Availability, Prices and Affordability of Nationally Negotiated Antidiabetic Drugs in China: A National Survey

Availability, Prices and Affordability of Nationally Negotiated Antidiabetic Drugs in China: A National Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Availability, Prices and Affordability of Nationally Negotiated Antidiabetic Drugs in China: A National Survey Wan Tang, Wei Li, Wei Lu, Zhengyi You, Hongdou Chen, Wei Sun, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7700188/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: This study aimed to investigate the availability, prices, and affordability of nationally negotiated antidiabetic drugs in China. Methods: Monthly data about the use of antidiabetic drugs from 2018 to 2023 were collected from the Chinese Medicine Economic Information Network (CMEI). This study covered 804 public general hospitals in 31 provincial administrative regions in China, among which 537 (66.79%) were tertiary, and 267 (33.21%) were secondary. The adjusted World Health Organization and Health Action International methodology was used to calculate the availability and affordability of 12 nationally negotiated antidiabetic drugs in the investigated hospitals. Price is expressed as the defined daily dose cost (DDDc). Results: On average, the total availability of 12 nationally negotiated antidiabetic drugs increased annually from 2018 to 2023. The median availability of all the investigated drugs in tertiary hospitals from 2018 to 2023 was 11.53%, 4.50%, 13.49%, 37.85%, 41.16% and 42.07%, respectively, while the indicator in secondary hospitals was 1.59%, 1.59%, 4.31%, 23.16%, 28.28% and 29.67%, respectively. The DDDc of the drugs newly covered by Medicare decreased noticeably. The affordability of the antidiabetic drugs has improved year by year from 2018 to 2023. In comparison, rural residents had lower affordability of the drugs than urban residents. Conclusions The overall availability, affordability and DDDc of 12 nationally negotiated antidiabetic drugs improved from 2018 to 2023. However, the overall availability of most antidiabetic drugs in China remained at a low level (less than 50%). Further efforts should be made to sufficiently and equally benefit diabetic patients. National Reimbursement Drug List (NRDL) Antidiabetic Drugs Prices Availability Affordability Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION According to the latest report from the International Diabetes Federation, nearly one ninth adults globally (589 million) are now living with diabetes. By 2050, the estimated number of adults with diabetes is projected to reach 853 million [ 1 ]. The prevalence rate among adults aged 18 and above stands at 11.9% in China, where there is the largest total number of diabetic patients globally [ 2 ]. Diabetes has become an urgent health issue for China since 1980 [ 3 , 4 ]. Economic development, aging population, and lifestyle changes are among the reasons for the high incidence of diabetes. Lifestyle intervention is a basic therapeutic measure for diabetes and should be carried out throughout the treatment of diabetes. If simple lifestyle intervention fails to bring blood glucose up to the target, drug therapy should be started in time. The use of hypoglycaemic drugs is an important clinical intervention for controlling blood glucose. In recent years, novel glucose-lowering medications including sodium-glucose cotransporter2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin analogs have rapidly entered the Chinese market. While they effectively control blood glucose and improve cardiovascular outcomes [ 5 , 6 ], these agents are progressively replacing traditional therapies. However, their typically high prices pose significant economic burdens on both patients and the society. Given that diabetes, as a highly prevalent chronic condition, requires lifelong pharmacological intervention, these elevated costs severely compromise medication adherence and patients’ willingness to persist with treatment. Consequently, this financial barrier undermines optimal healthcare access for people with diabetes. To effectively reduce the prices of patented and exclusive drugs and alleviate medication burdens on patients, the national healthcare security department has explored and established a medical insurance access negotiation mechanism since 2017. Through negotiations, high-priced drugs with high clinical value and proven efficacy have been progressively included into the National Reimbursement Drug List (NRDL) [ 7 ]. To date, over a dozen glucose-lowering medications have been incorporated into the NRDL through national medical insurance negotiations, securing coverage for patients [ 8 ]. However, their inclusion in the NRDL does not guarantee patient access to them. The landing of the national negotiation drugs in the medical institutions urgently needs to be studied. The prices, availability, and affordability are the main criteria to measure whether patients can purchase a medicine at an affordable price [ 9 , 10 ]. In 2003, the World Health Organization (WHO) and Health Action International (HAI) jointly developed the WHO/HAI Standard Survey Methodology to assess the accessibility of essential medicines worldwide [ 11 ].To date, numerous studies have been conducted globally using the WHO/HAI Standard Survey Methodology. Based on this foundation, China has now established the evaluation method that better suits its national conditions [ 9 , 12 ]. The scope of the drugs studied has expanded beyond essential medicines to include those previously not covered by the standard survey, such as glucose-lowering drugs [ 13 ]. To evaluate the accessibility of nationally negotiated glucose-lowering drugs, this study investigated their availability, affordability and prices across China using an adjusted WHO/HAI methodology. METHODS A cross-sectional survey was conducted from January 2019 to December 2023 across 31 provinces, municipalities and autonomous regions in China. The study evaluated the availability, prices, and affordability of nationally negotiated glucose-lowering drugs in 804 public general hospitals (including 537 tertiary hospitals and 267 secondary hospitals) in recent years. Selection of the investigated medicines A list of 12 drugs was included in this study, consisting of liraglutide injection, which was nationally negotiated in 2017, acarbose tablets, exenatide injection, lixisenatide injection, dapagliflozin tablets, canagliflozin tablets, and empagliflozin tablets negotiated in 2019, and Insulin degludec/aspart injection, benaglutide injection, dulaglutide injection, pegylated loxenatide injection and ertugliflozin tablets negotiated in 2020 (Table 1 ). Table 1 Characteristics of 12 national negotiation antidiabetic drugs Name ATC Code Dosage form DDD U Reimbursement date 1 Insulin degludec and insulin aspart A10AD06 Inj 40 U May 2019 2 Acarbose A10BF01 Tab 0.3 g Dec 1994 3 Exenatide A10BJ01 Inj 15 µg Aug 2009 4 Liraglutide A10BJ02 Inj 1.5 mg Apr 2011 5 Lixisenatide A10BJ03 Inj 20 µg Sep 2017 6 Beinaglutide A10BJ07 Inj 0.3 mg Dec 2016 7 Dulaglutide A10BJ05 Inj 0.16 mg Feb 2019 8 Polyethylene glycol loxenatide - Inj 14.3 µg Jun 2019 9 Dapagliflozin A10BK01 Tab 10 mg Mar 2017 10 Canaglifozin A10BK02 Tab 0.2 g Sep 2017 11 Empagliflozin A10BK03 Tab 17.5 mg Sep 2017 12 Ertuglifozin A10BK04 Tab 10 mg Jul 2019 Note: ATC Code from the WHO Collaborating Center for Drug Statistics Methodology ; -, not available Data sources The Chinese Medicine Economic Information Network (CMEI), one of the largest drug information service platforms in China covering over 1,500 public hospitals, served as the data source for this study [ 11 , 14 ]. By virtue of the CMEI, this study systematically collected related data including therapeutic category, generic name, dosage form, brand manufacturer, procurement volume, and procurement price for the 12 nationally negotiated antidiabetic drugs. Data Analysis Availability According to the WHO/HAI Standard Survey Methodology, the availability of a medicine was interpreted as the percentage of facilities in which this medicine was found on the day of data collection [ 13 , 15 ]. Accordingly, it is calculated as the number of hospitals where the drug is available divided by the total number of the investigated hospitals. To describe availability, the following ranges were used [ 16 – 18 ]: <30% (very low, the drug was very difficult to find), 30% to 49% (low, the drug was available in a few hospitals surveyed ), 50% to 80% (fairly high, the drug was available in many hospitals surveyed), and > 80% (high, the drug was available in most hospitals surveyed). Price The defined daily dose cost (DDDc) represents the price per standardized treatment unit, serving as an indicator of drug expenditure that reflects the overall price level of medicines. It indicates the average daily cost for patients who use a specific drug [ 19 ]. The DDDc was derived from dividing the total expenditure of a drug by defined daily doses (DDDs), whereas DDDs were calculated by dividing the total volume procured by the defined daily dose (DDD) [ 20 ]. The DDD value of each generic drug can be found in the Guidelines for Anatomical Therapeutic Chemical (ATC) classification and DDD assignment 2024 [ 21 ]. A higher DDDc value indicates that the drug is more expensive [ 22 ]. Affordability The WHO defines medicine affordability as the multiple of the lowest-paid unskilled government worker (LPGW)’s daily wage represented by the total medicine cost for a standard treatment regimen against a specific disease [ 23 ]. According to the WHO/HAI, a medicine is affordable if the cost of a treatment course is less than the daily wage of the LPGW (affordability < 1 ) [ 24 , 25 ]. Following previous research [ 26 ], due to the lack of data, the daily wage of the LPGW was proxied using the annual disposable income per capita for estimates. In China, the median annual disposable income per capita for all residents is divided by the standard number of workdays (250 days) to estimate the daily wage equivalent [ 27 ]. The treatment duration for an acute disease is the total duration of a full course of therapy while that for a chronic disease is 30 