P6147Access to essential cardiovascular medicines in Kerala, the state with the highest cardiovascular disease burden in India

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
G Satheesh ◽  
S Puthean ◽  
M Ansil ◽  
M K Unnikrishnan ◽  
A Sharma ◽  
...  
Keyword(s):  
Public Sector ◽  
Private Sector ◽  
Premature Mortality ◽  
Generic Medicine ◽  
Essential Medicines ◽  
World Health ◽  
Healthcare Needs ◽  
Consumer Prices ◽  
Majority Population ◽  
Government Worker

Abstract Introduction The 2030 Agenda for Sustainable Development has prioritized the reduction of premature mortality due to NCDs – including cardiovascular diseases (CVD) - by a third. To achieve this goal, countries must achieve 80% availability of affordable essential medicines. Essential medicines as identified by the World Health Organization are those that meet the priority healthcare needs of majority population. Globally, India has the second highest CVD burden with over 1.7 million deaths annually, with the highest CVD morbidity and mortality rate in Kerala. Purpose To evaluate the availability, prices and affordability of essential CVD medicines in Kerala state to facilitate implementation of informed public health policy. Methods Using WHO/HAI methodology, we obtained data on availability and prices for 25 essential CVD medicines in a representative sample of 7 public-sector hospitals (survey anchors) and 37 private retail pharmacies located near the survey anchors in four districts. Additionally, we obtained the data from 10 government-subsidized discount pharmacies. We report availability as percentage of surveyed facilities where a given medicine was found. Median prices ratios (MPRs) were calculated by comparing consumer prices to the MSH International Reference Prices (IRPs). Medicines were considered affordable if the monthly supply costs less than one-day's wage of the lowest paid government worker. Results In the public-sector facilities (hospital and discount pharmacies combined), the mean (SD) availability of the surveyed CVD medicines was 52% (35.3%) for generic and 35.3% (20.7%) for originator brand (OB) version. 28% of surveyed medicines (including amlodipine, clopidogrel, losartan, metformin) were available in over 80% pharmacies. 12% (captopril, streptokinase and glyceryl trinitrate) were not available in any of the facilities. In the private sector, mean (SD) availability of generic and OB versions was 64.4% (37.2%) and 43.7% (34.6%), respectively. MPR was 1.28 [range: 0.02 (insulin NPH) – 16.7 (simvastatin)] for both lowest-priced generics (LPG) and most-sold generics (MSG). The lowest paid government worker in Kerala would spend 0.06 - 3.48 days' wages for the monthly supply of essential CVD medicines in the private sector. In government-subsidized discount pharmacies, mean availability was 49.3%. The generic medicine prices were 74% lower than in the private sector. Conclusions Availability of essential CVD medications in both public and private sector pharmacies fall short of the 80% target. In the private-sector, many essential CVD medications seem unaffordable especially considering the polypharmacy among CVD patients. Introducing policies to improve medicine availability in government-subsidized discount pharmacies is crucial in tackling Kerala's ever-increasing CVD burden.

scholarly journals Prices, Availability And Affordability Of Essential Medicines For Non-Communicable Diseases: A Facility Based Survey In District Abbotabad

2021 ◽  
Vol 4 (2) ◽  
Author(s):  
Khizran Mir ◽  
Hafsa Ayyub
Keyword(s):  
Public Sector ◽  
Private Sector ◽  
Public Procurement ◽  
Essential Medicine ◽  
Simple Random Sampling ◽  
Communicable Diseases ◽  
Essential Medicines ◽  
World Health ◽  
Price Ratio ◽  
Non Communicable Diseases

