Access to Cardiovascular Disease and Hypertension Medicines in Developing Countries: An Analysis of Essential Medicine Lists, Price, Availability, and Affordability

Abstract

Background Access to medicines is important for long-term care of cardiovascular diseases and hypertension. This study provides a cross-country assessment of availability, prices, and affordability of cardiovascular disease and hypertension medicines to identify areas for improvement in access to medication treatment. Methods and Results We used the World Health Organization online repository of national essential medicines lists (EMLs) for 53 countries to transcribe the information on the inclusion of 12 cardiovascular disease/hypertension medications within each country's essential medicines list. Data on availability, price, and affordability were obtained from 84 surveys in 59 countries that used the World Health Organization's Health Action International survey methodology. We summarized and compared the indicators across lowest-price generic and originator brand medicines in the public and private sectors and by country income groups. The average availability of the select medications was 54% in low- and lower-middle-income countries and 60% in high- and upper-middle-income countries, and was higher for generic (61%) than brand medicines (41%). The average patient median price ratio was 80.3 for brand and 16.7 for generic medicines and was higher for patients in low- and lower-middle-income countries compared with high- and upper-middle-income countries across all medicine categories. The costs of 1 month's antihypertensive medications were, on average, 6.0 days' wage for brand medicine and 1.8 days' wage for generics. Affordability was lower in low- and lower-middle-income countries than high- and upper-middle-income countries for both brand and generic medications. Conclusions The availability and accessibility of pharmaceuticals is an ongoing challenge for health systems. Low availability and high costs are major barriers to the use of and adherence to essential cardiovascular disease and antihypertensive medications worldwide, particularly in low- and lower-middle-income countries.

Keywords: cardiovascular disease; essential medicine lists; healthcare access; healthcare costs; hypertension; medication; price, availability, and affordability.

Figure 1. Percentage of country EMLs with select CVD/hypertension medicines and class of medicines included.

Twelve medicines were categorized into 5 drug classes: ACE inhibitor (enalapril), β‐blockers (atenolol, carvedilol, metoprolol), calcium channel blockers (nifedipine, amlodipine), thiazide/thiazide‐like diuretics (chlorthalidone, hydrochlorothiazide), and statins (atorvastatin, lovastatin, pravastatin, and simvastatin). See Table S2 for country‐level data. ACE indicates angiotensin‐converting enzyme; CVD, cardiovascular disease; and EML, essential medicines list.

Figure 2. Availability of medicines in the public and private sectors.

Authors’ calculation using World Health Organization/Health Action International data obtained from http://www.haiweb.org/MedPr​iceDa​tabas​e/. Average availability (%) is the average (arithmetic mean) of availability of all antihypertensive medicines in the country. For countries with multiple years’ availability data, only the latest year's data are used. Amlod indicates amlodipine 5 mg; Ateno, atenolol 50 mg; Capto, captopril 25 mg; Enala, enalapril 10 mg; Furos, furosemide 40 mg; Hydro, hydrochlorothiazide 25 mg; Losar, losartan 50 mg; Lovas, lovastatin 20 mg; Nifed, nifedipine 20 mg. Data on public‐sector availability for the originator brand lovastatin are absent. See Tables S3 and S4 for availability data by World Health Organization regions and World Bank country groups.

Figure 3. Average availability of select CVD/hypertension medicines vs hypertension prevalence.

