The availability of priority medicines for children under 5 years in eThekwini, South Africa

Background Globally, an estimated 8.1 million children under 5 years die annually in developing countries. Ensuring essential medicines are accessible and affordable to the population is key to saving lives. This study investigated accessibility, availability and affordability of a basket of priority medicines for children under 5 years in public and private healthcare sector pharmacies in the eThekwini Metropolitan area in Durban, South Africa. Methods The WHO/HAI survey tool for assessing medicine prices, availability and affordability was adapted and employed for a basket of WHO Priority life-saving medicines for children under 5 years. Six district hospitals in the north, south and central eThekwini Metropolitan were selected as major facility reference points and for data collection and pharmacies within a 5 km radius from each major facility were also invited to participate in the study, as outlined in the WHO/HAI tool methodology. Of the 58 pharmacies selected, a total of 27 pharmacies from both private and public healthcare sectors agreed to participate and were surveyed, representing a 47% response rate. Data was analysed using Microsoft excel. Results All participating pharmacies (and hence the selected basket of priority medicines at these facilities) were deemed accessible. Overall the public sector had more medicines available on the shelf (averaging 64%) than the private sector (48%) which had more medicines available on order (84%). At least one medicine for each of the eight (8) conditions was available at both sectors which meant patients could be treated for these conditions. Medicines for priority conditions (except HIV, which was a 28-day course) were deemed affordable as these regimens were obtainable within a day’s wage for the lowest paid unskilled worker. Priority medicines for children under 5 years were more available and more affordable in the public sector. Conclusion The basket of WHO essential medicines for priority conditions for children under 5 years were accessible, available and affordable in the eThekwini Metropolitan areas. This was the first study in eThekwini to determine access to the WHO basket of priority medicines for children and can be scaled-up to a national study to provide a holistic comparison of these medicines in the country, and also for global comparison.

Ten-year prediction model for post-bronchodilator airflow obstruction and early detection of COPD: development and validation in two middle-aged population-based cohorts

BackgroundClassifying individuals at high chronic obstructive pulmonary disease (COPD)-risk creates opportunities for early COPD detection and active intervention.ObjectiveTo develop and validate a statistical model to predict 10-year probabilities of COPD defined by post-bronchodilator airflow obstruction (post-BD-AO; forced expiratory volume in 1 s/forced vital capacity<5th percentile).SettingGeneral Caucasian populations from Australia and Europe, 10 and 27 centres, respectively.ParticipantsFor the development cohort, questionnaire data on respiratory symptoms, smoking, asthma, occupation and participant sex were from the Tasmanian Longitudinal Health Study (TAHS) participants at age 41–45 years (n=5729) who did not have self-reported COPD/emphysema at baseline but had post-BD spirometry and smoking status at age 51–55 years (n=2407). The validation cohort comprised participants from the European Community Respiratory Health Survey (ECRHS) II and III (n=5970), restricted to those of age 40–49 and 50–59 with complete questionnaire and spirometry/smoking data, respectively (n=1407).Statistical methodRisk-prediction models were developed using randomForest then externally validated.ResultsArea under the receiver operating characteristic curve (AUCROC) of the final model was 80.8% (95% CI 80.0% to 81.6%), sensitivity 80.3% (77.7% to 82.9%), specificity 69.1% (68.7% to 69.5%), positive predictive value (PPV) 11.1% (10.3% to 11.9%) and negative predictive value (NPV) 98.7% (98.5% to 98.9%). The external validation was fair (AUCROC 75.6%), with the PPV increasing to 17.9% and NPV still 97.5% for adults aged 40–49 years with ≥1 respiratory symptom. To illustrate the model output using hypothetical case scenarios, a 43-year-old female unskilled worker who smoked 20 cigarettes/day for 30 years had a 27% predicted probability for post-BD-AO at age 53 if she continued to smoke. The predicted risk was 42% if she had coexistent active asthma, but only 4.5% if she had quit after age 43.ConclusionThis novel and validated risk-prediction model could identify adults aged in their 40s at high 10-year COPD-risk in the general population with potential to facilitate active monitoring/intervention in predicted ‘COPD cases’ at a much earlier age.

