Access To Medicines And Diagnostic Tests Integral In The .

Kibirige et al. International Journal for Equity in Health (2017) 16:154The public hospitals, private hospitals and private pharmacies where the data was collected accounted for 34, 26and 15% of total national registered public hospitals,private hospitals and private pharmacies respectively. Themajority of the study sites were selected from the centralregion of the country (N 83, 57.2%) because it has thegreatest number of registered hospitals and privatelyowned pharmacies. Study sites selected from the eastern,western and northern region accounted for 15.9, 17.9 and9% respectively.Sample size estimationBasing on one of the primary objectives of the ACCODADstudy i.e. to determine the availability of the medicines anddiagnostic tests of interest, the availability of 4 key medicines in DM and CVD management (intermediate insulinor insulitard , losartan, simvastatin and isosorbide mononitrate) of 10% as reported by the study performed inWestern Cameroon was used as the prevalence (P) [6].Using the formula: n Z2P (1-P)/d2 where Z (normalvalue corresponding to the 95% confidence interval) 1.96,P 0.1 and d 0.05 (desired precision of estimation), asample size of 138 health units (hospitals and privatepharmacies) was obtained. The study sample size washowever, increased to 145.Data collectionFor the ACCODAD study, we collected informationabout 37 medicines and 19 diagnostic tests significant inthe management of DM and CVD as highlighted by theUgandan local guideline and several international guidelines as highlighted below. The CVD of interest werehypertension, coronary artery disease, stroke, dilated cardiomyopathy, rheumatic heart disease, atrial fibrillation,peripheral arterial disease, venous thromboembolismand related complications like heart failure.The selected medicines of interest are part of the WHOessential medicines list for treatment of chronic diseasesin LMICs [24] and are recommended in the managementof DM and CVD by the 2012 Uganda clinical guidelines[25], the 2017 American Diabetes Association guidelinesof standard of care of DM and related CVD [22] and therecent European Society of Cardiology (ESC) guidelines ofmanagement of atrial fibrillation, acute myocardial infarction, acute heart failure [26–29].The respective medicine categories and medicines ofinterest were oral hypoglycaemic agents (OHA) whichincluded metformin 1 g and 500 mg, glibenclamide 5 mg,glimepiride 2 mg and pioglitazone 30 mg, angiotensin IIreceptor blockers (ARB) which included losartan 50 mgand telmisartan 40 mg, angiotensin converting enzyme inhibitors (ACEI) which included captopril 25 mg, thiazidediuretics (D) which included bendrofluazide 5 mg, ARB-Dwhich included losartan-hydrochlorothiazide 50/12.5 mgPage 3 of 12and telmisartan-hydrochlorothiazide 40/12.5 mg, loopdiuretics which included oral furosemide 40 mg and i.v.furosemide 20 mg, calcium channel blockers (CCB) whichincluded nifedipine 10 mg and 20 mg and amlodipine5 mg and 10 mg, statins which included simvastatin20 mg, atovastatin 20 mg and rosuvastatin 10 mg, antiplatelet drugs which included cardiac aspirin 75 mg andClopidogrel 75 mg, low molecular weight heparin whichincluded enoxaparin 60 mg and 80 mg and beta blockerswhich included atenolol 50 mg, bisoprolol 5 mg, nebivolol5 mg and carvedilol 6.25 mg. Other surveyed medicinesincluded: parenteral benzathine penicillin, oral digoxin,warfarin, spironolactone, hydralazine, soluble insulin,intermediate insulin, pre mixed insulin, isosorbide mononitrate and unfractionated heparin (UFH).The selected diagnostic tests are part of the WHOminimum workup tests for assessment and managementof cardiovascular (CV) risk [24] and are also recommended by the 2017 American Diabetes Associationguidelines of standard of care of DM and related CVD[22] and the recent European Society of Cardiology(ESC) guidelines of management of atrial fibrillation,acute myocardial infarction, acute heart failure [26–29].These included: lipid profile, glycated haemoglobin(HbA1c), serum uric acid, serum troponin, coagulationprofile, thyroid function tests, serum creatinine, serumurea, serum electrolytes, serum ketones, microalbuminuria, complete blood count, serum natriuretic peptides,electrocardiography (ECG), echocardiography (ECHO),chest X ray, liver function tests