[Access to medicines for the treatment of systemic arterial hypertension and type 2 diabetes mellitus in the Brazilian population: data from the 2019 Brazilian National Health Survey]. / Acesso a medicamentos para o tratamento de hipertensão arterial sistêmica e diabetes mellitus tipo 2 na população brasileira: dados da Pesquisa Nacional de Saúde de 2019.

This study aimed to measure access to medicines for the treatment of systemic arterial hypertension and type 2 diabetes mellitus in Brazil according to the mode of acquisition, as well as to analyze the factors associated with this access, based on data from the 2019 Brazilian National Survey of Health (PNS, acronym in Portuguese). Socioeconomic data and data related to the use of medicines by people aged 15 and over were analyzed in relation to access via the Brazilian Popular Pharmacy Program (PFPB, acronym in Portuguese) and via public services. The majority of Brazilians who took part in the PNS reported using medication to control hypertension in the previous 15 days (91.5%) and using oral medication for diabetes (95.2%) and/or insulin (70%). Most participants obtained oral medication for hypertension and type 2 diabetes mellitus via PFPB (45.2% and 53.6%, respectively), and the factors that most negatively influenced this access were older age, lower income, lower schooling, very poor self-rated health and not having private health insurance. Access to insulin, on the other hand, was most often via the public health service (69.7%), and the factors that most negatively influenced this access were black/mixed-race skin color, lower income, very poor self-rated health and not having private health insurance. Generally, the importance of the PFPB as a policy to increase access to essential medicines in Brazil was highlighted, considering the free supply of antihypertensive and antidiabetic drugs.

Este estudo objetivou mensurar o acesso aos medicamentos para o tratamento da hipertensão arterial sistêmica e diabetes mellitus tipo 2 no Brasil segundo a via de obtenção, bem como analisar os fatores associados a esse acesso, de acordo com os dados da Pesquisa Nacional de Saúde (PNS) de 2019. Foram analisados dados socioeconômicos e relacionados ao uso de medicamentos de pessoas de 15 anos ou mais, em relação ao acesso via Programa Farmácia Popular do Brasil (PFPB) e via serviço público. A maior parte dos brasileiros que participaram da PNS referiu fazer uso do medicamento para controle da hipertensão, nos últimos 15 dias (91,5%), assim como a maior parte referiu fazer uso de medicamento oral para diabetes (95,2%) e/ou uso da insulina (70%).Os medicamentos orais para hipertensão arterial sistêmica e diabetes mellitus tipo 2 foram obtidos majoritariamente via PFPB, sendo respectivamente (45,2% e 53,6%), e os fatores que mais influenciaram negativamente esse acesso foram maior faixa etária, menor renda, menor escolaridade, não ter plano de saúde e referir uma autoavaliação de saúde muito ruim. O acesso à insulina, por sua vez, se deu com maior frequência via serviço público de saúde (69,7%), e os fatores que mais influenciaram negativamente esse acesso foram raça preta/parda, menor renda, não ter plano de saúde e referir uma autoavaliação de saúde muito ruim. De forma geral, foi evidenciada a importância do PFPB como política de ampliação de acesso a medicamentos essenciais no Brasil, considerando a gratuidade dos anti-hipertensivos e antidiabéticos.

Este estudio tuvo como objetivo medir el acceso a los medicamentos para el tratamiento de la hipertensión arterial sistémica y de la diabetes mellitus tipo 2 en Brasil según la vía de obtención, además de analizar los factores asociados a este acceso, según datos de la Encuesta Nacional de Salud (PNS) de 2019. Se analizaron datos socioeconómicos y relacionados con el uso de medicamentos de personas de 15 años o más, con relación al acceso por medio del Programa Farmacia Popular de Brasil (PFPB) y por medio del servicio público. La mayor parte de los brasileños que participaron en la PNS refirió utilizar medicamentos para controlar la hipertensión, en los últimos 15 días (91,5%), así como la mayoría refirió el uso de medicamentos orales para la diabetes (95,2%) o uso de insulina (70%). Los medicamentos orales para hipertensión arterial sistémica y diabetes mellitus tipo 2 se obtuvieron en su mayoría por medio del PFPB, respectivamente (45,2% y 53,6%), y los factores que influyeron de forma más negativa en este acceso fueron mayor rango de edad, menores ingresos, menor escolaridad, no tener seguro de salud y reportar una autoevaluación de salud muy mala. El acceso a la insulina, a su vez, se produjo con mayor frecuencia por medio del servicio público de salud (69,7%), y los factores que influyeron de forma más negativa en este acceso fueron la raza negra/morena, menores ingresos, no tener plan de salud y reportar una autoevaluación de salud muy mala. En general, se destacó la importancia de la PFPB como política de ampliación del acceso a medicamentos esenciales en Brasil, considerando la gratuidad de los antihipertensivos y antidiabéticos.

