Equity and unmet need of non-communicable diseases services in Saudi Arabia using a National Household Survey (2019).

BACKGROUND: Saudi Arabia is implementing a comprehensive health system transformation in health services provision, governance, and financing. Given the high burden of non-communicable diseases (NCD), a key objective of the transformation is to integrate NCD prevention and treatment into primary care. The study objectives were to assess primary care service use for treatment of NCDs, to quantify existing inequities in preventive services utilization, and to identify regional and sociodemographic factors associated with these inequities. METHODS: Using the 2019 Kingdom of Saudi Arabia World Health Survey, multivariable logistic regression models were conducted to identify predictors of utilization of primary care services for NCD prevention and treatment, unmet need among those with a diagnosis of diabetes, hypertension, or dyslipidemia, and unmet need in breast and cervical cancer screening. RESULTS: Among those with an NCD diagnosis, living in a high-income household was associated with a lower probability of having an unmet need compared to those in low-income households. Furthermore, rural residents were less likely to have an unmet need compared to urban residents (OR 0.58, p=0.029). Individuals without a perceived need for healthcare within the last 12 months had three times the probability of unmet need in comparison to those with such a perceived need (p<0.001). Women in all regions had a lower probability of ever having a mammogram compared to women in the central regions around Riyadh. Women with an education above a secondary level had five times the odds of undergoing cervical cancer screening and three times the likelihood of ever having a mammogram (P=0.012, p=0.02) than other women. Compared to women in low-income households, those in middle (OR 1.99, P=0.026), upper middle (OR 3.47, p<0.001), or high-income households (OR 2.59, p<0.001) had a higher probability of having had cervical cancer screening. CONCLUSIONS: Inequities in NCD treatment and prevention services' utilization in Saudi Arabia are strongly associated with region of living, population density, wealth, income, education and perceived need for health care. More research is needed to better understand the extent of unmet primary care needs for NCD and how to address the underlying contributing factors to access inequities.

Determinants of private-sector antibiotic consumption in India: findings from a quasi-experimental fixed-effects regression analysis using cross-sectional time-series data, 2011-2019.

The consumption of antibiotics varies between and within countries. However, our understanding of the key drivers of antibiotic consumption is largely limited to observational studies. Using Indian data that showed substantial differences between states and changes over years, we conducted a quasi-experimental fixed-effects regression study to examine the determinants of private-sector antibiotic consumption. Antibiotic consumption decreased by 10.2 antibiotic doses per 1000 persons per year for every ₹1000 (US$12.9) increase in per-capita gross domestic product. Antibiotic consumption decreased by 46.4 doses per 1000 population per year for every 1% increase in girls' enrollment rate in tertiary education. The biggest determinant of private sector antibiotic use was government spending on health-antibiotic use decreased by 461.4 doses per 1000 population per year for every US$12.9 increase in per-capita government health spending. Economic progress, social progress, and increased public investment in health can reduce private-sector antibiotic use.

Policy responses to COVID-19: lessons for the global trade and investment regime.

BACKGROUND: During the past two years, the COVID-19 pandemic has cost millions of lives around the globe, caused major morbidity and provoked widespread economic and social disruption. In response, governments have enacted policies to mitigate the impacts of the pandemic. This research focuses in on policies aimed at increasing access to essential health products and services by comparing them to the global rules governing trade, investment and intellectual property. We have assessed whether these rules have or could have constrained countries in responding to this and future crises. The study identifies the nature and scope of the trade-related health sector policies implemented by our sample group of countries, selected because of their systemic significance: the United States, Germany, France, China, South Africa and India. Each policy is placed into one of five broad categories covered by trade and investment rules so that we could assess their consistency with those rules. RESULTS: We found, among other things, that the types of trade-related health measures were quite diverse. The high-income countries in our study were the most active in the policy space and tended to rely on subsidies-based measures while the middle-income countries relied more heavily on export and import measures. Policies directly relevant to intellectual property protection were virtually non-existent. When evaluating the implemented policies against the global trade and investment rules, we found potential constraints under five different types of rules: those governing subsidies, import and export trade barriers, investment measures, government procurement and trade-related intellectual property. CONCLUSIONS: Given the tension between the global rules and the practices of policymaking during the pandemic, we conclude that the tension must be resolved in favor of governments making policy rather than relying on existing exceptions or pushing national governments to comply more exactly with the rules. Although the pandemic itself does not respect national borders, governance still generally occurs at the national level because national governments are often the only entities with both the legal authority and the practical ability to respond.

Willingness to pay brand premiums for generic medicines in Kenya: A bidding game experiment.

BACKGROUND: Recent growth in the market share of higher priced branded generic medicines in low- and middle-income countries (LMICs) has raised concerns around affordability and access. We examined consumer willingness to pay (WTP) for branded versus unbranded generic non-communicable disease (NCD) medicines in Kenya. METHODS: We randomly assigned NCD patients to receive a hypothetical offer for either a Novartis Access-branded medicine or for an unbranded generic equivalent. We then analysed WTP data captured using a bidding game methodology. RESULTS: We found that WTP for Novartis Access medicines was on average 23% higher than for unbranded generic equivalents (p = 0.009). The WTP brand premium was driven almost entirely by wealthier patients. CONCLUSIONS: Our findings suggest that the dominance of branded generics in LMICs like Kenya reflect in part consumer preferences for these medicines. Governments and other health sector actors may be justified in intervening to improve access to these medicines and equivalent non-branded generics, particularly for the poorest patients who appear to have no preference for branded medicines.

Relative Risk Assessment for Substandard Antibiotics Along the Manufacturing and Supply Chain: A Proof-of-Concept Study.

BACKGROUND: Ensuring good quality of antibiotics is essential for desired health outcomes. Risk assessment of products for quality issues arising along the manufacturing and supply chain can thus have an important role in surveillance and management of interventions designed to reduce the burden of substandard antibiotics. Demonstrated and validated risk assessments are currently limited. OBJECTIVES: The objective of this study was to investigate whether a comparative risk assessment framework, which adapts the WHO criteria for estimating risks for quality issues posed by individual medicines, is applicable and can identify antibiotics with a higher relative risk of substandard prevalence. METHODS: For a proof-of-concept study, a set of antibiotics from the WHO essential medicines list was selected. Quantitative and qualitative data were extracted for each risk assessment criteria pertaining to severity and probability. A final risk matrix was then compared to field data for validation. RESULTS: Antibiotic products were classified by relative risk. Of all the antibiotic products assessed (n = 28), 32% were categorized as highest risk, 46% as high risk, 18% as medium risk, and 4% as lowest risk. The comparison of the risk scores and incidence of quality failure from the USP Medicines Quality Database showed significant correlation. CONCLUSION: The framework and extracted data sets appear applicable to determine relative risk for substandard antibiotics. Results of the risk matrix may be valuable for guiding pharmacovigilance, surveillance strategies, standardizing risk-based approaches, and mitigation efforts. Refinement with increased data availability may improve results.

Digital Health Technologies Applied by the Pharmaceutical Industry to Improve Access to Noncommunicable Disease Care in Low- and Middle-Income Countries.

BACKGROUND: There is limited research on how digital health technologies (DHTs) are used to promote access to care for patients with noncommunicable diseases (NCDs), particularly in low- and middle-income countries (LMICs). We describe the use of DHTs in pharmaceutical industry-led access programs aimed at improving access to NCD care in LMICs. METHODS: The Access Observatory is the largest publicly available repository containing detailed information about pharmaceutical industry-led access programs targeting NCDs. The repository includes 101 access program reports submitted by 19 pharmaceutical companies. From each report, we extracted data relating to geographic location, disease area, beneficiary population, use of DHTs, partnerships, strategies, and activities. Data were analyzed descriptively using SAS Statistical Software and categorized according to the World Health Organization Digital Health Classification Framework. RESULTS: A total of 43 access programs (42.6%) included DHTs. The majority of programs using DHTs were clustered across sub-Saharan Africa (72.1%) and targeted cancer (60.5%) followed by metabolic disorders (39.5%). The applied DHTs mostly related to program strategies on health service strengthening (74.4%) and community awareness (41.9%) and were largely directed toward health providers, followed by data services and clients. Only a few DHTs were used for health system management. To promote access, most DHTs focused on improving data collection, management, and use (51.1%); building health provider capacity through training (37.2%); and providing targeted patient information (34.8%). CONCLUSION: The range of DHTs applied by the pharmaceutical industry offers opportunities for more effective access to NCD care. Transparent reporting on DHT use and its contributions to access programs' achievements may reduce duplicative and redundant efforts and provide learnings for private and public stakeholders that may contribute to greater access to NCD care in LMICs.

