Assessing costs of a hypertension program in primary care: evidence from the HEARTS program in Mexico.

Objective: In 2021, Mexico launched the HEARTS program to improve the prevention and control of cardiovascular disease (CVD) risk factors in 20 primary care facilities in the states of Chiapas and Yucatán. This study projects the annual cost of program implementation and discusses budgetary implications for scaling up the program. Methods: We obtained district-level data on treatment protocols, medication costs, and other resources required to prevent and treat CVD. We used the HEARTS Costing Tool to estimate total and per-patient costs. A "partial implementation" scenario calculated the costs of implementing HEARTS if existing pharmacological treatment protocols are left in place. The second scenario, "full implementation," examined costs if programs use HEARTS pharmacological protocol. Results: Respectively in the partial and full implementation scenarios, total annual costs to implement and operate HEARTS were $260 023 ($32.1 per patient/year) and $255 046 ($31.5 per patient/year) in Chiapas, and $1 000 059 ($41.3 per patient/year) and $1 013 835 ($43.3 per patient/year) in Yucatán. In Chiapas, adopting HEARTS standardized treatment protocols resulted in a 9.7 % reduction in annual medication expenditures relative to maintaining status-quo treatment approaches. In Yucatán, adoption was $12 875 more expensive, in part because HEARTS hypertension treatment regimens were more intensive than status quo regimens. Conclusion: HEARTS in the Americas offers a standardized strategy to treating and controlling CVD risk factors. In Mexico, approaches that may lead to improved program affordability include adoption of the recommended HEARTS treatment protocols with preferred medications and task shifting of services from physicians to nurses and other providers.

Building the health-economic case for scaling up the WHO-HEARTS hypertension control package in low- and middle-income countries.

Generally, hypertension control programs are cost-effective, including in low- and middle-income countries, but country governments and civil society are not likely to support hypertension control programs unless value is demonstrated in terms of public health benefits, budget impact, and value-for-investment for the individual country context. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) established a standard, simplified Global HEARTS approach to hypertension control, including preferred antihypertensive medicines and blood pressure measurement devices. The objective of this study is to report on health economic studies of HEARTS hypertension control package cost (especially medication costs), cost-effectiveness, and budget impact and describe mathematical models designed to translate hypertension control program data into the optimal approach to hypertension care service delivery and financing, especially in low- and middle-income countries. Early results suggest that HEARTS hypertension control interventions are either cost-saving or cost-effective, that the HEARTS package is affordable at between US$ 18-44 per person treated per year, and that antihypertensive medicines could be priced low enough to reach a global standard of an average

En general, los programas de control de la hipertensión son costo-eficaces, incluso en los países de ingresos bajos y medios. Aun así, es poco probable que los gobiernos nacionales y la sociedad civil apoyen los programas de control de la hipertensión a menos que se demuestre su valor en términos de beneficios para la salud pública, impacto presupuestario y valor de la inversión para el contexto individual del país. La Organización Mundial de la Salud (OMS) y la Organización Panamericana de la Salud (OPS) implementaron la iniciativa HEARTS, un enfoque mundial estandarizado y simplificado para el control de la hipertensión, que incluye los medicamentos antihipertensivos y los dispositivos de medición de la presión arterial de preferencia. El objetivo de este estudio es informar sobre los estudios en el ámbito de la economía de la salud relativos al costo de las medidas de control de la hipertensión previstas en HEARTS (especialmente, de los medicamentos), la costo-efectividad y el impacto presupuestario, así como describir los modelos matemáticos diseñados para traducir los datos de este programa en un enfoque óptimo para la prestación y el financiamiento de los servicios de atención de la hipertensión, especialmente en países de ingresos medianos y bajos. Los primeros resultados indican que las intervenciones de HEARTS para el control de la hipertensión son de bajo costo o costo-eficaces, que el conjunto de medidas HEARTS es asequible, a un precio que oscila entre US$ 18 y US$ 44 al año por paciente tratado, y que los medicamentos antihipertensivos podrían tener un precio lo suficientemente bajo como para alcanzar un estándar medio mundial de

