Despite the image of diabetes as an affliction of fat Western people, eighty per cent of deaths from the disease are in low- and middle-income countries.
Type 1 diabetes is a chronic disease that requires lifelong insulin injections, and Dr Hans Hogerzeil, Professor of Global Health at the University of Groningen, said that corruption and poor healthcare systems in some countries meant that affordable medicine was out of reach for those who need it most.
Speaking in the wake of the third International Conference on Improving Use of Medicines, Dr Hogerzil said that many doctors and pharmacists are corrupt and will not buy the cheapest medicines because drug companies pay caregivers to prescribe their product. In Ghana, paying for insulin injections takes up to half the monthly salary of the lowest paid government workers.
Unlike in most Western countries, if patients in the second and third world cannot afford drugs, there is no government safety net to ensure they receive the treatment they need. When diabetes patients cannot afford insulin, there is no other source for the medicine. “Why are there so few people in Africa with type 1 diabetes? They go bankrupt and die,” said Dr Hogerzeil.
For most chronic, non-infectious diseases such as diabetes and hypertension, drugs have been free from patents for years and are produced in generic forms by thousands of pharmaceutical companies. In India, there are 19,000 companies producing generic branded drugs, each fiercely competing for their slice of the market. The drugs sold by each company are the same, and differ only in the packaging.
According to Dr Hogerzeil, this competition leads to bribery and corruption, as drug companies pay doctors and pharmacists back-handers to ensure they buy their medicine. A study in Vietnam revealed that patients were paying up to 8 times more than the international price for generic drugs, even in the public sector. “I think there’s still a big problem of corruption of the doctors,” Dr Hogerzeil said.
Cases of diabetes have exploded in recent years and there are now estimated to be 350 million sufferers worldwide. Although normally associated with overweight Westerners, diabetes can affect anybody, regardless of their lifestyle. Diabetes is either type 1, which can affect anyone and is strongly genetic in origin, and type 2, which is strongly associated with obesity.
Should governments intervene?
What can countries do to reduce the cost of medicines, for both the government and for patients? The Arab state of Oman, home to 3 million people, instigated a Rational Use of Medicines policy in 2000 to try to control the medicine bill and improve care for patients. Four-fifths of the doctors in Oman are foreign, and had a variety of prescribing policies, so all were required to undergo training to bring them to the same level. National treatment guidelines were issued, and a list of approved drugs is now published annually, with prices and prescription guidelines.
The number of drugs prescribed per patient has halved over the ten years the Oman policy has been in place, and the cost of healthcare has fallen from 3.1 per cent of GDP to 2.1 per cent. In the UK, NICE provides doctors with similar advice as the Omani Ministry of Health, ensuring clinicians give appropriate treatment.
It is not just in the developing world that patients do not have a free choice over what medicines they receive. In August this year, I visited a post-op transplant clinic at Emory University Hospital in Atlanta, and witnessed a doctor changing a patient’s prescription to a different brand of the same medicine, at the request of the patient’s insurance company. In the USA, insurance companies forge deals with pharmaceutical companies to use their medication, limiting the choice available to doctors and patients. The US health service is run on free market principles, but because insurance companies dictate what medicines doctors can prescribe, the system does not run efficiently.
Countries in the developing world are learning that to buy cheaper medicine, they must not allow pharmaceutical companies to influence prescribing practise. The United States, which has by far the most expensive healthcare system in the world, would do well to look at the result.
Corruption kills in Africa not really diabetes. Corrupt Chinese and Indians Pharmacological companies have colluded with unscrupulous importers that import fake cheap drugs that kill faster in 180 days. The alternative trado medical drugs has come to the rescue and they are working well. The success rate is 95%