Availability and affordability of antidiabetic medicines in Herat of Afghanistan in 2023

Abstract

Objectives

This study aims to investigate the availability, affordability, and accessibility of antidiabetic medications in Herat, Afghanistan, in 2023.

Methods

Adhering to WHO and HAI guidelines, a systematic survey approach was utilized to collect data on the pricing, availability, and affordability of commonly prescribed antidiabetic medications. Data collection spanned a month and involved four investigators using a standardized template. Data on the most-sold generic (MSG) and least expensive generic (LPG) options were compiled from pharmacies, and descriptive statistics were employed.

Results

The study reveals a heavy reliance on imported medications, mainly from Pakistan, with limited local production. Availability in pharmacies exhibited notable disparities, with essential medications sometimes lacking consistency. The financial analysis identified affordability challenges, particularly for certain Iranian and Pakistani brands. Notably, Metformin 500 mg emerged as the most consumed medication. Sitagliptin 50 mg had the highest average consumption when considering Pakistani brands, whereas Insulin Regular topped the list for Iranian brands.

Conclusions

The findings emphasize the need for comprehensive strategies to address diabetic patients’ challenges in Herat, Afghanistan. Strengthening the pharmaceutical supply chain, bolstering local production, and implementing measures to enhance medication affordability are crucial for improving diabetic care and advancing public health in the region.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01444-0.

Introduction

The pursuit of providing affordable, high-quality pharmaceuticals is essential for global healthcare [1]. Medicines, being pivotal components of the healthcare paradigm, constitute a fundamental aspect of the inherent human entitlement to holistic well-being [2, 3]. Unfortunately, due to high prices, one-third of the global population cannot afford necessary medications [3, 4]. A staggering 90% of low- and middle-income residents are responsible for paying for their own pharmaceutical needs out-of-pocket [4]. Simultaneously, a substantial range, spanning from 20 to 60% of healthcare expenditures, is intricately linked to the realm of pharmaceutical costs [5]. Policymakers in the healthcare industry are encouraged to revisit their pharmaceutical valuation strategies to improve availability, accessibility, and affordability in Low- and Middle-Income Countries (LMICs). This aligns with the principles of the World Health Organization (WHO) [1].

The chronic disorder known as diabetes mellitus, fraught with an array of complications, exerts a significant impact on the global healthcare landscape, contributing substantially to its increasing burdens [6]. Within the annals of mortality statistics, diabetes has assumed the position of the seventh leading cause of death in the United States [7]. Diabetes affects a large population of 422 million people globally, with the majority of cases being in low- and middle-income areas [7, 8]. This disease claims the lives of 1.5 million individuals every year [8].

In terms of the escalation of caseloads and the augmentation of prevalence, a continuous upward trajectory is evident in the historical records of diabetes over the past decades [9]. The International Diabetes Federation predicts that the number of people with diabetes will increase by 50% from 366 million in 2011 to an estimated number by 2030 [10]. This epidemiological upsurge is linked to population aging, obesity prevalence, and prolonged diabetes [11], underscores the potential for preventing afflictions and reducing mortality if pharmaceutical solutions for people with diabetes are made affordable and accessible [12].

NCDs are a growing problem in Afghanistan, accounting for over 35% of all deaths [13]. Diabetes is the third leading cause of death, with a prevalence of 2.7% among women and 3.7% among men [13]. WHO reports an 8.4% prevalence of diabetes and a 13.9% overweight rate among Afghani residents. A meta-analysis shows a 12.13% prevalence of diabetes across the country [13]. The Institute of Health Metrics and Evaluation (IHME), through estimative endeavors, burdens Afghanistan with an unfortunate mortality rate of 162 (ranging from 129 to 196) per 100,000 inhabitants, all attributed to the impact of NCDs [14]. Data on affordable diabetic medication accessibility in low- and middle-income areas is lacking [15, 16]. Antidiabetic treatment availability, affordability, and accessibility in Afghanistan are rarely discussed [17].

Afghanistan’s health expenditure is around 16.8% of its GDP [18]. The government’s financial commitment is only 5.1% [19]. Private donors cover 75.5%, and external donors contribute 19.4% [20]. Public health mechanisms insure almost 80% of the population [21]. The pharmaceutical expenditure in 2017 was $872 million, which accounts for approximately 34% of the entire health expenditure [20]. Public health services are free, while private healthcare can be costly [21].

Health economics manages resources and payments to reduce patient costs and improve access to healthcare. It also involves efficient resource allocation based on justice to provide effective treatment [22, 23]. Public access to pharmaceuticals is limited, particularly for pharmacotherapy and diabetic medications, causing significant upheaval in the country [24]. Therefore, this scholarly pursuit aims to meticulously assess the affordability and accessibility of antidiabetic medications in the urban area of Herat, Afghanistan.