Geralmente, os programas de controle de hipertensão são custo-efetivos, inclusive em países de baixa e média renda, mas os governos dos países e a sociedade civil provavelmente não apoiarão tais programas a menos que demonstrem valor em termos de benefícios à saúde pública, impacto orçamentário e retorno sobre o investimento no contexto individual do país. A Organização Mundial da Saúde (OMS) e a Organização Pan-Americana da Saúde (OPAS) criaram a Global HEARTS, uma abordagem padrão e simplificada ao controle da hipertensão arterial, que inclui medicamentos anti-hipertensivos preferidos e dispositivos para aferição da pressão arterial preferidos. O objetivo deste estudo é relatar os estudos de economia em saúde que analisaram o custo (especialmente custos de medicamentos), custo-benefício e impacto orçamentário do pacote HEARTS para controle da hipertensão e descrever modelos matemáticos elaborados para traduzir os dados do programa de controle de hipertensão em uma abordagem ideal para a prestação e financiamento de serviços de atenção às pessoas com hipertensão, especialmente em países de baixa e média renda. Os primeiros resultados sugerem que as intervenções HEARTS para controle da hipertensão são de baixo custo ou custo-efetivas, que o pacote HEARTS é acessível (custando de US$ 18 a 44 por pessoa tratada por ano) e que o preço dos medicamentos anti-hipertensivos poderia ser baixo o suficiente para atingir uma média global de

Revisiting the association between worldwide implementation of the MPOWER package and smoking prevalence, 2008-2017.

BACKGROUND: We revisited the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017 and offered an in-depth understanding of differential outcomes for various country groups. METHODS: We used data from six rounds of the WHO Reports on the Global Tobacco Epidemic and calculated a composite MPOWER Score for each country in each period. We categorised the countries in four initial conditions based on their tobacco control preparedness measured by MPOWER score in 2008 and smoking burden measured by age-adjusted adult daily smoking prevalence in 2006: (1) High MPOWER - high prevalence (HM-HP). (2) High MPOWER - low prevalence (HM-LP). (3) Low MPOWER - high prevalence (LM-HP). (4) Low MPOWER - low prevalence (LM-LP). We estimated the association of age-adjusted adult daily smoking prevalence with MPOWER Score and cigarette tax rates using two-way fixed-effects panel regression models including both year and country fixed effects. RESULTS: A unit increase of the MPOWER Score was associated with 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence for HM-HP and HM-LP countries, respectively. When tax rate was controlled for separately from MPOWE, an increase in tax rate showed a negative association with daily smoking prevalence for HM-HP and LM-LP countries, while the MPOWE Score showed a negative association for all initial condition country groups except for LM-LP countries. CONCLUSION: A decade after the introduction of the WHO MPOWER package, we observed that the countries with higher initial tobacco control preparedness and higher smoking burden were able to reduce the adult daily smoking prevalence significantly.

Hypertension in women: the role of adolescent childbearing.

BACKGROUND: Adolescent childbearing is associated with various health risks to the mother and child, and potentially with adverse socioeconomic outcomes. However, little is known about the role of adolescent childbearing in maternal health outcomes in adulthood. This study investigates the link between childbirth in adolescence and later-life risk of hypertension among women in India. METHODS: We obtained nationally representative data on demographic and health outcomes for 442,845 women aged 25 to 49 from the India National Family Health Survey (NFHS) 2015-16. We assessed the difference in hypertension prevalence between women who gave birth in adolescence (age 10 to 19) and those who did not, for the full sample and various sub-samples, using linear probability models with controls for individual characteristics, hypertension risk factors, and geographic fixed effects. RESULTS: Nearly 40% of the women in the sample gave birth in adolescence. The adjusted probability of being hypertensive in adulthood was 2.3 percentage points higher for this group compared to women who did not give childbirth in adolescence. This added probability was larger for women who gave birth earlier in adolescence (4.8 percentage points) and for women who gave birth more than once in adolescence (3.4 percentage points). CONCLUSIONS: Adolescent childbearing was strongly associated with a higher probability of adult female hypertension in India. This finding illustrates the intertemporal relationship between health risk factors during the life cycle, informing the importance of addressing adverse early life events (e.g. child marriage and adolescent childbirth) for hypertension outcomes among women in India.

