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A century after the discovery of insulin became a game changer for people living with diabetes, many are still unable to access this life-sustaining medication, and substantial numbers of people cannot obtain or afford the necessary supplies needed to self-manage their diabetes on a day-to-day basis. The removal of barriers to access and the reimagination of pathways for delivering necessary treatment are essential to tackling this unmet need.
Today, an estimated 463 million people are living with diabetes. Of these, approximately 100 million people need insulin, including all people living with type 1 diabetes and between 10% and 25% of people with type 2 diabetes. Meanwhile, the World Health Organization (WHO) reports that only half of those living with type 2 diabetes who need insulin are able to access it. Moreover, a substantial number of people living with diabetes cannot access or afford the commodities to measure their blood glucose (e.g. glucometers, test strips, lancets) or the needles and syringes needed to safely administer the insulin itself. This is a particularly problematic issue in middle- and low-income countries that account for 79% of the global burden of people living with diabetes.
Inconsistent access to insulin and its complementary products has a devastating impact because it forces those living with diabetes to ration insulin and testing/test strips, and ration or reuse needles. This rationing leads to increased pain from dulling needles, risk of infection, increased risk of hyperglycemia (or hypoglycemia in areas where there are high levels of food insecurity), and to complications such as amputation, blindness, kidney failure, or even death. We also know that the resulting morbidity brings substantial economic losses to people living with diabetes, their families and health systems and national economies through both direct medical costs and the loss of work and wages.
OBSTACLES TO HEALTH
This inconsistent availability translates to unreliable access at all levels of care, but especially at the primary care level. Beyond availability, many people struggle to afford insulin and the complementary products needed for its safe administration and self-management.
PATH, an organization fighting against NCDs at the global, national, and local levels, conducted a review of the 22 essential supplies needed for diabetes diagnosis and treatment in low-resource settings in 2015. The review found that facilities offering diabetes diagnosis or treatment had limited availability of the complementary products needed for safe administration of insulin. For example, in Mozambique, blood glucose test strips were only available in 27% of the public facilities, and in Kyrgyzstan, insulin syringes were only available in 25% of the public facilities. While availability was typically higher in the private sector than in the public sector, PATH found that these products are often unavailable in the same place/facility and require significant financial and time resources for people living with diabetes and their caregivers.
PATH’s assessment also looked at the median monthly treatment costs for medication, syringes, and blood glucose strips, measured by how many days the lowest paid government worker would need to work to earn enough to purchase a 30‐day supply of treatment in the public or private sector. In Senegal, the median monthly treatment cost was 14 days’ wages (public sector) and 17 days’ wages (private sector). In Kenya, affordability ranged between 15 days’ wages (public) and 21 days (private). Other research found that annual supply costs for minimal care (e.g., insulin, blood glucose meter, two blood glucose test strips/day, two syringes/week, and four HbA1c tests/year) ranges from $255 (Pakistan) to $1,185 (Burkina Faso), with a median cost of $553. While insulin prices are often flagged as a barrier to access, the cost of essential diabetes-related consumables as well as the indirect costs of accessing these products are less talked about. PATH found that an estimated 85% of the total cost people living with diabetes pay in Kenya and Senegal is driven by consumables. Even without considering indirect costs like transportation to retail outlets and time away from work, out-of-pocket (OOP) expenditures are well above the 30% benchmark that the WHO defines as catastrophic OOP costs.
DISRUPTING THE STATUS QUO
For effective self-care, people living with diabetes need reliable access to the full package of products to keep themselves in good health and improve their long-term health outcomes, without having to rely on the external health system infrastructure. The recently released Lancet Commission on Diabetes report highlighted this as a critical recommendation.
Using a human-centered, service design methodology, PATH and the Coalition for Access to NCD Medicines and Products, in partnership with ministries of health, have embarked on the Diabetes CarePak project, which aims to solve the important problem of how we increase access to high-quality diabetes self-care. It will build on lessons learned from co-packaging/bundling approaches successfully used in other areas of global health, including HIV. The projects’ main goals include:
This multisectoral collaboration, which was launched in January 2021, will focus on the needs of people living with diabetes, as well as on the constraints they experience within the environment and market to ensure that we are solving the system-level root cause issues.
CarePak is welcomed by key influencers in the global development community. Prashant Yadav, senior fellow at the Center for Global Development and Affiliate Professor of Technology and Operations Management at INSEAD says CarePak has the potential to simultaneously improve medication adherence, simplify the patient journey, reduce supply chain complexity and improve affordability, which can also make demand more predictable.
THE TIME TO INOVATE IS NOW
2021 represents the 100th anniversary of the discovery of insulin, the development and official launch of the new WHO Global Diabetes Compact, and the year that the world begins to recover and reimagine health delivery in the wake of the COVID-19 pandemic. We have a special opportunity to leverage this momentum to develop a concrete way to address all aspects of a person’s self-care journey, prevent costly diabetes-related complications, and drive sustainability by demonstrating the benefits and cost savings to health system. With collaboration from the many organizations and governments working to improve the care of NCDs, we have the power to change the diabetes landscape. If we do not take advantage of this unique moment in time where global attention is focused on health, we will continue to fail the millions of people living with diabetes. •
TEXT – Molly Guy, RN, MSN/MPH is a Senior Program Officer with PATH’s NCD Team and supports the work of the Coalition for Access to NCD Medicines and Products, where PATH is the Secretariat. Particular thanks to the Coalition membership whose feedback has been invaluable in contributing to this article.
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