Antimicrobial stewardship capacity and antibiotic utilisation practices in the Cape Coast Teaching Hospital, Ghana: A point prevalence survey study.

INTRODUCTION: Antimicrobial resistance (AMR) is a global threat that necessitates coordinated strategies to improve antibiotic prescribing and reduce AMR. A key activity is ascertaining current prescribing patterns in hospitals to identify targets for quality improvement programmes. METHODS: The World Health Organisation point prevalence survey methodology was used to assess antibiotic prescribing in the Cape Coast Teaching Hospital. All core variables identified by the methodology were recorded. RESULTS: A total of 78.8% (82/104) patients were prescribed at least one antibiotic, with the majority from adult surgical wards (52.14%). Significantly longer hospital stays were associated with patients who underwent surgery (p = 0.0423). "Access" antibiotics dominated total prescriptions (63.8%, 132/207) with ceftriaxone, cefuroxime, and ciprofloxacin being the most prescribed "Watch" antibiotics. The most common indications were for medical prophylaxis (59.8%, 49/82) and surgical prophylaxis (46.3%, 38/82). Over one-third of surgical prophylaxis (34.2%, 13/38) indications extended beyond one day. There was moderate documentation of reasons for antibiotic treatment in patient notes (65.9%, 54/82), and targeted therapy after samples were taken for antimicrobial susceptibility testing (41.7%, 10/24). Guideline compliance was low (25%) where available. CONCLUSIONS: There was high use of antibiotics within the hospital which needs addressing. Identified quality targets include developing surgical prophylaxis guidelines, reviewing "Watch" antibiotic prescribing, and assessing antibiotic durations for patients on two or more antibiotics. Organizational-level deficiencies were also identified that need addressing to help instigate ASPs. These can be addressed by developing local prescribing protocols and antibiotic stewardship policies in this hospital and wider in Ghana and across Africa.

Quality of ethnicity data within Scottish health records and implications of misclassification for ethnic inequalities in severe COVID-19: a national linked data study.

BACKGROUND: We compared the quality of ethnicity coding within the Public Health Scotland Ethnicity Look-up (PHS-EL) dataset, and other National Health Service datasets, with the 2011 Scottish Census. METHODS: Measures of quality included the level of missingness and misclassification. We examined the impact of misclassification using Cox proportional hazards to compare the risk of severe coronavirus disease (COVID-19) (hospitalization & death) by ethnic group. RESULTS: Misclassification within PHS-EL was higher for all minority ethnic groups [12.5 to 69.1%] compared with the White Scottish majority [5.1%] and highest in the White Gypsy/Traveller group [69.1%]. Missingness in PHS-EL was highest among the White Other British group [39%] and lowest among the Pakistani group [17%]. PHS-EL data often underestimated severe COVID-19 risk compared with Census data. e.g. in the White Gypsy/Traveller group the Hazard Ratio (HR) was 1.68 [95% Confidence Intervals (CI): 1.03, 2.74] compared with the White Scottish majority using Census ethnicity data and 0.73 [95% CI: 0.10, 5.15] using PHS-EL data; and HR was 2.03 [95% CI: 1.20, 3.44] in the Census for the Bangladeshi group versus 1.45 [95% CI: 0.75, 2.78] in PHS-EL. CONCLUSIONS: Poor quality ethnicity coding in health records can bias estimates, thereby threatening monitoring and understanding ethnic inequalities in health.

Selling antibiotics without prescriptions among community pharmacies and drug outlets: a simulated client study from Ghana.

BACKGROUND: Selling antibiotics without prescriptions is mostly illegal worldwide, including in Ghana, and promotes antimicrobial resistance. We evaluated the prevalence and practice of selling antibiotics without prescriptions among community pharmacies (CPs) and drug outlets, for the first time, in Ghana to quantify and characterize this issue to inform future interventions. RESEARCH DESIGN AND METHODS: Two scenarios utilizing the Simulated Client Methodology were enacted: an upper respiratory tract infection of viral origin (scenario one); and pediatric diarrhea (scenario two). CPs/Outlets were selected by stratified proportional random sampling from four metropolitan cities (~14% of the total Ghanaian population). Selling of antibiotics was assessed at three demand levels and its overall prevalence was estimated, then stratified by the study variables. RESULTS: Out of the 265 sampled CPs/outlets, the prevalence of selling antibiotic without prescription was 88.3% (n = 234/265), with variations not only across the four regions [92.5% (n = 123/133) in Kumasi, 87.5% (n = 14/16) in Cape Coast, 84.1% (n = 69/82) in Accra, and 82.4% (n = 28/34) in Tamale] but also across CPs [90% (n = 121/134)] and drug outlets [86% (n = 113/131)]. CONCLUSIONS: A very high prevalence/sub-optimal practice of selling antibiotics without prescriptions was found. This highlights the need to increase compliance with antibiotic dispensing legislation through evidence-based interventions including education of key stakeholders.