Long-distance effects of epidemics: Assessing the link between the 2014 West Africa Ebola outbreak and U.S. exports and employment.

Although the economic consequences of epidemic outbreaks to affected areas are often well documented, little is known about how these might carry over into the economies of unaffected regions. In the absence of direct pathogen transmission, global trade is one mechanism through which geographically distant epidemics could reverberate to unaffected countries. This study explores the link between global public health events and U.S. economic outcomes by evaluating the role of the 2014 West Africa Ebola outbreak in U.S. exports and exports-supported U.S. jobs, 2005-2016. Estimates were obtained using difference-in-differences models where sub-Saharan Africa countries were assigned to treatment and comparison groups based on their Ebola transmission status, with controls for observed and unobserved time-variant factors that may independently influence trends in trade. Multiple model specification checks were performed to ensure analytic robustness. The year of peak transmission, 2014, was estimated to result in $1.08 billion relative reduction in U.S. merchandise exports to Ebola-affected countries, whereas estimated losses in exports-supported U.S. jobs exceeded 1,200 in 2014 and 11,000 in 2015. These findings suggest that remote disruptions in health security might play a role in U.S. economic indicators, demonstrating the interconnectedness between global health and aspects of the global economy and informing the relevance of health security efforts.

Synergies between Communicable and Noncommunicable Disease Programs to Enhance Global Health Security.

Noncommunicable diseases are the leading cause of death and disability worldwide. Initiatives that advance the prevention and control of noncommunicable diseases support the goals of global health security in several ways. First, in addressing health needs that typically require long-term care, these programs can strengthen health delivery and health monitoring systems, which can serve as necessary platforms for emergency preparedness in low-resource environments. Second, by improving population health, the programs might help to reduce susceptibility to infectious outbreaks. Finally, in aiming to reduce the economic burden associated with premature illness and death from noncommunicable diseases, these initiatives contribute to the objectives of international development, thereby helping to improve overall country capacity for emergency response.

Chronic Health Outcomes and Prescription Drug Copayments in Medicaid.

BACKGROUND: Prescription drug copayments and cost-sharing have been linked to reductions in prescription drug use and expenditures. However, little is known about their effect on specific health outcomes. OBJECTIVE: To evaluate the association between prescription drug copayments and uncontrolled hypertension, uncontrolled hypercholesterolemia, and prescription drug utilization among Medicaid beneficiaries with these conditions. SUBJECTS: Select adults aged 20-64 from NHANES 1999-2012 in 18 states. MEASURES: Uncontrolled hypertension, uncontrolled hypercholesterolemia, and taking medication for each of these conditions. RESEARCH DESIGN: A differencing regression model was used to evaluate health outcomes among Medicaid beneficiaries in 4 states that introduced copayments during the study period, relative to 2 comparison groups-Medicaid beneficiaries in 14 states unaffected by shifts in copayment policy, and a within-state counterfactual group of low-income adults not on Medicaid, while controlling for individual demographic factors and unobserved state-level characteristics. RESULTS: Although uncontrolled hypertension and hypercholesterolemia declined among all low-income persons during the study period, the trend was less pronounced in Medicaid beneficiaries affected by copayments. After netting out concurrent trends in health outcomes of low-income persons unaffected by Medicaid copayment changes, we estimated that introduction of drug copayments in Medicaid was associated with an average rise in uncontrolled hypertension and uncontrolled hypercholesterolemia of 7.7 and 13.2 percentage points, respectively, and with reduced drug utilization for hypercholesterolemia. CONCLUSIONS: As Medicaid programs change in the years following the Affordable Care Act, prescription drug copayments may play a role as a lever for controlling hypertension and hypercholesterolemia at the population level.

Changes in cigarette prices, affordability, and brand-tier consumption after a tobacco tax increase in Thailand: Evidence from the Global Adult Tobacco Surveys, 2009 and 2011.

