Pharmac proposes removing priority access of type 2 diabetes meds for Māori, Pacific

A once-controversial decision to prioritise access to type 2 diabetes medication for Māori and Pacific people is showing life-saving benefits, just as Pharmac proposes removing that access.

Pharmac is proposing to widen access to three type 2 diabetes medicines from August, it expects 10,000 more people will benefit, but in the process the criteria which enables access to Māori and Pacific people would be removed.

Type 2 diabetes has a long history in Graham King's whānau, his grandmother died at 69 from complications with diabetes, his father was on dialysis and he was diagnosed in 1989 while living in Scotland.

"A lot of people think that because you eat bad food and you're fat, you're going to be a diabetic, but type 2 is all about the gene pool, right... and a complication of that gene pool is if you do become obese and stuff, there's a good chance that you're going to end up a diabetic."

When King, who is a board member for Diabetes Foundation Aotearoa, returned to Aotearoa he took part in a trial for the drug Jardiance, it changed his life but he said it was out of reach for many Māori.

"No matter what stats you looked at for urban Māori, it's really bad in relation to the way in which they receive treatment and all that sort of stuff, and a lot of it is because a lot of those people, especially in counties, can't afford to go to a doctor, you know, I've just been lucky, and they also can't afford the medications, you know, when Jardiance first came out, it was costing me a hundred dollars a month to take it, but it made a huge effect on my diabetes."

'Reduced mortality by up to fourfold'

Jardiance was among the medicines funded by Pharmac in 2021 with prioritised access for Māori and Pacific people.

A recent study, published in Diabetologia and led by the University of Waikato's Dr Lynne Chepulis, found that sodium-glucose co-transporter 2 (SGLT2) inhibitors deliver a greater reduction in risk of death for Māori and Pacific communities.

Co-chair of Mahitahi Matehuka (National Diabetes Network) Dr Ryan Paul told RNZ if treatment began soon enough the medications could delay dialysis by up to 15 years.

Approximately one in 12 Māori have diabetes, and for Pacific people it is one in seven, compared to roughly one in 20 Pākehā, he said.

"It's not only that Māori and Pacific are much more likely to get type 2 diabetes, but once they've got diabetes they're at least twice more likely to develop complications from their diabetes and to die from their diabetes," he said.

Pharmac announced last week it was seeking feedback on a proposal to widen access to empagliflozin, dulaglutide, and liraglutide (branded as Jardiance, Trulicity, and Victoza respectively).

In a statement Pharmac's director advice and assessment Dr David Hughes said its equity focus was on making sure people with the highest health need could access effective treatment.

"If this proposal is approved, around 10,000 more people are expected to benefit from these medicines in the first year, increasing to around 23,000 after five years. We expect that around a third of the people who will benefit from widened access to these medicines will be from Māori and Pasifika backgrounds.

"No one currently receiving these medicines will lose access. They will continue treatment and will not be affected by the proposed changes."

Pharmac's expert advisors said expanding clinical eligibility would mean most Māori and Pacific peoples with type 2 diabetes would meet the proposed criteria, and that clinical criteria were an effective way to determine who has high health need, he said.

"The study published in Diabetologia shows that Māori and Pasifika people with type 2 diabetes and a high risk of cardiovascular, respiratory and related disorders will benefit from having access to diabetes medicines.

"Our expert advisors have told us that expanding clinical eligibility criteria by lowering the five-year cardiovascular risk threshold will mean most Māori and Pacific peoples with type 2 diabetes and at high risk of cardiovascular or renal disease will meet the proposed criteria."

Associate Health Minister David Seymour welcomes proposal

Associate Health Minister David Seymour said Pharmac's mandate is to help people based on their medical need regardless of their race.

"So if they've got an objective which is premised on helping people depending on their race that is now contrary to government policy, which is need not race."

Seymour said very rarely was it the case that race was the only way to define need, although it could sometimes be an indicator.

"But if you look at the Cabinet circular on 'need not race' it requires agencies to look at all of the variables in front of them and use race as a variable for allocating resources only if there are no other good indicators.

"In this case I'm sure there probably are and that will [be] why they've made their decision, I, by the way, don't get involved in their specific decisions."

'The scientific community does not believe this is a warranted decision'

Pharmacist prescriber Dr Leanne Te Karu told RNZ Pharmac's 2021 decision was not done on a whim, it had wide support from clinicians and researchers. So last week's announcement came as a surprise to her.

"I didn't have, perhaps naively so, any inkling that this was going to be removed when we had been discussing where these medicines could be targeted even more so that they would benefit all of society and that was specifically in people who have got chronic kidney disease."

Te Karu said she would like Pharmac to undertake consultation authentically and examine the evidence with an open mind.

"These medicines have been shown to move us towards the equity line for rate of death. I mean it's so rare in medicine to have anything that we can demonstrate an equity outcome like this and, you know, this is huge bang for bucks across all of society so why we wouldn't want to hold on to that and build from it, I'm left wondering."

The evidence clearly showed that the ethnicity criteria was introduced precisely because clinical need was not being met equitably, she said.

"Māori and Pacific people develop diabetes and kidney disease significantly earlier, they experience more severe complications, less likely to receive timely evidence-based treatment despite this absolute greater need. So the criterion was not replacing clinical judgment, it was helping ensure that clinical need translated into actual access.

"If the health system were already delivering equitable assessment, prescribing and follow-up, the ethnicity criteria would never have been necessary. But everybody agreed that it was necessary in the first instance and the evidence has now shown that it's improved access, it's helped narrow survival inequities... So removing it before the underlying inequities are resolved just risks widening the gap again."

Te Karu said clinicians have not been given any breakdown on the data Pharmac is using, making consultation much more difficult.

Paul agreed that Pharmac have not been willing to share its data.

"So we are going away to look at our own data to try and see whether their claims are true. But I think to put this in perspective this has led to a very strong response in the diabetes workforce, the diabetes scientific community, diabetes organisations as well and you will see.

"I think there'll be a lot of joint submissions against the proposal to remove the ethnicity criterion... it's non-Māori and non-Pacific who are actually aghast at this. The scientific community does not believe this is a warranted decision."

One of the largest Iwi Māori Partnership Boards in the country, Waikato based Te Tiratū, is also calling on Pharmac to reconsider. Co-chair, Glen Tupuhi said treating all universally in the system did not create fairness, it entrenched inequity.

Consultation closes on 28 May, and if successful the changes would come into effect from August.

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