Health system performance for people with diabetes in 28 low- and middle-income countries: A cross-sectional study of nationally representative surveys
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Date
2019
Journal Title
Journal ISSN
Volume Title
Publisher
PLoS Med
Abstract
The prevalence of diabetes is increasing rapidly in low- and middle-income countries
(LMICs), urgently requiring detailed evidence to guide the response of health systems to
this epidemic. In an effort to understand at what step in the diabetes care continuum individuals
are lost to care, and how this varies between countries and population groups, this
study examined health system performance for diabetes among adults in 28 LMICs using a
cascade of care approach.
Methods and findings
We pooled individual participant data from nationally representative surveys done
between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose
� 7.0 mmol/l (126 mg/dl), random plasma glucose � 11.1 mmol/l (200 mg/dl), HbA1c �
6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were
as follows: tested, diagnosed, lifestyle advice and/or medication given (“treated”), and
controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic
region, World Bank income group, and individual-level characteristics (age, sex,
educational attainment, household wealth quintile, and body mass index [BMI]). We
then used logistic regression models with country-level fixed effects to evaluate predictors
of (1) testing, (2) treatment, and (3) control. The final sample included 847,413
adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income).
Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of
diabetes was 8.8% (95% CI: 8.2%–9.5%), and the prevalence of undiagnosed diabetes
was 4.8% (95% CI: 4.5%–5.2%). Health system performance for management of diabetes
showed large losses to care at the stage of being tested, and low rates of diabetes
control. Total unmet need for diabetes care (defined as the sum of those not tested,
tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled)
was 77.0% (95% CI: 74.9%–78.9%). Performance along the care cascade was
significantly better in upper-middle income countries, but across all World Bank income
groups, only half of participants with diabetes who were tested achieved diabetes control.
Greater age, educational attainment, and BMI were associated with higher odds of
being tested, being treated, and achieving control. The limitations of this study included
the use of a single glucose measurement to assess diabetes, differences in the
approach to wealth measurement across surveys, and variation in the date of the
surveys.
Conclusions
The study uncovered poor management of diabetes along the care cascade, indicating
large unmet need for diabetes care across 28 LMICs. Performance across the care cascade
varied by World Bank income group and individual-level characteristics, particularly
age, educational attainment, and BMI. This policy-relevant analysis can inform
country-specific interventions and offers a baseline by which future progress can be
measured.
Description
Keywords
Health system, Diabetes, Middle-income countries
Citation
Manne-Goehler J, Geldsetzer P, Agoudavi K, Andall-Brereton G, Aryal KK, Bicaba BW, et al. (2019) Health system performance for people with diabetes in 28 low- and middle-income countries: A cross-sectional study of nationally representative surveys. PLoS Med 16(3): e1002751. https://doi. org/10.1371/journal.pmed.1002751