Method

Study design

This investigation aims to obtain reliable insights into the cost, accessibility, and economic affordability of anti-diabetic medications within Herat, Afghanistan, during the year 2023. Herat, the third-largest city in Afghanistan, had an approximate population of 665,477 in 2023 and served as the capital of Herat Province. The methodology adopted for this study is grounded in the approach devised by the World Health Organization (WHO) and Health Action International (HAI) [25], a framework previously employed in various cross-national studies [26–30]. WHO and HAI conducted a systematic survey in 2019 to amass data on the pricing, availability, and affordability of principal anti-diabetic medicines, offering policy directives to tackle associated challenges [17]. This approach allows each nation to select a supplementary roster of medicines aimed at addressing critical domestic health concerns. The model consists of three core components: pricing, affordability, and accessibility.

Pricing aspect and affordability

The pricing aspect of this study is quantified per unit, denoting doses or tablets. Retail prices were documented within both the public and private sectors. The prices of medicines were translated into units and logged on the day of data compilation, encompassing solely registered products. Current pharmacy transactions furnished the price data. An anti-diabetic medicine is deemed affordable if its procurement cost does not strain household finances. In alignment with the WHO/HAI guidelines for assessing Medicine Prices and Affordability, we used two approaches for determining affordability in this study:

First approach: We have calculated the duration of usage for all diabetic medications on a monthly basis. This calculation takes into account the specific drug items, dosage, and treatment regimens recommended in international guidelines. A medication is considered affordable if the out-of-pocket expense for a patient’s daily dose is equal to or less than 20% of the daily minimum wage for workers, as specified by labor law. If the cost exceeds this threshold, it is deemed unaffordable.

Second approach: We assess the affordability of a medication based on whether its cost is equal to or falls below the minimum daily wage for workers within a month. The medication is considered affordable if the cost is within or below this threshold. Conversely, the medication is deemed unaffordable if the cost exceeds the minimum daily wage. The minimum daily salary used for this calculation is based on the official announcement from the labor office in Afghanistan [29].

Accessibility aspect

To gauge medicine availability, all outlets were canvassed and expressed as a percentage in both public and private domains, corresponding to the data collection day. Using this framework, availability below 30% is classified as very low, 30–49% as low, 50–80% as reasonably high, and surpassing 80% as high [25].

Data collection and analysis

This study focused on the pricing, accessibility, and affordability of 18 predominantly marketed generic (MSG) and least expensive generic (LPG) products. The sample includes a variety of anti-diabetic medications with standardized dosages such as, Metformin 500, Metformin 850, Metformin 1000, Sitagliptin 50, Sitagliptin 100, Glimepiride 1, Glimepiride 2, Glimepiride 3, Glimepiride 4, Glibenclamide 5, Empagliflozin 25, Dapagliflozin 5, Dapagliflozin 10, Empagliflozin + Metformin 5 mg/500, Empagliflozin + MET 5/850 mg, Pioglitazone + Metformin 15/500 mg, Pioglitazone + Metformin 15/850 mg, Empagliflozin + Metformin 12.5/800 mg, Glimepiride + Metformin 1/500 mg, Glimepiride + Metformin 2/500 mg, Sitagliptin + Metformin 50/500 mg, Sitagliptin + Metformin 50/1000 mg, Insulin NPH, Insulin Regular, Insulin glargine, Insulin Aspart, Insulin mix, Glebinclamid + Metformin 5/500 mg, linagliptin 5 mg, Gliclazide 30 mg, Gliclazide 60 mg, Empagliflozin 10 mg, and, Glibenclamid + metformin 2.5\500. The list provided only includes a standardized dosage for each Anti-Diabetic medication in Afghanistan. Although other products within this pharmaceutical category may not be included in this list, it is a comprehensive and accurate representation of available medications. To gain an enhanced comprehension of the comparative cost of anti-diabetic medicines within Afghanistan versus other markets, prices were also surveyed in select countries offering economical medications. We used a stratified random sampling method to select pharmacies. The five districts (North, South, West, East, and Central) were treated as separate strata, and the sample size was determined in proportion to the number of pharmacies in each district. In total, 72 pharmacies were included in the study.

Over a month, four well-versed investigators collected data by inspecting medicine vendors and employing a standardized data collection template. Data were compiled for the most-sold generic (MSG) and least expensive generic (LPG) options across all pharmacies for each medicine under scrutiny. Descriptive statistics were computed, including frequencies, percentages, means, and standard deviations.

Results

The findings of this study on the pharmaceutical landscape in Afghanistan, shown in Table 1, reveal that the majority of Afghanistan’s diabetes medicines are obtained from Pakistan. A significant portion of the medications utilized in Afghanistan, approximately 90%, are either produced in Pakistan or imported through this neighboring nation. Compared to Pakistan, Iran has a relatively small presence in Afghanistan’s pharmaceutical market, specifically in terms of insulins. Furthermore, other countries have minimal involvement in the anti-diabetic pharmaceutical sector within Afghanistan (Table 1).

Table 1.

