ABSTRACT
Introduction: Access to safe, effective, quality, and affordable essential medicines (EM) for all is one of the World Health Organization's Sustainable Development Goals for health. However, access to EM for the treatment of non-communicable diseases (NCDs) is lacking in many low-income (LICs) and lower-middle income countries (LMICs). Chronic kidney disease (CKD) is often a downstream consequence of other NCDs, such as diabetes (DM) and cardiovascular disease (CVD), further exacerbating the economic burden on healthcare systems and societies. In nephrology, access to EM is especially important to reduce the risk of CKD progression because kidney replacement therapy is unavailable or cost-prohibitive in many regions of the world. As members of the International Society of Nephrology (ISN) Emerging Leaders Program 2021 cohort, we conducted a scoping review to assess the breadth of evidence regarding EMs for management of CKD and related NCDs, with identification of barriers to EM access as one of our main aims. Method(s): We included English-language articles of any study design that addressed barriers to accessing essential medicines in populations with CKD (all stages, causes, and ages), CVD, hypertension, and/or DM. All ISN geographical regions and World Bank income categories were considered. We searched MEDLINE, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials to May 2021. Titles and abstracts were screened, and full texts were retrieved for potentially relevant publications. Each full-text article was assessed for inclusion. For included articles, data extraction was performed with a standardized form using Covidence software. Each step was performed by one reviewer and checked by a 2nd reviewer. Applying an ecological model, barriers were categorized as occurring at the national/health policy level, regional level, organization level, provider level, or patient level. Result(s): Ninety-six publications addressed barriers to access to essential medicines, including LICs (16 articles), LMICs (43 articles), upper-middle income countries (25 articles), high-income countries (10 articles), plus 21 articles which did not specify countries. Most publications assessed barriers at the health policy-level, which included high EM prices in the setting of current patent laws;lack of effective systems for public procurement of EM, resulting in large out-of-pocket household expenditure for medicines in LIC/LMIC;inefficient distribution systems with multiple price mark-ups;and lack of regulatory systems, giving rise to counterfeit medications. Regional-level barriers included lack of governance of supply chain logistics, lack of regional coordination, and poor transportation infrastructure, especially in rural settings. Organization-level barriers included medication stock-outs at facilities, and health care worker shortages. Provider-level barriers included irrational prescribing, lack of CKD identification, and poor communication with patients. Patient-level barriers included poverty, informational barriers/health literacy, and negative perception of generic medicines (Figure). [Formula presented] Conclusion(s): Barriers to accessing EM exist at several levels, particularly the health system-level, and affect LICs and LMICs disproportionately. This scoping review serves as an initial step towards designing implementation studies to address barriers to improve EM access. Conflict of interest Potential conflict of interest: MMMY has a consultancy agreement with George Clinical and served on a CKD advisory board sponsored by AstraZenecaCopyright © 2023