A national survey on registered products, availability, prices, and affordability of 100 essential medicines in community pharmacies across Sri Lanka.

INTRODUCTION: Availability of essential medicines that meet the expected quality standards, in appropriate dosage forms at affordable prices is a fundamental prerequisite to fulfill healthcare needs of given a population. This study assessed available products, prices and affordability of essential medicines (EM) in community pharmacies in Sri Lanka with comparison of registration status from the National Medicines Regulatory Authority(NMRA). METHODS: A cross-sectional island-wide survey of 80 pharmacies was conducted according to World Health Organization and Health Action International Manual (WHO/HAI). Hundred medicines were selected from the global core list(n = 14), regional core list(n = 16) and the Sri Lanka Essential Medicine List (SL-EML) (n = 70) based on healthcare needs. Number of registered products in 2015 and 2021 were compared. FINDINGS: Average availability was 85.4%(± 12.31) and availability was lowest in the Northern province (69.38 ± 21.18%)(p = 0.008). Availability between the state owned, franchise and privately owned pharmacies was not significantly different (p > 0.05). 89.4% medicines were affordable except for amiodarone, hydroxychloroquine, sitagliptin, soluble insulin, isophane insulin, losartan, levodopa carbidopa combination, clonazepam and ceftriaxone. The median price ratio (MPR) of 33.7% of medicines was less than 1 and MPR of 37.1% originator brands (OB) was over 3. Median number of generic brands in the market was 8(range 2-44), 9% of medicines had 20 or more products in the market and 72.7% medicines had more products available than the number registered in 2015. The average number of registered products were similar in 2015 (8.27) and 2021(7.59) (p = 0.15). CONCLUSION: The overall availability of EMs in Sri Lanka was high in all categories of community pharmacies. Medicines were largely affordable and reasonably priced in 2015, although OBs were generally more expensive. Majority of medicines had more products in the market than the number of registered products.

Economics of physical activity in low-income and middle- income countries: a systematic review.

BACKGROUND: Promotion of physical activity (PA) among populations is a global health investment. However, evidence on economic aspects of PA is sparse and scattered in low-income and middle-income countries (LMICs). OBJECTIVE: The objective of this study was to summarise the available evidence on economics of PA in LMICs, identify potential target variables for policy and report gaps in the existing economic evidence alongside research recommendations. DATA SOURCES: A systematic review of the electronic databases (Scopus, Web of Science and SPORTDiscus) and grey literature. STUDY ELIGIBILITY CRITERIA: Cost-of-illness studies, economic evaluations, interventions and descriptive studies on economic factors associated with PA using preset eligibility criteria. STUDY APPRAISAL AND SYNTHESIS OF METHODS: Screening, study selection and quality appraisal based on standard checklists performed by two reviewers with consensus of a third reviewer. Descriptive synthesis of data was performed. RESULTS: The majority of the studies were from upper-middle-income countries (n=16, 88.8%) and mainly from Brazil (n=9, 50%). Only one economic evaluation study was found. The focus of the reviewed literature spanned the economic burden of physical inactivity (n=4, 22%), relationship between PA and costs (n=6, 46%) and socioeconomic determinants of PA (n=7, 39%). The findings showed a considerable economic burden due to insufficient PA, with LMICs accounting for 75% of disability-adjusted life years (DALYs) globally due to insufficient PA. Socioeconomic correlates of PA were identified, and inverse relationship of PA with the cost of chronic diseases was established. Regular PA along with drug treatment as a treatment scheme for chronic diseases showed advantages with a cost-utility ratio of US$3.21/quality-adjusted life year (QALY) compared with the drug treatment-only group (US$3.92/QALY) by the only economic evaluation conducted in the LMIC, Brazil. LIMITATIONS: Meta-analysis was not performed due to heterogeneity of the studies. CONCLUSIONS AND RECOMMENDATIONS: Economic evaluation studies for PA promotion interventions/strategies and local research from low-income countries are grossly inadequate. Setting economic research agenda in LMICs ought to be prioritised in those areas. PROSPERO REGISTRATION NUMBER: CRD42018099856.

Comparative Analysis of Prescription Drug Prices in South Asian Association for Regional Cooperation Countries.