Evaluating essential medicines for treating childhood cancers: availability, price and affordability study in Ghana

Introduction Access to childhood cancer medicines is a critical global health challenge. There is a lack of sufficient context-specific data in Ghana on access to essential medicines for treating childhood cancers. Here, we present an analysis of essential cancer medicine availability, pricing, and affordability using the pediatric oncology unit of a tertiary hospital as the reference point. Method Data on prices and availability of 20 strength-specific essential cancer medicines and eight non-cancer medicines were evaluated using the modified World Health Organization (WHO)/Health Action International method. Two pharmacies in the hospital and four private pharmacies around the hospital were surveyed. We assessed their median price ratio using the WHO international reference price guide. The number of days wages per the government daily wage salary was used to calculate the affordability of medicines. Results The mean availability of essential cancer medicines and non-cancer medicines at the hospital pharmacies were 27 and 38% respectively, and 75 and 84% respectively for private pharmacies. The median price ratio of cancer medicines was 1.85, and non-cancer medicines was 3.75. The estimated cost of medicines for treating a 30 kg child with Acute lymphoblastic leukaemia was GHȻ 4928.04 (US$907.56) and GHȻ 4878.00 (US$902.62) for Retinoblastoma, requiring 417 and 413-days wages respectively for the lowest-paid unskilled worker in Ghana. Conclusion The mean availability of cancer medicines at the public and private pharmacies were less than the WHO target of 80%. The median price ratio for cancer and non-cancer medicines was less than 4, yet the cost of medicines appears unaffordable in the local setting. A review of policies and the establishment of price control could improve availability and reduce medicines prices for the low-income population.

Availability and affordability of children essential medicines in health facilities of southern nations, nationalities, and people region, Ethiopia: key determinants for access

Background Children in resource-limited countries are more likely to die from treatable conditions than those in higher resource settings due to a lack of the right essential medicine at the right time. Globally millions of children die every year from conditions that could be treatable with existing medicines before they reach their fifth birthday. This study aimed in assessing the availability and affordability of essential medicine for children in selected health facilities of southern nations, nationalities, and peoples’ regions (SNNPR), Ethiopia. Method A medicine outlets-based cross-sectional study was conducted to assess the availability, affordability, and prices of the 30 selected essential medicines (EMs) for children in 30 public and 30 private medicine outlets in SNNPR from March 29 to May 5, 2019, applying WHO and Health Action International (HAI) tools. Availability was expressed as the percentage of sampled medicine outlets per sector that the surveyed medicine was found on the day of data collection. The amount of daily wages required for the lowest-paid government unskilled worker (LPGW) to buy one standard treatment of an acute condition or treatment for a chronic condition for a month was used to measure affordability and median price ratio for the price of EMs. The results Availability varied by sector, type of medication, and level of health facilities. The average availability of EM was 57.67% for the public sector and 53.67% for the private sector. Ceftriaxone, SOR, zinc sulfate, and cotrimoxazole were the most widely available types of medications in the two sectors. The median price ratios (MPR) for the cheapest drugs LP were 1.26 and 2.24 times higher than their International Reference Price (IRP) in the public and private sectors respectively. Eighty-two percent of LP medicines in the public and 91 % of LP medicines in the private sectors used in the treatments of prevalent common conditions in the region were unaffordable as they cost a day’s or more wages for the LPGW. Conclusion Availability, affordability, and price are determinant pre-requisite for EMs access. According to the current work, although fair availability was achieved, the observed high price affected affordability and hence access to EMs.

Availability and Affordability of Children Essential Medicines in Health Facilities of Southern Nations, Nationalities, And People Region, Ethiopia: Key Determinants for Access.

Background: Children in resource-limited countries are more likely to die from treatable conditions than those in higher resource settings due to a lack of the right essential medicine at the right time. Globally millions of children die every year from conditions that could be treatable with existing medicines before they reach their fifth birthday. This study aimed in assessing the availability and affordability of essential medicine for children in selected health facilities of southern nations, nationalities, and peoples’ regions (SNNPR), Ethiopia. Method: A medicine outlets-based cross-sectional study was conducted to assess the availability, affordability, and prices of the 30 selected EMs for children in 30 public and 30 private medicine outlets in SNNPR from March 29 to May 5, 2019, applying WHO and Health Action International (HAI) tools. Availability was expressed as the percentage of sampled medicine outlets per sector that the surveyed medicine was found on the day of data collection. The number of daily wages required for the lowest-paid government unskilled worker (LPGW) to buy one standard treatment of an acute condition or treatment for a chronic condition for a month was used to measure affordability and median price ratio for the price of EDs. Results: Availability was varied by sectors, type of medicines, and level of health facilities. The average availability of EMs was 57.67% in the public sector and 53.67% in private sectors. Ceftriaxone, ORS, zink sulfate, and cotrimoxazole were the most widely available medicine types in both sectors. The median price ratios (MPR) for lowest-priced (LP) medicines were 1.26 and 2.24 times higher than their international reference price (IRP) in the public and private sectors respectively. Eighty-two percent of LP medicines in the public and ninety-one percent of LP medicines in the private sectors used in the treatments of prevalent common conditions in the region were unaffordable as they cost a day’s or more wages for the LPGW.Conclusion: Availability, affordability, and price are determinant pre-requisite for EMs access. According to the current work, although fair availability was achieved, the observed high price affected affordability and hence access to EMs.

