Access to medicines - a systematic review of the literature

From Vision to Reality: The EU's Pharmaceutical Reforms and the Path to Improved Access

Disparities in access to oncology medicines in European Union (EU) member states can impact patient outcomes profoundly, with availability and timely access varying significantly across and within member states. This paper discusses the intersection of the new European Health Technology Assessment Regulation (HTAR), the provisions of the proposed pharmaceutical legislation and their potential impacts on access to oncology medicines across EU member states. The HTAR, seeking to standardise the clinical evaluation of new medicines, has the potential to streamline the evaluation process but also risks oversimplifying diverse national healthcare needs. While the HTAR may accelerate access in countries with less-developed health technology assessment systems, it could potentially conflict with established practices in countries with advanced assessment systems, resulting in both joint and national clinical evaluations becoming necessary. The proposed pharmaceutical legislation reform, in both initial and updated forms, aims to incentivise an EU-wide launch of new medicines that challenges the feasibility for manufacturers, particularly in the context of diverse and complex national pricing and reimbursement systems. Both initiatives mark a significant shift towards more collaborative European healthcare policy yet faces the potential of unintended consequences owing to an apparent lack of pragmatism, such as delays in access because of increased administrative burdens and possible deterrents for innovation in Europe. The paper underscores the need for policy adaptation and multi-stakeholder collaboration to ensure the legislative changes achieve equitable and timely access to oncology treatments across the EU.

Assessment of out-of-pocket (OOP) expenditures on essential medicines for acute and chronic illness: a comparative study across regional and socioeconomic groups in India

BACKGROUND

Substantial out-of-pocket (OOP) expenditures push a large portion of the population below the poverty line, especially those residing in rural areas having low incomes. Individuals from economically disadvantaged states in India incur higher healthcare costs for hospitalization in public health centers than do those from more developed states. Economically poorer households in states such as Bihar and Odisha face significantly higher OOP expenditures for hospitalization in public health centers than do those in economically developed states such as Tamil Nadu.

OBJECTIVE

This study aims to compare households by using the wealth index and demographic factors concerning OOP expenditures on medicines for acute and chronic illnesses in Odisha, India.

METHODOLOGY

A cross-sectional household survey was adopted to conduct the research. Access to medicines focused on OOP expenditures in Odisha is being studied by purposively selecting six districts: Rayagada, Kalahandi, Angul, Keonjhar, Khordha, and Kendrapara. A total of 902 households were surveyed. A stratified random sampling procedure was adopted to select the locations and households. The survey took place from October 2021 to February 2022. The sampled respondents were investigated for acute and chronic illnesses. The software SPSS version 25 was used to analyze the data. The details of the expenditures for the past four weeks were compared with those of medicines and healthcare expenses. Households were categorized into wealthy, middle, and poor classes. The prevalence of acute and chronic illnesses was analyzed in light of the share of medicine expenditures to total household expenditures.

RESULTS

Out of 902 surveyed households, 173 (19.2%) spent out-of-pocket (OOP) money on medicines due to acute and chronic illnesses. Among the studied population, 23.7% were affected by acute illness, whereas 10.9% suffered from chronic illness. Wealthy households constituted most of the OOP expenditure (81 wealthy households), whereas 33 poor households also contributed to the OOP expenditure. According to the unadjusted odds ratio (UOR) analysis, wealthy households were 0.25 times less likely to spend more than 50% of their total monthly household budget on medicine than poor households (UOR = 0.25, 95% CI = 0.09-0.65). Similarly, ST households were 0.18 times less likely to spend more than 50% of their money on medicine from their budgets than SC households (UOR = 0.18, 95% CI = 0.04-0.72).

CONCLUSION

The present study again reveals that capital regions (metropolitan regions) are well protected against OOP expenditures on medicines, but tribal areas are still underserved. The odds ratio reveals a critical positive association between high OOP and poor economic status in households in Odisha. That association must be minimized or nullified for equitable economic and social development.

Portuguese Global Medicines Access Index 2021-An Indicator to Measure Access to Hospital Medicines

OBJECTIVES

Access to innovative and effective medication is a citizen's right. The main objectives of this study were to build an indicator to measure access to medicines within hospitals, the Global Medicines Access Index, and to identify the main existing barriers.

METHODS

Cross-sectional study carried out in Portuguese National Health Service hospitals. A consensus methodology (expert panel of 7 members) was used to define which dimensions should be included in the index and the weighting that each should take. The panel identified 6 dimensions: access to innovative medicines, proximity distribution, shortages, access to medicines before financing decision, value-based healthcare, and access to medication depending on cost/funding. Data were collected through an electronic questionnaire (September 2021).