Missing data on accessibility of children's medicines.

Child-appropriate medicines are essential for the safe and effective treatment of children, yet we have observed a large gap in the data required to adequately monitor access to these medicines. We have examined data on the availability and pricing of child-appropriate medicines across 50 surveys. Child-appropriate medicines for nine out of 12 priority diseases in children were infrequently surveyed or not at all. A similar data deficit on age-appropriate medicines is detectable in the broader scientific literature. We also note that existing instruments for collecting data on the availability or prices of medicines are limited in their ability to generate the required data for children. We have identified four priorities as key for improved monitoring of access to medicines for children: (i) dedicated child medicine surveys are needed on availability and prices of child-appropriate medicines; (ii) standardized survey instruments should include age-appropriate medicines and dosages; (iii) health facility service readiness survey tools should include the collection of data on the price of child-appropriate medicines in addition to the availability of medicines; and (iv) sustainable development goal indicator 3.b.3 should be modified to enable the monitoring of access to medicines for children. These deficiencies need to be addressed to ensure the monitoring of access to child medicines as part of the sustainable development goal agenda for 2030 and to implement appropriate interventions for improving access for this vulnerable population.

Disposer de médicaments adaptés aux enfants est essentiel à l'administration d'un traitement sûr et efficace. Pourtant, nous avons observé de vastes lacunes dans les données requises pour évaluer l'accès à ces médicaments. Nous avons passé 50 enquêtes au crible, à la recherche d'informations sur la disponibilité et le prix des médicaments pédiatriques. Dans le cas de neuf maladies infantiles prioritaires sur douze, les médicaments adaptés aux enfants n'étaient pas ou peu étudiés. Même constat dans le contexte plus large de la littérature scientifique. Nous avons également remarqué que les instruments servant à récolter des données sur la disponibilité ou le prix des médicaments avaient leurs limites et ne permettaient pas d'obtenir les informations requises concernant les enfants. Nous avons identifié quatre priorités majeures en vue d'améliorer la surveillance de l'accès aux médicaments pédiatriques: (i) la réalisation d'enquêtes sur les médicaments pédiatriques afin d'en connaître la disponibilité et le prix; (ii) l'intégration des médicaments et dosages adéquats dans les instruments d'enquête standard; (iii) outre la disponibilité, la prise en compte du prix des médicaments à usage pédiatrique dans les outils d'évaluation de l'état de préparation des services au sein des établissements de santé; et enfin, (iv) la modification de l'indicateur 3.b.3 des objectifs de développement durable, qui prévoirait dès lors un contrôle de l'accès aux médicaments adaptés aux enfants. Ces lacunes doivent être comblées pour assurer un suivi en matière d'accès aux médicaments pédiatriques dans le cadre du Programme de développement durable à l'horizon 2030, mais aussi pour adopter les mesures correspondantes afin d'améliorer la prise en charge de cette population vulnérable.

Los medicamentos indicados para los niños son esenciales para su tratamiento seguro y eficaz, pero se ha observado un gran vacío en los datos necesarios para supervisar de manera adecuada el acceso a estos medicamentos. Se han analizado los datos sobre la disponibilidad y el precio de los medicamentos indicados para los niños en 50 encuestas. Estos medicamentos para nueve de las 12 enfermedades prioritarias infantiles se encuestaron con poca frecuencia o no se encuestaron en absoluto. En la literatura científica más general, se detecta un déficit de datos similar sobre los medicamentos adecuados para la edad. También se observa que los instrumentos existentes para recopilar los datos sobre la disponibilidad o los precios de los medicamentos son limitados en su capacidad para generar los datos necesarios en el caso de los niños. Se han identificado cuatro prioridades para mejorar el seguimiento del acceso a los medicamentos pediátricos: (i) se necesitan encuestas específicas sobre la disponibilidad y los precios de los medicamentos indicados para los niños; (ii) los instrumentos de encuesta estandarizados deben incluir medicamentos y dosis adecuados para la edad; (iii) las herramientas de encuesta sobre la disponibilidad de los servicios sanitarios deben incluir la recopilación de los datos sobre el precio de los medicamentos indicados para los niños, además de la disponibilidad de los medicamentos; y (iv) el indicador 3.b.3 del Objetivo de Desarrollo Sostenible se debe modificar para permitir el seguimiento del acceso a los medicamentos pediátricos. Es preciso solucionar estas deficiencias para garantizar el seguimiento del acceso a los medicamentos pediátricos como parte de la agenda de los objetivos de desarrollo sostenible para 2030 y aplicar las intervenciones adecuadas para mejorar el acceso de esta población vulnerable.

