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

Chow CK 1 , Ramasundarahettige C 2 , Hu W 2 , AlHabib KF 3 , Avezum A 4 , Cheng X 5 Show all authors , Chifamba J 6 , Dagenais G 7 , Dans A 8 , Egbujie BA 9 , Gupta R 10 , Iqbal R 11 , Ismail N 12 , Keskinler MV 13 , Khatib R 14 , Kruger L 15 , Kumar R 16 , Lanas F 17 , Lear S 18 , Lopez-Jaramillo P 19 , McKee M 20 , Mohammadifard N 21 , Mohan V 22 , Mony P 23 , Orlandini A 24 , Rosengren A 25 , Vijayakumar K 26 , Wei L 5 , Yeates K 27 , Yusoff K 28 , Yusuf R 29 , Yusufali A 30 , Zatonska K 31 , Zhou Y 32 , Islam S 33 , Corsi D 2 , Rangarajan S 2 , Teo K 2 , Gerstein HC 2 , Yusuf S 2 , PURE investigators

Affiliations 

  • 1 Faculty of Medicine and Health, University of Sydney, The George Institute for Global Health and Westmead Hospital, Sydney, NSW, Australia; Population Health Research Institute, Hamilton, ON, Canada. Electronic address: [email protected]
  • 2 Population Health Research Institute, Hamilton, ON, Canada
  • 3 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  • 4 Research Division, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
  • 5 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
  • 6 College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Zimbabwe
  • 7 Institut Universitaire de Cardiologie et Pneumologie de Québec, Université Laval, QC, Canada
  • 8 Department of Medicine, University of the Philippines-Manila, Ermita, Manila, Philippines
  • 9 School of PublicHealth, University of the Western Cape, Bellville, Cape Town, Western Cape Province, South Africa
  • 10 Eternal Heart Care Centre and Research Institute, Jawahar Circle, Jaipur, India
  • 11 Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  • 12 Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
  • 13 Department of Internal Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
  • 14 Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
  • 15 Faculty of Health Science, North-West University, Potchefstroom Campus, Potchefstroom, South Africa
  • 16 Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India
  • 17 Department of Medicine, Universidad de La Frontera, Francisco Salazar, Temuco, Chile
  • 18 Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
  • 19 Fundacion Oftalmologica de Santander, Floridablanca-Santander, Bucaramanga, Colombia
  • 20 London School of Hygiene & Tropical Medicine, London, UK
  • 21 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  • 22 Madras Diabetes Research Foundation, Chennai, India
  • 23 Division of Epidemiology and Population Health, St John's Medical College and Research Institute, Bangalore India
  • 24 Estudios Clinicos Latinoamerica, Rosario, Santa Fe, Argentina
  • 25 Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Östra Hospital, Gothenburg, Sweden
  • 26 Department of Community Medicine, Amrita Institute of Medical Sciences, Cochin, Kerala, India
  • 27 Department of Medicine, Queen's University, Kingston, ON, Canada
  • 28 Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; University College Sedaya International (UCSI) University, Cheras, Selangor, Malaysia
  • 29 School of Life Sciences, Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
  • 30 Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
  • 31 Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
  • 32 Wujin DistrictCenter for Disease Control and Prevention, Changzhou, Jiangsu Province, China
  • 33 Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
Lancet Diabetes Endocrinol, 2018 10;6(10):798-808.
PMID: 30170949 DOI: 10.1016/S2213-8587(18)30233-X

Abstract

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).

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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