Study reveals poor levels of use, availability and affordability of cardiovascular disease medicines worldwide

New research published in The Lancet shows that the use of vital life-saving generic (and supposedly inexpensive) medicines for prevention in people with existing heart disease is poor worldwide. In low-income and middle-income countries these medicines are not widely available and, when available, can often be unaffordable. In rich countries, although such medicines are both available and affordable, 35% to 50% of patients who have heart disease or a previous stroke still do not receive them.

The authors say that a radical shift in how such medicines are provided, and how preventive care is organised in health care systems, is required. For example, provision of generic versions free of charge in developing countries and provision of medicines by non-physician health workers in all countries are needed to improve rates of use of these medicines, even in the richest countries.

The Prospective Urban Rural Epidemiology (PURE) study analysed data from 18 countries[1] and was led by Professor Salim Yusuf, Director of the Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada, and President of the World Heart Federation, Geneva, Switzerland; and Dr Rasha Khatib, Birzeit University, Birzeit, occupied Palestinian territory, and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada, and colleagues.

The World Health Organization (WHO) has proposed that medicines to prevent recurrent cardiovascular disease—including aspirin, β blockers, angiotensin-converting-enzyme (ACE) inhibitors, and statins—be available in 80% of communities and used by 50% of eligible individuals by 2025. The team of researchers that has authored this new Lancet study has previously reported that use of these medicines is very low worldwide, but here they assess how such low use relates to lack of medicine availability and/or affordability.

They analysed information about availability and costs of cardiovascular disease medicines in pharmacies gathered from 596 communities in 18 countries participating in the PURE study, covering the period 2003–13. 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.

All four of the classes of cardiovascular medicines recommended by WHO were available in 95% of urban and 90% of rural communities studied in high-income countries; decreasing to 80% of urban and 73% of rural communities in upper middle-income countries; 62% of urban and 37% of rural communities in lower middle-income countries; only 25% of urban and 3% of rural communities in low-income countries (excluding India); and 89% of urban and 81% of rural communities in India [1].

The cardiovascular disease medicines were potentially unaffordable for less than 1% of households in high-income countries, compared with 25% of upper middle-income countries, 33% of lower middle-income countries, 60% of low-income countries (excluding India), and 59% of households in India.

The authors say: “Given the very large effects of the availability and affordability of medicines on use that we noted, availability and affordability are likely to be essential factors influencing medicine use…unless both availability and affordability of these medicines are improved, their use is likely to remain low in most of the world.

Professor Yusuf adds: “Unless governments in most countries, especially low- and middle-income countries, begin initiatives to make these essential heart medicines available and provided free—as is done for HIV—then their use is always going to be far less than optimal. In rich countries, the key question is different—we need health systems in which there are organised approaches to secondary prevention, perhaps run by non-physicians such as trained nurses or other health workers, to improve uptake and adherence.”[2]

In a Comment, Professor Louis W Niessen and Dr Jahangir Khan, Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK suggest that mechanisms such as a global fund for essential medicines for non-communicable diseases might need to be created to help address these issues, and point to successes in mass provision of antiretroviral medicines for HIV and neglected tropical diseases. They conclude: “Further research is needed into the development of national regulatory mechanisms for drug pricing, to achieve prices that are closer to drug production costs. So far, mass antiretroviral treatment for HIV is the one success story. Universal access to medicines will be accelerated through increased health financing and greater availability of low cost medicines targeting major diseases among people with low incomes.”

[1] Countries included in this analysis were Sweden, United Arab Emirates, Canada (high income); Poland, Turkey, Chile, Malaysia, South Africa, Argentina, Brazil (upper-middle income); Colombia, Iran, China, occupied Palestinian territory (lower-middle income); Pakistan, Bangladesh, Zimbabwe (low income). India was included as a separate country in its own category due to its population size and the size of its generic medication market
[2] Quote direct from author and not taken from text of Article.