• diabetes mellitus
• non-communicable disease
• peripheral arterial diseases
• re-vascularization
• sub-saharan africa

• Humans
• Diabetes Mellitus, Type 1/diagnosis
• Diabetes Mellitus, Type 1/drug therapy
• Hypoglycemic Agents/therapeutic use
• Diabetes Mellitus, Type 2
• Blood Glucose Self-Monitoring
• Blood Glucose/metabolism
• Insulin/therapeutic use
• Insulin/metabolism
• Glucagon-Like Peptide-1 Receptor/agonists

• Accessibility
• Diabetes
• Healthcare services
• Patients
• Poverty

• Diabetes
• NGO
• health systems
• nongovernmental organisations

• changing diabetes in children
• life expectancy
• life for a child
• survival
• type 1 diabetes

• adolescents and young adults
• children
• limited resource countries
• limited resource settings
• low-income countries
• persons with diabetes
• resource limited
• type 1 diabetes
• type 2 diabetes

• Non-Communicable Diseases
• Prevention and Control
• Qualitative Study

• Humans
• Noncommunicable Diseases/epidemiology
• Noncommunicable Diseases/prevention & control
• Iran/epidemiology
• Policy Making
• Qualitative Research
• Delivery of Health Care

• epidemiology
• general diabetes
• quality in health care

• Adult
• Female
• Humans
• Male
• Glycated Hemoglobin
• Diabetic Neuropathies/epidemiology
• Diabetic Neuropathies/complications
• Diabetes Mellitus, Type 2/complications
• Diabetes Mellitus, Type 2/epidemiology
• Diabetes Mellitus, Type 2/therapy
• Diabetic Foot/epidemiology
• Diabetic Foot/therapy
• Diabetic Foot/complications
• Africa/epidemiology
• Retinal Diseases
• Peripheral Arterial Disease/complications

• European Developing Countries Clinical Trials Partnership

• Adult
• Child
• Diabetes Mellitus, Type 1/epidemiology
• Global Health
• Humans
• Incidence
• Life Expectancy
• Prevalence

• access
• barriers
• diabetes
• dyslipidemia
• facilitators
• hypertension (HTN)
• medicines
• non-communicable chronic diseases (NCDs)

• Agencia Nacional de Investigación y Desarrollo

• developing countries
• health delivery of health care
• insulin
• type 1 diabetes

• Developing Countries
• Diabetes Mellitus, Type 1/epidemiology
• Diabetes Mellitus, Type 1/therapy
• Humans
• Insulin/therapeutic use
• Kyrgyzstan/epidemiology
• Mali/epidemiology
• Peru
• Tanzania/epidemiology

• Leona M. and Harry B. Helmsley Charitable Trust

• health care delivery
• type 1 diabetes

• Adolescent
• Child
• Developing Countries
• Diabetes Mellitus, Type 1/therapy
• Humans
• Poverty
• Self-Management
• Telemedicine

• Leona M. and Harry B. Helmsley Charitable Trust

Background: Diabetes is among the top ten most prevalent diseases in Pakistan, and the availability of medicines to treat the disease is vital for a great percentage of the country’s population. Insulin was discovered a century ago; however, its access in several parts of the globe remains an issue. This study aims to evaluate prices, availability, and affordability (access components) of insulin and five comparator medicine access in Pakistan.

Methods: A nationwide cross-sectional survey was conducted to evaluate the access to insulin and some comparator medicines in eight cities of Pakistan, using a modified WHO/HAI methodology. The survey included 80 medicine outlets, i.e., 40 private pharmacies and 40 public hospitals. Data for every unique insulin product available in the Pakistani market were obtained, including five comparator medicines. Percentage availability, median unit prices (MUPs), and affordability (the number of days’ wages (NDWs) required for a month’s course by the lowest-paid unskilled government worker) of all products were calculated, including originator brands (OBs) and biosimilar (BS) products.

