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Severe and difficult asthma in a low- and middle-income country (LMIC) can relate to lack of ava
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ilability of basic medications; potentially reversible factors such as poor adherence or comorbidities such as obesity inhibiting a good response to treatment; and (rarely) true severe, therapy-resistant asthma. However, definitions of severity should encompass not merely doses of prescribed medication, but also underlying risk. The nature of asthmatic airway disease shows geographical variation, and LMIC asthma should not be assumed to be phenotypically the same as that in high-income countries (HICs). The first assessment step is to ensure another diagnosis is not being missed. Largely, political action is needed if children with asthma are to get access to basic medications. If a child is apparently not responding to low dose, simple medications, the next step is not to increase the dose but perform a detailed assessment of what factors (for example co-morbidities such as obesity, or social factors like poor adherence) are inhibiting a treatment response; in most cases, an underlying reason can be found. An assessment of risk of future severe asthma attacks, side-effects of medication and impaired lung development is also important. True severe, therapy-resistant asthma is rare and there are multiple underlying molecular pathologies. In HICs, steroid-resistant eosinophilia would be treated with omalizumab or mepolizumab, but the cost of these is prohibitive in LMICs, the biomarkers of successful therapy are likely only relevant to HICs. In LMICs, a raised blood eosinophil count may be due to parasites, so treating asthma based on the blood eosinophil count may not be appropriate in these settings.
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Climate change is damaging human health now and is projected to have a greater impact in the future. Low- and middle-
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income countries are seeing the worst effects as they are most vulnerable to climate shifts and least able to adapt given weak health systems and poor infrastructure. Low-carbon approach can provide effective, cheaper care while at the same time being climate smart. Low-carbon healthcare can advance institutional strategies toward low-carbon development and health-strengthening imperatives and inspire other development institutions and investors working in this space. Low-carbon healthcare provides an approach for designing, building, operating, and investing in health systems and facilities that generate minimal amounts of greenhouse gases. It puts health systems on a climate-smart development path, aligning health development and delivery with global climate goals. This approach saves money by reducing energy and resource costs. It can improve the quality of care in a diversity of settings. By prompting ministries of health to tackle climate change mitigation and foster low-carbon healthcare, the development community can help governments strengthen local capacity and support better community health.
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Official development assistance (ODA) is one of the most important means for donor countries to foster diplomatic relations with low- and
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middle-income countries and contribute to the welfare of the international community.Objective: This study estimated the sectoral allocation of
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Cardiovascular diseases, principally ischemic heart disease (IHD), are the most important cause of death and disability in the majority of low- and lower-
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middle-income countries (LLMICs). In these countries, IHD mortality rates are significantly greater in individuals of a low socioeconomic status (SES).
Three important focus areas for decreasing IHD mortality among those of low SES in LLMICs are (1) acute coronary care; (2) cardiac rehabilitation and secondary prevention; and (3) primary prevention. Greater mortality in low SES patients with acute coronary syndrome is due to lack of awareness of symptoms in patients and primary care physicians, delay in reaching healthcare facilities, non-availability of thrombolysis and coronary revascularization, and the non-affordability of expensive medicines (statins, dual anti-platelets, renin-angiotensin system blockers). Facilities for rapid diagnosis and accessible and affordable long-term care at secondary and tertiary care hospitals for IHD care are needed. A strong focus on the social determinants of health (low education, poverty, working and living conditions), greater healthcare financing, and efficient primary care is required. The quality of primary prevention needs to be improved with initiatives to eliminate tobacco and trans-fats and to reduce the consumption of alcohol, refined carbohydrates, and salt along with the promotion of healthy foods and physical activity. Efficient primary care with a focus on management of blood pressure, lipids and diabetes is needed. Task sharing with community health workers, electronic decision support systems, and use of fixed-dose combinations of blood pressure-lowering drugs and statins can substantially reduce risk factors and potentially lead to large reductions in IHD. Finally, training of physicians, nurses, and health workers in IHD prevention should be strengthened.
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Results from studies evaluating the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in humanitarian settings in low-income and middle-income
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countries have been inconsistent, showing varying results by setting and subgroup (eg, age or gender). We aimed to assess the effectiveness of these interventions, and to explore which children are likely to benefit most.
Lancet Glob Health 2018; 6: e390–400
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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
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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.
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Chronic kidney disease (CKD) is an important contributor to mortality from noncommunicable diseases. No decrease has been seen for CKD mortality contrary to many other important non-communicable diseases (e.g., cardiovascular disease). The prevalence of CKD and kidney failure are increasing all over
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the world – and thereby also the need for dialysis. Unfortunately, the prevalence increases most rapidly in lowand middle-income countries. Globally, there are great inequities in access and quality of management of kidney failure. Many low- and middle-income countries cannot meet the increased need for dialysis. If the patients receive dialysis, it might only be for a limited period due to the out-of-pocket expenses. There are global disparities in CKD mortality reflecting the disparities in access to care. Lack of access to dialysis is an important cause of the increased CKD mortality in low- and middle-income countries.
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The Global Status Report on Noncommunicable Diseases (NCDs) 2014 by the World Health Organization outlines the global impact of NCDs, including cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, which are responsible for a significant portion of global mortality, particular
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ly in low- and middle-income countries.
