On 11 January 1922, Leonard Thompson, a young 14 year-old diabetic, was the first patient in history to be injected with insulin to treat his type 1 diabetes. While this discovery will soon be celebrating its 100th anniversary, the hope it has generated is proving slow in materializing in a number of areas in the world, first and foremost in Africa. Despite the fact that needs are constantly increasing on the continent, access to insulin continues to be a privilege, a luxury that very few patients can afford.

Insuline 4 all
Insuline 4 all

Increasing needs for insulin

Africa is experiencing significant economic changes and is today faced with a major epidemiological transition. The emergence of a number of Non-Communicable Diseases (NCDs), including diabetes, is one of the main characteristics of this. In Africa, almost 15 million people now have diabetes and almost a third of them need insulin – both insulin-dependent type 1 diabetics and type 2 diabetics who need to take insulin. It is also estimated that 50,000 children have type 1 diabetes in Africa.

In addition, needs will constantly increase, with the extremely rapid pace of the explosion of the epidemic of diabetes on the continent in the coming decades: indeed, Africa’s diabetic population will double by 2030, which is a record incidence across all the continents.

 

Unequal access to insulin: a multifactorial reality

Today, despite this major epidemiological transition, Africa also comes up against a whole host of obstacles, which deprive the continent of universal access to insulin:

  1. The cost of insulin: in Mali, for example, the average cost of a year’s supply of insulin in the public sector amounts to USD 130.6, i.e. over 17% of a family’s income.
  2. Geographical access to insulin: while insulin is generally available in the private sector, but at costs 20 to 30% higher than the cost given above, in the public sector it is often only available in capital cities or in regional capitals.
  3. Additional costs, as insulin alone is not sufficient: blood sugar levels in patients who need to take insulin or are dependent on it cannot be regulated with insulin alone. Access to blood glucose meters and test strips or syringes is consequently essential for diabetes treatment. The high cost of these medical devices therefore increases the burden of the disease on patients and their families.
  4. The unfairness of development policies: while certain diseases benefit from international support and visibility, and rightly so, diabetes is often left out of the operational strategies of the main aid actors, both public (UN agencies, bilateral cooperation, etc.) and private (NGOs). As the President of Mali’s National Federation of Diabetics explained, “As diabetics, we find it very difficult to understand why patients with HIV or malaria can have free access to their treatments and their check-ups, when everything costs us a fortune, which often drags us into poverty and death amid indifference.”

 

Four priorities for action

The inaccessibility of insulin in Africa has serious consequences, both on people and on health systems. The current situation is firstly – and primarily – one of the causes of the 321,000 deaths due to diabetes every year on the continent. For example, with no access to insulin treatment, the average post-diagnosis life expectancy of a diabetic child is less than a year in most African countries. This is shocking when we know that today the majority of young Western diabetics will have the chance to live as long as the rest of the population.

But beyond this direct and immediate impact on people, if we do not provide a solution to this shortcoming today, the consequence for tomorrow will be a major economic burden on health systems in low- and middle-income countries. Indeed, as insulin is vital or stabilizing for a significant proportion of people with diabetes, the lack of it contributes to the development of a number of complications (blindness, kidney failure, diabetic feet, cardiovascular disease, etc.), which are particularly heavy and costly to treat.

In addition, faced with the needs and inequalities of access to healthcare caused by this type of system, it is urgent – and possible – to make insulin accessible to all and everywhere, in Africa, as in the rest of the developing world, through 4 priorities:

Conduct advocacy towards the pharmaceutical industry in order to reduce the purchase price of insulin and medical devices:

There are currently only three pharmaceutical companies which share almost 90% of the global insulin market.[1] In addition, most developing countries only have access to insulin from one of these three companies. These monopoly situations obviously hold back changes in purchase prices for the benefit of patients. Furthermore, to date, only one of these companies has established a specific policy for access to insulin. This initiative, which offers an average price of USD 5.6 per insulin bottle, is commendable, but remains largely insufficient in order to provide effective and universal access to this vital hormone in African countries.

