Similar problems are found in about a third of the countries regarding physical access to certain diabetes products and their points of dispensing. In all these countries most diabetes supplies can be dispensed at community level – mainly through local pharmacies. However, some supplies, especially medical devices, are dispensed at healthcare facilities, alongside visits to the doctor – and thus, are also affected by the difficulties mentioned above. Additionally, quotas and budget constraints are causing delays and inequalities in local access to certain devices, such as insulin pumps. In Portugal, the national quota on pumps translates into an up to two-year waiting list. As they can only be offered and dispensed at city hospitals, this leads to inequalities between urban and rural populations. Similar discrepancies are found in Croatia, where pumps have to be financed on the individual budget of each healthcare facility, and are therefore less available outside the capital city. Economic constraints also cause difficulties in the supply chain. Diabetes products do not appear to be affected to the same degree as healthcare professionals report for other medicines or devices.8,9 Nonetheless, some stock issues affecting diabetes supplies were reported in at least four countries of the sub-region. The causes for these problems varied from one country to another and were not always clearly identified but a number of issues were cited as potential explanations. In a supply chain described by certain stakeholders as being under increasing regulatory and financial pressure,10 the smaller stocks and delays across the supply chain may lead to temporary shortages at the point of dispensing. In Cyprus, such delays in delivery appear to be also related to the difficulties experienced by healthcare facilities to pay their suppliers. An interesting issue for this sub-region is parallel trade: while Portugal continues apparently to experience shortages because of parallel trade, other countries have already implemented measures to prevent that such a practice affects people’s access to the supplies they need. For example, Greece has implemented compulsory reporting on parallel exports and requires certain stakeholders in the supply chain to maintain a set stock level at all times. As communications from the European Commission recalls,11,12 although restrictions on exports are generally prohibited by EU treaties, such restrictions may be justified and authorised to protect health and life. Despite the difficulties, it appears that the impact of stock shortages on people’s treatment is limited. In the four countries where such supply issues were reported, alternatives could be offered within a few days. However, these difficulties appear to be more of a burden for healthcare professionals than for people with diabetes. 24
“[When people face difficulties], they Although the accessibility of diabespeak to the doctor first, because it’s a tes treatment and supplies does not therapeutic matter. However, it creates represent the biggest barrier in this a state of frustration. Generally people sub-region, the growing difficulties with diabetes see the stakeholders as that people with diabetes face in enemies and complain about having to this regard are making this issue a fight not just with diabetes but also with concern for the future: the difficulties bureaucracy.” above place at risk much of what has been achieved in terms of access A response from Italy to treatment. Moreover, while these difficulties might have a small impact individually, they have a cumulative effect when added to the constraints relating to the availability of diabetes products and those due to their costs.
Affordability All the countries in the sub-region provide some kind of financial coverage for diabetes medicines and medical devices. However, as healthcare and healthcare funding remain national or local competences, the organisation of healthcare coverage and the coverage offered to individuals vary from one country to another. An overview of each country’s coverage is available in the country profiles. However a number of trends have been identified. Please note that financial criteria have to be paired or added to those applied to each prescription. Six countries out of the eight offer insulin free of charge. The two that do not, Greece and Spain, cover most of “The problem is that not all oral the cost of insulin. Insulin injection medications are available through our devices and consumables – except public health services, and what is not insulin pumps, which follow specific available has to be purchased by the criteria – are also provided for free person with diabetes. Some types of in almost all countries of the subinsulin, although available, might not region. However, the quantity may be prescribed to people with type 2 be limited. The situation is more diabetes. Blood glucose monitoring divided concerning oral medications. devices and strips have to be bought by Only Italy appears to fully cover people with type 2 diabetes.” all anti-diabetes medication. The other countries may be split in two A response from Malta groups. Four of them have chosen