days [ 28 ]. Consequently, the affordability calculation formula for each drug in this study is defined as follows: Prior to their inclusion in the NRDL, the investigated drugs required 100% patient’s out-of-pocket payment. After national negotiations, these drugs were incorporated into Category B of the NRDL with nationwide implementation, but their reimbursement rates varied from place to place (ranging from about 50% to 85%) [ 29 , 30 ]. Based on established research evidence, this study standardized the reimbursement rate for Category B negotiated drugs at 65% [ 31 ]. According to the National Bureau of Statistics of China, the median annual disposable income per capita from 2018 to 2023 stood at 24,336 CNY, 26,523 CNY, 27,540 CNY, 29,975 CNY, 31,370 CNY and 33,036 CNY for all residents; at 36,413 CNY, 39,244 CNY, 40,378 CNY, 43,504 CNY, 45,123 CNY and 47,122 CNY for urban residents; and at 13,066 CNY, 14,389 CNY, 15,204 CNY, 16,902 CNY, 17,734 CNY and 18,748 CNY for rural residents, respectively [ 32 – 37 ]. Results Availability The availability of 12 investigated antidiabetic drugs from 2018 to 2023 is presented in online Supplementary Table 1 and Fig. 1 . The annual availability rate is calculated as the mean of the monthly availability rates (detailed monthly data are provided in online Supplementary Tables 2–4 ). The availability rates of all the investigated drugs except acarbose and exenatide demonstrated upward trends from baseline values (range: 7.14% to 20,384.85%), with insulin degludec and insulin aspart exhibiting the most substantial increase by 20,384.85%, whose availability rose from 0.33% in 2019 to 67.60% in 2023. In 2023, the availability rates of exenatide, lixisenatide, and benaglutide plummeted to merely 3.11%, 0.30%, and 1.01% respectively. Concurrently, five drugs demonstrated fairly high availability (50% to 80%): insulin degludec and insulin aspart (67.60%), acarbose (70.34%), liraglutide (51.67%), dulaglutide (55.38%), and dapagliflozin (77.11%). The analysis on hospital tier levels (Fig. 2 ) reveals that most antidiabetic drugs exhibited obviously increases in their availability rates across both secondary and tertiary hospitals. Moreover, their availability rates in tertiary hospitals were generally higher than those in secondary hospitals, which aligned with hospital tier disparities in resource allocation and clinical capacity. Prices As shown in Table 2 and Fig. 3 , in 2023 all the investigated drugs except ertugliflozin demonstrated significant reductions in DDDc values compared with baseline values, with decline rates ranging from 22.78% to 90.39%. Exenatide showed the most pronounced reduction, whose DDDc decreased from 113.29 CNY in 2018 to 10.89 CNY in 2023, representing a 90.39% decline. Notably, DDDc values generally decreased immediately following a drug’s entry into the NRDL, and the first formal implementation year (post-negotiation year) witnessed the most substantial reductions. Thereafter, DDDc values generally continued to decline gradually or stabilized. For example, the initial DDDc value of benaglutide during the study period was 30.16 CNY. It decreased to 29.90 CNY in the negotiation year (2020) and further dropped to 14.28 CNY in the first implementation year (2021). Table 2 DDDc of national negotiated innovative antidiabetic drugs in the investigated hospitals Negotiation year No Name DDDc / CNY 2018 2019 2020 2021 2022 2023 2020 1 Insulin degludec and insulin aspart - 21.07 21.04 11.81 11.73 10.01 2019 2 Acarbose 11.16 11.17 4.47 1.72 1.76 1.65 2019 3 Exenatide 113.29 58.37 13.67 11.46 10.61 10.89 2017 4 Liraglutide 34.20 34.13 28.24 28.23 26.26 26.26 2019 5 Lixisenatide - 24.40 18.44 18.48 18.38 18.84 2020 6 Beinaglutide 30.16 30.24 29.90 14.28 13.64 13.64 2020 7 Dulaglutide - 45.72 45.33 15.94 15.89 13.64 2020 8 Polyethylene glycol loxenatide - 28.24 28.24 13.42 13.37 13.37 2019 9 Dapagliflozin 16.26 16.11 4.34 4.36 4.36 4.36 2019 10 Canaglifozin 31.93 20.13 8.05 6.05 4.95 4.22 2019 11 Empagliflozin 31.11 18.32 7.37 5.72 4.55 4.30 2020 12 Ertuglifozin - - - 5.56 6.92 6.92 DDD, defined daily dose; DDDc, DDD costs; -, not available; CNY, Chinese Yua Affordability As shown in Fig. 4 , during the study period, while the affordability of ertugliflozin increased (by 12.97%), the affordability of all other investigated drugs decreased significantly, with decline rates ranging from 43.43% to 97.52%. Among them, exenatide showed the largest decrease in affordability (97.52%). As shown in Table 3 , all the drugs collected by the research institute were unaffordable during 2018 and 2019. In 2020, excluding ertugliflozin which was not collected, four of the other investigated drugs became affordable: acarbose (0.43), dapagliflozin (0.41), empagliflozin (0.70), and canagliflozin (0.77). In 2021, ertugliflozin (0.49) was added to the list of affordable medications. By 2022, two more drugs became affordable: insulin degludec and insulin aspart (0.98) and exenatide (0.89), achieving 7 affordable medications in total. In 2023, although no new drugs became affordable, the affordability rates of the remaining drugs still decreased. The affordability for urban residents was significantly better than that for rural residents. In 2023, urban residents could afford 10 of the investigated antidiabetic drugs, while rural residents could only afford 5 (Figs. 5 and 6 ). Table 3 Affordability ratio of each study drug from 2018 to 2023 2018 2019 2020 2021 2022 2023 Acarbose 3.44 3.16 0.43 0.15 0.15 0.13 Ertugliflozin - - - 0.49 0.58 0.55 Beinaglutide 9.30 8.55 8.14 1.25 1.14 1.08 Dapagliflozin 5.01 4.56 0.41 0.38 0.36 0.35 Insulin Degludec and Insulin Aspart - 5.96 5.73 1.03 0.98 0.80 Dulaglutide - 12.93 12.34 1.40 1.33 1.08 Empagliflozin 9.59 5.18 0.70 0.50 0.38 0.34 Polyethylene glycol loxenatide - 7.99 7.69 1.17 1.12 1.06 Canagliflozin 9.84 5.69 0.77 0.53 0.41 0.34 Liraglutide 3.69 3.38 2.69 2.47 2.20 2.09 Lixisenatide - 6.90 1.76 1.62 1.54 1.50 Exenatide 34.91 16.51 1.30 1.00 0.89 0.87 Note: -, not available Discussion Diabetes is a global health challenge that affected 529 million people in 2021 and is projected to affect 1.31 billion people by 2050 worldwide [ 38 ]. China has the world’s largest diabetic population, with more than 118 million people living with diabetes, accounting for approximately 22% of all suffering from diabetes worldwide [ 39 ]. Antidiabetic drugs, as a key means of controlling diabetes progression and lowering blood glucose levels, play a pivotal role in diabetes treatment. Deressa HD [ 40 ] found big gaps in availability and affordability of essential medicines (EMs) used for diabetes in central Ethiopia. Policy makers should work to improve access to EMs against diabetes. Caijun Yang’s study on the availability and affordability of oral antidiabetic drugs in Shaanxi Province, China, revealed that most antidiabetic medications failed to meet WHO supply targets [ 41 ]. Patients were under considerable economic pressure, and the medication affordability was disproportionate among rural residents. These findings underscore the need for government-led policy interventions to ensure better access to more affordable antidiabetic drugs for the Chinese people. In response, China has implemented the NRDL negotiation policy and has been progressively expanding the NRDL to cover more and newer antidiabetic drugs. This study was conducted using the WHO/HAI methodology to evaluate the availability, price, and affordability of nationally negotiated antidiabetic drugs in China, providing policymakers with the latest data reference for optimizing relevant policies. In this study, it was found that from 2018 to 2023, the overall availability of the investigated antidiabetic drugs showed an upward trend, while their DDDc exhibited a downward trend. The affordability of these drugs for the public has gradually improved, which is consistent with the anticipated outcomes. During the study period, an “inverted U-shaped” inflection point was observed in the availability of GLP-1 receptor agonists such as exenatide, liraglutide, lixisenatide, and benaglutide in 2021. This phenomenon may be primarily attributed to the fact that although these drugs were included in the NRDL, they were accompanied by stringent reimbursement restrictions (For patients with inadequately controlled type 2 diabetes requiring oral antihyperglycemic agents (e.g., metformin) or insulin and with a BMI ≥ 25 kg/m², the initial prescription must be issued by an endocrinologist or specialist at a secondary or higher medical facility [ 42 ]), as well as changes in market competition dynamics. These factors led to temporary imbalances or fluctuations in the actual availability of GLP-1 drugs, thereby affecting the stability of their availability. Another potential contributing factor could be the market impact caused by newer-generation GLP-1 drugs (such as dulaglutide and semaglutide). The availability of acarbose in 2023 was lower than that in 2018, which might be attributed to the gradual introduction of various newer antidiabetic drugs. This expansion in treatment options has provided alternative approaches for diabetes management, consequently impacting the demand for earlier-generation drugs such as acarbose. Among the 12 investigated drugs, insulin degludec and insulin aspart demonstrated the most significant increase in availability. As the first fully soluble co-formulation of insulin, it combines ultra-long-acting basal insulin degludec and rapid-acting meal-time insulin analog aspart, whose advantages include no requirement for resuspension before injection and an extended duration of action [ 43 ]. The improved availability of this insulin formulation may benefit a larger population of patients with diabetes. Among the 12 investigated antidiabetic drugs, the DDDc values decreased significantly for all except ertugliflozin. The slight increase in the DDDc value of ertugliflozin may be attributed to a floor effect. It was likely to result from its relatively late market entry (2021), which coincided with China’s implementation of the NRDL policy, leading to artificially suppressed market pricing during its first year on the market. It could also be linked to the volume-price