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Mental Health in the Asia-Pacific Region: An Overview
Alexander Lourdes Samy, Zahra Fazli Khalaf, & Wah-Yun Low
International Journal of Behavioral Science
(2015)
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Mental health problem is one of the growing major public health issues in the Asia Pacific region. It contributes to the high number of Disability Adjusted Life Years (DALYs), morbidity and mortality in the region. It is expected that leading mental health problems will occur in the
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low-and middle-income countries (LMICs) and majority of the countries which comes under this category are in the Asia Pacific region. In addition, mental health problem hamper the achievement of Millennium Development Goals (MDGs), particularly MDG 1, MDG 4 and MDG 5. The most common mental health problems in the region are depression, anxiety, posttraumatic stress disorder, suicidal behaviour and substance abuse disorder. Several modifiable and non-modifiable risk factors were identified for the cause of these major mental health issues. Interventions, programmes and policies need to be designed in order to curb mental health problems at all levels.
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Low- and middle-income countries (LMICs) expe
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rience a high disease burden for epilepsy, a chronic neurological condition.The authors evaluate the cost-effectiveness of community health workers (CHWs) to improve adherence to medication for epilepsy in South Africa. They found that utilizing CHWs to improve medication adherence was cost-effective.
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Background
Low- and middle-income countries
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now experience the highest prevalence and mortality rates of cardiovascular disease.
Main text
While improving the availability and delivery of proven, effective therapies will no doubt mitigate this burden, we posit that studies evaluating cardiovascular disease risk factors, management strategies and service delivery, in diverse settings and diverse populations, are equally critical to improving outcomes in low- and middle-income countries. Focusing on examples drawn from four cardiovascular diseases — coronary artery disease, stroke, diabetes and kidney disease — we argue that ethnicity, culture and context matter in determining the risk factors for disease as well as the comparative effectiveness of medications and other interventions, particularly diet and lifestyle interventions.
Conclusion
We believe that a host of cohort studies and randomized control trials currently being conducted or planned in low- and middle-income countries, focusing on previously understudied race/ethnic groups, have the potential to increase knowledge about the cause(s) and management of cardiovascular diseases across the world.
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Access to Services and Barriers faced by People with Disabilities: A Quantitative Survey
Nathan Grills, Lawrence Singh, Hira Pant, Jubin Varghese, GVS Murthy, Monsurul Hoq, Manjula Marella
Disability, CBR & Inclusive Development Journal (DCIDJ)
(2017)
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In low- and middle-income middle-
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income countries, reliable and disaggregated disability data on prevalence, participation and barriers are often unavailable. This study aimed to estimate disability prevalence, determine associated socio-demographic factors and compare access in the community between people with and without disability in Dehradun district of Uttarakhand, India, using the Rapid Assessment of Disability survey.
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The Economic Costs of Exclusion and Gains of Inclusion of People with Disabilities
Lena Morgon Banks and Sarah Polack
International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine
(2015)
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Evidence from Low and Middle Income Countries
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In many low- and middle-income countries, the
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re is a wide gap between evidencebased recommendations and current practice. Treatment of major CVD risk factors remains suboptimal, and only a minority of patients who are treated reach their target levels for blood pressure, blood sugar and blood cholesterol.
In other areas, overtreatment can occur with the use of non-evidence-based
protocols. The aim of using standard treatment protocols is to improve the quality
of clinical care, reduce clinical variability and simplify the treatment options,
particularly in primary health care. Standard treatment protocols can be developed by preparing new national treatment guidelines or by adapting or adopting international guidelines.
The Evidence-based protocols module uses hypertension and diabetes screening
and treatment as an entry point to control cardiovascular risk factors, prevent target organ damage, and reduce premature morbidity and mortality. A comprehensive risk- based approach for integrated management of hypertension, diabetes, and high cholesterol is included in the Risk-based CVD management module.
This module includes clinical practice points and sample protocols for:
1. hypertension detection and treatment
2. type 2 diabetes detection and treatment
3. identifying basic emergencies – care and referral.
HEARTS emphasizes adaptation, dissemination, and use of a standardized set of
simple clinical-management protocols, which should be drug- and dose-specific,
and include a core set of medications. The simpler the protocols and management tools, the more likely they are to be used correctly, and the higher the likelihood that a programme will achieve its goals.
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Overcoming barriers in low- and middle-income countr
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ies
For the first time, this year’s report includes information on hepatitis C diagnostics. With a focus on selected countries with diverse HCV epidemics, the report provides updates on the various dimensions of access to HCV diagnostics and pharmaceutical products, including product pricing, the regulatory environment and patent status, which together shape the national hepatitis response in different settings. It highlights key areas for action by ministries of health and other government decision-makers, pharmaceutical manufacturers and technical partners.
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Donor financing to low- and middle-income countries
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for reproductive, maternal, newborn, and child health increased substantially from 2008 to 2013. However, increased spending by donors might not improve outcomes, if funds are delivered in ways that undermine countries’ public financial management systems and incur high transaction costs for project implementation
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The growing challenges for people in low and middle-income
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countries to access new medicines.
Analysis 58
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Injection practices worldwide and especially in low- and middle-income
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countries (LMICs) include multiple, avoidable unsafe practices that ultimately lead to the large-scale transmission of bloodborne viruses among patients, health care providers and the community at large.
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