Results: Of all insulin products surveyed (n = 320), 87.5% were manufactured by foreign multinational companies (MNCs). None of the insulin products had an ideal availability of 80% in any of the surveyed health facilities. In the public sector, none of the insulin products had an availability of more than 50%. In the public sector, the overall availability of human insulin was 70% (including OB and BS). While in the private sector, the overall availability of human insulin was 90% and that of analog insulin was 62.5%. The analog insulin products were 72.8% costlier than the human insulin products. The median prices of BS insulin were 25.4% lower than the OB products, indicating that almost one-fourth of the cost could be saved by switching to BS human insulin from OB human insulin. All oral anti-diabetic medicines were found to be affordable, whereas none of the insulin was affordable. The NDWs for human and analog insulin were 1.38 and 5.06.

Conclusion: In Pakistan, the insulin availability falls short of the WHO’s benchmark of 80%. Insulin continues to be unaffordable in both private and government sectors. To increase insulin access, the government should optimize insulin procurement at all levels, promote local production, enforce biosimilar prescribing, and provide financial subsidies for these products.

• Advisory Committees
• Cardiovascular Diseases/mortality
• Comorbidity
• Data Management
• Diabetes Complications/economics
• Diabetes Complications/prevention & control
• Diabetes Mellitus/economics
• Diabetes Mellitus/epidemiology
• Diabetes Mellitus/therapy
• Diabetes, Gestational/epidemiology
• Environment
• Female
• Genetic Predisposition to Disease
• Global Burden of Disease
• Global Health
• Health Expenditures
• Health Policy
• Health Services Accessibility
• Humans
• Insulin-Secreting Cells/pathology
• Insurance Coverage
• Kidney Diseases/mortality
• Life Style
• Medically Underserved Area
• Mental Disorders/epidemiology
• Multiple Chronic Conditions/epidemiology
• Neoplasms/mortality
• Obesity/epidemiology
• Patient Education as Topic
• Population Dynamics
• Pregnancy
• Quality Assurance, Health Care
• Risk Assessment
• Risk Factors
• Self-Management
• Socioeconomic Factors
• Telemedicine

• MC_UU_00006/1 Medical Research Council
• MR/K023187/1 Medical Research Council
• MC_UU_12015/6 Medical Research Council
• MC_UU_00006/7 Medical Research Council
• MC_UU_00006/3 Medical Research Council
• MC_UU_12015/5 Medical Research Council
• MR/S019669/1 Medical Research Council

• Adolescent
• Child
• Child, Preschool
• Developing Countries
• Diabetes Mellitus, Type 1/epidemiology
• Diabetes Mellitus, Type 1/pathology
• Diabetes Mellitus, Type 1/therapy
• Disease Management
• Global Burden of Disease/trends
• History, 20th Century
• History, 21st Century
• Humans
• Hypoglycemic Agents/economics
• Hypoglycemic Agents/history
• Hypoglycemic Agents/therapeutic use
• Insulin/economics
• Insulin/history
• Insulin/therapeutic use
• Life Expectancy
• Universal Health Insurance

• 001 World Health Organization

The prevalence of type 2 diabetes mellitus (T2DM) and the burden of complications are increasing worldwide. Chronic kidney disease (CKD) is one serious complication. Our aim was to investigate the trends and inequalities of the burden of CKD due to T2DM between 1990 and 2019. Data were obtained from the Global Health Data Exchange database. Age-standardized incidence, mortality, and DALYs rates of CKD were used to estimate the disease burden across the Human Development Index (HDI). Joinpoint regression was performed to assess changes in trend, and the Gini coefficient was used to assess health inequality. A higher incidence was observed in more developed countries (p < 0.001), while higher mortality and DALYs rates were experienced in low and middle HDI countries in 2019 (p < 0.001). The trend of incidence has increased since 1990 (AAPC: 0.9–1.5%), while slight decrease was observed in low HDI countries in mortality (APC: −0.1%) and DALYs (APC: −0.2%). The Gini coefficients of CKD incidence decreased from 0.25 in 2006 to 0.23 in 2019. The socioeconomic development was associated with disease burden. Our findings indicate that awareness of complications should be improved in countries with high incidence, and cost-effective preventive, diagnostic, and therapeutic tools are necessary to implement in less developed regions.

