EFTA00753606.pdf

International Diabetes Federation Report on the International Insulin and Diabetes Supplies Survey on Cost and Availability 2006 Task Force on Insulin, Test Strips and Other Diabetes Supplies EFTA00753606 Table of Contents Executive Summary 3 Summary of key findings 3 1. Introduction 5 2. Methodology 6 Limitations 6 3. Findings 8 3.1.1 Access to insulin 8 3.1.2 Reasons for lack of access to insulin 9 3.1.3 People who require insulin but cannot obtain it 10 3.1.4 Taxes on insulin 11 3.1.5 Provision of insulin free or at subsidized prices 12 3.1.6 Where insulin can be bought 12 3.1.7 Cost of a 10ml vial of insulin 12 3.2.1 Strengths of insulin available 19 3.2.2 Types of insulin available 19 3.2.3 Proportion of animal and human insulin used 20 3.3.1 Access to syringes and needles 21 3.3.2 Reasons for lack of access to syringes and needles 22 3.3.3 Provision of syringes and insulin pens free or at subsidized prices 23 3.3.4 Who provides the subsidies for syringes, needles and insulin pens 24 3.3.5 Entitlement to free or subsidized insulin pen 27 3.3.6 Prices of syringes, needles and pens 27 3.4.1 Monitoring diabetes control 31 3.4.2 Types of blood glucose materials used 31 3.4.3 Reasons for not testing 31 3.4.4 Where testing strips and blood glucose meters can be bought 32 3.4.5 Cost of urine and blood glucose test strips, and blood glucose meters 32 4. Conclusion 35 Appendices 37 Appendix 1 Survey Questionnaire 37 Appendix 2 Types of insulin available in the different countries 47 Report on the International Insulin and Diabetes Supplies Survey on 2 Cost and Availability 2006 EFTA00753607 Executive Summary The International Diabetes Federation (IDF) Task Force on Insulin, Test Strips and Other Diabetes Supplies has as its aim to provide support to member associations with regard to access to, and availability and affordability of insulin, test strips and other diabetes supplies at national and international levels. In line with this remit the Task Force sent out a survey questionnaire to diabetes associations in 50 countries in the seven IDF Regions. Letters were initially sent to WHO Regional Offices to invite them to collaborate on the survey by identifying countries with poor access to insulin and diabetes supplies. Diabetes associations were also invited to send the questionnaire to their respective Ministries of Health to obtain official information. In total, completed questionnaires were received from 35 countries, of which 26 came from diabetes associations and nine from Ministries of Health, Central Medical Supplies and Pharmaceutical Services. Summary of key findings Access • Africa on the whole had the lowest level of access to insulin for people with type 1 diabetes. • Cambodia, COte d'Ivoire, Mali, Nepal and Togo reported that access to insulin for people with type 1 diabetes was less than 25% of the time. • Access to insulin for people with type 2 diabetes is similar to type 1 diabetes. Main reason for lack of access to insulin was that insulin was expensive. • People who required insulin were able to obtain it on a continuous basis in only seven countries. • Human insulin was used more widely than animal insulin. • The AFR region reported the most problems with regards to access to syringes, with the main one being the total supply of syringes being less than that required. • Three countries reported that people with diabetes 'Rarely' were able to access needles and syringes. Availability • 78% of countries responding to the survey provided insulin for free to people with diabetes while 55% provided insulin at a subsidized price. • Insulin was most widely available in private pharmacies, followed by public pharmacies, in countries where respondents gave an answer. • In almost all countries, 100IU strength of insulin was available while 12 of the countries had 40IU and two had 801U as well. • Nigeria reported 17 different types of insulin available, whereas Syria only two. Report on the International Insulin and Diabetes Supplies Survey on 3 Cost and Availability 2006 EFTA00753608 Affordability Half of the countries surveyed had taxes on insulin. The most expensive insulin was reported in the EUR Region in all three sectors (public, private and NGO) with a price at USD42 per 10m1 vial in Turkey. • In the AFR Region the