Availability of different types of Diabetic medicines in the city of Herat, Afghanistan

Drug	Iran	Pakistan	Average
Dapagliflozin 10 mg	0%	19%	9.5%
Dapagliflozin 5 mg	0%	19%	9.5%
Empagliflozin 10 mg	0%	1%	0.5%
Empagliflozin 25 mg	1%	4%	2.5%
Empagliflozin + Metformin 125/800 mg	0%	11%	5.5%
Empagliflozin + Metformin 5/500 mg	0%	19%	9.5%
Empagliflozin + Metformin 5/850 mg	0%	22%	11%
Glibenclamide 5 mg	1%	46%	23.5%
Glibenclamide + Metformin 25/500 mg	0%	6%	3%
Glibenclamide + Metformin 5/500 mg	0%	40%	20%
Gliclazide 30 mg	0%	1%	0.5%
Gliclazide 60 mg	0%	0%	0%
Glimepiride 1 mg	0%	67%	33.5%
Glimepiride 2 mg	0%	65%	32.5%
Glimepiride 3 mg	0%	57%	28.5%
Glimepiride 4 mg	0%	58%	29%
Glimepiride + Metformin 1/500 mg	0%	43%	21.5%
Glimepiride + Metformin 2/500 mg	0%	42%	21%
Insulin Aspart mg	0%	0%	0%
Insulin Glargine mg	0%	1%	0.5%
Insulin Mix mg	14%	10%	12%
Insulin NPH mg	8%	11%	9.5%
Insulin Regular mg	32%	15%	23.5%
Linagliptin 5 mg	0%	3%	1.5%
Metformin 1000 mg	0%	71%	35.5%
Metformin 500 mg	0%	81%	40.5%
Metformin 850 mg	0%	17%	8.5%
Pioglitazone + Metformin 15/500 mg	0%	4%	2%
Pioglitazone + Metformin 15/850 mg	0%	3%	1.5%
Sitagliptin 100 mg	0%	22%	11%
Sitagliptin 50 mg	0%	35%	17.5%
Sitagliptin + Metformin 50/1000 mg	0%	49%	24.5%
Sitagliptin + Metformin 50/500 mg	0%	50%	25%
Average	1.7%	27%	14.4%

Table 2 demonstrates the analysis of the number of pharmacies surveyed and the range of drug prices at these pharmacies. Our findings indicate that none of the drugs included in the study were available in all Herat City pharmacies. The results demonstrated that the generic Gliclazide 60 mg and Insulin Aspart were not available drugs to patients, and the most known drug for diabetic patients in Afghanistan is Metformin 500 mg (Table 2).

Table 2.

Lowest-priced generic and most-sold generic medicine based on manufacturing country in different areas of Herat, Afghanistan (USD)

#	medicine	Pakistan			Iran
		number	LPG	MSG	number	LPG	MSG
1	Metformin 500 mg	56	0.0003	0.0005	-	-	-
2	Metformin 850 mg	12	0.0004	0.0006	-	-	-
3	Metformin 1000 mg	49	0.0005	0.0008	-	-	-
4	Sitagliptin 50 mg	22	0.0016	0.0037	-	-	-
5	Sitagliptin 100 mg	14	0.0035	0.0047	-	-	-
6	Glimepiride 1 mg	45	0.0006	0.0016	-	-	-
7	Glimepiride 2 mg	45	0.0010	0.0027	-	-	-
8	Glimepiride 3 mg	38	0.0012	0.0031	-	-	-
9	Glimepiride 4 mg	39	0.0014	0.0041	-	-	-
10	Glibenclamide 5 mg	31	0.0002	0.0015	-	-	-
11	Empagliflozin 10 mg	1	0.0027	0.0027	-	-	-
12	Empagliflozin 25 mg	4	0.0006	0.0041	-	-	-
13	Dapagliflozin 5 mg	13	0.0018	0.0029	-	-	-
14	Dapagliflozin 10 mg	13	0.0029	0.0040	-	-	-
15	Linagliptin 5 mg	2	0.0014	0.0024	-	-	-
16	Gliclazide 30 mg	1	0.0006	0.0033	-	-	-
17	Gliclazide 60 mg	0	0.0000	0.0000	-	-	-
18	Empagliflozin 5 mg + Metformin 500 mg	14	0.0010	0.0027	-	-	-
19	Empagliflozin 5 mg + Metformin 850 mg	16	0.0014	0.0033	-	-	-
20	Empagliflozin 12.5 mg + Metformin 850 mg	7	0.0012	0.0043	-	-	-
21	Pioglitazone 15 mg + Metformin 500 mg	3	0.0006	0.0008	-	-	-
22	Pioglitazone 15 mg + Metformin 850 mg	2	0.0008	0.0008	-	-	-
23	Glimepiride 1 mg + Metformin 500 mg	29	0.0007	0.0029	-	-	-
24	Glimepiride 2 mg + Metformin 500 mg	28	0.0009	0.0051	-	-	-
25	Sitagliptin 50 mg + Metformin 500 mg	36	0.0018	0.0047	-	-	-
26	Sitagliptin 50 mg + Metformin 1000 mg	35	0.0019	0.0049	-	-	-
27	Glibenclamide 5 mg + Metformin 500 mg	27	0.0024	0.0043	-	-	-
28	Glibenclamide 5 mg + Metformin 500 mg	4	0.0008	0.0008	-	-	-
29	Insulin NPH	8	0.0024	0.0049	5	0.0024	0.0049
30	Insulin Regular	12	0.0024	0.0051	20	0.0024	0.0051
31	Insulin Glargine	1	0.0012	0.0067	-	-	-
32	Insulin Aspart	-	-	-	-	-	-
33	Insulin Mix	7	0.0031	0.0071	10	0.0031	0.0071