Estimated indirect costs of haemodialysis versus peritoneal dialysis from a patients' perspective at an Academic Hospital in Pretoria, South Africa.

In South Africa (SA), patients with kidney failure can be on either haemodialysis (HD), which is performed by a healthcare professional in a hospital thrice weekly; or peritoneal dialysis (PD), which can performed daily at home. There needs to be more studies within the South African healthcare sector on the cost of kidney failure and especially the indirect costs associated with patients being on dialysis to provide future guidance. This study aimed to determine and compare the indirect costs associated with HD and PD from the patients' perspective at an Academic Hospital in Pretoria. The study used a cross-sectional prospective quantitative study design. The researcher used face-to-face interviews to collect data and the human capital approach to calculate productivity losses. The study population included all patients over 18 receiving HD or PD for over three months; 54 patients participated (28 on HD and 26 on PD). The study lasted seven months, from September 2020 to March 2021. Haemodialysis patients incurred greater productivity losses per annum ($8127.55) compared to PD (R$3365.34); the difference was statistically significant with a P-value of p < 0.001. More HD (96.4%) patients were unemployed than (76.9%) PD patients.

Current rates of purchasing of antibiotics without a prescription across sub-Saharan Africa; rationale and potential programmes to reduce inappropriate dispensing and resistance.

INTRODUCTION: Antimicrobial resistance (AMR) is a global concern. Currently, the greatest mortality due to AMR is in Africa. A key driver continues to be high levels of dispensing of antibiotics without a prescription. AREAS COVERED: A need to document current rates of dispensing, their rationale and potential ways forward including antimicrobial stewardship programmes (ASPs). A narrative review was undertaken. The highest rates of antibiotic purchasing were in Eritrea (up to 89.2% of antibiotics dispensed), Ethiopia (up to 87.9%), Nigeria (up to 86.5%), Tanzania (up to 92.3%) and Zambia (up to 100% of pharmacies dispensing antibiotics without a prescription). However, considerable variation was seen with no dispensing in a minority of countries and situations. Key drivers of self-purchasing included high co-payment levels for physician consultations and antibiotic costs, travel costs, convenience of pharmacies, patient requests, limited knowledge of antibiotics and AMR and weak enforcement. ASPs have been introduced in some African countries along with quality targets to reduce inappropriate dispensing, centering on educating pharmacists and patients. EXPERT OPINION: ASP activities need accelerating among community pharmacies alongside quality targets, with greater monitoring of pharmacists' activities to reduce inappropriate dispensing. Such activities, alongside educating patients and healthcare professionals, should enhance appropriate dispensing of antibiotics and reduce AMR.

Ethnic inequalities in positive SARS-CoV-2 tests, infection prognosis, COVID-19 hospitalisations and deaths: analysis of 2 years of a record linked national cohort study in Scotland.

