Abstract
Background:Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions availability, affordability, accessibility, acceptability, and quality is crucial yet rarely performed, especially in low- and middle-income countries.Objective:To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal.Methods:We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public-sector: 11; private-sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during MayJuly 2017. Data for 13 routine diagnostics was obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 days wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepals adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality.Results:We found that mean availability of generic medicines is low (<50%) in both public and private sectors, and less than one-third medicines met WHOs availability target (80%). Mean (SD) availability of diagnostics was 73.1% (26.8%). Essential medicines appear locally unaffordable. On average, the lowest-paid worker would spend 1.03 (public-sector) and 1.26 (private-sector) days wages to purchase a monthly supply. For a person undergoing CVD secondary preventive-interventions in the private sector, the associated expenditure would be 7.511.2% of monthly household income. Exit-interviews suggest that a long/expensive commute to health-facilities and poor medicine affordability constrain access.Conclusions:This study highlights critical gaps in Nepals health system capacity to offer basic health services to CVD and diabetes patients, owing to low availability, poor affordability and accessibility of essential medicines and diagnostics. Research and policy initiatives are needed to ensure uninterrupted supply of affordable essential medicines and diagnostics.
Highlights
Non-communicable diseases (NCD) account for 71% of all deaths [1]
Our literature review found that the majority of ‘access’ studies in Nepal focused on medicine availability and affordability, and only a few commented on the barriers to access, local adoption of EMs, or access to essential diagnostics
None of these ‘access’ studies measured the impact of Cardiovascular diseases (CVDs) management costs on household income or systematically measured multiple dimensions of access in a nationally-representative sample (A ppendix E Table 1)
Summary
Non-communicable diseases (NCD) account for 71% of all deaths (i.e. estimated 41 of 57 million deaths in 2016) [1]. Over three-quarters of the CVD deaths occur in low- and middle-income countries (LMICs), disproportionately affecting the poor households [3, 4] To tackle this burden, the United Nations Member States have pledged to reduce premature NCD deaths by a third by the year 2030 (Sustainable Development Goal; SDG 3.4) [5]. The United Nations Member States have pledged to reduce premature NCD deaths by a third by the year 2030 (Sustainable Development Goal; SDG 3.4) [5] To achieve this goal, various international agencies – including the World Health Organization’s (WHO) 2013–2020 Global Action Plan and the World Heart Federation’s 25 × 25 vision – are calling for ensuring availability of affordable essential medicines and health services in at least 80% of the health facilities in all sectors [6,7,8]. Exit interviews suggest that a long/expensive commute to health facilities and poor medicine affordability constrain access
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