to cover certain oral medicines fully, while other drugs have lower or no financial coverage. The other three countries opted for partial coverage of all anti-diabetes medication. The coverage for self-monitoring devices and consumables is limited throughout the sub-region. Each person’s disease status (treatment regimen, type of diabetes) is the determining factor. Although most people with diabetes have limited out-pocket expenditure for their diabetes products (see Table 2 and Annex), the coverage available in the sub-region raises two issues in terms of affordability. In the countries where some co-payments are required, any out-of-pocket expenditure may be an issue for those affected by the economic crisis; while the limited coverage offered to certain categories of people with diabetes (typically, people with type 2 diabetes and/or treated with oral medication) leads to affordability issues in these groups, and inequalities within the countries. Note that income-related waivers or benefits for spending on diabetes supplies are not available in all the countries of the sub-region. Additionally, even the above-mentioned coverage has yet to be extended to all people with diabetes, either because the overall health coverage scheme does not cover the whole population (as in Cyprus and Greece, for example) or because specific procedures need to be undertaken by people with diabetes or their healthcare providers (as in Italy and Malta).
Table 2: Expenditure on diabetes medicines and medical devices per year † Annual median out-ofpocket spending on diabetes products
Share of Household Net Adjusted Disposable Income spent on diabetes products
Share of Household Net Adjusted Disposable Income for the poorest 20% spent on diabetes products
Croatia
USD 0
OECD data unavailable
OECD data unavailable
Cyprus
USD 0
OECD data unavailable
OECD data unavailable
Greece*
USD 0
0%
0%
Italy
USD 0
0%
0%
Portugal
USD 353
2%
5%
Slovenia*
USD 0
0%
0%
USD 428
2%
6%
Spain*
* The samples of respondents in these countries included only people with type 1 diabetes or people treated with insulin. Thus, the reported annual out-of-pocket spending may not be representative. † This information could not be obtained in Malta.
25
Most countries in the sub-region appear to have protected the coverage scheme for diabetes since the economic crisis began. But the financial pressure on health systems has led to the introduction of new payments or an increase of fees for some or all people with diabetes – in Italy and Spain for example. Meanwhile across half of the sub-region, national diabetes associations fear that new or further constraints will be applied on diabetes products, starting with device consumables and/or new technologies. The pressure on public financ“Six months ago, the authorities agreed es is making many countries with manufacturers to lower the price in the sub-region try to reduce of blood glucose test strips. Agreements the costs of all medicines and were also made with suppliers to lower medical devices. As prices of profits on these throughout the supply some or all diabetes products chain.” appear to be regulated by the authorities, price reducA response from Slovenia tions appear to be one of the main tools used by countries of the sub-region. At least five countries have applied price cuts to some or all reimbursed products.13 These cuts may also impact other countries in the area as six of the eight use external reference pricing as a price-setting tool.14 The two countries that do not, Cyprus and Malta, apply public tenders to provide diabetes products to their public sector, which may also give them some room for price reductions. Policies to promote non-branded products over branded ones have been reported only in Italy and Spain. However, since the number of non-branded diabetes supplies available on these markets appears to be very limited, such policies are unlikely to affect strongly diabetes-related spending. Additionally, the choice of brand for some or all diabetes products is constrained by public tenders in at least four countries, while in others, prescribers appear to be the key decision-makers in this matter. As described above, many national diabetes associations worry that, under the current economic pressure, further cost-containment measures may be applied to diabetes supplies. A number of the associations expressed concerns that the quality of supplies available to people with diabetes may be also impacted by some of these measures. While certain costcontainment measures may not have a direct impact on people’s access to