RESULTS

The response rate was 61.2%. Most hospitals used medicines with and without marketing authorization before the funding decision. Monitoring and generating evidence of new therapies results is still insufficient. The identified barriers were the administrative burden as the major barrier in purchasing medicines, with a relevant impact on shortages of medicines. Most respondents (87%) had a proximity distribution program, mainly implemented in the pandemic context, and the price/funding model was only identified by 10% as a barrier to access. The 2021 Global Medicines Access Index was 66%. Shortages and value-based use of medicines were the dimensions that had more influence in lowering the index value.

CONCLUSIONS

The new formula used to obtain a unique and multidimensional index for access to hospital medicines seems to be more sensitive and objective and will be used to monitor access.

Explanation of Socio-economic Inequality in Medicine Use: A Cross-sectional Analysis from Iran

Background

Despite the favorable progress in the production of medicines, there is no significant access to these important health inputs among different socio-economic groups.

Objectives

This study aimed to measure and explain socio-economic inequality in prescribed and non-prescribed medicine use in Iran.

Methods

Data were obtained from a recent household survey on health services in Iran conducted in 2016. The Erreygers concentration index (ECI) was used to measure socio-economic inequality in the use of prescribed and non-prescribed medicines. In addition, Decomposition analysis was conducted to explain socio-economic inequality.

Results

The ECI revealed pro-rich socio-economic inequality in prescribed medicine use (ECI = 0.067, SE = 0.010), indicating that prescribed medicine use was concentrated on the better-offs. On the other hand, this index showed pro-poor inequality in non-prescribed medicine use (ECI = -0.064, SE = 0.009). Decomposition analysis showed that economic status and place of residence were the main determinants of socio-economic inequality in prescribing medicines. These factors and the number of health care needs explained the majority of socio-economic inequality in non-prescribed medicine use.

Conclusions

Despite previous positive beliefs, we found remarkable socio-economic inequality in the use of medicines in Iran. Facilitating access to pharmaceutical services for disadvantaged households and rural residents and promoting of national essential medicines list could be recommended against socio-economic inequality in the pharmaceutical market of Iran.

Cysteamine Eye Drops in Hyaluronic Acid Packaged in Innovative Single-Dose Systems: Stability and Ocular Biopermanence

Cystinosis is a rare genetic disorder characterized by the accumulation of cystine crystals in different tissues and organs causing, among other symptoms, severe ocular manifestations. Cysteamine eye drops are prepared in hospital pharmacy departments to facilitate access to treatment, for which vehicles that provide adequate biopermanence, as well as adaptable containers that maintain its stability, are required. Difficulties related to cysteamine preparation, as well as its tendency to oxidize to cystamine, show the importance of conducting rigorous galenic characterization studies. This work aims to develop and characterize an ophthalmic compounded formulation of cysteamine prepared with hyaluronic acid and packaged in innovative single-dose systems. For this task, the effect of different storage temperatures and the presence/absence of nitrogen on the physicochemical stability of the formulation and its packaging was studied in a scaled manner, until reaching the optimal storage conditions. The results showed that 0.55% cysteamine, prepared with hyaluronic acid and packaged in single-dose containers, is stable for 30 days when stored at −20 °C. In addition, opening vials every 4 h at room temperature after 30 days of freezing maintains the stability of the cysteamine formulation for up to 16 h. Moreover, ocular biopermanence studies were conducted using molecular imaging, concluding that the biopermanence offered by the vehicle is not affected by the freezing process, where a half-life of 31.11 min for a hyaluronic acid formulation stored for 30 days at −20 °C was obtained, compared with 14.63 min for 0.9% sodium chloride eye drops.

Application and utility of geographic information systems in pharmacy specific health research: A scoping review

BACKGROUND

Geographic Information Systems (GIS) are considered essential tools to analyze spatially referenced health data.

OBJECTIVES

The purpose of this scoping review is to describe how GIS is used in pharmacy specific health research.

METHODS

During July 2020, the following databases were searched: EMBASE, MEDLINE (PubMed), Web of Science and Scopus. The search strategy included terms relating to spatial analysis and pharmacy. Studies were considered eligible if they involved the use of GIS and focused on pharmacies. A narrative and tabular synthesis of the results was carried out, structured around the spatial analysis methods utilized across studies, as well as the characteristics of pharmacies evaluated in studies.

