Access to insulin and diabetes diagnostics

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

2. The Rapid Assessment Protocol for Insulin Access (RAPIA) Multi-level assessment of Health system • Micro • Healthcare Workers • Traditional Doctors • Patients • Meso • Regional Health Organisation • Hospitals, Health Centres, etc. • Pharmacies, Drug Dispensaries • Macro • Ministry of Health • Ministry of Trade • Ministry of Finance • Central Medical Store • National Diabetes Association • Private/Public drug importer • Educators Perspectives on the problem of access to Insulin and Diabetes care Beran, D et al. BMC Health Serv Res, 2006

3. The countries where the RAPIA has been implemented Kyrgyzstan (2009) Mali (2004) Vietnam (2008) Nicaragua (2007) Philippines (2008)* Zambia (2003) Mozambique (2003) Reassessment (2009) * - carried out by WHO

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

7. Irrational choices and their financial implications US$ 738,936 = healthcare expenditure for ≈ 11,000 people * - Analogue insulin or insulin in penfill

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

9. Brand premium - Vietnam • High tender prices compared to international prices * - Only generic versions ** - Only branded versions

10. Poor tendering practices - Kyrgyzstan • High tender prices compared to international prices

11. 100% Medicine Cummulative price increases in Vietnam +5% import duty CIF +5% VAT Vietnam Distributor +7% distribution and other costs +7% distribution and other costs +7% distribution and other costs +5% +5% Private Pharmacies Public Hospital Wholesaler Patients with Health Insurance Patients without Health Insurance 10-20% 0% 0% 0% 5-10% Patient Final price: 130%-149% Inpatient Final price: 118%-124% Outpatient Final price: 118%-124% Inpatient Final price: 118%-124% Outpatient Final price: 124%-136%

12. Diabetes Type 1 Type 2 MINSA 30222,296 CIPS71414,283 RAPIA631 38,501 5% of total cost Diabetes Type 1 Type 2 IDF1,300 224,074 CAMDI186,708 x 5-10 ? Diabetes expenditure in Nicaragua: the tip of the iceberg

13. Financial impact on individuals in Vietnam

14. Availability of diagnostic tools

15. Comparison of the price range per syringe • VAT in all countries except for Nicaragua • Not readily available in Public Sector

16. A positive diabetes environment Accessibility and affordability of Medicines Positive policy environment Data collection Community involvement/ diabetes association Prevention measures Diagnostic tools and infrastructure Patient education and empowerment Adherence issues Healthcare workers Organised centres for care Drug procurement and supply Beran, D and Yudkin, JS. The Lancet, 2006

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

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 • (http://www.access2insulin.org/who-manual.html)