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ORIGINAL ARTICLE
Year : 2022 | Volume
: 13
| Issue : 5 | Page : 73-80
Accessibility and availability of insulin: A survey by International Diabetes Federation-Middle East and North Africa Region (IDF-MENA) Member Associations
Michele Abi Saad1, Shabeen Naz Masood2, Nizar Al Bache3, Samih Abed Odhaib4, Jamal Belkhadir5, Nadima Shegem6
1 Public Health Specialist, Administrator, Chronic Care Center, Hyderabad, Pakistan
2 Department of Obstetrics and Gynecology, Isra University, Hyderabad, Pakistan
3 Hotel-Dieu du Creusot Hospital, Le Creusot, France
4 Thi Qar Specialized Diabetes Endocrine and Metabolism, Thi Qar, Iraq
5 International Diabetes Federation, Regional Chair of Middle East North Africa
6 Jordanian Society for the Care of Diabetes, Amman, Jordan
Correspondence Address:
Prof. Shabeen Naz Masood
Department of Obstetrics and Gynecology, Isra University, New Hala - Mirpur Khas Rd Link, Hyderabad, Sindh
Pakistan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_114_22
Introduction: One hundred years after its discovery, insulin is still inaccessible for many people living with diabetes. In the recent World Health Organization (WHO) 2021 report on Barriers to Insulin Availability, WHO highlights the alarming state of global access to insulin. According to International Diabetes Federation (IDF), as reported in IDF Atlas, 10th edition, 73 million adult people with diabetes (PWD) live in Middle East and North Africa (MENA) Region. Materials and Methods: A survey was conducted in the International Diabetes Federation (IDF) MENA Region through its Member Associations in 2021. Eighteen countries out of 21 participated. Questions were about insulin support, beneficiaries, local production, insurance coverage, average cost, minimum wage, and barriers to access. Results: Fifty percent of countries had full government support and 44% had partial. In 56 % of countries, support is limited to human insulin, and the majority is restricted to citizens. Some PWDs have difficulties accessing insulin: low-income persons, refugees, noncitizens, or living in remote areas. Approximately 61% of countries have national social security funds and 61% private insurance coverage for insulin. In five countries, there is a law prohibiting nongovernmental organizations to receive international donations of insulin. Local production exists in only five countries surveyed. There is a wide variation in the cost of insulin from $1.42 to 100 and in the minimum wage ($7–2667). Additional barriers to access were delivery, storage, cost, electricity, war conditions, displacements, and sanctions. Conclusion: Although government support is available in the majority of countries, it is still mainly through the provision of human insulin and restricted to citizens. Many barriers affect access to insulin and its costremains unaffordable. Disparities exist between countries within the same classification of income. Mapping the current situation will help to improve it and monitor change. This document can be informative for PWD living or visiting any of these countries and can help understand cross-border travel for medical treatment, and local and regional policies.
Keywords: Access to insulin, availability, barriers, cost, diabetes, IDF, insulin, MENA Region
One hundred years after its discovery, insulin is still unavailable and unaffordable to many living with diabetes around the globe.
Insulin is listed on the World Health Organization’s (WHO) essential drug list and its availability is a human right. According to WHO,[1] it is a lifesaving medication for people with type 1 diabetes, an essential treatment for insulin-dependent type 2 diabetes, a gold standard treatment for diabetes in pregnancy, and important in preventing serious complications.
A new report published by WHO[1] highlights the alarming state of global access to insulin in diabetes care and finds that high prices, low availability of human insulin, the low number of producers dominating the insulin market, and weak health systems are the main barriers to universal access.
According to the International Diabetes Federation (IDF) Atlas publication 2021,[2] 73 million adults live with diabetes in the Middle East and North Africa (MENA) region.
