Research in context
Evidence before this study
We searched the PubMed database for articles about the availability and affordability of medicines for the secondary prevention of cardiovascular disease in countries at various stages of economic development published before May 1, 2014, without language restrictions. Our search terms included “availability”, “affordability”, “secondary prevention”, “CVD medicines or drugs”, “low-income countries”, and “middle-income countries”. We excluded studies that did not provide data for at least one of the four medicines recommended for the secondary prevention of cardiovascular disease (aspirin, β blockers, angiotensin-converting enzyme inhibitors or angiotensin-II receptor blockers, or statins), or a measure of affordability for the medicines.
We identified five reports that used different methods to measure the availability and affordability of different medicines for cardiovascular disease. Only one report considered the availability and affordability of the four medicines recommended by clinical guidelines. That report included data from five low-income and middle-income countries, and as a measure for affordability used the number of days wages it would cost the lowest paid government worker to purchase 1 month of treatment. Affordability varied by country; however, in view of the method used, the number of days wages that made treatment unaffordable (ie, a cutoff point to determine affordability) could not be determined. Additionally, information about the use of these medicines in the communities described was not collected and therefore the effects of little availability and affordability on use could not be deduced.
Added value of this study
To our knowledge, our study is the first to describe the availability and affordability of the four medicines recommended for the secondary prevention of cardiovascular disease in high-income, upper middle-income, lower middle-income, and low-income countries. It is also the first to relate these factors to medicine use. Our results suggest that the availability and affordability of these medicines is low in low-income and middle-income countries, which correlates with low rates of use. In India, these medicines are available in most communities given the large production of generic-brand medicines in the country. However, they remain unaffordable for large proportions of the community.
Implications of all the available evidence
Clinical guidelines recommend the use of four medicines for the secondary prevention of cardiovascular disease. However, the medicines remain unavailable and unaffordable for large proportions of communities in low-income and middle-income countries. Although our results show substantially lower use of key medicines when they are not available or unaffordable, it does not automatically mean that improving availability or affordability by themselves will increase their use. Additional research on how additional factors might further affect use of these medicines is needed (eg, access to health-care providers and attitudes to prevention on the part of both physicians and patients). Research on this topic is especially scarce in low-income and middle-income countries. Strategies to make proven medicines more available and affordable are crucially needed to increase their use in low-income and middle-income countries where the burden of cardiovascular disease is growing.