maximum price for insulin in the public sector was USD34 per 10m1 vial in the Congo. • There were 34 initiatives at national government level to provide syringes, needles and pens at subsidized prices or for free. • The average price for all responding countries for 100 syringes and needles was USD12.10. • The main reason for not testing reported from different countries was cost of supplies. The average cost for 100 urine test strips in the public sector was USD12.50. Report on the International Insulin and Diabetes Supplies Survey on 4 Cost and Availability 2006 EFTA00753609 1. Introduction Banting and Best's discovery of insulin at the University of Toronto in 1921 is often hailed as a medical miracle. This discovery meant that the draconian diets, horrible complications and death that people with this condition faced were now a thing of the past. However, as we celebrate 85 years since insulin's discovery and the many people it has helped over the years, lack of access to insulin still leads to much suffering in many of the world's poorest countries. Countries may face both acute and chronic shortages of insulin. This may be due to many factors, such as the cost of insulin, poor management of tenders and medicines supply, conflict and natural disasters. In either case lack of access to a continuous supply of insulin will lead to acute and long-term complications and unfortunately death. Insulin is not enough however, and access to syringes and proper testing equipment are just as important. Access to these essential tools is also problematic and adds to the challenges that people with type 1 diabetes face in many developing countries. The impact of this lack of access means that life expectancy of children in sub-Saharan Africa with type 1 diabetes can be as low as one year. This is in stark contrast to the developed world where people with the same condition can expect to live close to normal life expectancies. The International Diabetes Federation (IDF) Task Force on Insulin, Test Strips and Other Diabetes Supplies has as its aim to provide support to member associations with regard to access, affordability and other issues relating to insulin, test strips and other diabetes supplies at national and international levels. Several initiatives have been developed to address the lack of access to insulin and supplies in many countries and to try to overcome the disparity in access to essential medication and tools. However, these actions are but a drop in the ocean of programmes needed to help people with diabetes obtain lifesaving insulin and equipment on a continuous basis. It is the aim of the Task Force to call attention to the obstacles to access to insulin, syringes and testing equipment identified in this survey, and to assist member associations in those countries to find solutions to overcome these barriers. Report on the International Insulin and Diabetes Supplies Survey on 5 Cost and Availability 2006 EFTA00753610 2. Methodology The Task Force sent out a survey questionnaire to diabetes associations in 50 countries in the seven IDF Regions, which were selected in collaboration with the Regional Chairs. The selected countries were seen to have poor access to insulin and the data for some regions may not be representative for the whole region. This is the fourth survey carried out by the Task Force. The 2006 survey differs from earlier surveys in that it covers a limited number of countries which were selected based on a specific criterion. It was decided to carry out a smaller and more targeted survey as previous surveys had met with low response rates. At the same time many developing countries which were thought to have poor access to insulin and diabetes supplies did not participate in the earlier surveys. It was therefore decided to focus on countries where the need was seen to be greater and where follow up could be carried out with the limited resources of the Task Force. Given the selective nature of this survey, it was not possible to compare the results of this survey with previous ones. As previous surveys were limited by their reliability, it was felt that reliability could be improved if the survey questionnaire were completed by an official source such as the Ministry of Health. The Task Force Chair together with the appropriate