Access to insulin and diabetes diagnostics

David BeranResearcher and Lecturer

University of Geneva

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

The Rapid Assessment Protocol for Insulin Access (RAPIA)

Beran, D et al. BMC Health Serv Res, 2006

The 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)

Prices of insulin per 10ml 100 IU vial

Affordability and availability in the public sector to the individual

HI = Health Insurance 40% of interviewees had health insuranceIfL = Insulin for Life – supplies two of the three main paediatric hospitals in Vietnam

Irrational choices• 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 saving 738,936

Irrational choices and their financial implications

* - Analogue insulin or insulin in penfillUS$ 738,936 = healthcare expenditure for ≈ 11,000 people

Irrational choices and their financial implications• High overall cost due to choice of penfill versus vial and

analog versus human

– Comparison of different treatment options• Assumptions:

– 15 units long acting per day– 20 units short acting per day– 5 injections with one syringe or needle for pen– Pen amortised over 12 months

Monthly total cost (US$) RatioVial (Protophane and Actrapid) 5.84 1.0Penfill (Protophane and Actrapid) 14.51 2.5Analog (Lantus and NovoRapid) 49.45 8.5

• High tender prices compared to international pricesBrand premium - Vietnam

MedicinePrice in US$

Brand PremiumHigh Low Mean

Glimepride 2mg 0.21 0.04 0.14 5.1

Metformin 500mg and Glibenclamide 5mg 0.44 0.09 0.24 4.9

Metformin 850mg 0.14 0.03 0.08 4.7

Metformin 500mg 0.08 0.02 0.05 3.5

Glicazide 80mg 0.12 0.04 0.07 3.0

Rosiglitazone 2mg and Metformin 500mg 0.50 0.22 0.32 2.3

Metformin 500mg and Glibenclamide 2.5mg 0.18 0.08 0.13 2.3

Glimepride 4mg 0.29 0.15 0.23 2.0

Metformin 1,000mg 0.16 0.08 0.13 2.0

Glibenclamide 5mg 0.03 0.02 0.02 *

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

• High tender prices compared to international pricesPoor tendering practices - Kyrgyzstan

Medicine Cost per unit tablet or unit of insulin (US$)

International guidance price Ratio

Actrapid 0.005 0.004 1.2

Protophane 0.005 0.004 1.2

Actrapid 0.009 0.004 2.2

Protophane 0.011 0.004 2.5

Glibenclamide 0.014 0.003 5.3

NovoMix 0.031 0.006 5.4

Metformin 0.071 0.007 10.3

OutpatientFinal price: 118%-124%

PatientFinal price: 130%-149%

Private Pharmacies

+5% VAT

100%

+5% import duty

Medicine

CIF

Vietnam

Distributor

WholesalerPublic Hospital

Patients without Health Insurance

Patients with Health Insurance

OutpatientFinal price: 124%-136%

InpatientFinal price: 118%-124%

InpatientFinal price: 118%-124%

10-20%

+7% distribution and other costs

+7% distribution and other costs

+5%

+7% distribution and other costs

+5%

0% 0% 0% 5-10%

Cummulative price increases in Vietnam

DiabetesType 1 Type 2

MINSA 302 22,296CIPS 714 14,283RAPIA 631 38,501

DiabetesType 1 Type 2

IDF 1,300 224,074CAMDI 186,708

5% of total cost

x 5-10 ?

Diabetes expenditure in Nicaragua: the tip of the iceberg

Financial impact on individuals in Vietnam

Availability of diagnostic tools

Country Presence of urine glucose strips

Presence of ketone strips

Presence of glucometer

Kyrgyzstan (2009) 71% 38% 67%

Mali (2003) 54% 13% 43%

Mozambique (2003) 18% 8% 21%

Mozambique (2009) 73% 73% 87%

Nicaragua (2007) 59% 54% 95%

Vietnam (2008) 82% 59% 100%

Zambia (2003) 61% 49% 54%

Comparison of the price range per syringeCountry Price range (US$) per syringe

Mali 0.20-0.60

Mozambique 0.04-0.20

Nicaragua 0.11-0.25

Vietnam 0.03-0.15

Zambia 0.15-1.50

• VAT in all countries except for Nicaragua • Not readily available in Public Sector

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

A positive diabetes environment

Beran, D and Yudkin, JS. The Lancet, 2006

– Budget allocation for drugs – Adequate buying procedures – Quantification – Efficient procurement– Efficient distribution – Rational prescription– Proper patient compliance

Drug procurement and supply

Conclusion• Challenge with insulin– High cost– Limited producers

• Oral medicines– Quality– Pushing of ineffective treatments

• Medicines only one piece of the puzzle for NCDs• WHO Manual “How to investigate access to chronic Non

Communicable Disease care in LMICs– Pilot in Peru looking at diabetes and hypertension– (http://www.access2insulin.org/who-manual.html)