Alexander Boiko, general manager of Novo Nordisk Ukraine, provides insights into the recent progress and remaining room for improvement in Ukraine’s health capacity when it comes to preventing, diagnosing, and treating diabetes, as well as the company’s unique commitment to partner with the government at the moment an unprecedented set of reforms aims to further enhance the country’s overall health system.
You set up Novo Nordisk’s Ukrainian affiliate in 1993, which means you have been a privileged witness to the modern history of Ukraine’s health system. What is your assessment of the country’s diabetes capacity and its evolution?
“Beside very recent initiatives, no significant health reform has been implemented over the 25 years that followed our country’s independence in 1991, and our country’s health outcomes have been worryingly decreasing since the Soviet era.”
Beside very recent initiatives, no significant health reform has been implemented over the 25 years that followed our country’s independence in 1991, and our country’s health outcomes have been worryingly decreasing since the Soviet era. Looking specifically at diabetes, Ukraine still unfortunately remains a white spot on the global map of the International Diabetes Federation. Cardiovascular diseases stand as the leading cause of death in Ukraine, and it is now proven that diabetic adults are two to four times more likely to die from heart disease than adults without diabetes. Despite these scientific evidences, diabetes is still not high on the government’s agenda.
Ukraine’s official diabetes prevalence rate amounts to 2.8 percent of the adult population, which means our country holds around 1.3 million diagnosed patients overall. I recently visited Novo Nordisk’s affiliate in Bulgaria, a country with a population of seven million inhabitants, which moreover holds 500.000 diabetes patients, of which 100.000 are treated with insulin. Despite our country’s population being almost six times larger than Bulgaria, less than 200.000 Ukrainian diabetic patients are under insulin treatments. These dramatic numbers prove that a substantial number of our patients are still undiagnosed and untreated, do not get the treatment they need to control diabetes and they carry a high risk to develop dramatic complications.
As a company, we tirelessly strive to bring Novo Nordisk’s global diabetes expertise and international capacity to the Ukrainian ecosystem, from physician oriented education programs to a digital platform offering comprehensive information on the disease symptoms and its management. Nevertheless, as long as our country will not follow the approach already implemented by other advanced countries and truly approach diabetes as an epidemic that requires nation-wide programs and resources, we will not see any significant rise in positive patient outcomes. Ukraine’s previous national plan for diabetes came to an end in 2013, and we are still waiting for a new version to be released; although several drafts were designed, none of them have been approved.
There is however no time to lose. Our country very likely holds hundreds of thousands of undiagnosed diabetic patients. Without the rapid set up of targeted programs, these patients have a very high chance of developing diseases complications, which will generate an unsustainable economic burden for our health system. In a nutshell, it is high time that our country’s public authorities fully measure that – if we are not able to better control the disease – diabetes will become a real threat to our country.
Fortunately, we currently see that the current government is particularly committed to reforming our country’s health system. In this context, we have a role to play in shaping our diabetic capacity that would generate heightened patient outcomes. For example, I was actively involved in cross-sector working groups that aimed to design the recently implemented reform of the insulin supply.
Could you provide insights into this recent reform as well as the role that the Novo Nordisk has played in its design?
This reform aims to finally introduce a prescription-based system for insulin supply and delivery, instead of Ukraine’s historical tender-based approach, which forced patients to deal with frequently delayed tenders and insufficient supply. Furthermore, this reform will also ensure insulin is now stored and supplied at the pharmacy level in appropriate conditions– and not in hospitals any longer, where the cool chain was not always maintained.
Throughout the design phase of this critical reform, Novo Nordisk Ukraine has been extensively collaborating with public authorities and others related stakeholders, bringing data and international expertise to the table, as well as showcasing innovative solutions already implemented in other countries where Novo Nordisk also operates.
Unfortunately, this reform has not yet been implemented across the entire country – although the number of Ukrainian regions that have already completed this crucial transition keeps on increasing month after month. Furthermore, the recent implementation of a reimbursement mechanism covering 21 International Nonproprietary Names (INNs) could ramp up the selection process of the pharmacies involved in this insulin program, as the government could basically rely on the same pharmacies for both projects.
This pioneering implementation of a reimbursement mechanism in Ukraine will cover products in three therapeutic areas: cardiovascular diseases, asthma, and diabetes. What is your assessment of this important reform, in a country where over 85 percent of the medicine spending comes at out-of-pocket expenses?
The introduction of this reimbursement mechanism already stands as a great step forward for our health system – although only two diabetes-related INNs (metformin and glucozide) are covered in this first version of the program. As for the reform of insulin supply, the pharmaceutical industry in general and international innovators in particular were heavily involved in its design. After a first version was considered unsatisfactory to the eyes of industry players, we then worked with the government to develop of more sustainable system, which ultimately became operational on April 1st 2017 .
As it is, the current reimbursement mechanism still holds substantial rooms for improvement, but it definitely stands as a very positive change, which will moreover ensure Ukrainian patients experience a healthcare structure that is more aligned with the best international standards. In this regard, I am glad to see that all kinds of pharmacies can become part of the reimbursement mechanism, including independent dispensaries, which undoubtedly stands as the most patient centric way forward, in a country where many experts still seem to consider that only pharmacy chains should be involved in state procurement programs.
Furthermore, this reimbursement mechanism will also provide patients with a greater access to the 21 INNs initially covered, which is the only way to tackle Ukraine’s high share of out-of-pocket spending. Second, this new system will also ensure that prescription medicines are only provided to the patients holding the right prescription, which will help eliminate fraudulent situations.
Finally, this reimbursement and price compensation system will incite patients to visit their doctors more often and drastically reduce self-medication, which still stands as a major issue in Ukraine. In the meantime, more frequent doctor visits should allow improving our country’s screening and diagnostic capacities, whether it relates to diabetes or any other chronic diseases.
You just mentioned the crucial need to set up a nation-wide, targeted program to tackle diabetes in Ukraine. What should be this program’s main areas of focus?
First and foremost, we need to enhance our country’s diagnostic capacity, as we believe that Ukraine’s low prevalence rate is mostly due to our country’s inefficient screening infrastructure. As part of Novo Nordisk’s strong commitment to raising health outcomes in Ukraine, we for example set up free screening events and initiatives throughout the country, which are available to all adults that are willing to know their sugar level. To date, more than 30.000 Ukrainians have been screened thanks to this program. Worryingly, we found that around six percent of them had elevated sugar levels, while a large share of them were treatment naïve – which is way above our Ukraine’s official data.
In the meantime, we know that the right diagnostic does not lead to treatment efficacy without providing patients with a better understanding of the risks they face. As a result, we also decided to add specialized care units and nurses to our screening program, in order to advise recently diagnosed patients and raise awareness on the complications they may risk to develop if they do not appropriately manage their bodies’ levels of glucose.
When it comes to diagnosed patients, our country’s diabetes program should focus on treatment outcomes, which means key indicators of the treatments have to be diligently monitored. In 2013, Novo Nordisk Ukraine provided a USD two million humanitarian aid which notably comprised the supply of 1.000 HbA1c express analyzers and 100.000 tests [also called glycated haemoglobin tests, which give a good indication of how well a patient’s diabetes is being managed without having to conduct laboratory testings, e.d.]. As these testing devices can be connected to computers, we have been able to collect more than 85.000 patient-related data, whose analysis has shown that only 25 percent of diabetic patients actually meet their treatment targets, while more than 50 percent are completely out of range.
Finally, we need to dramatically increase the level of resources dedicated to diseases prevention and specific education programs, and truly integrate them within Ukraine’s reformed health system.
Beside its main areas of focus, we also need to design and prioritize this program’s next steps. In this vein, I identify two critical success factors: first, holding a precise and comprehensive understanding of the disease’s multiple dimensions, and, second, setting up efficient monitoring tools to control the impact of this program. As a company, Novo Nordisk holds a wealth of experience in the setup of national programs focused on diabetes, and this is definitely an area where we could closely collaborate with the government.
Is Novo Nordisk’s full portfolio available to Ukrainian patients?
Ukrainian patients can access the vast majority of Novo Nordisk products, while our company’s most recent and innovative products are now passing through the registration process. Nevertheless, due to Ukraine’s difficult economic situation and the large share of out-of-pocket spending that characterizes our country’s health system, most of the diabetes market still revolves around human insulin.
In this regard, we regret that negotiations with public authorities mainly relate to the absolute costs of products, rather than the outcomes they can offer to patients. This unfortunate mindset also trickles down to the doctor’s level, as they often decide to only prescribe the cheapest therapeutic options to their patients. This approach then prevents diabetic patients from choosing between different alternatives, whereas the latter could offer greater outcomes when it comes to disease management and weight control, for example.
What would be your final message?
Novo Nordisk has been operating in Ukraine for more than 25 years – a long-standing presence that truly makes a difference. Our company has already proven throughout all these years that it truly stands as the long-term partner of all Ukrainian stakeholders, physicians, and patients. The affiliate has successfully overcome many crises: in 1998, 2008, and 2013, which means we have been able to ensure patients can still access their highly needed drugs, regardless of the currency rate or the performance of the local pharmaceutical market. In the grand scheme of things, Ukraine’s ecosystem is constantly changing and always challenging; as per the affiliate, we have been through market disruptions that probably very few European Novo Nordisk offices have ever experienced.
As a company dedicated to the improvement of the lives of our patients, we however will never abandon them. In 2015, at the height of the crisis, we for instance provided a substantial quantity of insulin free of charge to some Ukrainian regions. Patients know they can rely on Novo Nordisk – whatever the market conditions are.