Out of Pocket Payment and Affordability of Medication for Geriatric Patients in Tehran, Iran

Background: Considering the importance of high out-of-pocket (OOP) payment (OOPP), as a marker of health system performance, and affordability of medications in the elderly, this study was conducted to determine these issues. Methods: In this cross-sectional study, prescriptions of patients aged 65 yr or older from 5 university-affiliated pharmacies in Tehran, Iran were evaluated from Jan to Mar 2014. Prescriptions were selected from four insurance organizations. We used the prescriptions data regarding patients’ demographics and the prescribers as well as the sales data for OOP. Affordability was calculated by considering the daily salary of an unskilled worker. Results: Totally, 1467 prescriptions were analyzed. Mean age of patients was 73.89(6.66) yr. Mean (SE) of reimbursable and OOPP of the prescriptions were 203820 (10831) and 230252 (10634) IRR (Iranian Rials) respectively (equivalent to 81.6 (4.33) and 92.17 (4.33) US$ respectively). Subspecialists imposed higher expenditures for patients and insurance organizations. Patients referred to the ophthalmologists paid less OOP. Nearly 50% of the total prescription costs was paid as OOP. The mean OOPP was averagely equal to 1.41(0.065) daily salary. These prescriptions were unaffordable for 36.2% of patients. Conclusion: The OOPP was higher than the insurance goal of 30% for outpatients in Iran. More than one-third of elderly patients could not afford their single prescription. Due to the health consequences of the unaffordability of medications, corrective actions are needed by the insurance organizations and the health system.

Economic Recession, Informal Sector and Skilled–Unskilled Wage Disparity in a Developing Economy: A Trade-Theoretical Analysis

The paper analyses some selective aspects of economic crises, namely skilled-sector recession, reversed international migration of labour and decline in foreign capital inflow on the informal sector employment and wage rate in developing economies and seeks to explain the non-monotonic effect on the informal sector both across nations and within nation across sectors. In so doing, we develop three-sector General Equilibrium models under two different scenarios which may apply to a large class of emerging market economies. In the first model, we have a traded informal export sector, and the role of the non-traded informal sector in the presence of credit market imperfection is analysed in the second model. Skilled-sector recession produces a favourable (unfavourable) effect on the workers employed in the traded informal sector (non-traded informal sector) due to an induced complementary relationship between the high-skilled export sector and the informal sector. A fall in emigration level of skilled or unskilled worker and a decline in foreign capital inflow hurt the workers in the informal traded sector, while the workers in the non-traded informal sector gain. The results of the paper reflect contradictions of an emerging economy, which is essentially hybrid economics in which capitalist nucleus has a conditional-conditioning relationship with an archaic structure. JEL Codes: F13, J31

Cardiovascular hospitalisation before and during the financial crisis among occupations in Taiwan

Background Cardiovascular diseases (CVD) were related to financial stress. Little was known about the effects of financial crisis on cardiovascular health by occupations. This study examined CVD hospitalisations before and during the 2008 financial crisis among five occupational groups in Taiwan. Methods Data were collected from the Taiwan Survey on Hypertension, Hyperglycemia and Hyperlipidaemia 2007, including 4,673 participants aged 20 and above, categorized into five types of occupations, i.e., professional & manager (PM), office clerk & administrative staff (OA), skilled work (SW), unskilled worker (UW) and non-worker (NW). We abstracted their CVD hospitalisation records in the three years before (September 2005 to August 2008) and during the 2008 financial crisis (September 2008 to August 2011) from the National Health Insurance Research Database. Using incidence rate ratios (IRRs), we compared CVD hospitalisation of the first, second, third year from September 2008 to the three-year average before September 2008 for five occupational groups. Random effect negative binomial models were performed to estimate IRRs. Results After adjusting for covariates including age, sex, education, smoking, alcohol drinking, exercise and body mass index, there was an increase of CVD hospitalisation incidence for NW in the first year of the financial crisis (IRR=1.46, 95% Confidence Interval [95% CI]=1.19-1.77); in the second year, SW had a raised risk of CVD hospitalisation (IRR= 2.71, 95% CI = 1.59-4.60). For all occupational groups, the incidence rates of CVD hospitalisation reached the peak in the third year (PM: IRR=2.68, 95% CI = 1.05-6.83; OA: IRR=2.70, 95% CI = 1.18-6.19; SW: IRR=5.13, 95% CI = 2.89-9.09; UW: IRR=2.12, 95% CI = 1.02-4.41; NW: IRR=1.85, 95% CI = 1.18-2.67). Conclusions CVD hospitalisation of all occupations were affected by the financial crisis; when non-workers were the early victims, skilled workers may be the most vulnerable in the 2008 financial crisis. Key messages This study investigated the effects of the 2008 financial crisis on cardiovascular disease hospitalization by five occupational types in Taiwan. All occupations, particularly skilled workers, were affected by the financial crisis.

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

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.