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Prevention and Improved Coverage of Healthcare for Diabetes
for people with diabetes is improved around the world. This is in Providing good diabetes care for a population requires co-ordination
addition to IDF’s five-year focus on Diabetes Education and across three levels of organization:
Prevention through its World Diabetes Day campaign. Marked each
year on November 14, the year-long campaign focuses on educating at the micro level, and at the centre of all care, are the people with
the public and individuals of diabetes warning signs and risk factors, diabetes, their families, and their immediate carers;
as well as diabetes management and control. The campaign asserts at the meso level is the community and healthcare organizations
that diabetes awareness is necessary in preventing type 2 diabetes, within which care is delivered; and
improving care for all people with diabetes, and effecting change. at the macro level are the supporting policy and financing frameworks.
Prevention The World Health Organization’s Innovative Care for Chronic
Most of the increase in the number of people with diabetes is due to Conditions (ICCC) Framework
12
(an evolution of the Chronic Care
an increase in the number of people with type 2 diabetes. Evidence Model
13
) provides guidance on the relationships between, and the
from trials in China,
3
Finland,
4
the US,
5
and India
6
have clearly contents of, these three levels. This framework can be used to help
demonstrated that type 2 diabetes can be prevented by improving repair the fragmentation of health services across the range of needs
diet (leading to weight loss) and increasing physical activity, or by that people with diabetes have, and to provide links to broader
pharmacological methods. Long-term follow-up of these trials is now population interventions, such as those for the prevention of
starting to show encouraging results. The follow-up of the Finnish diabetes. This approach has helped guide improvements in the
Diabetes Prevention Study (DPS)
7
showed a 43% reduction in the delivery of diabetes care in a number of countries, including the US
relative risk of diabetes; even after discontinuation of the intervention and the UK. In contrast to the refinements being made in higher-
a reduction was maintained, with a relative risk reduction of 36% in income countries, many low- and middle-income countries do not
the post-intervention period. Similarly, the Da Qing study in China, a yet care for diabetes at the primary care level. This results in a
six-year intervention, has recently shown that after 20 years of follow- poor distribution of healthcare relative to the distribution of people
up the risk of diabetes was lower in the intervention group.
8
with diabetes.
While there is good evidence from trials that diabetes can be Delivering care down to the primary level also requires human and
prevented, there is far less evidence regarding the implementation of material resources, and ideally should be considered within the levels
interventions in real life. Two studies, one in Finland
9
and one in the of the ICCC framework. Data published in the IDF Diabetes Atlas show
US,
10
have shown encouraging results. However, they were based on that insulin is not available or affordable in many low- and middle-
small samples, many subjects were self-selected, and the follow-up income countries. However, simply improving the availability of insulin
times were short. The IDF Bringing Research in Diabetes to Global alone is not sufficient to improve care for those who require insulin.
Environments and Systems (BRIDGES) program is currently funding Insulin is useless without syringes. In five countries examined,
a translational research project in India that is implementing a syringes were not available from public health services, and even
randomized trial of culturally specific, community-based lifestyle when insulin was available a combination of national policies and
intervention for the prevention of type 2 diabetes. Further work is high charges in private pharmacies meant that value-added tax (VAT)
required to translate the findings of these trials into the real world. was levied on syringes.
Economic evaluations of approaches to identifying and providing In addition to insulin and syringes, a small number of other essential
preventive measures to people at high risk of diabetes generally medicines and technologies for non-communicable diseases, most of
suggest that these are cost-effective. However, most evaluations which are out of patent and cost pennies to produce, have the
contain many uncertainties and there is a need for further work to potential to save many lives in low- and middle-income countries.
examine the cost-effectiveness of interventions in everyday practice. These include a generic statin, a generic angiotensin-converting
There is an even greater challenge in assessing the cost-effectiveness enzyme (ACE) inhibitor, and a generic thiazide antihypertensive.
of population-wide measures. Currently, these drugs are not readily available at the primary care
level in many low- and middle-income countries.
Treatment
When diabetes cannot be prevented, it can be treated. Diabetes care Change Is Possible
does not need to be expensive to be highly effective. In work carried So, can we provide good coverage of basic healthcare for diabetes?
out for the World Bank and World Health Organization,
11
interventions Yes we can. Based on what we already know about prevention,
for diabetes were classified into three levels based on an assessment effective interventions, and models of chronic care, it should be
of their feasibility and cost-effectiveness in developing country possible to make substantial gains and close the gap between optimal
settings. Interventions in the first level were found to be highly cost- and current care, particularly for those who are currently the most
effective or even cost-saving, and included moderate blood glucose disadvantaged. Coverage of good healthcare for diabetes is limited in
and blood pressure control and foot care. Recognizing that most many countries, but is attainable.
people with diabetes live in developing countries, the IDF Global
Guideline provides guidance appropriate to three different levels of IDF is also working with other organizations such as the World Health
resource availability. Organization, the World Economic Forum, the World Heart Federation,
US ENDOCRINOLOGY 27
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