Despite the 2009 implementation of a tobacco tax increase in Thailand, smoking rates remained unchanged between 2009 and 2011. Prior evidence has linked cigarette tax increases to compensatory behaviours aimed at lowering the cost of smoking, such as switching to lower-priced cigarette brands. Using data from 2009 and 2011 Global Adult Tobacco Surveys in Thailand, we estimated unadjusted changes in cigarette prices paid, cigarette affordability, and consumption of cigarettes in three price categories classified as upper-, middle-, and lower-priced brand tiers (or price tertiles). We used ordered logit regression to analyse the correlates of price-tier choice and to estimate the change in price-tier consumption adjusted for demographic and region characteristics. Between 2009 and 2011, real cigarette prices increased, but the affordability of cigarettes remained unchanged overall. There was a significant reduction in the consumption of cigarette brands in the top price-tier overall, accompanied by increases in the consumption of brands in the bottom and middle price-tiers, depending on the region. Adjusted estimates from the logit models indicate that, on average, the proportion of smokers selecting brands from upper- and middle price-tiers decreased while consumption of lower price-tier brands increased during the study period. The estimated shifts in consumption from more expensive to less expensive cigarette brands and the overall lack of change in cigarette affordability in Thailand between 2009 and 2011 are both factors that may have contributed to the observed lack of change in smoking rates after the 2009 tax increase.

Trends in beverage prices following the introduction of a tax on sugar-sweetened beverages in Barbados.

A 10% excise tax on sugar sweetened beverages (SSBs) was implemented in Barbados in September 2015. A national evaluation has been established to assess the impact of the tax. We present a descriptive analysis of initial price changes following implementation of the SSB tax using price data provided by a major supermarket chain in Barbados over the period 2014-2016. We summarize trends in price changes for SSBs and non-SSBs before and after the tax using year-on-year mean price per liter. We find that prior to the tax, the year-on-year growth of SSB and non-SSB prices was very similar (approximately 1%). During the quarter in which the tax was implemented, the trends diverged, with SSB price growth increasing to 3% and that of non-SSBs decreasing slightly. The growth of SSB prices outpaced non-SSBs prices in each quarter thereafter, reaching 5.9% compared to <1% for non-SSBs. Future analyses will assess the trends in prices of SSBs and non-SSBs over a longer period and will integrate price data from additional sources to assess heterogeneity of post-tax price changes. A continued examination of the impact of the SSB tax in Barbados will expand the evidence base available to policymakers worldwide in considering SSB taxes as a lever for reducing the consumption of added sugar at the population level.

Effect of cigarette prices on smoking initiation and cessation in China: a duration analysis.

BACKGROUND: China is the world's largest producer and consumer of cigarettes. The status of tobacco as both a contributor to China's economy and a liability for the health of its population may complicate the use of taxes for addressing smoking in the country. Understanding how cigarette prices affect transitions in smoking behaviour in China can increase understanding of how China's high smoking rates can be influenced by tax policy. METHODS: In order to estimate the effect of cigarette prices on smoking initiation and cessation in China, we construct pseudo-longitudinal samples for duration analysis using data from the Global Adult Tobacco Survey China 2010. We use the historical variation in prices representative of 4 China regions over a 20-year period to identify the average price effect on the hazards of initiation and cessation while controlling for unobserved fixed and time-varying region characteristics. FINDINGS: We find that initiation rates fall in response to higher prices (with a price elasticity of initiation estimated at -0.95 for men and -1.07 overall). CONCLUSIONS: The effect of prices on smoking in China is likely to occur through averting initiation over time. At the population level, cessation behaviour may be less responsive to price increases as the wide range of cigarette prices in China may provide relatively high opportunity for switching to lower priced brands.

Approaches for controlling illicit tobacco trade--nine countries and the European Union.

An estimated 11.6% of the world cigarette market is illicit, representing more than 650 billion cigarettes a year and $40.5 billion in lost revenue. Illicit tobacco trade refers to any practice related to distributing, selling, or buying tobacco products that is prohibited by law, including tax evasion (sale of tobacco products without payment of applicable taxes), counterfeiting, disguising the origin of products, and smuggling. Illicit trade undermines tobacco prevention and control initiatives by increasing the accessibility and affordability of tobacco products, and reduces government tax revenue streams. The World Health Organization (WHO) Protocol to Eliminate Illicit Trade in Tobacco Products, signed by 54 countries, provides tools for addressing illicit trade through a package of regulatory and governing principles. As of May 2015, only eight countries had ratified or acceded to the illicit trade protocol, with an additional 32 needed for it to become international law (i.e., legally binding). Data from multiple international sources were analyzed to evaluate the 10 most commonly used approaches for addressing illicit trade and to summarize differences in implementation across select countries and the European Union (EU). Although the WHO illicit trade protocol defines shared global standards for addressing illicit trade, countries are guided by their own legal and enforcement frameworks, leading to a diversity of approaches employed across countries. Continued adoption of the methods outlined in the WHO illicit trade protocol might improve the global capacity to reduce illicit trade in tobacco products.