agreements signed between the National Healthcare Security Administration and manufacturers during medical insurance and drug procurement price negotiations. Besides, during the study period, the number of drugs affordable to the public increased from 0 to 7. These findings indicate that the implementation of the NRDL policy has significantly alleviated the economic burden on patients. However, this study also revealed a substantial disparity in the affordability of the investigated drugs between urban and rural areas, with the affordability capacity of rural residents notably lower than that of urban residents. This can provide a solid theoretical foundation for the formulation and optimization of relevant policies by the government in the future. This study reports on the utilization of 12 nationally negotiated antidiabetic drugs in 804 public secondary and tertiary general hospitals across China from 2018 to 2023. It features a long duration, broad coverage, and a diverse range of drugs, allowing for a comprehensive evaluation of the implementation of the NRDL policy. However, this study also has certain limitations, such as potential underreporting in hospital procurement data and the absence of data from private hospitals and retail pharmacies during data collection. Therefore, the dataset will be further expanded in our subsequent studies to provide more objective and robust data support for assessing the implementation of the NRDL policy Conclusions This study demonstrates that the implementation of the NRDL policy has effectively improved the availability of antidiabetic drugs and alleviated the financial burden on patients with diabetes. However, the availability of many newer antidiabetic drugs remains relatively low, and significant disparities persist in affordability between urban and rural residents. Therefore, the government should introduce targeted policies to address urban-rural inequalities, further optimize the national healthcare security system, and ensure medication access for grassroots populations. Simultaneously, it is crucial to accelerate the establishment of a comprehensive evaluation system for new drug inclusion, so that more innovative medicines can be promptly incorporated into the national drug price negotiations. This will reduce the financial burden on patients and promote the comprehensive implementation of nationally negotiated drugs. Declarations Ethics approval and consent to participate Not applicable, as this study does not report on or involve the use of data from animals or human subjects. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author. Competing interests The authors declare no competing interests. Funding This study was funded by 2024 Municipal-level Medical Research Project of the Health Commission (DX202424) Authors` contributions WT was primarily responsible for the statistical analysis of research data and the writing of the manuscript; WLi wrote the article and performed language editing; WLu and ZZY searched and collected relevant literature and data; HDC collected and processed the data; HHW and WS provided the research design and conceptualization. Acknowledgements The authors appreciate Chinese Medicine Economic Information (CMEI) database. References Over 250 million people worldwide unaware they have diabetes, according to new research from the International Diabetes Federation (IDF). Diabetes Res Clin Pract. 2025,223:112176. doi: 10.1016/j.diabres. Chinese Diabetes Society, National Office for Primary Diabetes Care. National guidelines for the prevention and control of diabetes in primary care (2022).Chin J Intern Med. 2022,61(3):249-262. doi:10.3760/cma.j.cn112138-20220120-000063.. Wang Q, Zhang X, Fang L, et al. Prevalence, awareness, treatment and control of diabetes mellitus among middle-aged and elderly people in a rural Chinese population: a cross-sectional study. Plos One. 2018;13(6):e0198343. doi: 10.1371/journal.pone.0198343. Ma RCW. Epidemiology of diabetes and diabetic complications in China. Diabetologia. 2018;61(6):1249–1260. doi: 10.1007/s00125-018-4557-7. Li XH, Jin CN. Research progress on cardiovascular benefits of novel hypoglycemic agents SGLT2 inhibitors and GLP-1 receptor agonists. J Electrocardiol Circ. 2024;43(5):524-9. Ge SY. NNT study and economic evaluation of new hypoglycemic drugs on cardiovascular outcomes in patients with type 2 diabetes. Hebei Medical University, 2023. Xu W., Chen L. L., Wang N., et al. Thoughts on perfecting the medical insurance payment policy of national negotiated drugs. China Health Insur, 2020, (06): 8-11. National Healthcare Security Administration, Ministry of Human Resources and Social Security. Notice on Printing and Distributing the National Drug List for Basic Medical Insurance, Work-Related Injury Insurance, and Maternity Insurance . 2024. https://www.gov.cn/zhengce/zhengceku/202411/content_6989859.htm. Accessed November 27 2024. Liyanage CK, Gunawardane M, Kumaradasa PP, et al. A national survey on registered products, availability, prices, and affordability of 100 essential medicines in community pharmacies across Sri Lanka. BMC Health Serv Res. 2023;23(1):1121. Nguyen HTT, Dinh DX, Nguyen TD, et al. Availability, prices and affordability of essential medicines: A cross-sectional survey in Hanam province, Vietnam. PLoS One. 2021;16(11):e0260142. . Wan M, Liu JY, Yu GY, et al. Availability and affordability of osteoporosis treatment drugs in Wuhan based on the WHO/HAI standard survey method. J Chin Pharm Sci. 2023;32(5):417-425. . Wang X, Cao JY, Zhang JH, et al. Study on prices and availability of 50 medicines in shandong province by using WHO/HAI standardization method. China Pharm. 2021;24(10):1877-1881. Zeng L, Wang L, Liu D, et al. Accessibility of SGLT-2 inhibitors in Hubei province based on WHO/HAI standard survey method. Drug Eval. 2024;21(03):265-269. Science and Technology Development Center of Chinese Pharmaceutical Association. Brief introduction to CMEI. https://en.cmei.org.cn/index/network/introduction.html?catid=48. Accessed 8 Jun 2023. Wang X, Cao JY, Zhang JH, et al.Study on Prices and Availability of 50 Medicines in Shandong Province by Using WHO/HAI Standardization Method[J]. China Pharm. 2021;24(10):1877-1881. Ezezew M, Yehualaw A, Demsie DG. Assessment of availability and challenges of WHO recommended priority life-saving medicines for under five-year children in primary public health facilities of Amhara region. BMC Pediatr. 2023;23(1):395. doi:10.1186/s12887-023-04216-6. . Özler G, Işik O. Prices, availability and affordability of selected essential medicines for chronic diseases in Türkiye. East Mediterr Health J. 2023;26(11):850-860. . Shambira G, Suleman F. Retail pharmacy prescription medicines' availability, prices and affordability in Eswatini. Afr J Prim Health Care Fam Med. 2021;13(1):e1-e11. . Yang Y, Tong R, Yin S, et al. The impact of “4 + 7” volume-based drug procurement on the volume, expenditures, and daily costs of antihypertensive drugs in Shenzhen, China: an interrupted time series analysis. BMC Health Serv Res. 2021;21:1275. doi: 10.1186/s12913-021-07143-3. . Zhang L, Wang X, Yao H, et al. Impact of national drug price negotiation policy on the accessibility and utilization of PCSK9 inhibitors in China: an interrupted time series analysis. Int J Equity Health. 2024;23(1):116. . WCCF Methodology. Guidelines for ATC classification and DDD assignment 2024. 2024. Chen YJ, Cao WJ, Zeng X, et al. Analysis of the use and prescripation of hypoglycemic drugs in a hospital from 2020 to 2021. Chin J Drug Abuse Prev Treat. 2025;31(03):472-475. World Health Organization and Health Action International. Measuring medicine prices,availability,affordability and price components,2nd edition. 2008. http://www.haiweb.org/medicineprices/manual/documents.html?. Accessed May 23 2024 Raju PKS. WHO/HAI Methodology for Measuring Medicine Prices, Availability and Affordability, and Price Components. In: Vogler S, ed. Medicine price surveys, analyses and comparisons. Academic Press, 2019; 209-28. World Health Organization (WHO), Health Action International (HAI). Measuring Medicine Prices, Availability, Affordability and Price Components. 2nd ed. WHO, HAI; 2008. 2008. https://www.who.int/medicines/areas/access/medicines_prices08/en/. Accessed May 23 2024. Diao Y, Qian J, Liu Y, et al. How government insurance coverage changed the utilization and affordability of expensive targeted anti-cancer medicines in China: an interrupted time-series study. J Glob Health. 2019;9:020702. doi:10.7189/jogh.09.020702. Yuan J, Lu ZK, Xiong X,et al. Lowering drug prices and enhancing pharmaceutical affordability: an analysis of the national volume-based procurement (NVBP) effect in China. BMJ Glob Health. 2021;6(9):e005519. doi: 10.1136/bmjgh-2021-005519. Nguyen HTT, Dinh DX, Nguyen TD, et al. Availability, prices and affordability of essential medicines: A cross-sectional survey in Hanam province, Vietnam. PLoS One. 2021;16(11):e0260142. doi:10.1371/journal.pone.0260142. Xie JP, Shao R. Research on the typical model of provincial management concerning national medical insurance negotiation drugs. Chinese Health Econ 2020;39:42-5. Cao Z, Li SS, Cao RY, et al Research on the accessibility of national medical insurance negotiation drugs——an analysis based on the usage and reimbursement data of 17 national negotiated anticancer drugs in five cities. Health Econ Res. 2022;39:53–6. Li W, Lu W, Chen H, et al. Access to innovative anticancer medicines in China: a national survey on availability, price and affordability. BMJ Open. 2024;14(4):e077089. doi:10.1136/bmjopen-2023-077089. National Bureau of Statistics of China. Statistical Bulletin of the people’s Republic of China on national economic and social development in 2018. 2018. https://www.stats.gov.cn/sj/zxfb/202302/t20230203_1900203.html. Accessed 8 Jun 2024. National Bureau of Statistics of China. Statistical Bulletin of the people’s Republic of China on national economic and social development in 2019. 2019. https://www.stats.gov.cn/xxgk/sjfb/zxfb2020/202001/t20200117_1767741.html. Accessed 8 Jun 2024. National Bureau of Statistics of China. Statistical Bulletin of the people’s Republic of China on national economic and social development in 2020. 