OBJECTIVES: The SAARC (South Asian Association for Regional Cooperation) is a geopolitical organization composed of 8 neighboring countries: Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka. The objective of this study was to compare the prices of some selected drugs in SAARC countries. METHODS: A list of 24 drugs was prepared based on certain inclusion and exclusion criteria. The retail prices of the drugs were determined from different sources and verified manually in the open market. The prices obtained in local currencies were converted into US dollars for comparison purposes. In another analysis, the gross domestic product (GDP) of each country was factored for comparative analysis. RESULTS: Out of the 23 drugs, 17 comparisons across countries were statistically different at P < .05. These analyses revealed large differences in drug prices among SAARC countries. The GDP-adjusted median drug prices revealed a more polarized picture, with Nepal generally having the highest prices (19 out of 24 drugs) and Sri Lanka having the lowest (19 out of 24 drugs). For example, the widely used antipsychotic drug risperidone was 7 times more expensive in Pakistan ($0.316) compared with Sri Lanka ($0.045). Adjusting for GDP made risperidone more than 18 times more expensive ($21.90 and $1.20) across the same 2 countries. CONCLUSION: Prices of selected drugs varied markedly in SAARC countries. After adjusting for GDP, drug prices became more polarized across countries, with Nepal featuring the highest prices. In determining drug prices, the country's GDP and the population's purchasing power need to be taken into account.

The economics of physical activity in low-income and middle-income countries: protocol for a systematic review.

INTRODUCTION: Evidence on the economic costs of physical inactivity and the cost-effectiveness of physical activity interventions in low-income and middle-income countries (LMICs) is sparse, and fragmented where they are available. This is the first review aimed to summarise available evidence on economics of physical activity in LMICs, identify potential target variables for policy, and identify and report gaps in the current knowledge on economics of physical activity in LMICs. METHODS AND ANALYSIS: Peer-reviewed journal articles of observational, experimental, quasi-experimental and mixed-method studies on economics of physical activity in LMICs will be identified by a search of electronic databases; Scopus, Web of Science and SPORTDiscus. Websites of WHO, the National Institute for Health and Care Excellence international, World Bank and reference lists of included studies will be searched for relevant studies. The study selection process will be a two-stage approach; title and abstract screen for inclusion, followed by a review of selected full-text articles by two independent reviewers. Disagreements will be resolved by consensus and discussion with a third reviewer. Data will be extracted using standardised piloted data extraction forms. Risk of bias will be critically appraised using standard checklists based on study designs. Descriptive synthesis of data is planned. Where relevant, summaries of studies will be classified according to type of economic analysis, country or country category, population, intervention, comparator, outcome and study design. Meta-analysis will be performed where appropriate. This protocol for systematic review is prepared according to the Preferred Reporting Items for Systematic review and Meta-analysis for Protocols -2015 statement. ETHICS AND DISSEMINATION: Ethical approval is not obtained as original data will not be collected as part of this review. The completed review will be submitted for publication in a peer-reviewed journal and presented at conferences. PROSPERO REGISTRATION NUMBER: CRD42018099856.

Management, characteristics and outcomes of patients with acute coronary syndrome in Sri Lanka.

BACKGROUND: Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronary Syndrome Sri Lanka Audit Project (ACSSLAP) is the first national clinical-audit project that evaluated patient characteristics, clinical outcomes and care provided by state-sector hospitals. METHODS: ACSSLAP prospectively evaluated acute care, in-hospital care and discharge plans provided by all state-sector hospitals managing patients with ACS. Data were collected from 30 consecutive patients from each hospital during 2-4 weeks window. Local and international recommendations were used as audit standards. RESULTS: Data from 87/98 (88.7%) hospitals recruited 2177 patients, with 2116 confirmed as having ACS. Mean age was 61.4±11.8 years (range 20-95) and 58.7% (n=1242) were males. There were 813 (38.4%) patients with unstable angina, 695 (32.8%) with non-ST-elevation myocardial infarction (NSTEMI) and 608 (28.7%) with ST-elevation myocardial infarction (STEMI). Both STEMI (69.9%) and NSTEMI (61.4%) were more in males (P<0.001). Aspirin, clopidogrel and statins were given to over 90% in acute setting and on discharge. In STEMI, 407 (66.9%) were reperfused; 384 (63.2%) were given fibrinolytics and only 23 (3.8%) underwent primary percutaneous coronary intervention (PCI). Only 42.3 % had thrombolysis in <30 min and 62.5% had PCI in <90 min. On discharge, beta-blockers and ACE inhibitors/angiotensin II receptor blockers were given to only 50.7% and 69.2%, respectively and only 17.6% had coronary interventions planned. CONCLUSIONS: In patients with ACS, aspirin, clopidogrel and statin use met audit standards in acute setting and on discharge. Vast majority of patients with STEMI underwent fibrinolyisis than PCI, due to limited resources. Primary PCI, planned coronary interventions and timely thrombolysis need improvement in Sri Lanka.

