Correspondence
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Ding Y, He L, Zhang Q, et al. Organ distribution
of severe acute respiratory syndrome (SARS)
associated coronavirus (SARS-CoV) in SARS
patients: implications for pathogenesis and
virus transmission pathways. J Pathol 2004;
203: 622–30.
Wei C, Wan L, Yan Q, et al. HDL-scavenger
receptor B type 1 facilitates SARS-CoV-2 entry.
Nat Metab 2020; 2: 1391–400.
Access to insulin and
diabetes care in the
Philippines
Published Online
November 23, 2021
https://doi.org/10.1016/
S2213-8587(21)00309-0
16
Millions of people from low-income
and middle-income countries (LMICs)
are unable to access insulin and routine
diabetes care.1 The Philippines, a lowermiddle income country in southeast
Asia with almost 4 million adults
with diabetes,2 is no stranger to this
crisis. Diabetes ranks fourth among
the leading causes of death in the
Philippines.3
Filipino people face substantial
barriers to health care, which preclude
access to insulin and diabetes care,
including inadequate health financ­ing
leading to high out-of-pocket expendi­
ture and a fragmented referral system
from primary care to specialised care
units. During the COVID-19 pandemic,
access to diabetes medications became
an even greater problem for Filipino
people because of financial constraints
from the economic recession and
substantial supply deficits. Addressing
these barriers is instrumental to
solving the problem of insulin and
diabetes care access in the country.
In 2009, the Philippine Department
of Health launched the Insulin
Medicine Access Program (InMAP),
a public–private partnership to
provide affordable insulin. 4 Under
InMAP, pharmaceutical companies
provide insulin products through
consignment with 22 hospitals
across the country. However, most
of these hospitals are in cities,
presenting a challenge for patients
living in geographically isolated and
disadvantaged areas. Expanding
InMAP is crucial to increase
accessibility and reduce the out-ofpocket costs of insulin.
The Universal Health Care Act of the
Philippines, passed in 2019, created the
Health Technology Assessment Council
(HTAC), an advisory body mandated
to recommend medicines and tech­
nologies for government funding.5
Currently, a single insulin analogue
pen is worth 3 days of minimum wage
pay. To bring down these costs and
leverage government negotiations,
HTAC is working to include insulin
analogues in the Philippine formulary.
As this approach gains momentum,
strengthening primary care units and
referral systems is imperative to create
a robust infrastructure for diabetes care
delivery.
We agree with the sentiment
expressed in the recent Editorial1 in
The Lancet Diabetes & Endocrinology
that global collaborative action
is needed to tackle the diabetes
epidemic. We also support multi­
sectoral discussions among local
ministries of health, policy makers,
health-care workers, patient advo­
cates, community leaders, and
pharmaceutical companies to make
insulin more accessible and affordable.
Furthermore, we encourage LMICs to
come together and share best practice
in diabetes care and prevention given
limited resources. Not least, we look
forward to the fulfillment of the WHO
Global Diabetes Compact,6 which aims
to increase treatment access, improve
patient outcomes, and promote
prevention of diabetes. The Compact’s
vision can be realised, but only
through meaningful engagement,
united action, and lifelong
commitment among stakeholders
around the world.
CAJ has received honoraria for serving on the
speaker’s bureau for Novo Nordisk, Sanofi Aventis,
Merck, Merck, Sharpe and Dohme, Servier Philippines,
and Johnson and Johnson. CAJ has also received
support for attending meetings and travel for
conventions from Sanofi Aventis, Merck, Sharpe and
Dohme, Natrapharm, Novo Nordisk and AstraZeneca.
All other authors declare no competing interests.