Survey and analysis of accessibility, availability, and affordability of topical glaucoma medicines.

PURPOSE: Affordability and availability of medicines is a growing global challenge for health-care systems. Access to medicines is recognized as an important determinant of treatment adherence. The access to glaucoma medicines and how it affects glaucoma management are not known. The purpose of this study was to determine the availability, affordability, and accessibility of topical intraocular pressure (IOP) -lowering eye drops in Haryana state of northern India using the World Health Organization (WHO)/Health Action International (HAI) methods. METHODS: A cross-sectional study was done to collect data on prices and availability of glaucoma topical medications in public and private sector pharmacies and retail outlets using the WHO/HAI methodology between October 2021 and January 2022. The availability and affordability of topical glaucoma medicines was determined. Comparison of the local price with international prices was done by calculating the median price ratio (MPR). RESULTS: A total of 191 facilities were randomly sampled across 11 ( n = 55) urban, 29 ( n = 92) semi-urban, and 44 ( n = 44) rural places during the study period. The availability of topical medication for glaucoma was low (35.7 ± 22.3) across all sampled sites and all classes of topical glaucoma medications. The median price of topical medication and availability were negatively correlated, Pearson's coefficient r (18) = -0.44, P 0.05, though the relationship was weak. A lowest paid, unskilled Indian government worker must spend between 15% and 203% of their daily wage to acquire a glaucoma medication. CONCLUSION: The availability and accessibility of topical glaucoma medications was low in this survey.

Extent of a valsartan drug shortage and its effect on antihypertensive drug use in the Canadian population: a national cross-sectional study.

BACKGROUND: Drug shortages represent a growing global problem, with potentially serious consequences to patients and the health care system. Our study investigates the impacts of a major recall and shortage of valsartan, an angiotensin receptor blocker (ARB), in July 2018 in Canada. METHODS: We conducted a time-series analysis of antihypertensive drugs dispensed in Canada between 2015 and 2019 using commercially available retail prescription data. Using autoregressive integrated moving average (ARIMA) modelling, we evaluated the change in valsartan use after the recall. We also measured the overall use of ARBs, angiotensin-converting-enzyme (ACE) inhibitors and other antihypertensive drug classes for the same period. RESULTS: After the recall in July 2018, valsartan use decreased 57.8%, from 362 231 prescriptions dispensed in June 2018 to 152 892 in September 2018 (difference = 209 339, p < 0.0001). Overall use of the ARB drug class decreased 2.0%, from 1 577 509 prescriptions dispensed in June 2018 to 1 545 591 in September 2018 (difference = 31 918, p = 0.0003), but use of non-valsartan ARBs increased 14.6%, from 1 215 278 to 1 392 699 prescriptions dispensed (difference = 177 421, p < 0.0001) in the same time frame. Although use of ACE inhibitors initially declined, this reduction was not sustained. The valsartan recall was not associated with a significant impact on use of other antihypertensive drug classes. INTERPRETATION: Our findings illustrate the impact of a major drug shortage, with the immediate and substantial reduction of valsartan dispensed and cascading effects on other ARBs, though future research is warranted to understand the consequences of such extensive shortages on clinical outcomes and health system costs. Improved policy strategies are needed to address the underlying causes of drug shortages and to mitigate their effects.

Anti-hypertensive medication access and affordability and their association with blood pressure control at a teaching hospital in Ghana.

