Insulin price components: case studies in six low/middle-income countries

Abstract

IntroductionUnderstanding price components for insulin products can help design interventions to improve insulin affordability in low/middle-income countries.MethodsAn adapted WHO/Health Action International standardised methodology was used in Brazil (Rio de Janeiro), China (Hubei and Shaanxi Provinces), Ghana, India (Haryana State), Indonesia and Uganda. Selected insulin products had their prices traced backwards through the supply chain from public and private sector retail outlets in the capital city and a district town, supplemented with key informant interviews.ResultsCumulative mark-ups ranged from 8.7% to 565.8% but the magnitude of mark-ups was country specific and variable within and across sectors and regions. The proportion of the patient price attributed to the manufacturer’s selling price varied from 15.0% to 92.0%. Pricing regulations in China, India and Indonesia reduced wholesale and retail mark-ups but did not guarantee low prices. Most countries had removed import duties (Ghana, India, Indonesia, Uganda), but additional tariffs of 3.5% were still applied in Ghana. Value-added tax in the private sector ranged from 5% to 20% across the countries.ConclusionThere are no clear trends in the mark-ups applied to insulin or specific differences in the price structure. A uniform approach to improving insulin access through regulating price components is unlikely to be successful, but elimination of duties and taxes, price regulation and greater price transparency could help influence prices and hence affordability.

A global perspective on the issue of access to insulin

“…This change in practice has an impact on the cost of diabetes management for both the individual and the health system. In addition, pricing policies and mark-ups within the health system and supply chain affect the overall financial burden of diabetes management [ 6 , 30 , 33 ].…”

“…These mark-ups also apply at different stages of the supply system in the private sector. Ball et al [ 33 ] found that these mark-ups cumulatively equalled 8.7–47.7% of the manufacturer’s selling price for locally produced insulin and 10.0%–565.8% for imported insulins. It is important to note that, beyond price, a variety of geographical and health system factors can have an impact on access to insulin, such as distance of the patient to healthcare facilities [ 31 ].…”

ISPAD Clinical Practice Consensus Guidelines 2022: The delivery of ambulatory diabetes care to children and adolescents with diabetes

“…205 However, affordability for individuals remains a challenge in many settings with cumulative markups ranging from 8.7% to 565.8%. 206 In many LMICs, the price of insulin is paid for by the individual or, in some contexts, subsidies are in place. By contrast, in most HICs, various government-funded or health insurance schemes provide some form of financial protection, either ensuring that insulin is provided for free to the individual or, at least, that the person does not bear the full cost.…”

“…Given the reduced incidence of hypoglycemia, newer analogs may be even more cost‐effective 205 . However, affordability for individuals remains a challenge in many settings with cumulative markups ranging from 8.7% to 565.8% 206 . In many LMICs, the price of insulin is paid for by the individual or, in some contexts, subsidies are in place.…”

Access to insulin: a comparison between low‐ and middle‐income countries and the United Kingdom

“…Case studies in six LMICs found mark‐ups on insulin ranging from 8.7% to 565.8% depending on the country, sector and region within the country. The proportion of the final price attributed to the manufacturer's selling price varied from 15.0% to 92.0% 17 . A key issue is that many LMICs do not regulate mark‐ups in the supply chain nor control medicine prices.…”