Innovating to increase access to diabetes care in Kenya: an evaluation of Novo Nordisk's base of the pyramid project

A cross-sectional study on socio-demographic correlates of self-reported self-care practices for hypertension and type 2 diabetes among adults living in rural Kenya

BACKGROUND

Hypertension and type 2 diabetes are among the most common non-communicable diseases that contribute to a large number of adult morbidity and mortality in Kenya. The impact of these conditions may pose great challenges in rural areas with limited access to healthcare services. The objective of the study was to assess socio-demographic factors associated with self-reported self-care practices for hypertension and type 2 diabetes among adults living in rural Kenya.

METHODS

This study used data from the 2019 Baseline Assessment of the Prevention and Control of Non-Communicable Disease Project in Imenti South, Meru County conducted by the Kenyan Red Cross Society. A community-based study using a cross-sectional design was conducted among four hundred and thirty-five participants in Imenti South sub-County, Meru County in Kenya in November 2019. Chi-square test and logistic regression analyses were conducted to explore sociodemographic factors associated with self-reported self-care practices for hypertension and type 2 diabetes. Crude and Adjusted Odds Ratios with a 95% Confidence Interval (CI) were reported.

RESULTS

Among the 435 participants, 37.0% self-reported hypertension, while 15.4% reported having type 2 diabetes. Variances in self-care practices were evident between the conditions, notably in terms of adequate fruit and vegetable intake and blood pressure screening. Among individuals with type 2 diabetes, 94% lacked sufficient fruit and vegetable consumption, contrasting with 98.7% among hypertensive participants (p = 0.042). Similarly, a significant majority of individuals with hypertension (71.4%) had blood pressure screening (p = 0.031). Multivariable logistic regression analysis revealed that individuals over 40 years exhibited higher odds of good self-care practice for hypertension compared to their younger counterparts (AOR: 4.67, 95% CI: 1.53-14.27, p = 0.007), whereas those residing in Mitunguu were 71% less likely to engage in such practices than those in Abogeta (AOR: 0.29, 95% CI: 0.09-0.90, p = 0.033). However, none of the variables demonstrated a significant association with self-reported self-care practices for type 2 diabetes following adjustment for potential confounding variables in the multivariable logistic regression analysis.

CONCLUSIONS

Our study identified socio-demographic factors, including age (> 40 years) and ward (Mitunguu), associated with self-reported self-care practices for hypertension among adults living in rural Kenya. However, we did not find significant associations between sociodemographic factors and self-care practices for type 2 diabetes. Furthermore, factors such as gender, education level, marital status, religion, employment status, and average monthly income did not show significant associations with self-care practices for hypertension or type 2 diabetes. These results provide insights regarding sociodemographic factors associated with self-care practices for hypertension among adults living in rural Kenya. Our study underscores the relevance of considering socio-demographic factors when making evidence-based policy decisions and designing intervention strategies tailored to the adult population in rural Kenya.

Haemoglobin types and variant interference with HbA1c and its association with uncontrolled HbA1c in type 2 diabetes mellitus

Diabetes mellitus is among the leading global health concerns, causing over 1.5 million deaths alongside other significant comorbidities and complications. Conventional diagnosis involves estimating fasting, random blood glucose levels and glucose tolerance test. For monitoring purposes, long-term glycaemic control has been achieved through the measurement of glycated haemoglobin (HbA1c) which is considered reliable and preferred tool. However, its estimation could be affected by haemoglobin types like HbA0, HbA2, and HbF concentrations whose magnitude remains unclear as well as other haematological parameters. As such, the current study determined the association between HbA1c and haemoglobin types and determined correlation between haemoglobin types and haematological parameters among patients with type 2 diabetes mellitus (T2DM) compared to healthy non-diabetic participants. In this cross-sectional study, participants [n = 144 (72 per group), ages 23-80 years] were recruited and the desired parameter measured. HbA1c and other Haemoglobin variants were measured using ion-exchange high-performance liquid chromatography (HPLC) by the Bio-Rad D-10 machine (Bio-Rad Laboratories, Inc). Haematological parameters were measured using the Celtac G MEK-i machine (Nihon Kohden Europe). SPSS version 27 (IBM Corporation, Chicago, Illinois, United States) was used for the analysis. Chi-square (χ2) analysis, Mann-Whitney U test, Binary logistic regression and Pearson correlation were used to determine the differences between proportions, compare laboratory characteristics, associations and correlations respectively. With non-diabetics as the reference group, HbA1c was associated with increased HbA0 [OR = 1.509, 95% CI = 1.020-1.099, p = 0.003] and increased HbA2 [OR = 3.893, 95% CI = 2.161-7.014, p = 0.001]. However, there was no significant association between HbA1c and HbF [OR = 2.062, 95% CI = 0.873-4.875, p = 0.099]. Further, haematocrit (HCT) had a negative correlation with HbAO and a positive correlation with HbAS in participants with controlled diabetes. Mean cell volume (MCV) and mean cell haemoglobin (MCH) had a negative correlation with HbF. MCHC (mean cell haemoglobin concentration) had a negative correlation with HbA2 in participant with uncontrolled diabetes. The study concluded that levels of various haemoglobin types should be considered while monitoring glycaemic control through HbA1c. Additionally, MCHC should be considered in individuals with high concentration of HbA2 among T2DM patients while interpretating results for HbA1c.

