Surveys of medicine prices and availability, conducted using a standard methodology, have shown that poor medicine availability, particularly in the public sector, is a key barrier to access to medicines. Public sector availability of generic medicines is less than 60% across WHO regions, ranging from 32% in the Eastern Mediterranean Region to 58% in the European Region. Private sector availability of generic medicines is higher that in the public sector in all regions. However, availability is still less than 60% in the Western Pacific, South-East Asia and Africa Regions. Due to low availability of medicines in the public sector, patients are often forced to purchase medicines in the private sector. When originator brands are prescribed and dispensed for products that are also available in generic form, patients are paying four times more, on average, to purchase the brand. High medicine prices increase the cost of treatment. Low public sector availability can be addressed through improved procurement efficiency, and adequate, equitable and sustainable financing. Medicine prices can be reduced by eliminating duties and taxes on medicines and promoting the use of quality-assured generic medicines. Mark-ups can also be regulated to avoid excessive add-on costs in the supply chain. The most appropriate actions to follow depend on a country’s individual survey results and their underlying determinants, as well as local factors including existing pharmaceutical policies and market situations.
Equitable health services
Irrational use of medicines is an extremely serious global problem that is wasteful and harmful, according to the authors of this paper. In developing and transitional countries, in primary care less than 40% of patients in the public sector and 30% of patients in the private sector are treated in accordance with standard treatment guidelines. Antibiotics are misused and over-used in all regions. In developing and transitional countries, while only 70% of pneumonia cases receive an appropriate antibiotic, about half of all acute viral upper respiratory tract infection and viral diarrhoea cases receive antibiotics inappropriately. Patient adherence to treatment regimes is about 50% worldwide and lower in developing and transitional countries. Harmful consequences of irrational use of medicines include unnecessary adverse medicines events, rapidly increasing antimicrobial resistance (due to over-use of antibiotics) and the spread of blood-borne infections such as HIV and hepatitis B/C (due to unsterile injections) all of which cause serious morbidity and mortality and cost billions of dollars per year. Effective interventions to improve use of medicines are generally multi-faceted. They include provider and consumer education with supervision, group process strategies (such as peer review and self-monitoring), community case management (where community members are trained to treat childhood illness in their communities and provided with medicines and supervision to do it) and essential medicines programmes with an essential medicine supply element.
Many developing countries stressed the importance of access to medicines and of addressing the social determinants of health in order to prevent and control non-communicable diseases. Interventions also called for more funding and political commitment, better private sector regulation and policy-making free of conflict of interests. Several Member States also supported the inclusion of mental health in the context of NCDs. This was at the 64th World Health Assembly (WHA) meeting in Geneva on 16-24 May, during a discussion on the prevention and control of non-communicable diseases (NCDs) that considered the WHO Secretariat report on the matter and adopted a resolution sponsored by 61 Member States including EU member countries. The article reports on the debates and the resolution.
After a national voucher scheme in 2004 provided pregnant women and infants with highly subsidised insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania. The ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Nine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions.
The aim of this study was to synthesise knowledge concerning various models for the integrated delivery of TB/HIV services at health facility level in low- and middle-income countries. The authors conducted a systematic review of literature, selecting 63 papers and 70 abstracts for inclusion, which described 136 examples of models of integration. Strengths and weaknesses of different models of integration are identified. Models based on referral only are easiest to implement, requiring as little as additional staff training and supervision, if a functional referral system exists, but optimal communication is necessary. Models with closer integration are more efficient but require more staff training and may also require additional infrastructure, e.g. private space for HIV counselling. The authors conclude that their comparison of different models of integration of tuberculosis and HIV services was undermined by a lack of rigorous studies. More research is needed to investigate potential efficiencies of integrated care from the perspective of both provider and service user.
The objective of this study was to establish the feasibility and reliability of a questionnaire for healthcare service satisfaction and a questionnaire for satisfaction with information received about TB medicines among adult TB patients attending public and private programme clinics in Kampala, Uganda. Researchers recruited 133 patients of known HIV status and confirmed pulmonary TB who were receiving care at public and private hospitals in Kampala, Uganda. A translated and standardised 13-item patient healthcare service satisfaction questionnaire (PS-13) and the Satisfaction with Information about Medicines Scale (SIMS) tool were administered by trained interviewers. Of the 133 participants, 35% were starting, 33% had completed two months, and 32% had completed eight months of TB therapy. The male to female and public to private hospital ratios in the study population were 1:1. The PS-13 and the SIMS tools were highly acceptable and easily administered. Patients that were enrolled at the public hospital had relatively lower PS-13 satisfaction scores for technical quality of care and responsiveness to patient preferences when compared to patients that were enrolled at the private hospital. The authors conclude that their study provides preliminary evidence that the PS-13 service satisfaction and the SIMS tools are reliable measures of patient satisfaction in TB programmes. Satisfaction score findings suggest differences in patient satisfaction levels between public and private hospitals, as well as between patients starting and those completing TB therapy.