and urinalysis.Data was collected using a pre tested questionnairebased on the WHO and HAI standardised methods ofassessing medicine prices, availability and affordability inLMIC [21] from 15th January 2017 to 28th February2017. The data collection team underwent a brief trainingbefore commencement of the study to improve qualityand standardisation of data.Information about the availability of diagnostic testsand any medicine in the respective medicine categorywas obtained. The cost of performing each diagnostictest and the monthly cost of the recommended dose ofthe available lowest priced generic (LPG) medicine wasobtained in Uganda shillings (UgX) and then convertedto US dollars (USD) using the existing exchange rate atthe time of data collection (1 USD 3600 UgX). Theobtained costs of the medicines were the retail pricescharged directly to the patients at the respective pharmacies of the private hospitals and private pharmacies.The cost of the medicines in the public hospitals wasnot obtained since medical care is offered free of charge.Data analysisAvailability of the medicines and diagnostic tests wasassessed by calculating the proportion of hospitals and

Kibirige et al. International Journal for Equity in Health (2017) 16:154private pharmacies in which any desired dose of themedicine and diagnostic test was present on the day ofdata collection at the study site. We defined availabilityas low, moderate or high when the medicines and diagnostic tests of interest were available in 50, 50–79 and 80% of the study sites respectively. Availability of theselected medicines and diagnostic tests was comparedbetween the study sites to determine any statisticallysignificant difference which was defined as a p value of 0.05. The cost of the available LPG medicine was compared to the cost of the available originator medicine.The obtained unit retail prices of the medicines inUSD were converted to a median price ratio (MPR) bydividing the median local price by an international reference price (IRP). The IRP is obtained from the Management Sciences for Health International Drug PriceIndicator Guide which reports median prices of highquality multisource medicines offered to LMIC countriesby different suppliers. The MPR is used to express howmuch greater or less the median local medicine price isthan the IRP. An MPR of 3 would mean that the localmedicine price is three times greater than the IRP. Forpatients’ medicine prices, MPR 1.5 were consideredreasonable pricing [30].Affordability was estimated by calculating the numberof days’ wages required to purchase a one month courseof treatment or pay for a specific diagnostic test usingthe average salary of the lowest paid government workerin USD. Medicines and diagnostic tests that cost 3 days’wages were considered affordable. The exchange rate ofthe local currency (UgX) to USD used was the commercial “buy” rate at the time of data collection of 1USD 3600 UgX. The lowest paid government workerat the time of the study (scale U8 lower-non formaleducation teachers) earned a gross salary of 198,793UgX (USD 55.2). After tax deductions, this translated toa net salary of 139,155 UgX (USD 38.7) per month or4638.5 UgX (1.3 USD) daily [31].Page 4 of 12Availability of the diagnostic testsWith regard to the 19 diagnostic tests of interest, 8 (42.1%)were of low availability, 3 (15.8%) were of moderate availability and 8 (42.1%) were of high availability. The availability ranged from 6.8% for microalbuminuria to 100% forurinalysis. Apart from electrocardiography (ECG) and lipidprofile testing which were available in only 54.6 and 65.9%of the study hospitals, the rest of the recommended WHOminimum tests for DM and CVD workup were of highavailability (random blood glucose tests-97.7%, serumelectrolytes-88.6% and urinalysis-100%). Glycated haemoglobin (HbA1c) tests, a key test in DM diagnosis and monitoring of glycaemic control in diabetes care was availablein only 43.2% of the study hospitals. The majority of vitaltests in cardiac evaluation (echocardiography, coagulationprofile, serum natriuretic peptides and troponin tests) wereof low availability (summarised in Table 1).Comparison of the availability of selected medicines inthe different study sitesThere were significant differences in the availability ofkey medicines documented in the public hospitals andthe