INTRODUCTION: many hypertensive patients require two or more anti-hypertensive drugs, but in low- and middle-income countries there may be challenges with medication access or affordability. The objective of this study was to determine accessibility and affordability of anti-hypertensive medicines and their association with blood pressure (BP) control among hypertensive patients attending the Korle-Bu teaching hospital (KBTH) polyclinic. METHODS: a cross-sectional study was conducted among 310 systematically sampled hypertensive patients attending the KBTH Polyclinic in Ghana. A structured questionnaire was used to obtain data on patient demographics and clinical characteristics, prices, availability and mode of payment of generic anti-hypertensive medicines. RESULTS: fifty-nine patients (19.4%) made out-of-pocket payments. At the private pharmacy and hospital, 123 (40.5%) and 77 patients (25.3%) respectively could not afford four anti-hypertensive medicines. Medicines availability at KBTH was 60%. Continuous access to BP drugs at KBTH was 14.8%. Overall access was 74.9% (SD ± 41.3). Out-of-pocket affordability of the medicines was positively correlated with BP control (R=0.12, p=0.037). Obtaining medicines via health insurance only was more likely to result in BP control than making any out-of-pocket payments (OR= 2.185; 95% CI, 1.215 - 3.927). Access at KBTH was more likely to result in BP control (OR=1.642; 95% C.I, 0.843 - 3.201). CONCLUSION: there were access challenges although most patients obtained BP medication free. Out-of-pocket affordability is a challenge for some hypertensive patients. Access to affordable BP medication can improve BP control. These findings provide an impetus for urgently evaluating access to affordable anti-hypertensive medicines in other hospitals in Ghana.

[The importance of the logistic warehouse in pandemic period: the experience of the USL Umbria 1 (Perugia, Italy) during covid-19.] / L'importanza del magazzino logistico in periodo di pandemia: l'esperienza dell'USL Umbria 1 durante covid-19.

The pandemic period has generated major problems in the pharmacies of hospitals and local health care companies regarding the distribution of drugs to patients undergoing treatment with chronic drugs. This is because the patient, during the lockdown, was forced to leave the house and go several miles away to reach the place where the drug was dispensed. Moreover, very often, the place was placed in covid-19 hospitals, like the one in Perugia, and was also a risk for the patient himself. The logistical organization allows, in addition to the advantages of traceability, efficiency and savings, with the arrival of the drug at home, a very high patient compliance that also translates into greater security in a pandemic period. To the Usl Umbria 1 of Perugia (Italy) has been centralized the activity of warehouse for all the South area that includes three hospitals and four sanitary districts. Such warehouse, through computerized procedure, guarantees the direct distribution with sending of the medicines directly to the district of belonging of the patient. In this way the patient was not forced to make long and risky trips to continue their chronic therapies. Moreover, this logistic warehouse has also allowed to cope with the correct management of many medicinal specialties that have been used against the SARS-CoV-2 virus avoiding their temporary deficiency for patients already on therapy according to the normal therapeutic indications (anti-inflammatory, antiretroviral and immunomodulatory). This paper aims to demonstrate how logistical organization is of vital importance for a National Health System that has to face increasing costs, ensure the traceability of all processes and, last but not least, survive a worldwide pandemic period.

Prevalence of use and sources of antihypertensive medicine in Brazil: an analysis of the VIGITEL telephone survey. / Prevalência de uso e fontes de obtenção de medicamentos anti-hipertensivos no Brasil: análise do inquérito telefônico VIGITEL.

OBJECTIVE: The prevalence of hypertension in Brazil and worldwide has been increasing in recent decades, and drug therapy is one of the strategies used to control this condition. The objective of this study was to estimate the prevalence of use and identify the sources for obtaining antihypertensive drugs in Brazil, according to sociodemographic variables, comparing three periods: 2011, 2014 and 2017. METHODS: Data from individuals aged ≥20 years who reported a medical diagnosis of hypertension, interviewed by Vigitel in 2011, 2014 and 2017 were used. Frequency and prevalence of drug use in addition to the sources for obtaining medication were estimated by sociodemographic variables, with 95% confidence intervals. The differences between proportions were verified by Pearson's chi-square test (Rao-Scott), with a significance level of 5%. RESULTS: The prevalence of antihypertensive drug use remained stable (80%). Regarding the sources for obtaining these medicines, there was variation in the period, indicating a decrease in usage through the Brazilian Unified Health System (SUS) (44.2% in 2011; 30.5% in 2017). This decrease was accompanied with increase in PFPB (16.1% in 2011; 29.9% in 2017). The prevalence of other sources for obtaining medicine (private pharmacies/drugstores) showed stability in the period. CONCLUSIONS: The prevalence of medication use remained high and there was a change in the pattern of use according to sources, demonstrating migration between SUS pharmacies to the PFPB, and suggesting a reduction in the availability of medicines from public pharmacies universally, and for free.