RESULTS

After a review of 6967 sources, 48 studies were included in this review. Twenty-nine studies were conducted in the United States (60.4%) and thirty-six focused on accessibility (75.0%; n = 36). Twenty-two studies investigated the relationship between sociodemographic aspects of the population and the accessibility and availability of pharmacies (45.8%). Twelve studies (25.0%) performed distance analysis and six studies (12.5%) performed geostatistical analysis. Community pharmacies were the setting evaluated most frequently, with over-the-counter selling products being the most evaluated pharmacy variable (13.3%; n = 6). Population density (58.3%; n = 28), income indicators (43.8%; n = 21) and minority community composition rates (41.7%; n = 20) were the most used population variables.

CONCLUSIONS

GIS have been increasingly used in pharmacy specific health research. Generally, research has sought to identify potential barriers to access and their effects on the population. Future research may benefit by utilizing robust spatial methods and applications across countries outside of the United States. Doing so could help to confirm the impact of sociodemographic characteristics on the availability and/or accessibility of pharmacies globally.

How Do Iranian Stakeholders Think About Pharmaceutical Managed Entry Agreements?

Background: Uncertainty in real-world product profiles is the main barrier to pharmaceutical market access. Managed entry agreements (MEAs) are the formal arrangements to overcome these uncertainties. Despite the extensive experience of developed countries in implementing such agreements, the experience of developing countries is minimal. As health decision-makers in Iran have moved towards implementing MEAs since 2020, seeking stakeholders' insights is crucial for filling this experience gap and facilitating the optimal implementation of these new policies. Methods: Our research was done in three phases: (1) Focus group interviews to disclose the main objectives of implementing MEAs in Iran, (2) the AHP approach to prioritize uncertainties, and (3) individual semi-structured interviews to carry out strengths, weaknesses, opportunities, and threats (SWOT) analysis. Results: Based on our stakeholders' views, increasing flexibility in improving patients' access to innovative and expensive drugs and responding to budget impact uncertainty seems highly prioritized for conducting MEAs in Iran. The SWOT analysis showed that although MEAs have the chance for success due to their strengths and opportunities, such as providing early and assured access, allocating resources efficiently, and enhancing the efficiency of post-marketing studies, policymakers should consider the weaknesses and threats such as difficulty in defining outcomes, high transaction cost, and lack of suitable infrastructure to increase the success rate. Conclusions: Efficient implementation of MEAs depends on the weaknesses and threats and considering the views of relevant stakeholders. Constructive interaction among all stakeholders is essential for adequately executing MEAs.

Marketing authorization of COVID-19 vaccines across UK, EU, and the US: fact-checking and the implications for future research

While having access to safe and efficient vaccines is essential for eradicating the COVID-19 pandemic, gaining marketing authorisation is a critical step in enabling and speeding this process. On December 2, 2020, the United Kingdom became the first country to approve the first COVID-19 vaccine. This commentary aims to provide a quick overview of the UK’s COVID-19 vaccine authorization process and compare it to that of the EU and the US. While the UK, EU, and US expedited the COVID-19 vaccine approval process, regulatory authorities did not appear to cut corners in their approval of the Pfizer COVID-19 vaccine, as evidenced by their decisions to switch emergency use authorization to full authorization in the US and to renew conditional/temporary use authorization in the EU and UK, respectively. There is an opportunity to conduct a thorough investigation into and comparison of the filed dossiers, as well as the robustness of the evaluation process for the approval of COVID-19 vaccines.

Framing access to medicines during COVID-19: A qualitative content analysis of Gilead's Remdesivir

The COVID-19 pandemic calls into question the institutional structure underlying the pharmaceutical industry. While some have called for medical technologies to be global public goods and patent waivers on pharmaceuticals, much of the industry has pushed back against any attempts that might threaten their monopoly power to set prices. Public acceptance of the role of private companies to control life-saving drugs, as well as of the intellectual property system, informs campaigns guaranteeing universal access to medicines and corporate strategies to shape policy. This study consists of a qualitative content analysis of online comments about news reports of Gilead Science's pricing of remdesivir, a re-purposed drug that shows some positive efficacy against COVID-19 in clinical trials. Analysing elite and public framing about medicine pricing informs our understanding of the social construction of markets. The findings identify hegemonic and counter-hegemonic discourse about innovation, affordability, saving lives, health care savings and international comparisons that stimulate debate and potentially advocacy. As such, the discursive context delineates the possibilities for remediating the normative and material structure of a pharmaceutical system currently geared towards private profit instead of public health needs.