the socio-economic burden of diabetes in developing countries lessons from studies in egypt...
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The Socio-economic Burden of Diabetes in Developing Countries
Lessons from studies in Egypt
Professor Morsi Arab
Egypt
Socioeconomics of Diabetes
1- The patient and human environment.2- Patient’s Right and Obligations.3- Factors deciding the burden of diabetes.4- Size of the problem : Prevalence 5- Life Style 6- The national cost7- Government and Household expenditure.8- Cost of O.P. care9-The hospital burden 10- Costs comparative to other countries .
The people with Diabetes and their Environment
IDF
Media Public . Com.Diab. Associations
Family Friends
Health Care Team
Pharm. Ind. SyndicatesHealth Autho.
WHO
Patient
Determinants of impact
• 1. High prevalence
• 2. High cost of disease
• 3. Low economics
• 4. Adverse social conditions
CAIRO
Geographical distribution of the Egyptian population
UrbanAgriculturalDesert
56%
1% 43%
Age structure of the Egyptian population
40 30 20 10 0 10 20 30 40
60
-50
-40
-30
-60
-20
-10
The estimated prevalence with DM by IDF region, 2000
0
1
2
3
4
5
6
7
8
9
10
AFR EMME ER NA SACA SEA WP
Region
Pre
vale
nce
(%
)
Prevalence of DM in the whole of Egypt in different age groups
0
2
4
6
8
10
12
14
16
18
-10 -20 -30 -40 -50 -60 >60
?
Pre
vale
nce
(%
)
Prevalence of DM
0
5
10
15
20
25
-20 -30 -40 -50 -60 >60
ABC
Age range
Pre
vale
nce
(%
)
Effect of change of the life style in migrating ethnic groups on metabolic
parameters related to diabetesA lesson from the Nubians of Egypt
Professor Morsi Arab
University of Alexandria - Egypt
Prevalence of DM in patients over 40 yrs
0
2
4
6
8
10
12
14
16
U UN RN RA RD
% P
reva
len
ce (
>4
0yrs
)
Conclusions
1. Changes in life style (diet & exercise( of susceptible individuals or groups is liable to increase their predisposition to DM (incidence of transformation of IGT to DM and consequently increased DM prevalence).
2. The change is more profoundly demonstrated among groups that might be originally protected by some genetically inherited characteristics.
3. Most of the parameters of the metabolic syndrome seem to be closely bound together and are prone to change under the influence of the adverse changes of life style.
Controlled metabolic parameters (% in diab. population Egypt 2003 )
- Fasting Bl. Glucose : 19.8% - P.P Bl. Glucose : 21.4% - S. Cholesterol : 56.4 % - S. Triglycerides : 50.4% - Syst. B.P. : 53.7% - Diastolic B.P. : 64.6%
Diabetes Complications (Egypt 2003) % in Diabetic population
Retinopathy : 32.3% Neuropathy : 55.5% Nephropathy : 5.0% Cardiac Dis. : 21.3% Foot ulcers : 6.8% Foot amputations : 3.0% Foot deformities : 1.0%
The cost of Diabetes
Data from Alexandria hospitals
Allocation of Direct Costs in hospital
• Medical supplies:– insulin etc.…
• Doctors
• Lab charges
• Basal cost:– Salaries, equipment, food,
water, electricity’ laundry etc.
• Control of diabetes:– Insulin, OHA, medical
supplies
• Rx complications:– Antibiotics, laser, haemo-
dialysis , surgery etc.
DIRECT COST
Out-patient Hospital care
Indirect Costs
• Loss of working hours
• Diabetes mortality
• Premature death
PRODUCTION
The cost of diabetes in Egypt
• O.P. care (per person per year)– Doctors’ charges: 35.84 L.E.– Medical supplies 30.36 L.E.– Laboratory charges 19.68 L.E.
85.88 L.E. per year
• In-patient hospital care– Average total cost for one single
admission/year, at average stay:
148.31 L.E. per year
Alexandria Hospitals (86/88)
The economic burden of direct cost of DM
• Total direct cost of diabetes in 1986: 160m• Average inflation rate (1986-90) 11.85%• Estimated total direct cost in 1990 235.2m
• Total Government expenditure on health, 1990:– National production
31.3bn– Government expenditure at 40%
12.6bn– 2.8% Gov. expenditure on health
351.8m
Cost of DM in relation to funds available
DIRECT COST
OF TREATMENT
OF DM
L.E.235.2m
AVAILABLE GOVERNMENT
EXPENDITURE ON HEALTH
L.E. 351.8m
2/3!!
