David Beran Researcher and Lecturer University of Geneva Multilevel assessment of Health system Macro Ministry of Health Ministry of Trade Ministry of Finance Central Medical Store National Diabetes Association ID: 630661
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Slide1
Access to insulin and diabetes diagnostics
David BeranResearcher and LecturerUniversity of GenevaSlide2
Multi-level assessment of Health system
MacroMinistry of Health Ministry of TradeMinistry of Finance
Central Medical Store
National Diabetes Association
Private/Public drug importerEducators
MesoRegional Health OrganisationHospitals, Health Centres, etc.Pharmacies, Drug Dispensaries
MicroHealthcare WorkersTraditional DoctorsPatients
Perspectives on the problem of access to Insulin and Diabetes care
The Rapid Assessment Protocol for Insulin Access (
RAPIA
)
Beran, D et al. BMC Health
Serv
Res, 2006Slide3
The 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)Slide4
Prices of insulin per 10ml
100 IU vialSlide5
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 VietnamSlide6
Irrational choices
Essential medicines WHO list versus Kyrgyz list
WHO
Kyrgyzstan
Insulin
Soluble and Intermediate actingVials
No specification of formulations or types 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 tabletsSlide7
Insulin
Total units (
10ml
100IU vial equivalent)
Percentage of total volumeCost per 10ml 100IU vial equivalent (US$)
Cost (US$)Percentage of total costMeeting WHO criteria
160,00071%
5.12
818,40043%
Not meeting WHO criteria*
64,15029%
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
Irrational choices
and their
financial
implications
* - Analogue insulin or insulin in
penfill
US$ 738,936 = healthcare expenditure for ≈ 11,000 peopleSlide8
Irrational choices and their financial
implicationsHigh overall cost due to choice of penfill versus vial and
analog
versus human
Comparison of different treatment options
Assumptions:15 units long acting per day20 units short acting per day
5 injections with one syringe or needle for penPen amortised over 12 months
Monthly total cost (US$)
RatioVial (
Protophane and Actrapid)
5.841.0
Penfill (Protophane and Actrapid)
14.51
2.5
Analog
(
Lantus
and
NovoRapid
)
49.45
8.5Slide9
High tender prices compared to international prices
Brand premium - VietnamMedicine
Price in US$
Brand Premium
High
Low
Mean
Glimepride
2mg0.21
0.040.14
5.1Metformin
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 500mg0.500.220.322.3
Metformin 500mg and Glibenclamide 2.5mg0.180.080.132.3Glimepride
4mg0.29
0.15
0.23
2.0
Metformin
1,000mg
0.160.080.132.0Glibenclamide 5mg0.030.020.02*Rosiglitazone 4mg 0.960.960.96**
* - Only generic versions
** - Only branded versionsSlide10
High tender prices compared to international prices
Poor tendering practices - Kyrgyzstan
Medicine
Cost per unit tablet or unit of insulin (US$)
International guidance price
Ratio
Actrapid
0.0050.004
1.2
Protophane
0.005
0.0041.2
Actrapid
0.009
0.004
2.2
Protophane
0.011
0.004
2.5
Glibenclamide
0.014
0.003
5.3
NovoMix
0.031
0.006
5.4
Metformin
0.071
0.007
10.3Slide11
Outpatient
Final price: 118%-124%
Patient
Final price: 130%-149%
Private Pharmacies
+5% VAT
100%
+5% import duty
Medicine
CIF
Vietnam
Distributor
Wholesaler
Public Hospital
Patients without Health Insurance
Patients with Health Insurance
Outpatient
Final price: 124%-136%
Inpatient
Final price: 118%-124%
Inpatient
Final price: 118%-124%
10-20%
+7% distribution and other costs
+7% distribution and other costs
+5%
+7% distribution and other costs
+5%
0%
0%
0%
5-10%
Cummulative
price increases in VietnamSlide12
Diabetes
Type
1 Type 2
MINSA
302
22,296
CIPS 714 14,283
RAPIA
631 38,501
Diabetes
Type 1 Type 2
IDF
1,300 224,074
CAMDI
186,708
5% of total
cost
x 5-10 ?
Diabetes expenditure in Nicaragua: the tip of the icebergSlide13
Financial impact
on individuals in
Vietna
mSlide14
Availability of diagnostic tools
Country
Presence of urine glucose strips
Presence of ketone strips
Presence of glucometer
Kyrgyzstan (2009)
71%
38%
67%
Mali (2003)
54%
13%
43%
Mozambique (2003)
18%
8%
21%
Mozambique (2009)
73%
73%
87%
Nicaragua (2007)
59%
54%
95%
Vietnam (2008)
82%
59%
100%
Zambia (2003)
61%
49%
54%Slide15
Comparison of the price range per syringe
CountryPrice range (US$) per syringe
Mali
0.20-0.60
Mozambique
0.04-0.20Nicaragua0.11-0.25Vietnam
0.03-0.15Zambia0.15-1.50
VAT in all countries except for Nicaragua
Not readily available in Public SectorSlide16
Accessibility and
affordability of MedicinesHealthcare workers
Organised centres
for care
Data collection
Prevention
measuresDiagnostic tools
and infrastructure
Drug procurement and supply
Adherence issues
Patient education
and empowerment
Community
involvement/
diabetes association
Positive policy
environment
A positive diabetes environment
Beran
, D and
Yudkin
, JS. The Lancet, 2006Slide17
Budget allocation for drugs
Adequate buying procedures Quantification Efficient procurementEfficient distribution Rational prescription
Proper patient compliance
Drug procurement and supplySlide18
Conclusion
Challenge with insulinHigh costLimited producersOral
medicines
Quality
Pushing of ineffective treatments
Medicines only one piece of the puzzle for NCDsWHO Manual “How to investigate access to chronic Non Communicable Disease care in LMICsPilot in Peru looking at diabetes and hypertension
(http://www.access2insulin.org/who-manual.html)