Access to Cardiovascular Disease and Hypertension Medicines in Developing Countries: An Analysis of Essential Medicine Lists, Price, Availability, and Affordability.

Background Access to medicines is important for long-term care of cardiovascular diseases and hypertension. This study provides a cross-country assessment of availability, prices, and affordability of cardiovascular disease and hypertension medicines to identify areas for improvement in access to medication treatment. Methods and Results We used the World Health Organization online repository of national essential medicines lists (EMLs) for 53 countries to transcribe the information on the inclusion of 12 cardiovascular disease/hypertension medications within each country's essential medicines list. Data on availability, price, and affordability were obtained from 84 surveys in 59 countries that used the World Health Organization's Health Action International survey methodology. We summarized and compared the indicators across lowest-price generic and originator brand medicines in the public and private sectors and by country income groups. The average availability of the select medications was 54% in low- and lower-middle-income countries and 60% in high- and upper-middle-income countries, and was higher for generic (61%) than brand medicines (41%). The average patient median price ratio was 80.3 for brand and 16.7 for generic medicines and was higher for patients in low- and lower-middle-income countries compared with high- and upper-middle-income countries across all medicine categories. The costs of 1 month's antihypertensive medications were, on average, 6.0 days' wage for brand medicine and 1.8 days' wage for generics. Affordability was lower in low- and lower-middle-income countries than high- and upper-middle-income countries for both brand and generic medications. Conclusions The availability and accessibility of pharmaceuticals is an ongoing challenge for health systems. Low availability and high costs are major barriers to the use of and adherence to essential cardiovascular disease and antihypertensive medications worldwide, particularly in low- and lower-middle-income countries.

Collaborative Management Strategies for Drug Shortages in Neurocritical Care.

Drug shortages have become all too familiar in the health care environment, with over 200 drugs currently on shortage. In the wake of Hurricane Maria in September 2017, hospitals across the USA had to quickly and creatively adjust medication preparation and administration techniques in light of decreased availability of intravenous (IV) bags used for compounding a vast amount of medications. Amino acid preparations, essential for compounding parenteral nutrition, were also directly impacted by the hurricane. Upon realization of the impending drug shortages, hospitals resorted to alternative methods of drug administration, such as IV push routes, formulary substitutions, or alternative drug therapies in hopes of preserving the small supply of IV bags available and prioritizing them for them most critical needs. In some cases, alternative drug therapies were required, which increased the risk of medication errors due to the use of less-familiar treatment options. Clinical pharmacists rounding with medical teams provided essential, patient-specific drug regimen alternatives to help preserve a dwindling supply while ensuring use in the most critical cases. Drug shortages also frequently occur in the setting of manufacturing delays or discontinuation and drug recalls, with potential to negatively impact patient care. The seriousness of the drug shortage crisis reached public attention by December 2017, when political and pharmacy organizations called for response to the national drug shortage crisis. In this article, we review institutional mitigation strategies in response to drug shortages and discuss downstream effects of these shortages, focusing on medications commonly prescribed in neurocritical care patients.

Prevalência de uso e fontes de obtenção de medicamentos anti-hipertensivos no Brasil: análise do inquérito telefônico VIGITEL / Prevalence of use and sources of antihypertensive medicine in Brazil: an analysis of the VIGITEL telephone survey

