Nordisk Mexico – Erik Bakker, Market Access and Public Affairs Director
Novo Nordisk’s market access and public affairs director discusses the state of diabetes management in Mexico, highlighting the government’s recent commitment to tackle this public health issue and the company’s contribution to the dialogue.
When I first arrived in Mexico back in 2012 it was on what was supposed to be a business trip to set up a public affairs department. Eventually, I was offered the opportunity to stay permanently, which I decided to accept and I got market access just a few months ago.
Given our objectives, my timing couldn’t have been better, as it was the perfect moment for us to position ourselves in the new healthcare community and to define our priorities as an affiliate. I arrived just as the president-elect and his transition team were working closely with industry stakeholders, and because the ruling party changed, everyone had to establish new contacts, so we weren’t at any significant disadvantage against more established players.
We created ourselves a large opportunity by doing an in-depth survey about the knowledge and perception of diabetes among the Mexican population, which yielded many interesting findings. It showed for instance that a large proportion of patients with diabetes don’t know what type of diabetes they have and that there are many reasons why diabetes needs to be seen as a major public health issue. In general, there is a lot to be done in terms of awareness, treatment and prevention, as Mexico has one of the lowest insulin rates in the world – on the same level as certain less developed African countries, despite having much higher levels of income per capita. There are a number of prevalent myths surrounding insulin use, including that it causes blindness, and it is often seen only as a last resort before death or sometimes even the cause of death itself.
What are the reasons behind this stigma towards the use of insulin?
Doctors often threaten patients with an insulin prescription to motivate them to keep their glucose levels down, and are hesitant to put patients on insulin in the early stages, instead of treating it as the best –sometimes even the only – solution for the management of diabetes, where it is better to start quickly rather than wait. Part of the problem may be that while diabetes is the biggest healthcare issue in Mexico, medical students in average only spend ten hours of classroom on the disease.
I recently interviewed a patient, who is also a medical doctor; both his parents have diabetes and he was diagnosed at age 46, when he was in good shape and began insulin treatment immediately. That’s the way this disease needs to be handled, particularly when it’s evident that the patient is genetically predisposed to the condition, as it is the case for most Mexicans. It can prevent patients from reaching the late stages of the disease, or even reverse them if caught early enough, and reduces the overall costs of treatment. There really is an incredible amount to be done in terms of prevention in Mexico, which all has to begin with improving education on the subject; there is a lot of information available, of course, but our surveys reveal that even diagnosed patients aren’t particularly informed on the topic.
On the topic of prevention and given the burden diabetes is putting on the healthcare system as the third leading cause of death in the country, how would you assess the government’s commitment to the issue?
Given the low rates of diagnosis, it could very well be the leading cause of death in the country; however, in terms of mortality, patients rather die from strokes, heart attacks and other complications. The minister of health has called the situation a public health emergency and made a powerful statement explaining that if we don’t address diabetes and its consequences today, we’ll lose the gains in life expectancy from the last 40 years. Yet, it is a bit hard to get peoples’ attention with this issue because it kills very slowly and culturally Mexicans are quite fatalist. The federal government recognized very early that they are unable to tackle this issue on their own, and that all stakeholders –including state and municipal governments, civil organizations, and the private sector – must play an active role in improving the standard of treatment for diabetes.
After we finished our awareness survey, we had a press conference to which we invited the health coordinator of the president’s transition team and a senator of the ruling party. After presenting our findings, which showed the stark reality of how poorly diabetes is understood and treated in Mexico, the incoming administration responded with a firm commitment and showed their will to actively work with the industry to determine what could be done to improve the situation most effectively.
What role is Novo Nordisk as worldwide leader in diabetes treatment playing to revert this trend?
Novo Nordisk relies on an indisputable leadership in diabetes that no other player has and, at the end of the day, our goal is to ensure that patients are diagnosed and treated, so they can avoid suffering from serious complications, live longer and enjoy the same quality of life as a healthy person without diabetes. To achieve this, we want to change the perception of diabetes in Mexico, so that it is viewed as a manageable condition rather than a disease, and patients are seen as people with diabetes who can be fully healthy, instead of ‘diabetics’.
