Transcript Irrational Use of Diabetes Medicines in Resource

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
Meso
Micro
•Ministry of Health
•Ministry of Trade
•Ministry of Finance
•Central Medical Store
•National Diabetes Association
•Private/Public drug importer
•Educators
•Regional Health
Organisation
•Hospitals, Health Centres,
etc.
•Pharmacies, Drug
Dispensaries
•Healthcare Workers
•Traditional Doctors
•Patients
Perspectives on the problem of access to Insulin and Diabetes care
Countries where the RAPIA has been
implemented
Kyrgyzstan (2009)
Nicaragua (2007)
Mali (2004)
Zambia (2003)
Vietnam (2008)
Philippines
(2008)*
Mozambique (2003)
Reassessment (2009)
* - carried out by WHO
Results: Prices of insulin per 10ml 100 IU
vial
Affordability as a %age of GDP per
capita for 1 year of insulin (13 vials)
Results: Availability versus Affordability
30%
Mali 2004
25%
20%
Mozambique 2009
Mozambique 2003
15%
Vietnam (with HI
and IfL) 2008
10%
Nicaragua 2007
Zambia 2003
Vietnam (without HI
and IfL) 2008
5%
Kyrgyzstan 2009
0%
0%
20%
40%
60%
80%
100%
Availability of insulin in facilities visited where insulin should have
been present
Results: Irrational choices (Kyrgyzstan)
• Essential medicines WHO list versus Kyrgyz list
WHO
Kyrgyzstan
Insulin
Soluble and Intermediate No specification of
acting
formulations or types
•Vials
• 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 tablets
Glimepiride
Not included
1 mg, 2 mg, 3 mg, 4 mg and
6 mg tablets
Results: Irrational choices and their financial
implications (Kyrgyzstan)
Insulin
Total units
Percentage of
(10ml 100IU vial
total volume
equivalent)
Cost per
10ml 100IU
vial
equivalent
(US$)
Percentage
Cost (US$)
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
All insulin
purchased using
WHO criteria
224,150
Potential saving
1,886,584
5.12
1,147,648
738,936
* - Analogue insulin or insulin in penfill
Results: Poor purchasing practices (Vietnam)
• High tender prices compared to international prices
Medicine
Price in US$
High
Low
Brand
Mean Premium
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
Results: Overall financial cost
• 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
Key Lessons
• 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.
Policy Implications – A “positive diabetes
environment”
Accessibility and
affordability of
Medicines
Data collection
Positive policy
environment
Community
involvement/
diabetes association
Prevention
measures
Patient education
and empowerment
Diagnostic tools
and
infrastructure
Healthcare
workers
Adherence issues
Organised centres
for care
Drug procurement
and supply
Future research
• 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
Any questions?
International Insulin Foundation
www.access2insulin.org