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.
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.


RESULTS
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).


CONCLUSIONS
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.


BACKGROUND
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.
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.
Rasha
R
Khatib
Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.
Martin
M
McKee
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
Harry
H
Shannon
Westmead Hospital and The George Institute for Global Health, Sydney University, Sydney, NSW, Australia.
Clara
C
Chow
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Sumathy
S
Rangarajan
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Koon
K
Teo
National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China.
Li
L
Wei
St John's Medical College and Research Institute, Bangalore, Karnataka, India.
Prem
P
Mony
Madras Diabetes Research Foundation, Chennai, India.
Viswanathan
V
Mohan
Fortis Escorts Hospitals, JLN Marg, Jaipur, India.
Rajeev
R
Gupta
Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India.
Rajesh
R
Kumar
Dr Somervell Memorial CSI Medical College, Thiruvananthapuram, Kerala, India.
Krishnapillai
K
Vijayakumar
Simon Fraser University, Faculty of Health Sciences, Burnaby, BC, Canada.
Scott A
SA
Lear
Estudios Clínicos Latinoamérica, Rosario, Santa Fe, Argentina.
Rafael
R
Diaz
Dante Pazzanese Institute of Cardiology, São Paulo, SP, Brazil.
Alvaro
A
Avezum
Fundacion Oftalmologica de Santander, Floridablanca-Santander, Colombia.
Patricio
P
Lopez-Jaramillo
Universidad de La Frontera, Temuco, Chile.
Fernando
F
Lanas
Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; UCSI University, Cheras, Selangor, Malaysia.
Khalid
K
Yusoff
Department of Community Health, University Kebangsaan Malaysia Medical Centre, Wilayah Persekutuan, Kuala Lumpur, Malaysia.
Noorhassim
N
Ismail
Division of Cardiology, Department of Medicine, The Aga Khan University, Karachi, Pakistan.
Khawar
K
Kazmi
Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh.
Omar
O
Rahman
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Annika
A
Rosengren
Consultant Family Medicine, Health Affairs Department, Primary Health Care Services Sector, Dubai Health Authority, Dubai, United Arab Emirates.
Nahed
N
Monsef
Research Department, Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
Roya
R
Kelishadi
Faculty of Health Science North-West University, Potchefstroom Campus, Potchefstroom, South Africa.
Annamarie
A
Kruger
School of Public Health, University of the Western Cape, Bellville, Cape Town, South Africa.
Thandi
T
Puoane
Department of Internal Medicine, Wroclaw Medical University, Borowska, Wroclaw, Poland.
Andrzej
A
Szuba
Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
Jephat
J
Chifamba
Cardiology Department, Faculty of Medicine, Karabuk University, Karabuk, Turkey.
Ahmet
A
Temizhan
Laval University Heart and Lungs Institute, Quebec City, QC, Canada.
Gilles
G
Dagenais
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
Amiram
A
Gafni
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada. Electronic address: salim.yusuf@phri.ca.
Salim
S
Yusuf
D000319:Adrenergic beta-Antagonists / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use; D001118:Argentina; D001241:Aspirin / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use; D001459:Bangladesh; D001938:Brazil; D002170:Canada; D002317:Cardiovascular Agents / Q000191:economics / Q000600:supply & distribution* / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000188:drug therapy*; D002677:Chile; D002681:China; D003105:Colombia; D019049:Developed Countries; D003906:Developing Countries; D016527:Drug Costs; D005191:Family Characteristics; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use; D007182:Income; D007194:India; D007492:Iran; D008296:Malaysia; D010154:Pakistan; D010594:Pharmacies; D010975:Platelet Aggregation Inhibitors / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use; D011044:Poland; D012424:Rural Population; D055502:Secondary Prevention; D013019:South Africa; D013548:Sweden; D014421:Turkey; D014479:United Arab Emirates; D014505:Urban Population; D015030:Zimbabwe
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D002317:Cardiovascular Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin