From medicine price control to deregulation: assessing policy effects on insulin access in Pakistan’s private pharmacies

BACKGROUND: Pakistan faces the highest global prevalence of diabetes and has recently implemented a price deregulation policy for medicines not listed on the National Essential Medicines List (NEML). Pakistan's NEML 2023 is a direct adoption of the 23rd WHO Model EML rather than a country-specific prioritization; nonetheless, it has been used to identify medicines for exemption from price controls. METHODS: This study evaluated the effect of the price deregulation policy on insulin access in Pakistan. We surveyed 30 retail pharmacies across six regions using an adapted WHO/HAI approach. Post-deregulation data on consumer prices and availability were collected. Pre-deregulation prices were extracted from published sources. The insulin prices were standardized to 10 ml at 100 IU/ml. Difference-in-Differences (DiD) analysis was used to compare price changes between non-NEML insulins (treatment group) and NEML-listed insulins (control group), with each insulin product serving as the unit of analysis. The percentage of available insulin products and their affordability for the lowest-paid worker were calculated. Non-parametric tests were performed for categorical analyses. RESULTS: Overall, the median price of insulins increased by 31.87% (p < 0.001) i.e., from PKR 2030 (7.3 USD) to PKR 2678 (9.6 USD), after deregulation, except for short-acting human biosimilar (BS) insulins that stayed stable. As per the DiD-interaction term, prices of non-NEML insulins increased by 4.1 USD (p < 0.001) more than NEML insulins after deregulation. The median number of days' wages for the lowest-paid worker increased from 1.90 days before deregulation to 2.51 days after, to obtain a month's insulin supply. All surveyed outlets had at least one insulin product available. Originator brands (OB) had higher availability than BS, with 78.0% of human and 48.8% of analogue insulins available as OBs, compared to 51.1% and only 8.3% as BS insulins, respectively. CONCLUSION: Insulin prices increased significantly following the deregulation policy, particularly for non-NEML OBs, leading to reduced affordability despite fair availability. A policy review and stronger financial protection measures are needed to ensure equitable access to insulin.