Promoting global cardiovascular health ensuring access to essential cardiovascular medicines in low- and middle-income countries

Access to cardiovascular medicines in low- and middle-income countries: a mini review

BACKGROUND

Many cardiovascular (CV) medicines are required for long term. However, with their limited resources, low- and middle-income countries (LMICs) may have challenges with access to cardiovascular medicines. The aim of this review was to provide a summary of available evidence on access to cardiovascular medicines in LMICs.

METHODS

We searched PubMed and Google scholar for English language articles on access to cardiovascular medicines for the period 2010-2022. We also searched for articles reporting measures for challenges in access to CV medicines from 2007 to 2022. Studies conducted in LMICs, and reporting availability and affordability were included for review. We also reviewed studies reporting affordability or availability using the World Health Organisation/Health Action International (WHO/HAI) method. Levels of affordability and availability were compared.

RESULTS

Eleven articles met the inclusion criteria for review on availability and affordability. Although availability appears to have improved, many countries did not meet the availability target of 80%. Between economies and within countries, there are equity gaps in access to CV medicines. Availability is lower in public health facilities than private facilities. Seven out of 11 studies reported availability less than 80%. Eight studies which investigated availability in the public sector reported less than 80% availability. Overall, CV medicines, especially combined treatments are not affordable in the majority of countries. Simultaneous achievement of availability and affordability target is low. In the studies reviewed, less than 1-53.5 days wages were required to purchase one month supply of CV medicines. Failure to meet affordability was 9-75%. Five studies showed that, on average 1.6 days' wages of the Lowest-Paid Government Worker (LPGW) was required to purchase generic CV medicines in the public sector. Efficient forecasting and procurement, increased public financing and policies to improve generic use, among others are measures for improving availability and affordability.

CONCLUSIONS

Significant gaps exist in access to cardiovascular medicines in LMICs, and in many low-and lower middle-income countries access to cardiovascular medicines is low. To improve access and achieve the Global Action Plan on non-communicable diseases in these countries, policy interventions must be urgently instituted.

Assessing costs of a hypertension program in primary care: evidence from the HEARTS program in Mexico

Objective.

In 2021, Mexico launched the HEARTS program to improve the prevention and control of cardiovascular disease (CVD) risk factors in 20 primary care facilities in the states of Chiapas and Yucatán. This study projects the annual cost of program implementation and discusses budgetary implications for scaling up the program.

Methods.

We obtained district-level data on treatment protocols, medication costs, and other resources required to prevent and treat CVD. We used the HEARTS Costing Tool to estimate total and per-patient costs. A “partial implementation” scenario calculated the costs of implementing HEARTS if existing pharmacological treatment protocols are left in place. The second scenario, “full implementation,” examined costs if programs use HEARTS pharmacological protocol.

Results.

Respectively in the partial and full implementation scenarios, total annual costs to implement and operate HEARTS were $260 023 ($32.1 per patient/year) and $255 046 ($31.5 per patient/year) in Chiapas, and $1 000 059 ($41.3 per patient/year) and $1 013 835 ($43.3 per patient/year) in Yucatán. In Chiapas, adopting HEARTS standardized treatment protocols resulted in a 9.7 % reduction in annual medication expenditures relative to maintaining status-quo treatment approaches. In Yucatán, adoption was $12 875 more expensive, in part because HEARTS hypertension treatment regimens were more intensive than status quo regimens.

Conclusion.

HEARTS in the Americas offers a standardized strategy to treating and controlling CVD risk factors. In Mexico, approaches that may lead to improved program affordability include adoption of the recommended HEARTS treatment protocols with preferred medications and task shifting of services from physicians to nurses and other providers.

What Role Can the Right to Health Play in Advancing Equity in Kidney Care?