Background: Non communicable diseases (NCDs) are spreading like an epidemic worldwide. Essential medicines are crucial for prevention and control of NCDs. World Health Organization (WHO) has set a benchmark of 80% availability of essential medicines in public and private facilities. Availability being a predictor of access to medicines is low in Low and Middle income countries (LMICs). The objective of this study is to determine price, availability and affordability of essential medicines for NCDs in District Abbottabad. Methods: This study was based on the standardized protocol provided by WHO and Health Action International (HAI) for determination of availability, prices and affordability of medicines. A total of 50 medicines for NCDs that were enlisted in Essential Medicine List of district Khyber Pakhtun Khawa were selected for the study. Twenty seven medicine dispensing facilities belonging to public, private and other basic health units (BHUs) (managed by PPHI) sectors were surveyed in the district. Simple random sampling was employed to select facilities. Results: The mean overall percentage availability of essential medicines for NCDs was 0.1% for original brand and 1.9% for low price generic in public sector. Overall availability was better in private and other sectors (32.9% for OB and 13.8% for LPGs and 5.3% for OB and 11.1% for LPG respectively). The prices in public procurement sector were competitive. The median price ratio (MPR) in public procurement sector was 0.56. Prices were higher comparatively in private sector with MPR 2.83. Most of the medicines require less than a day wage to buy 30 days treatment. Conclusions: The availability of essential medicines for NCDs was poor in District Abbottabad. None of the sectors reached the benchmark of 80% with regard to availability of medicines. LPGs were not frequently available in the private sector. However, prices were reasonable in public sector and acceptable in private sector. Medicines were found to be affordable but affordability may differ for people living below poverty line of US $1.

scholarly journals A national survey of antibacterial consumption in Sri Lanka

PLoS ONE ◽  
2021 ◽  
Vol 16 (9) ◽  
pp. e0257424
Author(s):  
Shalini Sri Ranganathan ◽  
Chandanie Wanigatunge ◽  
G. P. S. G. Senadheera ◽  
B. V. S. H. Beneragama
Keyword(s):  
Public Sector ◽  
Sri Lanka ◽  
Private Sector ◽  
Data Sources ◽  
World Health ◽  
Beta Lactam ◽  
Public And Private ◽  
Defined Daily Doses ◽  
Public And Private Sector ◽  
National Consumption

Introduction Optimizing the use of antibacterial medicines is an accepted strategy to combat the antibacterial resistance. Availability of reliable antibacterial consumption (ABC) data is a prerequisite to implement this strategy. Objectives To quantify and describe the national ABC in Sri Lanka and to examine any differences in the consumption between public and private sector. Methods The methodology for this survey was adapted from World Health Organization (WHO) methodology for a global programme on surveillance of antimicrobial consumption. Aggregate data on national consumption of systemic antibacterials (J01- Anatomical Therapeutic Chemical Classification (ATC) for 2017 were retrospectively extracted from all available data sources and classified using ATC classification. Quantity of consumption was converted to Defined Daily Doses (DDDs). Data are presented as total consumption and comparison between the public and private sector. Selected key quality indicators of ABC were compared between these two sectors. Findings From the available data sources, the total ABC in 2017 was 343.46 million DDDs. Private sector consumption accounted for 246.76 million DDDs compared to 97.96 million DDDs distributed to entire public sector by the Ministry of Health. Beta-lactam-penicillins antibacterial group accounted for 58.79% in public sector compared to 27.48% in private sector while macrolides, quinolones and other beta-lactam antibacterials accounted for 60.51% in the private compared to 28.41% in public sector. Consumption of Reserve group antibacterials was negligible, and limited to private sector. Watch category antibacterials accounted for 46%, 24% and 54% of the total, public and private sector consumption, respectively. Conclusions A disproportionately higher use of broad spectrum and Watch category antibacterials was observed in the private sector which needs further study. This national consumption survey highlights the need and provides the opening for establishment of ABC surveillance in Sri Lanka.

scholarly journals Personnel Policy and Practice: Sustainable Management of Pharmacy, Pharmacists and Pharmaceuticals and How to Bridge the Gap in Human Resources for Health

2019 ◽  
Vol 4 (9) ◽  
Keyword(s):  
Public Sector ◽  
Human Resources ◽  
Private Sector ◽  
Human Resources For Health ◽  
World Health ◽  
Accurate Information ◽  
Medical Council ◽  
Pharmacy Services ◽  
Spare Capacity ◽  
The Public