Cigarette prices and smoking prevalence after a tobacco tax increase--Turkey, 2008 and 2012.

Raising the price of tobacco products has been shown to reduce tobacco consumption in the United States and other high-income countries, and evidence of this impact has been growing for low- and middle-income countries as well. Turkey is a middle-income country surveyed by the Global Adult Tobacco Survey (GATS) twice in a 4-year period, in 2008 and 2012. During this time, the country introduced a policy raising its Special Consumption Tax on Tobacco and implemented a comprehensive tobacco control program banning smoking in public places, banning advertising, and introducing graphic health warnings. The higher tobacco tax took effect in early 2010, allowing sufficient time for subsequent changes in prices and smoking to be observed by the time of the 2012 GATS. This report uses data from GATS Turkey to examine how cigarette prices changed after the 2010 tax increase, describe the temporally associated changes in smoking prevalence, and learn whether this smoking prevalence changed more in some demographic groups than others. From 2008 to 2012, the average price paid for cigarettes increased by 42.1%, cigarettes became less affordable, and smoking prevalence decreased by 14.6%. The largest reduction in smoking was observed among persons with lower socioeconomic status (SES), highlighting the potential role of tax policy in reducing health disparities across socioeconomic groups.

Who quits? An overview of quitters in low- and middle-income countries.

INTRODUCTION: Using the Global Adult Tobacco Surveys from 14 primarily low- and middle-income countries, we describe the association between the probability of being a recent quitter and a number of demographic and policy-relevant factors such as exposure to warning labels, work-site smoking bans, antismoking media messaging, tobacco marketing, and current cigarette and bidi prices. METHODS: Logistic regressions were used to examine the potential correlates of recent quitting and recent quit attempts. RESULTS: After accounting for country-specific attributes in pooled analyses, we found that higher rates of exposure to work-site smoking bans are associated with higher odds of being a quitter (odds ratio [OR] with 95% confidence interval [CI] = 1.13 [1.04, 1.22]). Exposure to antismoking media messaging (OR with 95% CI = 1.08 [1.00, 1.17]), work-site smoking bans (OR with 95% CI = 1.11 [0.99, 1.26]), and warning labels (OR with 95% CI = 1.03 [1.01, 1.05]); cigarette prices (OR with 95% CI = 1.01 [1.00, 1.02]), and bidi prices (OR with 95% CI =1.17 [1.11, 1.22]) are factors associated with higher odds of recent quit attempts in the pooled analysis. These effects vary by country. Exposure to warning labels is found to be associated with greater likelihood of recent quitting in Egypt (OR with 95% CI = 3.20 [1.53, 6.68]), and the positive association between exposure to work-site smoking bans and quitting is particularly strong for Southeast Asia (OR with 95% CI = 1.20 [1.06, 1.35]) and Asia Pacific countries (OR with 95% CI = 1.85 [0.93, 3.68]). Additionally, exposure to tobacco industry marketing is significantly associated with smaller odds of quitting in Asia Pacific (OR with 95% CI = 0.83 [0.79, 0.87]) and Latin American countries (OR with 95% CI = 0.78 [0.74, 0.82]). CONCLUSIONS: Although our results vary by country, they generally suggest that greater exposure to tobacco control polices is significantly associated with quitting.

The impact of cigarette excise taxes on smoking cessation rates from 1994 to 2010 in Poland, Russia, and Ukraine.

