Direct costs and availability of diabetes medicines in low-income and middle-income countries Birgit Volman 27/08/2008 Meeting on Access to Medicines for

Direct costs and availability of diabetes medicines in low-income and middle-income countries

Birgit Volman

27/08/2008

Meeting on Access to Medicines for Noncommunicable Chronic Diseases

World Health Organization, Geneva

2

Introduction

Methodology WHO/HAI

Follow-up ‘Price, availability and affordability – an international comparison of chronic diseases’ By Gelders S et al. (2006)

Consultative meeting 19/20 February

27/08/2008Meeting on Access to Medicines for

Noncommunicable Chronic Diseases

3

Background

Diabetes management: to control blood glucose concentration and to limit the chance for complications

Essential medicines: Metformin, Glibenclamide and Insulin

Monitoring equipments and syringes Literature study: - Medicine costs largest part- Treatment costs type 1 higher than type 2



4

Methodology

Objective: characterize costs and availability of diabetes medicines by country, WHO region and World Bank income group

Primary data- International Diabetes Federation (IDF)- International Insulin Foundation (IIF)- World Integrated Trade Solution database (WITS)- World Health Organization & Health Action International

(WHO/HAI)- IMS-Health

Secondary analysis: Prices adjusted for CPI and PPP



5

International Diabetes Federation

Four global surveys to identify barriers for accessing insulin and diabetes supplies

Methodology- 35 participating countries- Questionnaire

Results- Insulin was expensive and not available in rural

areas- Costs of diabetes treatment varied between

countries



6

International Insulin Foundation (I)

Rapid Assessment Protocol for Insulin Access (RAPIA)

Mali, Mozambique, Zambia and Nicaragua

Results:- Low availability Quantities were

estimated on past consumptions & poor communication

- Low mark-ups - High patient prices of insulin- High travel costs



7

International Insulin Foundation (II)

Differences in the procurement and patient price of insulin in the public and private sector

28,6%

-80,0%-73,5%

34,3%

14,8%

40,0%33,3%

-100%

-80%

-60%

-40%

-20%

0%

20%

40%

60%

M ali (2004) M ozambique (2003) Zambia (2003) Nicaragua (2007)

Surveyed countries

P ublic sector

P rivate sector



8

International Insulin Foundation (III)

32,02

5,88 4,19

36,26

53,09

38,12

63,32

0

10

20

30

40

50

60

70

Mali (2004) Mozambique (2003) Zambia (2003) Nicaragua (2007)

Pric

e in

ID

Patient prices of insulin in different sectors. Prices adjusted for CPI and PPP.

Public sector

Private sector



9

WITS database (I)

Import tariffs: custom duties set by the government of the importing country

- Provide little revenue- Influence the price for the patient- Not effectively used to protect local

industry



10

WITS database (II)

Import tariffs charged on finished products containing insulin.

Tariffs rate (%)

Number of countries

Low-income countries

Lower-middle-income countries

Upper-middle-income countries

High-income countries

0 92 (70%) 20 19 25 27

0-5 22 (17%) 6 13 3 0

5.1-10 11 (8%) 3 4 1 3***

10.1-20 6* (5%) 1 2 3 0

>20 1** (1%) 0 1 0 0

Total 132 30 39 32 30

* Countries with a 10.1-20% tariffs were Brazil, Uruguay, Argentina, Tunisia, Peru, India** Islamic Republic Iran (52%)*** Republic Korea, Austria and Israel



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WITS database (III)

Comparison of the charged tariffs on insulin products between the year 2005 and 2008

Tariff range Year 2005 Year 2008

0% 75 92

0-5% 25 22

5.1-10% 17 11

10.1-20% 6 6

>20% 3 1

Total 126 132



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World Health Organization/ Health Action International (I)

Data from 47 surveys

Results:- Wide variety between countries- Good procurement prices- High mark-ups (public sector)- Availability better in the private

sector than in the public sector



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World Health Organization/ Health Action International (III)

Differences between the procurement and patient price in the public sector for the LPG of glibenclamide 5 mg

248%

170%

234%

6%

90%

153%

5%

26%

311%

21%

22%

0% 50% 100% 150% 200% 250% 300% 350%

Chad (2004)

Ethiopia (2004)

Ghana (2004)

Nigeria (2004)

Sudan-Gadarif (2006)

Sudan-Kordofan (2006)

Tanzania (2004)

Indonesia (2004)

J ordan (2004)

P eru (2005)

Kazakhstan (2004)

Differences in percentage



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World Health Organization/ Health Action International (IV)