IDF Regional Chair wrote to WHO Regional Offices inviting them to collaborate on the survey. They were invited to identify the countries to be surveyed as well as suggest names of officials who could be approached. Only the WHO African Regional Office accepted the invitation to collaborate. At the same time, IDF Regional Chairs were requested to identify a maximum of five countries (10 in the African Region) which were thought to have poor access to insulin and diabetes supplies. The diabetes associations in the selected countries were then invited to send the questionnaire to their respective Ministries of Health to obtain official information or to identify an appropriate person to whom the questionnaire could be sent. Questionnaires were sent to 50 countries. A copy of the questionnaire is attached as Appendix 1. In total, completed questionnaires were received from 35 countries, of which 26 came from diabetes associations and nine from official sources such as Ministries of Health. This was a response rate of 70%, an improvement over the 2003 survey response of 50%. Respondents from the diabetes associations were contact persons in the IDF database while those from official sources had been identified by either the Regional Chair or the diabetes association. Limitations During the analysis of the data many limitations to the survey become apparent. These questionnaires were completed by, in most cases, one individual and were based on their experience with regards to diabetes in their country. Also the wording of some questions may have led to confusion and therefore poor results. Report on the International Insulin and Diabetes Supplies Survey on 6 Cost and Availability 2006 EFTA00753611 In some instances, the responses given by a respondent were inconsistent, while in others the responses were inconsistent with the known reality of a particular country. The data for some regions may not be representative for the whole region because of the selection criterion (only countries seen to have poor access to insulin and diabetes supplies). The data should therefore be interpreted with caution. The results for many questions are presented by region to facilitate the presentation of results and should not be interpreted as being representative of that region. Inconsistencies, where apparent, are pointed out in this report. In spite of these limitations, the survey results provide us with a picture of access to insulin and diabetes supplies in many countries with limited resources for healthcare. List of countries that participated in the 2006 survey Africa (AFR): Congo, C8te d'Ivoire, Democratic Republic of Congo, Madagascar, Mali, Nigeria, Senegal, Seychelles*, Togo and Uganda*. Eastern Mediterranean and Middle East (EMME): Egypt, Kuwait, Pakistan and Syria. Europe (EUR): Belarus, Poland, Turkey and Uzbekistan. North America (NA): Barbados*, British Virgin Islands, Jamaica and Mexico* South and Central America (SACA): Brazil*, Costa Rica*, Guatemala* and Paraguay*. South-East Asia (SEA): Bangladesh, Maldives*, Nepal and Sri Lanka. Western Pacific (WP): Cambodia, China, Mongolia, Philippines and Vietnam. 'official sources: ministry of Health, Joint Medical Stores, Pharmaceutical Services Report on the International Insulin and Diabetes Supplies Survey on 7 Cost and Availability 2006 EFTA00753612 3. Findings 3.1.1 Access to insulin Insulin is essential for all people with type 1 diabetes and can help improve outcomes for people with type 2 diabetes. Respondents to the survey were asked about the access to insulin that people with type 1 and type 2 diabetes had in their country. Africa on the whole had the lowest level of access to insulin for type 1 diabetes with half of the respondents saying that people with type 1 diabetes could only access insulin less than 50% of the time. The same was true for 40% of the countries responding in the Western Pacific Region and 25% of countries in the South-East Asian Region. Cambodia, C8te d'Ivoire, Mali, Nepal and Togo were countries that reported that access to insulin for people with type 1 diabetes was less than 25% of the time. Figure 1 gives the comparison for the different regions with regards to frequency of access to insulin for people with type 1 diabetes. Figure 1 Access to insulin for people with type 1 