Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data

Attaei, M W and Khatib, Rasha and McKee, Martin and Lear, Scott and Dagenais, Gilles and Igumbor, Ehimario U and AlHabib, Khalid F and Kaur, Manmeet and Kruger, Lanthe and Teo, Koon and Lanas, Fernando and Yusoff, Khalid and Oguz, Aytekin and Gupta, Rajeev and Yusufali, Afzalhussein M and Bahonar, Ahmad and Kutty, Raman and Rosengren, Annika and Mohan, V and Casaccia, G and Maini Cuneo, JM and Rahman, O and Yusuf, R and Azad, AK and Rabbani, KA and Cherry, HM and Mannan, A and Hassan, I and Talukdar, AT and Tooheen, RB and Khan, MU and Sintaha, M and Choudhury, T and Haque, R and Parvin, S and Avezum, A and Oliveira, GB and Marcilio, CS and Mattos, AC and Teo, K and Yusuf, S and Dejesus, J and Agapay, D and Tongana, T and Solano, R and Kay, I and Trottier, S and Rimac, J and Elsheikh, W and Heldman, L and Ramezani, E and Dagenais, G and Turbide, G and Poirier, P and Auger, D and De Bluts, A LeBlanc and Proulx, MC and Cayer, M and Bonneville, N and Lear, S and Gasevic, D and Corber, E and de Jong, V and Vukmirovich, I and Wielgosz, A and Fodor, G and Pipe, A and Shane, A and Lanas, F and Seron, P and Martinez, S and Valdebenito, A and Oliveros, M and Wei, Li and Lisheng, Liu and Chunming, Chen and Xingyu, Wang and Wenhua, Zhao and Hongye, Zhang and JiaXuan, and Bo, Hu and Yi, Sun and Jian, Bo and Xiuwen, Zhao and Xiaohong, Chang and Tao, Chen and Hui, Chen and Xiaohong, Chang and Qing, Deng and Xiaoru, Cheng and Qing, Deng and Xinye, He and Bo, Hu and JiaXuan, and Jian, Li and Juan, Li and Xu, Liu and Bing, Ren and Yi, Sun and Wei, Wang and Yang, Wang and Jun, Yang and Yi, Zhai and Hongye, Zhang and Xiuwen, Zhao and Manlu, Zhu and Fanghong, Lu and Jianfang, Wu and Yindong, Li and Yan, Hou and Liangqing, Zhang and Baoxia, Guo and Xiaoyang, Liao and Shiying, Zhang and BianRongwen, and TianXiuzhen, and Dong, Li and Di, Chen and Jianguo, Wu and Yize, Xiao and Tianlu, Liu and Peng, Zhang and Changlin, Dong and Ning, Li and Xiaolan, Ma and Yuqing, Yang and Rensheng, Lei and Minfan, Fu and Jing, He and Yu, Liu and Xiaojie, Xing and Qiang, Zhou and Lopez-Jaramillo, P and Lopez, PA Camacho and Garcia, R and Jurado, LJA and Gómez-Arbeláez, D and Arguello, JF and Dueñas, R and Silva, S and Pradilla, LP and Ramirez, F and Molina, DI and Cure-Cure, C and Perez, M and Hernandez, E and Arcos, E and Fernandez, S and Narvaez, C and Paez, J and Sotomayor, A and Garcia, H and Sanchez, G and David, T and Rico, A and Mony, P and Vaz, M and Bharathi, A V and Swaminathan, S and Shankar, K and Kurpad, AV and Jayachitra, KG and Kumar, N and Hospital, HAL and Mohan, V and Deepa, M and Parthiban, K and Anitha, M and Hemavathy, S and Rahulashankiruthiyayan, T and Anitha, D and Sridevi, K and Gupta, R and Panwar, RB and Mohan, I and Rastogi, P and Rastogi, S and Bhargava, R and Kumar, R and Thakur, J S and Patro, B and Lakshmi, PVM and Mahajan, R and Chaudary, P and Kutty, V Raman and Vijayakumar, K and Ajayan, K and Rajasree, G and Renjini, AR and Deepu, A and Sandhya, B and Asha, S and Soumya, HS and Kelishadi, R and Bahonar, A and Mohammadifard, N and Heidari, H and Yusoff, K and Ismail, TST and Ng, KK and Devi, A and Nasir, NM and Yasin, MM and Miskan, M and Rahman, EA and Arsad, MKM and Ariffin, F and Razak, SA and Majid, FA and Bakar, NA and Yacob, MY and Zainon, N and Salleh, R and Ramli, MKA and Halim, NA and Norlizan, SR and Ghazali, NM and Arshad, MN and Razali, R and Ali, S and Othman, HR and Hafar, CWJCW and Pit, A and Danuri, N and Basir, F and Zahari, SNA and Abdullah, H and Arippin, MA and Zakaria, NA and Noorhassim, I and Hasni, MJ and Azmi, MT and Zaleha, MI and Hazdi, KY and Rizam, AR and Sazman, W and Azman, A and Khatib, R and Khammash, U and Khatib, A and Giacaman, R and Iqbal, R and Afridi, A and Khawaja, R and Raza, A and Kazmi, K and Dans, A and Co, HU and Sanchez, JT and Pudol, L and Zamora-Pudol, C and Palileo-Villanueva, LAM and Aquino, MR and Abaquin, C and Pudol, SL and Cabral, ML and Zatonski, W and Szuba, A and Zatonska, K and Ilow#, R and Ferus, M and Regulska-Ilow, B and Różańska, D and Wolyniec, M and AlHabib, KF and Hersi, A and Kashour, T and Alfaleh, H and Alshamiri, M and Altaradi, HB and Alnobani, O and Bafart, A and Alkamel, N and Ali, M and Abdulrahman, M and Nouri, R and Kruger, A and Voster, H H and Schutte, A E and Wentzel-Viljoen, E and Eloff, FC and de Ridder, H and Moss, H and Potgieter, J and Roux, AA and Watson, M and de Wet, G and Olckers, A and Jerling, JC and Pieters, M and Hoekstra, T and Puoane, T and Igumbor, E and Tsolekile, L and Sanders, D and Naidoo, P and Steyn, N and Peer, N and Mayosi, B and Rayner, B and Lambert, V and Levitt, N and Kolbe-Alexander, T and Ntyintyane, L and Hughes, G and Swart, R and Fourie, J and Muzigaba, M and Xapa, S and Gobile, N and Ndayi, K and Jwili, B and Ndibaza, K and Egbujie, B and Rosengren, A and Boström, K Bengtsson and Lindblad, U and Langkilde, P and Gustavsson, A and Andreasson, M and Snällman, M and Wirdemann, L and Pettersson, K and Moberg, E and Yeates, K and Sleeth, J and Kilonzo, K and Oguz, A and Akalin, AAK and Calik, KBT and Imeryuz, N and Temizhan, A and Alphan, E and Gunes, E and Sur, H and Karsidag, K and Gulec, S and Altuntas, Y and Yusufali, AM and Almahmeed, W and Swidan, H and Darwish, EA and Hashemi, ARA and Al-Khaja, N and Muscat-Baron, JM and Ahmed, SH and Mamdouh, TM and Darwish, WM and Abdelmotagali, MHS and Awed, SA Omer and Movahedi, GA and Hussain, F and Shaibani, H Al and Gharabou, RIM and Youssef, DF and Nawati, AZS and Salah, ZAR Abu and Abdalla, RFE and Shuwaihi, SM Al and Omairi, MA Al and Cadigal, OD and Alejandrino, R.S. and Chifamba, J and Gwaunza, L (2017) Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. The Lancet Public Health, 2 (9). e411. ISSN 24682667