RESUMO: Objetivo: A prevalência de hipertensão arterial no Brasil e no mundo vem aumentando nas últimas décadas, sendo o uso de medicamentos uma das estratégias utilizadas no controle da doença. O objetivo deste estudo foi estimar a prevalência de uso e identificar as fontes de obtenção de anti-hipertensivos no Brasil, segundo variáveis sociodemográficas, comparando três períodos: 2011, 2014 e 2017. Métodos: Foram utilizados dados de indivíduos com idade ≥20 anos que referiram diagnóstico médico de hipertensão arterial, entrevistados pelo Vigitel nos anos de 2011, 2014 e 2017. Foi estimada a distribuição de frequências e as prevalências de uso de medicamentos, segundo variáveis sociodemográficas, de acordo com as fontes de obtenção, com intervalos de confiança de 95%. As diferenças entre as proporções foram verificadas pelo teste χ2 de Pearson (Rao-Scott), com nível de significância de 5%. Resultados: A prevalência de uso manteve-se estável (80%). Quanto às fontes de obtenção observou-se variação no período, indicando diminuição na obtenção por meio das Unidades de Saúde do SUS (44,2% em 2011; 30,5% em 2017). Esse decréscimo esteve acompanhado do aumento na obtenção pela Farmácia Popular (16,1% em 2011; 29,9% em 2017). A prevalência de obtenção por meio de farmácias privadas/drogarias mostrou estabilidade no período. Conclusões: A prevalência de uso de medicamentos se manteve alta e houve modificação no padrão de utilização segundo fontes de obtenção, evidenciando migração entre Unidades de Saúde do SUS para a Farmácia Popular, sugerindo redução da disponibilidade dos medicamentos pelas farmácias públicas de forma universal e gratuita.

ABSTRACT: Objective: The prevalence of hypertension in Brazil and worldwide has been increasing in recent decades, and drug therapy is one of the strategies used to control this condition. The objective of this study was to estimate the prevalence of use and identify the sources for obtaining antihypertensive drugs in Brazil, according to sociodemographic variables, comparing three periods: 2011, 2014 and 2017. Methods: Data from individuals aged ≥20 years who reported a medical diagnosis of hypertension, interviewed by Vigitel in 2011, 2014 and 2017 were used. Frequency and prevalence of drug use in addition to the sources for obtaining medication were estimated by sociodemographic variables, with 95% confidence intervals. The differences between proportions were verified by Pearson's chi-square test (Rao-Scott), with a significance level of 5%. Results: The prevalence of antihypertensive drug use remained stable (80%). Regarding the sources for obtaining these medicines, there was variation in the period, indicating a decrease in usage through the Brazilian Unified Health System (SUS) (44.2% in 2011; 30.5% in 2017). This decrease was accompanied with increase in PFPB (16.1% in 2011; 29.9% in 2017). The prevalence of other sources for obtaining medicine (private pharmacies/drugstores) showed stability in the period. Conclusions: The prevalence of medication use remained high and there was a change in the pattern of use according to sources, demonstrating migration between SUS pharmacies to the PFPB, and suggesting a reduction in the availability of medicines from public pharmacies universally, and for free.

Availability, prices and affordability of essential medicines for treatment of diabetes and hypertension in private pharmacies in Zambia.

OBJECTIVES: To explore availability, prices and affordability of essential medicines for diabetes and hypertension treatment in private pharmacies in three provinces of Zambia. METHODS: A cross-sectional survey was conducted in 99 pharmacies across three Zambian provinces. Methods were based on a standardized methodology by the World Health Organization and Health Action International. Availability was analysed as mean availability per pharmacy and individual medicine. Median prices were compared to international reference prices and differences in price between medicine forms (original brand or generic product) were computed. Affordability was assessed as number of days' salaries required to purchase a standard treatment course using the absolute poverty line and mean per capita provincial household income as standard. An analysis identifying medicines considered both available and affordable was conducted. RESULTS: Two antidiabetics and nine antihypertensives had high-level availability (≥80%) in all provinces; availability levels for the remaining surveyed antidiabetics and antihypertensives were largely found below 50%. Availability further varied markedly across medicines and medicine forms. Prices for most medicines were higher than international reference prices and great price variations were found between pharmacies, medicines and medicine forms. Compared to original brand products, purchase of generics was associated with price savings for patients between 21.54% and 96.47%. No medicine was affordable against the absolute poverty line and only between four and eleven using mean per capita provincial incomes. Seven generics in Copperbelt/Lusaka and two in Central province were highly available and affordable. CONCLUSIONS: The study showed that the majority of surveyed antidiabetic and antihypertensive medicines was inadequately available (<80%). In addition, most prices were higher than their international reference prices and that treatment with these medicines was largely unaffordable against the set affordability thresholds. Underlying reasons for the findings should be explored as a basis for targeted policy initiatives.