Michelle Ann B Eala,
John Jefferson V Besa,
Regiel Christian Q Mag-usara,
Anna Elvira S Arcellana,
*Cecilia A Jimeno
cajimeno@up.edu.ph
College of Medicine, University of the Philippines,
Manila, Philippines (MABE); Department of
Medicine, Philippine General Hospital, Manila,
Philippines (JJVB, RCQM); Division of Endocrinology,
Diabetes and Metabolism, Department of Medicine,
Philippine General Hospital, Manila, Philippines
(AESA, CAJ); Department of Pharmacology and
Toxicology, College of Medicine, University of the
Philippines, Manila 1000, Philippines (CAJ)
1
2
3
4
5
6
The Lancet Diabetes & Endocrinology. Insulin
for all: a hope yet to be realised.
Lancet Diabetes Endocrinol 2021; 9: 639.
International Diabetes Federation. IDF Western
Pacific Members: The Philippines.
May 14, 2020. https://idf.org/our-network/
regions-members/western-pacific/
members/116-the-philippines.html (accessed
Oct 10, 2021).
Philippine Statistics Authority. Causes of
deaths in the Philippines (preliminary):
January to December 2020. March 16, 2021.
https://psa.gov.ph/content/causes-deathsphilippines-preliminary-januarydecember-2020 (accessed Nov 11, 2021).
Department of Health, Republic of the
Philippines. Insulin access program.
https://doh.gov.ph/faqs/Insulin-AccessProgram (accessed Oct 10, 2021).
Department of Health, Republic of the
Philippines. Implementing rules and
regulations of the Universal Health Care Act
(Republic Act No. 11223). 2019. https://doh.
gov.ph/sites/default/files/health_magazine/
UHC-IRR-signed.pdf (accessed Oct 15, 2021).
Hunt D, Hemmingsen B, Matzke A, et al.
The WHO Global Diabetes Compact: a new
initiative to support people living with diabetes.
Lancet Diabetes Endocrinol 2021; 9: 325–27.
Diabetes and the WHO
Model List of Essential
Medicines
The WHO Model List of Essential
Medicines was first published in 1977
and includes minimum medicine
needs for a basic health-care system,
listing the most efficacious, safe, and
cost-effective medicines for priority
conditions.1 The goal of this list was
to choose the medications that would
be crucial to include in a population’s
formulary, which otherwise would be
inaccessible, especially in low-income
and middle-income countries.2 The
Model List of Essential Medicines
has evolved over the decades and
now takes into consideration other
www.thelancet.com/diabetes-endocrinology Vol 10 January 2022
Correspondence
important variables, such as public
health relevance, efficacy, safety, and
value.2
The list is updated every 2 years,
and in 2019, the EMA included
soluble and isophane (ie, regular
and neutral protamine Hagedorn)
insulin, gliclazide, and metformin
for people with diabetes. The 2021
Model List of Essential Medicines will
be remembered as a major change
in what is considered to be required
for the pandemic in diabetes, as both
long-acting insulin analogues and
SGLT2 inhibitors were added.1
For the 2021 Model List of Essential
Medicines, human insulins (and qualityassured biosimilars) are included, as
are long-acting insulin analogues
(and their biosimilars). The specific
analogues are listed by name: insulin
degludec, insulin detemir, and insulin
glargine. 1 Long-acting analogues
improve overall quality of life because
they conveniently can be dosed once
daily and result in less hypoglycaemia
than does neutral protamine Hagedorn
insulin.3 The hope is that these newer
insulins, particularly their biosimilars,
will result in more penetration in lowincome and middle-income countries
and more competitive pricing than
do the insulins included on previous
versions of the list. Notably, the rapidacting analogues were not included
in the latest Model List of Essential
Medicines.