Worldwide there are different systems for providing pharmacy services. Most countries have some element of state assistance, either for all patients or selected groups such as children, and some private provisions. Medicines are financed either through cost sharing or full private. The role of the private services is therefore much more significant. Nationally, there is a mismatch between the numbers of pharmacists and where are they worked, and the demand for pharmacy services. The position is exacerbated locally where in some areas of poor; there is a real need for pharmacy services, which is not being met and where pharmacists have little spare capacity. Various changes within the health-care system require serious attention be given to the pharmacy human resources need. In order to stem the brain drain of pharmacists, it is, however, necessary to have accurate information regarding the reasons that make the pharmacists emigrate to the private sector. Such knowledge is an essential in making of informed decisions regarding the retention of qualified, skilled pharmacists in the public sector for long time. There are currently 3000 pharmacists registered with the Sudan Medical Council of whom only 10% are working with the government. The pharmacist: population ratio indicates there is one pharmacist for every 11,433 inhabitants in Sudan, compared to the World Health Organisation (WHO) average for industrialised countries of one pharmacist for 2,300 inhabitants. The situation is particularly problematic in the Southern states where there is no pharmacist at all. The distribution of pharmacists indicates the majority are concentrated in Khartoum state. When population figures are taken into consideration all states except Khartoum and Gezira states are under served compared to the WHO average. This mal-distribution requires serious action as majority of the population is served in the public sector. This study reveals the low incentives, poor working conditions, job dissatisfaction and lack of professional development programmes as main reasons for the immigration to the private-sector. The objective of this communication is to highlight and provide an overview of the reasons that lead to the immigration of the public sector pharmacists to the private-sector in Sudan. The survey has been carried out in September 2014. Data gathered by the questionnaires were analysed using Statistical Package for Social Sciences (SPSS) version 12.0 for windows. The result have been evaluated and tabulated in this study. The data presented in this theme can be considered as nucleus information for executing research and development for pharmacists and pharmacy. More measures must be introduced to attract pharmacists into the public sector. The emerging crisis in pharmacy human resources requires significant additional effort to gather knowledge and dependable data that can inform reasonable, effective, and coordinated responses from government, industry, and professional associations.

scholarly journals PRESCRIBING TREND AMONG HOSPITALIZED PEDIATRIC PATIENTS IN PRIVATE SECTOR HOSPITAL: A PROSPECTIVE OBSERVATIONAL STUDY IN NADIAD, INDIA

2020 ◽  
pp. 195-198
Author(s):  
SANDIP B PATEL ◽  
YASH P PATEL ◽  
SHISHAV B SHAH
Keyword(s):  
Private Sector ◽  
Pediatric Patients ◽  
Indian Academy ◽  
Essential Medicines ◽  
World Health ◽  
Common Disease ◽  
Treatment Protocols ◽  
Study Results ◽  
Prescribing Trend ◽  
Health Organization

Objectives: Purpose of this study was to analyze the prescription pattern among the hospitalized pediatric patients in private sector hospital. Methods: The study was conducted from January 2018 to April, 2018 at Shaishav Hospital, Nadiad, Gujarat, India, and 178 patients were included into the study. Results were obtained by applying the World Health Organization (WHO) prescribing indicators as well as Indian Academy of Pediatrics List of Essential Medicines (IAP-LEM). Results: During the study period, infectious disease such as pneumonitis, bronchitis, enteric fever, gastroenteritis, and dehydration were the dominant disease among the patients. Average number of drugs per prescription was four but in many of prescription, poly-pharmacy has shown. Antibiotic agents were the most prescribed drug (38.6%) among different classes of drugs. Use of the parenteral route of drug administration was used beyond the range stated by the WHO (59% prescriptions vs. 13–24% WHO range). We found that doctor followed IAP-LEM (in 99.78% cases) for prescribing as well as for dosing also, which was very impressive. Conclusions: As this study indicates, there is a need of development of evidence-based treatment protocols for common disease condition for the rational use of medication, especially for an antibiotic medication.

scholarly journals Availability, prices, and affordability of selected essential cancer medicines in a middle-income country – the case of Mexico

2019 ◽  
Author(s):  
Daniela Moye-Holz ◽  
Margaret Ewen ◽  
Anahi Dreser ◽  
Sergio Bautista-Arredondo ◽  
Rene Soria-Saucedo ◽  
...  
Keyword(s):  
Health Insurance ◽  
Public Sector ◽  
Private Sector ◽  
Public Hospitals ◽  
World Health ◽  
Public And Private ◽  
Middle Income ◽  
The Public ◽  
Middle Income Countries ◽  
Public And Private Sector

