David Beran

Diabetes care in sub-Saharan Africa

The increasing numbers of people with type 2 diabetes is a worldwide concern. It presents an added challenge in sub-Saharan Africa, where diabetes must compete for resources with communicable diseases. A scarcity of financial resources and appropriate staff mean that many people with type 2 diabetes have complications and that those with type 1 diabetes have an extremely short life-expectancy, whether or not they have been diagnosed with the disorder. We review the current evidence on diabetes care in sub-Saharan Africa and propose an 11-point action plan to address this problem in the region.

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

Insulins indispensible nature is recognised by its inclusion in the World Health Organizations 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.

Use and Out-of-Pocket Costs of Insulin for Type 2 Diabetes Mellitus From 2000 Through 2010

Insulin analogs are molecularly altered forms of insulin. Compared with human synthetic and animal insulin for treatment of type 2 diabetes, short-acting analogs may offer flexible dosing and convenience, long-acting analogs less nocturnal hypoglycemia,1 but both at greater cost.2 Because insulin analogs have become increasingly popular,3,4 we examined trends in insulin use, out-of-pocket expenditures, and severe hypoglycemic events among privately insured US adults with type 2 diabetes from 2000 through 2010.

The insulin dilemma in resource-limited countries. A way forward?

The International Insulin Foundation (IIF) has developed and validated a needs-assessment instrument called the Rapid Assessment Protocol for Insulin Access (RAPIA) which has been used in seven countries in four continents to analyse the constraints to delivering effective continuing care for people with diabetes. One major contributor to the difficulties in availability of insulin is a failure to use the least costly sources and types of insulin and other effective drugs for diabetes. The purchase of insulins can consume as much as 10% of government expenditure on drugs, this being highly sensitive to the selection of newer analogue insulins as first-choice options, which cost between three and 13 times more than biosynthetic human insulin. Insulin cartridges for use with injection pens further add to costs. Similar considerations apply to most of the newer treatments for people with type 2 diabetes, which may cost up to 40 times more than metformin and sulfonylureas, still considered first-line drugs by European and US guidelines. Both biosynthetic human insulin and the first-line oral hypoglycaemic drugs are available from generic manufacturers. With the present price differentials, there is thus a growing need for countries involved in tendering for sourcing insulin to be provided with the guarantees of Good Manufacturing Practice, quality and bioequivalence, which would come from a WHO Pre-Qualification Scheme as currently exists for a variety of drugs for chronic diseases, both communicable and non-communicable. The IIF has developed a position statement on the provision and choice of diabetes treatments in resource-limited settings which should be applicable wherever consideration of resources is a component of therapeutic decision making.

Burden of asthma and chronic obstructive pulmonary disease and access to essential medicines in low-income and middle-income countries.

Demographic and epidemiological transitions are changing the age structure of the population and the most common diseases. Non-communicable respiratory diseases are an increasing problem at both ends of the age range in low-income and middle-income countries. In children, who represent a large proportion of the total population, the increasing problem of asthma is a strain on health services. Improved survival of the older population is increasing the proportion of morbidity and mortality attributable to chronic lung diseases. Health services in low-resource countries are poorly adapted to treating chronic diseases. Designed to respond episodically to acute disease, almost all historical investment has focused on infectious diseases. Crucial to the successful management of chronic diseases is an infrastructure designed to support pro-active management, providing not only an accurate diagnosis, but also a secure supply of cost effective drugs at an affordable price. The absence of such an infrastructure in many countries and the market failure that makes drugs generally more expensive in low-resource regions means that many people with chronic non-communicable lung diseases are not given effective treatment. This has damaging economic consequences. The common causes of poor lung health in low-income countries are not the same as those in richer countries, and there is a need to study why they are so common and how best to manage them.