National economics and Reflections on health
• Per capita income
• %Government expenditure on health
• % Household consumption
PARAMETERS
Gross National Product/Capita
02
4
68
10
12
1416
18
20
18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 19
$000s N I E S EE
0
10
20
30
40
50
60
18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 19
N I E S EE
Percentage share of government expenditure
Health DefenceEducation
%
0
10
20
30
40
50
60
70
18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 19
% N I E S EE
Percentage share of total household consumption
Medical care Total food Education
Middle East Countries - economic status
• Kuwait • Emerates• Qatar• Bahrain• Oman• Saudi Arabia• Libya• Israel
• Syria• Jordan• Tunisia• Egypt• Turkey• Yemen
• Iraq• Cyprus• Iran
HIGH ECONOMY
LOW ECONOMY
MIDDLE ECONOMY
>5,000US$ <2,000US$
Cost of out-patient ambulatory care of DM in Egypt compared with other Mediterranean countries (US$/month)
MEDICINES
Insulin Oral
SelfMonitor TOTAL
TreatCompl.
TOTALO.P.Tr.
Alex (Egypt) 2.44 1.12 2.49 6.06 2.28 8.34
29.94* 35*
Tunisia (Tunis) 12.24 2.85 3.23 6.69 4.17 10.86
Oran (Algeria) 23.14 9.87 15.45 27.54 71.08 98.62
Zagreb 23.56 2.54 15.34 24.16 7.44 31.60
Athens (Greece) 38.48 7.53 15.35 39.15 71.45 110.60
Pavia (Italy) 27.38 3.33 5.52 12.65 25.1 37.75
*including treatment by dialysis
Socio-economics - Some health and education parameters in 20 African countries
Country Per Capitaincome (US $)
Life Expectancy(Years)
AdultIlliteracy (%)
Total Cal. foodconsumption
/cap/day1. Mozambique 80 47 67 16802. Tanzania 110 48 - 22063. Ethiopia 120 48 - 17354. Somalia 120 48 76 19065. Uganda 220 65 52 21536. Nigeria 290 61 49 23127. Kenya 370 59 31 21898. Ghana 390 49 40 22409. Central Africa 390 49 62 203610. Zambia 420 50 27 201911. Sudan ……. 50 73 197412. Egypt 610 60 52 332713. Senegal 710 47 62 244014. Morocco 950 62 51 332015. Cameroon 960 57 46 220116. Congo 1010 53 43 260417. Tunisia 1440 67 35 308018. Algeria 2060 65 43 298919. Gabon 3330 53 39 224820. Libya 5637 62 36 3324MEAN (AFRICA) 1,011 54.5 49 2296MEAN (UK, USA &FRANCE)
19,127 76.6 < 5 3443
Socio-economics - Increasing total calorific intake
Years SubsaharanAfrica
North Africa &Middle East
1970 2138 2415
1975 2118 2586
1980 2120 2875
1985 2155 2984
1990 2099 3094
Distribution of costs of Hospital Treatment of Diabetic Patients ( L.E. per day ) at a Private Hospital for Middle Class Egyptian Population at the City of
Alexandria , Egypt 2001
Distribution of costs of Hospital Treatment of Diabetic Patients ( L.E. per day ) at a Private Hospital for Middle Class Egyptian Population at the City of
Alexandria , Egypt 2001
L.E. %
Cost of Medications and Medicalsupplies
99.00 55 %
Basic hospital expenses - Food - Health Care Team - All other running expenses
9.0019.8052.20
5 %11 %29 %
Average total cost per day 180 L.E. (= 40 $ ) 100 %
55% Medicine & Supp.
45% Basic( Food : 5%
H.C.Team 11%
Others: 29%)
Distribution of Hospital Cost
100%120.80%
354% 346%
0%
50%
100%
150%
200%
250%
300%
350%
400%
DM +CVD +R.F. +Diab. Foot
Hospital Treatment 2001 Cost /Day
Estimated Costs of Ambulatory (out patient) Treatment of Diabetes in Egypt at 2001
Cost Prices in USD/ year
Estimated Costs of Ambulatory (out patient) Treatment of Diabetes in Egypt at 2001
Cost Prices in USD/ year(A) Insulin ( Dose 10-80 units /d )(A) Insulin ( Dose 10-80 units /d )
Type of Insulin Cost in USD/y
Animal I U/40 *Human I U/40 **Human I U/100Human I in pen device U/100
3.6 – 29.214.6 – 116.832.8 – 262.854.7 – 438.0
(B) Oral Antidiabetic Agents (B) Oral Antidiabetic Agents
Type of oral antidiabetic Agents Daily dose Cost inUSD/y
GlibenclamideGliclazideGlimeprideMetforminRapiglinideNateglinideRosiglitazone
5 mg - 20 mg80 mg - 240 mg1 mg - 6 mg500 mg- 1500 mg
- 3 mg360 mg
4 mg
14.0- 56.027.0- 81.032.0-162.010.0- 30.0
- 235- 405- 446
* Heavily subsidized ** moderately subsidized
0 1 2 3 4 5
Hundreds
Animal u/40
Human u/40
Human u/100
Human/pen
Metformin
Glibenclam
Gliclazide
Glimeperide
Rapiglinide
Nateglinide
Rosiglitazone
Cost of O.P. Treatment (Egypt 2001) $/ y
Estimated Costs of Ambulatory (out patient) Treatment of Diabetes in Egypt at 2001
Cost Prices in USD/ year ( Cont.)
