doi:10.1038/nindia.2016.134 Published online 13 October 2016
Access to life-saving insulin for India's nearly 60 million diabetics is far lower than the World Health Organization's target of 80% says a new study1.
For a country that is rushing to become the world's diabetic capital, this should be a matter of "serious public health concern," warn Abhishek Sharma and Warren Kaplan, authors of the study form the Boston University School of Public Health in the U.S.
They are the first to analyze insulin availability in India's private sector that caters to majority of diabetes patients, who are forced to spend from their pockets due to the failure of national programmes to provide free health-care facilities.
Unaffordable prices, excessive dependence on foreign-made insulin and an unholy nexus between Indian doctors and foreign manufacturers that force patients to buy expensive insulins instead of cheaper local brands, are among the barriers cited in the study for the patients' poor access to insulin.
For this study, researchers surveyed the insulin products sold in select pharmacies in Delhi and interviewed private-sector insulin retailers and wholesalers. They found that Indian doctors do not trust local products and believe that insulin from foreign companies is better. Only 25% of surveyed pharmacies stocked Indian brands — a finding the study says is a sign of "public health failure."
Recombinant human insulins have been produced since 1980s using genetically modified microbes. "Analogue" insulin, an altered form of recombinant insulin and 5-9 times costlier, came into the market over the past decade. Wholesalers acknowledged that though recombinant insulin is cheaper, doctors are increasingly prescribing "analogues" made by foreign companies. "Of the five wholesalers we interviewed, only one supplied insulin products made by Indian companies," Sharma told Nature India.
The inclusion of analogue insulin on the Delhi Essential Medicines List is, in part, driving the transition to increased uptake of analogue insulins which are foreign-made and not produced by any Indian company, says the study.
The study found that some multinational insulin manufacturers, Indian doctors and even wholesalers are selling insulin directly to patients, cutting out pharmacies. This may force pharmacists "to either not stock insulin at all, or stock mostly more expensive insulins "further reducing patients' accessibility to insulin because of the cost factor", the authors report.
The study found that several pharmacists only stocked insulins made by foreign companies because those were the ones prescribed by doctors who "often engage in exploitative practices with the motive of earning profits."
This is an "indictment on the weak Indian medicine regulatory agency" and testimony to the marketing power of multinationals, the report says. "All this, of course, exacerbates the public health risk with regard to access and availability of quality assured, domestic insulins."
The Delhi study found that insulin market is dominated mainly by three foreign companies — Novo Nordisk, Eli Lilly and Sanofi Aventis. "A few Indian companies do supply recombinant human insulin but their market shares are small and diminishing," the report says.
The global market dominance by a few companies will likely continue even though patents on the current portfolio of insulin analogs will expire very soon, says the report. "Increasing competition from Indian companies is going to require some additional policies, not presently in place."
Both the government and pharmacy associations should work with stakeholders to better align the financial incentives of those in the insulin supply chain and promote local brands, the authors conclude. "To eliminate mistrust about Indian insulin, its efficacy and safety must be compared with imported products and the results made public."
"A practical way forward would be to find potential generic manufacturers and nudge them towards opportunities to diversify their national insulin markets with acceptable off-patent products for export," the authors suggest.