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Hypertension is the leading risk factor for preventable cardiovascular diseases and all-cause mortality globally, with majority of the hypertension-attributed deaths occurring in low- and middle-income countries like India. Several international and national clinical practice guidelines (CPGs) provide evidence-informed recommendations to achieve optimal control. CPGs produced by the World Health Organization, International Society for Hypertension, American (AHA/ACC-2017), and European (ESC/ESH-2018) are “major” as they are widely used and are highly cited. We compared the main recommendations for the pharmacological management of hypertension among the major CPGs and the two existing Indian CPGs for similarities and shortcomings. Several deviations from the major CPGs were observed among Indian CPGs. Important shortcomings pertain to Indian CPGs’ low priority for initial combination therapy and the use of single pill combinations. Having multiple CPGs providing conflicting recommendations might discourage the adoption of evidence-based practices. There is a need for updating Indian CPGs based on up-to-date evidence.

Optimal use of guideline-directed medical therapy (GDMT) can prevent hospitalization and mortality among patients with heart failure (HF). We aimed to assess the prevalence of GDMT use for HF across geographic regions and country-income levels. We systematically reviewed observational studies (published between January 2010 and October 2020) involving patients with HF with reduced ejection fraction. We conducted random-effects meta-analyses to obtain summary estimates. We included 334 studies comprising 1,507,849 patients (31% female). The majority (82%) of studies were from high-income countries, with Europe (45%) and the Americas (33%) being the most represented regions, and Africa (1%) being the least. Overall prevalence of GDMT use was 80% (95% CI 78%–81%) for β-blockers, 82% (80%–83%) for renin–angiotensin-system inhibitors, and 41% (39%–43%) for mineralocorticoid receptor antagonists. We observed an exponential increase in GDMT use over time after adjusting for country-income levels (p < 0.0001), but significant gaps persist in low- and middle-income countries. Multi-level interventions are needed to address health-system, provider, and patient-level barriers to GDMT use.

This article details a correction to: Satheesh, G., Gyawali, B., Sun, M.F.C., Huffman, M.D., Banerjee, A., Perel, P. and Murphy, A. (2024) ‘A Survey of Availability and Affordability of Polypills for Cardiovascular Disease in Selected Countries’. Global Heart. 19(1):p. 56. Available at: https://doi.org/10.5334/gh.1335.

Background: The recent inclusion of polypills—fixed-dose combinations of antihypertensive medicines and a statin with or without aspirin—in the World Health Organization’s Essential Medicines List (EML) reiterates the potential of this approach to improve global treatment coverage for cardiovascular diseases (CVDs). Although there exists extensive evidence on the effectiveness, safety and acceptability of polypills, there has been no research to date assessing the real-world availability and affordability of polypills globally. Methods: We conducted a cross-sectional survey, based on the WHO/Health Action International methodology, in 13 countries around the world. In the surveyed countries, we first ascertained whether any polypill was authorised for marketing and/or included in EMLs and clinical guidelines. In each country, we collected retail and price data for polypills from at least one public-sector facility and three private pharmacies using convenience sampling. Polypills were considered unaffordable if the lowest-paid worker spent more than a day’s wage to purchase a monthly supply. Results: Polypills were approved for marketing in four of the 13 surveyed countries: Spain, India, Mauritius and Argentina. None of these countries included polypills in national guidelines, formularies, or EMLs. In the four countries, no surveyed public pharmacies stocked polypills. In the private sector, we identified seven unique polypill combinations, marketed by eight different companies. Private sector availability was 100% in Argentina and Spain. Most combinations (n = 5) identified were in India. Combinations found in India and Spain were affordable in the local context. A lowest-paid government worker would spend between 0.2 (India) and 2.8 (Mauritius) days’ wages to pay the price for one month’s supply of the polypills. Polypills were likely to be affordable if they were manufactured in the same country. Conclusion: Low availability and affordability of polypills in the public sector suggest that implementation remains poor globally. Context-specific multi-disciplinary health system research is required to understand factors affecting polypill implementation and to design and evaluate appropriate implementation strategies.

Abstract The World Health Organization recommends salt reduction as a cost‐effective intervention to prevent noncommunicable diseases. Salt‐reduction interventions are best tailored to the local context, taking into consideration the varying baseline salt‐intake levels, population's knowledge, attitude, and behaviors. Fundamental to reduction programs is the source of dietary salt‐intake. In South Asian countries, there is a paucity of such baseline evidence around factors that contribute to community salt intake. Upon reviewing the electronic literature databases and government websites through March 31, 2021, we summarized dietary salt intake levels and aimed to identify major sources of sodium in the diet. Information on the current salt reduction strategies in eight South Asian countries were summarized, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. One hundred twelve publications (out of identified 640) met our inclusion‐exclusion criteria for full text review. Twenty‐one studies were included in the review. Quality of the included studies was assessed using the US National Heart, Lung, and Blood Institute assessment tool. The primary result revealed that mean salt intake of South Asian countries was approximately twice (10 g/day) compared to WHO recommended intake (