private hospitals and pharmacies. Low availabilitywas noted for these medicine categories in public hospitals compared to the private hospitals and pharmacies:ARBs, ARB-thiazide diuretics, statins, warfarin, LMWH,UFH and nitrates (summarised in Table 2).Comparison of the availability of selected diagnostic testsin public and private hospitalsWith regard to the diagnostic tests, a statistically significant difference in the availability of lipid profile, HbA1c,uric acid, troponin, coagulation profile and thyroid function tests was noted in the surveyed public hospitals compared to the private hospitals. All the documented testswere of low availability in the public hospitals. Tests forserum ketones, microalbuminuria, serum natriuretic peptides and ECHO were of low availability regardless of thestudy site (summarised in Table 3).ResultsAvailability of the medicinesLow, moderate and high availability was documented in 5(23.8%), 3 (14.3%) and 13 (61.9%) of the 21 surveyed medicines categories respectively. The availability of thesurveyed medicine categories ranged from 20.1% forunfractionated heparin (UFH) to 100% for OHA. Highavailability was noted for the majority of the key medicinecategories in the management of hypertension and cardiacdiseases i.e. ARBs, ACEI, D, CCB, statins, anti plateletdrugs and beta blockers. None of the insulin types was ofhigh availability. Soluble, intermediate and pre mixed insulin was available in 68.8, 34.7 and 60.1% of all the studysites respectively. Isosorbide nitrate, UFH and LMWHwere all of low availability (summarised in Table 1).Affordability of the study medicines and diagnostic testsof interestSelected medicinesThe only affordable medicines were parenteral benzathinepenicillin 2.4 MU (0.3 days’ wages), oral furosemide 40 mg(0.5 days’ wages), glibenclamide 5 mg (0.7 days’ wages),bendrofluazide 5 mg (0.7 days’ wages), atenolol 50 mg(0.7 days’ wages), cardiac aspirin 75 mg (0.9 days’wages), digoxin 0.25 mg (1.4 days’ wages), metformin500 mg (2.8 days’ wages), captopril 25 mg (2.8 days’wages) and nifedipine 20 mg (2.8 days’ wages). Themost unaffordable medicines were enoxaparin 80 mg(53.5 days’ wages), enoxaparin 60 mg (41.2 days’ wages)and UFH (38.5 days’ wages).

Kibirige et al. International Journal for Equity in Health (2017) 16:154Page 5 of 12Table 1 Availability of all the DM and CVD medicines and diagnostic tests in all the study sitesMedicines (N 21 classes)Availability (%)Diagnostic tests (N 19)Availability (%)UFH20.1Microalbuminuria6.8Isosorbide mono nitrate27.8Serum ketones11.4LMWH31.9Serum natriuretic peptides11.4Intermediate ulation profile36.4Pre mixed insulin60.1Serum troponin testing43.2Warfarin64.6HbA1c testing43.2Soluble insulin68.8Thyroid function tests43.2ARB-thiazide c acid testing56.8Statins84.0Lipid Urea86.4Benzathine penicillin87.5Serum electrolytes88.6Furosemide89.6Chest X-ray88.6Thiazide diuretics94.4Liver function tests95.5Anti platelet drugs95.1Glucometers97.7ACEI96.5CBC testing97.7Beta blockers97.2Urinalysis100CCB99.3OHA100UFH Unfractionated heparin, LMWH Low molecular weight heparin, ARB Angiotensin II receptor blockers, ACEI Angiotensin converting enzyme inhibitors, CCBCalcium channel blockers, OHA Oral hypoglycaemic agents, HbA1c Glycated haemoglobinMonthly management of an adult diabetic patient withthe cheapest oral hypoglycaemic agents (Glibenclamide5 mg and metformin 500 mg), ACEI (captopril 25 mg),statin (simvastatin 20 mg) and anti platelet drug (cardiacaspirin 75 mg) would cost a total of 15.8 USD; equivalentto 12.2 days’ wages. The monthly cost increased to 19.1USD or 14.7 days’ wages if glimepiride, a newer generationsulphonylurea was used or to 21.3 USD or 16.4 days’ wagesif pre mixed insulin was used instead of a sulphonylurea.Management of hypertension co-morbidity by addingthe cheapest CCB (nifedipine 20 mg) would cost 19.4USD or 14.9 days’ wages. Secondary prevention of CVDusing the cheapest selective beta blocker (bisoprolol5 mg), ACEI (captopril 25 mg), statin (simvastatin20 mg) and anti platelet drug (cardiac aspirin 75 mg)would cost a total of 18.3 USD per month which isequivalent to 14.1 days’ wages (summarised in Table 4).Median cost, pricing of the available LPG medicines andtheir comparison with the available originator medicinesWith regard to pricing as reflected by the MPR, the onlyreasonably