Diabetics largely dependent on foreign-made insulin

Government’s ambitious ‘Make in India’ initiative looks pale when it comes to manufacture of life-saving insulin for management of diabetes. A latest market analysis published in BMJ Global Health Journal has revealed that majority of people with diabetes in India are largely dependent on foreign-made insulin.

The study done by Center for Global Health and Development, Boston University and Precision Health Economics, Boston found that only 25 per cent of surveyed pharmacies in the national capital stocked human insulin (genetically identical to the body’s naturally produced insulin) made for and by Indian companies.

Also, Indian companies are not making analogue insulin (similar to regular human insulin, but changed slightly to allow them to act more quickly or slowly than regular human insulin) for the Delhi market. Indian pharmaceutical companies have been producing human insulin (non-analogue) for over a decade, however, the study found that Indian doctors and patients are largely dependent on insulin made by foreign-companies which is expensive in comparison to indigenous insulin.

The researchers used a modified World Health Organization/Health Action International (WHO/HAI) standard survey to assess insulin availability and prices, and qualitative interviews with insulin retailers (pharmacists) and wholesalers to understand insulin market dynamics.

“We studied access to insulin in the private sector market of Delhi. In 40 pharmacy outlets analysed, mean availability of the human and analogue insulin on the 2013 Delhi Essential Medicine List was 44.4 per cent and 13.1 per cent respectively. Around 82 per cent of pharmacies had domestically manufactured human insulin phials, primarily made in India under licence to overseas pharmaceutical companies,” said Abhishek Sharma and Warren A Kaplan, authors of the study.

“Analogue insulin was only in cartridge and pen forms that were 4.42 and 5.81 times, respectively, the price of human insulin phials. Domestically manufactured human phial and cartridge insulin (produced for foreign and Indian companies) was less expensive than their imported counterparts,” they said.

India’s majority of patients—including those living with diabetes—seek healthcare in the private sector through out-of-pocket payments. The lowest paid unskilled government worker in Delhi would work about 1.5 and 8.6 days, respectively, to be able to pay out-of-pocket for a monthly supply of human phial and analogue cartridge insulin.

“The mean availability of insulin in the Delhi private sector market was far lower than the WHO availability target of 80 per cent analogue insulin cartridges/pens were 5 to 9 times more expensive than human insulin phials; and private sector insulin prices appear unaffordable,” said Sharma.

“Doctors and patients in India believe that insulin from foreign companies is better and they do not trust Indian companies. Manufacturers, some doctors and wholesalers are selling insulin directly to patients, cutting out pharmacies, with the potential implication that pharmacists may choose either to not stock insulin at all or stock mostly more expensive insulin to guarantee some profit,” he said.

According to the study, interviews indicated that the Delhi insulin market is dominated by a few multinational companies that import and/or license in-country production. Several factors influence insulin uptake by patients, including doctor’s prescribing preference. Wholesalers have negative perceptions about domestic insulin manufacturing.

India is the “diabetes capital of the world” with over 6 crore diabetics, that is projected to at least double by 2030.

RECOMMENDATIONS FOR POLICY

The Government of India and pharmacy associations should work with stakeholders to better align the financial incentives of those in the insulin supply chain.

The Government of India and patient associations could play an important role by framing independent, evidence-based guidelines aimed at prioritising the use of quality-assured and less expensive human insulin whenever possible and when clinically indicated.