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
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