BACKGROUND: This study aims to estimate ethnic inequalities in risk for positive SARS-CoV-2 tests, COVID-19 hospitalisations and deaths over time in Scotland. METHODS: We conducted a population-based cohort study where the 2011 Scottish Census was linked to health records. We included all individuals ≥ 16 years living in Scotland on 1 March 2020. The study period was from 1 March 2020 to 17 April 2022. Self-reported ethnic group was taken from the census and Cox proportional hazard models estimated HRs for positive SARS-CoV-2 tests, hospitalisations and deaths, adjusted for age, sex and health board. We also conducted separate analyses for each of the four waves of COVID-19 to assess changes in risk over time. FINDINGS: Of the 4 358 339 individuals analysed, 1 093 234 positive SARS-CoV-2 tests, 37 437 hospitalisations and 14 158 deaths occurred. The risk of COVID-19 hospitalisation or death among ethnic minority groups was often higher for White Gypsy/Traveller (HR 2.21, 95% CI (1.61 to 3.06)) and Pakistani 2.09 (1.90 to 2.29) groups compared with the white Scottish group. The risk of COVID-19 hospitalisation or death following confirmed positive SARS-CoV-2 test was particularly higher for White Gypsy/Traveller 2.55 (1.81-3.58), Pakistani 1.75 (1.59-1.73) and African 1.61 (1.28-2.03) individuals relative to white Scottish individuals. However, the risk of COVID-19-related death following hospitalisation did not differ. The risk of COVID-19 outcomes for ethnic minority groups was higher in the first three waves compared with the fourth wave. INTERPRETATION: Most ethnic minority groups were at increased risk of adverse COVID-19 outcomes in Scotland, especially White Gypsy/Traveller and Pakistani groups. Ethnic inequalities persisted following community infection but not following hospitalisation, suggesting differences in hospital treatment did not substantially contribute to ethnic inequalities.

Assessment of the quality of antimicrobial prescribing among hospitalized patients in a teaching hospital in Ghana: findings and implications.

OBJECTIVE: There is a need to assess the quality of antimicrobial prescribing in hospitals as a first step toward improving future prescribing to reduce antimicrobial resistance (AMR). This is in line with Ghana's National Action Plan. METHODS: A point prevalence survey of antimicrobial use was undertaken at the adult medical, surgical, and pediatric wards of Tamale Teaching Hospital using the standardized Global Point Prevalence Survey (GPPS) tool. Key target areas include adherence to current guidelines, limiting the prescribing of 'Watch' antibiotics with their greater resistance potential, and limiting the prescribing of antibiotics post-operatively to prevent surgical site infections (SSIs). RESULTS: Out of 217 patients' medical records assessed, 155 (71.4%) patients were prescribed antimicrobials. The rates were similar among children (73.9%) and adults (70.3%). Most of the antibiotics prescribed were in the WHO 'Watch' group (71.0%) followed by those in the 'Access' group (29%). Out of the 23 cases indicated for surgical antimicrobial prophylaxis to prevent SSIs, the majority (69.6%) were given doses for more than 1 day, with none receiving a single dose. This needs addressing to reduce AMR and costs. Guideline compliance with the current Ghanaian Standard Treatment Guidelines (GSTG) for managing infections was also low (28.7%). The type of indication was the only independent predictor of guideline compliance (aOR = 0.013 CI 0.001-0.127, p-value = 0.001). CONCLUSION: Given current concerns with antimicrobial prescribing in this hospital, deliberate efforts must be made to improve the appropriateness of prescribing to reduce AMR via targeted antimicrobial stewardship programs.

Trends in the Cost of Medicines, Consultation Fees and Clinic Visits in Malaysia's Private Primary Healthcare System: Employer Health Insurance Coverage.

Objective: To examine trends in the cost of medicines, consultation fees and clinic visits among the employees covered by the employer health insurance in Malaysia's private primary healthcare system in Malaysia. Designs: Retrospective cross-sectional study. Setting: PMCare claims database from January 2016 to August 2019. Participants: A total of 83,556 outpatient clinic visits involving 10,150 IIUM employees of the International Islamic University Malaysia (IIUM) to private general practitioners (GPs). During the study period, IIUM adopts the incentive structure of capping coverage at Ringgit Malaysia (RM) 45/outpatient visit (USD 10.58) to cover for consultation fees and medicine costs. Main Outcome Measures: The monthly percentage change in the number of clinic visits, medicine costs, consultation fees and total costs between January 2016 and August 2019. A simple linear regression using Stata v15.1 was also performed to measure the association between the characteristics of the prescribed medicines and medicine charges. Results: The number of clinic visits per patient increased by 17% from January 2016 to August 2019, with consultation fees increasing by 113.9% and total costs by 7.9% per clinic visit per patient. Conversely, the cost of medicines and the number of medicines prescribed per clinic visit per patient decreased by 39.7% and 6.3%, respectively. Conclusion: Within the incentive structure of capping the total amount of coverage per clinic visit, medicine costs were reduced by decreasing the number of medicines prescribed, to offset the increased consultation fees. This may create perverse incentives that affect medicine use with negative consequences for the health system and health insurers.