Estimated Costs of Ambulatory (out patient) Treatment of Diabetes in Egypt at 2001
Cost Prices in USD/ year ( Cont.)
( C ) Other costs at average frequencies per year
Laboratory , and other follow – up
investigations (E.C.G radiol., etc. )
Physician fees and other specialist
consultations
Total 143
USD/Year
( C ) Other costs at average frequencies per year
Laboratory , and other follow – up
investigations (E.C.G radiol., etc. )
Physician fees and other specialist
consultations
Total 143
USD/Year
76.4
66.6
76.4
66.6
The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income
Middle East Countries, based on the Cost Prices of Insulins and Oral Antidiabetic Agents (in USD per year)
The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income
Middle East Countries, based on the Cost Prices of Insulins and Oral Antidiabetic Agents (in USD per year)
Egypt Morocco Qatar SaudiArabia
Percapit. Income inUSD
1490 1180 13730 6900
Animal Insulin U/40(40 units /d)
Human Insulin U/40(40 units /d)
Human InsulinU/100 (40 units/d)
Human Insulin inDevice U/100 (40units/d)
14.6 *
55.5 **
132.9
219.0
134.3
313.9
318.3
446.7
NA
NA
258.4
-------
NA
NA
213.0
-------
Egypt Morocco Qatar SaudiArabia
Percapit. Income inUSD
1490 1180 13730 6900
Animal Insulin U/40(40 units /d)
Human Insulin U/40(40 units /d)
Human InsulinU/100 (40 units/d)
Human Insulin inDevice U/100 (40units/d)
14.6 *
55.5 **
132.9
219.0
134.3
313.9
318.3
446.7
NA
NA
258.4
-------
NA
NA
213.0
-------
* Heavily subsidized ** moderately subsidized * Heavily subsidized ** moderately subsidized
8.85%
EGYPT
1.9%
QATAR
3.1%
SAUDI ARABIA
Year Cost / percapit. Burden for Human Insulin (40 u /d)
The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income Middle East
Countries , based on the Cost Prices of Insulins and Oral Antidiabetic Agents ( in USD per year) (Cont.)
The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income Middle East
Countries , based on the Cost Prices of Insulins and Oral Antidiabetic Agents ( in USD per year) (Cont.)
Egypt Morocco Qatar Saudi Arabia
Percapit. Incomein USD
1490 1180 13730 6900
Glibenclamide (5-20 mg)
Cliclazide(80-240 mg)
Glimeperide( 1-6 mg )
Metformin(100-1500 mg)
14-56
27-81
32-162
20-30
41-164
48-144
57-292
24-36
94-376
98-294
-------
44-66
Egypt Morocco Qatar Saudi Arabia
Percapit. Incomein USD
1490 1180 13730 6900
Glibenclamide (5-20 mg)
Cliclazide(80-240 mg)
Glimeperide( 1-6 mg )
Metformin(100-1500 mg)
14-56
27-81
32-162
20-30
41-164
48-144
57-292
24-36
94-376
98-294
-------
44-66
The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income Middle East
Countries , based on the Cost Prices of Insulins and Oral Antidiabetic Agents (in USD per year) (Cont.)
The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income Middle East
Countries , based on the Cost Prices of Insulins and Oral Antidiabetic Agents (in USD per year) (Cont.)
Egypt Morocco Qatar Saudi Arabia
Percapit.Income inUSD
1490 1180 13730 6900
Rapiglinide( 3mg)
Nateglinide(360 mg )
Rosiglitazine( 4 mg )
235
405
446
------
------
------
------
------
------
243
------
584
Egypt Morocco Qatar Saudi Arabia
Percapit.Income inUSD
1490 1180 13730 6900
Rapiglinide( 3mg)
Nateglinide(360 mg )
Rosiglitazine( 4 mg )
235
405
446
------
------
------
------
------
------
243
------
584
EGYPT
29.9%
Cost Burden of Oral Treatment related to Percapitum
QATAR
4.2%
8.4%
SAUDI ARABIA
Socio-economic impact on diabetes education
1. Lower economy;– less available resources for education
2. Lack of rational plan for:– patient education– physician education– other health personnel (nurses,dieticians,foot care
etc…)– general public (awareness: food intake, obesity,
exercise, early detection etc…)
-1
Socio-economic impact on diabetes education
3. Lack of government awareness
– of cost/benefit of education
4. Maldistribution
– of available education facilities (urban/rural)
5. High illiteracy
– adversely affects diabetes education & requires
special methods
-2
Socio-economic impact on diabetes education
6. Misconceptions & ...
7. Special education programmes
– e.g for Ramadan fasting
8. Need to tailor diabetes education
– & arrangements to suit local habits, traditions &
lifestyle
-3
Alexandrie – Palais du Montazah
Thank You