OBJECTIVE—The objective of this study was to assess the barriers to care for patients with insulin-requiring diabetes in Mozambique and Zambia.

RESEARCH DESIGN AND METHODS—We used the Rapid Assessment Protocol for Insulin Access to collect information through interviews, discussions, site visits, and document reviews. Government organizations, health facilities, care givers, and patients were asked about care for people with insulin-requiring diabetes. Between 100 and 200 interviews/discussions per country were undertaken in and around the capital city and the regional capital and in a rural area.

RESULTS—Insulin was present in both countries in sufficient quantities, although the financial burden for health services and patients meant that problems with supply exist. There are problems with quantification of needs and equitable distribution of insulin. Problems with availability of syringes and testing equipment were noted, particularly in Mozambique. This lack of tools and infrastructure for diagnosis and follow-up coupled with low levels of health care worker training and lack of diagnostic reagents resulted in a substantial risk of misdiagnosis or failure to detect diabetes. The estimated prevalence of insulin-requiring diabetes differs more than 10-fold between urban and rural areas in Mozambique and 4-fold between Mozambique and Zambia, suggesting that problems in diagnosis and care result in substantial worsening of prognosis for such patients.

CONCLUSIONS—Insulin is necessary but not sufficient to improve prognosis for diabetic patients. A Rapid Assessment Protocol methodology can be used to define problems in health care delivery for diabetes. Proper care for insulin-requiring diabetes necessitates health systems able to provide trained personnel, medicines in sufficient quantity, and diagnostic and monitoring facilities.

Type 1 diabetes has been estimated to affect ∼19,000 people in the world’s poorest countries (1), but there are a lack of good data on the disease prevalence in developing countries and in particular in sub-Saharan Africa. The annual incidence of type 1 diabetes in East Africa was found to be 1.5 per 100,000 population aged 0–19 years (2) compared with 10.3 per 100,000 population in African Americans (3) and 18 per 100,000 population in the U.K. (4). However, the low prevalence of the condition may reflect poor prognosis as well as low incidence.

### Health care worker and patient knowledge about diabetes

Health care workers in Mozambique and Zambia rarely encounter patients with insulin-requiring diabetes. This lack of familiarity and lack of tools for proper diagnosis mean that diabetes in many patients is likely to be missed or misdiagnosed. Diabetes in patients presenting in a coma may be misdiagnosed as cerebral malaria or HIV/AIDS.

In neither country was there a system of referral pathways and treatment guidelines, so that even if diabetes was diagnosed in patients correctly, their referral and treatment may be suboptimal. This is especially true in areas remote from main hospitals.

Low levels of health care worker knowledge about diabetes lead to poor understanding of their condition by patients. Misconceptions about diet and a low level of understanding regarding insulin use leads to poor diabetes management and frequent complications. A shortage of health care workers exists in both countries. This is particularly true in rural areas, and this shortage combined with strong traditional beliefs results in many people accessing health care only through traditional healers.

### The importance of traditional beliefs

Traditional healers are an integral part of the health care systems in Mozambique and Zambia. National associations exist to represent the healers, and at the ministry of health in each country a division deals with the role of traditional medicine within the health system. Many traditional healers stated that they cared for diabetic patients for a certain time and if their condition did not improve within that time frame they would then send the patients to allopathic facilities.

Many traditional healers had heard of diabetes and knew at least that the disease was characterized by excessive thirst and urination. In both countries they also stated that they would welcome closer collaboration with allopathic medical personnel and learning more about diabetes.

### Estimates of prevalence and prognosis

The RAPIA enabled rough estimates of prevalence to be calculated. In both Mozambique and Zambia numbers of patients were determined based on interviews with health care workers and from patient registers. If there was more than one facility treating patients in the same area, unless patients reported visiting more than one institution, it was assumed that there was no overlap. Official government population statistics were used as the denominator. The national prevalence was calculated using the respective proportion of populations living in rural and urban areas and the capital city and applying the calculated prevalence to this population. In Mozambique the estimated prevalence of insulin-requiring diabetes was 3.5 per 100,000 population and for Zambia it was 12.0 per 100,000 population. These figures compare with estimates of type 1 diabetes prevalence by the International Diabetes Federation of 5.2 per 100,000 for Mozambique and 4.8 per 100,000 for Zambia (4).