The role of the private sector in noncommunicable disease prevention and management in low- and middle-income countries: a series of systematic reviews and thematic syntheses

PURPOSE

Conduct six systematic reviews investigating for-profit private sector roles in NCD prevention and management in low- and middle-income countries (LMICs) through our a priori framework's pillars.

METHODS

Six systematic reviews and thematic syntheses were performed between March-August 2021, Six databases, websites of relevant organizations, and references lists of included studies were comprehensively searched. Studies published in English from 2000 onwards involving the pillar of interest, for-profit private sector, NCD prevention/management, and LMIC context were included. Results were synthesized using an inductive thematic synthesis approach.

RESULTS

Ultimately, 25 articles were included in the PPP review, 33 in Governance and Policy, 22 in Healthcare Provision, 15 in Innovation, 14 in Knowledge Educator, and 42 in Investment and Finance. The following themes emerged: PPPs (coordination; financial resources; provision; health promotion; capacity building; innovation; policy); Governance/Policy (lobbying; industry perception; regulation); Healthcare Provision (diagnosis/treatment; infrastructure; availability/accessibility/affordability); Innovation (product innovation; process innovation; marketing innovation; research; innovation dissemination); Knowledge Educator (training; health promotion; industry framework/guideline formation); Investment and Finance (treatment cost; regulation; private insurance; subsidization; direct investment; collaborative financing; innovative financing; research).

CONCLUSION

These findings will be instrumental for LMICs considering private sector engagement. Potential conflicts of interest must be considered when implementing private sector involvement.

Diabetes health care specific services readiness and availability in Kenya: Implications for Universal Health Coverage

Diabetes is a major cause of morbidity and mortality worldwide yet preventable. Complications of undetected and untreated diabetes result in serious human suffering and disability. It negatively impacts on individual's social economic status threatening economic prosperity. There is a scarcity of data on health system diabetes service readiness and availability in Kenya which necessitated an investigation into the specific availability and readiness of diabetes services. A cross sectional descriptive study was carried out using the Kenya service availability and readiness mapping tool in 598 randomly selected public health facilities in 12 purposively selected counties. Ethical standards outlined in the 1964 Declaration of Helsinki and its later amendments were upheld throughout the study. Health facilities were classified into primary and secondary level facilities prior to statistical analysis using IBM SPSS version 25. Exploratory data analysis techniques were employed to uncover the distribution structure of continuous study variables. For categorical variables, descriptive statistics in terms of proportions, frequency distributions and percentages were used. Of the 598 facilities visited, 83.3% were classified as primary while 16.6% as secondary. A variation in specific diabetes service availability and readiness was depicted in the 12 counties and between primary and secondary level facilities. Human resource for health reported a low mean availability (46%; 95% CI 44%-48%) with any NCDs specialist and nutritionist the least carder available. Basic equipment and diagnostic capacity reported a fairly high mean readiness (73%; 95% CI 71%-75%) and (64%; 95%CI 60%-68%) respectively. Generally, primary health facilities had low diabetic specific service availability and readiness compared to secondary facilities: capacity to cope with diabetes increased as the level of care ascended to higher levels. Significant gaps were identified in overall availability and readiness in both primary and secondary levels facilities particularly in terms of human resource for health specifically nutrition and laboratory profession.

Challenges to the delivery of clinical diabetes services in Ghana created by the COVID-19 pandemic

OBJECTIVE

The barriers to delivering clinical non-communicable disease services in low- and middle-income countries have risen with the onset of COVID-19. Using Ghana as a case study, this article examines the changes COVID-19 has brought to diabetes service delivery and considers policy responses to deal with future such outbreaks.

