MM, Miskan M, Rahman EA, Arsad MK, Ariffin F, Razak SA, Majid FA, Bakar NA, Yacob MY, Zainon N, Salleh R, Ramli MK, Halim NA, Norlizan SR, Ghazali NM, Arshad MN, Razali R, Ali S, Othman HR, Hafar CW, Pit A, Danuri N, Basir F, Zahari SN, Abdullah H, Arippin MA, Zakaria NA, Noorhassim I, Hasni MJ, Azmi MT, Zaleha MI, Hazdi KY, Rizam AR, Sazman W, Azman A, Khatib R, Khammash U, Khatib A, Giacaman R, Iqbal R, Afridi A, Khawaja R, Raza A, Kazmi K, Zatonski W, Szuba A, Zatonska K, Ilow R, Ferus M, Regulska-Ilow B, Różańska D, Wolyniec M, Kruger A, Voster HH, Schutte AE, Wentzel-Viljoen E, Eloff FC, de Ridder H, Moss H, Potgieter J, Roux AA, Watson M, de Wet G, Olckers A, Jerling JC, Pieters M, Hoekstra T, Puoane T, Igumbor E, Tsolekile L, Sanders D, Naidoo P, Steyn N, Peer N, Mayosi B, Rayner B, Lambert V, Levitt N, Kolbe-Alexander T, Ntyintyane L, Hughes G, Swart R, Fourie J, Muzigaba M, Xapa S, Gobile N, Ndayi K, Jwili B, Ndibaza K, Egbujie B, Rosengren A, Bengtsson Boström K, Lindblad U, Langkilde P, Gustavsson A, Andreasson M, Snällman M, Wirdemann L, Pettersson K, Moberg E, Oguz A, Akalin AA, Calik KB, Imeryuz N, Temizhan A, Alphan E, Gunes E, Sur H, Karsidag K, Gulec S, Altuntas Y, Yusufali AM, Almahmeed W, Swidan H, Darwish EA, Hashemi AR, Al-Khaja N, Muscat-Baron JM, Ahmed SH, Mamdouh TM, Darwish WM, Abdelmotagali MH, Omer Awed SA, Movahedi GA, Hussain F, Al Shaibani H, Gharabou RI, Youssef DF, Nawati AZ, Abu Salah ZA, Abdalla RF, Al Shuwaihi SM, Al Omairi MA, Cadigal OD, Alejandrino RS, Chifamba J, Gwaunza L, Terera G, Mahachi C, Murambiwa P, Machiweni T, Mapanga R.

Author information

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.

Comment in

PMID:
26498706
DOI:
10.1016/S0140-6736(15)00469-9
[Indexed for MEDLINE]

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