priced medicines were parenteral benzathinepenicillin (1.2), losartan 50 mg (0.8) and amlodipine10 mg (1.5). The MPR ranged from 0.8 for losartan50 mg to 11.1 for simvastatin (summarised in Table 4).With the exception of Glucophage (metformin) 1 g,Insulitard (intermediate insulin) and Mixtard (premixed insulin), all of the available originator medicinebrands cost more than the available LPG medicinebrands. One originator brand (Adalat 30 mg) cost up to10 times the cost of the available LPG brand (nifedipine20 mg) (summarised in Table 5).Selected diagnostic testsThe only affordable tests were random blood glucosemeasurement (1.1 days’ wages), urinalysis (1.3 days’wages), serum ketone measurement (2.1 days’ wages),serum uric acid measurement (2.1 days’ wages), serumcreatinine measurement (2.4 days’ wages) and serumurea measurement (2.4 days’ wages). The most unaffordable diagnostic tests were echocardiography andserum natriuretic peptides that cost 33.1 and 40.6 days’wages respectively.The cost of performing the WHO recommended testsfor CV risk assessment and management (proteinuria,ECG, FBG, lipid profile and serum electrolytes measurement) was 33.5 USD or 25.8 days’ wages if urinalysis wasused. The cost increased to 44.3 USD or 34.1 days’ wagesif microalbuminuria was used instead of urinalysis. TheWHO CV risk monitoring tests (lipid profile, FBG and

Kibirige et al. International Journal for Equity in Health (2017) 16:154Page 6 of 12Table 2 Comparison of the availability of the DM and CVD medicines between the public hospitals, private hospitals and pharmaciesAvailability of the medicines in %MedicinesPrivate hospitals (n 23)Public hospitals (n 22)Private pharmacy (n 100)P valueA: Medicines with a statistically significant difference between study sitesARBs87.031.899.0 0.001ARB-thiazide diuretics78.327.396.0 0.001Statins87.018.298.0 0.001Warfarin65.218.274.8 0.001Soluble insulin10081.858.6 0.001Thiazide orbide mono nitrate30.44.632.30.030B: Medicines with no statistically significant difference between study eta blockers95.610097.00.650Anti platelet drugs91.391.097.00.317Digoxin91.381.282.30.579Pre mixed insulin69.677.354.10.080Intermediate insulin43.527.334.30.516Benzathine penicillin91.310083.80.097Loop 166OHA1001001001UFH Unfractionated heparin, LMWH Low molecular weight heparin, ARB Angiotensin II receptor blockers, ACEI Angiotensin converting enzyme inhibitors, CCBCalcium channel blockers, OHA Oral hypoglycaemic agentsproteinuria) cost 23.6 USD/18.2 days’ wages or 12.8USD/7.1 days’ wages when using microalbuminuria orurinalysis respectively. Annual monitoring of adult diabetic patients using HbA1c measurement at least twicea year, annual ECG, microalbuminuria and lipid profileassessment as recommended by the ADA guidelines ofdiabetes management would cost 58.2 USD or 44.8 days’wages (summarised in Table 6).DiscussionThe ACCODAD study sought to provide contemporarydata about the availability, cost and affordability of medicines and diagnostic tests integral in the management ofDM and CVD in Uganda, a low income developing countryin East Africa. To the best of our knowledge, this is thelargest study in Uganda to comprehensively investigate theavailability, cost and affordability of a substantial number ofmedicines and diagnostic tests that play a fundamental rolein optimal DM and CVD management in clinical practice.Availability of medicines and diagnostic testsIn our study, low and moderate availability (availabilityof 80% in all study sites) was reported in 38.1% of themedicines and 57.9% of the diagnostic tests of interest.Several similar studies assessing access to medicines anddiagnostic tests of NCDs in LMIC have reported similarfindings of low availability of medicines and diagnostictests especially in the public sector [5–10].In the study reported from Western Cameroon, highavailability defined as availability 80% was only notedwith 6 (27%) of the surveyed medicines (parenteralbenzathine penicillin 2.4 MU, oral furosemide 40 mg,glibenclamide 5 mg, Actrapid/soluble insulin, metformin500 mg and Mixtard). The majority of rural study siteshad low availability of medicines [6]. In comparison withour study, with the exception of the soluble and premixed insulin, high availability of 80% was documentedwith parenteral benzathine penicillin, oral furosemide,glibenclamide and metformin.

