Diabetes Atlas
Looking beyond the issue of access to insulin: What is needed for proper diabetes care in resource poor settings

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Abstract

Insulin's indispensible nature is recognised by its inclusion in the World Health Organization's Essential Medicines List. Despite this insulin is still not available on an uninterrupted basis in many parts of the developing world. The International Insulin Foundation has conducted in-country assessments and based on these findings, the barriers to access to insulin were more to do with problems linked distribution, tendering and government policies than purely accessibility and affordability issues. Lack of insulin leads to poor outcomes for people with diabetes, but access to medicines alone cannot improve levels of health in resource poor settings. Aspects such as strong political will and local champions, data, trained healthcare workers and diabetes associations are just as necessary. Strengthening health systems and developing sustainable and locally owned solutions are vital to improve health and health care for people with diabetes and other chronic conditions in resource poor settings.

Introduction

Insulin is vital for the survival of people with Type 1 diabetes and used to improve management of blood glucose in people with Type 2 diabetes. Insulin's indispensible nature is recognised by its inclusion in the World Health Organization's (WHO) Essential Medicines List [1].

Despite this insulin is still not available on an uninterrupted basis in many parts of the developing world [2], [3], [4], [5], [6], [7]. The reasons for this are linked to the problems of affordability (being able to meet the expense of a given good) and accessibility (the right or privilege to make use of something). In order to address the problem of access to insulin it is essential to understand how medicines get to the individuals needing them and how issues of affordability and accessibility impact overall access.

For this purpose the International Insulin Foundation (IIF) developed the Rapid Assessment Protocol for Insulin Access (RAPIA) in order to assess the path of insulin and other diabetes related supplies to identify problems with affordability and accessibility [8]. In addition this protocol helps identify other barriers to proper diabetes care. This paper will highlight the lessons learnt from the IIF's in-country experience.

The IIF has conducted in-depth assessments in Mali (2004), Mozambique (2003), Nicaragua (2007), Vietnam (2008) and Zambia (2003) [9], [10], [11], [12], [13]. Based on these findings, the barriers to access to insulin were more to do with problems linked distribution, tendering and government policies than purely accessibility and affordability issues. However, these difficulties in accessing insulin were only part of the larger problems of accessing proper diabetes care and treatment. These include access to syringes, tools for diagnosis and follow-up, availability of trained healthcare workers, government policies and the role of diabetes associations.

The absence of this “essential package” for diabetes care leads to poor outcomes with the life expectancy of a child with newly diagnosed Type 1 diabetes in much of sub-Saharan Africa being as short as 1 year [14], [15] and life expectancy found to be 12 months and of 30 months in Mali and Mozambique, respectively [16]. This is in comparison to virtually normal life expectancy for a child with diabetes in industrialised countries.

Through the IIF's work what has become apparent is that the supply of insulin alone will not improve outcomes for people with diabetes. Insulin, syringes and testing equipment need to be present at the adequate facilities with the right infrastructure and personnel. The IIF has identified 11 points necessary for a “positive” diabetes environment [17]. These are:

  • 1.

    Organisation of the health system;

  • 2.

    Data collection;

  • 3.

    Prevention;

  • 4.

    Diagnostic tools and infrastructure;

  • 5.

    Drug procurement and supply;

  • 6.

    Accessibility and affordability of medicines and care;

  • 7.

    Healthcare workers;

  • 8.

    Adherence issues;

  • 9.

    Patient education and empowerment;

  • 10.

    Community involvement and diabetes associations;

  • 11.

    Positive policy environment.

Points 5 and 6 are directly related to the issue of affordability and availability of insulin. However the issue of improving the lives of people with Type 1 diabetes needs to look beyond this small part of improving diabetes care in order to create a health system able to manage all aspects of diabetes care.

Section snippets

Results from 5 countries

In looking at affordability and availability of insulin and other diabetes supplies it is important to look at the differences in these factors between different areas of a country and between the public and private sector. In the 5 countries people living in urban areas and near large tertiary facilities had better access to insulin and diabetes care than those living in rural areas. In Mozambique in 2003, for example, Maputo Province represented only 11.3% of the total population, but

Lessons learnt

Access to medicines alone cannot improve levels of health in developing countries. For this reason it is important to expand the concept of access to medicines to encompass that of access to treatment for the benefit of people with diabetes and the success of health systems in general [19]. Treatment includes such aspects as availaibility and affordability of diagnostic tools as well as trained healthcare workers, diabetes education and support provided by a diabetes association.

