When It’s Not Enough to Increase Access to Insulin

When it comes to caring for a complex disease like type 1 diabetes, there’s no silver bullet.

For those living with the condition, care is a complicated matrix of lifelong, regimented use of insulin, delivery devices, and blood glucose monitoring. Diabetes education and skilled health professionals are just as critical.

Reduced access to just one of those essential pillars of care – whether it’s the insulin, the delivery device, the monitoring equipment, education, or skilled care – can result in any number of potential complications. Nerve damage. Heart, kidney, and teeth problems. Blindness. Even death.

In low-resource settings, access to any of the above is more likely to be limited. With that in mind, it’s surprising that so much focus has been paid to insulin access, to the exclusion of other elements of diabetes care.

But a new study is changing that.

Published in the in World Journal of Diabetes by researchers at the Life for a Child (LFAC) Program at Diabetes NSW And ACT in Australia, the study looks at how likely people from low- and middle-income countries are to be able to access two essential elements of diabetes care: insulin delivery devices and a diagnostic blood test known as glycated hemoglobin (HbA1c) testing.

For the LFAC program, these aren’t just academic questions. For over 20 years, the program has been deeply involved in procuring and distributing type 1 diabetes medicines and supplies for children and adolescents.

Currently, LFAC supports 22,000 children and young children under the age of 26, in 43 countries and through 72 local health care partners, with insulin, syringes, blood glucose testing strips, and HbA1c testing and supplies.

Direct Relief has worked with LFAC for over 10 years, and currently arranges the transportation and delivery of the Program’s insulin, insulin syringes, and some blood glucose monitoring equipment to local healthcare partners. In 2019 alone, Direct Relief coordinated the delivery of 2 million insulin syringes and approximately 270,000 vials of insulin for the LFAC program.

When it comes to the study, findings were grim. Almost half of the public health systems surveyed did not provide any insulin syringes for people with type 1 diabetes – even though syringe usage was the most common method for administering insulin in more than 80% of the surveyed countries.

Many surveyed health centers could provide free or reduced-cost syringes for their patients – in large part due to private donations of supplies from LFAC and Direct Relief. However, the study also found that people who purchase these supplies from other sources, such as private retail pharmacies, can spend on average anywhere from $0.19 – $0.29 USD per syringe. That means the potential yearly cost could climb northwards of $400.00 for syringes alone – in countries where people often live on less than $3.20-$5.50 per day.

When it came to HbA1c testing, access wasn’t much better. The study found that, while more than 80% of centers did provide this testing for their patients, the costs could be prohibitive – an average of $9.34 per test at about a third of facilities. For those who sought testing from their country’s public health care system, costs could be even more significant – anywhere from $4 to $29 per test. In these settings, HbA1c testing is conducted 1 to 4 times per year – an annual cost of up to $116.

Even at those prices, access wasn’t a given – stockouts, maintenance, and limitations on staff training and refrigeration capacity were all reported to impact availability of the testing.

There are nearly half a billion people worldwide living with diabetes, according to the International Diabetes Federation. This figure is expected to increase dramatically – to almost 700 million people over the next 25 years. Almost 80% of these people live – and will most likely continue to live – in low- and middle-income countries, here the medicines and technologies needed to diagnose and manage diabetes are scarce, or prohibitively expensive.

As a result, people residing in these countries will bear a disproportionate burden of the estimated 4 million deaths or more that are attributable to diabetes each year. That makes this issue a major barrier to global health equity.

Approximately 90% of people with diabetes are thought to have type 2, which may be preventable, and can be managed effectively through early detection, education, social support, healthy lifestyle changes, and in some cases medication.

However, for those living with type 1 diabetes, including over a million children and adolescents, there is no evidence that the disease can be prevented. It can only be managed effectively, with continuous access to insulin, insulin delivery devices, and blood glucose testing, as well as education and social support.

Since 2011, the LFAC Program and Direct Relief have mobilized the delivery of nearly 7 million insulin syringes donated by BD for 10,000 children in 20 lower resourced countries.