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1.
Res Social Adm Pharm ; 2019 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-31796333

RESUMO

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.

2.
ESMO Open ; 4(6): e000550, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31798977

RESUMO

The Central European Cooperative Oncology Group (CECOG) and 'ESMO Open-Cancer Horizons' roundtable discussion brought together stakeholders from several European Union (EU) countries involved in drug development, drug authorisation and reimbursement or otherwise affected by delayed and unequal access to innovative anticancer drugs. The approval process of drugs is well established and access delays can be caused directly or indirectly by national or regional decision-making processes on reimbursement. The two key aspects for those involved in reimbursement decisions are first the level of evidence required to decide and second pricing, which can be challenging for some innovative oncology compounds, especially in Eastern and South-Eastern European countries. Other important factors include: available healthcare budget; the structure and sophistication of healthcare authorities and health technology assessment processes; societal context and political will. From the point of view of the pharmaceutical industry, better alignment between stakeholders in the process and adaptive pathway initiatives is desirable. Key aspects for patients are improved access to clinical trials, preapproval availability and reports on real-world evidence. Restricted access limits oncologists' daily work in Eastern and South-Eastern EU countries. The roundtable discussion suggested considering the sequencing of regulatory approval and reimbursement decisions together with more flexible contracting as a possible way forward. The panel concluded that early and regular dialogue between all stakeholders including regulators, payers, patient stakeholders and industry is required to improve the situation.

3.
Oncologist ; 2019 Nov 29.
Artigo em Inglês | MEDLINE | ID: mdl-31784494

RESUMO

BACKGROUND: Treatment of non-small cell lung cancer (NSCLC) improved substantially in the last decades. Novel targeted and immune-oncologic drugs were introduced into routine treatment. Despite accelerated development and subsequent drug registrations by the European Medicinal Agency (EMA), novel drugs for NSCLC are poorly accessible in Central and Eastern European (CEE) countries. MATERIAL AND METHODS: The Central European Cooperative Oncology Group conducted a survey among experts from 10 CEE countries to provide an overview on the availability of novel drugs for NSCLC and time from registration to reimbursement decision in their countries. RESULTS: Although first-generation epidermal growth factor receptor tyrosine kinase inhibitors were reimbursed and available in all countries, for other registered therapies-even for ALK inhibitors and checkpoint inhibitors in first-line-there were apparent gaps in availability and/or reimbursement. There was a trend for better availability of drugs with longer time from EMA marketing authorization. Substantial differences in access to novel drugs among CEE countries were observed. In general, the availability of drugs is not in accordance with the Magnitude of Clinical Benefit Scale (MCBS), as defined by the European Society for Medical Oncology (ESMO). Time spans between drug registrations and national decisions on reimbursement vary greatly, from less than 3 months in one country to more than 1 year in the majority of countries. CONCLUSION: The access to novel drugs for NSCLC in CEE countries is suboptimal. To enable access to the most effective compounds within the shortest possible time, reimbursement decisions should be faster and ESMO MCBS should be incorporated into decision making.

4.
Drug Alcohol Depend ; 206: 107743, 2019 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-31801107

RESUMO

BACKGROUND: Given the rising incidence of opioid overdose in the United States, naloxone access is critical for high-risk populations, such as persons who inject drugs (PWID). Yet not all PWID have access to this life-saving antidote. With PWID in Michigan recruited via respondent driven sampling in 2017, after the 2016 standing order expanding naloxone availability through local pharmacies, we explored possible access disparities. METHODS: With 46 seeds recruited from agencies serving local PWID communities, we obtained a sample of N = 410 PWID from Southeast Michigan (n = 285 form urban Detroit, and 125 for suburban/rural areas outside Detroit). Participants completed questionnaires detailing socio-demographics, health history, substance use and treatment access, including naloxone. We used multiple logistic regression to examine the predictors of self-reported naloxone access based on participant characteristics (e.g., demographics, health status) and geography (urban vs. suburban/rural). RESULTS: Self-reported naloxone access differed significantly by location (urban = 18.3 %; suburban/rural = 41.9 %). In multivariable analyses, naloxone access was significantly associated with race, household income, employment, health insurance, recent homelessness, prescription opioid usage, Hepatitis A and C status, Hepatitis A vaccination, Hepatitis C testing, access to drug treatment and services, and hospital as the usual place of care. CONCLUSION: Despite recent policies to expand access, our results indicate that naloxone access among high-risk PWID is low. This warrants future research to identify effective channels to reduce barriers and increase naloxone access.