2020. https://www.stats.gov.cn/sj/zxfb/202302/t20230203_1900970.html. Accessed 8 Jun 2024. National Bureau of Statistics of China. Statistical Bulletin of the people’s Republic of China on national economic and social development in 2021. 2021. https://www.stats.gov.cn/sj/zxfb/202302/t20230203_1901342.html. Accessed 8 Jun 2024. National Bureau of Statistics of China. Statistical Bulletin of the people’s Republic of China on national economic and social development in 2022. 2022. https://www.stats.gov.cn/sj/zxfb/202302/t20230203_1901715.html. Accessed 8 Jun 2024. National Bureau of Statistics of China. Statistical Bulletin of the people’s Republic of China on national economic and social development in 2023. 2024. https://www.stats.gov.cn/sj/zxfb/202401/t20240116_1946622.html. Accessed 8 Jun 2024. Xu Y, Lu J, Li M, Wang T, et al. Diabetes in China part 1: epidemiology and risk factors. Lancet Public Health. 2024;9(12):e1089-e1097. doi: 10.1016/S2468-2667(24)00250-0. . Ong KL, Stafford LK, McLaughlin SA, et al. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2023; 402: 203-34. Deressa HD, Abuye H, Adinew A, et al. Access to essential medicines for diabetes care: availability, price, and affordability in central Ethiopia. Glob Health Res Policy. 2024;9(1):12. doi:10.1186/s41256-024-00352-3. . Yang C, Hu S, Zhu Y, et al. Evaluating access to oral anti-diabetic medicines: A cross-sectional survey of prices, availability and affordability in Shaanxi Province, Western China. PLoS One. 2019;14(10):e0223769. doi: 10.1371/journal.pone.0223769. National Healthcare Security Administration. National Basic Medical Insurance, Work Injury Insurance, and Maternity Insurance Drug List. 2020. http://www.nhsa.gov.cn/art/2020/12/28/art_37_3850.html. Accessed 15 Jan 2025. Garber AJ, Handelsman Y, Grunberger G, et al. Consensus statement by the American Association of Clinical Endocrinologists and the American College of Endocrinology on the comprehensive type 2 diabetes management algorithm- 2020 executive summary. Endocrine Practice. 2020;26(1):107–139. doi: 10.4158/CS-2019-0472. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx SupplementaryTable2.docx SupplementaryTable3.docx SupplementaryTable4.doc Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 07 Jan, 2026 Reviews received at journal 11 Nov, 2025 Reviewers agreed at journal 06 Nov, 2025 Reviews received at journal 01 Nov, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers agreed at journal 29 Oct, 2025 Reviewers agreed at journal 29 Oct, 2025 Reviewers invited by journal 27 Oct, 2025 Editor assigned by journal 23 Oct, 2025 Editor invited by journal 01 Oct, 2025 Submission checks completed at journal 30 Sep, 2025 First submitted to journal 30 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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2","display":"","copyAsset":false,"role":"figure","size":1041738,"visible":true,"origin":"","legend":"\u003cp\u003eAvailability rates (%) of 12 antidiabetic drugs in secondary and tertiary hospitals from 2018 to 2023. Note: The size of the circles indicates the tier of the institution surveyed; The classification of medical institutions is based on China’s “Three-Tier and Ten-Grade” hospital accreditation system.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/a558390a428da14d499d3c83.jpg"},{"id":95340298,"identity":"697d4d77-563d-49a2-8e11-5ad6666721c5","added_by":"auto","created_at":"2025-11-07 01:26:57","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":768003,"visible":true,"origin":"","legend":"\u003cp\u003eTrends in the defined daily dose cost (DDDc) of the 12 investigated drugs. Note: CNY, Chinese Yuan\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/da3ad2900d015a4e03658557.jpg"},{"id":95524808,"identity":"73c160d2-8245-489c-9e10-89b71e1948ec","added_by":"auto","created_at":"2025-11-10 10:03:35","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1058357,"visible":true,"origin":"","legend":"\u003cp\u003eChange in the drug price and affordability by 12 nationally negotiated antidiabetic drugs. Drug prices are expressed in terms of the defined daily dose cost (DDDc). According to the WHO, medication affordability can be shown by a comparison between the cost for a treatment course (a chronic disease was 30 days) and the lowest paid unskilled government worker (LPGW)’s daily wage. A drug is affordable if the cost of a treatment course is less than the daily wage of the LPGW (affordability \u0026lt;1). Since the daily wage of the LPGW is not available in China, based on previous research, the average daily disposable income per capita was used (China had 250 workdays). The median annual disposable income per capita from 2018 to 2023 was obtained from the National Bureau of Statistics of China.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/c29820005e88a8a39c9e3a36.jpg"},{"id":95340305,"identity":"2686ef51-7a78-40d7-88f9-af4726fbafdc","added_by":"auto","created_at":"2025-11-07 01:26:57","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":851673,"visible":true,"origin":"","legend":"\u003cp\u003eAffordability rate of the 12 nationally negotiated drugs for urban residents. A drug is affordable if the cost of a treatment course is less than the daily wage of the LPGW (affordability \u0026lt;1).\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/befba44a233dcd9b9ff8f446.jpg"},{"id":95524708,"identity":"1ccd748b-181d-4631-85b0-d41e141f4af4","added_by":"auto","created_at":"2025-11-10 10:03:18","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":887928,"visible":true,"origin":"","legend":"\u003cp\u003eAffordability rate of the 12 nationally negotiated drugs for rural residents. A drug is affordable if the cost of a treatment course is less than the daily wage of the LPGW (affordability \u0026lt;1).\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/9177f989e1fd3f702a658a46.jpg"},{"id":95530796,"identity":"f87a0929-2124-4cc5-a915-b8ce7dd95bea","added_by":"auto","created_at":"2025-11-10 10:22:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6935311,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/f4187ae0-dd95-4043-88b4-df67ceee08b8.pdf"},{"id":95340293,"identity":"8ce8bce0-8c7e-4e52-8fbe-10bec3c96e73","added_by":"auto","created_at":"2025-11-07 01:26:57","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18196,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/cef320d854d405cb63f9b53d.docx"},{"id":95525448,"identity":"d4426d9f-335d-4f9f-9eb8-5ea8a6550e50","added_by":"auto","created_at":"2025-11-10 10:05:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":42525,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/c01ff474897f73c1764e3047.docx"},{"id":95524681,"identity":"1d61ad40-3f4e-4926-b544-d11198893287","added_by":"auto","created_at":"2025-11-10 10:03:13","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":42092,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/ebf4034b00658a6b633d25da.docx"},{"id":95340304,"identity":"4696a3a3-d396-459d-ae51-46b05fd34594","added_by":"auto","created_at":"2025-11-07 01:26:57","extension":"doc","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":317440,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable4.doc","url":"https://assets-eu.researchsquare.com/files/rs-7700188/v1/15ad77009080a1da50293082.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Availability, Prices and Affordability of Nationally Negotiated Antidiabetic Drugs in China: A National Survey","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAccording to the latest report from the International Diabetes Federation, nearly one ninth adults globally (589\u0026nbsp;million) are now living with diabetes. By 2050, the estimated number of adults with diabetes is projected to reach 853\u0026nbsp;million [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence rate among adults aged 18 and above stands at 11.9% in China, where there is the largest total number of diabetic patients globally [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Diabetes has become an urgent health issue for China since 1980 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Economic development, aging population, and lifestyle changes are among the reasons for the high incidence of diabetes. Lifestyle intervention is a basic therapeutic measure for diabetes and should be carried out throughout the treatment of diabetes. If simple lifestyle intervention fails to bring blood glucose up to the target, drug therapy should be started in time. The use of hypoglycaemic drugs is an important clinical intervention for controlling blood glucose.\u003c/p\u003e\u003cp\u003eIn recent years, novel glucose-lowering medications including sodium-glucose cotransporter2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin analogs have rapidly entered the Chinese market. While they effectively control blood glucose and improve cardiovascular outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], these agents are progressively replacing traditional therapies. However, their typically high prices pose significant economic burdens on both patients and the society. Given that diabetes, as a highly prevalent chronic condition, requires lifelong pharmacological intervention, these elevated costs severely compromise medication adherence and patients\u0026rsquo; willingness to persist with treatment. Consequently, this financial barrier undermines optimal healthcare access for people with diabetes.\u003c/p\u003e\u003cp\u003eTo effectively reduce the prices of patented and exclusive drugs and alleviate medication burdens on patients, the national healthcare security department has explored and established a medical insurance access negotiation mechanism since 2017. Through negotiations, high-priced drugs with high clinical value and proven efficacy have been progressively included into the National Reimbursement Drug List (NRDL) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. To date, over a dozen glucose-lowering medications have been incorporated into the NRDL through national medical insurance negotiations, securing coverage for patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, their inclusion in the NRDL does not guarantee patient access to them. The landing of the national negotiation drugs in the medical institutions urgently needs to be studied.