Duke University School of Medicine, DUMC 3710 Durham, NC 27710, USA.
Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA.
Health Policy Plan. 2019 Dec 1;34(Supplement_3):iii36-iii47. doi: 10.1093/heapol/czz012.
Substandard and falsified medications are a major threat to public health, directly increasing the risk of treatment failure, antimicrobial resistance, morbidity, mortality and health expenditures. While antimalarial medicines are one of the most common to be of poor quality in low- and middle-income countries, their distributional impact has not been examined. This study assessed the health equity impact of substandard and falsified antimalarials among children under five in Uganda. Using a probabilistic agent-based model of paediatric malaria infection (Substandard and Falsified Antimalarial Research Impact, SAFARI model), we examine the present day distribution of the burden of poor-quality antimalarials by socio-economic status and urban/rural settings, and simulate supply chain, policy and patient education interventions. Patients incur US$26.1 million (7.8%) of the estimated total annual economic burden of substandard and falsified antimalarials, including $2.3 million (9.1%) in direct costs and $23.8 million (7.7%) in productivity losses due to early death. Poor-quality antimalarials annually cost $2.9 million to the government. The burden of the health and economic impact of malaria and poor-quality antimalarials predominantly rests on the poor (concentration index -0.28) and rural populations (98%). The number of deaths among the poorest wealth quintile due to substandard and falsified antimalarials was 12.7 times that of the wealthiest quintile, and the poor paid 12.1 times as much per person in out-of-pocket payments. Rural populations experienced 97.9% of the deaths due to poor-quality antimalarials, and paid 10.7 times as much annually in out-of-pocket expenses compared with urban populations. Our simulations demonstrated that interventions to improve medicine quality could have the greatest impact at reducing inequities, and improving adherence to antimalarials could have the largest economic impact. Substandard and falsified antimalarials have a significant health and economic impact, with greater burden of deaths, disability and costs on poor and rural populations, contributing to health inequities in Uganda.
劣质和假冒药品是对公众健康的重大威胁，直接增加了治疗失败、抗菌素耐药性、发病率、死亡率和卫生支出的风险。虽然抗疟药物是中低收入国家最常见的质量较差的药物之一，但它们的分配影响尚未得到审查。本研究评估了在乌干达五岁以下儿童中使用劣质和假冒抗疟药物对健康公平的影响。我们使用儿童疟疾感染的概率代理基模（劣质和假冒抗疟药物研究影响，SAFARI 模型），按社会经济地位和城乡环境评估目前劣质抗疟药物负担的分布情况，并模拟供应链、政策和患者教育干预措施。患者承担了估计的劣质和假冒抗疟药物总年度经济负担的 2610 万美元（7.8%），其中包括 230 万美元（9.1%）的直接费用和 2380 万美元（7.7%）因过早死亡导致的生产力损失。劣质抗疟药物每年给政府造成 290 万美元的损失。疟疾和劣质抗疟药物的健康和经济影响负担主要落在贫困人口（集中指数-0.28）和农村人口（98%）身上。最贫困的五分之一财富人群因劣质和假冒抗疟药物而死亡的人数是最富裕的五分之一的 12.7 倍，而穷人每人的自费支出是最富裕的五分之一的 12.1 倍。由于劣质抗疟药物而死亡的人口中，农村人口占 97.9%，与城市人口相比，农村人口每年的自费支出高出 10.7 倍。我们的模拟表明，改善药品质量的干预措施可以最大程度地减少不平等现象，而提高抗疟药物的依从性可以产生最大的经济效益。劣质和假冒抗疟药物对健康和经济有重大影响，对贫困和农村人口的死亡、残疾和费用负担更大，导致乌干达的健康不平等。
