world health organisation (who) study guide · © london international model united nations 2015 !...

World Health Organisation (WHO)

Study Guide

© London International Model United Nations 2015 LIMUN | Charity No. 1096197 www.limun.org.uk

Table of Contents

Welcome Letters .......................................................................................................................................... 1

Introduction to WHO .................................................................................................................................. 2 Topic A: Utilizing social media and big data to improve world health ...................................... 3

Topic B: Reducing impact of diabetes on world health by 2030 .............................................. 13


1

Welcome Letters

Honorable delegates,

I am Tassilo Vogel and I will co-‐chair the World Health

Organisation committee with Dipen. Arguably the WHO has had

the biggest impact on the world out of all UN institutions by saving

so many lives through interventions such as vaccines. The

underlying reason is in my opinion that it relies on science and

evidence based policy making. I studied pharmaceutical sciences in Munich, Germany, my home

country, and now study MSc. International Health Management in London and want to do a

doctorate to fortify scientific research on mobile health and link it to real-‐time application. I take

part in MUN to meet and be inspired by diverse international students interested in changing the

world and look forward to the great ideas which will be floating around our committee.

Honorable delegates,

My name is Dipen Patel and I be will one of the chairs for the World

Health Organisation. I am very excited to be chairing the WHO as it

involves issues on public health which are of great interest to me. I

am in my second year studying for a BSc Biochemistry at the

University of Nottingham. I was born in London to parents who are

originally from India. I hope we can have fruitful debate and come up with ingenious solutions, but

most importantly that we enjoy this experience.

We look forward to meeting you, see you at LIMUN.


2

Introduction to WHO

The World Health Organisation (WHO) is the arm of public health for the United Nations. Health is

defined by the WHO as “a state of complete physical, mental and social well-‐being and not merely

the absence of disease or infirmity.”1 The WHO was established in 1948 as a specialized UN agency

to help tackle health challenges across the world.2 It is composed out of the Secretariat, an

Executive Board consisting of 34 Members and its Member States and their workforce that is

spread across regional offices and headquartered in Geneva, Switzerland.

The WHO manages global health, addressing and coordinating research, education and policy

matters of its member countries. It supports countries with evidence based policy-‐making

strategies and continuously monitors and assesses trends in health3. To better manage resources

and align itself with the needs of an increasingly complex and rapidly changing international

environment it is in ongoing reform. Part of the reform addresses the need to be flexible as well as

to set and streamline efforts towards measurable goals4. Both topics addressed for LIMUN will try

to incorporate these elements within their approach.

We are technically holding a simulation for the World Health Assembly (WHA). The WHA is

composed of all the WHO member states and is a forum to meet, discuss and come up with

resolutions to health issues. The results of such meetings involve the creation of new policies and

recommendations to Member States and other Organisations including UN bodies and

collaborative partners to help tackle global health issues. We recommend you have a look at the

Constitution of the WHO as well as at outcomes of the annual World Health Assembly found in the

bibliography of this guide. For the sake of simplicity we will only include Member States as

committee members and be calling our committee the WHO.


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Topic A: Utilizing social media and big data to improve world health Social Media Social media can be defined as “a group of Internet-‐based applications that build on the ideological

and technological foundations of Web 2.0, and that allow the creation and exchange of user-‐

generated content. “ The last decade has seen a huge growth in the different types of applications

available that connect people and allow them to share data and present it in new attractive ways.

Another trend this has coincided with is the trend towards smartphones. People enjoy sharing

information, emotions and experiences and social media and mobile technology empowers them to

do so. This considerably increases the actuality, accessibility, breadth and depth of data available

on and fed back from social groups and if consented, individuals. One mobile app can assemble as

many as 100 million users, extract relevant and useful data and deliver services to the benefit of

various stakeholders. In fact there are already dozens of services which, although they only exist

since a decade, unite more than 50 million users in one app. The diagram below shows a large

number of such applications and the functions they allow.

Diagram 1: Social Media Networks5


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The amount of time spent on these platforms has risen and over time the data we post on these

platforms has increased hugely. When we talk about data accumulating on such mediums as the

internet we are not far from delving into the topic of big data.

