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Access to insulin and diabetes diagnostics David Beran Researcher and Lecturer University of Geneva.

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Presentation on theme: "Access to insulin and diabetes diagnostics David Beran Researcher and Lecturer University of Geneva."— Presentation transcript:

1 Access to insulin and diabetes diagnostics David Beran Researcher and Lecturer University of Geneva

2 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

3 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)

4 Prices of insulin per 10ml 100 IU vial

5 Affordability and availability in the public sector to the individual HI = Health Insurance 40% of interviewees had health insurance IfL = Insulin for Life – supplies two of the three main paediatric hospitals in Vietnam

6 Irrational choices Essential medicines WHO list versus Kyrgyz list WHOKyrgyzstan InsulinSoluble and Intermediate acting Vials No specification of formulations or types 40IU and 100 IU in vial and cartridge presentations Glibenclamide2.5 mg and 5 mg tablets1.75 mg, 2.5 mg, 3.5 mg and 5 mg tablets Metformin500 mg tablets250 mg, 500 mg and 850 mg tablets GlicazideNot included30 mg, 40 mg and 80 mg tablets RosiglitazoneNot included2 mg, 4 mg and 8 mg tablets GlimepirideNot included1 mg, 2 mg, 3 mg, 4 mg and 6 mg tablets

7 Insulin Total 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 160,00071%5.12818,40043% Not meeting WHO criteria* 64,15029%16.651,068,18457% Total 224,1501,886,584 All insulin purchased using WHO criteria 224,1505.121,147,648 Potential saving 738,936 Irrational choices and their financial implications * - Analogue insulin or insulin in penfill US$ 738,936 = healthcare expenditure for 11,000 people

8 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$)Ratio Vial (Protophane and Actrapid) 5.841.0 Penfill (Protophane and Actrapid) 14.512.5 Analog (Lantus and NovoRapid) 49.458.5

9 High tender prices compared to international prices Brand premium - Vietnam Medicine Price in US$ Brand Premium HighLowMean Glimepride 2mg0. Metformin 500mg and Glibenclamide 5mg0.440.090.244.9 Metformin 850mg0. Metformin 500mg0. Glicazide 80mg0. Rosiglitazone 2mg and Metformin 500mg0.500.220.322.3 Metformin 500mg and Glibenclamide 2.5mg0. Glimepride 4mg0. Metformin 1,000mg0. Glibenclamide 5mg0.030.02 * Rosiglitazone 4mg0.96 ** * - Only generic versions ** - Only branded versions

10 High tender prices compared to international prices Poor tendering practices - Kyrgyzstan Medicine Cost per unit tablet or unit of insulin (US$) International guidance price Ratio Actrapid 0.0050.0041.2 Protophane 0.0050.0041.2 Actrapid 0.0090.0042.2 Protophane 0.0110.0042.5 Glibenclamide0.0140.0035.3 NovoMix 0.0310.0065.4 Metformin0.0710.00710.3

11 Outpatient Final price: 118%-124% Patient Final 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 Outpatient Final price: 124%-136% Inpatient Final price: 118%-124% Inpatient Final price: 118%-124% 10-20% +7% distribution and other costs +5% +7% distribution and other costs +5% 0% 5-10% Cummulative price increases in Vietnam

12 Diabetes Type 1Type 2 MINSA30222,296 CIPS71414,283 RAPIA63138,501 Diabetes Type 1Type 2 IDF1,300224,074 CAMDI186,708 5% of total cost x 5-10 ? Diabetes expenditure in Nicaragua: the tip of the iceberg

13 Financial impact on individuals in Vietnam

14 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% 87% Nicaragua (2007)59%54%95% Vietnam (2008)82%59%100% Zambia (2003)61%49%54%

15 Comparison of the price range per syringe CountryPrice range (US$) per syringe Mali0.20-0.60 Mozambique0.04-0.20 Nicaragua0.11-0.25 Vietnam0.03-0.15 Zambia0.15-1.50 VAT in all countries except for Nicaragua Not readily available in Public Sector

16 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

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

18 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 – (

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