The MENA Region has the highest regional prevalence at 16.2% and the second highest expected increase (86%) in the number of people with diabetes (PWD); it also has the highest percentage (24.5%) of deaths in people of working age. Although the MENA Region includes 13.6% of PWD worldwide, it counts for only 3.4% of total expenditures worldwide. In addition, the age-adjusted comparative prevalence of diabetes (20–79 years old) ranges from 5.4% to 30.8%. The top five countries for age-adjusted prevalence of PWD and number of PWD are Pakistan, Egypt, Iran, Saudi Arabia, and Sudan.[2]
According to a recent World Bank Classification,[3] MENA Region comprises four countries in the low-income category (Afghanistan, Sudan, Syria, Yemen), eight countries in the lower-middle category (Algeria, Egypt, Iran, Lebanon, Morocco, Pakistan, Palestine, and Tunisia), three countries in the upper-middle income category (Iraq, Jordan, and Libya), and six countries in the high-income category (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates).
The IDF-MENA Region currently represents 29 diabetes organizations in 21 countries and territories.[4]
The goal of the survey
The goal of the survey was to map the situation in the MENA Region regarding access to insulin to better comprehend the situation. It is essential to understand the gravity of the situation in this region regarding the level of governmental and nongovernmental support in the provision of insulin, the type of insulin provided, the category of patients supported, the insurance coverage, existing law prohibiting donations, local production of insulin, and barriers to access.
In addition, the scale of forced displacement resulting from armed conflict and humanitarian crises is at record-high levels.[5] Countries in the MENA Region are affected by war, a high number of displaced people, and sanctions that affect the availability of insulin to PWD.
Materials and MethodsTo achieve this goal, a survey was conducted in the IDF-MENA Region for the first time, using Google Forms. It was circulated to IDF-MENA Member Associations (MA) in 2021.
At first, the survey was piloted by a committee of the IDF-MENA Insulin Centenary group and endorsed by the IDF-MENA Survey committee.
Afterward, 18 countries out of 21 filled out the form through 21 MAs. The survey comprised questions regarding government and non-government insulin support, type of insulin, beneficiaries, insulin local production, insurance coverage, average cost, minimum wage, barriers to access, and further support needed.
Answers were analyzed, and consolidated into one answer per country, as, in some countries, several associations are represented. Validation of results was done in 2022 by resending consolidated responses to the delegate of participating MAs.
Analysis of results was done and data was represented in maps, charts, or tables.
ResultsResults of survey were consolidated by country and summarized in descriptive frequency tables.
Full Government support for the provision of insulin to people living with diabetes (PLWD) was reported in nine countries, partial support in eight countries and only one country did not get any support. Ten countries support only human Insulin whereas seven countries cover all types of Insulin. Seven countries extend their coverage to citizens only, eight countries to citizens and residents, and only two countries, Tunisia and Morocco, to everyone in the territory.
National Social Security Scheme exists in eleven countries of which nine require co-payment. Private insurance covers for insulin costs in only eleven countries.
There is local production of insulin in only five participating countries: Egypt, Iran, Morocco, Pakistan, and Syria.
A law prohibiting international donations to local nongovernmental organizations (NGOs) exists in five countries and only four countries reported having benefited from donations from Life for A Child (an IDF-related international NGO supporting young children with type 1 diabetes). Data per country are detailed in [Table 1].
Table 1: Government support, insurance, local production, and laws related to international donationsTwelve countries reported that people with a low income had difficulties in access to insulin and in nine countries the nonresidents were concerned. Refugees were also affected in seven countries and people in remote areas in six countries. Homeless, PWD without insurance and illegal persons were vulnerable populations in, respectively, four, three, and one countries. Details are described per country in [Table 2].
Human insulin vial’s cost varies in low-income countries between 1.5 and 12$, in the low middle between 1.42 and 50$, in the upper middle between 10 and 14$, and in high income between 15.85 and 50$. Cost of short-acting pen ranges from 4.5 to 10 $ in low-income countries, from 3.5 to 30 $ in low-middle-income, from 12 to 50 $ in upper-middle-income, and from 9 to 50 $ in high-income countries. As for cost of Long acting pen it varies between 4.5 and 15 $ in low-income countries, between 5 and 25$ in low-middle, between 20 and 30$ in upper-middle, and between 16.3 and 100$ in high-income countries. Insulin analogs are not available in Yemen.
