Over 65 million people in India have diabetes, and the number is growing. Insulin injections are needed by all with Type 1 diabetics and some with Type 2. Insulin has kept people with diabetes alive into old age since its discovery in Canada nearly 100 years ago. Given the high demand for this life-saving treatment, one would expect healthy market competition, high availability and low prices.

Yet, a new study published in the BMJ Global Health shows the opposite in Delhi’s private-sector insulin market.

Researchers Abhishek Sharma and Warren Kaplan of Boston University found that compared to WHO standards, insulin availability is low and prices are essentially unaffordable for most patients in Delhi. They also found three multinational companies dominate this market: Novo Nordisk, Sanofi and Eli Lilly.

These ‘Big 3’ companies either import and/or licence insulin production in India. It’s not just India – the Big 3 controls 96 per cent of the global market. Lawmakers in the US also recently levelled allegations of price fixing by these companies

India has several insulin manufacturers, including Biocon and Wockhardt, which produce and supply human insulins (similar to the Big 3) at a fraction of the cost. However, Indian manufacturers struggle to get their products on Delhi pharmacy shelves. The BMJ study found that only 25 per cent of Delhi pharmacies stock any Indian insulin product.

So why do Indian insulin manufacturers struggle against the oligopoly of the ‘Big 3’?

Sharma and Kaplan interviewed local pharmacists and wholesalers, finding surprising results.

The Big 3 – through their larger physician base – cleverly target the moment when patients first start insulin to get them on their brands. The strategy makes sense as companies know patients rarely switch to other insulins. Disturbingly, however, the study found some doctors receive financial benefits from companies when they start patients on their insulin products.

Adding to this problem is a strange situation where the Government of India imposes stronger price controls on domestic insulin than on the foreign-produced drug. This allows the ‘Big 3’ to make higher profits than Indian companies, for supporting their aggressive marketing activities that influence doctors and others in the insulin supply chain.

Doctors and patients in India were also found to believe that insulin from foreign companies were better. Simply put, many do not trust Indian companies.

“If we are to eliminate this mistrust, the efficacy and safety of domestically produced insulins must be compared to that of imported products”, said Sharma. Kaplan adds, “companies and some doctors are selling insulin directly to patients, cutting out pharmacies… pharmacists are choosing either to not stock insulin or only stock more expensive foreign insulins that guarantee profits.”

Unlike the controversial prices for some new treatments, the most commonly sold insulins in India are off-patent. Insulin prices show intellectual property is often not the most important barrier to affordable drugs. Real competition is crucial.

Diabetes should not be death sentence anywhere. Yet in India, and many other countries, insulin prices are a life or death issue for millions. Research by T1International has found that insulin prices in India are low compared to high-income countries (especially the US), but it's high relative to average Indian incomes. With more Indians needing insulin every day, action must be taken.

The Government of India should act and tackle shady marketing schemes, conflicts of interest, and an uneven playing field that keeps Indian insulin producers from competing against the ‘Big 3’. All people in India who need insulin must be able to afford it.

(The writer is with T1International, a global diabetes advocacy charity -- #insulin4all @t1international. Views expressed are personal.)

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