\u003c/p\u003e\u003cp\u003eThe prices, availability, and affordability are the main criteria to measure whether patients can purchase a medicine at an affordable price [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In 2003, the World Health Organization (WHO) and Health Action International (HAI) jointly developed the WHO/HAI Standard Survey Methodology to assess the accessibility of essential medicines worldwide [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].To date, numerous studies have been conducted globally using the WHO/HAI Standard Survey Methodology. Based on this foundation, China has now established the evaluation method that better suits its national conditions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The scope of the drugs studied has expanded beyond essential medicines to include those previously not covered by the standard survey, such as glucose-lowering drugs [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. To evaluate the accessibility of nationally negotiated glucose-lowering drugs, this study investigated their availability, affordability and prices across China using an adjusted WHO/HAI methodology.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eA cross-sectional survey was conducted from January 2019 to December 2023 across 31 provinces, municipalities and autonomous regions in China. The study evaluated the availability, prices, and affordability of nationally negotiated glucose-lowering drugs in 804 public general hospitals (including 537 tertiary hospitals and 267 secondary hospitals) in recent years.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e\u003cstrong\u003eSelection of the investigated medicines\u003c/strong\u003e\u003c/h2\u003e\n \u003cp\u003eA list of 12 drugs was included in this study, consisting of liraglutide injection, which was nationally negotiated in 2017, acarbose tablets, exenatide injection, lixisenatide injection, dapagliflozin tablets, canagliflozin tablets, and empagliflozin tablets negotiated in 2019, and Insulin degludec/aspart injection, benaglutide injection, dulaglutide injection, pegylated loxenatide injection and ertugliflozin tablets negotiated in 2020 (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of 12 national negotiation antidiabetic drugs\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eName\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eATC Code\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDosage form\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDDD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReimbursement date\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsulin degludec and insulin aspart\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10AD06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMay 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcarbose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BF01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDec 1994\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExenatide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BJ01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026micro;g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAug 2009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiraglutide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BJ02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eApr 2011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLixisenatide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BJ03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026micro;g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSep 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeinaglutide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BJ07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDec 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDulaglutide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BJ05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeb 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePolyethylene glycol loxenatide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026micro;g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJun 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDapagliflozin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BK01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMar 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCanaglifozin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BK02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSep 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmpagliflozin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BK03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSep 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eErtuglifozin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA10BK04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJul 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eNote: ATC Code from the WHO Collaborating Center for Drug Statistics Methodology ; -, not available\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eData sources\u003c/h3\u003e\n\u003cp\u003eThe Chinese Medicine Economic Information Network (CMEI), one of the largest drug information service platforms in China covering over 1,500 public hospitals, served as the data source for this study [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. By virtue of the CMEI, this study systematically collected related data including therapeutic category, generic name, dosage form, brand manufacturer, procurement volume, and procurement price for the 12 nationally negotiated antidiabetic drugs.\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eData Analysis\u003c/h2\u003e\n \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n \u003ch2\u003eAvailability\u003c/h2\u003e\n \u003cp\u003eAccording to the WHO/HAI Standard Survey Methodology, the availability of a medicine was interpreted as the percentage of facilities in which this medicine was found on the day of data collection [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Accordingly, it is calculated as the number of hospitals where the drug is available divided by the total number of the investigated hospitals. To describe availability, the following ranges were used [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]: \u0026lt;30% (very low, the drug was very difficult to find), 30% to 49% (low, the drug was available in a few hospitals surveyed ), 50% to 80% (fairly high, the drug was available in many hospitals surveyed), and \u0026gt;\u0026thinsp;80% (high, the drug was available in most hospitals surveyed).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003ePrice\u003c/h3\u003e\n\u003cp\u003eThe defined daily dose cost (DDDc) represents the price per standardized treatment unit, serving as an indicator of drug expenditure that reflects the overall price level of medicines. It indicates the average daily cost for patients who use a specific drug [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. The DDDc was derived from dividing the total expenditure of a drug by defined daily doses (DDDs), whereas DDDs were calculated by dividing the total volume procured by the defined daily dose (DDD) [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. The DDD value of each generic drug can be found in the Guidelines for Anatomical Therapeutic Chemical (ATC) classification and DDD assignment 2024 [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. A higher DDDc value indicates that the drug is more expensive [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eAffordability\u003c/h2\u003e\n \u003cp\u003eThe WHO defines medicine affordability as the multiple of the lowest-paid unskilled government worker (LPGW)\u0026rsquo;s daily wage represented by the total medicine cost for a standard treatment regimen against a specific disease [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. According to the WHO/HAI, a medicine is affordable if the cost of a treatment course is less than the daily wage of the LPGW (affordability\u0026thinsp;\u0026lt;\u0026thinsp;1 ) [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. Following previous research [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e], due to the lack of data, the daily wage of the LPGW was proxied using the annual disposable income per capita for estimates. In China, the median annual disposable income per capita for all residents is divided by the standard number of workdays (250 days) to estimate the daily wage equivalent [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. The treatment duration for an acute disease is the total duration of a full course of therapy while that for a chronic disease is 30 days [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. Consequently, the affordability calculation formula for each drug in this study is defined as follows:\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1762452381.png\" width=\"495\" height=\"80\"\u003e\u003c/p\u003e\n \u003cp\u003ePrior to their inclusion in the NRDL, the investigated drugs required 100% patient\u0026rsquo;s out-of-pocket payment. After national negotiations, these drugs were incorporated into Category B of the NRDL with nationwide implementation, but their reimbursement rates varied from place to place (ranging from about 50% to 85%) [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Based on established research evidence, this study standardized the reimbursement rate for Category B negotiated drugs at 65% [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. According to the National Bureau of Statistics of China, the median annual disposable income per capita from 2018 to 2023 stood at 24,336 CNY, 26,523 CNY, 27,540 CNY, 29,975 CNY, 31,370 CNY and 33,036 CNY for all residents; at 36,413 CNY, 39,244 CNY, 40,378 CNY, 43,504 CNY, 45,123 CNY and 47,122 CNY for urban residents; and at 13,066 CNY, 14,389 CNY, 15,204 CNY, 16,902 CNY, 17,734 CNY and 18,748 CNY for rural residents, respectively [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eAvailability\u003c/h2\u003e\u003cp\u003eThe availability of 12 investigated antidiabetic drugs from 2018 to 2023 is presented in online \u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The annual availability rate is calculated as the mean of the monthly availability rates (detailed monthly data are provided in online \u003cb\u003eSupplementary Tables\u0026nbsp;2\u0026ndash;4\u003c/b\u003e). The availability rates of all the investigated drugs except acarbose and exenatide demonstrated upward trends from baseline values (range: 7.14% to 20,384.85%), with insulin degludec and insulin aspart exhibiting the most substantial increase by 20,384.85%, whose availability rose from 0.33% in 2019 to 67.60% in 2023. In 2023, the availability rates of exenatide, lixisenatide, and benaglutide plummeted to merely 3.11%, 0.30%, and 1.01% respectively. Concurrently, five drugs demonstrated fairly high availability (50% to 80%): insulin degludec and insulin aspart (67.60%), acarbose (70.34%), liraglutide (51.67%), dulaglutide (55.38%), and dapagliflozin (77.11%). The analysis on hospital tier levels (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) reveals that most antidiabetic drugs exhibited obviously increases in their availability rates across both secondary and tertiary hospitals. Moreover, their availability rates in tertiary hospitals were generally higher than those in secondary hospitals, which aligned with hospital tier disparities in resource allocation and clinical capacity.