Healthcare workers

One vital factor is the role of healthcare workers in the initial diagnosis of Type 1 diabetes and its ensuing management. Healthcare workers in these 5 countries rarely encounter people with Type 1 diabetes. This lack of familiarity and unavailability of tools for proper diagnosis mean that diabetes in many people is likely to be missed or misdiagnosed. Diabetes in people presenting in a coma may be misdiagnosed as cerebral malaria or HIV/AIDS [20], [21].

Diabetes Associations

In addition Diabetes Associations play a vital role in education, support, advocacy and also sometimes care of people with diabetes. The role of the Diabetes Association should be seen to evolve with the needs of people with diabetes. In Mozambique and Mali the associations delivered care as the health system was unable to do so. The Diabetes Association of Zambia provided some care, but this was mainly for Type 1 diabetes. A very active organization of parents with children and adolescents

Policies, data and training

Based on the IIF's experience in Mozambique and elsewhere, strong political will and local champions are necessary for a national diabetes programme to be established and for diabetes to be recognised as a health problem. This political will can be generated through different means, but one of the necessities is data on the size and scope of the problem of diabetes. In many countries this data has been in the form of the WHO stepwise approach [22] and the RAPIA. The development of a national

Conclusion

Insulin supply is thus an essential element of care for people with insulin-requiring diabetes, but alone it is insufficient to provide good care. A complete package is required, the key elements of which are described in the World Health Organization's Innovative Care for Chronic Conditions Framework (ICCCF) [24]. The ICCCF contains 8 elements:

  • Support a Paradigm Shift (from a focus on acute, episodic care to one that also includes chronic conditions);

  • Manage the political environment;

  • Build

Conflict of interest

There are no conflicts of interest.

Acknowledgments

The authors would like to acknowledge the support of the Trustees of the International Insulin Foundation John Bowis MEP, Professor Maximilian de Courten, Professor Geoffrey Gill, Professor Harry Keen, Professor Ayesha Motala, Dr. Kaushik Ramaiya, Professor Solomon Tesfaye and Professor Nigel Unwin.

The pilot and development of the RAPIA was made possible thanks to a grant from the World Diabetes Foundation. For the work in Vietnam the International Insulin Foundation received a grant from the

References (26)

  • J.S. Yudkin

    Insulin for the world's poorest countries

    Lancet

    (2000)
  • A.B. Swai et al.

    Diabetes mellitus misdiagnosed as AIDS

    Lancet

    (1989)
  • World Health Organization

    WHO Model List of Essential Medicines

    (2007)
  • K.G. Alberti

    Insulin dependent diabetes mellitus: a lethal disease in the developing world

    BMJ

    (1994)
  • L. Deeb et al.

    Insulin availability among International Diabetes Federation member associations

    Diabetes Care

    (1994)
  • D. McLarty et al.

    Insulin availability in Africa: an insoluble problem?

    Int. Diabetes Digest

    (1994)
  • A. Savage

    The insulin dilemma: a survey of insulin treatment in the tropics

    Int. Diabetes Digest

    (1994)
  • International Diabetes Federation Task Force on Insulin, Test Strips and Other Diabetes Supplies

    Survey on Access to Insulin and Diabetes Supplies 2006

    (2006)
  • D. Beran et al.

    Assessing health systems for insulin-requiring diabetes in sub-Saharan Africa: Developing a ‘Rapid Assessment Protocol for Insulin Access’

    BMC Health Serv. Res.

    (2006)
  • D. Beran et al.

    Report on the Rapid Assessment Protocol for Insulin Access in Nicaragua

    (2007)
  • D. Beran et al.

    Report on the Rapid Assessment Protocol for Insulin Access in Vietnam

    (2009)
  • International Insulin Foundation

    Report of the International Insulin Foundation on the Rapid Assessment Protocol for Insulin Access in Mozambique

    (2004)
  • International Insulin Foundation

    Final Report of the International Insulin Foundation on the Rapid Assessment Protocol for Insulin Access in Mali

    (2004)
  • Cited by (0)

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