diabetes 1 Access to insulin for people with type 1 diabetes 100% 90% ■ Frequency 80% ■ 100°4 70% ❑ 75-99% 60% o 50-74% C 50% ■ 26-49% 40% o >25% cc 30O/ 20% 10% 0% AFR ENIVE EUR NA SAGA SEA WP Region The Western Pacific Region on the whole had the lowest level of access to insulin for type 2 diabetes with 1000/0 of respondents saying that people with type 2 diabetes could only access insulin less than 50% of the time. The same was true for 50% of countries in the European and African Regions, and 25% of countries from the South and Central America Region. Cambodia, C8te d'Ivoire, Mali, Togo, Turkey and Vietnam were countries that reported that access to insulin for people with type 2 diabetes was less than 25% of the time. Report on the International Insulin and Diabetes Supplies Survey on 8 Cost and Availability 2006 EFTA00753613 Figure 2 gives the comparison for the different regions with regards to frequency of access to insulin for people with type 2 diabetes. Figure 2 Access to insulin for people with type 2 diabetes Access to insulin for people with type 2 diabetes 100% 90% • 80% Frequency 70% MI 100% a £ 60% O 75-99% cQ 50% O 50-74% 40% • 26-49% cc 30% 13 >25% 20% 10% 0% AFR EWE EUR NA SAGA SEA WP Region Access to insulin for people with type 2 diabetes is similar to those with type 1 diabetes. For people with type 1 diabetes, 23 respondents reported access to insulin greater than 50% of the time, for type 2 diabetes this figure is 22. Five countries reported access less than 25% of the time for type 1 diabetes, this figure is six for type 2 diabetes. Africa remains the region where access is most problematic. 3.1.2 Reasons for lack of access to insulin This survey confirmed once again that cost was a significant barrier to access to insulin. 'Insulin was expensive' was cited by the majority of respondents as the main reason for lack of access to insulin, and was also the only barrier present in all the regions (see Table 1). This was followed by unavailability in regional/rural areas, lack of diabetes education and transportation problems for people collecting insulin as a problem respectively (see Figure 3). Other barriers mentioned included the difficulty in finding animal insulin and storage issues. Report on the International Insulin and Diabetes Supplies Survey on 9 Cost and Availability 2006 EFTA00753614  Table 1 Main barriers to access to insulin Number of countries reporting the following reasons for lack of access to insulin Transport- Insulin is ation available, Insulin is Insulin is The total problems but not not supply of faced by preference generally generally insulin is people with is given to available in available in less than diabetes in Lack of people with major cities regional/ the amount collecting diabetes Insulin is type 1 Region and towns rural areas required insulin education expensive diabetes AFR 0 7 4 5 2 7 0 EMME 0 0 0 0 1 2 2 EUR 0 0 2 0 3 2 2 NA 0 0 0 1 2 1 0 SACA 0 2 0 0 0 2 0 SEA 0 3 0 3 0 4 0 WP 1 4 2 2 4 3 0 Total 1 16 8 11 12 21 4 Figure 3 Main barriers to access to insulin Major barriers to access to insulin Number of respondents 0 5 10 15 20 25 Insulin is expensive Not generally available in regional/rural areas Lack of diabetes education Transportation problems Supply is less than required Preference given to people with type 1 ciabeles Not generally mailable in major cities and towns 3.1.3 People who require insulin but cannot obtain it Respondents were asked the percentage of people in their respective countries who required insulin but could not obtain it due to high cost. In only seven countries could all people who required insulin obtain it on a continuous basis. At the other end of the spectrum there were no countries which reported a complete lack of access by people who required insulin (see Table 2). In Uzbekistan 76-99% of people requiring insulin were unable to afford it. Seven countries reported that 50-75% of people needing insulin were not able to afford Report on the International Insulin and Diabetes Supplies Survey on 10 Cost and Availability 2006 EFTA00753615  it and in six countries 25-49% of people were unable to access insulin because of too high a cost (see Table 2). These results again highlight that cost is a major barrier to access compounded by other factors discussed above. Table 