Out-of-pocket expenditure on medicines in Bangladesh: An analysis of the national household income and expenditure survey 2016-17.

BACKGROUND AND OBJECTIVES: High out-of-pocket expenditures (OOPE) increases the probability that households will become impoverished or will forgo needed care. The aim of this paper is to study household medicines expenditure and its associated determining factors to develop policies to protect households from financial hardship. METHODS: The present cross-sectional and population-level study used the Bangladesh 2016-17 National Household Income and Expenditure Survey (HIES). The final sample size was 46,080 households. We analyzed the probability of OOPE for medicines, the share of total OOPE due to medicines out of total OOPE in health (reported as a ratio between zero and one), the OOPE amount for medicines reported (in United States Dollars), and the share of OOPE amount on medicines out of total household expenditure (reported as a ratio between zero and one). Predictors of analyzed outcomes were identified using three regression models. RESULTS: Out of those households who spent on healthcare, the probability of having any OOPE on medicines was 87.9%. Of those who spent on medicines, the median monthly expenditure was US$3.03. The poorest households spent 9.97% of their total household expenditure as OOPE on medicines, nearly double that of the wealthiest households (5.86%). The characteristic which showed the most significant correlation to a high OOPE on medicines was the presence of chronic diseases, especially cancer. Twenty six percent of all surveyed households spend more than 10% of their OOPE on medicines. CONCLUSIONS: Our study shows that financial protection should be targeted at the poorest quintiles and such protection should include enrollment of rural households. Further, outpatient medicines benefits should include those for non-communicable diseases (NCDs).

Challenges of Guaranteeing Access to Medicines in Mexico: Lessons from Recent Changes in Pharmaceuticals Procurement.

During the last two decades, Mexico adopted policies intended to increase the efficiency and effectiveness of medicines procurement in its nationally fragmented health system. In this policy report, we review Mexico's efforts to guarantee access to medicines during three national administrations (from 2000 to 2018), and then examine major health system changes introduced by the current government (2018-2024), which have created significant setbacks in guaranteeing access to medicines in Mexico. These recent changes are having important consequences in the levels of satisfaction of health care users and citizens, household expenditure on health, and health conditions. We suggest key lessons for Mexico and other countries seeking to improve pharmaceutical procurement as part of guaranteeing access to medicines.

Commercial and Social Value of Pharmaceutical Industry-led Access Programs: Conceptual Framework and Descriptive Analysis.

Pharmaceutical industry-led access programs are growing in number globally and are increasingly adopting a hybrid approach intended to generate commercial and social value in parallel. We developed and applied a new conceptual framework in a descriptive analysis of observable indicators measuring commercial and social value for 91 programs registered in the Access Observatory. We found that most programs had features consistent with the generation of commercial value, directly through revenue generation (50.0%), or indirectly by creating competitive advantage (70.3%). We also found that most programs were implemented in countries where the company has commercial products registered (85.5%). While many programs had features consistent with the generation of social value, it was difficult to ascertain the level of that value because most did not share data (83.5%) and had not been evaluated (74.7%). Future efforts by the global health community and the pharmaceutical industry should focus on strengthening measurement and reporting on commercial and social indicators of industry-led access programs.

Probability and amount of medicines expenditure according to health insurance status in Kenya: A household survey in eight counties.