5.
Vaccine ; 2019 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-31706808

RESUMO

BACKGROUND: Since 2016, the Government of Tanzania has been implementing TImR, an integrated Electronic Immunization registry-logistics management information system (EIR-LMIS) that includes stock notifications. The objective of this study is to estimate the impact of this intervention on vaccine availability. METHODS: Monthly stock-out data were collected from paper registers at facilities, an Excel-based system at districts, and the new system (TImR) across all 924 health facilities in Arusha, Tanga and Kilimanjaro Regions. Six months of stockout rates pre- and post-introduction, by antigen, were compared via a two-way analysis of variance (ANOVA). A mixed-effects logistic regression model with the TImR data identified predictors of vaccine availability across antigens. FINDINGS: Post-introduction, ANOVA models estimated that overall stock-out rates declined from a monthly average of 7.1% to 2.1% (p < 0.01). Three specific vaccines had fewer stock-outs; OPV's monthly average dropped from 12.5% to 2.1% (p < 0.01), MR from 9.4% to 1.0% (p < 0.01) and DTP-HepB-HiB from 8.1% to 1.7% (p < 0.01). In the mixed-effects logistic regression model, controlling for antigen, odds of stock-out were 4.1% (95% CI: 3.3 - 4.9) lower for each week of tenure. Compared to DTP-HepB-HiB vaccine, odds of BCG vaccine being stocked out were 4.31 as high (95% CI: 3.1 - 5.0). The odds of being stocked-out were 29.7% lower for PCV (95% CI: 8.8 - 45.8) and 26.6% (95% CI: 3.4 - 44.1) lower for rotavirus vaccines compared to DTP-HepB-HiB. The odds of stock out were 37.7% lower for MR vaccine than DTP-HepB-HiB (95% CI: 18.1 - 52.6). CONCLUSIONS: Tanzania's integrated EIR-eLMIS may increase vaccine availability compared to its paper and Excel based system. Post-introduction of an eLMIS, the odds of a vaccine stock-out reduced over time. Further research could determine the impact of this intervention on vaccine wastage and replenishment response times.

6.
J Chromatogr A ; : 460684, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31711612

RESUMO

A novel restricted access media-magnetic molecularly imprinted polymers (RAM-MMIPs) was prepared as magnetic-solid phase extraction (M-SPE) material for tetracyclines (TCs). The RAM-MMIPs can not only specifically adsorb target molecules in samples, but also effectively eliminate the interference of protein macromolecules. The protein exclusion rate is 99.4%. Besides, RAM-MMIPs have a uniform imprinted and hydrophilic layer (600 nm), rapid binding kinetic (35 min), high selectivity and larger adsorption capacity. The M-SPE was coupled with HPLC/UV to extract TCs from untreated milk and egg samples, and several major factors affecting M-SPE efficiency were optimized. Under optimized conditions, the developed method achieved good linearity (R2>0.9989), lower limits of detection (LOD) and higher recoveries of TCs. For milk samples, the LOD is 1.03-1.31 µg L - 1 and the recovery is 86.7% to 98.6% with relative standard deviation (RSD) of 1.4-5.7%. For the egg samples, the LOD, recovery and RSD are 2.21-2.67 µg L - 1, 84.2-96.5% and 1.7-5.9%, respectively. Consequently, this work provides an improved strategy for the selective extraction and detection of target molecules directly from complex samples with proteins.