2 Percentage of people with diabetes unable to access insulin because it is too expensive Percentage of people unable to access insulin because it is Region Country too expensive 0% 1-24% 25-49% 50-75% 76-99% 100% Congo X Democratic Republic of Congo X C6te d'Ivoire X Madagascar X AFR Mali X Nigeria X Senegal X Seychelles* X Togo X Uganda* X Egypt X Kuwait X EMME Pakistan X Syria X Belarus X Poland X EUR Turkey X Uzbekistan X Barbados* X British Virgin NA Islands X Jamaica X Mexico* X Brazil* X Costa Rica* X SACA Guatemala* X Paraguay* X Bangladesh X Maldives* X SEA Nepal X Sri Lanka Cambodia X China X WP Mongolia X Philippines X Vietnam X Total 7 13 6 7 1 0 *official source 3.1.4 Taxes on insulin The cost of insulin (and therefore the ability to afford it or not) to people with diabetes is determined, among other factors, by the selling price of the manufacturer, shipping and insurance costs, custom duties and any internal Report on the International Insulin and Diabetes Supplies Survey on 11 Cost and Availability 2006 EFTA00753616 mark-ups on medicines and other value added taxes. Insulin is on the WHO essential drug list and therefore should not be subjected to any taxes, but this is often not the case; 55% of countries surveyed had taxes on insulin. These taxes were applied to both imported and locally produced insulin. The maximum percentage of tax on imported insulin was 3O% in Mongolia, with an overall average of 13%. For locally produced insulin the maximum percentage of tax was 35% in Brazil and the average was 20.5%. 3.1.5 Provision of insulin free or at subsidized prices In about half of the responding countries people with diabetes could purchase insulin at a subsidized price while insulin was provided free in about three- quarters of the countries. It should be noted that in spite of this, many respondents also indicated that the high cost of insulin was a barrier to access in their countries. Although this might seem inconsistent, one possible explanation could be that free or subsidized insulin was available only to particular groups. It could also indicate that while insulin may be available, it is not always accessible to people with diabetes because of reasons other than cost such as transportation problems in collecting the insulin. Subsidized and free insulin can be found in different sectors of each country (see Table 3). Subsidies and free insulin were provided by a variety of organizations, both international and national, faith-based, diabetes associations and the government. Table 3 Provision of free or subsidized insulin Number of Non- National Regional countries governmental Governments Governments providing: organizations Free insulin 1O 4 4 Subsidized insulin 6 4 4 Free and 5 1 3 subsidized insulin 3.1.6 Where insulin can be bought Insulin could be bought in public pharmacies in 83% of countries surveyed, 1O00/0 in private pharmacies, 66% in diabetes associations and 40% in charities. Knowing where insulin can be bought is important, as this will have an impact on the price of insulin for the person with diabetes. 3.1.7 Cost of a 1Oml vial of insulin In all regions the least costly insulin could be found in the public sector (see Figure 4). Insulin was available from non-governmental organizations (NGOs) in four regions (AFR, EMME, EUR and SACA) and in three out of four regions it was the second cheapest source, indicating the potential this sector has in providing affordable insulin. In the EUR Region, however, insulin from the NGO sector was actually the most expensive on average. Report on the International Insulin and Diabetes Supplies Survey on 12 Cost and Availability 2006 EFTA00753617 The most expensive insulin was found in the EUR region in all three sectors with a price of USD42 per 10ml vial in Turkey. In the AFR region the maximum price for insulin in the public sector was USD34 per 10ml vial in the Congo. The largest range in price was also found in the AFR region with Senegal having a price of USD2.50 in all sectors and Congo having a price of USD34 in the public sector, Madagascar a price of USD36 in the private sector and Nigeria a price of USD20 in the NGO sector. Table 4 details the median and price range for insulin in the three sectors in the different regions. Figures 5 to 11 present these results in a