BACKGROUND: National and county governments in Kenya have introduced various health insurance schemes to protect households against financial hardship as a result of large health expenditure. This study examines the relationship between health insurance and medicine expenditure in eight counties in Kenya. METHODS: A cross-sectional study of collected primary data via household survey in eight counties was performed. Three measures of medicine expenditure were analysed: the probability of any out-of-pocket expenditure (OOPE) on medicines in the last 4 weeks; amount of OOPE on medicines; and OOPE on medicines as a proportion of total OOPE on health. RESULTS: Out of the 452 individuals, those with health insurance (n = 225) were significantly different from individuals without health insurance (n = 227): overall, they were older, had a higher level of educational attainment and possessed more assets. Adjusting for covariates, individuals with health insurance had a reduced probability of OOPE on medicines (0.40, CI95% 0.197-0.827) and spent proportionally less on medicines out of total health expenditure (0.50, CI95% 0.301-0.926). CONCLUSIONS: Kenya has made great strides to scale up Universal Health Coverage including access to medicines. Prioritising enrollment of low-income individuals with non-communicable diseases can accelerate access to medicines and financial protection.

Outpatient cardiovascular diseases and diabetes medicines dispensing in the population with government health insurance in Syria between 2018 and 2019: a retrospective analysis.

BACKGROUND: Low- and middle-income countries bear the highest burden of non-communicable diseases (NCDs) mortality and morbidity. Syria has undergone an epidemiological transition from infectious diseases to NCDs in the past decades. Despite the high prevalence of cardiovascular diseases (CVDs) and diabetes in Syria, little is known about medicines utilization or prescriptions for these diseases. The aims of this study are to present the patterns and rates of dispensing medicines used for CVDs and diabetes among patients with government health insurance in Syria and examine age, sex, and regional variation in the dispensing of these medicines. METHODS: Outpatient data from June 2018 to May 2019 on dispensed medicines for 81,314 adults with government health insurance were obtained. The dispensing rate was expressed as the number of defined daily doses (DDDs) per 1000 beneficiaries per day (DID). The DID is a measurement that is used in drug utilization research to control for differences or changes in population size between or within countries. The number of DIDs was adjusted according to beneficiaries' sex, age, and governorate. RESULTS: Beneficiaries received 302.09 DIDs of CVDs medicines and 35.66 DIDs of diabetes medicines, including 0.96 DID of insulin (2.99% of the total of diabetes medicines). CVDs and diabetes medicine dispensing rates were low during the study period and included very low rates of insulin dispensing compared to the dispensing rates of these medicines in other countries in East Mediterranean Region or in Europe. We found lower dispensing rates of CVDs medicines among female beneficiaries (249.59 DIDs) than male beneficiaries (388.80 DIDs). Similarly, the dispensing rates of diabetes medicines among female beneficiaries (29.42 DIDs) were lower than those among male beneficiaries (45.98 DIDs). In addition, there were lower rates of CVDs and diabetes medicines and very low to no dispensing of insulin in some governorates that were partly controlled by the Syrian government compared to other governorates that were completely or mostly controlled by the Syrian government. CONCLUSIONS: Additional efforts are needed to raise awareness about the prevention and management of CVDs and diabetes especially among females in Syria and consider cultural issues that might influence access to healthcare services. There is a crucial need to address the political and geographical challenges caused by the conflict which have limited access to CVDs and diabetes medicines in some regions in Syria.

Public health insurance and ethnic disparities in maternal health care: the case of vulnerable Mexican women over the last 25 years.

This article examines the coverage in the continuum of antenatal-postnatal care for vulnerable women in Mexico according to indigenous status and assesses the influence of public health insurance strategies on the evolution of coverage over the last 25 years. We studied a total of 19 613 567 Mexican women, aged 12-54 years at last birth, based on a pooled cross-sectional analysis of data from the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics. After describing sociodemographic characteristics and maternal-health coverage by indigenous status, we constructed a pooled fixed-effects and interaction multivariable regression model to assess the influence of the Seguro Popular programme on continuum of care. We estimated adjusted continuum of care coverage between 1994 and 2018 according to Seguro Popular affiliation and indigenous status. Prior to the Seguro Popular programme, crude coverage in the continuum of care for non-indigenous women stood at 14.5% [95% confidence interval (CI): 13.2-15.8%] or 11 percentage points higher than for indigenous women. During the last period of the programme, it rose to 46.5% [95% CI: 45.6-47.5%] and 34.1% [95% CI: 30.7-37.4%], respectively. Our regression analysis corroborated findings that, on average, indigenous women faced lower odds of benefiting from continuum of care [adjusted odds ratio (aOR) = 0.48, 95% CI: 0.40-0.57] than did their non-indigenous counterparts. It also revealed that coverage for indigenous women without Seguro Popular affiliation was 26.7% [95% CI: 23.3-30.1%] or 12 percentage points lower than for those with Seguro Popular affiliation (38.6%, 95% CI: 35.7-41.4%). Our regression results confirmed that the latter benefited from higher odds of continuum of care (aOR = 1.67, 95% CI: 1.36-2.26). Gaps between those of indigenous and non-indigenous status have persisted, but the Seguro Popular clearly contributed to reducing the coverage gaps between these two groups of women. Strategies yielding better outcomes are required to improve the structural conditions of indigenous populations.

