August 14, 2022

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Health for a better future

Member states conclude negotiations on diabetes, will be presented at WHA

A health worker prepares an insulin shot. Photo by: Sebastián Oliel-OPS / OMS / CC BY-NC

Member states have concluded negotiations on a resolution on diabetes to be presented to the 74th World Health Assembly this week. The draft resolution puts to rest some civil society concerns over exclusion of text on diabetes medicine transparency — including insulin — and the development of targets for the prevention and management of diabetes.

Advocates have been calling for a resolution that includes price transparency on insulin, and one that mandates the World Health Organization to develop targets on detection and treatment of diabetes. But there was pushback on a diabetes-specific resolution, according to sources Devex has spoken to.

The same sources, who are familiar with the negotiations but requested to remain anonymous as they are not authorized to comment on the resolution, told Devex that member states were split on having more transparency on the market for and the prices of diabetes medicines, including insulin. Some member states also expressed opposition to developing targets, particularly the European Union and the United States, they said.

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Devex reached out to the European Commission and the U.S. mission in Geneva, but did not receive a response.

But the text now for adoption at the WHA includes an operative paragraph requesting the WHO director-general to develop recommendations to strengthen and monitor diabetes responses within national noncommunicable disease programs, and “recommendations for the prevention and management of obesity over the life course, including considering the potential development of targets in this regard.” The WHO director-general will submit these recommendations to the 75th World Health Assembly in 2022.

It also retains language looking at a mechanism to share information on the diabetes medicine market.

The draft asks the WHO director-general to “continue to analyse the availability of data on inputs throughout the value chain, including data on clinical trials and price information, with a view to assessing the feasibility and potential value of establishing a web-based tool to share information relevant to the transparency of markets for diabetes medicines, including insulin, oral hypoglycemic agents and related health products, including information on investments, incentives, and subsidies.”

Premature mortality from diabetes increased by 5% between 2000 and 2016, and global deaths from diabetes increased 70% between 2000 and 2019. Diabetes was among the top 10 leading causes of death worldwide, according to WHO’s 2019 Global Health Estimates, published in December 2020. But only half of the people who need it have access to the drug, according to a study published in 2019.

The current global voluntary targets on NCDs include halting the rise of diabetes by 2025, but there are no specific targets on diagnosis and access to insulin, a drug discovered 100 years ago.

Advocates welcome the resolution, arguing it’s an important step to tackle diabetes, although some are disappointed that the resolution didn’t go far enough to specifically set global targets for the diagnosis, treatment, and control of diabetes types 1 and 2 similar to the 90-90-90 targets used in the global HIV response.

“The global compact outlines the 90-90-90 approach, but this should have been explicitly mentioned in the resolution. We’re disappointed to see that the global targets only talk about getting onto treatment and do not mention control rates, which would be covered by a third 90 and is a major issue we see in our projects,” said Dr. Helen Bygrave, chronic diseases adviser for Médecins Sans Frontières’ Access Campaign.

“We need to put this issue higher on the international health agenda, and to make sure that all people, in all countries, have access to affordable life-saving insulin if they need it.”

— Dag-Inge Ulstein, international development minister, Norway

MSF wanted the resolution to maintain its original title that focuses on diabetes prevention and management, and that includes access to insulin. But the current text has dropped the mention of insulin, and instead points to reducing the burden of NCDs through strengthening the prevention and control of diabetes.

Split views on insulin price transparency

“We believe this resolution is important, since diabetes is causing 1.6 million deaths every year – which makes it one of the world’s top 10 killers. And the number is rapidly growing in low-and middle income countries,” Dag-Inge Ulstein, Norway’s international development minister, told Devex in an email last week. Norway is a co-sponsor of the resolution.

“We need to put this issue higher on the international health agenda, and to make sure that all people, in all countries, have access to affordable life-saving insulin if they need it,” he said, adding that combating diabetes and NCDs is part of Norway’s development policy, and it supports both the development of targets for diabetes, and transparency on insulin.

But the development minister also said that during negotiations, “One of the questions that have come up, where countries have different views, is the issue of a price mechanism for insulin.” “Another difficult question is the issue of developing global targets on detection and treatment of diabetes,” he added.

Insulin prices vary across countries, and based on surveys in low- and middle-income countries can go up to as much as $25 for a 10mL vial of human insulin, and as much as $100 for analogue insulin, according to Molly Lepeska, project manager at Health Action International.

Such high prices make it challenging for diabetic patients to access this life-saving medicine, but few governments publish how much they pay for insulin in procurement, and manufacturers don’t disclose their prices either.

Insulin is among the top five most expensive drugs in programs tackling NCDs, according to MSF. Apart from price transparency, Bygrave told Devex early last week the resolution should include “specific asks” on insulin access, including how to increase market competition and secure global supply to meet growing demand for the drug, with more generic biosimilar producers. Currently, the market for insulin is dominated by only three companies, according to WHO.

Civil society groups have been calling for transparency on insulin prices, as well as other related medical supplies, such as blood glucose monitors. There’s been a particular push this year for a resolution on diabetes that emphasizes access to insulin as the world marks the 100th year since the drug was discovered by scientists at the University of Toronto. Last month, WHO launched the Global Diabetes Compact, whose components include global price reporting for insulin and other essential diabetes medicines, and targets for treatment coverage.

Civil society asks for more engagement with WHO member states

The first WHO-led informal meetings with nonstate organizations in advance of the 74th World Health Assembly concluded last week. Here’s what happened, including WHO’s response to civil society and nonstate organizations’ feedback on the meetings.

“Price transparency empowers government procurers and others in determining what is a reasonable price. Countries opposing transparency are bowing to the pharmaceutical industry who don’t want anyone to know their actual selling prices,” Health Action International’s Lepeska said.

Ulstein is aware of the high retail price of insulin, which he said may go as high as 10 times the production costs, and said Norway supports a global price reporting mechanism for insulin, arguing “there clearly is a need for more transparency.”

“In Norway, people with diabetes can live well with their disease, since they have access to affordable insulin. This may not be the case for a poor family in Malawi, having a child with diabetes Type 1 and not being able to provide life-saving insulin. Or having to choose between life-saving insulin for one child or food for the other,” he added.

While diabetes is mentioned twice in the nine global voluntary targets for NCDs, civil society would also like more detailed targets for the detection and treatment of diabetes to galvanize more government action.

All indicators on diabetes are off track and “going in the wrong direction,” said Nina Renshaw, policy and advocacy director for NCD Alliance.

“The targets that are there at the moment don’t really say anything at all about access to diagnosis. There’s still an enormous gap … A lot of people living with diabetes don’t necessarily know their status until they have some kind of acute complications,” Renshaw said.

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