Worldwide shift in heart medication delivery required: study

South Africa - Many people in the world who need essential heart medicine do not get it, even in rich countries, says new research published in the medical journal The Lancet.

In low- and middle-income countries the drugs are not widely available and, when available, are often unaffordable. In rich countries, although these medicines are available and affordable, still 35% to 50% of patients who have heart disease or previous stroke do not receive the drugs.

The research team for the study was led by Dr Salim Yusuf and Dr Rasha Khatib of the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences. Yusuf is director of the PHRI and president of the World Heart Federation of Geneva, Switzerland; and Khatib is a researcher at the Institute of Community and Public Health, at Birzeit University, Birzeit, occupied Palestinian territory. The study in South Africa is led by Prof Annamarie Kruger of AUTHeR, and snr researcher in the MRC Unit for hypertension in the Faculty of Health Sciences at the North-West University, Potchefstroom campus.

Their analysis of the Prospective Urban Rural Epidemiology (PURE) study studied data from 18 countries* to assess how low use of heart medicine relates to their lack of availability or affordability. 2

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

The World Health Organisation is seeking to ensure that medicines to prevent recurrent cardiovascular disease-including aspirin, beta 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 analysed information about availability and costs of cardiovascular disease medicines in pharmacies gathered from 596 communities participating in the PURE study, covering the period 2003-2013. 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 types of medicine above 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, and only 25% of urban and in 3% of rural communities in low-income countries (excluding India), and 89% of urban and 81% of rural communities in India.

The four 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 study shows, Yusuf said: "Unless governments in most countries, especially low- and middle-income countries begin initiatives to make these essential heart medications available and provided free-as is done for HIV-then the use of these drugs 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."

In a comment on the study in the same issue of The Lancet, two health economists for the Liverpool School of Tropical Medicine, in the UK, suggest that mechanisms such as a global fund for essential medicines for non-communicable diseases may need to be created to help address these issues, and point to successes in mass production of antiretroviral medicines for HIV and neglected tropical diseases.

Louis W Niessen and Jahangir Khan say: "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."

*Countries included in this analysis: High-income: Sweden, United Arab Emirates, Canada Upper-middle income: Poland, Turkey, Chile, Malaysia, South Africa, Argentina, Brazil Lower-middle income: Colombia, Iran, China, occupied Palestinian territory Low-income: Pakistan, Bangladesh, Zimbabwe

For more information: Prof Annamarie Kruger Director: AUTHeR Faculty of Health Sciences North-West University [email protected] 018-2992095

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