Access to Insulin Limited in Nepal.

Access to insulin, an essential medicine for both type 1 and 2 diabetes, is a major concern globally. Access to insulin is particularly limited in low- and middle-income countries with no local production facilities.

Now, a new study co-authored by School of Public Health researcher has found that access to insulin in Kathmandu Valley, Nepal, is limited due to low availability and highly unaffordable prices.

The study was published in International Health.

“Diabetes is one among several non-communicable diseases that place a heavy burden on the healthcare systems of low-income countries,” says co-author Warren Kaplan, clinical assistant professor of global health. “Insulin, the lack of which would be fatal in many patients, is manufactured primarily by European and US-based pharmaceutical companies that continue to market expensive, modified [analogue] insulins, which are replacing less expensive unmodified insulins.”

Nepal is a low-income country with a weak healthcare system; the country also suffers from a high burden of type 2 diabetes. Prior studies found that diabetes affected 1.4 percent to 19 percent of the population; in 2017 it was estimated that more than 650,000 individuals were living with diabetes in Nepal. Nepal also has one of the highest rates of type 1 diabetes in Southeast Asia. While insulin is listed on the 2011 Nepal Essential Medicines List, it is not listed as one of the 70 medicines Nepal provides free of charge to all patients.

“With its burgeoning diabetes burden, one would expect a high demand for insulin therapy in Nepal. Earlier studies involving high level situational analysis through document review and key informant interviews have reported poor insulin access in low-income countries,” the authors wrote. “However, there have been no detailed in-country assessments of insulin access in Nepal.”

The researchers assessed insulin availability, prices, and factors influencing supply, uptake, and market competition in the Kathmandu Valley. Using a modified version of the World Health Organization (WHO)/Health Action International method to check for availability, they also conducted a number of interviews and questionnaires to understand the supply and access of insulin in the valley.

The researchers found that the availability of two human insulins was 14.3 percent and 42.85 percent in the surveyed private- and public-sector pharmacies, respectively; the WHO target of availability is 80 percent. Moreover, depending on insulin type, the researchers calculated that the lowest-paid worker would need to spend between 3 and 17 days’ wages to purchase a month’s supply of insulin out of pocket.

Says co-author Shiva Raj Mishra, founding board member of the Nepal Development Society, “There is consensus that insulin analogues offer no clinically significant benefit over unmodified insulins. It would be beneficial for the Nepalese health system and the patients to resort away from expensive analogues, unless clinically indicated. Nepal must educate physicians and develop independent insulin-initiation clinical guidelines to curb the growing market for analogue insulin and promote rational use.”

Most insulin in Nepal comes from European and US-based pharmaceutical companies and not from the insulin made in India, which serves the same function—even though the distance between Delhi and Kathmandu is less than 1,500 kilometers.

“Nepal’s existence as a land-locked country, with the insulin market dominated by a few companies, and its position as having a single primary gateway (i.e., trading partner India) for imported insulin poses certain challenges in this regard,” the authors wrote. “Nepal should employ pooled procurement mechanisms and strategic price negotiations with companies and develop collaborations with neighboring countries to ensure a supply of quality-assured, affordable insulin.”

The study was led by alumnus Abhishek Sharma (SPH’15). Other co-authors included Parash Mani Bhandari and Dipika Neupane from the Institute of Medicine, Kathmandu.

— Salma Abdalla