From these prevalence estimates and by using an estimate of diabetes incidence of 1.5 per 100,000 per year (2), it is possible to estimate life expectancy for patients with insulin-requiring diabetes, both nationally and by geographical location. This life expectancy varied from 0.6 years for a child in rural Mozambique to 27 years for an adult living in the capital city in Zambia (Table 2). The prevalence and life expectancy estimates mirror differences in the quality of care, availability of diagnostic tools, and availability of insulin between and across these two countries, with prognosis in rural Mozambique being particularly poor.

No previous study has examined in systematic fashion the patterns of diabetes care across countries in sub-Saharan Africa. Furthermore, studies of type 1 diabetes prevalence in sub-Saharan Africa are few (20,21) and neither a representative diabetes survey nor diabetes registry is available in the countries assessed. The RAPIA was developed to provide a situational analysis of insulin-requiring diabetes to be able to make recommendations to the national ministries of health and diabetes associations. In both Mozambique and Zambia local stakeholders were actively involved in the assessment. This resulted in the process acting as a catalyst in bringing diabetes to the attention of the health authorities, making the RAPIA an effective tool for advocacy.

The RAPIA has suggested that management of patients with insulin-requiring diabetes in these countries is problematic, particularly outside the catchment area of the major referral hospitals. Insulin availability at a national level did not appear to be a constraint to care. Nevertheless, in Mozambique, the availability of insulin to patients, particularly outside the capital, was a major barrier. Insulin is necessary, but not sufficient, for the survival of a patient with insulin-requiring diabetes. The dearth of health care available for most insulin-requiring diabetic patients outside the capital cities, particularly in Mozambique, also included intermittent availability of supplies needed for diabetes care such as syringes, urine and blood reagent strips, and, perhaps most crucially, little experience in management of diabetes by most health care workers. The nonavailability of blood or urine glucose testing facilities at the majority of health units raises the likelihood that the major contribution to the “missing patients” is failure of diagnosis at presentation.

The Mozambique study showed marked differences in diabetes care and in diabetes prevalence in the capital city and in other parts of the country. These estimates seem to be approximately two to three times higher for Zambia than for Mozambique, and the urban-rural variation appears substantially lower in Zambia. It is improbable that the Mozambique findings represent differences in incidence in different parts of the country. The size of the country and the distances involved make it unlikely that patients would travel substantial distances for their care. The lower numbers of diabetic patients in other towns and rural areas are likely to represent poorer prognosis away from centers of excellence. The higher priority of diabetes care in national health care planning in Zambia may be attributed, in part, to the active advocacy and educational role played by the Diabetes Association of Zambia.

As stated by former U.S. President Bill Clinton, “Until we build the human and physical infrastructure needed to deliver effective treatment, programs will not succeed” (22). Although he was referring to HIV/AIDS, the same is true for diabetes. A system with such components including continuing supplies of drugs, diagnostic facilities, health worker training and retention, and patient education is vital in the management of diabetes. Improvements in health care systems are, then, a vital component of improving health and health care for patients with many chronic conditions across sub-Saharan Africa.

The pilot of the RAPIA in Mozambique was made possible thanks to a generous grant from the World Diabetes Foundation. The IIF’s work in Zambia was made possible through the generous support of the Diabetes Foundation, U.K., and the World Health Organization Essential Drugs and Medicines Unit. We also acknowledge the support of all the other generous donors of the IIF and the logistical and administrative support of University College London in helping with its establishment. The IIF is a U.K. Registered Charity (registration no. 1099032).

We are grateful to Dr. Carla Silva-Matos, Ministerio do Saude, Mozambique, Professor Aires Fernandes and Dr. Paula Caupers of Hospital Central Maputo, and Ms. Dalila Maciel of Associação Moçambicana dos Diabéticos for help with establishing the RAPIA in Mozambique. We also thank Dr. Chishimba Lumbwe, Chairman of the Diabetes Association of Zambia, Dr. Susan Zimba of the University Teaching Hospital Lusaka, and Dr. Benjamin Chirwa and Dr. Velepi Mtonga at the Central Board of Health, Lusaka. We gratefully acknowledge the advice and support of the trustees of the International Insulin Foundation, Professor Harry Keen, Professor Jak Jervell, Dr. Kaushik Ramaiya, Professor Jean-Claude Mbanya, Dr. Peter Watkins, Dr. Geoffrey Gill, and Dr. John Day, and our Patrons Professor Errol Morrison and Mrs. Glenys Kinnock, MEP.

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A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.