Age‐standardized cross‐country hypertension prevalence data for males and females are available from the 2017 NCD Risk Factor Collaboration (http://www.ncdri​sc.org/data-downl​oads-blood-press​ure.html). For a particular country, the latest available data for select medicines could be from surveys of different years (eg, 2010 for amlodipine, 2014 for atenolol). In those cases, the latest year's hypertension prevalence is used to produce availability vs hypertension prevalence scatterplots. The dotted lines in the x and y axes represent the corresponding cross‐country averages. Since cross‐country male‐female prevalence rates correlate well, Figure 3 is produced using the male prevalence data only. Three‐digit country codes are used for the data points; blue color fonts are for the HUMICs, and red color fonts are for the LLMICs. The dotted lines in the scatterplots represent the corresponding average availabilities (y axes) and hypertension prevalence (x axes). Country codes—AFG, Afghanistan; ARE, United Arab Emirates, BDI, Burundi; BFA, Burkina Faso; BOL, Bolivia; BRA, Brazil; CHN, China; CMR, Cameroon; COD, Democratic Republic of Congo; COG, Republic of Congo; COL, Colombia; ECU, Ecuador; ETH, Ethiopia; FJI, Fiji; GHA, Ghana; HTI, Haiti; IDN, Indonesia; IND, India; IRN, Iran; JOR, Jordan; KAZ, Kazakhstan; KEN, Kenya; KGZ, Kyrgyzstan; KWT, Kuwait; LAO, Lao PDR; LBN, Lebanon; MAR, Morocco; MDA, Moldova; MEX, Mexico; MLI, Mali; MNG, Mongolia; MUS, Mauritius; MYS, Malaysia; NGA, Nigeria; NIC, Nicaragua; OMN, Oman; PAK, Pakistan; PER, Peru; PHL, Philippines; RUS, Russia; SAU, Saudi Arabia; SDN, Sudan; SLV, El Salvador; SYR, Syria; TCD, Chad; THA, Thailand; TJK, Tajikistan; TUN, Tunisia; TZA, Tanzania; UGA, Uganda; UKR, Ukraine; USA, USA; UZB, Uzbekistan; YEM, Yemen; ZAF, South Africa. CVD indicates cardiovascular disease; HUMICs, high‐ and upper‐middle‐income countries; and LLMICs, low‐ and lower‐middle‐income countries.

Figure 4. Procurement price in the public sector.

Authors’ calculation using World Health Organization/Health Action International data obtained from http://www.haiweb.org/MedPr​iceDa​tabas​e/. Countries with multiple years’ data, the latest available year's data are used, and are converted into 2010 base year price. Amlod, Amlodipine 5 mg; Ateno, atenolol 50 mg; Capto, captopril 25 mg; Enala, enalapril 10 mg; Furos, furosemide 40 mg; Hydro, hydrochlorothiazide 25 mg; Losar, losartan 50 mg; Lovas, lovastatin 20 mg; Nifed, nifedipine 20 mg. Data on procurement prices for the branded hydrochlorothiazide and branded lovastatin were absent. See Table S5 for data by World Health Organization regions and World Bank income groups.

Figure 5. Patient prices in the public and private sector.

Authors’ calculation using World Health Organization/Health Action International data obtained from http://www.haiweb.org/MedPr​iceDa​tabas​e/. Prices for the latest available year for corresponding countries are used, and are converted into 2010 base year price. Amlod, amlodipine 5 mg; Ateno, atenolol 50 mg; Capto, captopril 25 mg; Enala, enalapril 10 mg; Furos, furosemide 40 mg; Hydro, hydrochlorothiazide 25 mg; Losar, losartan 50 mg; Lovas, lovastatin 20 mg; Nifed, nifedipine 20 mg. Data on procurement prices for the branded hydrochlorothiazide and branded lovastatin were absent. See Tables S6 and S7 for data by World Health Organization regions and World Bank income groups.

Figure 6. Public procurement price vs patient price in public sector.

The data points are presented with 3‐digit country codes and represent the same country/year combination.

Figure 7. Affordability of select medicines in the public and private sector.

Authors’ calculation using World Health Organization/Health Action International data obtained from http://www.haiweb.org/MedPr​iceDa​tabas​e/. Countries with affordability data for multiple years, only the latest year data are used. Amlod, amlodipine 5 mg; Ateno, atenolol 50 mg; Capto, captopril 25 mg; Enala, enalapril 10 mg; Furos, furosemide 40 mg; Hydro, hydrochlorothiazide 25 mg; Losar, losartan 50 mg; Lovas, lovastatin 20 mg; Nifed, nifedipine 20 mg. The country‐ and year‐specific data on wages are provided in the World Health Organization/Health Action International website. See Tables S8 and S9 for data by World Health Organization regions and World Bank income groups.

Figure 8. The World Health Organization access to drugs and medicine framework.

The figure has been recreated using contents from the World Health Organization.32