The minimum wage per month was reported to vary between 7 and 50 USD in low-income, between 68 and 440$ in low-middle, between 75 and 350$ in upper-middle, and between 500 and 2667$ in high-income countries.
[Table 3] shows the cost per human insulin vial, cost of analog pen, and minimum wage per country.
Table 3: Market cost of insulin in 2021 (subject to constant change) and monthly minimum wageDelivery of Insulin has been described in eleven countries to be a barrier, cost, and storage in seven countries, electricity in six countries, war-related issues in five countries, the high number of displaced in four countries, and international sanction in one country, Iran. The type of insulin available was described to be a barrier in three countries, education in two, and the quantity of insulin available another barrier in Yemen. [Table 4] details the barriers per country.
DiscussionLevel of government support and type of insulin
In terms of government support, 50% of countries had full support towards the availability of Insulin (Algeria, Bahrain, Egypt, Libya, Morocco, Palestine, Qatar, Saudi Arabia, and Syria), 44% had partial support with patient contribution, and only one country, Afghanistan, had no support.
Type of insulin supported
It is important to know which types of insulin are supported by governments, humans (Rapid and NPH), or analogs.
There are a considerable number of reports showing that short-acting insulin analogs (lispro, aspart, and glulisine) have profiles closer to normal when compared with regular human insulin. In addition, basal insulin analogs (glargine and detemir) are reported to offer longer duration of action, less variability, more predictability, less hypoglycemia, and a favorable effect on weight.[6]
Analog insulins were described to be important and cost-effective in two situations. For people with type 1 diabetes, basal analog insulin provides the needed 24-h coverage. Analogs also help prevent the unusual occurrence of overnight hypoglycemia in people with type 2 diabetes.[6]
According to the WHO guidelines, in low-resource settings, human insulin products, both short-acting regular insulin, and intermediate-acting NPH insulin, are strongly recommended as the insulin of choice in adults with type 1 diabetes mellitus and as the third-line treatment for individuals with type 2 diabetes mellitus; long-acting insulin analogs are suggested for patients with frequent severe hypoglycemia with human insulin.[7]
As to the type of insulin supported by the government, in 56% of countries, it is only limited to human insulin, in 39% of countries all types of insulin are provided (human and analogs). In one country, there was no support for the provision of any type of insulin.
The method of support was in majority by direct provision; only two countries (Algeria and Iran) by reimbursement of the insulin cost.
Provision of insulin
Insulin is available to everyone in the market but government support is restricted in some countries.
The provision of insulin by the government was in majority restricted to citizens (83%): in 39% of countries it is provided only to citizens, in 44% of countries to citizens and residents and only in 11%, that is, two countries (Tunisia and Morocco), insulin is provided by the government to anyone in the territory.
This information is important for patients who are traveling for a short stay or holiday, migrants, or for displaced people. This non-availability of insulin is such a pressing issue that, according to data from few countries, noncitizens with diabetes not covered by insurance policies for insulin provision feel compelled to marry the citizen of the country so that insulin is provided to them.
Accessibility
Despite governmental support, some patients still have difficulties accessing insulin. In a majority of countries, they are people of low-income, refugees, noncitizens, refugees, or living in remote areas. These people look for governments, NGOS, charities, international bodies (WHO and UN agencies), and to a lesser extent for pharmaceutical companies for help.
Nongovernment support
Charities/nongovernmental organizations
Many PWDs rely on nongovernmental support, local charities or NGOs for the provision of insulin. In some countries, there is a law prohibiting NGOs to receive international donations of insulin.
Life for a child (LFAC) is a program related to IDF offering young people with Type-1 Diabetes free insulin and other supplies. According to the LFAC website, the organization supported 34,000 children and young PLWD in 44 under-resourced countries.[8]
According to the survey results, only three countries have benefited so far from LFAC’s support: Lebanon, Pakistan, Palestine, and Sudan.
With respect to Government Law prohibiting insulin donations to national associations from international NGOs, in 29% of countries laws do not allow associations to receive insulin donations, which is a big barrier. In many of those countries, the local production of insulin is available like in Morocco, Syria, and Iran.