Physical activity patterns among South-Asian adults: a systematic review.

Physical activity (PA) has many beneficial physical and mental health effects. Physical inactivity is considered the fourth leading risk factor for global mortality. At present there are no systematic reviews on PA patterns among South Asian adults residing in the region. The present study aims to systematically evaluate studies on PA patterns in South Asian countries. A five-staged comprehensive search of the literature was conducted in Medline, Web of Science and SciVerse Scopus using keywords 'Exercise', 'Walking', 'Physical activity', 'Inactivity', 'Physical Activity Questionnaire', 'International Physical Activity Questionnaire', 'IPAQ', 'Global Physical Activity Questionnaire' and 'GPAQ', combined with individual country names. The search was restricted to English language articles conducted in humans and published before 31st December 2012. To obtain additional data a manual search of the reference lists of articles was performed. Data were also retrieved from the search of relevant web sites and online resources. The total number of hits obtained from the initial search was 1,771. The total number of research articles included in the present review is eleven (India-8, Sri Lanka-2, Pakistan-1). In addition, eleven country reports (Nepal-3, Bangladesh-2, India-2, Sri Lanka-2, Bhutan-1, Maldives-1) of World Health Organization STEPS survey from the South-Asian countries were retrieved online. In the research articles the overall prevalence of inactivity was as follows; India (18.5%-88.4%), Pakistan (60.1%) and Sri Lanka (11.0%-31.8%). STEPS survey reports were available from all countries except Pakistan. Overall in majority of STEPS surveys females were more inactive compared to males. Furthermore, leisure related inactivity was >75% in studies reporting inactivity in this domain and people were more active in transport domain when compared with the other domains. In conclusion, our results show that there is a wide variation in the prevalence of physical inactivity among South-Asian adults within and between countries. Furthermore, physical inactivity in South Asian adults was associated with several socio-demographic characteristics. Majority of South Asian adults were inactive during their leisure time. These Factors need to be considered when planning future interventions and research aimed at improving PA in the region.

Medium of language in discharge summaries: would the use of native language improve patients' knowledge of their illness and medications?

Sri Lankan inpatients receive a discharge summary in English known as a diagnosis card. The authors investigated whether supplementing the diagnosis summary with native language improved patients' knowledge of illness and medication. Participants were 130 newly diagnosed patients with noncommunicable chronic diseases (92 men, 70.8%; 38 women, 29.2%; M age = 55.4 years, SD age = 12.8 years) who were randomized to a control group receiving an English discharge summary and intervention group receiving a supplementary native language discharge summary. A questionnaire assessed knowledge of illness and prescribed medications at discharge and at 2 weeks. The groups were comparable for knowledge of diagnosis and prescribed medications at discharge. At 2 weeks, the intervention group had significantly higher scores than did the control group for knowledge on diagnosis, M = 81.41, SD = 34.63, versus M = 27.95, SD = 41.26, respectively, p < .001; and on medications, M = 54.48, SD = 33.91, versus M = 12.55, SD = 20.44, respectively, p < .001. The increase in scores was explained by the dichotomous variable, whether supplementary discharge summary was given or not (p < .001). A higher proportion in the intervention group read the discharge summary to gain knowledge of diagnosis (81.5%) and medication (80%) than in the control group (4.6% and 6.2%, respectively; p < .001). A total of 121 participants (92.1%) preferred a discharge summary in native language. This simple model may be useful to improve patient knowledge relating to illness in countries that predominantly use another language for medical communications, rather than a native language.

The costs in provision of haemodialysis in a developing country: a multi-centered study.

