Republic of Moldova: Improving access to insulin and oral medicines for diabetes
Although insulin is on WHO's Model List of Essential Medicines, access in resource-poor settings can still be a problem because of international and national barriers – not just because of costs but also because of access issues.
The Republic of Moldova – where around one in eight adults (12.3% of the population) has diabetes or reduced tolerance to glucose according to a 2014 survey (1) – has tried to address these issues within its broader health systems strengthening. Financial access to services improved with the introduction of mandatory health insurance in 2002, which became fully operational in 2004. Health expenditure as a percentage of state budget has increased to an appropriate and stable level. There has been an expansion of coverage of basic health services, enabling universal access to primary health care and pre-hospital emergency care, and additional benefits introduced to expand coverage to drugs prescribed in outpatient settings.
Positive developments in the last decade relating to pharmaceuticals that are of relevance to diabetes include: increased funding for public reimbursement of outpatient drugs; introduction of external reference pricing; inclusion of insulin in the list of reimbursed drugs since 2013; and introduction of mandatory generic prescribing (2). All Moldovan citizens are now entitled to free access to oral medicines for diabetes and insulin: there are three types of insulin and four oral medicines for diabetes that are 100% reimbursable.
Previously, insulin shortages had been reported by both patient representatives and doctors which were thought to be the result of distribution problems, ineffective systems for monitoring stock levels, and the high number of tests required by the quality control system that caused delays in supply. There has been a change in the procurement of insulin since 2013, with a move from a national tender programme to decentralized procurement by pharmacies. In principle, such a move was expected to lead to several positive changes: a more reliable supply; increased choice of insulin types; greater availability across the country; and shorter travel times for patients.
There is still some way to go but the general view of clinicians and patients is that great progress has been made. The Republic of Moldova has also recognised that access to medicines needs to be addressed in parallel to creating a health system able to manage all aspects of diabetes care.
(1) WHO, Republic of Moldova STEPS survey 2013: Fact sheet. 2014, World Health Organization: Geneva
(2) WHO Regional Office for Europe, Better noncommunicable disease outcomes: challenges and opportunities for health systems. Republic of Moldova country assessment. 2014, World Health Organization: Copenhagen