Transcript Improving access to diabetes care : taking a health systems

Access to insulin and diabetes
diagnostics
David Beran
Researcher and Lecturer
University of Geneva
The Rapid Assessment Protocol for Insulin
Access (RAPIA)
Macro
Multi-level assessment of Health system
Micro
Meso
•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
Beran, D et al. BMC Health Serv Res, 2006
The 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
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 insurance
IfL = Insulin for Life – supplies two of the three main paediatric hospitals in
Vietnam
Irrational choices
• 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
Irrational choices and their financial
implications
Total units
Percentage of
(10ml 100IU vial
total volume
equivalent)
Insulin
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
1,886,584
All insulin
purchased using
WHO criteria
224,150
5.12 1,147,648
Potential saving
738,936
US$ 738,936 = healthcare expenditure for ≈ 11,000 people
* - Analogue insulin or insulin in penfill
Irrational choices and their financial
implications
• High overall cost due to choice of penfill versus vial and
analog versus human
Monthly total cost (US$)
Vial (Protophane and Actrapid)
Ratio
5.84
1.0
Penfill (Protophane and Actrapid)
14.51
2.5
Analog (Lantus and NovoRapid)
49.45
8.5
– Comparison of different treatment options
• Assumptions:
–
–
–
–
15 units long acting per day
20 units short acting per day
5 injections with one syringe or needle for pen
Pen amortised over 12 months
Brand premium - Vietnam
• High tender prices compared to international
prices
Price in US$
Medicine
High
Low
Mean
Brand
Premium
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
Poor tendering practices - Kyrgyzstan
• High tender prices compared to international prices
Medicine
Cost per unit tablet or
unit of insulin (US$)
International
guidance price
Ratio
Actrapid
0.005
0.004
1.2
Protophane
0.005
0.004
1.2
Actrapid
0.009
0.004
2.2
Protophane
0.011
0.004
2.5
Glibenclamide
0.014
0.003
5.3
NovoMix
0.031
0.006
5.4
Metformin
0.071
0.007
10.3
Cummulative
price increases
in Vietnam
Medicine
100%
CIF
+5% import
duty
Vietnam
+5% VAT
Distributor
+7% distribution and
other costs
+5%
Public Hospital
Patients with
Health Insurance
0%
+7% distribution and
other costs
Wholesaler
Patients without
Health Insurance
0%
0%
+7% distribution and
other costs
+5%
Private Pharmacies
10-20%
5-10%
Patient
Inpatient
Outpatient
Inpatient
Outpatient
Final price:
118%-124%
Final price:
118%-124%
Final price:
118%-124%
Final price:
124%-136%
Final price:
130%-149%
Diabetes expenditure in Nicaragua: the tip
of the iceberg
Diabetes
Type 1
MINSA 302
CIPS
714
RAPIA 631
Type 2
22,296
14,283
38,501
Diabetes
Type 1 Type 2
IDF
1,300 224,074
CAMDI
186,708
5% of
total
cost
x 5-10 ?
Financial impact on individuals in Vietnam
Availability of diagnostic tools
Presence of
glucometer
Presence of urine
glucose strips
Presence of
ketone strips
Kyrgyzstan (2009)
71%
38%
67%
Mali (2003)
54%
13%
43%
Mozambique (2003)
18%
8%
21%
Mozambique (2009)
73%
73%
87%
Nicaragua (2007)
59%
54%
95%
Vietnam (2008)
82%
59%
100%
Zambia (2003)
61%
49%
54%
Country
Comparison of the price range per syringe
Country
Price range (US$) 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
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
Beran, D and Yudkin, JS. The Lancet,
2006
Drug procurement
and supply
Drug procurement and supply
–
–
–
–
–
–
–
Budget allocation for drugs
Adequate buying procedures
Quantification
Efficient procurement
Efficient distribution
Rational prescription
Proper patient compliance
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)