visual manner for each region. Table 4 Median (Range) of price in different sectors (USD) Median (Range) of price in different sectors (USD) Region Public Private NGO AFR 10 (2.50-34) 11.10 (2.50-36) 4.50 (2.5-20) EMME 5 (0-7.70) 13 (5-14) 5 (5) EUR 12.50 (0-42) 16 (15-42) 42 (42) NA 14 (1-15) 18 (15-25) SACA 3.40 (0-7) 17 (14-20) 11.50 (9-14.10) SEA 5 (4.50-5.60) 8.50 (5.80-14) WP 9.50 (6-11.60) 10 (6-21.40) - Report on the International Insulin and Diabetes Supplies Survey on 13 Cost and Availability 2006 EFTA00753618 Figure 4 Average prices for 10ml vial of insulin (USD) Average prices per 10ml vial 45.0 40.0 El 35.0 r 30.0 25.0 ci Public ■ Private 8 20.0 ❑ NGO g.a) 15.0 la' 10.0 5.0 0.0 AFR EMME EUR NA SAGA SEA WP Regions Report on the International Insulin and Diabetes Supplies Survey on 14 Cost and Availability 2006 EFTA00753619  Figure 5 AFR Region: average, median, maximum and minimum price for a 10ml vial of insulin (USD) AFR Region 40 35 • g 30 a 25 ♦ Max ■ Min g 20 Average is Median 0 o lo 5 ■ • 0 10-ml vial 10-ml vial 10-ml vial Public sector Private sector Nongovernmental organizations Sector Figure 6 EMME Region: average, median, maximum and minimum price for a 10ml vial of insulin (USD) EMME Region 16 14 • Cost 10n1vial (USE) 12 10 •Max ■ Min 8 ♦ Average 6 X Median x 4 2 0 ■ 10-ml vial 10-ml vial 10-ml vial Public sector Private sector Nongovernmental organizations Sector Report on the International Insulin and Diabetes Supplies Survey on 15 Cost and Availability 2006 EFTA00753620  Figure 7 EUR Region: average, median, maximum and minimum price for a 10ml vial of insulin (USD) EUR Region 45 • 40 a 35 rn • 30 • Max 25 • Min g 20 Average 44 15 Median 0 O 10 5 0 t0-ml - vial IO-ml vial 10 ml vial Public sector Private sector Non-governmental organizations Sector Figure 8 NA Region: average, median, maximum and minimum price for a 10ml vial of insulin (USD) NA Region 30 25 r • = 20 •Max •Min 15 • Average zr, 10 x Median 0 5 0 104n1vial 10-ml vial Public sector Private sector Sector Report on the International Insulin and Diabetes Supplies Survey on 16 Cost and Availability 2006 EFTA00753621  Figure 9 SACA Region: average, median, maximum and minimum price for a 10ml vial of insulin (USD) SACA Region 25 20 • Max To 15 > El Min Average g 10 x Median 0 • 5 0 • 10-ml vial g•ml vial ig•ml vial Public sector Private sector Non-governmental organizations Sector Figure 10 SEA Region: average, median, maximum and minimum price for a 10ml vial of insulin (USD) SEA Region 16 14 • 12 cn 2. 10 •Max > •Mln 8 Average 6 • • X Median 0 0 4 2 0 10-ml vial 10 -ml vial Public sector Private sector Sector Report on the International Insulin and Diabetes Supplies Survey on 17 Cost and Availability 2006 EFTA00753622  Figure 11 WP Region: average, median, maximum and minimum price for a 10ml vial of insulin (USD) WP Region 25 • a 20 ♦ Max m 15 Mtn Avorago Median 0 10-ml vial 10-mi vial Public sector Private sector Sector Report on the International Insulin and Diabetes Supplies Survey on 18 Cost and Availability 2006 EFTA00753623  Different factors such as strength (number of units per vial of 10ml), type of insulin available (animal, human and analogues), and whether insulin is available in vial or cartridge form will have an impact on the cost of insulin to the person with diabetes. Table 5 shows the ratio of cost of a 10ml vial of human insulin to other types of insulin in selected countries. Table 5 Ratio to Drice 10ml vial of insulin Ratio to price 10ml vial Price in the 10ml vial public One box (5 10mi vial 10ml vial •f sector per box) of of pork of beef beef/pork 10ml vial 10ml 3m1 insulin insulin insulin insulin of beef vial pen (100 (100 (100 insulin (40 Country (USD) cartridges units/ml) units/ml) units/ml) units/ml) Lantus Bangladesh 4.5 3.6 15.6 Belarus 9.0 2.9 0.9 China 9.0 5.0 0.7 0.3 Congo 34.0 2.1 C8te d'Ivoire 10.0 1.0 Mongolia 10.0 8.0 0.5 Nigeria 21.0 2.0 0.7 0.5 Pakistan 7.7 2.2 0.4 Sene • al 2.5 12.2 Se chelles* 18.0 1.8 Turke 42.0 1.7 0.5 Vietnam 6.0 5.0 0.7 *official source 3.2.1 Strengths of insulin available Almost all the countries had 100IU strength insulin available while 12 had 40IU, and only two had 80IU as well. Turkey was the only country that reported it did not have 100IU insulin and only 40 and 80IU. 3.2.2 Types of insulin available