Abstract Background: More alternatives have become available for the diagnosis and treatment of cancer in low- and middle-income countries. Because of increasing demands, governments are now facing a problem of limited affordability and availability of essential cancer medicines. Yet, precise information about the access to these medicines is limited, and the methodology is not very well developed. Objective: To assess the availability and affordability of essential cancer medicines in Mexico, and compare their prices against those in other countries of the region. Methods: We surveyed 21 public hospitals and 19 private pharmacies in 8 states of Mexico. Data were collected on the availability and prices of 49 essential cancer medicines. Prices were compared against those in Chile, Peru, Brazil, Colombia and PAHO’s Strategic Fund. Results: Of the various medicines, mean availability in public and private sector outlets was 61.2% and 67.5%, respectively. In the public sector, medicines covered by the public health insurance “People’s Health Insurance” were more available. Only seven (public sector) and five (private sector) out of the 49 medicines were considered affordable. Public sector procurement prices were 41% lower than in other countries of the region. Conclusions: The availability of essential cancer medicines, in the public and private sector, falls below World Health Organization’s 80% target. The affordability remains suboptimal as well. A national health insurance scheme could serve as a mechanism to improve access to cancer medicines in the public sector. Comprehensive pricing policies are warranted to improve the affordability of cancer medicines in the private sector.

scholarly journals Challenges constraining availability and affordability of insulin in Bengaluru region (Karnataka, India): evidence from a mixed-methods study

2019 ◽  
Vol 12 (1) ◽  
Author(s):  
Gautam Satheesh ◽  
M. K. Unnikrishnan ◽  
Abhishek Sharma
Keyword(s):  
Mixed Methods ◽  
Public Sector ◽  
Private Sector ◽  
Human Insulin ◽  
Market Competition ◽  
Supply And Demand ◽  
Health Sector ◽  
Essential Medicine ◽  
Unskilled Worker ◽  
Consumer Prices

Abstract Introduction Considering limited global access to affordable insulin, we evaluated insulin access in public and private health sectors in Bengaluru, India. Methods Employing modified WHO/HAI methodology, we used mixed-methods analysis to study insulin access and factors influencing insulin supply and demand in Bengaluru in December 2017. We assessed insulin availability, price and affordability in a representative sample of 5 public-sector hospitals, 5 private-sector hospitals and 30 retail pharmacies. We obtained insulin price data from websites of government Jan Aushadhi scheme (JAS) and four online private-sector retail pharmacies. We interviewed wholesalers in April 2018 to understand insulin market dynamics. Results Mean availability of insulins on India’s 2015 Essential Medicine List was 66.7% in the public sector, lower than private-sector retail (76.1%) and hospital pharmacies (93.3%). Among private retailers, mean availability was higher among chain (96.7%) than independent pharmacies (68.3%). Non-Indian companies supplied 67.3% products in both sectors. 79.1% products were manufactured in India, of which 60% were marketed by non-Indian companies. In private retail pharmacies, median consumer prices of human insulin cartridges and pens were 2.5 and 3.6 times, respectively, that of human insulin vials. Analogues depending on delivery device were twice as expensive as human insulin. Human insulin vials were 18.3% less expensive in JAS pharmacies than private retail pharmacies. The lowest paid unskilled worker would pay 1.4 to 9.3 days’ wages for a month’s supply, depending on insulin type and health sector. Wholesaler interviews suggest that challenges constraining patient insulin access include limited market competition, physicians' preference for non-Indian insulins, and the ongoing transition from human to analogue insulin. Rising popularity of online and chain pharmacies may influence insulin access. Conclusion Insulin availability in Bengaluru’s public sector falls short of WHO’s 80% target. Insulin remains unaffordable in both private and public sectors. To improve insulin availability and affordability, government should streamline insulin procurement and supply chains at different levels, mandate biosimilar prescribing, educate physicians to pursue evidence-based prescribing, and empower pharmacists with brand substitution. Patients must be encouraged to shop around for lower prices from subsidized schemes like JAS. While non-Indian companies dominate Bengaluru’s insulin market, rising market competition from Indian companies may improve access.

scholarly journals Impact of National Drug Pricing Policy 2018 on access to medicines in Lahore division, Pakistan: a pre-post survey study using WHO/HAI methodology