Based on the average medicine consumption in Afghanistan, as per Pakistan’s medicine brands, Sitagliptin 50 mg had the highest average consumption at 3423.33 ± 4814.76 mg, while Insulin Glargine had the lowest consumption at 1 ± 8.48 IU. On the other hand, when considering Iran’s medicine brands, Insulin Regular had the highest average medicine consumption at 65.66 ± 97.69 mg, whereas Empagliflozin 25 mg had the lowest medicine consumption at 8.75 ± 74.24 IU (Table 3).

Table 3.

Mean and standard deviation of affordability of diabetic medicines consumed in Herat based on the pharmaceutical products of Pakistan and Iran and the differences in the study population

#	Name of medicine	Pakistan	Iran
		Mean ± Standard Deviation
1	Metformin 500 mg	92.5 ± 47.7	-
2	Metformin 850 mg	237.5 ± 546.8	-
3	Metformin 1000 mg	1283.33 ± 848.86	-
4	Sitagliptin 50 mg	3423.33 ± 4814.76	-
5	Sitagliptin 100 mg	49.03 ± 92.64	-
6	Glimepiride 1 mg	1927.50 ± 1452.06	-
7	Glimepiride 2 mg	47.64 ± 36.59	-
8	Glimepiride 3 mg	78.79 ± 71.55	-
9	Glimepiride 4 mg	35.82 ± 31.91	-
10	Glibenclamide 5 mg	320.83 ± 523.93	11.67 ± 98.99
11	Empagliflozin 10 mg	3.16 ± 26.81	-
12	Empagliflozin 25 mg	96.25 ± 540.23	8.75 ± 74.24
13	Dapagliflozin 5 mg	150.83 ± 310.66	-
14	Dapagliflozin 10 mg	94.58 ± 194.74	-
15	Linagliptin 5 mg	7.92 ± 48.81	-
16	Gliclazide 30 mg	13.33 ± 113.13	-
17	Gliclazide 60 mg	-	-
18	Empagliflozin 5 mg + Metformin 500 mg	37.71 ± 81.07	-
19	Empagliflozin 5 mg + Metformin 850 mg	56.88 ± 116.27	-
20	Empagliflozin 12.5 mg + Metformin 850 mg	52.82 ± 154.59	-
21	Pioglitazone 15 mg + Metformin 500 mg	4.23 ± 20.47	-
22	Pioglitazone 15 mg + Metformin 850 mg	3.38 ± 19.99	-
23	Glimepiride 1 mg + Metformin 500 mg	82.46 ± 110.82	-
24	Glimepiride 2 mg + Metformin 500 mg	115.83 ± 179.98	-
25	Sitagliptin 50 mg + Metformin 500 mg	260.946 ± 289.94	-
26	Sitagliptin 50 mg + Metformin 1000 mg	271.88 ± 305.58	-
27	Glibenclamide 5 mg + Metformin 500 mg	65.83 ± 82.21	-
28	Glibenclamide 5 mg + Metformin 500 mg	6.67 ± 27.68	-
29	Insulin NPH	29.33 ± 83.93	17.07 ± 58
30	Insulin Regular	40.22 ± 100.25	65.66 ± 97.69
31	Insulin Glargine	1 ± 8.48	-
32	Insulin Aspart	-	-
33	Insulin Mix	39.16 ± 120.55	34 ± 86.06

Tables 4 and 5 indicate that the assessment of the patient’s financial capability is established by classifying their household’s decile position based on comparing the cost of one month’s medication with the minimum daily wage of a worker and comparing the daily medication expenses with 20% of the household’s income. The results of the study showed that according to the approach comparing the daily medication expenses with 20% of the household’s income, most of the Pakistani brand medicines could be provided for patients financially, except medicines included Metformin 850 mg, Metformin 1000 mg, Sitagliptin 50 mg, Glimepiride 1 mg, and Empagliflozin 25 mg. Furthermore, based on comparing the cost of one month’s medication with the minimum daily wage of a worker, there is no ability to pay for the purchase of most Iranian and Pakistani brand medicines among the people of Afghanistan.

Table 4.