Big Data

Big data is the term given to the huge amounts of data collected and the process of making sense of

that to generate useful results. The difficulty with such large amounts of data is searching what you

are finding for and making use of that information. This requires complex analysis of data that

requires a huge amount of information technology infrastructure. 6 By looking for and connecting

the right data we can find links and trends that were unknown even a decade ago. This is known as

data mining. Especially businesses are using the large amounts of data available on the internet as

well as from other inputs such as sensors, devices and machines to unlock further economic value.

By finding the right algorithms and applying them correctly a lot of problems and obstacles can be

overcome.

The United Nations and Big Data

The United Nations is involved in the Global Pulse Initiative. Developed in 2009, the UN created this

working group to tackle problems such as humanitarian aid and sustainable development. It puts

forth the idea of big data being a renewable resource of this planet and the group’s vision is “a

future in which big data is harnessed safely and responsibly as a public good” 7. It is concerned with

gathering data and collaborating with businesses that collect data in public private partnerships.

Importantly it advocates anonymization of data as to protect the privacy of individuals.

Furthermore it means to improve awareness and develop analytical tools for big data that can be

harnessed across the entire United Nations ecosystem. As discussed in the committee introduction

the UN means to improve performance indicators regarding global development. By gathering and

analyzing the right data it plans to analyze human well-‐being and trends in real time in order to

better respond to emerging crises and vulnerabilities.


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UN Pulse Research

UN Pulse research is diverse and the group is involved in several projects that collaborate with a

large range of institutions including universities, startups, companies and governments. One

example is that mobile phone data from an East-‐African country was used as a poverty indicator:

the airtime credit purchases (top-‐ups) of mobile phones made were used to estimate food security.

This research was undertaken by the UN World Food Programme and Université Catholique de

Louvain as well as Real Impact Analytics. The amount of partners shows the increasing need of

people to work together in multidisciplinary groups to tackle complex problems. Looking at the

setting also helps us see why such projects are of importance: mobility, shortage of human and

financial resources and communication can all be addressed by correctly applying big data analysis.

The internet and mobile phones allow us to study a large number of people irrespective of their

geographic location. As of now, 3 Billion people use the internet8 and the large technology

companies are investing heavily to ensure that all people are connected. Even when looking at

smartphone users we already reached 1.75 Billion users, nearly 25% of the world’s population,

exactly 1 year ago9. Out of this reason social media, one of the main activities done on smartphones

is becoming increasingly attractive for the United Nations Pulse Initiative. For example, it is

currently working with the Brazilian Ministry of Health and UN AIDS to test the efficiency of remote

monitoring and detection of HIV using social media. 10

Social Media and Health

Facebook is the most prevalent social media site. This site has 800 million daily active users with

subgroups of e.g. 200,000 people liking a health relevant subject such as “hypothyroid mums”11,12.

This outlines the potential for combining mobile applications with health, a market that is predicted

to generate USD 23 Billion in revenue by 2017.13 Facebook has been used in conjunction with

health education to improve nutrition among low-‐income women14. Also Twitter has been used to

find and analyse cancer patients’ tweets with the eventual goal to provide better personalized

care15. The most shared science article this year was a study with N=689,003 users carried out on

Facebook investigating emotional contagion by altering the Facebook newsfeed. 16,17


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Finding Collaborative Partners and Financing

Access to data and analytics is one of the challenges experienced by the United Nations.18 The

main stakeholders gathering new data of interest are telecom providers, social media and

technology companies which provide e.g. the operating systems such as Android or iOS and

Windows. A major task of Global Pulse is to find contractual agreements that benefit both parties

involved. The information analysed is sensitive and could be of value to competitors. One of the

trends playing into the cards is increasing consumer awareness and a desire for data to become

transparent and open source. There is a hope that data philanthropy will become more common

but addressing this problem will still be difficult.

One of the ways around this is working together with young businesses involved with data

analytics. By involving entrepreneurs together with the United Nations there can be a win-‐win

situation created as the startup benefits from the reputation of the UN and the UN from the

expertise and access to new ideas and tools. Health is still a market with many barriers to entry for

local as well as global entrepreneurs and thus policies have to be created that help push forward

young talent to take up the risk of starting a business also for the good of the society-‐ social

entrepreneurship.