Assessment of care provision for hypertension at the emergency Department of an Urban Hospital in Mozambique.

BACKGROUND: Management of hypertension in Mozambique is poor, and rates of control are amongst the lowest in the world. Health system related factors contribute at least partially to this situation, particularly in settings where there is scarcity of resources to address the double burden of infectious and non-communicable diseases. This study aimed to assess the management of hypertension in an emergency department (ED). METHODS: During a pragmatic and prospective 30-day snapshot study (with 24 h surveillance) and random profiling of one-in-five presentations to the ED of Hospital Geral de Mavalane, Maputo, we assessed patient's flow and care, as well as health facility's infrastructure and resources through direct observation. Reports from pharmacy and laboratory stocks were used to assess availability of diagnostics and medicines needed for hypertension management. RESULTS: The 1911 hypertensive patients included in the study had several stops during their journey inside the health facility and followed a non-standardized care flow. No clinical protocols or algorithms for risk stratification of hypertension were available. Stock-outs of basic diagnostic tools for risk stratification and medicines were registered. The availability of medicines was 28% on average. CONCLUSIONS: Critical gaps in health facility readiness to address arterial hypertension seen in ED were uncovered, including lack of clinical protocols, insufficient availability of diagnostics and essential medicines, as well as low affordability of the families to guaranty continuum of care. Innovative financing mechanisms are needed to support the health system to address hypertension.

Scaling up effective treatment of hypertension-A pathfinder for universal health coverage.

High blood pressure is the world's leading cause of death, but despite treatment for hypertension being safe, effective, and low cost, most people with hypertension worldwide do not have it controlled. This article summarizes lessons learned in the first 2 years of the Resolve to Save Lives (RTSL) hypertension management program, operated in coordination with the World Health Organization (WHO) and other partners. Better diagnosis, treatment, and continuity of care are all needed to improve control rates, and five necessary components have been recommended by RTSL, WHO and other partners as being essential for a successful hypertension control program. Several hurdles to hypertension control have been identified, with most related to limitations in the health care system rather than to patient behavior. Treatment according to standardized protocols should be started as soon as hypertension is diagnosed, and medical practices and health systems must closely monitor patient progress and system performance. Improvement in hypertension management and control, along with elimination of artificial trans fat and reduction of dietary sodium consumption, will improve many aspects of primary care, contribute to goals for universal health coverage, and could save 100 million lives worldwide over the next 30 years.

Access to medicines for hypertension: a survey in rural Yogyakarta province, Indonesia.

INTRODUCTION: Obtaining an adequate supply of medicines is an important step in facilitating medication adherence. This study aimed to determine (1) how people with hypertension in rural villages in Indonesia obtain their supply of anti-hypertensive medications, (2) the type of hypertension medication taken and (3) factors associated with where and how people obtain their medicines supplies. METHOD: Data pertaining to people with hypertension (age ≥45 years) were collected from eight rural villages in the Bantul district, Yogyakarta province, Indonesia, using a researcher-administered questionnaire. RESULTS: Of 384 participants, 203 (52.9%) obtained anti-hypertensive medications from public or private healthcare services. The most common way was by purchasing these medicines without prescription in community pharmacies (n=64, 17%). The medicines obtained this way included captopril, amlodipine, nifedipine, and bisoprolol. One-hundred and nineteen (15%) participants obtained their medicines at no cost by visiting public healthcare services such as community health centres (n=51), the Integrated Health Service Post for the Elderly (n=53), and the public hospitals (n=15). Direct dispensing from clinicians was reported by participants who visited a doctor (n=15), midwife (n=23) or nurse (n=21). Having access to an adequate medication supply (ie for an entire 30 days) was reported by 40 (10.4%) participants, who obtained the medication from a community health centre (n=18), public hospital (n=4), community pharmacy (n=5), private hospital (n=2), or multiple sources (n=11). A higher formal education level was associated with obtaining medicines from multiple sources rather than from the public or private provider only. Living near a community health centre and having government insurance were associated with obtaining medicines from the public health service. Age, gender, employment, presence of other chronic diseases, and knowledge about hypertension were not significantly associated with how participants obtained their medications. CONCLUSION: These Indonesian participants obtained their anti-hypertensive medications from various sources; however, the inadequate supplies found in this study could compromise both short- and long-term management of hypertension. Direct dispensing, non-doctor prescribing, and self-medication with anti-hypertensive medications indicate the current complex healthcare system in Indonesia. This study also shows some challenges involved in managing patients with chronic diseases such as hypertension in resource-poor settings. It provides important findings for quality improvement practices that should be considered to improve the health lifespan in populous countries such as Indonesia.

Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data.

BACKGROUND: Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development. METHODS: We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level. FINDINGS: The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and middle-income countries (except for India) than in high-income countries. The proportion of communities with four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90), 71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13% in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of 65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in communities that had all four drug classes available were more likely to use at least one blood pressure-lowering medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59-3·12); p<0·0001), combination therapy (1·53, 1·13-2·07; p=0·054), and have their blood pressure controlled (2·06, 1·69-2·50; p<0·0001) than were those in communities where blood pressure-lowering medicines were not available. Participants with known hypertension from households able to afford four blood pressure-lowering drug classes were more likely to use at least one blood pressure-lowering medicine (adjusted OR 1·42, 95% CI 1·25-1·62; p<0·0001), combination therapy (1·26, 1·08-1·47; p=0·0038), and have their blood pressure controlled (1·13, 1·00-1·28; p=0·0562) than were those unable to afford the medicines. INTERPRETATION: A large proportion of communities in low-income and middle-income countries do not have access to more than one blood pressure-lowering medicine and, when available, they are often not affordable. These factors are associated with poor blood pressure control. Ensuring access to affordable blood pressure-lowering medicines is essential for control of hypertension in low-income and middle-income countries. FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Canadian Institutes of Health Research Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, the Ontario Ministry of Health and Long-Term Care, pharmaceutical companies (with major contributions from AstraZeneca [Canada], Sanofi Aventis [France and Canada], Boehringer Ingelheim [Germany amd Canada], Servier, and GlaxoSmithKline), Novartis and King Pharma, and national or local organisations in participating countries.

Availability, cost, and prescription patterns of antihypertensive medications in primary health care in China: a nationwide cross-sectional survey.

BACKGROUND: Around 200 million adults in China have hypertension, but few are treated or achieve adequate control of their blood pressure. Available and affordable medications are important for successfully controlling hypertension, but little is known about current patterns of access to, and use of, antihypertensive medications in Chinese primary health care. METHODS: We used data from a nationwide cross-sectional survey (the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project primary health care survey), which was undertaken between November, 2016 and May, 2017, to assess the availability, cost, and prescription patterns of 62 antihypertensive medications at primary health-care sites across 31 Chinese provinces. We surveyed 203 community health centres, 401 community health stations, 284 township health centres, and 2474 village clinics to assess variation in availability, cost, and prescription by economic region and type of site. We also assessed the use of high-value medications, defined as guideline-recommended and low-cost. We also examined the association of medication cost with availability and prescription patterns. FINDINGS: Our study sample included 3362 primary health-care sites and around 1 million people (613 638 people at 2758 rural sites and 478 393 people at 604 urban sites). Of the 3362 sites, 8·1% (95% CI 7·2-9·1) stocked no antihypertensive medications and 33·8% (32·2-35·4) stocked all four classes that were routinely used. Village clinics and sites in the western region of China had the lowest availability. Only 32·7% (32·2-33·3) of all sites stocked high-value medications, and few high-value medications were prescribed (11·2% [10·9-11·6] of all prescription records). High-cost medications were more likely to be prescribed than low-cost alternatives. INTERPRETATION: China has marked deficiencies in the availability, cost, and prescription of antihypertensive medications. High-value medications are not preferentially used. Future efforts to reduce the burden of hypertension, particularly through the work of primary health-care providers, will need to improve access to, and use of, antihypertensive medications, paying particular attention to those with high value. FUNDING: CAMS Innovation Fund for Medical Science, the Entrusted Project from the China National Development and Reform Commission, and the Major Public Health Service Project from the Ministry of Finance of China and National Health and Family Planning Commission of China.

Quality of integrated chronic disease care in rural South Africa: user and provider perspectives.

The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian's structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries.

Access to and use of high blood pressure medications in Brazil.

