Availability, cost and affordability of essential medicines for chronic respiratory diseases in low-income and middle-income countries: a cross-sectional study

Contemporary data on the availability, cost and affordability of essential medicines for chronic respiratory diseases (CRDs) across low-income and middle-income countries (LMICs) are missing, despite most people with CRDs living in LMICs. Cross-sectional data for seven CRD medicines in pharmacies, healthcare facilities and central medicine stores were collected from 60 LMICs in 2022–2023. Medicines for symptomatic relief were widely available and affordable, while preventative treatments varied widely in cost, were less available and largely unaffordable. There is an urgent need to address these issues if the Sustainable Development Goal 3 is to be achieved for people with asthma by 2030.

Each investigator was asked to complete the form for three facilities: one pharmacy, one HCF and CMS.Public, private, and other facilities were included and chosen using convenience sampling.Investigators visited or contacted each facility to complete the data collection form.Data for at least one facility per country had to be BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) submitted and multiple entries were allowed.If facilities were missing, the author (MS) contacted other investigators or used publicly available data to complete the dataset.

Sampling and recruitment
Investigators were recruited through international respiratory networks and "snowballing" aiming to include as many LMICs as possible (Figure 1).LMICs were defined by 2022 World Bank category. 6

Data analysis
For each country the availability and cost of each medicine at the specified doses was reported for each of the facility types.When multiple doses were available, standardised doses were calculated which represented one month's treatment, or one course of treatment (Table 1).A medicine was available if it was present in the facility on the day of data collection.Medicine prices were expressed in local currency and converted to US$, using mean daily or monthly exchange rates. 7A medicine was affordable if one month's treatment cost less than one day's wage of the lowest paid government worker, defined by national minimum wage defined by the International Labour Organization. 8Affordability was only calculated for pharmacies and HCFs as CMS prices were usually wholesale prices.The costs of the cheapest products by facility were compared across countries.If there were multiple submissions for one facility the best availability and cost were presented.Descriptive analyses were applied throughout.
The funder had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript.
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

Figure 1 :
Figure 1: Flowchart of sampling strategy for potential collaborators.

Table 1 :
Standardised doses and preparations for one month's treatment for essential medicines for chronic respiratory diseases, derived from WHO EMLO 5 *Originator: product that was first authorised for marketing worldwide; (1): Inhaled beclomethasone and budesonide were considered equipotent.

Table 3 :
Cohort study-Give the eligibility criteria, and the sources and methods of selection of participants.Cohort study-If applicable, explain how loss to follow-up was addressed Case-control study-If applicable, explain how matching of cases and controls was addressed Cross-sectional study-If applicable, describe analytical methods taking account of sampling strategy of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based 9Information on the STROBE Initiative is available at www.strobe-statement.org.BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Overview of included LMICs and facilities by income group and WHO region LMIC: Low-income and middle-income country; WHO: World Health Organization; HCF: Healthcare facility; CMS: Central medicine stores; No information: NIA available; NGO: Non-governmental organisation.(1)Data for 3 private pharmacies submitted; (2) Data for 2 private pharmacies submitted; (3) Data for 2 private pharmacies submitted; (4) Data for 3 HCFs submitted, 2 public and 1 private HCF; (5) Data for 2 public HCFs submitted; (6) Data for 3 pharmacies submitted, 2 pubic and 1 private pharmacy.
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Thorax doi: 10.1136/thorax-2023-Vietnam Tran Thien Quan Vu University of Medicine and Pharmacy at Ho Chi Minh city BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Thorax doi: 10.1136/thorax-2023-221349 -679.BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Thorax doi: 10.1136/thorax-2023-221349 -679.Describe methods of follow-up Case-control study-Give the eligibility criteria, and the sources and methods of case ascertainment and control selection.Give the rationale for the choice of cases and controls Cross-sectional study-Give the eligibility criteria, and the sources and methods of selection of participants 4, Appendix (b) Cohort study-For matched studies, give matching criteria and number of exposed and unexposed Case-control study-For matched studies, give matching criteria and the number of controls per case N/A Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers.Give diagnostic criteria, if applicable 4, Appendix Data sources/ measurement 8* For each variable of interest, give sources of data and details of methods of assessment (measurement).Describe comparability of assessment methods if there is more than one group 4, Appendix

Table 4 :
Availability, cost, and affordability of SABA by country and type of facility.is for standardised dose and formulation (inhaled salbutamol 100mcg/dose, 200 doses).CMS costs are wholesale costs, unsuitable for affordability calculations.Affordable: one month's treatment costs less than one day's wage of national minimum wage.$: US$; SABA: Short-acting beta-agonist inhaler; HCF: Healthcare facility; CMS: Central medicine stores; NIA: No information available; DRC: Democratic Republic of Congo; NGO: Non-governmental organisation.

Table 5 :
Availability, cost, and affordability of ICS by country and type of facility.isfor standardised dose and formulation (inhaled beclomethasone or budesonide 100 mcg/dose, 200 doses).CMS costs are wholesale costs, unsuitable for affordability calculations.Affordable: one month's treatment costs less than one day's wage of national minimum wage.$:US$; ICS: inhaled corticosteroid; HCF: Healthcare facility; CMS: Central medicine stores; NIA: No information available; DRC: Democratic Republic of Congo; NGO: Non-governmental organisation.(1):Clenil 250mcg/dose available in pharmacy; (2): Flixotide 50 mcg/dose, 125 cmg/dose, 250 mcg/dose available in pharmacy and HCF; (3): Oxalair (fluticasone) 125 mcg/dose available in pharmacy; (4): Flixotide 125 mcg/dose available in pharmacy; (5) ciclesonide 160mcg/dose available in HCF; (6): Flixotide 50 mcg/dose available in pharmacy, HCF, CMS; (7): Flixotide 50mcg/dose, 125 mcg/dose available in CMS; (8): Mometasone 50 mcg/dose available in pharmacy; (9): Fluticasone 100 mcg/dose, 125 mcg/dose available in pharmacy and HCF.BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)