Another potential entry route to data is via the increasing corporate social responsibility programs

rolled out by companies and partnering up with influential charity Organisations. For example,

major collaborative partners of UN Pulse include Amazon and Microsoft. Another major funding

partner of worldwide health programs is the Bill and Melinda Gates Foundation. This Organisation

has invested heavily into improving healthcare having already donated 31.6 Billion USD for

charitable causes since its inception. Its mission is to “help all people live health and productive

lives”19. Gates himself is heavily involved in using social media to advertise the concept of helping

people in the developing world and promoting entrepreneurship to help solve challenges across the

globe. The foundation has focused on collaborating with a wide variety of partners and promoted

evidence-‐based policy making and thus has recurring dialogue with the World Health Organisation.


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Global Healthcare and Big Data

One of the main goals of the World Health Organisation is eliminating diseases such as HIV,

Malaria or Tubercolosis as well as handling epidemics such as Ebola. For all diseases an

important step is knowing the geographies affected by the disease. Once this is known it

becomes easier to streamline efforts of health interventions by tackling the disease from the

right angle. Another factor is knowing the human body; here genomic analysis place a large

role. Our DNA is composed out of 4 base pairs. Computer technology is composed out of 0s and

1s. Therefore analysing DNA is not too different from analysing for instance internet sites. A

combination of biotechnology and computing power has enabled us to decode the human genome.

This makes genomic data of individuals an input of interest. Through social media and mobile

applications a lot of data can be collected about human behavior. Furthermore, more and more

countries are moving towards electronic health records. All such data can be analysed by big

data analytics to gain insights on health and improve outcomes as well as save costs through

smarter decisions. This is higlighted in the diagram below. If these inputs are managed and

processed adequately great value can be created for public health and therefore the World

Health Organisation is interested in collaborating with UN Pulse and other data analytics

initiatives on such matters.

Diagram 2: Overall Goals of Big Data Analytics in Healthcare20


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Responsible Handling of Data

A key issue is involving the right stakeholders to ensure that the data collected is handled

responsibly. Health data is arguably one of the most vulnerable types of data available and so it has

to be handled with great care. Healthcare professionals such as doctors need to be involved in such

large scale operations to ensure that data is handled appropriately. Public health bodies such as

national and international organisations have to discuss issues such as regulation, safety and

ownership of data. There are multiple levels concerning this issue. First and foremost it includes

everyone’s individual rights as a human being and not being discriminated because of data

available on one’s health. The consent given from individual’s requiring healthcare data has to be

made very clear and sharing data should be regulated and handled with the utmost sensitivity. Data

security is another issue. Institutions of all kind have to ensure that their hardware and software

including encryption techniques are updated in such a way as to minimize security breaches. Data

has to be anonymized and stored in different locations to ensure that theft, whether physical or

not, is inefficient. Furthermore data should not be stored for a definite amount of time. The United

Nations has a role to play in educating its member states on these matters and ensuring that

governments are aware of their responsibilities regarding health informatics.

Piecing it all Together

The above illustrate the potentials and challenges of utilizing big data and social media to make

studies on small as well as large groups of people with an impacting and useful outcome for the

individual’s health and well-‐being. The key lies in combining these approaches to ensure progress is

made in improving public health -‐ that is to use mobile services and public-‐private partnerships to

gather, analyse and process information on crowd involvement in order to address regional,

national as well as global health challenges. So far there is no resolution on the topic that puts

together the individual pieces and collaborations outlined above. The World Health Organisation

can help improve awareness and educate people by streamlining its policies to get projects started

in individual countries. It also has a role to play as an educator to help ensure projects are

sustainable and take into account the needs of its member states and people by focusing on

regulations and minimizing fears of privacy and safety. Currently there are societal movements

towards empowering individuals as well as data transparency. If these are matched with patient

needs, new doors in public health will be opened.


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Questions to be considered: Which social media applications does your country use? Are there any barriers to using them?

What is the mobile phone penetrance, smartphone penetrance, internet user penetrance in your

country?

Which providers/companies/NGOs/governments/partnerships is your country collaborating with to

improve such penetration?

What research and which projects and companies have been working on mobile health in your

country or region?

What experiences does your country have with public-‐private partnerships to work on healthcare?

What are the data privacy rules and regulations of your country or region you are operating in,

especially with respect to healthcare? This can be seen quite easily if you look at news and

government views of your country regarding facebook/google/twitter.

What incentives are there for entrepreneurs to start a healthcare company or mobile company in

your country and what is missing or what makes the incentives good and useful for other

countries?

