Access to care for people living with diabetes in LMICs
Author: Yildiz Arslan
Limited or inadequate access to healthcare is a significant challenge faced by about 4.5 billion people, which means that more than half of the world’s population lack full access to essential health services. This is mainly due to systemic barriers such as distance to clinics, high consultation fees, and inadequate capacity and quality in the healthcare system.
This results in an increased burden on individuals suffering from non-communicable diseases (NCDs), but also a burden on their families and communities. From a structural and economic perspective, insufficient or delayed care for people with NCDs leads to higher treatment costs, preventable and premature deaths, and loss of income for families, thereby putting pressure on health budgets and in turn national economies, especially in low- and middle-income countries (LMICs) where these are already vulnerable.
This underscores the need for better screening and care to catch and treat chronic diseases before they result in complications or early death. This is not an easy task to take on, yet WDF's support has enabled partnering organisations to bring about positive change in the access to and the quality of care in countries where we engage.
The WDF approach to strengthening access to care has been refined over the past 20 years, and one of the most significant examples of its impact is seen in Tanzania.
Since 2003, WDF has collaborated with the Tanzanian Diabetes Association (TDA), transforming diabetes care from a humble pop-up container clinic in Dar es Salaam to the endorsement of a nationwide NCD programme owned and run by the Tanzanian government.
For WDF, strengthening primary healthcare is the most inclusive and impactful approach to building sustainable health systems and addressing the growing burden of diabetes in LMICs.
Primary level care serves as the first point of contact with healthcare for the majority of the population in low and middle income countries. When healthcare professionals are trained, and accurate diagnostics and registries are in place, diabetes can be detected early, and complications such as blindness and renal failure can be prevented. Strong frontline services at the primary level can help ensure early diagnosis, treatment, and better outcomes for individuals, as well as lower costs for healthcare.
The World Health Organization (WHO) recommends that low-resource countries strengthen primary level services through integration, gradually abandoning vertical, single-disease-based structures. In the context of NCDs, integrated health services are implemented in a way that ensures people living with NCDs receive a full continuum of healthcare that fits local contexts.
Studies have confirmed that health systems with strong primary healthcare at their core have lower costs, better population health, higher patient satisfaction, fewer unnecessary hospital admissions, and greater socioeconomic equity. As a result, supporting LMICs in developing and deploying models of care to address diabetes and related NCDs at primary care level is a key intervention area for WDF.
The WDF-funded 'Tanzania Model' for integrated care, along with its 'common triaging' concept at primary level, has been recognised as a replicable and scalable model to improve care in low- and middle-income countries. This approach has been published in peer-reviewed research papers in renowned global journals such as The Lancet and Nature.
Establishment of so-called ‘triaging desks’ at health facilities ensures that most patients attending primary care will be screened for common conditions and risk factors, including both non-communicable and infectious diseases, before being referred to more specific care.
An estimated 1 in 8 of adults among Tanzania’s 64 million population are living with diabetes. More than half of those are undiagnosed. A 2017 external evaluation of WDF-supported projects in Tanzania concluded that, on average, there were 526 more diabetes patients and 1,224 more hypertension patients under treatment per district per month in districts where WDF programmes were implemented, compared to districts not yet enrolled.
The current WDF Tanzania programme, running from 2021 until 2025, aims to reach 2.5 million diabetes patients and 5 million hypertension patients with improved care, training of staff in 702 health centres, reaching 2,880 health care providers and providing NCD screening starter kits to improve the ability of health facilities to diagnose and manage NCDs effectively.
For the past seven years, WDF has worked in direct partnership with the Tanzanian Diabetes Association, the Ministry of Health, and the President's Office for Regional Administration and Local Government. The 'Tanzania National NCD Programme - Phase II' is the newest addition to this collaboration, launched in 2019 with additional funding from the Novo Nordisk Foundation.
To date, WDF has supported 17 projects in Tanzania aiming to strengthen care for diabetes and other NCDs with almost 13 million USD, of which 6 million was granted in 2019 for the ongoing second phase. Through this support, more than 7,000 healthcare providers have been trained, and 260,000 patients have been registered and received treatment at the supported clinics. On-line training modules have been developed for different cadres of healthcare providers to ensure continuous professional development and overcoming the challenges of staff attrition. These on-line courses have been accredited with respective professional councils. Finally, treatment and referral guidelines have been developed and rolled out in the public healthcare system supporting a change also at organisational level.
