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

Results: Irrational choices (Kyrgyzstan) 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

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% ,40043% Not meeting WHO criteria* 64,15029%16.651,068,18457% Total 224,1501,886,584 All insulin purchased using WHO criteria 224, ,147,648 Potential saving 738,936 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) Medicine Price in US$ Brand Premium HighLowMean Glibenclamide 5mg * Glimepride 2mg Glimepride 4mg Metformin 500mg Metformin 850mg Metformin 1,000mg Rosiglitazone 2mg and Metformin 500mg Glicazide 80mg Metformin 500mg and Glibenclamide 2.5mg Metformin 500mg and Glibenclamide 5mg Rosiglitazone 4mg0.96 ** * - 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

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