• chronic kidney disease
• disease burden
• global burden of disease
• inequalities
• socioeconomic development

• Bolivia
• Community participation
• Developing countries
• Diabetes mellitus
• Health literacy
• Health planning
• Long-term care
• Patient-Centred care
• Self-management

• Bolivia
• Community Participation
• Delivery of Health Care
• Diabetes Mellitus, Type 2/therapy
• Female
• Health Literacy
• Health Personnel
• Health Planning
• Humans
• Male
• Needs Assessment
• Patient-Centered Care
• Self-Management
• Suburban Population

• Vlaamse Interuniversitaire Raad

• Chronic kidney disease
• Diabetes
• Ketoacidosis
• Pregnancy
• Resource-limited settings
• SGLT inhibitors

• Diabetes Mellitus, Type 2/complications
• Diabetic Ketoacidosis/diagnosis
• Diabetic Ketoacidosis/etiology
• Diabetic Ketoacidosis/therapy
• Female
• Fluid Therapy
• Humans
• Hypoglycemic Agents/therapeutic use
• Pregnancy
• Renal Insufficiency, Chronic/complications

• African cuisine
• Carbohydrate
• Insulin therapy
• Meal pattern
• Type 2 diabetes

• Africa
• Diabetes mellitus
• Meta-analysis
• Undiagnosed

Young people with type 1 diabetes in low-and-middle income countries face many challenges in accessing care, with various essential supplies needed for survival and long-term health.

To study insulin delivery devices and glycated haemoglobin (HbA1c) testing.

A survey was conducted in 2019 of leading diabetes centres in 41 countries supported by the Life for a Child Program. The survey covered numerous aspects concerning availability and costs at all levels of the health system, local usage patterns and attitudes, obstacles, and other aspects.

Thirty-seven countries returned the survey (90.2% response rate). Key findings included: Syringe use was most common (83.1%), followed by insulin pens (16.7%) and pumps (0.2%). 48.6% of public health systems did not provide syringes, even with a co-payment. Use of suboptimal syringe/needle combinations was common. Needles were generally reused in almost all countries (94.3%, n = 35). Aside from donated supplies, there was variable access to HbA1c testing within public health facilities, and, when available, patients often had to cover the cost. Provision was further compromised by numerous problems including stock-outs, and challenges with understanding the test, equipment maintenance, and refrigeration.

Large gaps exist for adequate access to appropriate insulin delivery devices and HbA1c testing. Public health systems in low-and-middle income countries should increase affordable provision. There are also needs for specific health professional training and diabetes education; elimination of customs duties and taxes; development of inexpensive, robust HbA1c testing methods that do not require refrigeration of testing supplies; differential pricing schemes; and other solutions.

• Type 1 diabetes
• Diagnostics
• Glycated haemoglobin
• Syringes
• Insulin
• Access

• diabetes-related mortality
• epidemiology
• health economics
• type 1 diabetes

• Adolescent
• Age Factors
• Child
• Child, Preschool
• Diabetes Mellitus, Type 1/complications
• Diabetes Mellitus, Type 1/drug therapy
• Diabetes Mellitus, Type 1/metabolism
• Diabetic Nephropathies/epidemiology
• Diabetic Nephropathies/etiology
• Diabetic Neuropathies/epidemiology
• Diabetic Neuropathies/etiology
• Diabetic Retinopathy/epidemiology
• Diabetic Retinopathy/etiology
• Female
• Glycated Hemoglobin/metabolism
• Humans
• Hypoglycemic Agents/therapeutic use
• Insulin/therapeutic use
• Male
• Prevalence
• Risk Factors
• Tanzania/epidemiology
• Time Factors

To explore availability, prices and affordability of essential medicines for diabetes and hypertension treatment in private pharmacies in three provinces of Zambia.

A cross-sectional survey was conducted in 99 pharmacies across three Zambian provinces. Methods were based on a standardized methodology by the World Health Organization and Health Action International. Availability was analysed as mean availability per pharmacy and individual medicine. Median prices were compared to international reference prices and differences in price between medicine forms (original brand or generic product) were computed. Affordability was assessed as number of days’ salaries required to purchase a standard treatment course using the absolute poverty line and mean per capita provincial household income as standard. An analysis identifying medicines considered both available and affordable was conducted.

