Bulletin of the World Health Organization最新文献

The prevalence of Parkinson disease is increasing globally. Despite the existence of effective and affordable medicines for Parkinson disease, access to these medicines is limited in the World Health Organization (WHO) African Region. Several factors influence accessibility, including lack of prioritization of Parkinson disease, shortage of a trained health workforce, barriers to health financing and lack of inclusion of medicines in national essential medicines lists. We determined alignment of the most recent national essential medicines lists of 47 countries in the WHO African Region with the 23rd edition of the WHO Model list of essential medicines for Parkinson disease medicines. Overall, of any formulation or strength, 81% (38/47) of countries included levodopa + carbidopa or levodopa + benserazide as a therapeutic alternative on their national lists; and 79% (37/47) included biperiden or trihexyphenidyl as a therapeutic alternative. Inclusion of specific formulations for medicines was lower; for example, 45% (21/47) of countries included levodopa + carbidopa or levodopa + benserazide in a 4:1 ratio. Furthermore, 11% (5/47) of national essential medicines lists included none of the four medicines. While inclusion of medicines for Parkinson disease in national essential medicines lists provides no guarantee of immediate access, it can encourage procurement, prescribing and use, and can help lower costs, raise awareness of and create political will for Parkinson disease treatment. This analysis provides further evidence of the need for action to improve the accessibility of medicines for Parkinson disease in the WHO African Region.

Many global clinical trials primarily estimate a single overall treatment effect. However, when treatment effects are likely to differ between populations, for example due to differences in the disease, population characteristics or health-care systems, this approach can lead to misleading conclusions and raise ethical concerns. Justice is compromised when research conducted in low-resourced countries benefits primarily or exclusively populations of wealthier countries. A clinical trial design and analysis that focuses on estimating a single treatment effect, assumed to apply to all participating populations, goes against the ethical principle of justice and the positions of the World Health Assembly. To address this issue, we suggest a methodological strategy based on hierarchical modelling. This approach enables researchers to estimate treatment effects that are valid for each participating population, while potentially retaining efficiency comparable to traditional pooled analysis, as we demonstrate in an example. When substantial between-population differences exist, it produces valid, region-specific results. Strategies such as this one, if adopted into the standards for global trials, would allow regulators, funders and other stakeholders to ensure that trials are designed to help preserve justice for all participant populations.

Objective: To calculate the total life-course expenditure of smokers on cigarettes alone, before or without accounting for any economic losses as a result of smoking-attributable death and disease.

Method: We used data from Global Adult Tobacco Surveys to calculate annual cigarette consumption and expenditure in 15 low- and middle-income countries. We extracted data on average earnings from the ILOSTAT database of the International Labour Organization. We calculated life-course cigarette expenditures using cohort life expectancies and inflation, and converted these expenditures into net present value terms using a 3% social discount rate.

Findings: The average age of adult cigarette smokers in our sample was 40 years, and their average expenditure on cigarettes was equivalent to 7.2% of annual average earnings. Given an average life expectancy of 55 years at the age of 15 years, we estimated an average life-course consumption of 217 752 cigarettes and a full life-course expenditure of 8481 United States dollars (US$) in net present value terms, more than twice the current average annual earnings of workers. However, by quitting, current adult smokers can avoid an average of US$ 6612 in expenditure on cigarettes over their remaining life-course.

Conclusion: The affordability of cigarettes is an important determinant of cigarette use and tax policies can have a large effect on consumers, especially young adults. These costs will only increase over time as governments continue to raise taxes to address the market failures inherent within the tobacco market.

Objective: To develop new methods to analyse the distributions of diarrhoea, pneumonia and measles deaths in children younger than 5 years across wealth quintiles.

Methods: We used Demographic and Health Surveys conducted since 2013 from 21 sub-Saharan African countries. We implemented multidimensional optimization techniques to estimate the joint impact of risk factors (that is, stunting, wasting, underweight, vitamin A deficiency and unsafe sanitation), immunization coverage and treatment utilization, on the distribution of deaths from diarrhoea, pneumonia and measles across wealth quintiles in each country. For each country, we created wealth-related gradients to show the risk of dying from either diarrhoea, pneumonia or measles.

Findings: Across all countries and diseases, the risks of dying from diarrhoea, pneumonia and measles decrease with increasing household wealth: children in the wealthiest quintile are at the lowest risk (set to 1), except in a few rare instances. Yet, the magnitudes of these estimated risk gradients varied considerably across diseases and countries, from under 2 to above 10. Wealth-related risks of dying seemed to be unrelated to the countries' levels of under-5 mortality.

Conclusion: We estimate that inequalities in deaths from diarrhoea, pneumonia and measles are large in many countries of sub-Saharan Africa, with more deaths occurring among children in the poorest wealth quintiles compared with the richest. Our new and generalizable methods can help research on health disparities to explore new directions.