Kidney disease, whether acute or chronic, is an important health concern for more than 750 million people worldwide. Although its magnitude has been better studied within developed countries, evidence increasingly suggests similar scales of impact in developing and underdeveloped countries. On a shared planet where limited resources and high costs keep life-saving care out of reach for the poor and other structurally disadvantaged populations, addressing health concerns on such a large scale requires a governing basis in the recognition of the universal right to health. As designed under international human rights law, the right to health is meant to be legally enforceable on par with other human rights, and so provides a firm guiding framework for advancing health equity. This article traces the evolution of the right to health in international human rights law while assessing the framework's potential contributions to equitable access to treatment in forums including domestic litigation and rights-based advocacy tools. This article ultimately outlines and clarifies the right to health as a viable, justiciable means for advancing equitable access to kidney treatment and care.

A novel initiative to improve access to medicines for control of non-communicable diseases in low-and middle- income countries

The global burden of non-communicable diseases (NCDs) is growing, and access to prevention and treatment strategies remain limited, especially for those in low- and middle-income countries (LMICs). Novel approaches are needed to improve access and affordability of medicines that can treat NCDs in LMICs.  The Access and Affordability Initiative (AAI) is a public private partnership aiming to improve access to and availability of essential medicines for the treatment of NCDs and strengthening of health systems. Through this novel initiative a prospective cohort of patients with hypertension and diabetes were followed in Ghana and the Philippines to examine the effect of differential pricing on access to treatment of hypertension and diabetes. An integrated approach including differential pricing, health systems strengthening, improved supply chain management and greater affordability can improve access to medicines for NCDs.   While differential pricing has several advantages for improving the affordability of NCD medicines in LMICs, it can’t overcome all barriers as a standalone approach.  An integrated approach to health systems strengthening, supply chain management and affordability are needed to overcome key challenges in getting medicines for NCD to patients in LMICs. Availability and affordability of medicines to treat NCDs among vulnerable patients will help achieve Universal Health Coverage (UHC).

Hypertension Treatment Rates and Health Care Worker Density

Elevated blood pressure is the leading cause of death worldwide; however, treatment and control rates for hypertension are low. Here, we analyze the relationship between physician and nurse density and hypertension treatment rates worldwide. Data on hypertension treatment rates were collected from the STEPwise approach to Surveillance country reports, individual studies resulting from a PubMed search for articles published between 1990 and 2010, and manual search of the reference lists of extracted studies. Data on health care worker density were obtained from the Global Atlas of the Health Workforce. We controlled for a variety of variables related to population characteristics and access to health care, data obtained from the World Bank, World Development Indicators, United Nations, and World Health Organization. We used clustering of SEs at the country level. Full data were available for 154 hypertension treatment rate values representing 68 countries between 1990 and 2010. Hypertension treatment rate ranged from 3.4% to 82.5%, with higher treatment rates associated with higher income classification. Physician and nurse/midwife generally increased with income classification. Total healthcare worker density was significantly associated with hypertension treatment rate in the unadjusted model ( P<0.001); however, only nurse density remained significant in the fully adjusted model ( P=0.050). These analyses suggest that nurse density, not physician density, explains most of the relationship with hypertension treatment rate and remains significant even after adjusting for other independent variables. These results have important implications for health policy, health system design, and program implementation.

The global burden of kidney disease and the sustainable development goals

Kidney disease has been described as the most neglected chronic disease. Reliable estimates of the global burden of kidney disease require more population-based studies, but specific risks occur across the socioeconomic spectrum from poverty to affluence, from malnutrition to obesity, in agrarian to post-industrial settings, and along the life course from newborns to older people. A range of communicable and noncommunicable diseases result in renal complications and many people who have kidney disease lack access to care. The causes, consequences and costs of kidney diseases have implications for public health policy in all countries. The risks of kidney disease are also influenced by ethnicity, gender, location and lifestyle.  Increasing economic and health disparities, migration, demographic transition, unsafe working conditions and environmental threats, natural disasters and pollution may thwart attempts to reduce the morbidity and mortality from kidney disease. A multisectoral approach is needed to tackle the global burden of kidney disease. The sustainable development goals (SDGs) emphasize the importance of a multisectoral approach to health. We map the actions towards achieving all of the SDGs that have the potential to improve understanding, measurement, prevention and treatment of kidney disease in all age groups. These actions can also foster treatment innovations and reduce the burden of such disease in future generations.

Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease

In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness.

Overcoming Obstacles To Enable Access To Medicines For Noncommunicable Diseases In Poor Countries

The modern access-to-medicines movement grew largely out of the civil-society reaction to the HIV/AIDS pandemic three decades ago. While the movement was successful with regard to HIV/AIDS medications, the increasingly urgent challenge to address access to medicines for noncommunicable diseases has lagged behind-and, in some cases, has been forgotten. In this article we first ask what causes the access gap with respect to lifesaving essential noncommunicable disease medicines and then what can be done to close the gap. Using the example of the push for access to antiretrovirals for HIV/AIDS patients for comparison, we highlight the problems of inadequate global financing and procurement for noncommunicable disease medications, intellectual property barriers and concerns raised by the pharmaceutical industry, and challenges to building stronger civil-society organizations and a patient and humanitarian response from the bottom up to demand treatment. We provide targeted policy recommendations, specific to the public sector, the private sector, and civil society, with the goal of improving access to noncommunicable disease medications globally.

Barriers and Facilitators to Nurse Management of Hypertension: A Qualitative Analysis from Western Kenya

BACKGROUND

Hypertension is the leading global risk for mortality. Poor treatment and control of hypertension in low- and middle-income countries is due to several reasons, including insufficient human resources. Nurse management of hypertension is a novel approach to address the human resource challenge. However, specific barriers and facilitators to this strategy are not known.

OBJECTIVE

To evaluate barriers and facilitators to nurse management of hypertensive patients in rural western Kenya, using a qualitative research approach.

METHODS

Six key informant interviews (five men, one woman) and seven focus group discussions (24 men, 33 women) were conducted among physicians, clinical officers, nurses, support staff, patients, and community leaders. Content analysis was performed using Atlas.ti 7.0, using deductive and inductive codes that were then grouped into themes representing barriers and facilitators. Ranking of barriers and facilitators was performed using triangulation of density of participant responses from the focus group discussions and key informant interviews, as well as investigator assessments using a two-round Delphi exercise.

RESULTS

We identified a total of 23 barriers and nine facilitators to nurse management of hypertension, spanning the following categories of factors: health systems, environmental, nurse-specific, patient-specific, emotional, and community. The Delphi results were generally consistent with the findings from the content analysis.

CONCLUSION

Nurse management of hypertension is a potentially feasible strategy to address the human resource challenge of hypertension control in low-resource settings. However, successful implementation will be contingent upon addressing barriers such as access to medications, quality of care, training of nurses, health education, and stigma.

Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012

Objectives

The purpose of this study is to describe trends in the utilization of antihypertensive medications, overall and by type of medication, specifically thiazide diuretics, as well as uncontrolled hypertension, in the Palestine refugee population in Jordan between 2008 and 2012.

Methods

We analyzed aggregate procurement data on antihypertensive medications derived from the United Nations Relief and Works Agency (UNRWA) pharmacy records between 2008 and 2012. Antihypertensive medications were aggregated and utilization was calculated overall and for specific types of antihypertensive medications (e.g. β-blockers, diuretics). We used the WHO (World Health Organization) defined daily dose (DDD) methodology, often used to evaluate drug utilization patterns using aggregate data, to calculate utilization defined as DDDs per 100 persons with hypertension. In addition, UNRWA medical records were used to measure the prevalence of uncontrolled hypertension in the primary care setting. Uncontrolled hypertension was defined as a systolic/diastolic blood pressure ≥140/90 in at least 2 out of 3 readings, one of which is the most recent reading, during the year for a patient diagnosed with hypertension.