Diabetes in sub-Saharan Africa: from clinical care to health policy

Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA (Prof R Atun FRCP, Prof T Bärnighausen MD, I Postolovska ScD, S Vollmer PhD, B Ammon, A Annamreddi, A Awasthi, S Bhadriraju, J Chai MPH, J Ho BS, S S Kakarmath MBBS MS, R Kharel, M A Kyle, S C Lee MD, A Lichtman MD, J Manne-Goehler MD, M Nair MPH, O L O Okafor MPH, O Okunade MD, D Sando, A Sharma MPH, A S Syed MPH); Harvard Medical School, Harvard University, Boston, MA, USA (Prof R Atun, A Binagwaho MD, P Chipendo MD, J Manne-Goehler); Centre for Global Health, King’s College London, Weston Education Centre, London, UK (J I Davies MD); MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Education Campus, University of Witwatersrand, Parktown, South Africa (J I Davies); University of Bristol, Bristol, UK (E A M Gale FRCP); Muhimbili University of Health and Allied Sciences, and Abbas Medical Centre, Dar es Salaam, Tanzania (Z G Abbas MMed); Institute of Public Health, Faculty of Diabetes in sub-Saharan Africa: from clinical care to health policy

Access to medicines versus access to treatment: the case of type 1 diabetes

In recent years considerable attention has been paid to the issue of access to medicines. The topic burst into the global public spotlight in 2000 when 39 pharmaceutical companies took the South African government to court over its introduction of allegedly unlawful legislation, which gave the minister of health the right to import generic versions of patented drugs and allowed generics to be manufactured locally through compulsory licenses. After this trial, the terms parallel importation, compulsory licensing, intellectual prop-erty, generic drugs and TRIPS (the World Trade Organization’s agreement on trade-related aspects of intellectual property rights) became part of the vocabulary of many nongovernmental organizations and policy-makers seek-ing to improve access to medicines in the world’s poorest countries.Since then public-health policy debates have largely focused on patents on medicines as the main barrier to patients’ access to treatment. Advocates of this view blame patents for the high prices of essential medicines, putting them out of reach of many people who need them. Much of this controversy has specifically addressed medicines for communicable diseases such as HIV/AIDS, malaria and tuberculosis. Less attention has been paid to the avail-ability of drugs for noncommunicable diseases, although this group of illnesses including cardiovascular disease, can -cer, chronic lung diseases and diabetes represents the leading causes of death worldwide.

Diabetes in Kyrgyzstan: changes between 2002 and 2009

Health system reform in Kyrgyzstan is seen as a relative success story in central Asia. Initially, most attention focused on structural changes, and it is only since 2006 that the delivery of care and the experience of health service users have risen on the agenda. One exception from the earlier period was a rapid appraisal of the management of diabetes, undertaken in 2002. Using that study as a baseline, we describe the findings of a new evaluation of diabetes management, undertaken in 2009, using the Rapid Assessment Protocol for Insulin Access, now implemented in seven countries. Access to care has improved through the creation of the Family Medical Centres and the deployment of endocrinologists to them. Another improvement is the access to insulin and related medicines, although assessment of the procurement system reveals that the government is getting very poor value for money. Looking ahead, there are grounds for optimism that the passage of the law on diabetes may progressively have a greater impact. Although the law is not yet fully implemented, it has enabled the diabetes associations to defend the rights of their members. This increased capacity is credited with some improvements in diabetes care.

Twinning for better diabetes care: a model for improving healthcare for non-communicable diseases in resource-poor countries

To many people, the major health problem for sub-Saharan Africa is infectious disease. The avoidability of deaths from AIDS, tuberculosis and malaria are a valid justification for the major drives to fundraising to tackle these. But there is another spectre waiting in the wings: non-communicable diseases (NCDs) are now the major cause of death in every continent other than Africa. Even in Africa, absolute death rates from NCD exceed those in industrialised countries1—it is only the fact that infection mortality is still higher in Africa that prevents NCD deaths from heading the list. The extraction of insulin and its purification in Canada in 1922 was followed, within months, by a transformation in the prospects for a newly diagnosed child with diabetes in North America and Europe. Yet over 80 years later, across much of Africa, the life expectancy for such a child is less than 1 year,2 with the unreliable availability of diagnostic tools, insulin and the healthcare needed for its safe use being largely to blame. The world’s poorest countries, as defined by the World Bank, are mostly in sub-Saharan Africa, where 10% of the world’s population live, surviving on an average of around US

Delivering Diabetes Care in the Philippines and Vietnam Policy and Practice Issues

2 per day. When national healthcare priorities, and donor support, are focused on infectious diseases and on the targets set as the Millennium Development Goals, services and drugs for NCDs are sometimes neglected by health ministries. So when insulin is not in stock at the local hospital, patients and their families may have to find the US