Diabetes Care in subSaharan Africa

1
Diabetes Care in sub-Saharan Africa
David Beran Project Coordinator, International
Insulin Foundation Senior Research Fellow, Centre
for International Health and Development,
Institute of Child Health, University College
London
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Increase in Type 2 diabetes sub-Saharan Africa

• Globalisation
• Urbanisation and westernisation
• Changes in the human environment, and in
  behaviour and lifestyle
• Changes in diet
• Changes in physical activity - sedentary
  behaviour
• Increase in obesity
• People living longer

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Type 2 diabetes in children in sub-Saharan Africa

• Very little published data
• Some anecdotal data from main referral hospitals
• Case report from Togo on 5 children (Barruet and
  Gbadoe, 2006)
• Mean age at diagnosis was 13.2 ? 1.79 years
• All five patients were obese and had risk factors
  for obesity (high fat intake, sedentary lifestyle
  and lack of physical exercise)
• All had a familial history of Type 2 diabetes

4
Prevalence of Type 2 diabetes in IDF regions
(2007-2025) and increase during this period

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Prevalence of Type 1 diabetes
- International Diabetes Federation - Diabetes
Atlas - International Insulin Foundation
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Type 1 diabetes in sub-Saharan Africa

• Reasons for lower prevalence
• Lower incidence in sub-Saharan Africa 1 per
  100,000 per year (Swai, Tanzania, 1993)
• Compared to
• African Americans (15.2 per 100,000 in
  Philadelphia Lipman et al. 2006)
• Finland (41.4 per 100,000 Kondrashova et al.
  2005)
• Genetic factors ?
• Environmental factors ?
• Undiagnosed/misdiagnosed cases
• Poorer prognosis
• High rates of childhood illness in sub-Saharan
  Africa
• 38,800 cases of Type 1 diabetes versus
• Malaria killing 3,000 children daily
• Malunutrion and starvation 17 million deaths each
  year
• Around 2 million children living with HIV/AIDS

7
Lancet November 2006
Gale, EA. Dying of diabetes. The Lancet. 2006
368(9548) 1626-8 Beran, D and Yudkin, JS.
Diabetes Care in sub-Saharan Africa. The Lancet.
2006 368(9548)1689-95.
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International Insulin Foundation

• Established in 2002 by international specialists
  in the field of diabetes
• Why an International Insulin Foundation?
• Banting and Best
• Leonard Thompson the first patient to receive
  insulin in 1922
• Before 1922 people with Type 1 diabetes faced
  wasting and death in a matter of months or even
  weeks

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Background to the International Insulin Foundation

• Ideally what is needed to manage
  insulin-requiring diabetes in resource poor
  settings?
• Barriers to care exist
• How can these be clearly identified?
• Development of the Rapid Assessment Protocol for
  Insulin Access (RAPIA)

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The RAPIA

• Multi-level assessment of Health System
• Study the path of insulin from its arrival in the
  country
• Study the path of care
• Other Problems
• Information collected through
• Interviews
• Discussions
• Document reviews
• Observations

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The RAPIA

• Macro
• Ministry of Health
• Ministry of Trade
• Ministry of Finance
• Central Medical Store
• National Diabetes Association
• Private/Public drug importer
• Educators

• Meso (3 areas)
• Regional Health Organisation
• Hospitals, Health Centres, etc. (Public and
  Private)
• Pharmacies, Drug Dispensaries (Public and
  Private)
• Laboratories (Public and Private)

• Micro (3 areas)
• Healthcare Workers
• Traditional Healers
• Patients

Perspectives on the problem of access to insulin
and diabetes care
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The countries where the RAPIA has been implemented
Mali
Nicaragua
Zambia
Mozambique
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Comparison Mali, Mozambique and Zambia versus the
UK
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Insulin
The purchasing prices of insulin in Mali,
Mozambique and Zambia
Mozambique and Zambia have measures for patients
to receive free or subsidised insulin even though
these are not standardised or clear to patients.
15
Expenditure on Medicines
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Syringes

• VAT in all countries where the IIF has worked
• Not readily available in Public Sector

Comparison of the price range per syringe in
Mali, Mozambique and Zambia
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Testing materials

• Mali average urine glucose test 0.89 blood
  glucose test 2.38
• Mozambique laboratory tests for inpatients are
  free some outpatients need to pay a fee for
  blood glucose 0.21

Availability of diagnostic tools in Mali,
Mozambique and Zambia at different health
facilities visited
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Access to diabetes care

• Access along the urban/rural divide
• Access across the rich/poor divide

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Access to diabetes care

• Lack of Access to Healthcare facilities
• General lack of health facilities
• (1 million people/hospital Mozambique)
• Distance
• (Majority of patients 1-2 hours from healthcare
  centres)
• Lack of Healthcare workers
• Numbers
• Mali 4 / 100,000
• Mozambique 3.4 / 100,000
• Zambia 6.9 / 100,000
• Compared to UK 164 / 100,000
• In all 3 countries only 2 Endocrinologists/Diabeto
  logists
• Training

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Access to diabetes care

• Infrastructure
• Laboratories - Diagnosis
• Health facilities - Treatment
• Pharmacies - Dispensing
• Supply networks - Roads/Warehouses

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Access to diabetes care

• Distribution
• Loss of medicines (expiry, damage)
• Inadequate storage facilities
• No control and coordination
• Quantification
• Needs
• Complements

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Access to diabetes care

• Health Care Workers
• We know what we see
• Management of chronic conditions
• Social Distance
• No accountability
• No treatment guidelines
• No referral pathways

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Access to diabetes care

• Other
• Poverty of individuals and of countries
• Traditional Healers and Beliefs
• Government priorities

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Impact of these problems
Calculated life expectancies for people with
insulin-requiring diabetes in Mali, Mozambique
and Zambia
0-14
15
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A comparison between Boston (1897-1945) and
Mozambique (2003)
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Results from the RAPIA

• In-country recommendations
• Purchase and supply of insulin, medicines and
  other diabetes related supplies
• Healthcare worker training
• Development of diabetes association
• Organisation of care
• Data collection
• Patient education
• NCD policies

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The Diabetes Foundation report on implementing
national diabetes programmes in sub-Saharan Africa

• Based on
• The experience of the International Insulin
  Foundation
• Discussions with key opinion leaders
• Joint IDF/WHO AFRO meetings
• Review of the literature
• Provides a recipe for the management of
  diabetes in sub-Saharan Africa

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The 11 ingredients

• Organisation of the Health System
• Data Collection
• Prevention
• Diagnostic tools and infrastructure
• Drug procurement and supply
• Accessibility and affordability of medicines and
  care
• Healthcare workers
• Adherence issues
• Patient education and empowerment
• Community involvement and diabetes associations
• Positive policy environment

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Conclusion

• In 1901 a missionary doctor in Africa wrote
  diabetes is very uncommon but very fatal
• 106 years later this is still true for Type 1
  diabetes
• Type 2 diabetes is increasing in epidemic
  proportions
• Insulin alone is not enough
• A range of tools are needed to address the
  problem of diabetes, both Type 1 and Type 2, in
  sub-Saharan Africa
• Trained healthcare workers
• Functioning referral system
• Guidelines
• Availability and affordability of insulin,
  medicines and syringes
• Diagnostic tools
• Lack of donor interest in diabetes and chronic
  conditions
• Developments in insulin, delivery systems, etc.
  have dramatically improved the outcomes for
  children with diabetes in the developed world,
  but

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Canada circa 1922
Tanzania circa 2002
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Thank you! www.access2insulin.org