Management of type 1 diabetes in low- and middle-income countries: Comparative health system assessments in Kyrgyzstan, Mali, Peru and Tanzania.

AIMS: To describe and compare the health system responses for type 1 diabetes in Kyrgyzstan, Mali, Peru and Tanzania. METHODS: The Rapid Assessment Protocol for Insulin Access, a multi-level assessment of the health system, was implemented in Kyrgyzstan, Mali, Peru and Tanzania using document reviews, site visits and interviews to assess the delivery of care and access to insulin. RESULTS: Despite the existence of noncommunicable or diabetes strategies and Universal Health Coverage policies including diabetes-related supplies, this has not necessarily translated into access to insulin or diabetes care for all. Insulin and related supplies were often unavailable and unaffordable. Across the four countries test strips and insulin, when paid for by the individual, represented respectively 48-82% and 25-36% of total costs. Care was mainly delivered at tertiary-level hospitals by specialists. Only Kyrgyzstan had data collection systems integrated into the Ministry of Health structure. In addition, issues with healthcare worker training and education and empowerment of people with diabetes were present in these health systems. CONCLUSIONS: People with type 1 diabetes in these countries face different barriers, including the cost of insulin and care. Given the renewed attention to diabetes on the global health agenda tailored health system responses for type 1 diabetes are needed. Insulin should be prioritized as it is the foundation of type 1 diabetes care, but other elements of care and support need to be fostered by different actors.

Availability, prices, and affordability of selected essential cancer medicines in a middle-income country - the case of Mexico.

BACKGROUND: More alternatives have become available for the diagnosis and treatment of cancer in low- and middle-income countries. Because of increasing demands, governments are now facing a problem of limited affordability and availability of essential cancer medicines. Yet, precise information about the access to these medicines is limited, and the methodology is not very well developed. We assessed the availability and affordability of essential cancer medicines in Mexico, and compared their prices against those in other countries of the region. METHODS: We surveyed 21 public hospitals and 19 private pharmacies in 8 states of Mexico. Data were collected on the availability and prices of 49 essential cancer medicines. Prices were compared against those in Chile, Peru, Brazil, Colombia and PAHO's Strategic Fund. RESULTS: Of the various medicines, mean availability in public and private sector outlets was 61.2 and 67.5%, respectively. In the public sector, medicines covered by the public health insurance "People's Health Insurance" were more available. Only seven (public sector) and five (private sector) out of the 49 medicines were considered affordable. Public sector procurement prices were 41% lower than in other countries of the region. CONCLUSIONS: The availability of essential cancer medicines, in the public and private sector, falls below World Health Organization's 80% target. The affordability remains suboptimal as well. A national health insurance scheme could serve as a mechanism to improve access to cancer medicines in the public sector. Comprehensive pricing policies are warranted to improve the affordability of cancer medicines in the private sector.

Access to cancer medication in public hospitals in a middle-income country: The view of stakeholder.

BACKGROUND: Access to cancer medicines is a core component of comprehensive cancer care; as such, it is included in Mexico's public health insurance: Seguro Popular de Salud (SPS). Learning about stakeholders' experiences on processes and barriers influencing access to essential cancer medicines within healthcare facilities allows identifying needed policies to improve access to cancer care. OBJECTIVE: The aim of this study was to obtain the insights of health professionals in public hospitals in Mexico on how SPS influences access to cancer medicines regarding medicine selection, financing, and procurement and supply systems. The purpose is to identify policy areas that need strengthening to improve access to cancer medicines. METHODS: Semi-structured interviews were conducted with 67 health professionals from 21 public hospitals accredited by SPS across Mexico. A framework analysis was used with categories of analysis derived from the World Health Organization's Access framework. RESULTS: Most stakeholders reported that the availability of listed cancer medicines was sufficient. However, cancer specialists reported that medicines coverage by SPS was restrictive covering only basic cancer care. Public hospitals followed SPS treatment protocols in selecting and prescribing cancer medicines but used different procurement procedures. When essential cancer medicines were unavailable (not listed or stocked-out), hospitals reported several strategies such as prescribing alternative therapies, resorting to direct purchases, and assisting patients in obtaining medicines elsewhere. Other reported barriers to access to treatment were: distance to health facilities, poor insurance coverage, and financial restrictions. CONCLUSIONS: Health professionals have encountered benefits and challenges from the implementation of SPS influencing access to cancer medicines and care in Mexico, pointing to areas in which action is necessary. Finding the right balance between expanding the range and cost of cancer treatments covered by insurance and making basic cancer care available to all is a challenge faced by Mexico and other middle-income countries.

