Objective India's majority of patients—including those living with diabetes—seek healthcare in the private sector through out-of-pocket (OOP) payments. We studied access to insulin in the private-sector market of Delhi state, India.
Methods A modified World Health Organization/Health Action International (WHO/HAI) standard survey to assess insulin availability and prices, and qualitative interviews with insulin retailers (pharmacists) and wholesalers to understand insulin market dynamics.
Results In 40 pharmacy outlets analysed, mean availability of the human and analogue insulins on the 2013 Delhi essential medicine list was 44.4% and 13.1%, respectively. 82% of pharmacies had domestically manufactured human insulin phials, primarily was made in India under licence to overseas pharmaceutical companies. Analogue insulin was only in cartridge and pen forms that were 4.42 and 5.81 times, respectively, the price of human insulin phials. Domestically manufactured human phial and cartridge insulin (produced for foreign and Indian companies) was less expensive than their imported counterparts. The lowest paid unskilled government worker in Delhi would work about 1.5 and 8.6 days, respectively, to be able to pay OOP for a monthly supply of human phial and analogue cartridge insulin. Interviews suggest that the Delhi insulin market is dominated by a few multinational companies that import and/or license in-country production. Several factors influence insulin uptake by patients, including doctor's prescribing preference. Wholesalers have negative perceptions about domestic insulin manufacturing.
Conclusions The Delhi insulin market is an oligopoly with limited market competition. Increasing competition from Indian companies is going to require some additional policies, not presently in place. As more Indian companies produce biosimilars, brand substitution policies are needed to be able to benefit from market competition.
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Handling editor Seye Abimbola
Contributors AS conceived the study. AS and WAK designed the research methodology and planned the field survey. AS conducted the survey and data collection. AS and WAK conducted data analysis and the literature review. AS wrote the first draft of the paper. AS and WAK interpreted the results, revised and edited subsequent versions of the manuscript to its final stages, and approved the final manuscript.
Funding The Delhi Field Survey was funded through a Santander University Scholarship that AS received from the Boston University School of Public Health. All references and conclusions are intended for educational and informative purposes.
Disclaimer The views expressed in this article are of the authors and not necessarily of the institutions they represent. The work is that of the authors alone and does not necessarily reflect the views of Helmsley Charitable Trust, sponsors of Santander Universities Scholarship, Boston University or Precision Health Economics.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
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