An escalation in the overall costs of treating diabetes, with a marked increase in the use of newer, expensive insulin and oral anti-diabetic drugs (OADs) over traditional ones, has adversely affected patients, especially from the lower socio-economic strata, researchers and doctors told The Sunday Guardian. They say that these new OADs and insulin that have come to dominate the market owing to aggressive marketing techniques of the manufacturers and sellers are priced as high as Rs 2,000 per vial, in contrast to the older medicines, some of which can be bought at Rs 200-Rs 400 per vial. Diabetes affects 77 million people in India, known as the “diabetes capital of the world”.
Rajeev Kumra, a taxi driver, recalled how until six months ago, he and his family would spend between Rs 15,000 and Rs 20,000 annually for his father-in-law’s treatment. Kumra would take his father-in-law to a private doctor near his home in Preet Vihar in New Delhi. The doctor would write a prescription for the patient’s diabetes. The cost of the drugs and the “analogue insulin”—new age insulin—would normally be pegged between Rs 2,000 and Rs 4,000 for each visit; Kumra had no knowledge that drugs cheaper than the ones he would be asked to buy, and with almost similar effects and results, even existed.
Experts have unanimously pointed out that the indiscriminate use of new oral drugs and insulin that have not been proved, at least theoretically, to be substantially better than traditional drugs, is a matter of worry. According to reports, the annual cost of diabetes treatment in India is Rs 1.5 lakh crore, which is 4.7 times higher than the Centre’s allocation of Rs 32,000 crore on health. The swelling costs of diabetes treatment, as experts collectively told The Sunday Guardian, have made the accessibility of healthcare for the poor grossly inadequate.
According to a recently published study in Diabetes, Technology and Therapeutics Journal, led by Dr Anoop Misra, Chairman, Fortis C-DOC Hospital for Diabetes and Allied Specialities, the sale of insulin increased from Rs 151.2 crore to Rs 218.7 crore (44% growth) between 2008 and 2012. The study further stated that insulin sales continued to see an upward trend between 2012 and 2014, with sales more than doubling from Rs 218.7 crore to Rs 467.8 crore (114% growth). Researchers have claimed that the growth happened due to increased availability and aggressive marketing of newer insulin analogues. Between 2014 and 2016, the sale of insulin continued to see a substantial upward trend, from Rs 467.8 crore to Rs 842 crore (80% growth).
Only 35% to 63% of primary health centres in India stock even the most basic OADs, the study stated. Nearly 7% experience catastrophic expenditure for diabetes. This is when a minuscule population in India is covered with health insurance, and even then, only the cost of hospitalisation is paid by the insurance companies.
INADEQUATE REGULATIONS
Experts have noted that despite the Centre’s advisory to doctors and pharmacists to prescribe only generic drugs, the drug industry in India suffers from inadequate regulations and implementation. Dr Anoop Misra, who spearheaded the study, told The Sunday Guardian that the unsavoury market practices comprising unethical promotional strategies need to be curtailed.
“Given the huge commercial potential of drug sales in India, new and expensive insulin like Degludec are sold at Rs 1,800 per vial, which is more expensive than in Europe, and is so much more costly than human insulin, which is priced at Rs 133 per vial,” he said.
Dr Misra added that the multinational pharmaceutical companies selling expensive insulin in India also face competition from Indian companies making similar insulin. So these MNCs face more economic challenges compared to what they face in many other regions of the world. In this context, some Indian physicians who do not have adequate exposure to continuing medical education, get influenced by the pharmaceutical companies’ aggressive campaigns and exaggerated claims.
Dr Suresh Vatsyayann, who is a voluntary health consultant, reiterated a similar sentiment and said that times like these call for a system that regulates the regulatory body itself. “How can the same salt drug have a minimum retail price written on the drug packaging as five to ten times the normal price? Chemists selling the drugs are mostly the licence holders, but the ones who provide you the drugs haven’t even done matriculation. How can a drug store have no pharmacist on the premises?” he asked.
According to Dr Biswajit Ghoshdastidar, consultant physician and diabetologist, Government of India’s announcement this year that prescribing of generic medicines is compulsory, has been welcomed by the medical fraternity institutions and doctors alike. Yet, retail chemists are unable to cope with this, in the absence of an adequate number of qualified pharmacists. This leads to the harassment of patients. He added that many consumers were unsure about the quality of generic drugs, which automatically made them go for branded/more expensive drugs.
OLD VS NEW
Dr Biswajit Ghoshdastidar said that while newer oral drugs have an excellent track record, there is no evidence that they are more effective than the traditional ones.
“The newer drugs are prohibitively expensive and their superiority over older drugs has never yet been compared in any head-to-head trial. Hence, it is always wise to optimise the choice of drugs, and affordability should be the topmost priority, particularly in a country like ours where domiciliary treatment (which is medical treatment for a period exceeding three days for any disease, illness or injury which in the normal course would require care and treatment at a hospital) is not covered by insurance,” he said.
According to Dr Suresh, the diabetologist, 50% to 75% of diabetics do not even need any medicines and insulin. “It is only when lifestyle changes, followed by raw food intake and other appropriate measures to control the disease do not work after being followed for months that the patient needs to take medicines. If medicines fail to show results, then oral anti-diabetics should be resorted to,” he said, adding that the burden of diabetes would get relieved if people understood diabetes as it comes as a disease in a person.
Dr Biswajit added: “The current designer insulin should be used where conventional insulin does not work. Sparing some extra time towards educating the patient can prevent the condition all together.”