INTRODUCTION: We studied the impact of cigarette excise taxes on the rates of smoking cessation with data from 3 neighboring Eastern European countries (Russia, Poland, and Ukraine) during the post-transitional period of the 1990s and 2000s. METHODS: Using Global Adult Tobacco Survey data from 11,106 former and current smokers, we estimated the impact of cigarette taxes on the smokers' likelihood of quitting over time. We first transformed the survey's cross-sectional data into a pseudo-longitudinal format in which the average observation period for individual subjects was 12 years and then employed duration analysis. RESULTS: We estimated that a 10% increase in cigarette taxes during the observation period increased the probability of smoking cessation among smokers in these countries by 1.6% to 2.3%. CONCLUSIONS: Cigarette tax increases have played a significant role in driving smoking cessation in Poland, Russia, and Ukraine. Further increases in cigarette excise taxes are likely to encourage further cessation and thus impact the prevalence of smoking in the region.

Cigarette excise tax structure and cigarette prices: evidence from the global adult tobacco survey and the U.S. National Adult Tobacco Survey.

INTRODUCTION: The importance of tobacco tax structure in determining the relative prices of different tobacco products and brands has become increasingly recognized. The structuring of tobacco tax across products and brands within a country can impact the variability of prices within a country, shaping consumption and influencing tobacco users' incentives to switch down to cheaper alternatives in response to tax and price increases. METHODS: Brand-specific data on the average prices paid for the top 5 cigarette brands in 13 countries were obtained from the Global Adult Tobacco Survey, and for the United States, data were obtained from the National Adult Tobacco Survey. The variability of cigarette prices paid across brands was analyzed in the context of each country's tobacco tax structure. RESULTS: Countries with simpler cigarette tax structures, particularly those that emphasize specific taxes and do not involve tier-based taxes, exhibit less variability in the prices smokers pay for cigarettes across brands. CONCLUSIONS: Increases in cigarette taxes in countries with simpler tax structures will be more effective in reducing cigarette smoking and its health and economic consequences than comparable tax increases in countries where tax structures are more complicated and there are greater opportunities for switching to cheaper brands in order to avoid a tax increase.

Exploring the relationship between cigarette prices and smoking among adults: a cross-country study of low- and middle-income nations.

INTRODUCTION: Evidence on the relationship between cigarette prices and adult smoking in low- and middle-income countries (LMICs) is relatively limited. This study offers new descriptive evidence on this relationship using data from a set of 13 LMICs. METHODS: We use Global Adult Tobacco Survey (GATS) cross-country data from approximately 200,000 participants aged 15 and older. Estimates on the relationship between prices and adult smoking were obtained from logit models of smoking participation and ordinary least squares models of conditional cigarette demand. RESULTS: Higher prices were associated with lower demand across countries, in terms of both smoking prevalence and daily number of cigarettes smoked among smokers. Our estimates suggest that the total price elasticity of cigarette demand in LMICs is approximately -0.53. We find that higher socioeconomic status (SES), represented through wealth and education effects is associated with lower chance of smoking overall, but among existing smokers, it may be associated with a larger number of cigarettes smoked. CONCLUSIONS: After controlling for a set of individual demographic and country characteristics, cigarette prices retain a significant role in shaping cigarette demand across LMICs. Because higher SES is associated with a reduced chance of smoking overall but also with increased daily consumption among current smokers, optimal tobacco tax policies in LMICs may face an added need to accommodate to shifting SES structures within the populations of these countries.

A cross-country study of cigarette prices and affordability: evidence from the Global Adult Tobacco Survey.

OBJECTIVE: To describe the characteristics of two primary determinants of cigarette consumption: cigarette affordability and the range of prices paid for cigarettes (and bidis, where applicable) in a set of 15 countries. From this cross-country comparison, identify places where opportunities may exist for reducing consumption through tax adjustments. DATA: Self-response data from 45,838 smokers from 15 countries, obtained from the Global Adult Tobacco Survey (GATS) 2008-2011. DESIGN: Using self-response data on individual cigarette expenditure and consumption, we construct a measure of the average cigarette price smokers pay for manufactured cigarettes (and bidis, where applicable) in 15 countries. We use these prices to evaluate cigarette affordability and the range of prices available in each country. These survey-derived measures of cigarette price and affordability are uniquely suited for cross-country comparison because they represent each country's distinctive mix of individual consumption characteristics such as brand choice, intensity of consumption, and purchasing behavior. RESULTS: In this sample of countries, cigarettes are most affordable in Russia, which has the most room for tobacco tax increase. Affordability is also relatively high in Brazil and China for cigarettes, and in India and Bangladesh for bidis. Although the affordability of cigarettes in India is relatively low, the range of cigarette prices paid is relatively high, providing additional evidence to support the call for simplifying the existing tax structure and reducing the width of price options. China has both high affordability and wide price ranges, suggesting multiple opportunities for reducing consumption through tax adjustments.

