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Background: Medicines affect the environment throughout their lifecycle, from production and distribution to use and disposal. They contribute to the pollution of air, water, and soil, impacting ecosystems and human health. Recognizing these risks, regulatory bodies and organizations have highlighted pharmaceutical pollution as a global concern, emphasizing the need for environmental risk assessments and sustainable practices. Methods: This study reviewed the essential medicines lists (EMLs) from 158 countries and examined the available ecotoxicological data. Medicines with high bioaccumulation, persistence, and toxicity were identified and cross-referenced with their inclusion in EMLs. Additionally, we analyzed the presence of alternative medicines with similar therapeutic effects but potentially lower environmental risks. Results: Five medicines—ciprofloxacin, ethinylestradiol, levonorgestrel, ibuprofen, and sertraline—were selected as illustrative examples due to their high environmental persistence and toxicity. All were listed in the 2023 WHO model list, with ciprofloxacin appearing in 94.3% of national EMLs. Conclusions: This study underscores the limited availability of ecotoxicological data, which hinders environmental risk assessment for medicines. EMLs could serve as a tool to enhance the awareness and data mobilization of pharmaceutical pollution. Incorporating environmental criteria into EMLs could support more sustainable medicine selection and regulatory practices.

Background Cancer is a major cause of mortality worldwide, and differences in cancer mortality rates between countries are, in part, due to differences in access to cancer care, including medicines. National essential medicines lists (NEMLs) play a role in prioritization of healthcare expenditure and access to medicines. We examined the association between amenable cancer mortality and listing medicines used in the management of eight cancers (non-melanoma skin, uterine, breast, Hodgkin lymphoma, colon, leukemia, cervical, and testicular) in national essential medicines lists of 158 countries and summarized changes to the inclusion of cancer treatments in NEMLs. Methods We conducted a cross-sectional examination of NEMLs for 158 countries, which were obtained in May 2023. We identified medicines used to treat each of the eight cancers and determined the number of medicines listed by NEMLs for each cancer. We conducted multiple linear regressions to examine the association between the number of medicines listed on the NEMLs and cancer mortality. Results We found associations between cancer medicine listing and outcomes for six of the eight examined cancers (non-melanoma skin cancer ( p  = 0.001), uterine cancer ( p  = 0.006), breast cancer ( p  = 0.001), Hodgkin lymphoma ( p  = 0.021), colon cancer ( p  = 0.006), and leukemia ( p  = 0.002)), when adjusting for healthcare expenditure and population size. Conclusion There was an association between listing cancer medicines on NEMLs and cancer mortality. Further research is required to explore how cancer mortality may be impacted by other cancer interventions, as well as policies to improve equitable access to cancer care.

Objective/designLacking diversity in pharmaceutical leadership positions could contribute to inequities in medicine access. The objective of this cross-sectional study was to determine the gender and racial identities of individuals who hold leadership positions in the Canadian pharmaceutical sector.ParticipantsWe compiled a list of all Canadian governmental bodies, pharmaceutical companies and insurance providers. We identified individuals who were part of the leadership team, including executives and members of the board of directors.Primary outcome measuresThe main outcomes of the study were the racialisation and gender of the individuals in leadership positions. The gender and racialisation of an individual were determined by reviewing their name, pronouns and institutional profile through internet searches. Two members of the research team performed the assessment and a third reviewer resolved disagreements.ResultsWe identified 957 individuals holding leadership positions within the pharmaceutical sector, including 280 drug evaluation committee members, 12 governmental executive officers, 273 insurance company executive and board members and 392 executive and board members. Reviewers identified a total of 375 (39.2% of 957) women holding leadership roles, with most of these positions being held by governmental leaders (52.4% of 292) and a minority by insurance (37.0% of 273) and pharmaceutical (30.9% of 392) leaders. There were a total of 157 (16.4% of 957) racialised leaders, with most of these positions being held by governmental (18.5% of 292) and pharmaceutical (18.1% of 392) leaders, and a minority in insurance companies (11.7% of 273). Across the pharmaceutical sector, there were a total of 48 (5.0% of 957) racialised women and 327 (34.2% of 957) white women.ConclusionsLeaders within the Canadian pharmaceutical sector are mostly white men, and racialised women hold few leadership roles. Public policy should recognise that these institutions are mostly led by white men and reasons for this disparity could be explored.