METHODS

We conducted 18 interviews between November 2020 and February 2021 with health professionals and administrators from primary, secondary and tertiary facilities within the Ghana Health Service. The analysis was performed using deductive and inductive methods.

RESULTS

There were six general themes in interviewees' responses: (1) COVID-19 had exacerbated the problems of high medicine and service costs and medicine shortages, (2) the pandemic had exacerbated problems of poor patient record keeping, (3) COVID-19 had reduced the availability of suitably trained health providers, (4) staff had become demoralized by management's unwillingness to make innovative changes to cope with the pandemic, (5) COVID-19 led to a reorganization of diabetes services, and (6) the country's national health insurance scheme lacked flexibility in dealing with the pandemic.

CONCLUSIONS

Access to resources is limited in LMICs. However, our study highlights practical policy responses that can improve health providers' response to COVID-19 and future pandemics.

Peer support and social networking interventions in diabetes self-management in Kenya and Uganda: A scoping review

BACKGROUND

Diabetes mellitus is a growing worldwide health challenge especially in sub-Saharan Africa. While the use and effectiveness of diabetes self-management interventions is well documented in high-income countries, little information exists in sub-Saharan Africa. Therefore, this study attempted to synthesize information in the literature on the use and efficacy of peer support and social networking in diabetes self-management in Kenya and Uganda.

OBJECTIVE

The purpose of this scoping review is to summarize research on the extent of use and efficacy of peer support and social networking interventions in diabetes self-management in Kenya and Uganda.

DESIGN

We searched PubMed, ScienceDirect and Cochrane Library databases for articles reporting peer support and social networking interventions in Kenya and Uganda published in English between 2000 and September 2021. Key words encapsulated three major themes: peer support, social networking and self-management. Hand searches were also conducted to select eligible papers. Data was extracted using a form prepared and piloted in line with PRISMA-ScR guidelines.

RESULTS

Thirteen peer reviewed articles were selected for analysis. Eleven studies reported peer support interventions while two focused on social networks in diabetes self-management. Peer support and social networking interventions incorporated microfinance and group medical visits, diabetes self-management education, telephone support and Medication Adherence Clubs. Most interventions were delivered by multidisciplinary teams comprising nurses and other professionals, peer educators, peer leaders and community health workers. Most interventions were effective and led to improvements in HbA1c and blood pressure, eating behaviors and physical activity and social support.

CONCLUSIONS

The limited studies available show that peer support and social networking interventions have mixed results on health and other outcomes. Importantly, most studies reported significant improvements in clinical outcomes. Further research is needed on the nature and mechanisms through which peer support and social network characteristics affect health outcomes.

Impact of Parental Knowledge and Beliefs on HPV Vaccine Hesitancy in Kenya-Findings and Implications

Cervical cancer can be prevented by human papillomavirus (HPV) vaccination. However, parents can have concerns about vaccinating their daughters. Consequently, there is a need to identify prevalence and risk factors for HPV vaccine hesitancy among parents in Kenya. A descriptive cross-sectional study was conducted among parents with children aged 9−14 years attending a leading referral hospital in Kenya. Data on sociodemographic traits, HPV knowledge, beliefs and vaccine hesitancy were collected. Out of 195 participants, 183 (93.5%) were aged >30 years. Thirty-four (46.4%) of males and 39 (35.1%) of females did not know that the vaccine is given to prevent HPV infection. Encouragingly, levels of vaccine acceptance were high (90%) although one-third (37.9%) had a negative perception about the effectiveness of the vaccine, with vaccine hesitancy attributed to safety concerns (76%) and feelings that the child was too young (48%). Positive beliefs and knowledge of the vaccine were positively associated with parental willingness to vaccinate their children. Low levels of parenteral education and a younger age among mothers were negatively associated with willingness to vaccinate. Most parents (59%) would consult their daughters before vaccination, and 77% (n = 150) recommended early sex education. Despite low knowledge levels, there was high parental willingness to have their children vaccinated.

Improving access to diabetes care for children: An evaluation of the changing diabetes in children project in Kenya and Bangladesh

BACKGROUND

The changing diabetes in children (CDiC) project is a public-private partnership implemented by Novo Nordisk, to improve access to diabetes care for children with type 1 diabetes. This paper outlines the findings from an evaluation of CDiC in Bangladesh and Kenya, assessing whether CDiC has achieved its objectives in each of six core program components.