BACKGROUND: Chronic Kidney Disease is a major public health problem worldwide with enormous cost burdens on health care systems in developing countries. We aimed to provide a detailed analysis of the processes and costs of haemodialysis in Sri Lanka and provide a framework for modeling similar financial audits. METHODS: This prospective study was conducted at haemodialysis units of three public and two private hospitals in Sri Lanka for two months in June and July 2010. Cost of drugs and consumables for the three public hospitals were obtained from the price list issued by the Medical Supplies Division of the Department of Health Services, while for the two private hospitals they were obtained from financial departments of the respective hospitals. Staff wages were obtained from the hospital chief accountant/chief financial officers. The cost of electricity and water per month was calculated directly with the assistance of expert engineers. An apportion was done from the total hospital costs of administration, cleaning services, security, waste disposal and, laundry and sterilization for each unit. RESULTS: The total number of dialysis sessions (hours) at the five hospitals for June and July were 3341 (12959) and 3386 (13301) respectively. Drug and consumables costs accounted for 70.4-84.9% of the total costs, followed by the wages of the nursing staff at each unit (7.8-19.7%). The mean cost of a dialysis session in Sri Lanka was LKR 6,377 (US$ 56). The annual cost of haemodialysis for a patient with chronic renal failure undergoing 2-3 dialysis session of four hours duration per week was LKR 663,208-994,812 (US$ 5,869-8,804). At one hospital where facilities are available for the re-use of dialyzers (although not done during study period) the cost of consumables would have come down from LKR 5,940,705 to LKR 3,368,785 (43% reduction) if the method was adopted, reducing costs of haemodialysis per hour from LKR 1,327 at present to LKR 892 (33% reduction). CONCLUSIONS: This multi-centered study demonstrated that the costs of haemodialysis in a developing country remained significantly lower compared to developed countries. However, it still places a significant burden on the health care sector, whilst possibility of further cost reduction exists.

Preoperative testing in elective surgery: Is it really cost effective?

INTRODUCTION: During preoperative preparation, patients undergo investigations to detect asymptomatic diseases. The probability of finding significant abnormalities on such routine investigations is small, and these investigations unnecessarily increase costs of perioperative care. We evaluated current practices, compliance with national guidelines and costs of preoperative investigations at the National Hospital of Sri Lanka (NHSL). MATERIALS AND METHODS: Patients undergoing elective surgery at the general surgical units of the NHSL from June to August 2010 were included in this study. The National Guidelines on Preoperative Investigations were the standard of assessment. Data on preoperative investigations were collected using an expert-validated pretested interviewer-administered questionnaire. RESULTS: Sample size was 2,061 patients. Mean age of the patients was 46.7±15.8 years; males constituted 54.2% of the study population. Majority of the patients were ASA-I (68.5%) and surgical grade II (62.0%). Request for chest X-ray and prothrombin time / international normalized ratio least conformed to the guidelines. Only fasting blood sugar / random blood sugar demonstrated 'good' compliance (>70%) to the guidelines. An 'acceptable' compliance (50%-70%) was seen for electrocardiogram, blood grouping and full blood count. All other investigations demonstrated 'poor' compliance (<50%) with the guidelines. The total excess cost incurred due to non-recommended investigations during the study period of 3 months was Sri Lankan Rupees (LKR.) 1,324,860 to 2,044,210 (per patient LKR. 642.82-991.85). Intern house officers (IHOs) were involved in the planning of preoperative investigations in 2,001 patients (97.1%), followed by medical officeranesthesia / registrar-anesthesia (n=1,625; 78.8%), surgical registrars (n=190; 9.2%), consultant (n=70; 3.4%), senior registrar (n=46; 2.2%) and senior house officers (n=22; 1.1%). Non-recommended investigations were requested mostly by the IHOs and medical officer-anesthesia / registrar-anesthesia. CONCLUSIONS: Unnecessary preoperative investigations are common at our institution, leading to substantially excessive costs. There is ample opportunity to rationalize practices and reduce expenditure.

Patterns and correlates of adult height in Sri Lanka.

The present study examines patterns and socioeconomic and demographic correlates of adult height among Sri Lankan adults. Data were available for height and socio-demographic factors from a nationally representative cross-sectional sample of 4477 subjects above 18 years. Recruitment was between 2005 and 2006. Mean age of all subjects was 46.1±15.1 years. Mean height of males and females were 163.6±6.9cm and 151.4±6.4cm respectively. Mean height showed a significant negative correlation with age (p<0.001, r=-0.207). Highest mean height in females 154.0±5.9cm and males 165.6±6.9cm were observed in those born after 1977. Rural females (151.4±6.2cm) were significantly taller than the urban (151.3±7.2cm). However, this was not observed in males. In multivariate analysis, year of birth, level of education and household income were significantly associated with height. Height demonstrated a significant negative correlation with systolic blood pressure (r=-0.032), presence of diabetes (r=-0.069), total cholesterol (r=-0.106), HDL cholesterol (r=-0.142) and LDL cholesterol (r=-0.104). Height was associated with household income and level of education in Sri Lanka and demonstrated a distinct increasing trend over successive generations.