7.
Artigo em Inglês | MEDLINE | ID: mdl-31736154

RESUMO

INTRODUCTION: This study aimed to determine the prices, availability, and affordability of national essential medicines in public primary hospitals in poverty-stricken areas of Anhui province, China. METHODS: A cross-sectional study was conducted in 143 public primary hospitals in Anhui province, eastern China. Data on access to 44 essential medicines was evaluated using the standardized methodology available in the World Health Organization and Health Action International manual. RESULTS: Median price rates show that 46.51% (21 of 44) of the lowest price generics and 100% of the originator brands were more expensive than the international reference price. The median availability of the 44 medicines was 31.47%, and 65.91% (29 of 44) of the medicines had less than 50% availability. The majority of the medicines were affordable as they would cost less than a day's income in sample areas. Suppliers could respond to 88.27% of the procuring orders raised by the 143 hospitals in the study, but this ranged from 43.96% to 99.86%. CONCLUSIONS: There is poor availability and non-ideal response rate of medicine delivery in public primary hospitals in poverty-stricken areas in eastern China. Further implementation of national essential medicine policy needs to focus on improving both availability and distribution efficiency in these areas.

8.
PLoS One ; 14(11): e0225270, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31756224

RESUMO

BACKGROUND: To understand how to reduce antibiotic use, greater knowledge is needed about the complexities of access in countries with loose regulation or enforcement. This study aimed to explore how households in Bangladesh were accessing antimicrobials for themselves and their domestic animals. METHODS: In-depth interviews were conducted with 48 households in one urban and one rural area. Households were purposively sampled from two lower income strata, prioritising those with under 5-year olds, older adults, household animals and minority groups. Households where someone was currently ill with a suspected infection (13 households) were invited for a follow-up interview. Framework analysis was used to explore access to healthcare and medicines. FINDINGS: People accessed medicines for themselves through five pathways: drugs shops, private clinics, government/charitable hospitals, community/family planning clinics, and specialised/private hospitals. Drug shops provided direct access to medicines for common, less serious and acute illnesses. For persistent or serious illnesses, the healthcare pathway may include contacts with several of these settings, but often relied on medicines provided by drug shops. In the 13 households with an unwell family member, most received at least one course of antibiotics for this illness. Multiple and incomplete dosing were common even when prescribed by a qualified doctor. Antibiotics were identified by their high cost compared to other medicines. Cost was a reported barrier to purchasing full courses of antibiotics. Few households in the urban area kept household animals. In this rural area, government animal health workers provided most care for large household animals (cows), but drug shops were also important. CONCLUSIONS: In Bangladesh, unregulated drug shops provide an essential route to medicines including those prescribed in the formal sector. Wherever licensed suppliers are scarce and expensive, regulations which prohibit this supply risk removing access entirely for many people.

9.
Health Econ Policy Law ; : 1-16, 2019 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-31668160

RESUMO

In recent years, a variety of 'accelerated access' schemes have been introduced by pharmaceutical regulators and funders globally. These schemes aim to overcome perceived regulatory and reimbursement barriers to accessing medicines - particularly for patients with limited time or therapeutic options. However, patient access to approved medicines is mediated by a number of third parties including regulators and payers, and physicians who act both as gatekeepers and guides to prescribed medications. It is therefore essential to know how physicians think about accelerated access as they are responsible for advising patients on and prescribing medicines made available via these pathways. We conducted semi-structured interviews with 18 Australian physicians focusing on their attitudes towards accelerated access. We identified three 'archetypes' of physicians: 'confident accelerators', 'cautious accelerators', and 'decelerators'. Although all acknowledged the potential risks and benefits of accelerated access, they disagreed on their magnitude and extent and how they should be balanced in both policy formation and clinical practice. Overall, our results illustrate the diversity of clinical opinions in this area and the importance of monitoring both the prescribing and clinical outcomes that result from accelerated access programmes to ensure that these are both clinically and morally acceptable.

10.
Expert Rev Clin Pharmacol ; : 1-8, 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31760892

RESUMO

Introduction: Pharmacokinetic-pharmacodynamic (PK-PD) studies of antibiotics in pediatrics are limited. Pediatric dosing regimens for many antimicrobial drugs have been historically derived from adult pharmacokinetic data. Most pediatric formularies and dosing guidelines globally are expert-based and provide no rationale for the recommended doses, leading to heterogeneous guidance.Areas covered: We systematically reviewed the current dosing for 28 antibiotics listed in the Access and Watch groups of the 2019 World Health Organization (WHO) Essential Medicines List for children (EMLc). PubMed and EMBASE were searched for all PK-PD and pharmacological studies in pediatrics up to May 2018. In total, 262 pediatric related articles were deemed eligible. The most studied drugs were those where therapeutic drug monitoring is routine (aminoglycosides, glycopeptides) and study reporting detail was variable, with only 60.0% using the PK-PD results in make dosing recommendations. Based on this evidence, dose recommendations for each antibiotic were made.Expert opinion: We provide an up-to-date review of the limited available evidence on pediatric dosing for the 28 commonly prescribed antibiotics in the 2019 WHO EMLc. We propose synthesized dosing recommendations for those antibiotics administered systemically for the treatment of serious infections. Further PK-PD studies in children, particularly with underlying conditions, are needed.