Phone-based monitoring to evaluate health policy and program implementation in Kenya.

Monitoring and evaluating policies and programs in low- and middle-income countries are often difficult because of the lack of routine data. High mobile phone ownership in these countries presents an opportunity for efficient data collection through telephone interviews. This study examined the feasibility of collecting data on medicines through telephone interviews in Kenya. Data on the availability and prices of medicines at 137 health facilities and 639 patients were collected in September 2016 via in-person interviews. Between December 2016 and December 2017, monthly telephone interviews were conducted with health facilities and patients. An unannounced in-person interview was conducted with respondents to validate the telephone interview within 24 h. A bottom-up itemization costing approach was used to estimate the costs of telephone and in-person data collection. In-depth interviews were conducted with data collectors and respondents to explore their perceptions on both modes of data collection. The level of agreement between data on medicines availability collected through phone and in-person interviews was strong at the health facility level [kappa = 0.90; confidence interval (CI) 0.88-0.92] and moderate at the household level (kappa = 0.50, CI 0.39-0.60). Price data from telephone and in-person interviews showed strong intra-class correlation at health facilities [intra-class correlation coefficient (ICC) = 0.96] and moderate intra-class correlation at households (ICC = 0.47). The cost per phone interview at health facilities and households were $19.73 and $16.86, respectively, compared to $186.20 for a baseline in-person interview. Participants considered telephone interviews to be more convenient. In countries with high cell phone penetration, telephone data collection should be considered in monitoring and evaluating public health programs especially at health facilities. Additional strategies may be needed to optimize this mode of data collection at the household level. Variations in cell phone ownership, telecommunication network and data collection costs across different settings may limit the generalizability of the findings from this study.

Geographical accessibility of medicines: a systematic literature review of pharmacy mapping.

BACKGROUND: Measuring access to medicines has often been limited to assessing availability and affordability, while little is known regarding other dimensions of access including geographical accessibility. Our study aims to provide a systematic review of literature on the accessibility of medicines by studying the geographical distribution of pharmacies using Spatial Analytical methods. METHODS: As systematic review of scientific peer-reviewed literature between 2000 and 2018 was carried out using PubMed, Web of Science, Google Scholar, Google and the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA). Data regarding pharmacy density, distance to pharmacies in relation of pharmacy to sociodemographic factors and pharmacy characteristics were extracted from studies that meet the inclusion criteria. FINDINGS: Twenty papers fulfilled our inclusion criteria, of which only three were from middle income countries and rest from high-income economies. Pharmacy density per population was reported in 15 studies. Although geographical information was utilized in all studies, only 14 studies reported distance to pharmacies represented as Euclidean (straight line) distance. Disparities in accessibility was reported according to population income and rural or urban location. Seven studies described additional pharmacy characteristics including opening hours, presence of a pharmacist and delivery services. CONCLUSIONS: Geographical accessibility is a key dimension of access to medicines. Pharmacy density per population is a relevant indicator to assess geographical accessibility which should be complemented by an equity analysis using socio-demographic information and population perception of accessibility.

Barriers to Accessing Medicines among Syrian Asylum Seekers and Refugees in a German Federal State.