Perceptions of and Preparedness for the Application of Pharmacoeconomics in Practice, among Final Year Bachelor of Pharmacy Students in South Africa: A National Cross-Sectional Study.

For the improvement of access to health, many countries including South Africa, have adopted universal healthcare. However, this requires skills to apply health technology assessments for the facilitation of investment decisions. This study aimed to ascertain final year Bachelor of Pharmacy (BPharm) students' perceptions of the relevance of pharmacoeconomics in pharmacy practice, and their level of preparedness to apply pharmacoeconomic principles, using a quantitative, cross-sectional, and descriptive design. Data were collected using a self-administered questionnaire over 12 months, and included student demographics, knowledge about pharmacoeconomics and its applicability in practice, as well as students' satisfaction with the appropriateness of the curriculum content. Five of nine universities offering pharmacy education took part. The overallstudent response rate was 38.1% (189/496), with 26.2% (45/172) of students signifying a good understanding of basic pharmacoeconomic concepts. Pharmacoeconomics application in South Africa was perceived to be relevant by 87.5% (140/160); however, 47.0% (79/168) felt they were not prepared to apply pharmacoeconomic principles in medicine management, and 86.7% (137/158) wanted to acquire additional pharmacoeconomic knowledge. Whilst students' perceptions of the relevance of pharmacoeconomics were positive, results indicated a gap in knowledge, understanding, and application. Addressing this gap may increase students' preparedness to apply pharmacoeconomic principles and better equip them for the practical application of pharmacoeconomics post qualification. Consequently, we have started this process.

The impact of the COVID-19 pandemic on cardiovascular disease prevention and management.

How the Coronavirus Disease 2019 (COVID-19) pandemic has affected prevention and management of cardiovascular disease (CVD) is not fully understood. In this study, we used medication data as a proxy for CVD management using routinely collected, de-identified, individual-level data comprising 1.32 billion records of community-dispensed CVD medications from England, Scotland and Wales between April 2018 and July 2021. Here we describe monthly counts of prevalent and incident medications dispensed, as well as percentage changes compared to the previous year, for several CVD-related indications, focusing on hypertension, hypercholesterolemia and diabetes. We observed a decline in the dispensing of antihypertensive medications between March 2020 and July 2021, with 491,306 fewer individuals initiating treatment than expected. This decline was predicted to result in 13,662 additional CVD events, including 2,281 cases of myocardial infarction and 3,474 cases of stroke, should individuals remain untreated over their lifecourse. Incident use of lipid-lowering medications decreased by 16,744 patients per month during the first half of 2021 as compared to 2019. By contrast, incident use of medications to treat type 2 diabetes mellitus, other than insulin, increased by approximately 623 patients per month for the same time period. In light of these results, methods to identify and treat individuals who have missed treatment for CVD risk factors and remain undiagnosed are urgently required to avoid large numbers of excess future CVD events, an indirect impact of the COVID-19 pandemic.

Data Resource Profile: The Hospital Electronic Prescribing and Medicines Administration (HEPMA) National Data Collection in Scotland.

Introduction: To support both electronic prescribing and documentation of medicines administration in secondary care, hospitals in Scotland are currently implementing the Hospital Electronic Prescribing and Medicines Administration (HEPMA) software. Driven by the COVID-19 pandemic, agreements have been put in place to centrally collate data stemming from the operational HEPMA system. The aim was to develop a national data resource based on records created in secondary care, in line with pre-existing collections of data from primary care. Methods: HEPMA is a live clinical system and updated on a continuous basis. Data is automatically extracted from local systems at least weekly and, in most cases, on a nightly basis, and integrated into the national HEPMA dataset. Subsequently, the data are subject to quality checks including data consistency and completeness. Records contain a unique patient identified (Community Health Index number), enabling linkage to other routinely collected data including primary care prescriptions, hospital admission episodes, and death records. Results: The HEPMA data resource captures and compiles information on all medicines prescribed within the ward/hospital covered by the system; this includes medicine name, formulation, strength, dose, route, and frequency of administration, and dates and times of prescribing. In addition, the HEPMA dataset also captures information on medicines administration, including dates and time of administration. Data is available from January 2019 onwards and held by Public Health Scotland. Conclusion: The national HEPMA data resource supports cross-sectional/point-prevalence studies including drug utilisation studies, and also offers scope to conduct longitudinal studies, e.g., cohort and case-control studies. With the possibility to link to other relevant datasets, additional areas of interest may include health policy evaluations and health economics studies. Access to data is subject to approval; researchers need to contact the electronic Data Research and Innovation Service (eDRIS) in the first instance.