Insurance schemes
Insurance schemes can also play a role in access to insulin.
- National Social Security Scheme: Insurance offered to employees whereby governments, employers, and employees participate in the premium. 61% of countries have a National Social Security Fund (NSSF) and the majority of them (80%) require a co-payment, except Algeria and Iraq. Countries that do not have NSSF are Afghanistan, Bahrain, Libya, Pakistan, Palestine, Qatar, and Yemen. It is worth mentioning that, out of these countries, Bahrain, Libya, Palestine, and Qatar have already full government support for the provision of insulin.- Private insurance is expected to cover for the cost of insulin, but in some countries of MENA Regions, private insurance companies do not cover for chronic diseases; they also consider Type-1 Diabetes a congenital disease, or impose a long latent period before providing insulin coverage or very high premiums. In 61% of countries, private insurance covers for insulin cost, whereas in seven other countries (Algeria, Tunisia, Libya, Lebanon, Iraq, Pakistan, and Yemen) insulin is not covered.
Availability
Access to insulin is obviously dependent on its availability. Local production of insulin plays a pivotal role in easier accessibility. Local production exists in only five participating countries (Egypt, Iran, Morocco, Pakistan, and Syria). It is worth mentioning that those countries have high numbers of PWDs; Pakistan, Egypt, and Iran are the highest in the region, with respectively 33 million, 10.9 million, and 5.5 million.[2]
Accessibility
Cost of insulin
Cost of insulin and its affordability is a key factor to access. There is a wide range of insulin costs in the region and within the same category of classified income countries [Table 3].
The cost of a human insulin vial is between $1.42 and $50, with an average $11. Cost of short-acting analog pen varies between $3.5 and $50, with an average of $15, and the cost of a long-acting analog pen is between $4.5 and $100, with an average of $18.5.
Approximately 61% of countries have a minimum wage of less than $200 and 88% less than $500. Variation in minimum wages (from 7 to $2667 $) was reported in the MENA Region [Table 3]. The low minimum wage applied in some countries affects the purchasing power of life-saving medications like insulin.
Additional barriers
Additional reported barriers to access to insulin were its delivery, storage, cost and electricity. It is worth mentioning that in five countries with war conditions, the high number of displacements and sanctions were barriers to access to insulin. The type of insulin, the quantity available, and education were also disabling factors (refer to country [Table 4]).
Limitations
The survey answers reflect the professional opinion of the MENA-IDF MA and not official government positions. The accuracy of the data remains at the discretion of the MA. Results lack information from three countries from the MENA Region which did not participate in the survey.
ConclusionA century after its discovery, insulin remains inaccessible to many across the world. Access to insulin varies in the MENA Region between different countries as far as government support, insurance coverage, local insulin production, cost and affordability. Although government support is available in the majority of countries, it is still often through the provision of human insulin and only restricted to citizens. Noncitizens, refugees, and people living in remote areas find difficulties accessing Insulin. On the contrary, local production in five high diabetes prevalence countries is important in facilitating access to insulin. Barriers like delivery, storage, electricity and a large number of displaced PWD are still affecting access in several countries. Moreover, some governments have a law prohibiting NGOs from receiving insulin from international donors which limits international support. Cost of insulin, especially analogs, remains unaffordable in many countries where the minimum wage is very low. Disparities exist between countries within the same classification of income regarding several factors affecting access to insulin including cost of insulin. Mapping of the current situation will help countries to improve the situation and monitor change. This document can be an informative source for healthcare providers and PWD if they ever consider living or visiting any of these countries where such regulations, conditions, or sanctions are imposed. It can also help understand cross-border travel for medical treatment, local, and regional policies.
IDF-MENA can help by influencing government and policymakers to encourage pharmaceutical donations, NGO donations including LFAC, WHO, and in advocacy to international partners or for lifting of sanctions on essential drugs like insulin.
Acknowledgement
Profound thanks to Member Associations of the 18 countries from MENA Region for participating in the survey and gratitude to Mr. Karim Anani for editing the manuscript.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
References
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