In Germany, asylum seekers and refugees (AS&Rs) face challenges when accessing healthcare services including medicines. The aim of this study was to explore the barriers to accessing medicines among Syrian AS&Rs in the state of North Rheine-Westphalia, and to provide an understanding of their perspectives towards taking medicines that contain alcohol or pork products. This study is based on a cross-sectional survey using a combination of sampling methods. We used descriptive statistics to analyze quantitative data. Participants' answers to an open-ended question yielded qualitative data that were categorized based on the thematic areas they discussed or addressed. Among the 1641 respondents, language barriers had more of an effect on the access to medicines than any other factor studied. The effect of language barriers on access to medicines was more pronounced for female participants, those who were older than 50 years, and participants who had chronic diseases in comparison to the other groups of participants. Male participants and those younger than 50 years of age showed more acceptance towards taking medicines that contain alcohol or pork products. Based on our results, we recommend providing more support for AS&Rs to learn the German language, particularly for female refugees, older refugees, and those with chronic diseases or disabilities. We also recommend providing translated medical leaflets for patients who wish to receive them in their native language. Healthcare providers should try to consider the special conditions of AS&Rs patients and take into account their perspectives about treatments and diseases.

Incremental Risk of Developing Severe COVID-19 Among Mexican Patients With Diabetes Attributed to Social and Health Care Access Disadvantages.

OBJECTIVE: Diabetes is an important risk factor for severe coronavirus disease 2019 (COVID-19), but little is known about the marginal effect of additional risk factors for severe COVID-19 among individuals with diabetes. We tested the hypothesis that sociodemographic, access to health care, and presentation to care characteristics among individuals with diabetes in Mexico confer an additional risk of hospitalization with COVID-19. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using public data from the General Directorate of Epidemiology of the Mexican Ministry of Health. We included individuals with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 between 1 March and 31 July 2020. The primary outcome was the predicted probability of hospitalization, inclusive of 8.5% of patients who required intensive care unit admission. RESULTS: Among 373,963 adults with COVID-19, 16.1% (95% CI 16.0-16.3) self-reported diabetes. The predicted probability of hospitalization was 38.4% (37.6-39.2) for patients with diabetes only and 42.9% (42.2-43.7) for patients with diabetes and one or more comorbidities (obesity, hypertension, cardiovascular disease, and chronic kidney disease). High municipality-level of social deprivation and low state-level health care resources were associated with a 9.5% (6.3-12.7) and 17.5% (14.5-20.4) increased probability of hospitalization among patients with diabetes, respectively. In age-, sex-, and comorbidity-adjusted models, living in a context of high social vulnerability and low health care resources was associated with the highest predicted probability of hospitalization. CONCLUSIONS: Social vulnerability contributes considerably to the probability of hospitalization among individuals with COVID-19 and diabetes with associated comorbidities. These findings can inform mitigation strategies for populations at the highest risk of severe COVID-19.

Availability and prices of medicines for non-communicable diseases at health facilities and retail drug outlets in Kenya: a cross-sectional survey in eight counties.

OBJECTIVES: The objective of this study was to determine the availability and prices of medicines for non-communicable diseases (NCDs) in health facilities and private for-profit drug outlets in Kenya. DESIGN: Cross-sectional study. METHODS: All public and non-profit health facilities in eight counties (Embu, Kakamega, Kwale, Makueni, Narok, Nyeri, Samburu and West Pokot) that purchased medicines from the Mission for Essential Drugs and Supplies, a major wholesaler, were surveyed in September 2016. For each health facility, one nearby private for-profit drug outlet was also surveyed. Data on availability and price were analysed for 24 NCD and 8 acute medicine formulations. Availability was analysed separately for medicines in the national Essential Medicines List (EML) and those in the Standard Treatment Guidelines (STGs). Median price ratios were estimated using the International Medical Products Price Guide as a reference. RESULTS: 59 public and 78 non-profit facilities and 135 drug outlets were surveyed. Availability of NCD medicines was highest in private for-profit drug outlets (61.7% and 29.3% for medicines on the EML and STGs, respectively). Availability of STG medicines increased with increasing level of care of facilities: 16.1% at dispensaries to 31.7% at secondary referral facilities. The mean proportion of availability for NCD medicines listed in the STGs (0.25) was significantly lower than for acute medicines (0.61), p<0.0001. The proportion of public facilities giving medicines for free (0.47) was significantly higher than the proportion of private non-profit facilities giving medicines for free (0.09) (p<0.0001). The mean price ratio of NCD medicines was significantly higher than for acute medicines in non-profit facilities (4.1 vs 2.0, respectively; p=0.0076), and in private for-profit drug outlets (3.5 vs 1.7; p=0.0013). CONCLUSION: Patients with NCDs in Kenya appear to have limited access to medicines. Increasing access should be a focus of efforts to achieve universal health coverage.