What patient assessment skills do pharmacist independent prescribers require to prescribe immunomodulators in myeloma?

AIM: To gain consensus on the patient assessment skills required by pharmacist independent prescribers prescribing immunomodulators in myeloma across National Health Service Scotland. METHODS: This was a two-phase study which used nominal group technique to gain local consensus followed by a two-round eDelphi questionnaire to gain national consensus across all cancer networks. SETTING: This project was conducted across the three cancer networks within NHS Scotland: South East Scotland Cancer Network; West of Scotland Cancer Network and North Cancer Alliance. SUBJECTS: Participants were invited from each cancer network (South East Scotland Cancer Network, West of Scotland Cancer Network and North Cancer Alliance) and included haematology consultants, haematology specialist registrars, haematology advanced nurse practitioners and haematology pharmacists. RESULTS: There were five participants in the nominal group technique. Twenty-two out of 31 patient assessment skills gained local consensus, seven patient assessment skills did not gain consensus and two patient assessment skills were deemed irrelevant. There were 12 and 14 participants in round one and two of the eDelphi questionnaire, respectively. Twenty-nine patient assessment skills were included in the first-round questionnaire and 21 gained consensus. The remaining eight patient assessment skills were included in round two where seven did not achieve consensus and one achieved disagreement consensus. CONCLUSION: This research outlines 21 patient assessment skills required for pharmacist independent prescribers to prescribe immunomodulators for myeloma patients according to haematology specialists in Scotland. Discussion on patient assessment skills without consensus showed that the pharmacist independent prescribers would have a shared responsibility with the consultant. This work should inform the development of a competency framework to allow training of pharmacist independent prescribers in Scotland. Some patient assessment skills could be transferrable for pharmacist independent prescribers prescribing systemic anti-cancer therapy for other haematological malignancies.

Utilisation Trend of Long-Acting Insulin Analogues including Biosimilars across Europe: Findings and Implications.

BACKGROUND: Diabetes mellitus rates and associated costs continue to rise across Europe enhancing health authority focus on its management. The risk of complications is enhanced by poor glycaemic control, with long-acting insulin analogues developed to reduce hypoglycaemia and improve patient convenience. There are concerns though with their considerably higher costs, but moderated by reductions in complications and associated costs. Biosimilars can help further reduce costs. However, to date, price reductions for biosimilar insulin glargine appear limited. In addition, the originator company has switched promotional efforts to more concentrated patented formulations to reduce the impact of biosimilars. There are also concerns with different devices between the manufacturers. As a result, there is a need to assess current utilisation rates for insulins, especially long-acting insulin analogues and biosimilars, and the rationale for patterns seen, among multiple European countries to provide future direction. Methodology. Health authority databases are examined to assess utilisation and expenditure patterns for insulins, including biosimilar insulin glargine. Explanations for patterns seen were provided by senior-level personnel. RESULTS: Typically increasing use of long-acting insulin analogues across Europe including both Western and Central and Eastern European countries reflects perceived patient benefits despite higher prices. However, activities by the originator company to switch patients to more concentrated insulin glargine coupled with lowering prices towards biosimilars have limited biosimilar uptake, with biosimilars not currently launched in a minority of European countries. A number of activities were identified to address this. Enhancing the attractiveness of the biosimilar insulin market is essential to encourage other biosimilar manufacturers to enter the market as more long-acting insulin analogues lose their patents to benefit all key stakeholder groups. CONCLUSIONS: There are concerns with the availability and use of insulin glargine biosimilars among European countries despite lower costs. This can be addressed.

Validity of Pneumonia Severity Assessment Scores in Africa and South Asia: A Systematic Review and Meta-Analysis.