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePrices\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, in 2023 all the investigated drugs except ertugliflozin demonstrated significant reductions in DDDc values compared with baseline values, with decline rates ranging from 22.78% to 90.39%. Exenatide showed the most pronounced reduction, whose DDDc decreased from 113.29 CNY in 2018 to 10.89 CNY in 2023, representing a 90.39% decline. Notably, DDDc values generally decreased immediately following a drug\u0026rsquo;s entry into the NRDL, and the first formal implementation year (post-negotiation year) witnessed the most substantial reductions. Thereafter, DDDc values generally continued to decline gradually or stabilized. For example, the initial DDDc value of benaglutide during the study period was 30.16 CNY. It decreased to 29.90 CNY in the negotiation year (2020) and further dropped to 14.28 CNY in the first implementation year (2021).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDDDc of national negotiated innovative antidiabetic drugs in the investigated hospitals\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNegotiation year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eName\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c9\" namest=\"c4\"\u003e\u003cp\u003eDDDc / CNY\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInsulin degludec and insulin aspart\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e11.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e10.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcarbose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExenatide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e113.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e11.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e10.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e10.89\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLiraglutide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e34.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e28.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e26.26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLixisenatide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e18.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e18.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e18.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBeinaglutide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e14.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e13.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e13.64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDulaglutide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e45.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e15.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e15.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e13.64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePolyethylene glycol loxenatide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e13.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e13.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e13.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDapagliflozin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e4.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e4.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e4.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanaglifozin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e6.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e4.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmpagliflozin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e5.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e4.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e4.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eErtuglifozin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e5.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e6.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e6.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eDDD, defined daily dose; DDDc, DDD costs; -, not available; CNY, Chinese Yua\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eAffordability\u003c/h2\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, during the study period, while the affordability of ertugliflozin increased (by 12.97%), the affordability of all other investigated drugs decreased significantly, with decline rates ranging from 43.43% to 97.52%. Among them, exenatide showed the largest decrease in affordability (97.52%). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, all the drugs collected by the research institute were unaffordable during 2018 and 2019. In 2020, excluding ertugliflozin which was not collected, four of the other investigated drugs became affordable: acarbose (0.43), dapagliflozin (0.41), empagliflozin (0.70), and canagliflozin (0.77). In 2021, ertugliflozin (0.49) was added to the list of affordable medications. By 2022, two more drugs became affordable: insulin degludec and insulin aspart (0.98) and exenatide (0.89), achieving 7 affordable medications in total. In 2023, although no new drugs became affordable, the affordability rates of the remaining drugs still decreased. The affordability for urban residents was significantly better than that for rural residents. In 2023, urban residents could afford 10 of the investigated antidiabetic drugs, while rural residents could only afford 5 (Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAffordability ratio of each study drug from 2018 to 2023\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcarbose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eErtugliflozin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBeinaglutide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDapagliflozin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsulin Degludec and Insulin Aspart\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDulaglutide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmpagliflozin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePolyethylene glycol loxenatide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCanagliflozin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiraglutide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLixisenatide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExenatide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: -, not available\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDiabetes is a global health challenge that affected 529\u0026nbsp;million people in 2021 and is projected to affect 1.31\u0026nbsp;billion people by 2050 worldwide [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. China has the world\u0026rsquo;s largest diabetic population, with more than 118\u0026nbsp;million people living with diabetes, accounting for approximately 22% of all suffering from diabetes worldwide [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Antidiabetic drugs, as a key means of controlling diabetes progression and lowering blood glucose levels, play a pivotal role in diabetes treatment. Deressa HD [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] found big gaps in availability and affordability of essential medicines (EMs) used for diabetes in central Ethiopia. Policy makers should work to improve access to EMs against diabetes. Caijun Yang\u0026rsquo;s study on the availability and affordability of oral antidiabetic drugs in Shaanxi Province, China, revealed that most antidiabetic medications failed to meet WHO supply targets [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Patients were under considerable economic pressure, and the medication affordability was disproportionate among rural residents. These findings underscore the need for government-led policy interventions to ensure better access to more affordable antidiabetic drugs for the Chinese people. In response, China has implemented the NRDL negotiation policy and has been progressively expanding the NRDL to cover more and newer antidiabetic drugs.