93 Medication use by insurance coverage in the Southern Cone of Latin America 4 two drugs. Interestingly, ACE-inhibitor use was higher among the uninsured population. These differences may be explained by the inclusion of these drug classes in programs that provide medication free of charge or with discounts to the uninsured population, while the participants with an additional insurance coverage may have to face higher out-of-pocket costs for these medications. We observe that other antihypertensives like beta-blockers or ARBs were used more frequently by the participants with additional coverage (although the differences for ARBs were not significant), and overall use of antihypertensives was not different between the two groups. Abreu et al (19) reported higher use of beta-blockers in CHD patients at discharge in the public sector in Argentina, and similar use of statins and antiplatelet medications between coverage types. Similarly, a study in Brazil showed higher use of ACE-inhibitors, and no difference in the use of beta-blockers (both medications were provided free of charge by the Popular Pharmacy Program) in CHD participants without private insurance, while the use of the other medications was higher in the subjects with private insurance (9). Overall, we do not find significant differences in medication use between participants in the public sector or with additional coverage. This is contrary to the previous studies, that report higher use of cardioprotective medication in individuals with private insurance (9,23), though one reports higher medication use in the public sector (35). However, these studies were conducted in other countries and generalizability to the Southern Cone of Latin America is limited due to differences in healthcare system organization and coverage in different countries. The lack of differences in medication use that we observed may have several explanations. First, most medications recommended for secondary prevention of CHD are included in programs like Remediar, ASSE and AUGE, and are provided free of charge or with a discount to increase access among the vulnerable sectors of the population. Although problems of medicines availability in the public sector have been reported (15,22), this did not cause a lower access to medications subjects with exclusive public insurance compared to those with additional coverage in our study. Nazzal et al (36) finds that the levels of medication in CHD patients at discharge were higher after the implementation of AUGE in Chile, and that the adequate access provided by the program benefitted medication adherence. Nonetheless, among those with social security and private insurance, co-payments may be a barrier to medication use and adherence (22). Secondly, the coverage types that we defined (public insurance, social security and private insurance) are heterogeneous. Access and costs medication and have substantial variations within the categories, arising from the complex organization of the healthcare system. Regarding the public sector, the Remediar program in Argentina provides some medications free of charge, but people might need to find other medications not included in the program in provincial or municipal health centres, which have their own medicines list. The social security sector includes over 300 plans in Argentina, organized by occupations and provinces, and they provide a different basket of services and medication discounts (15,22). Marin et al exemplified this with the cost of widely-used antihypertensives: they have large discounts for some social security plans, but have to be paid in full by others (22). In Uruguay, the
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