Kibirige et al. International Journal for Equity in Health (2017) 16:154Page 7 of 12Table 3 Comparison of the availability of the DM and CVD diagnostic tests between the private and public hospitalsAvailability of the tests (%)TestPrivate hospitals (n 23)Public hospitals (n 24)P valueA: Diagnostic tests with a statistically significant difference between study sitesLipid profile86.445.50.004HbA1c63.622.70.006Uric acid77.336.40.006Serum troponin68.218.20.001Coagulation profile59.113.60.002Thyroid function tests72.713.6 0.001B: Diagnostic tests with no statistically significant difference between study sitesSerum creatinine95.577.30.079Serum urea95.577.30.079Glucometers10095.50.312Serum electrolytes95.581.80.154Serum 5.51000.312Serum natriuretic hest X-ray95.581.80.154Liver function lysis100100NAHbA1c Glycated haemoglobin, CBC Complete blood countIn another study that assessed the availability, pricingand affordability of 5 key cardiovascular medicines(atenolol, captopril, hydrochlorothiazide, losartan andnifedipine) in 36 LMIC (Uganda inclusive), upper middleincome and high income countries found an overall pooravailability of these medicines. Only 26.3 and 57.3% ofthe medicines were available in the public and privatesector respectively [7]. In another similar multicentrestudy involving 90 primary care facilities in 8 LMIC,some of the 12 surveyed CVD and DM medicines werenot available in some countries. Soluble and long actinginsulin was absent in all study sites in Benin, Eriteria,Bhutan and Vietnam. Isosorbide mono nitrate wasabsent in Benin, Eriteria, Sudan and Bhutan and simvastatin and amlodipine were absent in Eriteria andBhutan [10]. Low availability of nitrates, intermediateand pre-mixed insulin was also reported by our study(27.8, 34.7 and 60.1% respectively).With regard to the availability of diagnostic tests, crosssectional studies in LMIC had reported similar findingsof low availability [5–9]. In one of these studiesperformed in the Western Cameroon in 2012, high availability defined as availability 80% was only noted with50% of the surveyed diagnostic tests (RBG, urinalysis,serum creatinine, serum urea and CBC). Serum electrolytes, lipid profile and uric acid tests, HbA1c tests andECG were only available in 60, 40, 20 and 10% of all thestudy sites [6].Another multicentre study performed in 90 primarycare centres of 8 LMIC (Benin, Bhutan, Eritrea, SriLanka, Sudan, Suriname, Syria, and Vietnam), lipid profile testing was available only in 33, 25, 20, 14 and 8% ofall study sites in Sudan, Benin, Suriname, Syria and SriLanka. Low availability of serum creatinine tests was alsoreported in the majority of the study sites. Of all studysites, serum creatinine tests were available in 58% inSudan, 33% in Benin, 10% in Suriname and 8% in SriLanka. Lipid profile tests were absent in Eriteria andVietnam while serum creatinine tests were absent inall study sites in Eriteria, Bhutan and Syria. Serumtroponin tests were absent in all the countries exceptBenin and Sudan where it was available in only 8% ofthe s

Ugandan public hospitals lacked the recommended national and international guidelines of management of NCDs and essential medicines and diagnostic tests [19]. There is limited contemporary data about the avail-ability, cost and affordability of medicines and diagnostic