The patient’s financial capacity is evaluated by categorizing their household’s decile ranking and comparing the daily medication expenses with 20% of the household’s income

#	Name of medicine	Affordable		Un- Affordable		Unavailable
		Pakistan	Iran	Pakistan	Iran	Pakistan	Iran
1	Metformin 500 mg	58(80.6%)	-	-	-	14(19.4%)	72(100%)
2	Metformin 850 mg	-	-	12(16.7%)	-	60(83.3%)	72(100%)
3	Metformin 1000 mg	-	-	51(70.8%)	-	21(29.2%)	72(100%)
4	Sitagliptin 50 mg	-	-	25(34.7%)	-	47(65.3%)	72(100%)
5	Sitagliptin 100 mg	16(22.2%)	-	-	-	56(77.8%)	72(100%)
6	Glimepiride 1 mg	-	-	48(66.7%)	-	24(33.3%)	72(100%)
7	Glimepiride 2 mg	47(65.3%)	-	-	-	25(34.7%)	72(100%)
8	Glimepiride 3 mg	41(56.9%)	-	-	-	31(43.1%)	72(100%)
9	Glimepiride 4 mg	42(58.3%)	-	-	-	30(41.7%)	72(100%)
10	Glibenclamide 5 mg	28(38.9%)	1(1.4%)	5(6.9%)	-	39(54.2%)	71(98.6%)
11	Empagliflozin 10 mg	1(1.4%)	-	-	-	71(98.6%)	72(100%)
12	Empagliflozin 25 mg	-	1(1.4%)	3(4.2%)	-	69(95.8%)	71(98.6%)
13	Dapagliflozin 5 mg	14(19.4%)	-	-	-	58(80.6%)	72(100%)
14	Dapagliflozin 10 mg	14(19.4%)	-	-	-	58(80.6%)	72(100%)
15	Linagliptin 5 mg	2(2.8%)	-	-	-	70(97.2%)	72(100%)
16	Gliclazide 30 mg	1(1.4%)	-	-	-	71(98.6%)	72(100%)
17	Gliclazide 60 mg	-	-	-	-	72(100%)	72(100%)
18	Empagliflozin 5 mg + Metformin 500 mg	14(19.4%)	-	-	-	58(80.6%)	72(100%)
19	Empagliflozin 5 mg + Metformin 850 mg	16(22.2%)	-	-	-	56(77.8%)	72(100%)
20	Empagliflozin 12.5 mg + Metformin 850 mg	8(11.1%)	-	-	-	64(88.9%)	72(100%)
21	Pioglitazone 15 mg + Metformin 500 mg	3(4.2%)	-	-	-	69(95.8%)	72(100%)
22	Pioglitazone 15 mg + Metformin 850 mg	2(2.8%)	-	-	-	70(97.2%)	72(100%)
23	Glimepiride 1 mg + Metformin 500 mg	31(43.1%)	-	-	-	41(56.9%)	72(100%)
24	Glimepiride 2 mg + Metformin 500 mg	30(41.7%)	-	-	-	42(58.3%)	72(100%)
25	Sitagliptin 50 mg + Metformin 500 mg	36(50.0%)	-	-	-	36(50.0%)	72(100%)
26	Sitagliptin 50 mg + Metformin 1000 mg	35(48.6%)	-	-	-	37(51.4%)	72(100%)
27	Glibenclamide 5 mg + Metformin 500 mg	29(40.3%)	-	-	-	253(87.8%)	72(100%)
28	Glibenclamide 5 mg + Metformin 500 mg	4(5.6%)	-	-	-	68(94.4%)	72(100%)
29	Insulin NPH	8(11.1%)	6(8.3%)	-	-	64(88.9%)	66(91.7%)
30	Insulin Regular	10(14.1%)	23(31.9%)	-	-	61(85.9%)	49(68.1%)
31	Insulin Glargine	1(1.4%)	-	-	-	71(98.6%)	72(100%)
32	Insulin Aspart	-	-	-	-	72(100%)	72(100%)
33	Insulin Mix	7(9.7%)	10(13.9%)	-	-	65(90.3%)	62(86.1%)

Table 5.

The assessment of the patient’s financial capability is established by classifying their household’s decile position based on comparing the cost of one month’s medication with the minimum daily wage of a worker