12.
J Viral Hepat ; 2019 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-31698545

RESUMO

Gaps in hepatitis C virus (HCV) testing, diagnosis, liver disease assessment and treatment uptake among people who inject drugs (PWID) persist. We aimed to describe the cascade of HCV care among PWID in Australia, prior to and following unrestricted access to direct-acting antiviral (DAA) treatment. Participants enrolled in an observational cohort study between 2014 and 2018 provided finger-stick whole-blood samples for dried blood spot and Xpert HCV Viral Load, and venepuncture samples. Participants underwent transient elastography and clinical assessment by a nurse or general practitioner. Among 839 participants (mean age 43 years), 66% were male (n=550), 64% (n=537) injected drugs in the previous month, and 67% (n=560) reported currently receiving opioid substitution therapy. Overall, 45% (n=380) had detectable HCV RNA, of whom 23% (n=86) received HCV treatment within 12 months of enrolment. HCV treatment uptake increased from 2% in the pre-DAA era to 38% in the DAA era. Significant liver fibrosis (F2-F4) was more common in participants with HCV infection (38%) than those without (19%). Age 50 years or older (aOR, 2.88; 95% CI, 1.18-7.04) and attending a clinical follow-up with nurse (aOR, 3.19; 95% CI, 1.61-6.32) or physician (aOR, 11.83; 95% CI, 4.89-28.59) were associated with HCV treatment uptake. Recent injection drug use and unstable housing were not associated with HCV treatment uptake. HCV treatment uptake among PWID has increased markedly in the DAA era. Evaluation of innovative and simplified models of care is required to further enhance treatment uptake.

13.
Artigo em Inglês | MEDLINE | ID: mdl-31698773

RESUMO

Background: Since 2015, in order to handle the increasing prevalence of age-related diseases and escalating health expenditures arising from the aging population, the full coverage of essential medicines (FCEMs) policy for rural seniors has been implemented in primary healthcare institutions of Qidong County of Jiangsu, China. The purpose of this study is to examine the long-term effects of the introduction of FCEMs' policy on the utilization and accessibility of primary healthcare service for elderly beneficiaries. Methods: The retrospective study was conducted in Qidong County in the Jiangsu province, China. A 47-month longitudinal dataset involving 91,444 health insurance claims records of inpatients aged 70 and older in primary healthcare institutions was analyzed. Changes in health service utilization (average length of stay), patient copayments (out-of-pocket expenses), New Rural Cooperative Medical System (NRCMS) reimbursement rate and daily hospitalization costs per patient were analyzed using interrupted time series analysis. Augment Dicky-Fuller unit root method was used to test the stationarity of the series alongside the Durbin Watson method to test autocorrelation. Results: Average length of stay increased at 0.372 bed-days per month before the implementation of FCEMs policy, whereas the increasing trend was slowed down at 0.003 bed-days per month after the implementation of FCEMs policy (p < 0.001). The average out-of-pocket expenses increased by 38.035 RMB monthly in pre-implementation of the policy period, but it decreased at the rate of 5.180 RMB per month after the implementation of the FCEMs policy (p = 0.006). The NRCMS reimbursement rate increased at 0.066% per month in pre-implementation of policy and the increasing trend was sharper at 0.349% in post-implementation of policy (p = 0.135). The daily hospitalization costs per patient decreased by 6.263 RMB (p = 0.030) per month, whereas it increased at the rate of 3.119 RMB (p = 0.002) per month afterwards. Conclusions: Based on interrupted time series analyses, we concluded that FCEMs policy was associated with positive changes of average LOS and average OOP expenses. The FCEMs policy has alleviated the financial burden of the rural seniors and slightly improved the efficiency of primary health service utilization. However, it had no positive effect on daily hospitalization costs. Therefore, in the general framework of FCEMs policy, the Chinese health policy-maker should take necessary supporting measures to curb climbing hospitalization expenditures and promote the rational drug use in primary healthcare institutions.