What applications can you think of that could use an app or data from an app to improve

healthcare? There are two options here: using data already generated by users or getting users to

generate further relevant data. Brainstorm about how one could use the data and services available

from e.g. facebook, google, amazon, linkedin, quora, twitter, snapchat, whatsapp, pinterest,

Instagram to improve healthcare.

We especially encourage you to take a look at the UN Pulse Initiative as well as the reports

prepared by the United Nations focusing on the Data Revolution to aid with your understanding of

the concepts. A sample WHO resolution on a healthcare topic – Hepatitis-‐ can also be found in the

bibliography below.


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1 (WHO 1948) 2 (WHO 2014) 3 (WHO 2015) 4 (WHO 2014) 5 (Cavazza 2013) 6(Economist 2010) 7 United Nations 2015) 8( Internetlivestats 2015) 9 (eMarketer 2014) 10 (United Nations 2015) 11 (Facebook 2014) 12 (Facebook 2015) 13 (PWC 2012) 14 (Lohse B 2013) 15 (Tsuya A, et. al. 2014) 16 (D. I. Kramera, et al 2014) 17 (Chris Parr -‐ TES Global LTD, 2014) 18 (New York Times, 2013) 19 (Gates Foundation, 2015) 20 (SIAM 2013)


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Bibliography-‐ Topic A

Adam D. I. Kramera, Jamie E. Guillory, and Jeffrey T. Hancock, (2014) Experimental evidence of massive-‐scale emotional contagion through social networks. Proceedings of the National Academy of Sciences 111 (24) 8788–8790, doi: 10.1073/pnas.1320040111

Barbara Lohse, (January–February 2013) Facebook Is an Effective Strategy to Recruit Low-‐income Women to Online Nutrition Education. Journal of Nutrition Education and Behavior, 45 (1), 69-‐76

Bill and Melinda Gates Foundation (2014), Foundation Fact Sheet, available on http://www.gatesfoundation.org/Who-‐We-‐Are/General-‐Information/Foundation-‐Factsheet accessed 9.1.2015

Cavazza Frederic (2013), Social Media Landscape, available on http://www.fredcavazza.net/2013/04/17/social-‐media-‐landscape-‐2013/ accessed on 9.1.2015

Chris Parr for Times Higher Education-‐ TES Global LTD, (2014) The 10 most popular academic papers of 2014 Available from http://www.timeshighereducation.co.uk/news/the-‐10-‐most-‐popular-‐academic-‐papers-‐of-‐2014/2017470.article accessed on 05.01.2014

eMarketer (2014), Smartphone Users Worldwide Will Total 1.75 Billion in 2014, available from http://www.emarketer.com/Article/Smartphone-‐Users-‐Worldwide-‐Will-‐Total-‐175-‐Billion-‐2014/1010536 accessed on 9.1.2015

Facebook, (2014) Quarterly Earnings Slides Q3 2014, Available from http://files.shareholder.com/downloads/AMDA-‐NJ5DZ/3793703010x0x789303/06DECC7B-‐0588-‐4A52-‐A8DD-‐3A591AB02395/FBQ314EarningsSlides20141027.pdf, accessed on 06.01.2015

Facebook, (2015) Page-‐ Hypothyroid Mom, Available from https://www.facebook.com/HypothyroidMom?fref=ts, accessed on 06.01.2015

Global Pulse (2014), Using mobile phone data and airtime credit purchases to estimate food security, available from http://www.unglobalpulse.org/mobile-‐CDRs-‐food-‐security accessed 9.1.2015

Global Pulse (2014), Social Media for Remote Monitoring and Detection of HIV in Brazil, available from http://www.unglobalpulse.org/social-‐media-‐HIV accessed on 9.1.2015

Independent Expert Advisory Group on a Data Revolution for Sustainable Development (2014), A World that Counts-‐ mobilising the data revolution for sustainable development, Available from http://www.undatarevolution.org/wp-‐content/uploads/2014/12/A-‐World-‐That-‐Counts2.pdf accessed on 9.1.2015 Internet Live Stats (2015), Internet Users, available from http://www.internetlivestats.com/internet-‐

users/ accessed on 9.1.2015

Kaplan Andreas M., Haenlein Michael (2010). Users of the world, unite! The challenges and opportunities of social media. Business Horizons 53 (1). p. 61. doi:10.1016/j.bushor.2009.09.003.