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e034720
Author(s):  
Amna Saeed ◽  
Hamid Saeed ◽  
Zikria Saleem ◽  
Caijun Yang ◽  
Minghuan Jiang ◽  
...  
Keyword(s):  
Public Sector ◽  
Private Sector ◽  
Standard Treatment ◽  
Access To Medicines ◽  
Essential Medicines ◽  
Drug Pricing ◽  
Pricing Policy ◽  
The Public ◽  
National Drug ◽  
The Mean

ObjectiveTo evaluate the impact of new National Drug Pricing Policy (NDPP) 2018 on access to medicines in terms of prices, availability and affordability.DesignTwo cross-sectional surveys were undertaken before and after the launch of NDPP 2018, using a modified WHO/Health Action International (WHO/HAI) methodology.SettingFour districts of Lahore division, Pakistan.Participants16 public sector hospitals and 16 private sector retail pharmacies.MeasuresThe pre and post survey data on prices and availability of lowest price generics (LPGs) and originator brands (OBs) of 50 medicines were obtained by visiting the same public and private sector health facilities (n=32). Out of 50, 46 surveyed medicines were from the National Essential Medicines List. Inflation-adjusted median unit prices (MUPs) and median price ratios (MPRs) from 2019 were used for price comparison. Affordability was calculated in terms of number of days’ wages required to get a standard treatment by the lowest paid unskilled government worker.ResultsThe overall mean percent availabilities remained poor in both years, that is, far less than 80%. In the public sector, the mean percent availability of OBs improved from 6.8% to 33.1%, whereas, in the case of LPGs, it was reduced from 35.1% to 9%. In the private sector, the mean percent availability of both OBs and LPGs demonstrated slight improvements in 2019, that is, 55.0%–58.3% and 20.3%–32.3%. The adjusted MUPs and MPRs of OBs significantly increased by a median of 4.29% (Wilcoxon test p=0.001, p=0.0001), whereas the adjusted MUPs and MPRs of LPGs increased by a median of 15.7% (p=0.002, p=0.0002). Overall, the affordability of many medicines for common ailments was reduced significantly in 2019.ConclusionsThe availability of medicines slightly improved, except in the case of LPGs, which was reduced in the public sector. The implementation of NDPP 2018 led to increase in drug prices, making the standard treatment for some of the most prevalent ailments unaffordable. So verily, the drug pricing policy must be reviewed to ensure access to essential medicines.

scholarly journals Price, availability and affordability of medicines

2014 ◽  
Vol 6 (1) ◽  
Author(s):  
Brenda S. Mhlanga ◽  
Fatima Suleman
Keyword(s):  
Supply Chain ◽  
Public Sector ◽  
Low Income ◽  
Essential Medicines ◽  
World Health ◽  
Middle Income ◽  
Originator Brand ◽  
Private And Public ◽  
Daily Wage ◽  
Health Organization

Background: Medicines play an important role in healthcare, but prices can be a barrier to patient care. Few studies have looked at the prices of essential medicines in low- and middle-income countries in terms of patient affordability.Aim: To determine the prices, availability and affordability of medicines along the supply chain in Swaziland.Setting: Private- and public-sector facilities in Manzini, Swaziland.Methods: The standardised methodology designed by the World Health Organization and Health Action International was used to survey 16 chronic disease medicines. Data were collected in one administrative area in 10 private retail pharmacies and 10 public health facilities. Originator brand (OB) and lowest-priced generic equivalent (LPG) medicines were monitored and these prices were then compared with international reference prices (IRPs). Affordability was calculated in terms of the daily wage of the lowest-paid unskilled government worker.Results: Mean availability was 68% in the public sector. Private sector OB medicines were priced 32.4 times higher than IRPs, whilst LPGs were 7.32 times higher. OBs cost473% more than LPGs. The total cumulative mark-ups for individual medicines range from 190.99% – 440.27%. The largest contributor to add-on cost was the retail mark-up (31% – 53%). Standard treatment with originator brands cost more than a day’s wage.Conclusion: Various policy measures such as introducing price capping at all levels of the medicine supply chain, may increase the availability, whilst at the same time reducing the prices of essential medicines for the low income population.

scholarly journals Access to essential medicines for children: a cross-sectional survey measuring medicine prices, availability and affordability in Hanam province, Vietnam

