To the best of our knowledge, this is the first study to report CVDs and diabetes medicine dispensing at the population level in Syria using health insurance data from a large sample (81,314 beneficiaries) over a 12-month period. This study contributes to our knowledge regarding treatments for two common NCDs in Syria: CVDs and diabetes. Our analysis yielded three key findings: 1) CVDs and diabetes medicine dispensing rates were low during the study period and included very low rates of insulin dispensing; 2) there were lower dispensing rates of CVDs and diabetes medicines among female beneficiaries; and 3) there were higher rates of CVDs and diabetes medicines dispensed in governorates that were completely or mostly controlled by the government and very low to no dispensing of insulin in some governorates that were partly controlled by the Syrian government.
The rates for dispensing cardiovascular system medicines (C) were the highest in comparison to the other medicine groups. This can be explained by the high rate of CVDs in Syria . CVDs medicine dispensing rates in our study were, however, low compared to many other countries. A study from Australia reported higher rates of dispensed CVD medicines (566.00 DIDs) , and a study from Serbia reported higher dispensing rates for some antihypertensives as well (283 DIDs) . These differences in medicine use between countries may be the result of differences in the age and sex distribution of the populations, differences in the prevalence of high blood pressure and cholesterol, and variation in clinical practices . Other reasons for the low dispensing rates of CVDs medicines found in this study could be associated with the ongoing conflict in Syria. Access to medicines, including CVDs medicines, can be affected by several barriers, including travel bans and checkpoints during conflict .
Antithrombotic medicines were the most dispensed group among the CVDs medicines. Antithrombotic drugs, which include antiplatelet and anticoagulant therapies, prevent and treat a number of cardiovascular disorders and are some of the most commonly prescribed drugs globally . The high rate of antithrombotic medicines included acetyl salicylic acid, which accounted for 67.20% of the antithrombotic medicine rates and was the most dispended CVDs medicine. Acetyl salicylic acid is the most prescribed antiplatelet medicine for CVDs prevention in many countries .
The dispensing rate of diabetes medicine in Syria was 35.66 DIDs. This rate is quite low compared to those in other countries. A study that reported on the consumption of antidiabetic medicine in the 28 countries of the Organization for Economic Co-operation and Development (OECD) found that the average rate of diabetes medicine consumption was 68 DIDs, which is nearly double the rate found in our study. Similarly, in neighboring Turkey the consumption rate of diabetes medicine is 73 DIDs, which is more than double the rate we found in our study . Another study reported that the rate of diabetic medicine consumption in Iran in 2012 was also low in comparison to other countries (33.54 DIDs) . However, this rate may have increased in the years 2018–2019 to exceed the rate of diabetes medicine consumption in our study, as the authors of that report indicated an ongoing increase in diabetes medicine rates with time in Iran. The low dispensing rates of diabetic medicine that we found could be related to a potentially high number of undiagnosed diabetes in Syria. The WHO has reported that four in five undiagnosed diabetic patients live in LMICs . One study has reported that diabetes was well controlled in only 16.7% of type-2 diabetes patients in Aleppo in 2011—before the start of the conflict . Since there is evidence on the low number of controlled diabetes cases it would be expected that there is a low rate of diabetes medicines utilization. In addition, the low dispensing rates of diabetes medicines may be explained by factors related to the conflict situation in Syria. A study conducted among a group of diabetes patients in main public hospitals in Damascus during the Syrian crisis reported that 41.2% of the patients had stopped their medicines for at least one month over the course of seven years of conflict, and 74.8% of these patients attributed stopping their therapy to the unavailability of medicines. Furthermore, approximately half of the patients had to change their medicines brand names because many pharmaceutical companies closed due to the conflict. In addition, half of the diabetic patients struggled to reach a healthcare center . Moreover, food insecurity in countries affected by conflict limits the possibility of diabetes patients to adhere to recommended diets, which would present an obstacle to maintaining treatment as diabetes medicines must be taken with food .
A total of 97.31% of the dispensed diabetes medicines were oral. Metformin, a first-line treatment for type-2 diabetes , was the most common medicine. This is in line with studies that have reported metformin as the most commonly dispensed diabetes medicine in many countries [47–49]. We found an insulin dispensing rate of 0.96 DID. Higher rates of insulin prescriptions in other counties has been reported. For instance, a study from Albania reported a 5.64 DIDs insulin outpatient prescription rate , while Iran reported higher insulin consumption rates in 2012 (5.73 DIDs) . A study from Portugal reported an insulin dispensing rate of 15.1 DIDs in 2014. In addition to the factors we have previously mentioned to explain the low dispensing rates of diabetes medicine, specific factors related to insulin could also explain the low rates. The limited availability of insulin due to the conflict in the country may be another factor. Approximately 60% of insulin-dependent Syrians are at risk due to limited supplies [11, 23]. Furthermore, insulin requires cold-chain transportation and the maintenance of temperatures between 2°C and 8°C. The storage of insulin by patients is an additional challenge as the lack of refrigeration is common due to frequent energy cuts . In addition, our data may not include all of the insulin given to insulin-dependent diabetic patients, as they could have received insulin through other channels such as humanitarian organizations—the WHO is now the main supplier of insulin in Syria . Poor adherence to insulin caused by injection phobia among some patients has been recorded in other studies . This can also further explain the very low rates of insulin dispensing in our study.