Results

Overall, total utilization of antihypertensive medications has not changed between 2008 and 2012; hypertensive patients persistently used at least 2 antihypertensive medications daily (range 200–280 DDDs/100 patients with hypertension) during this five-year period. However, there is significant variation in utilization patterns by type of antihypertensive medication. While Angiotensin Converting Enzyme Inhibitors (ACE-I) were persistently the most commonly used antihypertensive medication, there utilization significantly (P < 0.05) declined by 26%. However, there was a statistically significant increase of 124% in the utilization of thiazide diuretics. Further, the prevalence of uncontrolled hypertension has also declined at a rate of 3% annually between 2008 and 2012.

Conclusion

Our findings indicate that the STGs for hypertension management implemented in 2009 as part of UNRWA's essential drug program have increased the utilization of thiazide diuretics, and potentially contributed to improvements in hypertension control. This study also demonstrates that feasibility of drug utilization studies in monitoring and evaluating trends in the use of essential medications in low-resource settings.

Access to diagnostic tests and essential medicines for cardiovascular diseases and diabetes care: cost, availability and affordability in the West Region of Cameroon

OBJECTIVE

To assess the availability and affordability of medicines and routine tests for cardiovascular disease (CVD) and diabetes in the West region of Cameroon, a low-income setting.

METHODS

A survey was conducted on the availability and cost of twelve routine tests and twenty medicines for CVD and diabetes in eight health districts (four urban and four rural) covering over 60% of the population of the region (1.8 million). We analyzed the percentage of tests and medicines available, the median price against the international reference price (median price ratio) for the medicines, and affordability in terms of the number of days' wages it would cost the lowest-paid unskilled government worker for initial investigation tests and procurement for one month of treatment.

RESULTS

The availability of tests varied between 10% for the ECG to 100% for the fasting blood sugar. The average cost for the initial investigation using the minimum tests cost 29.76 days' wages. The availability of medicines varied from 36.4% to 59.1% in urban and from 9.1% to 50% in rural settings. Only metformin and benzathine-benzylpenicilline had a median price ratio of ≤ 1.5, with statins being largely unaffordable (at least 30.51 days' wages). One month of combination treatment for coronary heart disease costs at least 40.87 days' wages.

CONCLUSION

The investigation and management of patients with medium-to-high cardiovascular risk remains largely unavailable and unaffordable in this setting. An effective non-communicable disease program should lay emphasis on primary prevention, and improve affordable access to essential medicines in public outlets.

Bioimaging and subclinical cardiovascular disease in low- and middle-income countries

Cardiovascular disease (CVD) is the leading cause of mortality worldwide and also exerts a significant economic burden, especially in low- and middle-income countries (LMICs). Detection of subclinical CVD, before an individual experiences a major event, may therefore offer the potential to prevent or delay morbidity and mortality, if combined with an appropriate care response. In this review, we discuss imaging technologies that can be used to detect subclinical atherosclerotic CVD (carotid ultrasound, coronary artery calcification) and nonatherosclerotic CVD (echocardiography). We review these imaging modalities, including aspects such as rationale, relevance, feasibility, utilization, and access in LMICs. The potential gains in detecting subclinical CVD may be substantial in LMICs, if earlier detection leads to earlier engagement with the health care system to prevent or delay cardiac events, morbidity, and premature mortality. Thus, dedicated studies examining the feasibility, utility, and cost-effectiveness of detecting subclinical CVD in LMICs are warranted.

Taking cardiac surgery to the people

Cardiovascular disease (CVD) is currently the leading cause of mortality in the world, and it is estimated that 80% of the disease burden is encountered in low- and middle-income countries (LMICs). While numerous wake-up calls have been issued in the recent years to face this emerging epidemic, little has been achieved. One particularly deficient area is cardiac surgery. This article aims to address the challenges and barriers to establishing cardiac surgery programs in LMICs and some of the existing efforts to overcome them, focusing on a center in Aswan, Egypt, as an example.