BMJ Open ◽  
2021 ◽  
Vol 11 (8) ◽  
pp. e051465
Author(s):  
Dai Xuan Dinh ◽  
Huong Thi Thanh Nguyen ◽  
Van Minh Nguyen
Keyword(s):  
Public Sector ◽  
Private Sector ◽  
Urban Areas ◽  
Essential Medicines ◽  
Secondary Outcome ◽  
National Study ◽  
Cross Sectional ◽  
The Public ◽  
The Mean ◽  
Medicines For Children

ObjectiveTo identify the availability, prices and affordability of essential medicines for children (cEMs) in Hanam province, Vietnam.DesignCross-sectional study.SettingOne city and five districts of Hanam province.Participants66 public health facilities and 66 private drugstores.Primary and secondary outcome measuresThe standardised methodology of the WHO and Health Action International was used to investigate 30 paediatric essential medicines. For each medicine, data were collected for two products: the lowest-priced medicine (LPM) and the highest-priced medicine (HPM). The availability of medicine was computed as the percentage of facilities in which this medicine was found on the day of data collection. Median prices of individual medicines were reported in local currency. Affordability was calculated as the number of days’ wages required for the lowest-paid unskilled government worker to purchase standard treatments for common diseases. Data were analysed using R software V.4.1.0.ResultsThe mean availability of LPMs in the private sector (33.2%, SD=38.0%) was higher than that in the public sector (24.9%, SD=39.4%) (p<0.05). The mean availability of HPMs was extremely low in both sectors (11.3% and 5.8%, respectively). The mean availability of cEMs in urban areas was significantly higher than that in rural areas (36.5% and 31.6%, respectively, p<0.05). In the public sector, the prices of LPMs were nearly equal to the international reference prices (IRPs). In the private sector, LPMs were generally sold at 4.06 times their IRPs. However, in both sectors, the affordability of LPMs was reasonable for most conditions as standard treatments only cost a day’s wage or less.ConclusionThe low availability was the main reason hindering access to cEMs in Hanam, especially in the countryside. A national study on cEMs should be conducted, and some practical policies should be promulgated to enhance access to cEMs.

scholarly journals Availability, prices and affordability of essential medicines: A cross-sectional survey in Hanam province, Vietnam

PLoS ONE ◽  
2021 ◽  
Vol 16 (11) ◽  
pp. e0260142
Author(s):  
Huong Thi Thanh Nguyen ◽  
Dai Xuan Dinh ◽  
Trung Duc Nguyen ◽  
Van Minh Nguyen
Keyword(s):  
Public Sector ◽  
Urban Areas ◽  
Health Facilities ◽  
Essential Medicines ◽  
World Health ◽  
Price Ratio ◽  
The Public ◽  
Private Medicine ◽  
The Mean ◽  
Medicine Outlets

Objective To measure medicines’ prices, availability, and affordability in Hanam, Vietnam. Methods The standardized methodology developed by the World Health Organization (WHO) and Health Action International was used to survey 30 essential medicines (EMs) in 30 public health facilities and 35 private medicine outlets in 2020. The availability of medicine was computed as the percentage of health facilities in which this medicine was found on the data-collection day. International reference prices (IRPs) from Management Sciences for Health (2015) were used to compute Median Price Ratio (MPR). The affordability of treatments for common diseases was computed as the number of days’ wages of the lowest-paid unskilled government worker needed to purchase medicines prescribed at a standard dose. Statistic analysis was done using R software version 4.1.1. Results The mean availability of originator brands (OBs) and lowest-priced generics (LPGs) was 0.7%, 63.2% in the public sector, and 13.7%, 47.9% in the private sector, respectively. In private medicine outlets, the mean availability of both OBs and LPGs in urban areas was significantly higher than that in rural areas (p = 0.0013 and 0.0306, respectively). In the public sector, LPGs’ prices were nearly equal to their IRPs (median MPRs = 0.95). In the private medicine outlets, OBs were generally sold at 6.24 times their IRPs while this figure for LPGs was 1.65. The affordability of LPGs in both sectors was good for all conditions, with standard treatments costing a day’s wage or less. Conclusion In both sectors, generic medicines were the predominant product type available. The availability of EMs was fairly high but still lower than WHO’s benchmark. A national-scale study should be conducted to provide a comprehensive picture of the availability, prices, and affordability of EMs, thereby helping the government to identify the urgent priorities and improving access to EMs in Vietnam.

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