Brand premiums (glibenclamide 5 mg) in the private sector

11,515,00

9,001,16

1,010,890,880,871,031,03

5,002,56

1,851,64

5,93

6,0113,84

2,082,38

2,050,88

2,004,03

1,354,88

5,50

1,092,04

0,00 2,00 4,00 6,00 8,00 10,00 12,00 14,00 16,00

Ethiopia (2004)Ghana (2002)Ghana (2004)

India-Chennai (2004)

India-Haryana (2004)India-Karnataka (2004)

India-Maharashtra 12 districts (2004)India-Maharashtra 4 regions (2005)

India-Rajasthan (2003)

India-W est Bengal (2004)Kenya (2004)

Mali (2004)Nigeria (2004)

Pakistan (2004)Yemen (2006)

Fiji (2004)Indonesia (2004)

Jordan (2004)Morocco (2004)

Peru (2002)Philippines (2002)

Philippines (2005)Tunisia (2004)

Kazakhstan (2004)Lebanon (2004)

Malaysia (2004)

Kuw ait (2004)United Arab Emirates (2006)

LI

LM

IU

MI

HI

Co

un

trie

s p

er

inco

me

gro

up

Brand premium



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World Health Organization/ Health Action International (VI)

Availability of the LPG of glibenclamide 5 mg and metformin 500 mg in the private and public sector of 33 countries

28%

19%

28%

53%

49%

56%

63%

33%

56%

68%

61%

69%

0% 10% 20% 30% 40% 50% 60% 70% 80%

LI countries

LM I countries

A ll countries

Availability in percentage

P rivate sector

P rivate sector

P ublic sector

P ublic sector

Glibenclamide

Glibenclamide

M etformin

M etformin

Glibenclamide

Glibenclamide

Glibenclamide

Glibenclamide

M etformin

M etformin

M etformin

M etformin



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World Health Organization/ Health Action International (VII)

Affordability of one months therapy with the LP G of glibenclamide (5 mg, 2 times a day) and the LP G of metformin (500 mg, 3 times a day) in the private sector

0 1 2 3 4 5 6 7 8 9

Ethiopia (2004)Ghana (2004)

India-Chennai (2004)India-Haryana (2004)

India-Karnataka (2004)India-M aharashtra 12 districts (2004)India-M aharashtra 4 regions (2005)

India-Rajasthan (2003) India-West Bengal (2004)

Kenya (2004)M ongolia (2004)

Nigeria (2004)P akistan (2004)Tanzania (2004)

Sudan-Gadarif (2006)Sudan-Khartoum (2005)Sudan-Kordofan (2006)

Uganda (2004)Yemen (2006)

F iji (2004)Indonesia (2004)

J ordan (2004)M orocco (2004)

P eru (2005)P hilippines (2005)

Syria (2003)

Lebanon (2004)M alaysia (2004)

Kuwait (2004)United Arab Emirates (2006)

Affordability in days wages

M etformin500 mg

Glibenclamide5 mg



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IMS-Health (I)*

49 low-income and middle-income countries

2000, 2005, 2006 and 2007 Defined Daily Dose

Results:- Increased consumption of metformin- Decreased consumption of glibenclamide- Increased total consumption of oral

hypoglycemic agents and insulin in low-income and middle-income countries



18

IMS-Health (II)*

Trend of oral hypoglycaemic agent consumption in 49 low-income and middle-income countries (% growth by year)

0

500

1000

1500

2000

2500

2000 2005 2006 2007Year

M ETFORM IN (38.3%)

GLIM EPIRIDE (128.3%)

GLIBENCLAM IDE (-2.8%)

GLICLAZIDE (4.2%)

GLIPIZIDE

PIOGLITAZONE



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IMS-Health (III)*

Annual increase rates of oral hypoglycaemic agents and insulin by income group

GNI-group Annual increase rate (overall for 6 years from 2000 to 2007)

Oral hypoglycemic agents Insulin

Low-income countries 16.6% 12.7%

Lower-middle-income countries

13.8% 36.0%

Upper-middle-income countries

15.4% 15.9%

Total 15.5% 21.3%



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Discussion/Conclusion

Objective: characterize costs and availability of diabetes medicines by country, WHO region and World Bank income group

- Variety per country- Availability: Poor communication, estimations

based on past consumption. Availability better in the private sector than in the public sector.

- Price: Taxes & tariffs. Low procurement price of metformin and glibenclamide, high procurement price of insulin. Large differences between the procurement price and patient price.



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Recommendations

Governments should be aware of the low availability and large differences

Reasons for the large differences should be investigated

Differential pricing initiatives should be promoted Procurement in the public sector should be funded Competition should be stimulated Quality assured generics should be promoted Price and availability reporting mechanism should

be available at each WHO-region More detailed information per country is needed



22

Questions?



Documents

Direct costs and availability of diabetes medicines in low-income and middle-income countries Birgit Volman 27/08/2008 Meeting on Access to Medicines for