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Overall availability, affordability of essential diabetes medicines poor worldwide
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Insulin was available to those with diabetes who need it in only half of surveyed pharmacies worldwide, whereas the availability of metformin and sulfonylureas varied across low-income vs. high-income countries, according to findings published in The Lancet Diabetes & Endocrinology.
Many participants in the study were also estimated to be unable to afford diabetes medicines defined as essential by WHO, in particular insulin, with a cost multiple times higher than the cost for oral antihyperglycemic agents, according to the researchers.
“Data is scarce on the availability of diabetes medicines, particularly from [low- and middle-income countries],” Clara K. Chow, MBBS, FRACP, PhD, professor at the University of Sydney School of Medicine and director of community-based cardiac services at Westmead Hospital, Australia, and colleagues wrote in the study background. “Data from selected countries hint toward a poor availability for insulin, and reviews have called for greater attention to the availability and affordability of essential medicines for diabetes (especially insulin), a discussion of possible barriers and a need for a global perspective.”
Chow and colleagues analyzed data from 156,625 adults recruited from 110,803 households across 604 communities as part of the ongoing PURE study, a prospective analysis involving 22 countries. Researchers asked participants to indicate whether they had been diagnosed with diabetes and if they were taking medications for diabetes and to list all their medications consumed at least once a week for the past month. Researchers also used data on medicine availability and cost collected from pharmacies as part of a community audit; cost data were used to estimate the cost of a 1-month supply of essential medicines for diabetes, defined as metformin (1,000 mg daily), the sulfonylureas gliclazide (80 mg) and glibenclamide (5 mg) and insulin (50 IU/mL). Availability was defined as the presence of medicines for diabetes at any dose in the pharmacy on the day of the survey. Affordability was defined as when the total monthly costs at standard doses and recommended frequencies were less than 20% of the household capacity-to-pay, expressed as total monthly cost of medicines as a proportion of the monthly household capacity-to-pay. Researchers analyzed the proportion of participants with a diagnosis of diabetes who reported medication use by income quartiles and tertiles within country groups. All data on income and medicine costs were converted to U.S. dollars and adjusted for purchasing power parity and standardized to 2015 prices using World Bank inflation rates. Researchers used multilevel, mixed-effects logistic regression models to analyze the association between the availability and affordability of medicines for diabetes with the use of such medicines.
Data from India were presented separately from other low-income countries, as the availability and affordability of medicines were unique to this country, possibly relating to the size of its domestic pharmaceutical industry, according to researchers.
Within the global cohort, 13,569 (8.7%) reported a diagnosis of diabetes. In most of the 22 countries, medications were partially subsidized in hospitals.
Medicine availability
The researchers found that metformin was the most widely available diabetes medicine, available in 88.7% of community pharmacies surveyed; however, availability declined with country income level. Metformin was available in 100% of high-income countries, 88.2% of upper-middle-income countries, 86.1% of lower-middle-income countries and 64.7% of low-income countries. Metformin was available in 100% of Indian pharmacies surveyed.
The sulfonylureas glibenclamide and gliclazide were available in 69.3% and 57.9% of pharmacies overall, respectively, with availability rates ranging from 84.1% for high-income countries to 57.4% for low-income countries. Insulin was available in 48.3% of pharmacies overall, ranging from 93.8% in high-income countries to 10.3% in low-income countries.
Monthly medicine costs
Metformin was the most affordable diabetes medicine, with the monthly costs as a median of 2.3% of the capacity-to-pay overall and ranging from 0.4% in high-income countries to 13.4% in low-income countries. The median monthly cost of metformin was $5.20, ranging from $4.30 in India to $9.90 in high-income countries, according to the researchers. Differences between urban and rural costs were minimal.
Conversely, insulin was the least affordable diabetes medicine, with the monthly costs as a median of 10% of the capacity-to-pay overall and ranging from 1.2% in high-income countries to 65.8% in low-income countries.
The researchers estimated that, overall, 13.8% of households containing adults with diabetes would be unable to afford a monthly prescription for metformin, ranging from 0.7% in high-income countries to 26.9% in low-income countries. Overall, researchers estimated that 36.7% of households with participants with diabetes would be unable to afford a prescription for insulin, ranging from 2.8% in high-income countries to 63% in low-income countries.
Greater access needed
The researchers noted that increasing evidence supports that the availability and affordability of chronic disease medications are related to the use of such treatments.
“WHO has set a voluntary target of 80% availability and 50% use of affordable essential medicines to treat noncommunicable diseases in the public and private sectors by 2025,” the researchers wrote. “The analyses presented here suggest that this target is only being consistently met in high-income countries for [oral antihyperglycemic agents] and insulin. These data draw further attention to the need for governments to implement strategies to make essential medications for cardiovascular disease and diabetes more widely available and affordable to achieve the WHO target.”
In commentary accompanying the study, Alessandra Ferrario, PhD, a postdoctoral research fellow at Harvard Medical School and the Harvard Pilgrim Health Care Institute, noted that the PURE survey data provide important information on individuals who are usually not covered by health insurance and pay for medicines out of pocket; however, data from household and facility surveys are limited, and studies that combine such surveys with other routinely collected information may present a clearer picture.
“To measure progress in improving availability and affordability of diabetes medicines and other essential medicines, reliable, longitudinal data are needed, in addition to household and facility data to guide action,” Ferrario wrote. “While additional data collection is needed in various settings, greater use of existing routinely collected data is an opportunity that should not be missed.” – by Regina Schaffer
Disclosures: The authors report no relevant financial disclosures.
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