Review Outlines Barriers to Insulin, Calls for Change.

Access to affordable insulin has been hampered by a lack of market competition, import costs, and other factors that have translated into a life expectancy as low as one year for some children with type 1 diabetes in sub-Saharan Africa, according to a review in the journal Lancet Diabetes & Endocrinology co-authored by a School of Public Health researcher.

In the review, the research team finds that the high costs of insulin—essential to the survival of people with type 1 diabetes and needed for improved management of type 2 diabetes—threaten the health of not only residents of poor nations, but also of poor residents in the richest nations. In the US, for example, discontinuation of insulin use because of the drug’s cost was found to be the leading cause of diabetic ketoacidosis, a serious condition among type 1 diabetics, in an inner-city setting.

Manufacturers’ selling prices of various insulin formulations, taxes, mark-ups, and other supply chain costs affect the price of insulin and hence the drug’s affordability to health systems and individuals, the review says: “Although insulin is essential . . . very little has been done globally to address the issue of access, despite the UN’s political commitment to address non-communicable diseases and ensure universal access to drugs for these disorders.”

Insulin is used by all people with type 1 diabetes and up to a quarter of those with type 2 disease to control blood sugar and regulate metabolism. The authors say that insulin’s cost and the concentration of its manufacturing among three companies has created an environment that puts insulin beyond the reach of too many people who need it, despite its listing as an essential medicine by the World Health Organization (WHO).

They say the level of global action to ensure access to diabetes medication has paled compared to that of HIV and AIDS. “Arguably, this scarcity of action is mainly because of the lack of a global diabetes voice defending the interests of those with diabetes in less fortunate situations,” they write. “In view of this absence of global leadership, the response to diabetes might be a unique chance for individual countries to take the lead and identify ways to address the challenge of access to insulin specifically for their context.”

The authors called for a series of action steps, including: groups that fund diabetes research and care should allocate 5 percent of their funds for innovation in the delivery of care and insulin; insulin should be included in universal health coverage benefits packages; the World Health Organization should investigate prequalification of insulin and develop a regulatory framework for biosimilars and insulin; a global compact with the insulin industry should be forged to guarantee that human insulin and insulin in vial form will not be removed from the market. They warned that over the past decade, there has been a rapid rise in the use of analog, or synthetic, insulin, causing animal insulin to vanish from the market.

They also called on the academic community and advocacy groups to “speak with a unified voice” when calling for better diabetes care.

The review was led by David Beran of Geneva University Hospitals and the University of Geneva. Co-authors included SPH’s Richard Laing, professor of global health, and Margaret Ewen of Health Action International of the Netherlands.

—Lisa Chedekel