Irrational Use of Diabetes Medicines in Resource-Poor Settings

International Insulin Foundation

David Beran, Geoff Gill, John S. Yudkin and Harry Keen

Background

• Ideally what is needed to manage diabetes in resource poor settings?

• Barriers to care exist

• How can these be clearly identified?

• Development of the Rapid Assessment Protocol for Insulin Access (RAPIA)

Rapid Assessment Protocol for Insulin Access (RAPIA)

Multi-level assessment of Health system

Macro•Ministry of Health •Ministry of Trade•Ministry of Finance•Central Medical Store•National Diabetes Association•Private/Public drug importer•Educators

Meso•Regional Health Organisation•Hospitals, Health Centres, etc.•Pharmacies, Drug Dispensaries

Micro•Healthcare Workers•Traditional Doctors•Patients

Perspectives on the problem of access to Insulin and Diabetes care

Countries where the RAPIA has been implemented

Zambia (2003) Mozambique (2003)Reassessment (2009)

Nicaragua (2007) Philippines (2008)*

Mali (2004) Vietnam (2008)

* - carried out by WHO

Kyrgyzstan (2009)

Results: Prices of insulin per 10ml 100 IU vial

Results: Availability versus Affordability

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%0%

5%

10%

15%

20%

25%

30%

Mali 2004

Vietnam (without HI and IfL) 2008

Nicaragua 2007

Vietnam (with HI and IfL) 2008

Mozambique 2003

Zambia 2003

Kyrgyzstan 2009

Mozambique 2009

Availability of insulin in facilities visited where insulin should have been present

Affor

dabi

lity

as a

%ag

e of

GDP

per

ca

pita

for 1

yea

r of i

nsul

in (1

3 vi

als)

Results: Irrational choices (Kyrgyzstan)• Essential medicines WHO list versus Kyrgyz listWHO Kyrgyzstan

Insulin Soluble and Intermediate acting•Vials

No specification of formulations or types• 40IU and 100 IU in vial and cartridge presentations

Glibenclamide 2.5 mg and 5 mg tablets 1.75 mg, 2.5 mg, 3.5 mg and 5 mg tablets

Metformin 500 mg tablets 250 mg, 500 mg and 850 mg tablets

Glicazide Not included 30 mg, 40 mg and 80 mg tablets

Rosiglitazone Not included 2 mg, 4 mg and 8 mg tabletsGlimepiride Not included 1 mg, 2 mg, 3 mg, 4 mg and

6 mg tablets

InsulinTotal units

(10ml 100IU vial equivalent)

Percentage of total volume

Cost per 10ml 100IU

vial equivalent

(US$)

Cost (US$)Percentage

of total cost

Meeting WHO criteria 160,000 71% 5.12 818,400 43%Not meeting WHO criteria* 64,150 29% 16.65 1,068,184 57%Total 224,150 1,886,584All insulin purchased using WHO criteria 224,150 5.12 1,147,648

Potential saving738,936

Results: Irrational choices and their financial implications (Kyrgyzstan)

* - Analogue insulin or insulin in penfill

• High tender prices compared to international prices

Results: Poor purchasing practices (Vietnam)

MedicinePrice in US$

Brand PremiumHigh Low Mean

Glibenclamide 5mg 0.03 0.02 0.02 *

Glimepride 2mg 0.21 0.04 0.14 5.1

Glimepride 4mg 0.29 0.15 0.23 2.0

Metformin 500mg 0.08 0.02 0.05 3.5

Metformin 850mg 0.14 0.03 0.08 4.7

Metformin 1,000mg 0.16 0.08 0.13 2.0

Rosiglitazone 2mg and Metformin 500mg 0.50 0.22 0.32 2.3

Glicazide 80mg 0.12 0.04 0.07 3.0

Metformin 500mg and Glibenclamide 2.5mg 0.18 0.08 0.13 2.3

Metformin 500mg and Glibenclamide 5mg 0.44 0.09 0.24 4.9

Rosiglitazone 4mg 0.96 0.96 0.96 *** - Only generic versions** - Only branded versions

• Health Systems– Nicaragua: Estimated that 1 in 5 people with diabetes are

receiving treatment• Represents 5% of total health budget

– Mozambique: In 2003 purchase of insulin = 10% of government expenditure on medicines• Improved tendering + LEAD Initiative resulted in decrease of average

price per vial from US$ 8.03 to US$ 4.50 (2003 to 2009)• Individuals– Mali: US$ 340 per year for treatment of an individual requiring

insulin • 61% of per capita GDP

– Vietnam: US$ 55 per month for treating child with Type 1 diabetes• 79% of per capita GDP

Results: Overall financial cost

• Not one price of insulin– Focus on proper purchasing at central level– Focus on cost to end user

• Focus on affordability and availability– Mozambique 2003 versus 2009

• Rational medicine policies– Taxing– Selection– Purchasing– Prescribing

• Someone has to pay– Health Systems versus Individuals

• Access to Medicines versus Access to Treatment– Trained healthcare workers– Diagnostic tools– Education– Etc.

Key Lessons

Accessibility and affordability of

Medicines

Healthcare workers

Organised centres for care

Data collection

Prevention measures

Diagnostic tools and

infrastructure

Drug procurement and supply

Adherence issues

Patient education and empowerment

Community involvement/

diabetes association

Positive policy environment

Policy Implications – A “positive diabetes environment”

• Further understanding of access to medicines for diabetes, especially insulin

• How to improve affordability for medicines and care• Improving not only access to medicines, but also treatment for

diabetes• Further RAPIAs

– Assessments– For health system comparisons– As a tool for M&E– As a tool for Policy change

• A model for other chronic diseases

Future research

Any questions?

www.access2insulin.org

International Insulin Foundation