#	Name of medicine	Affordable		Un- Affordable		Unavailable
		Pakistan	Iran	Pakistan	Iran	Pakistan	Iran
1	Metformin 500 mg	58(80.6%)	-	-	-	14(19.4%)	72(100%)
2	Metformin 850 mg	-	-	12(16.7%)	-	60(83.3%)	72(100%)
3	Metformin 1000 mg	-	-	51(70.8%)	-	21(29.2%)	72(100%)
4	Sitagliptin 50 mg	-	-	25(347%)	-	47(65.3%)	72(100%)
5	Sitagliptin 100 mg	-	-	16(22.2%)	-	56(77.8%)	72(100%)
6	Glimepiride 1 mg	-	-	48(66.7%)	-	24(33.3%)	72(100%)
7	Glimepiride 2 mg	47(65.3%)	-	-	-	25(34.7%)	72(100%)
8	Glimepiride 3 mg	38(52.8%)	-	3(4.2%)	-	31(43.1%)	72(100%)
9	Glimepiride 4 mg	42(58.3%)	-	-	-	30(41.7%)	72(100%)
10	Glibenclamide 5 mg	-	-	33(45.8%)	1(1.4%)	39(54.2%)	71(98.6%)
11	Empagliflozin 10 mg	-	-	1(1.4%)	-	71(98.6%)	72(100%)
12	Empagliflozin 25 mg	-	-	3(4.2%)	1(1.4%)	69(95.8%)	71(98.6%)
13	Dapagliflozin 5 mg	-	-	14(19.4%)	-	58(80.6%)	72(100%)
14	Dapagliflozin 10 mg	-	-	14(19.4%)	-	58(80.6%)	72(100%)
15	Linagliptin 5 mg	-	-	2(2.8%)	-	70(97.2%)	72(100%)
16	Gliclazide 30 mg	-	-	1(1.4%)	-	71(98.6%)	72(100%)
17	Gliclazide 60 mg	-	-	-	-	72(100%)	72(100%)
18	Empagliflozin 5 mg + Metformin 500 mg	1(1.4%)	-	13(18.1%)	-	58(80.6%)	72(100%)
19	Empagliflozin 5 mg + Metformin 850 mg	-	-	16(22.2%)	-	56(77.8%)	72(100%)
20	Empagliflozin 12.5 mg + Metformin 850 mg	-	-	8(11.1%)	-	64(88.9%)	72(100%)
21	Pioglitazone 15 mg + Metformin 500 mg	3(4.2%)	-	-	-	69(95.8%)	72(100%)
22	Pioglitazone 15 mg + Metformin 850 mg	2(2.8%)	-	-	-	70(97.2%)	72(100%)
23	Glimepiride 1 mg + Metformin 500 mg	16(22.2%)	-	15(20.8%)	-	41(56.9%)	72(100%)
24	Glimepiride 2 mg + Metformin 500 mg	1(1.4%)	-	29(40.3%)	-	42(58.3%)	72(100%)
25	Sitagliptin 50 mg + Metformin 500 mg	-	-	36(50.0%)	-	36(50.0%)	72(100%)
26	Sitagliptin 50 mg + Metformin 1000 mg	-	-	35(48.6%)	-	37(51.4%)	72(100%)
27	Glibenclamide 5 mg + Metformin 500 mg	14(19.4%)	-	15(20.8%)	-	43(59.7%)	72(100%)
28	Glibenclamide 5 mg + Metformin 500 mg	4(5.6%)	-	-	-	68(94.4%)	72(100%)
29	Insulin NPH	-	1(1.4%)	8(11.1%)	5(6.9%)	66(91.7%)	66(91.7%)
30	Insulin Regular	-	2(2.8%)	10(14.1%)	21(29.2%)	61(85.9%)	49(68.1%)
31	Insulin Glargine	1(1.4%)	-	-	-	71(98.6%)	72(100%)
32	Insulin Aspart	-	-	-	-	72(100%)	72(100%)
33	Insulin Mix	-	-	7(9.7%)	10(13.9%)	65(90.3%)	62(86.1%)

Table 6 presents a comprehensive analysis of anti-diabetic medication prices in Afghanistan and comparative data from countries like Iran, Pakistan, India, Nigeria, and Egypt, which have the lowest prices. The prices of various brands or generics were collected from official sources, encompassing each medication’s lowest and highest price ranges. Subsequently, the daily treatment costs were computed based on this information.

Table 6.

Comparison of the prices of anti-diabetic medicines in Afghanistan and five countries (USD)