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World Health Organisation (1946), Preamble to the Constitution of the World Health Organisation as adopted by the International Health Conference, New York, 19-‐22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organisation, no. 2, p. 100) and entered into force on 7 April 1948.

PricewaterhouseCoopers Private Limited, (2012) Touching lives through mobile health-‐ Assessment of the global market opportunity, Available from http://www.pwc.in/assets/pdfs/telecom/gsma-‐pwc_mhealth_report.pdf, accessed on 04.01.2014

Society for Industrial and Applied Mathematics (2013), Big Data Analytics for Healthcare available from http://www.siam.org/meetings/sdm13/sun.pdf accessed 9.1.2015

The New York Times (2013), Searching Big Data for ‘Digital Smoke Signals’ available on http://www.nytimes.com/2013/08/08/technology/development-‐groups-‐tap-‐big-‐data-‐to-‐direct-‐humanitarian-‐aid.html?pagewanted=2&_r=1 accessed 9.1.2015

Tsuya A, Sugawara Y, Tanaka A, et al. (2014) Do cancer patients tweet? Examining the twitter use of cancer patients in Japan, J Med Internet Res. 16(5):e137. 10.2196/jmir.3298

United Nations (2013), UN Pulse Annual Report, available from http://www.unglobalpulse.org/2013-‐Annual-‐Report accessed 9.1.2015

United Nations (2014), About the Independent Expert Advisory Group, available from Grouphttp://www.undatarevolution.org/about-‐ieag/, accessed 9.1.2015

United Nations Global Pulse, About, available from http://www.unglobalpulse.org/about-‐new accessed 9.1.2015

World Health Assembly Resolution 67.6 (24 May 2014) Hepatitis, available from http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R6-‐en.pdf

World Health Organisation (2014), Change@WHO. Available on http://www.who.int/about/who_reform/change_at_who/issue5/Change_at_WHO_Newsletter_May_2014_en.pdf?ua=1 accessed on 9.1.2015

World Health Organisation (2015), About WHO. Available on: http://www.who.int/about/en/ Accessed on 8.1.2015

World Health Organisation, (2005) Constitution of the World Health Organisation, available on http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-‐en.pdf?ua=1&ua=1 accessed on 8.1.2015


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Topic B: Reducing impact of diabetes on world health by 2030

Glucose is a key molecule to life. It provides vast amounts of energy our bodies need to

survive and perform everyday actions. We get glucose by breaking down the food we eat, and

sometimes when we eat a bit more food than we need, our bodies face an excess of energy.

Usually glucose would be used as a short term source of energy, however as our bodies won’t

always use all the energy it decides to store the glucose in the form of tissue fats, this form of

energy can allow glucose to be stored in the body for long periods of time. High glucose levels in

blood is toxic to the body and glucose needs to be kept at a constant level, if its lower than this

level, the body uses the stored energy to increase glucose levels back to the norm (Table 1 shows

the criteria normal and elevated levels of glucose). Insulin is key as it tells the body to store the

excess glucose as fats. Insulin fails at its job when it cannot maintain blood glucose levels, glucose

levels will increase, eventually resulting in diabetes. Figure 1 shows how insulin works.

Figure 1: Mechanism of action for insulin. Insulin will bind to the insulin receptor which opens the glucose channel allowing glucose to enter the cell


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“Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or

when the body cannot effectively use the insulin it produces. This leads to an increased

concentration of glucose in the blood (hyperglycaemia).” – WHO definition of diabetes21

From 1500 BCE, people have been suffering

from a disease which has been described as ‘too

great emptying of the urine’. It was until 2000

years later that Indian physicians were able to

distinguish between the two types of diabetes,

type 1 was associated with the youth while the

latter was associated with obesity, type 2 diabetes

has the greatest impact on the world. Close to 350

million23 people worldwide are thought to have

diabetes and this number is only going to increase,

with the WHO estimating diabetes to be 7th leading

cause of death by 2030, 3.8 million people die from

diabetes every year, this is comparable to HIV/AIDS

in its reach. For some populations there is a

genetic factor that influences susceptibility of

diabetes, these factors are difficult to avoid.