Medical devices and diagnostics for cardiovascular diseases in low-resource settings

Noncommunicable diseases (NCDs), including cardiovascular diseases and diabetes, have emerged as an underappreciated health threat with enormous economic and public health implications for populations in low-resource settings. In order to address these diseases, devices that are to be used in low-resource settings have to conform to requirements that are generally more challenging than those developed for traditional markets. Characteristics and issues that must be considered when working in low- and middle-income countries (LMICs) include challenging environmental conditions, a complex supply chain, sometimes inadequate operator training, and cost. Somewhat counterintuitively, devices for low-resource setting (LRS) markets need to be of at least as high quality and reliability as those for developed countries to be setting-appropriate and achieve impact. Finally, the devices need to be designed and tested for the populations in which they are to be used in order to achieve the performance that is needed. In this review, we focus on technologies for primary and secondary health-care settings and group them according to the continuum of care from prevention to treatment.

Global perspective on acute coronary syndrome: a burden on the young and poor

Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.

Nurse management of hypertension in rural western Kenya: implementation research to optimize delivery

BACKGROUND

Hypertension is the leading global risk factor for mortality. Hypertension treatment and control rates are low worldwide, and insufficient human resource capacity is among the contributing factors. Thus, a critical component of hypertension management is to develop novel and effective solutions to the human resources challenge. One potential solution is task redistribution and nurse management of hypertension in these settings.

OBJECTIVES

The aim of this study is to investigate whether nurses can effectively reduce blood pressure in hypertensive patients in rural western Kenya and, by extension, throughout sub-Saharan Africa.

METHODS

An initial phase of qualitative inquiry will assess facilitators and barriers of nurse management of hypertension. In addition, we will perform usability and feasibility testing of a novel, electronic tablet-based integrated decision-support and record-keeping tool for the nurses. An impact evaluation of a pilot program for nurse-based management of hypertension will be performed. Finally, a needs-based workforce estimation model will be used to estimate the nurse workforce requirements for stable, long-term treatment of hypertension throughout western Kenya.

FINDINGS

The primary outcome measure of the impact evaluation will be the change in systolic blood pressure of hypertensive individuals assigned to nurse-based management after 1 year of follow-up. The workforce estimation modeling output will be the full-time equivalents of nurses.

CONCLUSIONS

This study will provide evidence regarding the effectiveness of strategies to optimize task redistribution and nurse-based management of hypertension that can be applicable to noncommunicable disease management in low- and middle-income countries.

Bibliographic review of research publications on access to and use of medicines in low-income and middle-income countries in the Eastern Mediterranean Region: identifying the research gaps

OBJECTIVES

We assessed the situation of academic publications on access to and use of medicines (ATM) in low-income and middle-income countries (LMICs) of the Eastern Mediterranean Region (EMR). We aimed to inform priority setting for research on ATM in the region.

DESIGN

Bibliographic review of published studies.

SETTING

LMICs in EMR.

INCLUSION CRITERIA

Publications on ATM issues originating from or focusing on EMR LMICs covering the period 2000-2011. Publications involving multinational studies were included if at least one eligible country had been included in the study.

INFORMATION SOURCES AND DATA EXTRACTION

We conducted comprehensive searches of the PubMed, Social Science Citation Index and Science Citation Index. We used the WHO ATM framework for data extraction and synthesis. We analysed the data according to the ATM issues, health system levels, year of publication and the countries of origin or focus of the studies.

RESULTS

151 articles met the inclusion criteria. Most articles (77%) originated from LMICs in EMR, suggesting that the majority of evidence on ATM in the region is home-grown. Over 60% of articles were from Iran, Pakistan, Jordan and Lebanon (in order of volume), while we found no studies assessing ATM in Somalia, Djibouti and South Sudan, all low-income countries. Most studies focused on the rational use of medicines, while affordability and financing received limited attention. There was a steady growth over time in the number of ATM publications in the region (r=0.87).

CONCLUSIONS

There is a growing trend, over the years, of more studies from the region appearing in international journals. There is a need for further research on the financing and affordability aspects of ATM in the region. Cross-border issues and the roles of non-health sectors in access to medicines in the region have not been explored widely.

Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration

Access to medicines and vaccines to prevent and treat non-communicable diseases (NCDs) is unacceptably low worldwide. In the 2011 UN political declaration on the prevention and control of NCDs, heads of government made several commitments related to access to essential medicines, technologies, and vaccines for such diseases. 30 years of experience with policies for essential medicines and 10 years of scaling up of HIV treatment have provided the knowledge needed to address barriers to long-term effective treatment and prevention of NCDs. More medicines can be acquired within existing budgets with efficient selection, procurement, and use of generic medicines. Furthermore, low-income and middle-income countries need to increase mobilisation of domestic resources to cater for the many patients with NCDs who do not have access to treatment. Existing initiatives for HIV treatment offer useful lessons that can enhance access to pharmaceutical management of NCDs and improve adherence to long-term treatment of chronic illness; policy makers should also address unacceptable inequities in access to controlled opioid analgesics. In addition to off-patent medicines, governments can promote access to new and future on-patent medicinal products through coherent and equitable health and trade policies, particularly those for intellectual property. Frequent conflicts of interest need to be identified and managed, and indicators and targets for access to NCD medicines should be used to monitor progress. Only with these approaches can a difference be made to the lives of hundreds of millions of current and future patients with NCDs.

Performance of rest myocardial perfusion imaging in the management of acute chest pain in the emergency room in developing nations (PREMIER trial)

BACKGROUND

Rest myocardial perfusion imaging (MPI) is effective in managing patients with acute chest pain in developed countries. We aimed to define the role and feasibility of rest MPI in low-to-middle income countries.

METHODS AND RESULTS

Low-to-intermediate risk patients (n = 356) presenting with chest pain to ten centers in eight developing countries were injected with a Tc-99m-based tracer, and standard imaging was performed. The primary outcome was a composite of death, non-fatal myocardial infarction (MI), recurrent angina, and coronary revascularization at 30 days. Sixty-nine patients had a positive MPI (19.4%), and 52 patients (14.6%) had a primary outcome event. An abnormal rest-MPI result was the only variable which independently predicted the primary outcome [adjusted odds ratio (OR) 8.19, 95% confidence interval 4.10-16.40, P = .0001]. The association of MPI result and the primary outcome was stronger (adjusted OR 17.35) when only the patients injected during pain were considered. Rest-MPI had a negative predictive value of 92.7% for the primary outcome, improving to 99.3% for the hard event composite of death or MI.

CONCLUSIONS

Our study demonstrates that rest-MPI is a reliable test for ruling out MI when applied to patients in developing countries.

Patent and exclusivity status of essential medicines for non-communicable disease

OBJECTIVE

The threat of non-communicable diseases ("NCDs") is increasingly becoming a global health crisis and are pervasive in high, middle, and low-income populations resulting in an estimated 36 million deaths per year. There is a need to assess intellectual property rights ("IPRs") that may impede generic production and availability and affordability to essential NCD medicines.

METHODS

Using the data sources listed below, the study design systematically eliminated NCD drugs that had no patent/exclusivity provisions on API, dosage, or administration route. The first step identified essential medicines that treat certain high disease burden NCDs. A second step examined the patent and exclusivity status of active ingredient, dosage and listed route of administration using exclusion criteria outlined in this study.

MATERIALS

We examined the patent and exclusivity status of medicines listed in the World Health Organization's ("WHO") Model List of Essential Drugs (Medicines) ("MLEM") and other WHO sources for drugs treating certain NCDs. i.e., cardiovascular and respiratory disease, cancers, and diabetes. We utilized the USA Food and Drug Administration Orange Book and the USA Patent and Trademark Office databases as references given the predominant number of medicines registered in the USA.

RESULTS

Of the 359 MLEM medicines identified, 22% (79/359) address targeted NCDs. Of these 79, only eight required in-depth patent or exclusivity assessment. Upon further review, no NCD MLEM medicines had study patent or exclusivity protection for reviewed criteria.