\u003c/p\u003e\u003cp\u003eThis study was conducted using the WHO/HAI methodology to evaluate the availability, price, and affordability of nationally negotiated antidiabetic drugs in China, providing policymakers with the latest data reference for optimizing relevant policies. In this study, it was found that from 2018 to 2023, the overall availability of the investigated antidiabetic drugs showed an upward trend, while their DDDc exhibited a downward trend. The affordability of these drugs for the public has gradually improved, which is consistent with the anticipated outcomes. During the study period, an \u0026ldquo;inverted U-shaped\u0026rdquo; inflection point was observed in the availability of GLP-1 receptor agonists such as exenatide, liraglutide, lixisenatide, and benaglutide in 2021. This phenomenon may be primarily attributed to the fact that although these drugs were included in the NRDL, they were accompanied by stringent reimbursement restrictions (For patients with inadequately controlled type 2 diabetes requiring oral antihyperglycemic agents (e.g., metformin) or insulin and with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 kg/m\u0026sup2;, the initial prescription must be issued by an endocrinologist or specialist at a secondary or higher medical facility [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]), as well as changes in market competition dynamics. These factors led to temporary imbalances or fluctuations in the actual availability of GLP-1 drugs, thereby affecting the stability of their availability. Another potential contributing factor could be the market impact caused by newer-generation GLP-1 drugs (such as dulaglutide and semaglutide). The availability of acarbose in 2023 was lower than that in 2018, which might be attributed to the gradual introduction of various newer antidiabetic drugs. This expansion in treatment options has provided alternative approaches for diabetes management, consequently impacting the demand for earlier-generation drugs such as acarbose. Among the 12 investigated drugs, insulin degludec and insulin aspart demonstrated the most significant increase in availability. As the first fully soluble co-formulation of insulin, it combines ultra-long-acting basal insulin degludec and rapid-acting meal-time insulin analog aspart, whose advantages include no requirement for resuspension before injection and an extended duration of action [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The improved availability of this insulin formulation may benefit a larger population of patients with diabetes.\u003c/p\u003e\u003cp\u003eAmong the 12 investigated antidiabetic drugs, the DDDc values decreased significantly for all except ertugliflozin. The slight increase in the DDDc value of ertugliflozin may be attributed to a floor effect. It was likely to result from its relatively late market entry (2021), which coincided with China\u0026rsquo;s implementation of the NRDL policy, leading to artificially suppressed market pricing during its first year on the market. It could also be linked to the volume-price agreements signed between the National Healthcare Security Administration and manufacturers during medical insurance and drug procurement price negotiations. Besides, during the study period, the number of drugs affordable to the public increased from 0 to 7. These findings indicate that the implementation of the NRDL policy has significantly alleviated the economic burden on patients. However, this study also revealed a substantial disparity in the affordability of the investigated drugs between urban and rural areas, with the affordability capacity of rural residents notably lower than that of urban residents. This can provide a solid theoretical foundation for the formulation and optimization of relevant policies by the government in the future.\u003c/p\u003e\u003cp\u003eThis study reports on the utilization of 12 nationally negotiated antidiabetic drugs in 804 public secondary and tertiary general hospitals across China from 2018 to 2023. It features a long duration, broad coverage, and a diverse range of drugs, allowing for a comprehensive evaluation of the implementation of the NRDL policy. However, this study also has certain limitations, such as potential underreporting in hospital procurement data and the absence of data from private hospitals and retail pharmacies during data collection. Therefore, the dataset will be further expanded in our subsequent studies to provide more objective and robust data support for assessing the implementation of the NRDL policy\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that the implementation of the NRDL policy has effectively improved the availability of antidiabetic drugs and alleviated the financial burden on patients with diabetes. However, the availability of many newer antidiabetic drugs remains relatively low, and significant disparities persist in affordability between urban and rural residents. Therefore, the government should introduce targeted policies to address urban-rural inequalities, further optimize the national healthcare security system, and ensure medication access for grassroots populations. Simultaneously, it is crucial to accelerate the establishment of a comprehensive evaluation system for new drug inclusion, so that more innovative medicines can be promptly incorporated into the national drug price negotiations. This will reduce the financial burden on patients and promote the comprehensive implementation of nationally negotiated drugs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, as this study does not report on or involve the use of data from animals or human subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;datasets\u0026nbsp;used\u0026nbsp;and/or\u0026nbsp;analysed\u0026nbsp;during\u0026nbsp;the\u0026nbsp;current\u0026nbsp;study\u0026nbsp;are\u0026nbsp;available\u0026nbsp;from\u0026nbsp;the\u0026nbsp;corresponding\u0026nbsp;author.\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by 2024 Municipal-level Medical Research Project of the Health Commission (DX202424)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors` contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWT was primarily responsible for the statistical analysis of research data and the writing of the manuscript; WLi wrote the article and performed language editing; WLu and ZZY searched and collected relevant literature and data; HDC collected and processed the data; HHW and WS provided the research design and conceptualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors appreciate Chinese Medicine Economic Information (CMEI) database.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOver 250 million people worldwide unaware they have diabetes, according to new research from the International Diabetes Federation (IDF). Diabetes Res Clin Pract. 2025,223:112176. doi: 10.1016/j.diabres.\u003c/li\u003e\n\u003cli\u003eChinese Diabetes Society, National Office for Primary Diabetes Care. National guidelines for the prevention and control of diabetes in primary care (2022).Chin J Intern Med. 2022,61(3):249-262. doi:10.3760/cma.j.cn112138-20220120-000063..\u003c/li\u003e\n\u003cli\u003eWang Q, Zhang X, Fang L, et al. Prevalence, awareness, treatment and control of diabetes mellitus among middle-aged and elderly people in a rural Chinese population: a cross-sectional study. Plos One. 2018;13(6):e0198343. doi: 10.1371/journal.pone.0198343.\u003c/li\u003e\n\u003cli\u003eMa RCW. Epidemiology of diabetes and diabetic complications in China. Diabetologia. 2018;61(6):1249\u0026ndash;1260. doi: 10.1007/s00125-018-4557-7.\u003c/li\u003e\n\u003cli\u003eLi XH, Jin CN. Research progress on cardiovascular benefits of novel hypoglycemic agents SGLT2 inhibitors and GLP-1 receptor agonists. J Electrocardiol Circ. 2024;43(5):524-9.\u003c/li\u003e\n\u003cli\u003eGe SY. NNT study and economic evaluation of new hypoglycemic drugs on cardiovascular outcomes in patients with type 2 diabetes. Hebei Medical University, 2023.\u003c/li\u003e\n\u003cli\u003eXu W., Chen L. L., Wang N., et al. Thoughts on perfecting the medical insurance payment policy of national negotiated drugs. China Health Insur, 2020, (06): 8-11.\u003c/li\u003e\n\u003cli\u003eNational Healthcare Security Administration, Ministry of Human Resources and Social Security. Notice on Printing and Distributing the National Drug List for Basic Medical Insurance, Work-Related Injury Insurance, and Maternity Insurance . 2024. https://www.gov.cn/zhengce/zhengceku/202411/content_6989859.htm. Accessed November 27 2024.\u003c/li\u003e\n\u003cli\u003eLiyanage CK, Gunawardane M, Kumaradasa PP, et al. A national survey on registered products, availability, prices, and affordability of 100 essential medicines in community pharmacies across Sri Lanka. BMC Health Serv Res. 2023;23(1):1121.\u003c/li\u003e\n\u003cli\u003eNguyen HTT, Dinh DX, Nguyen TD, et al. Availability, prices and affordability of essential medicines: A cross-sectional survey in Hanam province, Vietnam. PLoS One. 2021;16(11):e0260142. .\u003c/li\u003e\n\u003cli\u003eWan M, Liu JY, Yu GY, et al. Availability and affordability of osteoporosis treatment drugs in Wuhan based on the WHO/HAI standard survey method. J Chin Pharm Sci. 2023;32(5):417-425. .\u003c/li\u003e\n\u003cli\u003eWang X, Cao JY, Zhang JH, et al. Study on prices and availability of 50 medicines in shandong province by using WHO/HAI standardization method. China Pharm. 2021;24(10):1877-1881.\u003c/li\u003e\n\u003cli\u003eZeng L, Wang L, Liu D, et al. Accessibility of SGLT-2 inhibitors in Hubei province based on WHO/HAI standard survey method. Drug Eval. 2024;21(03):265-269.\u003c/li\u003e\n\u003cli\u003eScience and Technology Development Center of Chinese Pharmaceutical Association. Brief introduction to CMEI. https://en.cmei.org.cn/index/network/introduction.html?catid=48. Accessed 8 Jun 2023.\u003c/li\u003e\n\u003cli\u003eWang X, Cao JY, Zhang JH, et al.Study on Prices and Availability of 50 Medicines in Shandong Province by Using WHO/HAI Standardization Method[J]. China Pharm. 2021;24(10):1877-1881.\u003c/li\u003e\n\u003cli\u003eEzezew M, Yehualaw A, Demsie DG. Assessment of availability and challenges of WHO recommended priority life-saving medicines for under five-year children in primary public health facilities of Amhara region. BMC Pediatr. 2023;23(1):395. doi:10.1186/s12887-023-04216-6. .\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zler G, Işik O. Prices, availability and affordability of selected essential medicines for chronic diseases in T\u0026uuml;rkiye. East Mediterr Health J. 2023;26(11):850-860. .\u003c/li\u003e\n\u003cli\u003eShambira G, Suleman F. Retail pharmacy prescription medicines\u0026apos; availability, prices and affordability in Eswatini. Afr J Prim Health Care Fam Med. 2021;13(1):e1-e11. .