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

Objectives: 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. Design: This is a systematic review that follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources: We systematically searched for articles published in English up to 7 June 2024 in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Eligibility criteria: 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. Data extraction and synthesis: 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. Results: 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. Conclusions: 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.