Perhaps the best evidence of Novo Nordisk’s commitment to making progress in diabetes in Mexico is the priority that has been placed on getting new products approved here. Mexico was the third country to approve and the first country in the Americas to launch our long-acting insulin Tresiba® and the first country to approve and launch Ryzodeg®, an innovative combination of Novo’s fast-acting insulin aspart, sold as NovoRapid® on its own, with Tresiba®, which was launched just four months ago. We also have recently submitted an anti-obesity drug, and hope we will be one of the first countries to launch this product as well.
There are approximately thirteen million people with diabetes in Mexico, and half of them are undiagnosed. This means there really is a greater need here than in many other countries, which is what has motivated us to bring the products, support the initiatives and make the investments we have done so far. According to the national health and nutrition survey, 25 percent of diabetes patients have their condition ‘under control’, but that’s only 25 percent of diagnosed patients, and ‘under control’ doesn’t mean that they are being treated in a way which results in the best patient outcomes. There are at least 11.4 million people with diabetes whose condition is not being treated either adequately or at all.
How do you define ‘best patient outcome’?
Best patient outcome to us means completely free of complications, and given the extremely low insulin rate use in Mexico, patient outcomes can be greatly improved. The first crucial two steps to improving the situation is increasing the insulin use rate, which consequently means training doctors on when patients need to be put on insulin and best treatment options available, and ensuring patients have access to these treatment options.
How would you assess market access in Mexico?
Market access in Mexico is quite good on the surface, as COFEPRIS (the Federal Commission for the Protection against Sanitary Risk) has made great improvements in recent years. However, the bigger issue is that following the initial registration it takes on average 4.2 years for a product to be generally available to the population through the public system. The rate at which new products are included in the public health scheme is extremely low, with only a few products each year and no products at all last year in IMSS. It’s very sad, because while it is understandable due to the burden of adding new products, there is clearly a lack of understanding in the public system on how much this burden will grow as patients remain untreated. Investing now and getting patients on insulin as early as possible can only improve patient outcomes and reduce the overall cost to the healthcare system by reducing the costs imposed by eventual hospitalizations. Of course, being able to properly understand and model these dynamics requires better data than the healthcare system currently has access to, as patient records are overall still on paper in Mexico. For this reason one of the first steps for improving overall quality of healthcare will be improving medical information management.
Yet, there is a lot of political will to affect significant change, and I am very optimistic that by the end of this presidential administration we will have witnessed some very significant changes. As you’ve seen with many of the recent reforms in other areas, they have managed to get some very extensive legislation through the congress, so I am confident that they will make some progress. Moreover, with seven or eight different public healthcare providers, increasing efficiency will require severe restructuring, as well as a sector-wide initiative to professionalize administration and management, something the federal ministry of health recently announced. Alas, achieving any progress in this regard will be very challenging because of the fragmentation of the Mexican healthcare system.
What is Novo Nordisk’s goal or vision for Mexico?
What we want to achieve is a change in diabetes care: we’re lobbying to make sure diabetes is seen as a healthcare priority for the country and that sufficient funds are being allocated to fight the disease. In part, this involves education to change mindsets, so people understand that insulin is the best treatment available, that patients need to start taking insulin as early as possible to prevent complications, and that quality care is what patients need to demand and healthcare providers need to provide.
The big problem is evidence, because beyond the data available from the national health and nutrition survey of 2012, the World Health Organization and the International Diabetes Federation, there isn’t much available in Mexico so having a fact-based discussion about actual costs is nearly impossible. As far as we can tell, the diabetes situation could have actually worsened considerably from 2006 to 2012.
So one of our goals is to help improve the quality of data on the prevalence of diabetes in the Mexican population, and we are starting by gathering a representative sample throughout all the municipalities of Mexico City. Once we’ve developed this new data and the new methodology, we will have a better idea of the prevalence of the condition, diagnosis, treatment rates and quality to later replicate the study in other major cities like Monterrey, Guadalajara and Merida.
With so much remaining to be done in the Mexican diabetes market, what is your top priority?
Finding the most skilled staff and building a strong team. The public affairs and market access department is new to Novo Nordisk Mexico and is a relatively new specialty worldwide, so we are still working on establishing a good team in general. There is also the challenge of finding the right type of people in terms of ethics as there are a lot of unethical practices in Mexico. Novo Nordisk worldwide always plays a very clean game in terms of business ethics and Mexico is no exception to this rule.
To read more articles and interviews from Mexico, and to download the latest free report on the country, click here.