Overcoming key barriers to quality diabetes care around the world
This oped was originally published on Foresight Global Health on 3rd June 2021.
Innovations in diabetes treatment and management have made enormous contributions to global health over the past 100 years, but there are still obstacles that must be overcome to slow the growth of the disease and reduce its impact.
Exactly a century ago, two researchers at the University of Toronto were credited with discovering a pancreatic extract that could lower peoples’ blood sugar. The insulin treatment they pioneered, and other innovative diabetes medicines, have since saved countless people from suffering or dying from diabetes.
And yet, as we mark this anniversary, effective prevention, treatment, and control of diabetes remains out of reach for many. The burden of diabetes—for individuals, their families, and health systems—is especially acute in low- and middle-income countries, where it is estimated 79 percent of people living with diabetes (PLWD) reside.
The number of people with diabetes has quadrupled in the last 40 years. According to the World Health Organisation (WHO), it is the only major noncommunicable disease for which the risk of dying early is increasing. Today more than 450 million people have one of the several types of the disease, in which the body either can’t make insulin (Type 1) or can’t properly use what it produces (Type 2 and pregnancy-related). As many as 80 to 100 million people, including all of those with Type 1 and some with Type 2 diabetes, need insulin to survive. Among all diabetic patients, failure to prevent, treat or manage the condition can lead to a range of complications, including blindness, kidney failure, heart attack, and lower-limb amputation.
A complex and multifaceted global health issue
Governments, healthcare professionals, life sciences and medical technology companies, and civil society organizations can and should work together to reverse this trend. But how? Yearning for an easy fix, some point to the cost of insulin as the chief barrier to success. It is not that simple. Whilst insulin availability and affordability does indeed represent an important component of managing this multi-faceted disease, PLWD need access to a package of products, services, and support to enable them to achieve affordable, quality diabetes prevention, diagnosis, treatment, and control.
For those who are insulin-dependent, regular blood glucose monitoring and safe administration of insulin can be a major challenge when the consumables required—test strips, lancets, digital readers, and scales—can cost significantly more than insulin itself. A 2015 study from the respected global public health organization PATH found that in Kenya and Senegal, 85% of the cost PLWD pay to manage their diabetes goes to such devices.
Meanwhile, a 2020 PATH survey conducted in Kenya and Ghana demonstrated that markups by middlemen along the supply chain running as high as 288 percent, and frequent product stockouts, significantly increased the cost of care for end users in countries where out-of-pocket payments (and lack of government funding) are still prevalent.
According to research conducted by the IQVIA Institute, across 32 low- and middle-income countries, there is a diverse and growing mix of insulin manufacturers and distributors selling insulin. The per-day cost of insulin charged by manufacturers is relatively low, ranging from 20 cents for human insulins to ~$1 or more for analogue insulins. The analysis found no correlation between the number of insulin suppliers, market share, pricing, and availability for PLWD. Clearly there is a complex array of different factors that impact insulin affordability at the point of care.
Collaborating to build integrated care solutions
To address diabetes effectively for PLWD, the global health community needs a joined-up approach—from governments putting in place adequate financing, improved regulatory approval, prescription policies, and enhanced supply chains to collaboration aimed at improving affordable access and building health system capacity for controlling diabetes. This includes providing healthcare professionals with the tools and training they need, and empowering PLWD with quality information concerning diabetes prevention, treatment, and control. In this regard, digital health tools can play an important role.
Diagnosis is a necessary first step for enhanced diabetes control. Today half of adults with Type 2 diabetes remain undiagnosed. Patients need to be identified and treated long before they appear at a doctor’s office or hospital suffering from debilitating health impacts.
Another major success factor will be prevention. In addition to the 450 million people who already have diabetes, 350 million have higher than normal blood glucose (so-called “pre-diabetes”), meaning they have an elevated risk of developing the disease.
But there is reason to believe we can slow this trajectory. While the causes of Type 1 diabetes are likely genetic, risk factors for Type 2 diabetes include those that are controllable, such as physical inactivity, stress, and obesity. WHO’s new Global Diabetes Compact will include a focus on these risk factors.
At a policy and advocacy level, we need much greater collaboration. Over the years, many diabetes initiatives have remained siloed from one another, either by country, organization, or disease type. This fragmented approach has made it hard to scale up solutions, including improved supply mechanisms, educational tools for empowering patients and communities, and tools for healthcare professionals to ensure timely diabetes diagnosis and quality care.
The life sciences companies that develop diabetes treatments and other health products have worked over many decades to continuously develop new modalities of treatments and monitoring solutions, and to improve access to care in partnership with credible stakeholders. But they also need to build new alliances across industrial sectors – by reaching out to companies that specialize in medical devices, diagnostic tools, consumer technology, and even transportation and logistics.
Global leaders weigh in
The increased risk of death and suffering from Covid-19 for PLWD has become painfully evident over the past 12 to 18 months. As WHO Director General Tedros Adhanom Ghebreyesus and others recently urged heads of state, “Covid-19 must be the wake-up call for governments to finally step up and invest in [noncommunicable diseases].” The appeal also urged governments to “build back better” by investing in healthy populations and resilient health systems that include NCDs as part of their UHC package. We fully support this call and hope that the global health community will step up its efforts to explore new funding mechanisms and co-create innovative, multi-stakeholder solutions to provide integrated diabetes prevention, treatment, and control to PLWD.
The 2021 World Health Assembly adopted a Resolution on “Diabetes Prevention and Management, including access to insulin.” The text contains a number of positive proposals aimed at improving quality diabetes prevention, treatment, and care (e.g., health system strengthening, multi-stakeholder collaborations, increased NCDs funding and integrated care initiatives). At the same time, the resolution missed an opportunity to emphasize the need for WHO and Member States to step up efforts to address diabetes as part of UHC.
We have come a long way in one hundred years. But the global fight against diabetes has to accelerate so that we can prevent, treat, and/or control everyone who is at risk. I personally hope that the recently launched WHO Global Diabetes Compact will fulfil these bold objectives through cross-sectoral and genuine collaboration.
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