Exploring factors affecting access to non-communicable disease medicines in low- and middle-income countries: a...

This systematic review sought to identify factors affecting access to non-communicable disease (NCD) medicines across low- and middle-income countries (LMICs) and gaps for further inquiry.

This is a systematic review that follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

We systematically searched for articles published in English up to 7 June 2024 in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials.

We included qualitative, quantitative and mixed methods articles that included data collected from at least one LMIC; referenced at least one of the four major NCDs (ie, cardiovascular disease, cancer, diabetes and chronic respiratory disease); and described access to medicines. We excluded articles written in languages other than English and countries not categorised as LMICs.

Six reviewers completed data extraction and retrieved key findings on six dimensions of access: accessibility, acceptability, availability, price, affordability and quality. We analysed extracted data through narrative synthesis and compared key determinants across the articles. Quality assessment was completed using the Joanna Briggs Institute Critical Appraisal Tools.

Database searches resulted in 2339 articles, and 157 articles met inclusion criteria. Articles covered 118 countries, with most located in sub-Saharan Africa (n=33) and Latin America and the Caribbean (n=24). The most common NCDs were cardiovascular diseases (n=133), diabetes (n=98) and respiratory diseases (n=79). The majority of articles reported on availability (n=127) and affordability (n=103). The following key determinants affected most or all dimensions of access to NCD medicines: health facility type (private or public), medicine type (generic or originator) and quality, and patient socioeconomic status and geographic location.

Challenges across all six dimensions of access significantly affect access to NCD medicines. These challenges were exacerbated during the COVID-19 pandemic. Access recommendations include (1) improved evidence-based forecasting to reduce stockouts through investments in data infrastructure, innovative LMIC-specific forecasting tools and pooled procurement; (2) increased use of quality-assured generic medicines through international non-proprietary name prescribing, regulation of originator brand promotion and generic substitution; (3) improved quality of NCD medicines through stringent regulatory requirements and national and supranational pharmacovigilance systems; and (4) expansion of NCD medicine financing through universal health coverage.