Two antidiabetics and nine antihypertensives had high-level availability (≥80%) in all provinces; availability levels for the remaining surveyed antidiabetics and antihypertensives were largely found below 50%. Availability further varied markedly across medicines and medicine forms. Prices for most medicines were higher than international reference prices and great price variations were found between pharmacies, medicines and medicine forms. Compared to original brand products, purchase of generics was associated with price savings for patients between 21.54% and 96.47%. No medicine was affordable against the absolute poverty line and only between four and eleven using mean per capita provincial incomes. Seven generics in Copperbelt/Lusaka and two in Central province were highly available and affordable.

The study showed that the majority of surveyed antidiabetic and antihypertensive medicines was inadequately available (<80%). In addition, most prices were higher than their international reference prices and that treatment with these medicines was largely unaffordable against the set affordability thresholds. Underlying reasons for the findings should be explored as a basis for targeted policy initiatives.

• Blood glucose monitoring
• Diabetes
• Insulin
• Sustainable development goals
• Type 1 diabetes
• Universal Health Coverage

• Blood Glucose Self-Monitoring/methods
• Costs and Cost Analysis
• Humans
• Insulin/economics
• Universal Health Insurance/standards

• diabetes
• health system building blocks
• health system integration
• health system strengthening
• integrated diagonal health systems approach
• sub-Saharan African

• diabetes & endocrinology
• epidemiology
• health informatics

• Adolescent
• Adult
• Algorithms
• Autopsy
• Cause of Death
• Child
• Child, Preschool
• Cohort Studies
• Female
• Humans
• Hyperglycemia/diagnosis
• Hyperglycemia/mortality
• Infant
• Malawi
• Male
• Middle Aged
• Reproducibility of Results
• Young Adult

• K43 TW010698 FIC NIH HHS

• Diabetes care
• Guinea-Bissau
• chronic disease
• health system organization

Background: The Base of the Pyramid (BoP) project is a public–private partnership initiated by Novo Nordisk that aims to facilitate access to diabetes care for people at the base of the economic pyramid in low- and middle-income countries (LMICs). In Kenya, the BoP, through a partnership model, aims to strengthen five pillars of diabetes care: increased awareness of diabetes; early diagnosis of diabetes; access to quality care by trained professionals; stable and affordable insulin supply; and improved self-management through patient education.

Objectives: This study evaluates the extent to which BoP Kenya is scalable and sustainable, whether stakeholders share in its value, and whether BoP Kenya has improved access to diabetes care.

Method: The Rapid Assessment Protocol for Insulin Access (RAPIA), an approach developed to provide a broad situational analysis of diabetes care, was used to examine health infrastructure and diabetes care pathways in Kenya. At the national level, the RAPIA was applied in a SWOT analysis of the BoP through in-depth interviews with key stakeholders. At individual and county health system levels, RAPIA was adapted to explore the impact of the BoP on access to diabetes care through a comparison of an intervention and control county.

Results: The BoP was implemented in 28 of 47 counties in Kenya. Meru, a county where BoP was implemented, had 35 of 62 facilities (56%) participating in the BoP. Of the five pillars of the BoP, most notable progress was made in achieving the fourth (stable and affordable insulin supply). A price ceiling of 500KSh (US$5) per vial of insulin was established in the intervention county, with greater fluctuation and stock-outs in the non-intervention county. Despite reduced insulin costs, many patients with diabetes could not afford the additive expenses of monitoring, medicines, and travel. Less progress was made over the other pillars, which also faced challenges to sustainability and scalability.

Conclusion: In the context of the rising prevalence of non-communicable diseases in LMICs, cross-sector approaches to improving access to care are increasingly needed. Public–private partnerships such as the BoP are necessary but not sufficient to ensure access to health care for people with diabetes at the base of the economic pyramid in Kenya.

• Diabetes
• access
• health systems
• insulin
• service delivery

Globally, one in two people needing insulin lack access. High prices and poor availability are thought to be key contributors to poor insulin access. However, few studies have assessed the availability, price and affordability of different insulin types in low-income and middle-income countries in a systematic way.