BACKGROUND: Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development. METHODS: We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level. FINDINGS: The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and middle-income countries (except for India) than in high-income countries. The proportion of communities with four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90), 71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13% in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of 65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in communities that had all four drug classes available were more likely to use at least one blood pressure-lowering medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59-3·12); p<0·0001), combination therapy (1·53, 1·13-2·07; p=0·054), and have their blood pressure controlled (2·06, 1·69-2·50; p<0·0001) than were those in communities where blood pressure-lowering medicines were not available. Participants with known hypertension from households able to afford four blood pressure-lowering drug classes were more likely to use at least one blood pressure-lowering medicine (adjusted OR 1·42, 95% CI 1·25-1·62; p<0·0001), combination therapy (1·26, 1·08-1·47; p=0·0038), and have their blood pressure controlled (1·13, 1·00-1·28; p=0·0562) than were those unable to afford the medicines. INTERPRETATION: A large proportion of communities in low-income and middle-income countries do not have access to more than one blood pressure-lowering medicine and, when available, they are often not affordable. These factors are associated with poor blood pressure control. Ensuring access to affordable blood pressure-lowering medicines is essential for control of hypertension in low-income and middle-income countries. FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Canadian Institutes of Health Research Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, the Ontario Ministry of Health and Long-Term Care, pharmaceutical companies (with major contributions from AstraZeneca [Canada], Sanofi Aventis [France and Canada], Boehringer Ingelheim [Germany amd Canada], Servier, and GlaxoSmithKline), Novartis and King Pharma, and national or local organisations in participating countries.

Item Type:Article
Official URL/DOI:http://dx.doi.org/10.1016/S2468-2667(17)30141-X
Uncontrolled Keywords:PURE; blood pressure
Divisions:Department of Diabetology
ID Code:1080
Deposited By:surendar radha
Deposited On:09 Mar 2018 14:14
Last Modified:09 Mar 2018 14:14

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