BACKGROUND: Although community-acquired pneumonia (CAP) severity assessment scores are widely used, their validity in low- and middle-income countries (LMICs) is not well defined. We aimed to investigate the validity and performance of the existing scores among adults in LMICs (Africa and South Asia). METHODS: Medline, Embase, Cochrane Central Register of Controlled Trials, Scopus and Web of Science were searched to 21 May 2020. Studies evaluating a pneumonia severity score/tool among adults in these countries were included. A bivariate random-effects meta-analysis was performed to examine the scores' performance in predicting mortality. RESULTS: Of 9900 records, 11 studies were eligible, covering 12 tools. Only CURB-65 (Confusion, Urea, Respiratory Rate, Blood Pressure, Age ≥ 65 years) and CRB-65 (Confusion, Respiratory Rate, Blood Pressure, Age ≥ 65 years) were included in the meta-analysis. Both scores were effective in predicting mortality risk. Performance characteristics (with 95% Confidence Interval (CI)) at high (CURB-65 ≥ 3, CRB-65 ≥ 3) and intermediate-risk (CURB-65 ≥ 2, CRB-65 ≥ 1) cut-offs were as follows: pooled sensitivity, for CURB-65, 0.70 (95% CI = 0.25-0.94) and 0.96 (95% CI = 0.49-1.00), and for CRB-65, 0.09 (95% CI = 0.01-0.48) and 0.93 (95% CI = 0.50-0.99); pooled specificity, for CURB-65, 0.90 (95% CI = 0.73-0.96) and 0.64 (95% CI = 0.45-0.79), and for CRB-65, 0.99 (95% CI = 0.95-1.00) and 0.43 (95% CI = 0.24-0.64). CONCLUSIONS: CURB-65 and CRB-65 appear to be valid for predicting mortality in LMICs. CRB-65 may be employed where urea levels are unavailable. There is a lack of robust evidence regarding other scores, including the Pneumonia Severity Index (PSI).

Evidence-based public policy making for medicines across countries: findings and implications for the future.

Aim: Global expenditure on medicines is rising up to 6% per year driven by increasing prevalence of non-communicable diseases (NCDs) and new premium priced medicines for cancer, orphan diseases and other complex areas. This is difficult to sustain without reforms. Methods: Extensive narrative review of published papers and contextualizing the findings to provide future guidance. Results: New models are being introduced to improve the managed entry of new medicines including managed entry agreements, fair pricing approaches and monitoring prescribing against agreed guidance. Multiple measures have also successfully been introduced to improve the prescribing of established medicines. This includes encouraging greater prescribing of generics and biosimilars versus originators and patented medicines in a class to conserve resources without compromising care. In addition, reducing inappropriate antibiotic utilization. Typically, multiple measures are the most effective. Conclusion: Multiple measures will be needed to attain and retain universal healthcare.

Assessment of adherence to pneumonia guidelines and its determinants in an ambulatory care clinic in Ghana: findings and implications for the future.

BACKGROUND: Adherence to local standard guidelines is seen as a pragmatic way to measure and improve the quality of future prescribing in ambulatory care to reduce morbidity, mortality and healthcare costs. OBJECTIVES: To evaluate adherence to the Ghana Standard Treatment Guidelines (STGs) for the empirical antibiotic treatment of ambulatory care patients with community-acquired pneumonia (CAP) in a region in Ghana and factors associated with it. METHODS: A cross-sectional survey was conducted using a checklist to collect data from the hospital electronic database, which included sociodemographic details, payment type and clinical information of all ambulatory patients attending Keta Municipal Hospital, diagnosed and managed for CAP from September 2018 to January 2019. Prescriptions were assessed for adherence to the Ghana STG based on choice of antibiotics. A χ2 test and multiple logistic regression were subsequently conducted. RESULTS: A total of 1929 patient records with diagnosis of CAP within the study period at the ambulatory clinic were identified. The overall rate of adherence to the Ghana STG was 32.50% (n = 627). From the patient records collected, 62.50% were female, 41.84% were children (0-12 years), and 97.15% had a valid national health insurance status. Adherence was associated with the duration of antibiotic prescribing, number of additional antibiotics prescribed and some patients' clinical characteristics. CONCLUSIONS: The rate of adherence to Ghana STG among the study population was low. Efforts must be made to train and encourage prescribers to follow empirical guidelines to reduce inappropriate selection of antibiotics in the ambulatory care settings.

Changes in Availability, Utilization, and Prices of Medicines and Protection Equipment for COVID-19 in an Urban Population of Northern Nigeria.