#	Name of Medicines	Iran	Pakistan	India	Nigeria	Egypt
1	Metformin 500	0.0133	0.0108	0.048	0.11	0.0224
2	Metformin 850	0	0.0129	0.0144	0.11	0.016
3	Metformin 1000	0.0195	0.0324	0.078	0.1375	0.0384
4	Sitagliptin 50	0.0473	0.0977	0.372	0.0786	0.1664
5	Sitagliptin 100	0.0926	0.171	0.378	0.2359	0.2624
6	Glimepiride 1	0.0222	0.0187	0.0481	0.0968	0.0211
7	Glimepiride 2	0.0236	0.0288	0.0768	0.1474	0.0448
8	Glimepiride 3	0.0251	0.045	0.0864	0.1562	0.0499
9	Glimepiride 4	0.0265	0.0597	0.1296	0.2684	0.064
10	Glibenclamide 5	0.0051	0.0075	0.06	0.0528	0.0115
11	Empagliflozin 25	0.1906	0.2736	0.684	1.5675	0.2432
12	Dapagliflozin 5	0.0377	0.0846	0.132	0.7865	0.112
13	Dapagliflozin 10	0.0553	0.1224	0.138	0.8833	0.3084
14	Empagliflozin + Metformin 5 mg/500	0.0740	0.0822	0.3576	0	0.1568
15	Empagliflozin + Metformin 5/850 mg	0	0.0601	0	0	0.1728
16	Pioglitazone+ Metformin 15/500 mg	0.0142	0.0252	0.0972	0.1749	0.0432
17	Pioglitazone+ Metformin 15/850 mg	0	0.04348	0	0.1881	0.0508
18	Empagliflozin + Metformin 12.5/800 mg	0	0.07405	0	0	0.2048
19	Glimepiride + Metformin 1/500 mg	0	0.0432	0.15	0.143	0.0384
20	Glimepiride + Metformin 2/500 mg	0	0.0442	0.156	0.154	0.048
21	Sitagliptin + Metformin 50/500 mg	0.0639	0.1004	0.342	0.1562	0.144
22	Sitagliptin + Metformin 50/1000 mg	0.0697	0.1130	0.36	0.1573	0.2016
23	Insulin NPH	1.6583 (1000 IU/10ML)	3.1572 (100IU/ML)	1.02 (40IU/ML)	7.59 (100IU/ML)	1.76 (100IU/ML)
24	Insulin Regular	1.6583 (1000 IU/10ML)	2.106 (100IU/ML)	1.02 (40IU/ML)	7.59 (100IU/ML)	1.76 (100IU/ML)
25	Insulin glargine	2.5591 (300 IU/3ML)	4.284 (300 IU/3ML)	14.4 (300 U/3ML)	8.558 (300 IU/3ML)	4.64 (300 IU/3ML)
26	Insulin Aspart	2.9622 (300 IU/3ML)	4.32 (300 IU/3ML)	9.48 (300 IU/3ML)	7.975 (300 IU/3ML)	3.392 (300 IU/3ML)
27	insulin mix	2.5591 (300 IU/3ML)	4.6296 (300 IU/3ML)	8.16 (300 IU/3ML)	7.975 (300 IU/3ML)	4.08 (300 IU/3ML)
28	Glibenclamide+ Metformin 5/500 mg	0.0109	0.0136	0.06	0.1826	0.0512
29	linagliptin 5 mg	0.0523	0.0216	0.096	0.6721	0.3507
30	Gliclazide 30 mg	0.0212	0.0288	0.09	0.0935	0.0307
31	Gliclazide 60 mg	0.0276	0.0648	0.126	0.1039	0.0512
32	Empagliflozin 10 mg	0.1147	0.252	0.48	0.5874	0.16
33	Glibenclamide+ Metformin 2.5\500	0.0100	0.0108	0.0408	0.1628	0.0288

Discussion

Based on our current understanding, there is a lack of comprehensive research on the extent of Afghanistan’s pharmaceutical market’s availability, accessibility, and affordability [30]. This detailed study provides an in-depth analysis of the antidiabetic medicines landscape in Herat, Afghanistan, in 2023. It uncovers several critical findings that shed light on the complex challenges faced by diabetic patients in the region.

One of the significant revelations of the study is the heavy reliance on imports in the pharmaceutical market in Herat, with Pakistan being the dominant supplier of about 90% of the anti-diabetic drugs consumed in Afghanistan. The study highlights the risks and concerns associated with such dependence on a single source, especially in the face of potential disruptions. According to a study by Semin and Güldal in 2008, the effect of globalization on the pharmaceutical sector has resulted in a decrease in exportation and domestic production, accompanied by an increase in importation of pharmaceuticals and a rise in prices and expenditures [31]. However, in the case of Afghanistan, the lack of industrialization, especially in the healthcare sector and pharmaceutical industries, plays a pivotal role in this country’s dependence on foreign products [32].

The study also delves into the availability of prescribed medicines in Herat and reveals significant challenges in ensuring a consistent supply of essential anti-diabetic medications. Surprisingly, none of the surveyed pharmacies had all the considered drugs in stock, and the absence of widely prescribed drugs such as Gliclazide 60 mg and Insulin Aspart is particularly alarming. The study calls for urgent attention to address the gaps in the availability of these crucial medications for diabetic patients. The Shojaee et al. study in 2023 [33] showed that all injectable antidiabetic drugs are increasing, except for vial insulins, which include beef, mixed, and glulisine insulins, which had a decreasing trend. The highest increase was for pen insulins, including aspart, glulisine, detemir, and glargine. On the other hand, vial insulins, including beef and mixed insulins, had a decreasing trend in the past and are expected to have the same decreasing trend in the future. However, pen insulins, especially aspart, glulisine, detemir, and glargine, are expected to have an increasing trend in the coming years. These findings align with similar studies in other countries that reported a growing trend of pen insulins when used as monotherapy [34] and combined with an oral drug [31, 35–37]. In the commonwealth countries and regional countries such as the Arab countries of the Persian Gulf, the utilization of injectable medicines, including pen insulins in the form of monotherapy or combination with oral medications, has been very high, with an increasing trend [38–46]. Previous studies reported similar results for Iran [47–51] and worldwide [52, 53]. The results of our study, in conjunction with previously published research, indicate that a shortage of insulin pens poses a severe risk to patients. Because new guidelines recommend the use of insulin in combination with oral antidiabetic medications, and insulin has become the essential treatment in all kinds of diabetes [54–56].