14.
Pan Afr Med J ; 33: 294, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31692797

RESUMO

The number of children who survive to adolescence is increasing in Nigeria, significantly due to the success of child survival programs, with immunization as a major theme. However, the national immunization schedule in Nigeria is presently restricted to early childhood with no attention paid to immunization in adolescence. Presently, the vaccines that are readily available for adolescents include tetanus toxoid which is normally administered to pregnant women, so necessarily includes adolescent mothers; and a few research programs which offers hepatitis B vaccines. Also, there are few Nigerian adolescents who access immunization as a requirement for travelling outside the country or as a result of parental effort. Knowledge and awareness about adolescent immunization is generally poor. Nigerian adolescents have been shown to be poorly protected from tetanus, rubella and hepatitis B which are vaccine preventable. Neonatal, childhood and adult tetanus, congenital rubella syndrome, cervical cancer and hepatocellular carcinoma are just few of the diseases whose incidence can be reduced with an effective adolescent immunization program. This will also ensure that the gains of childhood immunization is concretized and socio-economic losses as a result of vaccine preventable diseases are eliminated to create a healthy and vibrant workforce. There is an urgent need to build a viable adolescent immunization program in Nigeria as adolescents represent a window of opportunity to prevent diseases which affect both the younger and older age group. This can be extended to other developing countries as well.


Assuntos
Programas de Imunização/organização & administração , Esquemas de Imunização , Imunização/métodos , Vacinas/administração & dosagem , Adolescente , Fatores Etários , Conhecimentos, Atitudes e Prática em Saúde , Acesso aos Serviços de Saúde , Humanos , Nigéria
15.
J Nurs Care Qual ; 2019 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-31743327

RESUMO

BACKGROUND: The management of acute gastrointestinal hemorrhage (GIH) is focused on early resuscitation through 2 large-bore intravenous (2LBIV) catheters, although adherence to this recommendation is low. LOCAL PROBLEM: Of 100 patients hospitalized with GIH in 2017, only 14 received 2LBIV access. The goal of this study was to improve this measure. METHODS: A multidisciplinary team used the DMAIC (define, measure, analyze, improve, and control) framework to perform a quality improvement initiative. INTERVENTIONS: The team used quality tools including a stakeholder survey, swimlane diagram, and fishbone diagram. The first intervention involved education of the hospitalists directing admissions, and the second intervention involved education of emergency department (ED) physicians and nurses regarding the importance of 2LBIV placement. RESULTS: Following the second intervention, there was a substantial increase in 2LBIV placement to 37 of 86 (43%). CONCLUSIONS: Carefully directed education of ED physicians and nurses with monthly feedback was effective in improving appropriate intravenous placement in patients with GIH.

17.
BMJ Open ; 9(11): e029016, 2019 Nov 24.
Artigo em Inglês | MEDLINE | ID: mdl-31767580

RESUMO

OBJECTIVE: To investigate timely access to palliative medicines/drugs (PMs) from community pharmacies to inform palliative care service delivery. DESIGN: Mixed methods in two sequential phases: (1) prospective audit of prescriptions and concurrent survey of patients/representatives collecting PMs from pharmacy and (2) interviews with community pharmacists (CPs) and other healthcare professionals (HCPs). SETTING: Five community pharmacies in Sheffield, UK and HCPs that deliver palliative care in that community. PARTICIPANTS: Phase 1: five CPs: two providing access to PMs within a locally commissioned service (LCS) and three not in the LCS; 55 patients/representatives who completed the survey when accessing PMs and phase 2: 16 HCPs, including five phase 1 CPs, were interviewed. RESULTS: The prescription audit collected information on 75 prescriptions (75 patients) with 271 individual PMs; 55 patients/representatives (73%) completed the survey. Patients/representatives reported 73% of PMs were needed urgently. In 80% of cases, patients/representatives received all PMs on the first pharmacy visit. One in five had to travel to more than one pharmacy to access PMs. The range of PMs stocked by pharmacies was the key facilitating factor. CPs reported practical issues causing difficulty keeping PMs in stock and playing a reactive role with palliative prescriptions. Confidentiality concerns were cited by other HCPs who were reluctant to share key patient information proactively with pharmacy teams. Inadequate information transfer, lack of CP integration into the care of palliative patients and poor HCP knowledge of which pharmacies stock PMs meant patients and their families were not always able to access PMs promptly. CONCLUSIONS: Consistent routine information transfer and integration of pharmacy teams in the care of palliative patients are needed to achieve timely access to PMs. Commissioners of PM access schemes should review and monitor access. HCPs need to be routinely made aware and reminded about the service and its locations.