\u003c/li\u003e\n\u003cli\u003eYang Y, Tong R, Yin S, et al. The impact of \u0026ldquo;4\u0026thinsp;+\u0026thinsp;7\u0026rdquo; volume-based drug procurement on the volume, expenditures, and daily costs of antihypertensive drugs in Shenzhen, China: an interrupted time series analysis. BMC Health Serv Res. 2021;21:1275. doi: 10.1186/s12913-021-07143-3. .\u003c/li\u003e\n\u003cli\u003eZhang L, Wang X, Yao H, et al. Impact of national drug price negotiation policy on the accessibility and utilization of PCSK9 inhibitors in China: an interrupted time series analysis. Int J Equity Health. 2024;23(1):116. .\u003c/li\u003e\n\u003cli\u003eWCCF Methodology. Guidelines for ATC classification and DDD assignment 2024. 2024.\u003c/li\u003e\n\u003cli\u003eChen YJ, Cao WJ, Zeng X, et al. Analysis of the use and prescripation of hypoglycemic drugs in a hospital from 2020 to 2021. Chin J Drug Abuse Prev Treat. 2025;31(03):472-475.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization and Health Action International. Measuring medicine prices,availability,affordability and price components,2nd edition. 2008. http://www.haiweb.org/medicineprices/manual/documents.html?. Accessed May 23 2024\u003c/li\u003e\n\u003cli\u003eRaju PKS. WHO/HAI Methodology for Measuring Medicine Prices, Availability and Affordability, and Price Components. In: Vogler S, ed. Medicine price surveys, analyses and comparisons. Academic Press, 2019; 209-28. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO), Health Action International (HAI). Measuring Medicine Prices, Availability, Affordability and Price Components. 2nd ed. WHO, HAI; 2008. 2008. https://www.who.int/medicines/areas/access/medicines_prices08/en/. Accessed May 23 2024.\u003c/li\u003e\n\u003cli\u003eDiao Y, Qian J, Liu Y, et al. How government insurance coverage changed the utilization and affordability of expensive targeted anti-cancer medicines in China: an interrupted time-series study. J Glob Health. 2019;9:020702. doi:10.7189/jogh.09.020702.\u003c/li\u003e\n\u003cli\u003eYuan J, Lu ZK, Xiong X,et al. Lowering drug prices and enhancing pharmaceutical affordability: an analysis of the national volume-based procurement (NVBP) effect in China. BMJ Glob Health. 2021;6(9):e005519. doi: 10.1136/bmjgh-2021-005519.\u003c/li\u003e\n\u003cli\u003eNguyen HTT, Dinh DX, Nguyen TD, et al. Availability, prices and affordability of essential medicines: A cross-sectional survey in Hanam province, Vietnam. PLoS One. 2021;16(11):e0260142. doi:10.1371/journal.pone.0260142.\u003c/li\u003e\n\u003cli\u003eXie JP, Shao R. Research on the typical model of provincial management concerning national medical insurance negotiation drugs. Chinese Health Econ 2020;39:42-5.\u003c/li\u003e\n\u003cli\u003eCao Z, Li SS, Cao RY, et al Research on the accessibility of national medical insurance negotiation drugs\u0026mdash;\u0026mdash;an analysis based on the usage and reimbursement data of 17 national negotiated anticancer drugs in five cities. Health Econ Res. 2022;39:53\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eLi W, Lu W, Chen H, et al. Access to innovative anticancer medicines in China: a national survey on availability, price and affordability. BMJ Open. 2024;14(4):e077089. doi:10.1136/bmjopen-2023-077089.\u003c/li\u003e\n\u003cli\u003eNational Bureau of Statistics of China. Statistical Bulletin of the people\u0026rsquo;s Republic of China on national economic and social development in 2018. 2018. https://www.stats.gov.cn/sj/zxfb/202302/t20230203_1900203.html. Accessed 8 Jun 2024.\u003c/li\u003e\n\u003cli\u003eNational Bureau of Statistics of China. Statistical Bulletin of the people\u0026rsquo;s Republic of China on national economic and social development in 2019. 2019. https://www.stats.gov.cn/xxgk/sjfb/zxfb2020/202001/t20200117_1767741.html. Accessed 8 Jun 2024.\u003c/li\u003e\n\u003cli\u003eNational Bureau of Statistics of China. Statistical Bulletin of the people\u0026rsquo;s Republic of China on national economic and social development in 2020. 2020. https://www.stats.gov.cn/sj/zxfb/202302/t20230203_1900970.html. Accessed 8 Jun 2024.\u003c/li\u003e\n\u003cli\u003eNational Bureau of Statistics of China. Statistical Bulletin of the people\u0026rsquo;s Republic of China on national economic and social development in 2021. 2021. https://www.stats.gov.cn/sj/zxfb/202302/t20230203_1901342.html. Accessed 8 Jun 2024.\u003c/li\u003e\n\u003cli\u003eNational Bureau of Statistics of China. Statistical Bulletin of the people\u0026rsquo;s Republic of China on national economic and social development in 2022. 2022. https://www.stats.gov.cn/sj/zxfb/202302/t20230203_1901715.html. Accessed 8 Jun 2024.\u003c/li\u003e\n\u003cli\u003eNational Bureau of Statistics of China. Statistical Bulletin of the people\u0026rsquo;s Republic of China on national economic and social development in 2023. 2024. https://www.stats.gov.cn/sj/zxfb/202401/t20240116_1946622.html. Accessed 8 Jun 2024.\u003c/li\u003e\n\u003cli\u003eXu Y, Lu J, Li M, Wang T, et al. Diabetes in China part 1: epidemiology and risk factors. Lancet Public Health. 2024;9(12):e1089-e1097. doi: 10.1016/S2468-2667(24)00250-0. .\u003c/li\u003e\n\u003cli\u003eOng KL, Stafford LK, McLaughlin SA, et al. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2023; 402: 203-34.\u003c/li\u003e\n\u003cli\u003eDeressa HD, Abuye H, Adinew A, et al. Access to essential medicines for diabetes care: availability, price, and affordability in central Ethiopia. Glob Health Res Policy. 2024;9(1):12. doi:10.1186/s41256-024-00352-3. .\u003c/li\u003e\n\u003cli\u003eYang C, Hu S, Zhu Y, et al. Evaluating access to oral anti-diabetic medicines: A cross-sectional survey of prices, availability and affordability in Shaanxi Province, Western China. PLoS One. 2019;14(10):e0223769. doi: 10.1371/journal.pone.0223769.\u003c/li\u003e\n\u003cli\u003eNational Healthcare Security Administration. National Basic Medical Insurance, Work Injury Insurance, and Maternity Insurance Drug List. 2020. http://www.nhsa.gov.cn/art/2020/12/28/art_37_3850.html. Accessed 15 Jan 2025.\u003c/li\u003e\n\u003cli\u003eGarber AJ, Handelsman Y, Grunberger G, et al. Consensus statement by the American Association of Clinical Endocrinologists and the American College of Endocrinology on the comprehensive type 2 diabetes management algorithm- 2020 executive summary. Endocrine Practice. 2020;26(1):107\u0026ndash;139. doi: 10.4158/CS-2019-0472. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"National Reimbursement Drug List (NRDL), Antidiabetic Drugs, Prices, Availability, Affordability","lastPublishedDoi":"10.21203/rs.3.rs-7700188/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7700188/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThis study aimed to\u003cstrong\u003e \u003c/strong\u003einvestigate the availability, prices, and affordability of nationally negotiated antidiabetic drugs in China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eMonthly data about the use of antidiabetic drugs from 2018 to 2023 were collected from the Chinese Medicine Economic Information Network (CMEI). This study covered 804 public general hospitals in 31 provincial administrative regions in China, among which 537 (66.79%) were tertiary, and 267 (33.21%) were secondary.\u003cstrong\u003e \u003c/strong\u003eThe adjusted World Health Organization and Health Action International methodology was used to calculate the availability and affordability of 12 nationally negotiated antidiabetic drugs in the investigated hospitals. Price is expressed as the defined daily dose cost (DDDc).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOn average, the total availability of 12 nationally negotiated antidiabetic drugs increased annually from 2018 to 2023. The median availability of all the investigated drugs in tertiary hospitals from 2018 to 2023 was 11.53%, 4.50%, 13.49%, 37.85%, 41.16% and 42.07%, respectively, while the indicator in secondary hospitals was 1.59%, 1.59%, 4.31%, 23.16%, 28.28% and 29.67%, respectively. The DDDc of the drugs newly covered by Medicare decreased noticeably. The affordability of the antidiabetic drugs has improved year by year from 2018 to 2023. In comparison, rural residents had lower affordability of the drugs than urban residents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e The overall availability, affordability and DDDc of 12 nationally negotiated antidiabetic drugs improved from 2018 to 2023. However, the overall availability of most antidiabetic drugs in China remained at a low level (less than 50%). Further efforts should be made to sufficiently and equally benefit diabetic patients.\u003c/p\u003e","manuscriptTitle":"Availability, Prices and Affordability of Nationally Negotiated Antidiabetic Drugs in China: A National Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-07 01:26:52","doi":"10.21203/rs.3.rs-7700188/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-07T07:17:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T12:37:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22717636583778048811728898626790420446","date":"2025-11-06T11:21:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-01T14:07:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27129825637742648962108512108861222224","date":"2025-10-30T08:11:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153076784013168225128591378856000029803","date":"2025-10-29T21:12:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"269141294030914594419981420285345034739","date":"2025-10-29T15:58:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-27T14:58:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-23T09:27:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-01T10:13:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-30T09:22:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-09-30T08:37:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c17136e-841a-443b-8b75-2e610495d90f","owner":[],"postedDate":"November 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T14:54:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-07 01:26:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7700188","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7700188","identity":"rs-7700188","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}