Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries

a prospective epidemiological study

The PURE investigators

Research output: Contribution to journalArticle

13 Citations (Scopus)

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).

Original languageEnglish
Pages (from-to)798-808
Number of pages11
JournalThe Lancet Diabetes and Endocrinology
Volume6
Issue number10
DOIs
Publication statusPublished - 1 Oct 2018

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Epidemiologic Studies
Pharmacies
Prospective Studies
Metformin
Insulin
Costs and Cost Analysis
India
Glyburide
Medicine
Epidemiology
Gliclazide
Health Expenditures
Pharmaceutical Preparations

ASJC Scopus subject areas

  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism
  • Endocrinology

Cite this

@article{38c9b355311c4e809d95d92a5eff4141,
title = "Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study",
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).",
author = "{The PURE investigators} and Chow, {Clara K.} and Chinthanie Ramasundarahettige and Weihong Hu and AlHabib, {Khalid F.} and Alvaro Avezum and Xiaoru Cheng and Jephat Chifamba and Gilles Dagenais and Antonio Dans and Egbujie, {Bonaventure A.} and Rajeev Gupta and Romaina Iqbal and Ismail, {Noor Hassim} and Keskinler, {Mirac V.} and Rasha Khatib and Lanth{\'e} Kruger and Rajesh Kumar and Fernando Lanas and Scott Lear and Patricio Lopez-Jaramillo and Martin McKee and Noushin Mohammadifard and Viswanathan Mohan and Prem Mony and Andres Orlandini and Annika Rosengren and Krishnapillai Vijayakumar and Li Wei and Karen Yeates and Khalid Yusoff and Rita Yusuf and Afzalhussein Yusufali and Katarzyna Zatonska and Yihong Zhou and Shariful Islam and Daniel Corsi and Sumathy Rangarajan and Koon Teo and Gerstein, {Hertzel C.} and Salim Yusuf",
year = "2018",
month = "10",
day = "1",
doi = "10.1016/S2213-8587(18)30233-X",
language = "English",
volume = "6",
pages = "798--808",
journal = "The Lancet Diabetes and Endocrinology",
issn = "2213-8587",
publisher = "Elsevier BV",
number = "10",

}

TY - JOUR

T1 - Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries

T2 - a prospective epidemiological study

AU - The PURE investigators

AU - Chow, Clara K.

AU - Ramasundarahettige, Chinthanie

AU - Hu, Weihong

AU - AlHabib, Khalid F.

AU - Avezum, Alvaro

AU - Cheng, Xiaoru

AU - Chifamba, Jephat

AU - Dagenais, Gilles

AU - Dans, Antonio

AU - Egbujie, Bonaventure A.

AU - Gupta, Rajeev

AU - Iqbal, Romaina

AU - Ismail, Noor Hassim

AU - Keskinler, Mirac V.

AU - Khatib, Rasha

AU - Kruger, Lanthé

AU - Kumar, Rajesh

AU - Lanas, Fernando

AU - Lear, Scott

AU - Lopez-Jaramillo, Patricio

AU - McKee, Martin

AU - Mohammadifard, Noushin

AU - Mohan, Viswanathan

AU - Mony, Prem

AU - Orlandini, Andres

AU - Rosengren, Annika

AU - Vijayakumar, Krishnapillai

AU - Wei, Li

AU - Yeates, Karen

AU - Yusoff, Khalid

AU - Yusuf, Rita

AU - Yusufali, Afzalhussein

AU - Zatonska, Katarzyna

AU - Zhou, Yihong

AU - Islam, Shariful

AU - Corsi, Daniel

AU - Rangarajan, Sumathy

AU - Teo, Koon

AU - Gerstein, Hertzel C.

AU - Yusuf, Salim

PY - 2018/10/1

Y1 - 2018/10/1

N2 - 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).

AB - 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).

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U2 - 10.1016/S2213-8587(18)30233-X

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JO - The Lancet Diabetes and Endocrinology

JF - The Lancet Diabetes and Endocrinology

SN - 2213-8587

IS - 10

ER -