The study also provides insights into the consumption patterns of different anti-diabetic medicines, revealing variations in the popularity and usage of specific drugs. For instance, the study highlights that Metformin 500 mg is the most accessible drug for diabetic patients in Herat, owing to its affordability compared to other medications. It is worth noting that in studies conducted on medication availability, Metformin and Glibenclamide were widely accessible, with only a few exceptions [57–63]. The poor availability could be due to multiple reasons, such as cash flow constraints [64], insufficient local manufacturing capacities, and resulting reliance on imports [65–68]. Pharmacy managers have emphasized the significance of delivery lead times, which are subject to variation based on various factors, such as the location, size, and working capital of pharmacies. They have also highlighted the close relationship between stock and demand, which means that pharmacies predominantly stock fast-moving products as other medicines run a high risk of expiring. Although pharmacies can order specific medicines on request or receive stock between regularly scheduled deliveries, the feasibility of these options depends on several factors that influence delivery lead times. Smaller or remotely located pharmacies, in particular, may find it challenging to make these options work. As such, further research is necessary to document the significance of these findings and identify potential solutions to the challenges at hand. Similarly, Afghanistan’s pharmaceutical market mechanisms and business conditions require further investigation. It is essential to identify ways of improving the availability of antidiabetic medication, which is crucial for the health and well-being of many people. With better insights into these mechanisms and conditions, developing strategies to address the challenges and help more people access the needed medications may be possible.

The financial aspect of accessing anti-diabetic medicines is another critical concern discussed in this study. The findings indicate that most Pakistani brand medicines are financially accessible to patients based on a conservative approach of comparing daily medication expenses with 20% of the household’s income. However, the study reveals that most Iranian and Pakistani brand medicines become financially out of reach for a significant portion of the Afghan population when considering the cost of one month’s medication against the minimum daily wage.

The study also provides a comparative analysis of anti-diabetic medication prices across Afghanistan, Iran, Pakistan, India, Nigeria, and Egypt, highlighting the significant challenges faced by Afghan citizens in accessing anti-diabetic drugs. According to the study’s findings, the prices of essential medicines in Afghanistan are considerably higher than in other countries [17, 69–76]. This highlights the need to closely examine the pricing mechanisms and explore potential interventions to enhance the affordability of these essential medications for the local population. The authorities must take appropriate measures to ensure that the pricing of medicines is fair and just and that the public has access to essential drugs at reasonable prices. Therefore, it is recommended that further research be conducted to identify the underlying factors that contribute to the high cost of medications in Afghanistan and to develop and implement effective policies that can sustainably address this issue.

To the author’s knowledge, this study is the first research in this field to focus on the affordability and availability of pivotal medicines like antidiabetic medicines in Afghanistan. This study presents a comprehensive analysis of the pharmaceutical landscape in Afghanistan, mainly focusing on the availability, affordability, and consumption patterns of anti-diabetic medications. By adopting a rigorous methodology grounded in international frameworks, the study provides valuable insights into the challenges faced by diabetic patients in the region. Including quantitative data from surveys conducted across multiple pharmacies enhances the precision and reliability of the findings, while international comparisons offer a broader contextual understanding of medication pricing and accessibility. Despite its strengths, the manuscript has several limitations that warrant consideration. One notable limitation is the lack of qualitative insights from stakeholders such as healthcare providers or patients, which could provide additional perspectives on medication access and affordability. Additionally, the focus on a specific set of antidiabetic medications and the exclusion of qualitative data may limit the generalizability of the findings to other regions or countries with different healthcare systems and socioeconomic contexts. Furthermore, the absence of longitudinal data prevents the assessment of trends over time, potentially hindering the identification of evolving challenges and the evaluation of intervention effectiveness. Addressing these limitations by including qualitative data, broader medication coverage, and longitudinal studies could enhance the manuscript’s validity and relevance for informing policy and practice in pharmaceutical access and affordability. Overall, the manuscript contributes significantly to the existing literature on pharmaceutical access in low- and middle-income countries and underscores the importance of addressing these challenges to promote public health in Afghanistan.

Conclusion

In conclusion, this study provides a comprehensive understanding of the intricate landscape of antidiabetic medicines in Herat, Afghanistan. It emphasizes the need for comprehensive strategies to address the challenges diabetic patients face in the region. The study underscores the importance of strengthening the pharmaceutical supply chain, improving local production capabilities, and implementing measures to enhance the financial accessibility of essential medications. Addressing these challenges is crucial to ensuring the well-being of individuals with diabetes and promoting public health in the region.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

AMT, MV, and LS contributed to the designing and running of the model. AMT, LS, and NS gathered the required data for the model, including literature review, cost, and efficacy data. AMT, MV, AKH, VGH, and FSH contributed to the study’s statistical and epidemiological parts and double-checked all analyses. AMT and MV wrote the manuscript, and all authors participated in reviewing the manuscript and revising it. They were involved in research, interpretation, and finalizing the manuscript.

Funding

This study had no budget.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participant

Ethical approval was not required as this study’s data were neither confidential nor commercially sensitive. However, the study has been approved by the Ethics Committee of Ghalib University with the code of Afg-Gh.U.H-R.E.C.2024-0032. Relevant guidelines and regulations are carried out for all methods. Furthermore, informed consent was obtained from all subjects.