Issue: July 2017 - Improving access to diabetes care
Section: The global campaign
Country report: access to insulin analogs in Bolivia
In Bolivia, the public health system does not serve the general population. According to data from the National Institute of Health Insurance (INASES), only 38.8% of the total Bolivian population has access to any health insurance which when translated into real numbers means that approximately 6 million people do not have health insurance. There are exceptions: children under 5 years, women in pregnancy and adults over age 60 years have full access to free healthcare. Otherwise, Bolivian public hospitals have a system of a structured fee mechanism, where patients are charged the costs of care according to their economic capacity.
Although there are approximately a half million people with diabetes and many more people with pre diabetes, Bolivia does not have a diabetes policy, strategy or action plan. In many parts of Bolivia, especially in rural locations, people do not know the treatment for diabetes or have false beliefs about how to treat it. From small villages to cities people do not have adequate diabetes education. In terms of Bolivia’s middle-class, people with diabetes who have health insurance have access to NPH (intermediate-acting) and R (short-acting) human insulins but these same individuals do not receive any essential supplies. The rest of the people with diabetes who aren’t insured struggle every day to buy their insulin. Many people with diabetes seek healthcare in the private sector through out-of-pocket payments.
Although the WHO Expert Committee on the Selection and Use of Essential Medicine has concluded that insulin analogs have “no significant clinical advantage” over recombinant human insulin, little by little Bolivia is having a transition from human insulin to analog insulin but most people living with diabetes, cannot afford the cost of analog insulin, devices like insulin pens, nor can they measure their blood sugar every day. Many people do not have money to buy test strips and spend weeks without measuring their glucose. A person’s care varies a lot depending on their economic power.
In Bolivia, insulin analogs are five times more expensive than human insulins. The Bolivian insulin analog market is an oligopoly, and such limited market competition has implications for insulin prices and usage. While insulin biosimilars are not yet expected to hit the market, Basaglar is an example of a promising biosimilar, and there is great hope it and other biosimilars will enter the marketplace soon. This would result in greater competition among brand-name insulins, potentially helping to bring down costs and lessen the financial burden for many families.
However, insulin alone is not enough. Syringes are required for the delivery of insulin, and they are not available in the public sector. The private sector is the main source for people purchasing supplies and like test strips and other devices for testing, the cost and availability of syringes also means that people are reusing single-use syringes or like the test strips, eliminating their frequency.
Douglas Villarroel is an endocrinologist, educator and Bolivian author. Currently, Dr. Villarroel is Editor-in-Chief of Diabetes Voice.
Solutions proposed have mainly focused on lowering cost, but access to diabetes care is more than just medicine. Insulin alone is not enough for proper diabetes care. To improve the lives of people with diabetes, access to medicine needs to be addressed in parallel to creating a healthcare system able to manage all aspects of diabetes care.