OBJECTIVE: To analyze the access to and use of medicines for high blood pressure among the Brazilian population according to social and demographic conditions. METHODS: Analysis of data from Pesquisa Nacional Sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines), a nationwide cross-sectional, population-based study, with probability sampling, carried out between September 2013 and February 2014 in urban households in the five Brazilian regions. The study evaluated the access and use of medicines to treat people with high blood pressure. The independent variables were gender, age, socioeconomic status and Brazilian region. The study also described the most commonly used drugs and the percentage of people treated with one, two, three or more drugs. Point estimations and confidence intervals were calculated considering the sample weights and sample complex plan. RESULTS: Prevalence of high blood pressure was 23.7% (95%CI 22.8-24.6). Regarding people with this condition, 93.8% (95%CI 92.8-94.8) had indication for drug therapy and, of those, 94.6% (95%CI 93.5-95.5) were using the medication at the time of interview. Full access to medicines was 97.9% (95%CI 97.3-98.4); partial access, 1.9% (95%CI 1.4-2.4); and no access, 0.2% (95%CI 0.1-0.4). The medication used to treat high blood pressure, 56.0% (95%CI 52.6-59.2) were obtained from SUS (Brazilian Unified Health System), 16.0% (95%CI 14.3-17.9) from Popular Pharmacy Program, 25.7% (95%CI 23.4-28.2) were paid for by the patients themselves and 2.3% (95%CI 1.8-2.9) were obtained from other locations. The five most commonly used drugs were, in descending order, hydrochlorothiazide, losartan, captopril, enalapril and atenolol. Of the total number of patients on treatment, 36.1% (95%CI 34.1-37.1) were using two medicines and 13.5% (95%CI 12.3-14.9) used three or more. CONCLUSIONS: Access to medicines for the treatment of high blood pressure may be considered high and many of them are available free of charge. The most commonly used drugs are among those recommended as first-line treatment for high blood pressure control. The percentage of people using more than one drug seems to follow the behavior observed in other countries. OBJETIVO: Analisar o acesso e a utilização de medicamentos para a hipertensão na população brasileira segundo condições sociais e demográficas. Análise dos dados da Pesquisa Nacional Sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos, estudo nacional de delineamento transversal de base populacional, com amostra probabilística, realizado entre setembro de 2013 e fevereiro de 2014 em domicílios urbanos nas cinco regiões do Brasil. Avaliou-se o uso e acesso aos medicamentos para os cuidados com pessoas que apresentam hipertensão arterial. As variáveis independentes utilizadas foram sexo, idade, nível socioeconômico e região do País. Também foram descritos os fármacos mais utilizados e a proporção de pessoas tratadas com um, dois, três ou mais fármacos. As estimativas de ponto e os intervalos de confiança foram calculados considerando os pesos amostrais e o plano complexo da amostra. A prevalência de hipertensão arterial foi de 23,7% (IC95% 22,8-24,6). Das pessoas com a condição, 93,8% (IC95% 92,8-94,8) tinham indicação de tratamento com medicamentos e, destes, 94,6% (IC95% 93,5-95,5) estavam usando os medicamentos no momento da entrevista. O acesso total aos medicamentos foi de 97,9% (IC95% 97,3-98,4); o acesso parcial, de 1,9% (IC95% 1,4-2,4); e o acesso nulo, de 0,2% (IC95% 0,1-0,4). Dos medicamentos utilizados para tratar a hipertensão, 56,0% (IC95% 52,6-59,2) foram obtidos no SUS, 16,0% (IC95% 14,3-17,9), no Programa Farmácia Popular, 25,7% (IC95% 23,4-28,2) pago do próprio bolso e 2,3% (IC95% 1,8-2,9) em outros locais. Os cinco fármacos mais utilizados foram, em ordem descrente, hidroclorotiazida, losartana, captopril, enalapril e atenolol. Do total de tratados, 36,1% (IC95% 34,1-37,1) estavam usando dois fármacos e 13,5% (IC95% 12,3-14,9) utilizavam três ou mais fármacos. CONCLUSÕES: : O acesso aos medicamentos para tratamento da hipertensão pode ser considerado elevado e grande parte desses medicamentos é obtida gratuitamente. Os fármacos mais utilizados estão entre os preconizados como de primeira linha para o controle de hipertensão arterial. A proporção de pessoas utilizando mais de um fármaco parece seguir o comportamento observado em outros países.