CONCLUSIONS

We find that ensuring availability and affordability of potential generic formulations of NCD MLEM medicines appears to be more complex than the presence of IPRs with API, dosage, or administration patent or exclusivity protection. Hence, more sophisticated analysis of NCD barriers to generic availability and affordability should be conducted in order to ensure equitable access to global populations for these essential medicines.

White paper report of the 2011 RAD-AID Conference on International Radiology for Developing Countries: integrating multidisciplinary strategies for imaging services in the developing world

The 2011 RAD-AID Conference on International Radiology for Developing Countries discussed data, experiences, and models pertaining to radiology in the developing world, where widespread shortages of imaging services significantly reduce health care quality and increase health care disparities. This white paper from the 2011 RAD-AID conference represents consensus advocacy of multidisciplinary strategies to improve the planning, accessibility, and quality of imaging services in the developing world. Conference presenters and participants discussed numerous solutions to imaging and health care disparities, including (1) economic development for radiologic service planning, (2) public health mechanisms to address disease and prevention at the population and community levels, (3) comparative clinical models to implement various clinical and workflow strategies adapted to unique developing world community contexts, (4) education to improve training and optimize service quality, and (5) technology innovation to bring new technical capabilities to limited-resource regions.

Effectiveness of interventions for hypertension care in the community--a meta-analysis of controlled studies in China

Background

Hypertension is a serious public health problem in China and in other developing countries. Our aim is to conduct a systematic review of studies on the effectiveness of community interventions for hypertension management in China.

Methods

China National Knowledge Infrastructure, PubMed, and references of retrieved articles were searched to identify randomised or quasi-randomised controlled studies that evaluated community hypertension care in mainland China. One reviewer extracted and a second reviewer checked data from the included studies.

Results

We included 94 studies, 93 of which were in Chinese language, that evaluated the following interventions: health education, improved monitoring, family-support, self-management, healthcare management changes and training of providers. The study quality was generally poor, with high risk of biased outcome reporting and significant heterogeneity between studies. When reported, the vast majority of the included studies reported statistically significantly improved outcomes in the intervention group. By assuming zero treatment effects for missing outcomes, the weighted reduction in the intervention group was 6∙9 (95% CI: 4∙9 to 8∙9) mm Hg for systolic BP, and 3∙8 (95% CI: 2∙6 to 5∙0) mm Hg for diastolic BP. Exploratory subgroup analyses found no significant differences between different interventions.

Conclusions

After taking account of possible reporting biases, a wide range of community interventions for hypertension care remain effective. The findings have implications for China and other low and middle income countries facing similar challenges. Because of significant heterogeneity and high risk of bias in the available studies, further well designed studies should be conducted in China to provide high quality evidence to inform policy decisions on hypertension control.

Cardiovascular defense challenges at the basic, clinical, and population levels

Cardiovascular disease (CVD) is now the leading cause of mortality worldwide. Particularly in low and middle income countries, rapid urbanization and secondary factors, such as increasing obesity, poor diet, and lack of exercise, have combined to propel CVD into this position. Given the enormous scope of this problem and the complex cultural, societal, and political issues that are involved, an equally sophisticated and multipronged approach is required to combat CVD at the global level. In this review, we outline the basic, clinical, and population level challenges that we face in defending ourselves against this disease.

From treating complex coronary artery disease to promoting cardiovascular health: therapeutic transitions and challenges, 2010-2020

Cardiovascular disease (CVD) has become the most common cause of mortality worldwide. Obesity, insufficient physical exercise, diabetes, and advancing age are major risk factors for developing cardiovascular disease that are currently increasing in prevalence. Nevertheless, significant progress has recently been made in the treatment of complex cardiovascular and coronary artery disease (CAD), with pharmacological management set to assume an increasingly important role. Other timely factors, such as the development of the polypill and high-level medical and political interest in advancing cardiovascular health, are driving forces that may help to make inroads into the global cardiovascular disease burden. In this article, we critically review the key challenges that we face in the coming decade as we strive to transition and apply our growing knowledge of complex CAD to promoting global cardiovascular health.