RESEARCH DESIGN AND METHODS

The Rapid Assessment Protocol for Insulin Access (RAPIA) framework was used to analyze the path of insulin provision and the healthcare infrastructure in place for diagnosis and treatment of diabetes. The RAPIA facilitates a mixed-methods approach to multiple levels of data collection and systems analysis. Information is collected through questionnaires, in-depth interviews and focus group discussions, site visits, and document reviews, engaging a wide range of stakeholders (N = 127). All transcripts were analyzed thematically.

RESULTS

The CDiC scheme provides a stable supply of free insulin to children in implementing facilities in Kenya and Bangladesh, and offers a comprehensive package of pediatric diabetes care. However, some elements of the CDiC program were not functioning as originally intended. Transitions away from donor funding and toward government ownership are a particular concern, as patients may incur additional treatment costs, while services offered may be reduced. Additionally, despite subsidized treatment costs, indirect costs remain a substantial barrier to care.

CONCLUSION

Public-private partnerships such as the CDiC program can improve access to life-saving medicines. However, our analysis found several limitations, including concerns over the sustainability of the project in both countries. Any program reliant on external funding and delivered in a high-turnover staffing environment will be vulnerable to sustainability concerns.

Enhancing Choices Regarding the Administration of Insulin Among Patients With Diabetes Requiring Insulin Across Countries and Implications for Future Care

There are a number of ongoing developments to improve the care of patients with diabetes across countries given its growing burden. Recent developments include new oral medicines to reduce cardiovascular events and death. They also include new modes to improve insulin administration to enhance adherence and subsequent patient management thereby reducing hypoglycaemia and improving long-term outcomes. In the case of insulins, this includes long-acting insulin analogues as well as continuous glucose monitoring (CGM) systems and continuous subcutaneous insulin infusion systems, combined with sensor-augmented pump therapy and potentially hybrid closed-loops. The benefits of such systems have been endorsed by endocrine societies and governments in patients with Type 1 diabetes whose HbA1c levels are not currently being optimised. However, there are concerns with the low use of such systems across higher-income countries, exacerbated by their higher costs, despite studies suggesting their cost-effectiveness ratios are within accepted limits. This is inconsistent in higher-income countries when compared with reimbursement and funding decisions for new high-priced medicines for cancer and orphan diseases, with often limited benefits, given the burden of multiple daily insulin injections coupled with the need for constant monitoring. This situation is different among patients and governments in low- and low-middle income countries struggling to fund standard insulins and the routine monitoring of HbA1c levels. The first priority in these countries is to address these priority issues before funding more expensive forms of insulin and associated devices. Greater patient involvement in treatment decisions, transparency in decision making, and evidence-based investment decisions should help to address such concerns in the future.

Current utilization patterns for long-acting insulin analogues including biosimilars among selected Asian countries and the implications for the future

INTRODUCTION

Prevalence rates for diabetes mellitus continue to rise, which, coupled with increasing costs of complications, has appreciably increased expenditure in recent years. Poor glycaemic control including hypoglycaemia enhances complication rates and associated morbidity, mortality and costs. Consequently, this needs to be addressed. Whilst the majority of patients with diabetes have type-2 diabetes, a considerable number of patients with diabetes require insulin to help control their diabetes. Long-acting insulin analogues were developed to reduce hypoglycaemia associated with insulin and help improve adherence, which can be a concern. However, their considerably higher costs have impacted on their funding and use, especially in countries with affordability issues. Biosimilars can help reduce the costs of long-acting insulin analogues thereby increasing available choices. However, the availability and use of long-acting insulin analogues can be affected by limited price reductions versus originators and limited demand-side initiatives to encourage their use. Consequently, we wanted to assess current utilisation rates for long-acting insulin analogues, especially biosimilars, and the rationale for patterns seen, across multiple Asian countries ranging from Japan (high-income) to Pakistan (lower-income) to inform future strategies.

METHODOLOGY

Multiple approaches including assessing utilization and prices of insulins including biosimilars among six Asian countries and comparing the findings especially with other middle-income countries.

RESULTS

Typically, there was increasing use of long-acting insulin analogues among the selected Asian countries. This was especially the case enhanced by biosimilars in Bangladesh, India, and Malaysia reflecting their perceived benefits. However, there was limited use in Pakistan due to issues of affordability similar to a number of African countries. The high use of biosimilars in Bangladesh, India and Malaysia was helped by issues of affordability and local production. The limited use of biosimilars in Japan and Korea reflects limited price reductions and demand-side initiatives similar to a number of European countries.