'Can you imagine as a kid you were told, if you don't do this, you are gonna die! ', Anita Bulindi says. 'It was pretty hard; it was really hard. And I really didn't like it, at all.'
The story of Anita Bulindi is a shining example of the impact that complex policy changes, partnership development and health interventions can create for the individual person struggling with diabetes and other chronic conditions every single day.
In 2005, WDF met Anita, a lively 10-year-old juggling school, family, friends, and a diagnosis of type 1 diabetes. During a visit to the diabetes clinic at Muhimbili National Hospital in Dar es Salaam, Tanzania, her blood sugar was higher than expected, and she admitted to having eaten an ice cream. She learned how to manage her diabetes at a WDF-supported clinic in Dar es Salaam.
Later, now a young woman, she co-founded the Tanzanian Diabetes Youth Alliance, a platform under the umbrella of TDA that operates in more than ten regions to enhance understanding of type 1 diabetes by improving education and type 1 health services where they are insufficient.
Anita explains how the alliance 'is a group of youth with diabetes in Tanzania who are trying to make a change for our fellow youth who have diabetes, as well as children. We are part of this whole big family, with one thing in common: being diabetics.'
In 2002, fewer than 30 Tanzanians were known to be living with type 1 diabetes. Today, the situation looks significantly different. The country now boasts 82 clinics all over the country with more than 6,000 children with type 1 diabetes. The clinics are supported by Life for a Child (LFAC), Changing Diabetes in Children (CDiC), and the National Type 1 Diabetes Programme (WDF, Novo Nordisk Foundation).
In some sub-Saharan countries in Africa, life expectancy for a child with type 1 diabetes is less than one year after diagnosis. The increased availability of type 1 diabetes health services mean hope - for the many children and young people with the condition and for their families.
In a 2022 peer reviewed article on paediatric diabetes, a key finding showed how the type 1 diabetes programme in Tanzania has had a significant impact on the longevity for children with type 1 diabetes in the country.
Prof Kaushik Ramaiya, Honorary General Secretary of the Tanzania Diabetes Association (TDA) and internationally renowned diabetes expert, is in Denmark for the March 2024 meeting of the WDF Board of Directors and the launch of the new large-scale framework agreement with the Novo Nordisk Foundation.
WDF first partnered with TDA in 2003 and has been persistently supporting the association ever since. Prof Kaushik underscores how the Foundation’s support helped build TDA. Funding in the early days made it possible for TDA to hire a programme manager and systematically pursue every little opportunity to strengthen care for diabetes, and eventually also other NCDs.
With each new WDF grant, TDA was able to test and scale health interventions, proving a need for NCD care in Tanzania. 'We created guidelines for management of diabetes and its complications for health professionals and diabetes educators and those regional guidelines helped us build documentation at the national level. Suddenly policymakers realised that the demand for NCD services started increasing,' he explains, underscoring that 'when the demand is created, policies will change'.
TDA has worked towards establishment of an NCD unit at the Ministry of Health and with persistent advocacy been able to integrate NCDs in the Parliamentary Committee on HIV/AIDS, TB and substance abuse. Today the Ministry of Health has a budget line dedicated to NCDs in their strategic plan and allocates funds for this from its own budget, this has even filtered down to district level with Council Health budgets. These achievements pose a very tangible example of the impact of many years of collaboration.
When it comes to policy level changes, it can be hard to pinpoint the impact of a specific partnership or grant. To shed some light on the partnership between WDF, TDA and the Tanzanian Ministry of Health, we invited Dr Omary Ubuguyu, Assistant Director & Head of the NCD Section in Tanzania's Ministry of Health, for an interview. An invitation which he kindly accepted.
During the conversation, Dr Ubuguyu shared his reflections on policy changes in the Tanzanian NCD arena, which have been enabled with WDF's support. 'Over the past two years, we have managed to develop a framework for coordination on NCDs with support from TDA and WDF,' he says, and explains how it works as a coordination tool for national NCD services. In April 2024, the framework was presented to the Permanent Secretaries from fifteen other Tanzanian ministries with the aim of integrating NCD care and prevention in policy making beyond just the Ministry of Health.
Dr UbuguyuAssistant Director and Head of the NCD Section in Tanzania’s Ministry of Health
“After successfully building NCD capacity at the zonal, regional and district levels, we are now taking the next step - strengthening access to care for people with diabetes and other NCDs closer to their homes and within their communities.”