Type 1 diabetes is a form of diabetes where the immune system destroys the beta cells in

the pancreas which produce the insulin necessary for the breakdown of glucose, basically the body

cannot produce enough insulin. Blood and urine glucose levels increase as a result. Symptoms

include more frequent urination, increased thirst, increased hunger and weight loss. This type of

diabetes accounts for 5%24 of all the cases of diabetes and is most commonly diagnosed amongst

the youth population, the highest rates for type 1 diabetes is found in the United States and

Northern Europe. The usually diagnosis is when patients have diabetic ketoacidosis (dry skin, rapid

deep breathing, drowsiness, abdominal pain, vomiting and other symptoms).

Type 2 diabetes is a form of diabetes whereby cells develop a resistance to insulin.

Symptoms include increased thirst, frequent urination, and constant hunger amongst others. 90%

Condition 2 hour glucose Fasting

glucose

Unit mmol/l(mg/dl) mmol/l(mg/dl)

Normal <7.8 (<140) <6.1 (<110)

Impaired

fasting

glycaemia

<7.8 (<140) ≥ 6.1(≥110) &

<7.0(<126)

Impaired

glucose

tolerance

≥7.8 (≥140) <7.0 (<126)

Diabetes

mellitus ≥11.1 (≥200) ≥7.0 (≥126)

Table 1: The various levels of blood glucose. 2 hour glucose is

usually measured after eating a meal22


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of all cases of diabetes involve this type, a lack of insulin production is common as the disease

progresses. Lifestyle factors greatly influence those who are affected, with the primary cause being

obesity. Key WHO recommendations include; having a healthy diet, regular exercise, maintaining

normal body weight and avoiding tobacco which are factors that can prevent or delay the onset of

type 2 diabetes. Although a manageable disease with plenty of treatments available, 80% of deaths

come from low and middle income countries which show a key component to its control is from

access to healthcare.

Gestational diabetes is a temporary form of diabetes which affect pregnant women as they

develop high blood sugar levels. Various pregnancy-‐related factors cause a failure in the ability of

insulin receptors to act. This affects up to 10% of pregnancies, and is an easily manageable disease

with a controlled diet being one of the first steps to tackle this. Diagnosis comes from primarily

from pre-‐natal screening and countries with good health infrastructure can detect this disease

before it is able to properly harm expectant mothers. Babies who were born to mothers with

gestational diabetes have a higher lifetime risk of developing obesity and type 2 diabetes.

Impaired Glucose tolerance is a precursor to type 2 diabetes. This is a condition whereby

blood glucose levels are higher than the norm but below the level required for diagnosis of

diabetes, a conservative estimate is that 50 million people have this condition as many cases are

not diagnosed. These people are targets to prevent the onset of diabetes, and recommendations to

this group include healthier eating and greater exercise, such is the effect of the recommendation

that type 2 diabetes in many cases have been prevented.

Economic costs of Diabetes

Diabetes in the modern world is a manageable disease, and for many countries, people with

diabetes remain part of the workforce until retirement. Thus this disease does not fully withdraw a

person’s economic activity, however there are costs to the economy. A systematic review carried

out suggests that two thirds of the overall costs of diabetes were a direct result of treatment, whilst

one third was indirect costs which among other factors include losses in productivity for those who

work despite having diabetes25. Between 2005 and 2014, WHO estimates suggest that more than

$1trillion was lost in national income as a result of diabetes’ treatments and economic losses, as

the problems surrounding diabetes worsen that figure is expected to triple by 2030, and these are


16

highly conservative estimates26. Healthcare providers will have to face the increased costs of

treating more diabetic patients and treatment of their complications. It is the developing countries

that will have to face the biggest share of the costs due to the increasing diabetic populations, this

coupled with the fact that spending on diabetes treatment and preventative measures in

developing countries is low means that there will be significant costs which may spiral out of

control.

For all employers an increasingly diabetic work force is a worry due to the productivity

losses, patients may need more temporary leave of the workplace to manage the disease, thus

employers need to play a part in improving the conditions of the workplace. Some companies

participate in workplace wellness programmes27, where the aim is to get employees more active

and aware of their health. Some initiatives include clinical screening (blood pressure, cholesterol)

and access to corporate membership rates at fitness centres. Having access to these programmes

allow for employees to lead healthier lifestyles and this can have a further impact on society as

families feel of the employees follow the lead in being healthier. Although these employer-‐led

initiatives are costly in the short term, it is generally seen to save money and potentially increase

profits in the long term

Complications that arise from Diabetes

Further complications

can arise later on in life as a

result of diabetes. Diabetics

need to get examinations on

their eyes once a year as they

are at high risk of getting

diabetic retinopathy. Figure 228

shows that when there is an

increase in glucose levels, the

percent of people with retinopathy increases.