Nigeria reported 17 different types of insulin available, whereas Syria only had two. Table 6 shows the number of countries which reported having the different types of insulin available. A detailed list of which countries have each type of insulin is provided in Appendix 2. Report on the International Insulin and Diabetes Supplies Survey on 19 Cost and Availability 2006 EFTA00753624 Table 6 Number of countries and type of insulin available _ape of insulin Number of countries Human Regular 30 Human Lyspro (Humalog) 21 Novolog (Novo Rapid) 19 Human NPH 32 Human Lente 18 Human Semilente 10 Human Ultralente 5 Lantus (Glargine) 22 Beef Regular 7 Beef NPH 6 Beef Lente 2 Beef Semilente 1 Beef Ultralente 1 Insulin Determir 3 Pork Regular 7 Pork NPH 7 Pork Lente 2 Pork Semilente 2 Pork Ultralente 2 Beef/Pork Regular 1 Beef/Pork Regular 1 3.2.3 Proportion of animal and human insulin used Overall the highest percentage for animal insulin being used in a given country was 65% in Vietnam. All responding countries in the NA Region reported only human insulin being used. On average overall the regions had a presence of more than 90% of human insulin (see Figure 12). Countries in WP used the highest proportion of animal insulin, which equalled an overall percentage of 31% of all insulin used. Report on the International Insulin and Diabetes Supplies Survey on 20 Cost and Availability 2006 EFTA00753625 Figure 12 Proportion of animal to human Insulin used Proportion of animal to human insulin used 100 90 80 70 Percentage (%) 60 o Animal insulin 50 ■ Human insulin 40 30 20 10 0 AFR EMME EUR NA SAGA SEA WP Regions 3.3.1 Access to syringes and needles Syringes and needles are needed for insulin delivery but these are not always available to people with diabetes who require them. Cambodia, Costa Rica and Mongolia reported that people with diabetes 'Rarely' were able to access needles and syringes. Figure 13 shows the proportion of responding countries in relation to frequency of access to needles and syringes. Figure 13 Access to syringes and needles Report on the International Insulin and Diabetes Supplies Survey on 21 Cost and Availability 2006 EFTA00753626 There was no region where 100% of countries indicated that all people with diabetes could 'Always' access syringes. The majority would be able to access syringes 'Usually'. Figure 14 shows the access to syringes and needles by region. Figure 14 Access to syringes and needles by region Access to syringes and needles 100% !:! 90% Respondents (To) 80% ■ Always 70% 60% o Regularly 50% ❑ Usually 40% ■ Sometimes 30% Rarely 20% 10% 0% AFR EMME EUR NA SAGA SEA WP Regions 3.3.2 Reasons for lack of access to syringes and needles There were two main reasons why access to syringes and needles was problematic for people with diabetes: insulin syringes and needles were not generally available in regional/rural areas and the cost of syringes and needles. Respondents from the AFR region reported the most problems, with the main one being the total supply of syringes being less than what is required. In all the other regions, except for the NA Region, lack of syringes in rural areas seemed to be the main problem with regards to access. For the NA Region the total amount of syringes was less than the quantity required and also people with diabetes faced transportation problems to get their syringes (see Figure 15). Report on the International Insulin and Diabetes Supplies Survey on 22 Cost and Availability 2006 EFTA00753627 Figure 15 Reasons why syringes and needles are unavailable Reasons why syringes and needles are not available a Insulin syringes and needles are cn 100% expenske. ep cn 90% C • Lack of diabetes education O 80% co 70% OTransponation problems in collecting 60% syringes aid needes. "a ae 50% to v 40% Er Total supply of its din syringes and cn needes less than the amount required. 30% m c 20% O Insulin syringes and needes not generally 10% mailable o regional/rural areas. 43 O. 0% 13 Insulin syringes and needles not generally MR EWE EUR NA SACA SEA VP Overall mailable n major cities and large lawns. Regions 3.3.3 Provision of syringes and insulin pens free or at subsidized prices Overall people with diabetes in 17 countries received free syringes while those in 11 countries could purchase syringes at subsidized prices.