CVDs medicine dispensing rates were significantly higher among males than females (388.80 DIDs and 249.59 DIDs, respectively). Other studies have reported higher rates of hypertension among middle-aged females (35 to 65 years) than males in Syria and other countries of the Eastern Mediterranean region and North Africa . Moreover, women of Arab ethnicity present with coronary artery disease ten years earlier than those from Europe or East Asia . Obesity, a significant risk factor of CVDs, also has a higher prevalence among females in Eastern Mediterranean region countries, including Syria [35, 52, 53]. Cultural and religious norms, as well as circumstances related to the conflict and lack of security, restrict women from sports and limit physical activity. These factors may also contribute to the CVDs burden among women in Syria and the region . The lower dispensing rates of CVDs medicines among females in our study contrasts with other studies that have reported higher rates of CVDs in females in Syria. This suggests that CVDs were undertreated among females in our study population. Despite being the leading cause of death among women globally, CVDs in women are still understudied, underdiagnosed, and undertreated . There is a common misperception that CVDs affect men more than women, and this may contribute to the suboptimal treatment of CVDs among women . Similar to CVDs, the dispensing rates of diabetes medicines, including insulin dispensing rates, were significantly higher among males than females (45.98 DIDs and 29.42 DIDs, respectively); however, the WHO has reported a higher prevalence of diabetes among females in Syria than males (12.6% and 11.2%, respectively) . This result indicates the undertreatment of diabetes among females in our study. Other studies have reported poorer control of type-2 diabetes among women than men [55–57]. Furthermore, the conflict situation in Syria may have contributed to women’s vulnerability in comparison to men. The crisis has restricted women’s movement more than men and limited their access to healthcare, including diabetic care [11, 58]. Unsurprisingly, the dispensing rates of CVDs and diabetes medicines increased with increasing age, which is due to the increasing prevalence of CVDs and diabetes with increasing age [59, 60].
There was a significant difference in the dispensing rates of CVDs and diabetes medicines between the different governorates in Syria. The Damascus countryside, Latakia, and Tartous had the highest dispensing rates for CVDs and diabetes medicines, while Idlib, Deer el-Zour, and Quneitra had the lowest rates. The major areas of the three governorates with the highest CVDs and diabetes medicines dispensing rates (Damascus countryside, Latakia, and Tartous) were under the Syrian government’s control. However, while the major areas of Deer el-Zour and Idlib were out of the Syrian government’s control, they were affected by the armed conflict during the study period . This regional variation may be related to the conflict situation that has rendered services damaged or unavailable. There is an uneven distribution of healthcare services, including medicines, across geographical regions [62, 63]. Through internal displacement, the conflict has also contributed to regional variation in Syrian healthcare services. The disruption of healthcare in some parts of Syria has forced patients with chronic diseases, especially older individuals, to flee their homes to other parts of the country to access better healthcare . Our data did not record insulin dispensing in Al-Hasakah, Idlib, Deer el-Zour, and Daraa. Being a cold chain product, delivery of insulin in these regions may have been extremely challenging. The distribution of essential medicines, including insulin even when it was available, can be complex due to geographical and political barriers . Thus, insulin-dependent diabetes patients may have relied on private funding or the assistance of humanitarian organizations to access insulin.
Strengths and limitations
The study’s limitations principally arose from the data that was used, as it did not provide the diagnoses underlying the prescribed medicines. The generalizability is also limited as our data only included people with government health insurance. The majority of our study population were employed by the Syrian government. Government employees in Syria belong usually to the country’s middle-income class . The study did not include people living in areas of Syria that were out of government control. In particular, the number of insured people in Deer el-Zour and Idlib was significantly lower than other governorates because large areas of these regions were beyond the Syrian government’s control. Further studies are necessary to reach those regions. Our data did not necessarily include all the diabetes medicines used by diabetic patients because some might receive these medicines, especially insulin, through other sources such as humanitarian organizations. Despite these limitations, our study represents an essential step towards understanding medicine use for NCDs such as CVDs and diabetes in a country plagued by an ongoing conflict since 2011. Our research also provides a picture of CVD and diabetes management in a large sample that is diverse in terms of age and sex and included data on medicine use in 13 out of 14 Syrian governorates. Finally, reporting medicine dispensing rates and patterns using ATC/DDD methodology enables the comparison of medicine dispensing at the international level .