Background Since national essential medicine lists guide the procurement of medicines for populations in many countries, and cardiovascular diseases are the leading cause of death globally, including cardiovascular medicines on these lists can significantly impact healthcare outcomes. Methods In this cross-sectional study, national essential medicines’ lists from 158 countries were analysed on whether or not they included medicines to treat ischemic heart disease, cerebrovascular disease, and hypertensive heart disease. A linear regression model was used to evaluate the association between countries’ coverage scores and amenable mortality. Results Listing of cardiovascular disease treatment was associated with amenable mortality from hypertensive heart disease. Health expenditure per capita was also associated with amendable mortality due to ischemic heart disease, and hypertensive heart disease. Conclusions Listing essential medicines for cardiovascular disease is an important aspect of healthcare quality that is associated with cardiovascular mortality.

ObjectivesOut-of-pocket medication costs can contribute to financial insecurity and many Canadians have trouble affording medicines. This study aimed to determine if the effect of eliminating out-of-pocket medication costs on individual’s financial security varied by gender, racialisation, income and location.DesignIn this post hoc subgroup analysis of the CLEAN Meds trial, a binary logistic regression model was fitted and a qualitative inductive thematic analysis of comments related to participant’s ability to make ends meet was carried out.SettingPrimary care patients in Ontario, Canada.ParticipantsAdult patients (786) who reported not being able to afford medicines during the previous 12 months.InterventionFree access to a comprehensive list of essential medicines for 24 months.Primary outcome measureAbility to make ends meet or afford basic necessities.ResultsThere were no significant differences in the effect of free medicine distribution by gender (OR for male 0.82; 95% CI 0.51 to 1.33, p=0.76), age (older than 65 years OR 1.28; 95 % CI 0.62 to 2.64, p=0.73), racialisation (OR 0.85; 95 % CI 0.51 to 1.45, p=0.66), household income level (above US$30 000 per year OR 1.08; 95 % CI 0.64 to 1.80, p=0.99) or location (urban OR 0.47; 95 % CI 0.23 to 0.96, p=0.10). The main theme in the qualitative analysis was insufficient income, and there were three related themes: out-of-pocket medication expenses, cost-related non-adherence and the importance of medication coverage. In the intervention group, additional themes identified included improved health, functioning and access to basic needs.ConclusionsProviding free essential medications improved financial security across subgroups in a trial population who all had trouble affording medicines. Free access to medicines could improve health directly by improving medicine adherence and indirectly by making other necessities more accessible to people who have an insufficient income.Trial registration numberNCT02744963.

Persaud et al discuss the recommendations for equitable COVID1-19 pandemic recovery in Canada. Health inequities-or avoidable differences in health status between populations -that were exposed and exacerbated during the COVID-19 pandemic can be addressed through interventions and policy changes that were studied before SARS-CoV-2 spread across Canada. Racialized people, women, people with a low income, people experiencing homelessness, people who use substances and people who are incarcerated were disproportionately affected during the pandemic. Inequities that were exposed and exacerbated by COVID-19 will continue to threaten health after the pandemic. Specific interventions and changes that relate to income, housing, safety from intimate partner violence, childcare, access to health care and antiracism are known to be beneficial.

