Innovating to increase access to diabetes care in Kenya: an evaluation of Novo Nordisk’s base of the pyramid project

Figures & data

Figure 1. The five pillars of the BoP programme.

Table 1. County summary of Meru and Trans Nzoia.

Indicator	Meru	Trans Nzoia
Location	300 km northeast of Nairobi	390 km northwest of Nairobi
Population	1,584,575	956,559
% of population located in urban areas	16%	20%
Gross domestic product (GDP) per capita	US$533	US$349
GINI index	0.348	0.360
Educational status	18% secondary or above 62% primary education only 21% no formal education	21% secondary or above 59% primary education only 20% no formal education
Health system overview	116 public facilities, 66 FBOs, 3 non-government organisations, and 20 private sector owned facilities. 58% of all services are run through the government	54 public facilities, 15 FBOs, 5 non-government organisations and 78 private sector owned facilities, generally small private clinics

Data sources [26–29].

Table 2. Summary of Macro-, Meso-, and Micro-level interviews.

Table 3. Direct medical and non-medical costs involved in seeking care for diabetes.

Comparative costs of diabetes care in Meru and Trans Nzoia
		Meru (intervention)			Trans Nzoia (control)
		Govt	FBO	Private	Govt	FBO	Private
Medicine	Insulin	Buy at 320 KSh and sell at 200 KSh/vial as per govt directive	500 KSh/vial or 50 KSh/unit as inpatient	Street cost 550–600/vial (previously up to 1800 KSh)	Buy at 320 KSh and sell at 200 KSh/vial but often out of stock	Not available	Price fluctuates from 500–2200 KSh/vial (only available in Kitale city)
	AHGs	2–4 KSh per tablet (Metformin)	50 KSh per month	5–6 KSh per tablet	Metformin 2 KSh/500 mg tablet Glibeclamide 2 KSh/tablet currently out of stock	Not available	5–6 KSh per tablet
	Medications for comorbidities	-	-	-	Aspirin 75 mg 1 KSh/tab Enalapril 2 KSh/tab vit B 2 KSh/tab	-	-
Equipment	Glucose meter	Free with purchasing strips	-	3000–4000 KSh	Free with strips	-	3000–4000 KSh
	Strips	1500 KSh for 50 strips	100 KSh per test	-	-	100 KSh per test	-
	HbA1C machine	Upto 10,000 KSh for strips plus machine	-	-	-	-	-
	Syringes	-	15 KSh/syringe	-	-	-	-
Diet		Variable, but agreed across all locations that nutritious, fresh food more expensive ‘Cash crops’ sold at market, diet mainly maize
Travel		Up to 2000 KSh per month of travel			300–2000 per month on travel
Medical consultations		200/consultation	150–200
Lab testing	HbA1C	1000 KSh/test	400–700 KSh		600 KSh/test
	BSL	150 KSh/test	50–140 KSh		100–120 KSh/test

Figures triangulated between interviews, focus group discussions, and field observations.

Table A1. Adapting the RAPIA method to the Kenyan BoP Evaluation.

Stakeholder	RAPIA interview themes	Objectives addressed
MACRO-LEVEL INTERVIEWS
Novo-Nordisk	Distribution of insulin Insulin tendering and purchase Value share to Novo-Nordisk Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities	Is BoP scalable? Is BoP sustainable? Is there shared value in the scheme?
Phillips Pharmaceuticals Ltd	Distribution of insulin Insulin tendering and purchase Value share to Phillips Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities	Is BoP scalable? Is BoP sustainable? Is there shared value in the scheme?
Ministry of Health	Organisation of diabetes care Resources for diabetes care National diabetes programmes Pricing of insulin Distribution of insulin Funding for insulin and diabetes Insulin tendering and purchase Educating patients Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities	Is BoP scalable? Is BoP sustainable? Has BoP improved access to diabetes care?
Ministry of Trade	Trade issues (laws, barriers) Trade infrastructure Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities	Is BoP scalable? Is BoP sustainable? Has BoP improved access to diabetes care?
Ministry of Finance	Funding of health system Taxes on insulin Funding for insulin and diabetes Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities	Is BoP scalable? Is BoP sustainable? Has BoP improved access to diabetes care?
Local drug distribution networks (e.g. MEDS)	Pricing of insulin Distribution of insulin Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities Perceived value share from BoP	Is BoP sustainable? Is there shared value in the scheme? Has BoP improved access to diabetes care?
Faith-based associations, e.g. The Christian Health Association of Kenya (CHAK) and the Kenya Conference of Catholic Bishops (KCCB)	Organisation of diabetes care Resources for diabetes and insulin Distribution of insulin Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities Perceived value share from BoP	Is BoP sustainable? Is there shared value in the scheme? Has BoP improved access to diabetes care?
Diabetes Associations including Kenya Defeat Diabetes Association and Diabetes Kenya Association	Issues with diabetes and insulin Education campaigns Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities Perceived value share from BoP	Is BoP sustainable? Is there shared value in the scheme? Has BoP improved access to diabetes care?
Central Medical Store/Kenya Medical Supplies Authority (KEMSA)	Insulin tendering and purchase Insulin distribution and storage Insulin pricing Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for sustained and up-scaled BoP activities	Is BoP sustainable? Is there shared value in the scheme? Has BoP improved access to diabetes care?
MESO-LEVEL INTERVIEWS
County/district health organisation	Issues with diabetes and insulin Organisation of diabetes care Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for up-scaled BoP	Is BoP scalable? Is BoP sustainable? Is there shared value in the scheme? Has BoP improved access to diabetes care?
Hospitals, clinics, health centres, dispensaries, etc.	Treatment and management of diabetes Access to appropriate tools to diagnose and treat patients Infrastructure present and/or lacking for insulin provision Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for up-scaled BoP	Is BoP sustainable? Is there shared value in the scheme? Has BoP improved access to diabetes care?
Laboratories	Infrastructure for diagnosis and follow-up Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Institutional support for up-scaled BoP	Is BoP sustainable? Has BoP improved access to diabetes care?
Pharmacies	Insulin distribution and storage Insulin pricing Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for up-scaled BoP	Is BoP sustainable? Has BoP improved access to diabetes care?
MICRO-LEVEL INTERVIEWS
Health workers and traditional healers	Problems encountered in diagnosis and treatment of patients Training Infrastructure present and/or lacking Tools present and/or lacking Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for up-scaled BoP	Is BoP sustainable? Has BoP improved access to diabetes care?
Market traders selling drugs	Awareness of diabetes and Insulin Access to insulin for resale Pricing of insulin Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability Stakeholder engagement in BoP Institutional support for up-scaled BoP	Is BoP sustainable? Has BoP improved access to diabetes care?
Patients and carers	Diagnosis Access to treatment Cost of treatment Awareness of diabetes Awareness of BoP Perceptions of BoP acceptability, effectiveness and sustainability	Is BoP sustainable? Has BoP improved access to diabetes care?

Meru County Government. Meru county. 2017. Available from: http://meru.go.ke

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Kenya National Bureau of Statistics. Exploring Kenya’s Inequality: Trans Nzoia County. Nairobi: Kenya National Bureau of Statistics (KNBS) and Society for International Development (SID), 2013.

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