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ABSTRACT
SELECTING NATURAL INSULIN IMPROVES ACCESS TO
COST-EFFECTIVE THERAPY OF DIABETIC PATIENTS IN THE
PUBLIC SECTOR OF DAR ES SALAAM, TANZANIA
Title: Selecting Natural Animal Insulin Improves Access to Cost-Effective Therapy of Diabetic
Patients in the Public Sector of Dar es Salaam, Tanzania
Problem Statement: Prevalence of diabetes in urban communities of developing countries
is expected to triple within the next 25 years. Rising prevalence and long-term complications
will lead to a drastic increase in both the burden of diabetes on health care systems and the
need for insulin. Life expectancy of diabetic type 1 patients can be significantly improved
with provision of insulin. Access to insulin, however, is limited due to irregular supply and
cost. Human synthetic insulin causes more cases of serious hypoglycemia, and frequent
glucose monitoring adds to its high cost. Natural animal insulin is cheaper and has lower
hypoglycemia rates. In the early 1990s, diabetes care in Dar es Salaam was centralized at
the national referral hospital and five-year survival was estimated at 60% for diabetes type 1
patients.
Objectives: To improve the quality of life and life expectancy of diabetes patients in Dar es
Salaam in a sustainable way by increasing rational drug use based on provision of natural
animal insulin, cost sharing, and decentralization of diabetes care.
Design: Operational research with baseline data and final evaluation. Data collection from
patient interviews, questionnaires for health workers, semi-structured interviews with key
informants and record review.
Setting and Population: The public health sector of Dar es Salaam: diabetic care clinics
integrated at the three municipal hospitals. Population attending the public sector is
estimated at approximately 30% of 3 million. As of 1994, a combined 450 type 1 and type 2
diabetic patients attended the three clinics at the ditrict hospitals.
Intervention: In 1994, diabetes clinics were decentralized and integrated into three district
hospitals; health staff was trained; funding was provided to procure low-cost, good-quality
natural animal insulin. Cost sharing was also introduced.
Outcome Measures: Availability of natural animal insulin, number of attendances, number
of reported serious cases of hypoglycemia, patient satisfaction, ability to pay.
Results: Natural animal insulin is generally available. Patients contribute 50% to the cost of
natural animal insulin. Financial burden per patient is approximately USD 23 per year (per
capita gross national product is USD 280). Eleven percent of patients are unable to pay for
drugs. Attendance rates increased from 450 type 1 and 2 diabetic patients combined in 1994
to more than 5,500 patients in 2002 (30% insulin-dependent type 1 diabetics). Serious
hypoglycemia was reported in 1.5 patients per month in 2002. 77% of patients were satisfied
with the insulin and 97% were satisfied with instructions given.
Conclusions: Drug therapy can be optimized by selecting cost-effective natural animal
insulin for diabetes patients in a low-income country while also improving access to
treatment. Life expectancy and quality of life of diabetic patients can be improved with by
strengthening rational drug use, with decentralized provision of natural animal insulin and
cost sharing at affordable levels. Increasing workload, supply management, and exemption
policy need to be addressed.
BACKGROUND AND SETTING
Prevalence of diabetes in urban
communities of developing countries is
expected to triple within the next 25 years.
Rising prevalence and long-term
complications will lead to a drastic increase in
both the burden of diabetes on health
care systems and the need for insulin.
Life expectancy of diabetic type 1 patients
can be significantly improved with provision
of insulin.
Access to insulin, however, is limited due
to irregular supply and cost.
Human synthetic insulin causes more
cases of serious hypoglycemia, and frequent
glucose monitoring adds to its high cost.
Natural animal insulin is cheaper and has
lower hypoglycemia rates.
In the early 1990s, diabetes care in Dar
es Salaam was centralized at the national
referral hospital and five-year survival was
estimated at 60% for diabetes type 1
patients.
STUDY OBJECTIVES
To improve the quality of life and life
expectancy of diabetes patients in Dar es
Salaam
in a sustainable way
by increasing rational drug use
based on provision of natural animal insulin
cost sharing, and
decentralization of diabetes care.
METHODS 1
Design: Operational research with baseline data
and final evaluation.
Data collection from patient interviews,
questionnaires for health workers, semi-structured
interviews with key informants and record review
Setting: The public health sector of Dar es
Salaam: diabetic care clinics integrated at the three
municipal hospitals
Population attending the public sector is
estimated at approximately 30% of 3 million.
Initially in 1994, a combined 450 type 1 and type 2
diabetic patients attended the three clinics at the
district hospitals
METHODS 2
Intervention:
In 1994, diabetes clinics were decentralized
and integrated into three district hospitals
Health staff was trained
Funding was provided to procure low-cost,
good-quality natural animal insulin.
Cost sharing was also introduced
Outcome Measures:
Availability of natural animal insulin
Number of attendances
Number of reported serious cases of
hypoglycemia
Patient satisfaction, ability to pay
RESULTS 1
Natural animal insulin is generally available
Patients contribute 50% to the cost of
natural animal insulin
Financial burden per patient is approximately
USD 23 per year (per capita gross national
product is USD 280)
Eleven percent of patients are unable to pay
for drugs
Attendance rates increased from 450 type 1
and 2 diabetic patients combined in 1994 to
more than 5,500 patients in 2002 (30%
insulin-dependent type 1 diabetics)
RESULTS 2
At district clinics where natural animal insulin
is provided, serious hypoglycemia was
reported in 1.5 patients per month on
average in 2002
At Muhimbili referral hospital where human
synthetic insulin is provided, serious
hypoglycemia was reported in 3 patients per
month on average in 2002
77% of patients were satisfied with the
insulin and 97% were satisfied with
instructions given.
RESULTS 3
Development of attending diabetic patients
type 1 and 2
5000
Temeke
4000
Kinondoni
3000
Ilala
2000
Total
1000
Year
200
2
200
0
199
7
199
8 /9
9
199
6
0
199
5
Number of patients
6000
DISCUSSION
•
Drug therapy of diabetic patients in Dar es
Salaam could be optimized by selecting costeffective natural animal insulin
•
A combination of elements improved access
to insulin:
- low cost natural animal insulin
- decentralized provision of insulin
- cost-sharing at affordable levels
•
In a setting of poverty, access to natural
animal insulin with less monitoring
expenses is an important advantage
•
Natural animal insulin also added clinical
benefit with less cases of serious
hypogylcemia
CONCLUSION AND
RECOMMENDATIONS
•
Drug therapy of diabetic patients can be
optimized by selecting cost-effective natural
animal insulin for diabetes patients in a lowincome country
•
Access to treatment can be improved with
selection of low cost natural animal insulin
•
Life expectancy and quality of life of
diabetic patients can be improved by
improving availability and affordability of
insulin
•
Selection of natural animal insulin improves
rational drug use
•
Serious hypoglycemia can be reduced with
natural animal insulin
•
Increasing workload, supply management,
and exemption policy need to be addressed.