Background and Aims Interventions to address potentially inappropriate prescribing (PIP), where risks outweigh benefits, are effective but often not implemented due to barriers (e.g., patient, provider, systems). Concerns about questioning healthcare providers or symptom resurgence when discontinuing medications may make PIP interventions less acceptable. This systematic review aims to determine the acceptability of PIP interventions among older adult outpatients. Methods We searched MEDLINE, Embase, and other databases for controlled studies of PIP interventions including older adults (≥ 65 years) residing in community or care home settings. The review included interventions aimed at reducing PIP, whether clinical or external providers. We assessed risk of bias and performed a meta‐analysis. Results Nine studies (n = 4,843) were included: six randomized controlled trials, two prospective cohort studies, and one pre‐post study. Studies spanned the US, England, Ireland, Lebanon, the Netherlands, Spain, and Switzerland. Seven out of nine (78%) studies were assessed as having a low risk of bias; two out of nine (22%) at moderate risk. Meta‐analysis showed no significant difference in patient satisfaction between PIP interventions and standard care, though satisfaction was slightly higher with PIP interventions (SMD 0.45; 95% CI −0.14 to 1.04, I² = 96%, n = 4,414). Meta‐analysis showed more patients discussed discontinuing medications with their prescriber after a PIP intervention (RR 4.32; 95% CI 0.0 to 56,270, I² = 43%, n = 429). Conclusion PIP interventions are as acceptable to patients as usual care, despite some burden for patients and prescribers. Patients are more willing to engage in deprescribing conversations when a deprescribing intervention is present. Summary What is Already Known About This Subject Interventions to address potentially inappropriate prescribing (PIP) are effective but often underutilized due to patient, provider, and system barriers, including concerns about questioning providers or symptom resurgence from discontinuing medications. What This Study Adds This study highlights the importance of acceptability in implementing interventions addressing PIP, particularly for older adults at risk from polypharmacy. By encouraging healthcare providers to integrate these interventions into routine practice and fostering critical discussions about medication management, such efforts can reduce hospitalizations and improve health outcomes for vulnerable populations.

IntroductionNational essential medicines lists (NEMLs) guide medicine selection and procurement and are key tools for promoting equitable access. While countries adapt their lists to national priorities, underlying medical needs are broadly similar across settings; however, factors beyond epidemiological need influence which medicines are included on national lists. We assessed whether countries can be empirically grouped based on their NEML content and examined how these groupings relate to geography, economic status and selected health system characteristics.MethodsWe assessed NEMLs from 158 WHO Member States and selected non-Member States and territories. Countries were clustered using k-means analysis applied to principal components derived from binary medicine-inclusion data. Cluster profiles were characterised using ORs and compared across WHO region, gross domestic product (GDP) per capita, health expenditure, life expectancy and population size.ResultsFour medicine-based clusters were identified. Cluster 1 (66 countries, 41.8%), largely from the African Region and the Region of the Americas, emphasised medicines for infectious and neglected diseases, vaccines and antisera. Cluster 2 (65 countries, 41.1%) included countries from multiple regions listing a heterogeneous mix of older, off-patent medicines for symptomatic management and selected chronic conditions. Cluster 3 (18 countries, 11.4%), primarily from the European, Eastern Mediterranean and Region of the Americas, prioritised medicines for chronic noncommunicable diseases. Cluster 4 (9 countries, 5.7%), predominantly from the European Region, included newer, higher cost medicines. Cluster membership was significantly associated with WHO region (χ², p<0.001), but clusters did not correspond exclusively to any single region or income group, with substantial within-cluster heterogeneity in GDP and health expenditure.ConclusionCountries can be grouped according to the medicines prioritised on their NEMLs. These clusters reflect patterns in medicine selection and related health system policies that cut across traditional geographic and economic classifications and provide a complementary framework for comparative health system analysis and policy benchmarking.

Background Cancer is the second leading cause of death worldwide. Alongside other interventions, access to certain medicines may decrease cancer‐associated mortality. Listing medicines on national essential medicines lists may improve health outcomes. We examine the association between cancer mortality amenable to care and the listing of cancer medicines on national essential medicines lists (NEMLs) of 124 countries. Methods In this cross‐sectional study, we determined the number of medicines used to treat eight cancers on NEMLs and used multiple linear regression to analyze the association between cancer health outcome scores and the number of medicines on NEMLs while controlling for GDP. A sensitivity analysis was also conducted using selected medicines. Findings The number of cancer medicines on NEMLs was not associated with cancer health outcome scores when GDP was controlled for non‐melanoma skin (p = 0.224), uterine (p = 0.221), breast (p = 0.145), Hodgkin's lymphoma (p = 0.697), colon (p = 0.299), leukemia (p = 0.103), cervical (p = 0.834), and testicular cancers (p = 0.178). Interpretation There was a weak association between listing medicines for eight cancers in NEMLs and amenable mortality. Further studies are required to explore association between cancer health outcomes and other factors such as actual availability of medicines listed, access to surgeries, accurate diagnosis, radiotherapy, and early detection.