In 2016, 15 insulin price and availability surveys were undertaken (using an adaptation of the WHO/Health Action International medicine price and availability measurement methodology) in Brazil, China (Hubei and Shaanxi Provinces), Ethiopia, Ghana, India (Haryana and Madhya Pradesh States), Indonesia, Jordan, Kenya, Kyrgyzstan, Mali, Pakistan, Russia (Kazan Province) and Uganda. Data were collected in three sectors (public, private pharmacies and private hospitals/clinics) in three regions per survey. Insulin prices were standardised to 10 mL 100 IU/mL in US dollars ($). Data were also collected for four comparator medicines.

Mean availability was higher for human (55%–80%) versus analogue insulins (55%–63%), but only short-acting human insulin reached 80% availability (public sector). Median government procurement prices were $5 (human insulins) and $33 (long-acting analogues). In all three sectors, median patient prices were $9 for human insulins. Median patient prices for analogues varied between the public sector ($34) and the two private sectors ($44). Vials were cheaper than pens and cartridges. Biosimilars, when available, were mostly cheaper than originators. A low-income person had to work 4 and 7 days to buy 10 mL human and analogue insulin, respectively. For isophane human insulin, only three countries meet the WHO target of 80% availability of affordable essential medicines for non-communicable diseases in any sector.

Improving insulin availability and affordability needs to be addressed through national and global actions, including prioritising the supply of more affordable human insulin, increasing competition through the use of lower priced quality-assured biosimilars, negotiating lower prices from manufacturers and improving distribution systems.

• affordability
• availability
• diabetes
• insulin
• low- and middle-income countries
• prices

• Diabetes mellitus
• glycated nail proteins
• laboratory medicine
• point-of-care testing
• sub-Saharan Africa

• Type 1 diabetes
• Uganda
• chronic care model
• diabetes clinic
• healthcare
• low-income

As Mozambique faces a double burden of diseases, with a rise of Non Communicable Diseases (NCD) superimposed to uncontrolled communicable diseases (CD), routine disease surveillance system does not include NCD. The objectives of our study were to i) upgrade of the current surveillance system by adapting the data collection tools to NCD; ii) describe the occurrence and profile of selected NCD using these data collection tools.

Workshops were implemented in a first referral urban hospital of Mozambique to train clinical staff, administrative workers and nurses on NCD surveillance, as well as select conditions to be prioritized. Based on the WHO Global Action Plan and Brazaville Declaration for NCD prevention and control, we selected arterial hypertension, diabetes, stroke, chronic respiratory diseases, mental illness and cancers. Data collection tools used for CD were changed to include age, gender, outcome and visit type. Between February/2014 and January/2015 we collected data at an urban hospital in Mozambique’s capital.

Over 12 months 92,018 new patients were assisted in this hospital. Data was missing or diagnosis was unreadable in 2637 (2.9%) thus only 89,381 were used for analysis; of these 6423 (median age 27 years; 58.4% female) had at least one selected NCD as their primary diagnosis: arterial hypertension (2397;37.31%), mental illness (1497;23.30%), asthma (1495;23.28%), diabetes (628;9.78%), stroke (299;4.66%), chronic obstructive pulmonary disease 61 (0.95%) and cancers 46 (0.72%). Emergency transfers were needed for 76 patients (1.2%), mainly due to hypertensive emergencies (31; 40.8%) and stroke (18;23.7%). Twenty-four patients died at entry points (0.3%); 10 of them had hypertensive emergencies.

Changes in existing surveillance tools for communicable diseases provided important data on the burden and outcomes of the selected NCD helping to identify priority areas for training and health care improvement. This information can be used to design the local NCD clinics and to strengthen the health information system in resource-limited settings in a progressive and sustainable way.

The online version of this article (10.1186/s12889-019-6473-2) contains supplementary material, which is available to authorized users.

• Disease surveillance
• Health information system
• Non-communicable diseases

• Biosensors
• Immobilization
• Multifunctional protein
• Protein engineering
• Resource-poor production
• Sarcosine
• Silaffin
• Silica

• Blood Glucose/metabolism
• Blood Glucose Self-Monitoring/economics
• Blood Glucose Self-Monitoring/instrumentation
• Costs and Cost Analysis
• Diabetes Mellitus/metabolism
• Disease Management
• Equipment and Supplies/economics
• Equipment and Supplies/supply & distribution
• Health Expenditures
• Health Resources
• Humans
• Internationality