Barriers to accessibility of medicines for hyperlipidemia in low- and middle-income countries.

Despite the high burden of hyperlipidemia and the effectiveness of treatment, evidence suggests that the accessibility of hyperlipidemia medicines can be low in many low- and middle-income countries (LMICs). The aim of this study was to identify common barriers to the accessibility of medicines for hyperlipidemia in LMICs. A multimethod analysis and multiple data sources were used to assess the accessibility and barriers of medicines for hyperlipidemia in selected LMICs. The overall median availability of statins for hyperlipidemia in public facilities was 0% and 5.4%, for originators and generics, respectively. In private facilities, median availability was 13.3% and 35.9%, for originators and generics, respectively. Statin availability was lowest in Africa and South-East Asia. Private facilities generally had higher availability than public facilities. Statins are less affordable in lower-income countries, costing around 6 days' wages per month. Originator statins are less affordable than generics in countries of all income-levels. The median cost for statin medications per month ranges from a low of $1 in Kenya to a high of $62 in Mexico, with most countries having a median monthly cost between $3.6 and $17.0. The key informant interviews suggested that accessibility to hyperlipidemia medicines in LMICs faces barriers in multiple dimensions of health systems. The availability and affordability of statins are generally low in LMICs. Several steps could be implemented to improve the accessibility of hyperlipidemia medicines, including private sector engagement, physician education, investment in technology, and enhancement of health systems.

Scaling hypertension treatment in 24 low-income and middle-income countries: economic evaluation of treatment decisions at three blood pressure cut-points.

OBJECTIVE: Estimate the incremental costs and benefits of scaling up hypertension care in adults in 24 select countries, using three different systolic blood pressure (SBP) treatment cut-off points-≥140, ≥150 and ≥160 mm Hg. INTERVENTION: Strengthening the hypertension care cascade compared with status quo levels, with pharmacological treatment administered at different cut-points depending on the scenario. TARGET POPULATION: Adults aged 30+ in 24 low-income and middle-income countries spanning all world regions. PERSPECTIVE: Societal. TIME HORIZON: 30 years. DISCOUNT RATE: 4%. COSTING YEAR: 2020 USD. STUDY DESIGN: DATA SOURCES: Institute for Health Metrics and Evaluation's Epi Visualisations database-country-specific cardiovascular disease (CVD) incidence, prevalence and death rates. Mean SBP and prevalence-National surveys and NCD-RisC. Treatment protocols-WHO HEARTS. Treatment impact-academic literature. Costs-national and international databases. OUTCOME MEASURES: Health outcomes-averted stroke and myocardial infarction events, deaths and disability-adjusted life-years; economic outcomes-averted health expenditures, value of averted mortality and workplace productivity losses. RESULTS OF ANALYSIS: Across 24 countries, over 30 years, incremental scale-up of hypertension care for adults with SBP≥140 mm Hg led to 2.6 million averted CVD events and 1.2 million averted deaths (7% of expected CVD deaths). 68% of benefits resulted from treating those with very high SBP (≥160 mm Hg). 10 of the 12 highest-income countries projected positive net benefits at one or more treatment cut-points, compared with 3 of the 12 lowest-income countries. Treating hypertension at SBP≥160 mm Hg maximised the net economic benefit in the lowest-income countries. LIMITATIONS: The model only included a few hypertension-attributable diseases and did not account for comorbid risk factors. Modelled scenarios assumed ambitious progress on strengthening the care cascade. CONCLUSIONS: In areas where economic considerations might play an outsized role, such as very low-income countries, prioritising treatment to populations with severe hypertension can maximise benefits net of economic costs.