The SGLT2 inhibitors listed by
name in the latest Model List of
Essential Medicines are empagliflozin,
canagliflozin, and dapagliflozin. 1
These medications have become
widely favourable for use in the
management of type 2 diabetes
because of their benefits for patients
with cardiovascular disease or chronic
kidney disease. The most substantial
benefits have been seen with a
reduction in hospital admissions
for heart failure and a deceleration
of kidney disease progression.4 We
agree that these definitive and major
benefits outweigh concerns for
possible minor and severe adverse
effects: genitourinary infections in
geographical areas that might not
have access to treatment and rare, but
life-threatening, euglycaemic diabetic
ketoacidosis, which can be missed
even in advanced health-care settings.5
With these changes to the 2021
Model List of Essential Medicines,
WHO has taken a major step towards
improving the lives of people with
diabetes across the world. Notably,
long-acting insulin analogues
have become standard of care in
low-income and middle-income
countries, yet the SGLT2 inhibitors are
underused. Hopefully, the addition
of this class to the Model List of
Essential Medicines will promote
appropriate use in low-income and
middle-income countries. With
improvement in competitive pricing
for long-acting insulin analogues and
SGLT2 inhibitors, these medications
are likely to be used more frequently
and effectively than they currently
are. Ideally, the beneficial outcomes
of these two additions with less major
hypoglycemic, cardiovascular, and
renal events will be shown worldwide
as the use of these medications
increases.
FNK declares no competing interests. IBH receives
research funding from Medtronic Diabetes, Insulet,
and Beta Bionics. IBH receives consulting fees from
Abbott Diabetes Care, Roche, Bigfoot, and GWave.
Farah N Khan, *Irl B Hirsch
ihirsch@uw.edu
University of Washington Medicine Diabetes
Institute, University of Washington, Seattle,
WA 98109, USA (FNK, IBH)
1
2
3
4
WHO. WHO Model List of Essential Medicines—
22nd list, 2021. Sept 30, 2021. https://www.
who.int/publications/i/item/WHO-MHP-HPSEML-2021.02 (accessed Nov 7, 2021).
Laing R, Waning B, Gray A, Ford N, ‘t Hoen E.
25 years of the WHO essential medicines lists:
progress and challenges. Lancet 2003;
361: 1723–29.
Hirsch IB, Juneja R, Beals JM, Antalis CJ,
Wright EE. The evolution of insulin and how it
informs therapy and treatment choices.
Endocr Rev 2020; 41: 733–55.
Zelniker TA, Wiviott SD, Raz I, et al.
Comparison of the effects of glucagon-like
peptide receptor agonists and sodium-glucose
cotransporter 2 inhibitors for prevention of
major adverse cardiovascular and renal
outcomes in type 2 diabetes mellitus.
Circulation 2019; 139: 2022–31.
www.thelancet.com/diabetes-endocrinology Vol 10 January 2022
5
Tahrani AA, Barnett AH, Bailey CJ.
SGLT inhibitors in management of diabetes.
Lancet Diabetes Endocrinol 2013; 1: 140–51.
The WHO Model List of Essential
Medicines provides a core list of
medicines that are safe, cost-effective,
and necessary to address major public
health concerns. 1 Including longacting insulin analogues on the WHO
Model List of Essential Medicines
emphasises global inequities in insulin
but does not profoundly change that
the availability and affordability of all
insulins is poor.2,3
Median government procurement
prices for long-acting insulin
analogues are 6·6 times higher than
for human insulin (ie, US$33 vs $6).3
When people need to pay for insulin
out of pocket, the median price in
the public sector is $29 for insulin
analogues versus $9 for human insulin.
However, the cost of production
for human and insulin analogues is
similar.4 Given that manufacturers sell
analogues at a premium, will human
insulin disappear from the market as
was seen with animal insulin?2
For countries providing insulin for
free, the price of insulin can already
stretch tight budgets.2 Unless prices
of analogues fall, they could seriously
affect universal health coverage,
because either insulin will be too costly
to be included or resources will be
reallocated to cover these additional
costs. Further, the expense of insulin
can strain funds that should cover
associated devices, such as syringes
and supplies for monitoring blood
glucose.3
When changing insulins, training
and education for health professionals
and people with diabetes is essential
given the differences in duration,
method of administration, and
dosage. Switching insulin delivery
from syringes to pens should also
be considered, particularly as each
manufacturer has specific single-use
pen devices or cartridges for reusable
pens that often have differences in
their operation.
17