18.
Health Info Libr J ; 2019 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-31710155

RESUMO

BACKGROUND: Cancer is a leading cause of death around the world and often is a chronic long term disease. This calls for an expanded workforce to include non-traditional health care providers. OBJECTIVE: To determine effectiveness of a cancer information training project with clergy from selected rural Appalachian areas to improve comfort and willingness to work as part of the cancer health care team. METHODS: Clergy were trained in the consumer health database of the National Library of Medicine MedlinePlus.gov. Exercises were required that were done using an iPad tablet with an online curriculum. They were also taught how to do a population health assessment of their particular area and develop a health ministry for their church. RESULTS: Three key elements were confirmed that would enable replication of the pilot: access to medlineplus, programmed learning modules using mobile technology such as iPads, and staff support including librarians and medical staff. With these key elements, the cancer project is potentially replicable with other groups beyond clergy. CONCLUSION: Knowledge about population health, built on new awareness and topical health knowledge, and using new skills to identify relevant information and library resources, could open minds and enhance community support for preventive and medical interventions.

19.
Artigo em Inglês | MEDLINE | ID: mdl-31623326

RESUMO

OBJECTIVES: With the increasing incidence of cancer, poor access to affordable anticancer medicines has been a serious public health problem in China. To help address this issue, we assessed the availability, price and affordability of pharmacotherapy for cancer in public hospitals in the Jiangsu Province, China. METHODS: In 2012 and 2016, anticancer medicine availability and price information in the capital and five other cities was collected. A total of six cancer care hospitals, 26 tertiary general hospitals and 28 secondary general hospitals were sampled, using an adaptation of the World Health Organization/Health Action International methodology. Data was collected for the anticancer medicines in stock at the time of the surveys. Prices were expressed as inflation-adjusted median unit prices (MUPs). Medicine was affordable if the overall cost of all the prescribed anticancer medicines was less than 20% of the household's capacity to pay. We used generalized estimating equations to estimate the significance of differences in availability from 2012 to 2016 and the Wilcoxon rank test to estimate the significance of differences in MUPs. Multivariate logistic regression was computed to measure predictors of affordability. RESULTS: From 2012 to 2016 there was a significant decrease in the mean availability of originator brands (OBs) (from 7.79% to 5.71%, p = 0.012) and lowest-priced generics (LPGs) (36.29% to 32.67%, p = 0.009). The mean availability of anticancer medicines in secondary general hospitals was significantly lower than the cancer care, as well as in tertiary general hospitals. The MUPs of OBs (difference: -21.29%, p < 0.01) and their LPGs (-22.63%, p < 0.01) decreased significantly from 2012 to 2016. The OBs (16.67%) of all the anticancer medicines were found to be less affordable than LPGs (34.62% for urban residents and 30.77% for rural residents); their affordability varied among the different income regions. From 2012 to 2016, the proportion of LPGs with low availability and low affordability dropped from 30.77% to 19.23% in urban areas and 34.62% to 26.92% in rural areas, respectively. Generic substitution and medicine covered by basic medical insurance are factors facilitating affordability. CONCLUSION: There were concerning decreases in the availability of anticancer medicines in 2016 from already low availability in 2012. Anticancer medicines were more affordable for the patients in high-income regions than the patients in low-income regions. Governments should consider using their bargaining power to reduce procurement prices and abolish taxes on anticancer medicines. Policy should focus on the special health insurance plan for low-income patients with cancer. The goal of drug policy should ensure that first-line generic drugs are available for cancer patients and preferentially prescribed.

20.
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