OBJECTIVE: Measures are ongoing to prevent the spread of COVID-19 and treat it with medicines and personal protective equipment (PPE). However, there has been considerable controversy surrounding treatments such as hydroxychloroquine with misinformation fuelling prices hikes and suicides. Shortages have also appreciably increased costs of PPE, potentially catastrophic among lower- and middle-income countries such as Nigeria with high copayment levels. Consequently, a need to investigate changes in availability, utilization, and prices of relevant medicines and PPE during the pandemic in Nigeria. METHODS: Exploratory study among community pharmacists with a survey tool comprising four sections including questions on changes in consumption, prices, and shortages of medicines and PPE from the beginning of March 2020 to the end of June 2020. In addition, suggestions from community pharmacists and co-authors on ways to reduce misinformation. FINDINGS: 30 out of 34 pharmacists participated giving a response rate of 88.2%. Significant increases were seen (3-fold or more increase) in the consumption of hydroxychloroquine (100%), vitamins/immune boosters (96.7%) and antibiotics (46.7%) as well as PPE (100%). Considerable price increases (50% increase or greater) also seen for antimalarials (96.7%), antibiotics (93.3%), vitamins/immune boosters (66.7%), and PPE (100%). Shortages are also seen for hydroxychloroquine and vitamins/immune boosters but most severe for PPE (80% of pharmacies). CONCLUSION: Encouraging to see increases in the utilization of vitamins/immune boosters and PPE. However, a considerable increase in the utilization and prices of antimicrobials is a concern that needs addressing including misinformation. Community pharmacists have a key role in providing evidence-based advice and helping moderate prices.

Health systems, population and patient challenges for achieving universal health coverage for hypertension in Ghana.

Ghana has signed on to the United Nations Sustainable Development Goal to achieve universal health coverage (UHC), ensuring that all individuals receive the health care they require without financial hardship. Achieving that goal is a difficult task in any setting. The challenges are further exacerbated by a changing disease landscape, as the burden of non-communicable diseases (NCDs) is increasing and creating a dual burden along with infectious diseases. This study explores the existing health system for delivering hypertension care and the challenges of delivering UHC for hypertension in Ghana. Document analysis of national health reports, policies and legislations along with a review of research articles was conducted to explore the challenges of delivering UHC for NCDs in Ghana, and hypertension in particular. The main themes and indicators related to the challenges of delivering UHC for hypertension were mapped and analysed. The main challenges to delivering UHC for hypertension can be grouped into population and patient, on the one hand, and health system factors, on the other. Population and patient factors include (1) unhealthy lifestyles overburdening the health system, (2) poor health-seeking behaviour and (3) poor adherence to medication, which has led to uncontrolled cases and poor clinical outcomes even among treated patients with hypertension. Health system factors include (1) inadequate health system capacity for early diagnosis due to an increasing number of patients, (2) inequitable distribution of health care facilities affecting access, (3) financial sustainability of the National Health Insurance Scheme and delays in reimbursement of claims to facilities that affect the health system's ability to provide timely management of hypertension and (4) health care facilities and practitioners' use of non-standardized and uncalibrated blood pressure measuring equipment. Ghana therefore will need to make important decisions to overcome operational and financial challenges on its path to UHC.

Potential approaches for the pricing of cancer medicines across Europe to enhance the sustainability of healthcare systems and the implications.

Introduction: There are growing concerns among European health authorities regarding increasing prices for new cancer medicines, prices not necessarily linked to health gain and the implications for the sustainability of their healthcare systems.Areas covered: Narrative discussion principally among payers and their advisers regarding potential approaches to the pricing of new cancer medicines.Expert opinion: A number of potential pricing approaches are discussed including minimum effectiveness levels for new cancer medicines, managed entry agreements, multicriteria decision analyses (MCDAs), differential/tiered pricing, fair pricing models, amortization models as well as de-linkage models. We are likely to see a growth in alternative pricing deliberations in view of ongoing challenges. These include the considerable number of new oncology medicines in development including new gene therapies, new oncology medicines being launched with uncertainty regarding their value, and continued high prices coupled with the extent of confidential discounts for reimbursement. However, balanced against the need for new cancer medicines. This will lead to greater scrutiny over the prices of patent oncology medicines as more standard medicines lose their patent, calls for greater transparency as well as new models including amortization models. We will be monitoring these developments.