Real advocacy needs to be conducted towards these companies to make them develop (or reinforce) significant policies for differentiated tariffs. Advocacy also needs to be conducted towards industries which produce blood glucose meters and test strips.

Improve geographical and financial access in African countries themselves:

The cost of insulin is obviously determined by the purchase price from pharmaceutical companies, but also by the various national factors of African countries. Prices are first of all influenced by the tax policies applied in these countries and by the taxes on drugs imposed by governments. They are then influenced by the legal sales margins which the various public and private actors benefit from, and the national scheme for drug supply.

Consequently, there is a pressing need to work together with health authorities in African countries in order to reduce these barriers and thereby make insulin more affordable. This will increase geographical access and reduce the sale price of the hormone at the end of the supply chain in outlying areas.

Integrate NCDs as a priority, including diabetes, in health coverage schemes:

Since the Abuja Declaration in 2001 on health financing, a number of African countries, including Mali and Burkina Faso, have gradually been adopting social protection systems, based on either a universal coverage or health insurance model. Universal health coverage (UHC) is, moreover, sub-goal n° 3.8 of the Sustainable Development Goals for 2016-2030. Yet the emergence of NCDs in developing countries disrupts health financing systems due to the considerable burden of the cost that these diseases have for patients and health systems themselves.

For example, in Mali, each diabetic patient must spend an average of almost USD 230 a year simply for treatment for diabetes with no complications. If we add treatment for the most frequent complication – diabetic foot – this annual cost stands at a minimum of USD 910 a year in the public sector, and reaches up to USD 6,800 in the private sector. At national level, the annual cost borne by the State for the treatment of diabetes without complications alone is estimated at some USD 20m.[2] When we consider the chronic nature of the disease and the increasing number of patients in developing countries, the amounts required for diabetes treatment by the patient and the State quickly become staggering.

There is consequently a pressing need to consider integrating NCDs, including diabetes, into social protection schemes to ensure that they are no longer an economic burden for diabetic patients, especially the poorest.

Fully integrate NCDs into health development policies and humanitarian crisis responses:

The specific nature of the management of NCDs, including diabetes, as well as the need for a horizontal structuring of health systems to address it, requires an innovative approach by aid policies. Whether in a development context or crisis context, the emergence of NCDs in Africa calls for a renewal of certain operational strategies, which is something that too few international donors and NGOs have engaged in for the time being, with the notable exception of Agence Française de Développement and Doctors Without Borders (MSF).

In the specific case of humanitarian crises, such as the Syrian conflict or the crisis in Mali since 2012, the management of NCDs has become a critical issue for all aid actors in recent years, as the patients affected by these diseases are particularly vulnerable in such situations. Yet the absence of emergency kits for NCD treatment once again demonstrates the fact that these diseases are an operational priority for very few NGOs or donors. There is consequently a pressing need, following on from the recent positions taken by the international community on the issue of NCDs, for Technical and Financial Partners for aid to integrate these diseases into their assistance policies.

While World Health Day 2016, which takes place on 7 April, is devoted to diabetes, these four priorities call fo :

  • International institutions, including WHO, to operationalize, in Africa, their encouraging positions in terms of the fight against NCDs;
  • African governments to facilitate the availability and accessibility of insulin in their countries;
  • Aid operators to consider the vulnerability of diabetic patients in both development contexts and crisis contexts.

But these efforts must be made in cooperation with and in support of African civil society, in particular diabetic patient associations, which is a real local vehicle for building an effective fight against diabetes and an appropriate barometer of needs.

 

 

The opinions expressed on this blog are those of the authors and do not necessarily reflect the official position of their institutions or of AFD.

[1] R. Knox, W. Kaplan, V. Wirtz, The Global Insulin Market: Opportunities and Challenges to Promote Equitable Access to Affordable Insulin, Boston University School of Public Health, Department of Global Health, Boston, USA.
[2] Simple calculator to estimate the medical cost of diabetes in sub-Saharan Africa, Alouki, K., H. Delisle, S. Besançon, N. Baldé, A. Sidibé-Traoré, J. Drabo, F. Djrolo, J.C. Mbanya and S. Halimi, World J Diabetes, 2015, Nov.

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