Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study

Summary

Background

Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use.

Methods

In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35–70 years (n=156 625) were recruited from 110 803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys.

Findings

Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines.

Interpretation

Availability and affordability of essential diabetes medicines are poor in low-income and middle-income countries. Awareness of these global differences might importantly drive change in access for patients with diabetes.

Funding

Full funding sources listed at the end of the paper (see Acknowledgments).

Introduction

The global burden of incident and prevalent diabetes and diabetes-related morbidity and mortality are increasing.¹ Most people with diabetes remain unidentified, untreated, or inadequately treated, particularly in low-income and middle-income countries (LMICs)² despite the availability of simple diagnostic tests and cheap medicines. The problem is a large and growing one especially for LMICs where most of the world's patients with diabetes reside.³ The WHO framework for health systems states that a well functioning health system ensures equitable access to essential medical products, vaccines, and technologies of assured quality, safety, efficacy, and cost-effectiveness, and their scientifically sound and cost-effective use. To achieve such objectives, WHO also state that information is needed on prices, supply, distribution systems, and rational use.⁴ Data is scarce on the availability and affordability of diabetes medicines, particularly from LMICs. Data from selected countries hint towards a poor availability of insulin,5, 6, 7, 8 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.⁹

Research in context

Evidence before this study

We searched PubMed and reference lists of identified papers for papers on access, availability, and affordability of diabetes medicines from inception to June 25, 2018, with no language restrictions. We were particularly interested in information available from low-income and middle-income countries (LMICs). We identified several papers that reported on availability or affordability, or both, of diabetes medicines from single countries or regions, including a number from LMICs. We identified a few papers that examined this issue across multiple countries, but most of these papers accessed data from secondary data sources, did not involve direct data collection, and did not relate this data to use of diabetes medicines.

Added value of this study

This report provides a global perspective on the availability and affordability of essential medicines for diabetes, including comparative data from LMICs. The data used in this study were collected directly from individuals and communities, unlike other methods that collect data from key informants, secondary data sources, and policy and health system documents. Direct data collection from communities and individuals provides information on the downstream implementation of policies and more comprehensive information about the patient experience. Our analyses use data collected at baseline from 156 625 participants in 604 communities and 22 countries. An estimated 61% of the global total number of people with diabetes reside in these 22 countries. We found that the availability and affordability of essential medicines for diabetes is poor in some low-income countries, both in terms of poor availability on pharmacy shelves and prohibitive costs for people on average incomes. Availability and affordability of insulin was particularly poor and the disparity between oral hypoglycaemics and insulin was several times greater in low-income countries than in high-income countries. For example, metformin was available in 100% and insulin in 94% of pharmacies audited in communities from high-income countries, whereas metformin was available in 65% and insulin in 10% of pharmacies in low-income countries. Also, about 0·7% of households with patients with diabetes could not afford metformin in high-income countries; this proportion was 26·9% of households in low-income countries. For insulin, the divide between high-income and low-income countries was greater, with 2·8% of households not able to afford insulin in high-income countries compared with 63·0% of households in low-income countries.

Implications of all the available evidence

The poor availability and affordability of essential diabetes medicines in many communities, especially those from LMICs, is a substantial driver of lower use of these medicines. Access to medicines is recognised by WHO as part of the right to health. Although several countries have programmes to provide subsidised medicines, the data presented here show universal access is still a distant prospect and that government and industry really are not doing enough to ensure the availability and affordability of these essential medicines to people that need them. These data also underwrite the importance of having strong monitoring systems to track the progress towards universal access to essential medicines.

Most people (80%) with type 2 diabetes reside in urban environments, but despite the availability of essential medicines in some areas, access to these medicines is not guaranteed in many LMICs. Previous studies have highlighted the very large gaps in the availability and affordability of essential medicines for chronic diseases in LMICs and the need to monitor them.10, 11, 12, 13 In 2007, a survey¹⁴ of availability of 32 medicines to treat cardiovascular disease, diabetes, chronic respiratory disease, and glaucoma in six LMICs found less than 7·5% of these medicines were available in the public sector, and the cost of a 1-month course of intermediate-acting insulin ranged from 2·8 days of wages in Brazil to 19·6 days of wages in Malawi. Availability and affordability of these medicines might affect their use. Several countries have brought in schemes to subsidise the cost of diabetes medicines, but the penetration of these programmes is uncertain. Better data are needed from individuals, communities, and large populations ascertained with uniform methods across populations to better quantify the problems of availability and affordability of diabetes medicines and to inform the development of interventions to tackle this issue.

The aim of our analyses was to examine the availability and affordability of essential medicines for diabetes (metformin, sulfonylureas, insulin) across different countries and regions and to explore the effect of availability and affordability on use of these medicines.