Prof Kaushik RamaiyaHonorary General Secretary of the Tanzania Diabetes Association (TDA)
Over the years, WDF’s funding has ensured training for a total of 610,000 doctors, nurses, and other healthcare providers in the 120 countries we have supported. The healthcare professionals trained bring their new skills in NCD screening, diagnosis, and care back to healthcare units across communities in all corners of the world. The cascade effect means that the reach of screening and care for NCDs increases. This is particularly important for communities in remote areas, where people risk living with diabetes undiagnosed until the onset of severe complications such as eye problems or loss of a limb.
Training of healthcare workers is also a main component of Tanzania’s National NCD Programme. Experiences from the Tanzanian programme help us understand why training of healthcare providers is such an impactful component when seeking to strengthen care. During a 2022 evaluation of their work, the TDA programme team interviewed trainees to understand the effects of the trainings. Participants reported keeping in touch with fellow trainees, supporting and advising each other. Back at home, many also established WhatsApp groups where local healthcare providers can share experiences, challenges, and achievements related to NCD prevention and management.
'A majority say they now set specific days for presentations on NCDs to patients and colleagues at their facilities,' says Dr Rachel Nungu, Programme Manager of the National NCD programme at TDA. The evaluation also found that all the participants surveyed have set up monthly to weekly NCD clinics in the healthcare facilities where they work.
'The aim of this programme is to help communities fight NCDs through screening and quality basic management for the NCD patients, so this finding is really meaningful,' Dr Nungu says. 'A triage desk at these facilities gives us hope that we can offer early detection and prevent the community from succumbing to premature deaths from NCDs.'
“WDF can't cover everything. But we use whatever we can get as a stimulus to cascade the interventions. For example, regarding the digital transformation with WDF, we had originally planned to have this in two regions as a demonstration site. But after developing a web-based database for NCDs in the two districts, it has already spilled over to three more regions and more than 300 primary health care facilities. In that way, WDF’s support becomes a catalyst for initiatives that we would have otherwise thought were impossible to pursue.”
With a mission to further empower Tanzanian healthcare providers to reach even more people in the future, WDF has supported the development and initial implementation of the diabetes screening app, the Diabetes Compass, in the country. With the algorithm-based screening app, healthcare providers can conduct screenings in communities that are far away from health facilities. The screenings can be done without blood tests or internet connection. If the screening indicates a high risk of diabetes, the person will travel to the nearest clinic for further testing and referral to more specialised care if needed. The Diabetes Compass will also allow the Tanzanian health authorities to get better patient data, which can be used at policy level to further promote the NCD agenda.
The 'Tanzania model' has inspired WDF's approach in many LMICs over the years with a mission to build health services that will last - also after a partnership project with WDF ends.
To enable sustainable project outcomes, WDF requires its partners to cover running costs such as healthcare staff and consumables. WDF also advocates for the gradual incorporation of necessary resources towards NCDs in the national health budget planning.
A key factor to the success of the Tanzanian model lies in the focus on strengthening the health system to build a solid infrastructure for diagnosis and treatment of people with NCDs. The health system has been strengthened from the top down, ensuring that more specialised care for people living with diabetes is in place first. Once referral pathways are set, the outreach to local communities can start. As the Tanzanian experience shows, this takes years of persistent work, a sharp eye for new opportunities, and reliable funding.
Diabetes is one of the greatest health challenges of the 21st century, hitting LMICs the hardest. Three in four people with diabetes now live in low-income countries, which is over 400 million people living where financial and human resources are scarce. By 2045, this number is expected to increase to a staggering 587 million, assuming the proportions remain the same.
WDF supports several projects in Africa, Europe, Latin America, and Asia where nationwide scale-up investments would now be possible. WDF has proven its capacity, network, and experience to support partners in taking on the challenge of easing the burden of chronic diseases on the horizon. The Tanzanian ‘recipe’ for impact has been a source of inspiration for ministries of health and other partners in many countries supported by WDF over the past 20 years. WDF will continue its efforts to improve access to care for people living with diabetes and other NCDs.
The World Diabetes Foundation (WDF) has received a DKK 5 million grant from Novo Nordisk Foundation to support the COVID-19 (coronavirus) response in Tanzania with focus on people living with diabetes and other NCDs.
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