Abstract Background Insomnia continues to be neglected globally, despite its high prevalence. Guidelines by the health regulatory agencies call for studies to evaluate the effect of sedative-hypnotics on sleep quality. Methods We conducted a pre-post observational study to evaluate sleep quality among 186 inpatients receiving short-term oral sedative-hypnotic therapy in a tertiary care teaching hospital in Kozhikode (Kerala), India. Using Pittsburgh Sleep Quality Index_Past-Week (PSQI_PW) questionnaire, patients were interviewed upon hospital admission and at follow up after ≥1-week of sedative-hypnotic therapy. Additionally, we interviewed 36 physicians to understand the current clinical perception about sedative-hypnotics. Results Mean (SD) age of the study patients was 59 (7.5) years. Majority (63.4%) of the patients were men. Of the various primary diagnoses for hospitalization, cardiovascular disease was the most common (22.6%, n = 49). Sedative-hypnotic therapy improved the mean (SD) PSQI_PW overall score by 6.79 points (pre: 12.70 (3.5) vs. post: 5.91 (2.8); p

Background: Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions – availability, affordability, accessibility, acceptability, and quality – is crucial yet rarely performed, especially in low- and middle-income countries. Objective: To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal. Methods: We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public sector: 11; private sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during May–July 2017. Data for 13 routine diagnostics were obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 day’s wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepal’s adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality. Results: We found that mean availability of generic medicines is low (

Background & objectiveThough blended learning (BL), is widely adopted in higher education, evaluating effectiveness of BL is difficult because the components of BL can be extremely heterogeneous. Purpose of this study was to evaluate the effectiveness of BL in improving knowledge and skill in pharmacy education.MethodsPubMed/MEDLINE, Scopus and the Cochrane Library were searched to identify published literature. The retrieved studies from databases were screened for its title and abstracts followed by the full-text in accordance with the pre-defined inclusion and exclusion criteria. Methodological quality was appraised by modified Ottawa scale. Random effect model used for statistical modelling.Key findingsA total of 26 studies were included for systematic review. Out of which 20 studies with 4525 participants for meta-analysis which employed traditional teaching in control group. Results showed a statistically significant positive effect size on knowledge (standardized mean difference [SMD]: 1.35, 95% confidence interval [CI]: 0.91 to 1.78, pConclusionBL is associated with better academic performance and achievement than didactic teaching in pharmacy education.

Introduction Considering limited global access to affordable insulin, we evaluated insulin access in public and private health sectors in Bengaluru, India. Methods Employing modified WHO/HAI methodology, we used mixed-methods analysis to study insulin access and factors influencing insulin supply and demand in Bengaluru in December 2017. We assessed insulin availability, price and affordability in a representative sample of 5 public-sector hospitals, 5 private-sector hospitals and 30 retail pharmacies. We obtained insulin price data from websites of government Jan Aushadhi scheme (JAS) and four online private-sector retail pharmacies. We interviewed wholesalers in April 2018 to understand insulin market dynamics. Results Mean availability of insulins on India’s 2015 Essential Medicine List was 66.7% in the public sector, lower than private-sector retail (76.1%) and hospital pharmacies (93.3%). Among private retailers, mean availability was higher among chain (96.7%) than independent pharmacies (68.3%). Non-Indian companies supplied 67.3% products in both sectors. 79.1% products were manufactured in India, of which 60% were marketed by non-Indian companies. In private retail pharmacies, median consumer prices of human insulin cartridges and pens were 2.5 and 3.6 times, respectively, that of human insulin vials. Analogues depending on delivery device were twice as expensive as human insulin. Human insulin vials were 18.3% less expensive in JAS pharmacies than private retail pharmacies. The lowest paid unskilled worker would pay 1.4 to 9.3 days’ wages for a month’s supply, depending on insulin type and health sector. Wholesaler interviews suggest that challenges constraining patient insulin access include limited market competition, physicians’ preference for non-Indian insulins, and the ongoing transition from human to analogue insulin. Rising popularity of online and chain pharmacies may influence insulin access. Conclusion Insulin availability in Bengaluru’s public sector falls short of WHO’s 80% target. Insulin remains unaffordable in both private and public sectors. To improve insulin availability and affordability, government should streamline insulin procurement and supply chains at different levels, mandate biosimilar prescribing, educate physicians to pursue evidence-based prescribing, and empower pharmacists with brand substitution. Patients must be encouraged to shop around for lower prices from subsidized schemes like JAS. While non-Indian companies dominate Bengaluru’s insulin market, rising market competition from Indian companies may improve access.