The authors of this study set out to assess the prevalence of cardiovascular (CV) risk factors in Seychelles, a middle-income African country, and compare the cost-effectiveness of single-risk-factor management with management based on total CV risk. CV risk factor prevalence and a CV risk prediction chart for Africa were used to estimate the 10-year risk of suffering a fatal or non-fatal CV event among individuals aged 40–64 years. These figures were used to compare single-risk-factor management with total risk management in terms of the number of people requiring treatment to avert one CV event and the number of events potentially averted over 10 years. With single-risk-factor management, 60% of adults would need to be treated and 157 cardiovascular events per 100,000 population would be averted per year, as opposed to 5% of adults and 92 events with total CV risk management. Management based on high total CV risk optimizes the balance between the number requiring treatment and the number of CV events averted. In conclusion, total CV risk management is much more cost-effective than single-risk-factor management. These findings are relevant for all countries, but especially for those economically and demographically similar to Seychelles.
On 14 February 2011, the GAVI Alliance rolled out its plan for a new pneumococcal vaccine for children, which it aims to administer in 19 countries by 2012 and in more than 40 countries by 2015. GAVI’s plan is part of the global drive to reach the Millennium Development Goals for Maternal and Child Health. The Kenya Medical Research Institute in Kilifi has welcomed the vaccine's rollout in the fight against penicillin-resistant and multi-drug resistant pneumococcal strains of the disease that are emerging in Africa. The Institute noted that the disease also causes severe financial difficulties and emotional burdens for families and communities, most of whom never have sufficient funding to treat their affected children. At US$3.50 per dose, the vaccine being issued in developing countries is about 90% cheaper than in the developed world. GAVI and its partner countries will co-finance the rollout, with governments in the poorest income bracket paying US$0.15 per dose. GAVI warned that participating countries would need to step up their health system capacity to achieve this. In addition, the Alliance’s plans to roll out this and other vaccines for major killer diseases are threatened by a funding gap of US$3.7 billion over the next five years.
Antimicrobial resistance is a global problem that affects all countries. This year’s World Health Day on 7 April aims to make governments more aware of the problem and to encourage them to take measures to combat this global threat. According to this article, clinicians agree that one of the biggest challenges is finding out the true size of the problem of resistant infections in each country. Data is lacking, they say. The problem of microbial resistance is significant in middle- and low-income countries: for example, poor children in Africa, Asia and Latin America suffering from pneumonia, meningitis or blood stream infections are often given old drugs rendered ineffective by resistance since they are the only available treatment options. For some, simply restricting over-the-counter sales of antimicrobials does not go far enough, and they suggest that more is needed to curb the use of second-line antibiotics, which should be used to treat infections when first-line antibiotics fail and may be the last resort. They argue that the beneficial effect of restriction of first-line antibiotics sold over the counter will be evident in the long term, but what is needed most is restriction of higher-end antibiotics used in hospitals.
In Zanzibar, the Ministry of Health and its partners accelerated malaria control from September 2003 onwards by scaling up provision of insecticide-treated nets, indoor-residual spraying and artemisinin-combination therapy. The authors of this study assessed the impact of the scale up on malaria burden at six out of seven in-patient health facilities in Zanzibar by comparing numbers of out-patient and in-patient cases and deaths between 2008 and the pre-intervention period 1999-2003. They found that, in 2008, for all age groups combined, malaria deaths had fallen by an estimated 90%, malaria in-patient cases by 78% and parasitologically confirmed malaria out-patient cases by 99.5%. Anaemia in-patient cases decreased by 87%, but declines in anaemia deaths and out-patient cases were statistically insignificant due to small numbers. Reductions were similar for children under-five and older ages. The authors conclude that the government’s scaling up effective malaria interventions reduced malaria-related burden at health facilities by over 75% over a period of five years. They argue that, in high-malaria settings, intensified malaria control can substantially contribute to reaching the Millennium Development Goal 4 target of reducing under-five mortality by two-thirds between 1990 and 2015.