CONCLUSIONS

Increasing use of long-acting insulin analogues across countries is welcomed, adding to the range of insulins available, which increasingly includes biosimilars. A number of activities are needed to enhance the use of long-acting insulin analogue biosimilars in Japan, Korea and Pakistan.

The Current Situation Regarding Long-Acting Insulin Analogues Including Biosimilars Among African, Asian, European, and South American Countries; Findings and Implications for the Future

Background: Diabetes mellitus rates continue to rise, which coupled with increasing costs of associated complications has appreciably increased global expenditure in recent years. The risk of complications are enhanced by poor glycaemic control including hypoglycaemia. Long-acting insulin analogues were developed to reduce hypoglycaemia and improve adherence. Their considerably higher costs though have impacted their funding and use. Biosimilars can help reduce medicine costs. However, their introduction has been affected by a number of factors. These include the originator company dropping its price as well as promoting patented higher strength 300 IU/ml insulin glargine. There can also be concerns with different devices between the manufacturers. Objective: To assess current utilisation rates for insulins, especially long-acting insulin analogues, and the rationale for patterns seen, across multiple countries to inform strategies to enhance future utilisation of long-acting insulin analogue biosimilars to benefit all key stakeholders. Our approach: Multiple approaches including assessing the utilisation, expenditure and prices of insulins, including biosimilar insulin glargine, across multiple continents and countries. Results: There was considerable variation in the use of long-acting insulin analogues as a percentage of all insulins prescribed and dispensed across countries and continents. This ranged from limited use of long-acting insulin analogues among African countries compared to routine funding and use across Europe in view of their perceived benefits. Increasing use was also seen among Asian countries including Bangladesh and India for similar reasons. However, concerns with costs and value limited their use across Africa, Brazil and Pakistan. There was though limited use of biosimilar insulin glargine 100 IU/ml compared with other recent biosimilars especially among European countries and Korea. This was principally driven by small price differences in reality between the originator and biosimilars coupled with increasing use of the patented 300 IU/ml formulation. A number of activities were identified to enhance future biosimilar use. These included only reimbursing biosimilar long-acting insulin analogues, introducing prescribing targets and increasing competition among manufacturers including stimulating local production. Conclusions: There are concerns with the availability and use of insulin glargine biosimilars despite lower costs. This can be addressed by multiple activities.

Health systems challenges and opportunities in tackling non-communicable diseases in rural areas of India

The increasing burden of non-communicable diseases in rural areas poses new challenges to an already overburdened health systems. We detail these challenges and identify opportunities to address them. The major challenges in service delivery in rural areas include poor accessibility, shortage of adequate manpower especially specialists in rural areas, irregular supply of medicines and lack of adequate diagnostic facilities. This has led to an increased dependency on the private sector resulting in high out-of-pocket and catastrophic health expenditure. The challenges are amplified by lower health literacy, large pool of informal or untrained healthcare practitioners, and lack of proper referral and follow up. The health system opportunities identified include task-shifting by training of mid-level healthcare providers and practitioners from Indian systems of medicine, widening use of e-health and m-health, community engagement and public-private partnerships. Participatory health governance through community engagement has been shown to improve accountability and quality in health systems. Civil society organizations (CSO) can also improve awareness and health-seeking behaviour. New and evidence-based strategies need to be implemented to address health system challenges for tackling non-communicable diseases in rural areas.

Coronavirus Disease 2019 (COVID-19) set to increase burden of atherosclerotic cardiovascular disease in Kenya

The coronavirus disease 2019 (COVID-19), first reported in Kenya on March 13, 2020, is spreading rapidly. As of 30th June 2020, over 6,190 cases had been reported with a case fatality of 3.2%. Previous Coronavirus outbreaks have been associated with a significant burden of Cardiovascular disease. For COVID-19, however, there has been no direct reference to potential long-term cardiovascular effects, especially in Africa where atherosclerotic diseases are an emerging challenge. This article, therefore, aims at describing possible long-term effects on the burden of atherosclerotic disease among Kenyans. Available data indicate that COVID-19 and cardiovascular disease share pathomechanisms and risk factors which include ACE2 receptor invasion and renin-angiotensin system signaling, oxidative stress, systemic inflammation, and endothelial dysfunction. Further, SAR-COV-2 infection causes dyslipidemia, dysglycemia, kidney, and liver disease. These mechanisms and diseases constitute risk factors for the initiation, progression, and complications of atherosclerosis. In Kenya, the common risk factors for atherosclerotic cardiovascular disease, and COVID-19 comprising Hypertension, Diabetes Mellitus, Obesity, Cigarette Smoking, Respiratory Tract Infections, Pulmonary Thromboembolism, Chronic Obstructive Pulmonary Disease, and Renal disease are not uncommon and continue to increase. In essence, the prevalence of the common risk factors/comorbidities, between COVID-19 and CVD occurrence of ACE2 receptors on the endothelium, and hence pathomechanisms of SARS-COV-2 infection imply that COVID-19 may increase the burden of atherosclerotic disease in Kenya. All due care should be taken, to prevent and effectively manage the disease, to avert an imminent epidemic of atherosclerotic disease.

Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future

Background

There has been an appreciable increase in the number of people in Africa with metabolic syndrome and Type 2 diabetes (T2DM) in recent years as a result of a number of factors. Factors include lifestyle changes, urbanisation, and the growing consumption of processed foods coupled with increasing levels of obesity. Currently there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless controlled. This has a considerable impact on morbidity, mortality and costs in the region. There are a number of issues to address to reduce the impact of T2DM including improving detection rates and current access to services alongside addressing issues of adherence to prescribed medicines. There are also high rates of co-morbidities with infectious diseases such as HIV and tuberculosis in patients in Africa with T2DM that require attention.

Objective

Document ongoing activities across Africa to improve the care of patients with T2DM especially around issues of identification, access, and adherence to changing lifestyles and prescribed medicines. In addition, discussing potential ways forward to improve the care of patients with T2DM based on ongoing activities and experiences including addressing key issues associated with co-morbidities with infectious diseases.

Our Approach

Contextualise the findings from a wide range of publications including internet based publications of national approaches coupled with input from senior level government, academic and other professionals from across Africa to provide future guidance.

Ongoing Activities

A number of African countries are actively instigating programmes to improve the care of patients with T2DM starting with improved diagnosis. This recognises the growing burden of non-communicable diseases across Africa, which has been neglected in the past. Planned activities include programmes to improve detection rates and address key issues with diet and lifestyle changes, alongside improving monitoring of care and activities to enhance adherence to prescribed medicines. In addition, addressing potential complexities involving diabetes patients with infectious disease co-morbidities. It is too early to fully assess the impact of such activities.

Conclusion

There are a number of ongoing activities across Africa to improve the management of patients with diabetes including co-morbidities. However, more needs to be done considering the high and growing burden of T2DM in Africa. Ongoing research will help further benefit resource allocation and subsequent care.

Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future

BACKGROUND

Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa.

METHODOLOGY

Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa.

RESULTS

Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care.

CONCLUSION

There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.

Patient costs of diabetes mellitus care in public health care facilities in Kenya

OBJECTIVE

To estimate the direct and indirect costs of diabetes mellitus care at five public health facilities in Kenya.

METHODS

We conducted a cross-sectional study in two counties where diabetes patients aged 18 years and above were interviewed. Data on care-seeking costs were obtained from 163 patients seeking diabetes care at five public facilities using the cost-of-illness approach. Medicines and user charges were classified as direct health care costs while expenses on transport, food, and accommodation were classified as direct non-health care costs. Productivity losses due to diabetes were classified as indirect costs. We computed annual direct and indirect costs borne by these patients.

RESULTS

More than half (57.7%) of sampled patients had hypertension comorbidity. Overall, the mean annual direct patient cost was KES 53 907 (95% CI, 43 625.4-64 188.6) (US$ 528.5 [95% CI, 427.7-629.3]). Medicines accounted for 52.4%, transport 22.6%, user charges 17.5%, and food 7.5% of total direct costs. Overall mean annual indirect cost was KES 23 174 (95% CI, 20 910-25 438.8) (US$ 227.2 [95% CI, 205-249.4]). Patients reporting hypertension comorbidity incurred higher costs compared with diabetes-only patients. The incidence of catastrophic costs was 63.1% (95% CI, 55.7-70.7) and increased to 75.4% (95% CI, 68.3-82.1) when transport costs were included.

CONCLUSION

There are substantial direct and indirect costs borne by diabetic patients in seeking care from public facilities in Kenya. High incidence of catastrophic costs suggests diabetes services are unaffordable to majority of diabetic patients and illustrate the urgent need to improve financial risk protection to ensure access to care.