The Impact of Price Negotiations on Public Procurement Prices and Access to 8 Innovative Cancer Medicines in a Middle-Income Country: The Case of Mexico.

BACKGROUND: To mitigate the effect of high prices, in 2008 Mexico established a commission that negotiates single procurement prices for patented medicines in the public sector. OBJECTIVES: We assessed the possible effect of price negotiations on the prices of new essential cancer medicines in Mexico between 2010 and 2016 and on access to these new cancer medicines. METHODS: We retrieved the public procurement prices and volume of 8 selected innovative cancer medicines in Mexico in addition to their maximum retail prices in the private sector. We calculated the median, interquartile (25%-75%) range, and maximum and minimum public procurement prices to analyze price changes and trends. We assessed changes between the maximum retail prices and the public procurement prices and changes in the volume procured from 2010 to 2016. RESULTS: Between 2010 and 2016, the prices of selected patented cancer medicines in the public sector decreased by 40% to 85%, expressed in US dollars. When expressed in Mexican pesos, public prices for 5 medicines reduced and others remained stable, whereas prices increased in the private sector over the same period. Procurement prices were not uniform between and within public institutions. The volumes of selected cancer medicines supplied in the public sector increased over the years, suggesting better access. CONCLUSION: Although direct causality is difficult to prove, the establishment of the negotiating commission seems to have led to reduced prices and possibly better access in the public sector. Medicine procurement by public hospitals should be monitored to ensure that negotiated prices benefit all institutions.

Access to innovative cancer medicines in a middle-income country - the case of Mexico.

BACKGROUND: Cancer has become the third cause of death in Mexico. Treatment for cancer is often complex and lengthy. New and better medicines enter the market at high prices, which may limit access. Like most Latin American countries, Mexico has an essential cancer medicines list that includes innovative medicines. Their accessibility and use in the public sector remains unknown. Therefore, we describe the use, as a proxy of access, of innovative and essential cancer medicines in the public sector in Mexico, by insurance institution, and by five regions between 2010 to 2016. METHODS: We used drug utilization research methods to assess the use of eight patented cancer medicines. Through the national transparency platform, we obtained data on the quantities of these medicines used in all public health facilities and social health insurance institutions and recalculated those figures into defined daily dose (DDD) per 1000 population per year. RESULTS: Overall, the use of all medicines increased over the years, especially for trastuzumab, rituximab and imatinib. The use of innovative medicines was higher per population covered in social health insurance institutions than in governmental facilities. Throughout the study period, the Central region (including Mexico City) has used more medicines per population than the other regions. CONCLUSIONS: The use and access of some essential innovative cancer medicines has increased over the years, but remains unequal across insurance schemes and regions. Particularly, the Ministry of Health Insurance scheme and Northern and Western regions in the country would benefit from additional efforts to increase access to essential cancer medicines.

Policy approaches to improve availability and affordability of medicines in Mexico - an example of a middle income country.

BACKGROUND: The World Health Organization recommends establishing and implementing a national pharmaceutical policy (NPP) to guarantee effective and equitable access to medicines. Mexico has implemented several policy approaches to regulate the pharmaceutical sector, but it has no formal NPP. This article describes the approach that the Mexican government has taken to improve availability and affordability of essential medicines. METHODS: Descriptive policy analysis of public pharmaceutical policy proposals and health action plans on the basis of publicly available data and health progress reports, with a focus on availability and affordability of medicines. RESULTS: The government has implemented pooled procurement, price negotiations, and an information platform in the public sector to improve affordability and availability. The government mainly reports on the savings that these strategies have generated in the public expenditure but their full impact on availability and affordability has not been assessed. CONCLUSIONS: To increase availability and affordability of medicines in the public sector, the Mexican government has resorted on isolated strategies. In addition to efficient procurement, price negotiations and price information, other policy components and pricing interventions are needed. All these strategies should be included in a comprehensive NPP.

Diez recomendaciones para mejorar el uso de medicamentos en paises en vias de desarrollo / Ten recommendations to improve the use of drugs in developing countries

Este documento revisa el estado actual de conocimientos acerca de la efectividad de las estrategias para mejorar la utilización de los medicamentos en paises en vías de desarrollo, y sugiere lo que pueden hacer los responsables de formular políticas de salud y administradores del sistema de salud para lograr este objetivo