Typically those that are in the 8th decile and above would be diabetic. Having poor eyesight has

more knock-‐on consequences as it can impair driving ability which makes that person less mobile

Figure 2: Prevalence of retinopathy by Decile of fasting glucose


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and have a negative impact on the persons’ wellbeing. The graph is a significant for a greater truth,

whilst spending on research of non-‐communicable diseases such as diabetes is really low, there are

greater costs than previously thought, spending also needs to be directed towards complications

that can arise from diabetes.

Other such complications that need to addressed include kidney disease of which diabetics

have an increased risk29. Diabetes is a leading cause of chronic kidney disease, and damage to

kidneys can develop which lead to their efficiency reducing or complete failure. This increases the

strain on kidney transplant waiting lists, there is already a shortage of organ donors and the further

projected increase in diabetes is likely to lead to a greater strain on kidney transplant waiting lists.

As with retinopathy, these complications can be managed, a combination of regular checkups

coupled with maintaining normal blood glucose and pressure can reduce the risk of these

complications arising.

Further costs of diabetes complications come from cardiovascular disease30. This is the most

common cause of death and disability amongst people who have diabetes. Cardiovascular disease

is one of the leading causes of death worldwide, and diabetics can suffer from heart attacks to

strokes. When these complications arise it further puts a strain on public resources as well as the

individual, the individual would be away from work for long periods of time and it would take

months before they are economically active again, for employers this means having to find a

temporary replacement which can be difficult if a particular job has a specified set of skills, finally

for health services it means having to care and rehabilitate a patient for a long period of time, the

opportunity cost lies in the fact that other patients can be treated, and strokes in particular occupy

a lot of resources.

Blood pressure control can be particularly useful as a prevention method for all vascular

diseases, ACE inhibitors and diuretics come in the form of generic drugs and can be very cheap for

developing countries where blood pressure control is sub standard, improving access to these

drugs can bring the greatest savings to developing nations.

Similar problems arise in particular with nerve damage where the extremeties are at risk, if

these problems escalate it can potentially lead to foot amputations. Risk of amputation amongst

diabetics is 25 times31 greater than those without diabetes, large amounts of care is needed if

amputations take place, regular foot care can mean a reduced risk of amputation.


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Health expenditure on Diabetes

In countries with a lower income, national health infrastructure is usually not as advanced,

and unlike the developed world where most governments have some form of provision of national

healthcare, it is up to the individual to bear a vast amount of costs to deal with diabetes. Total

expenditure of diabetes amongst the developing world is 20%; these are the countries that have

the most cases of diabetes and are not spending enough to treat it. For individuals in countries like

India they need to spend on average 25% of their income on private care for diabetes, this figure

increases for central and southern America where an average of 50% of income is spent on

diabetes care32. Despite individuals spending a high proportion of their income on diabetes care,

health outcomes are significantly lacking when compared to the developed world where out of

pocket expenses are minimal. Families will face increased economic stress as they cannot afford to

purchase other goods, such is the situation that many families have to forgo education for their

children due to high out of pocket expenses. For the many in the developed world, the relative cost

of care would seem a lot less, people in the developing world cannot afford the cheap and generic

drugs that are readily available, these drugs can prevent renal failure, heart attacks, strokes and

Figure 3: Mean diabetes-‐related health expenditure per person with diabetes (20-‐79 years of age), data from 2013


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amputations, yet the individual does not have the small amount of money required to purchase

these drugs.

Spending in USD is highlighted in figure 333, a huge disparity in spending between developed

and developing countries is seen. In India, less than $100 is spent per person, and this figure

reaches $400 per person in China, regardless of rapid economic growth in these countries,

resources for diabetics is vastly lacking. The disparity is further highlighted when in Burundi only $6

is spent per person nationally compared to USA where this figure exceeds $10,000 per person. In

lower income countries, children with diabetes may have to sacrifice their education to get funds

for their or a relatives’ treatment. This has an adverse effect on the child’s future outcomes, they

won’t be able to earn a higher income

later on in life due to a lack of

education, which means they stay in

the poverty trap. As their offspring are

more susceptible to diabetes then the

process continues, it becomes difficult

to break this cycle.

By 2025, 80% of all cases will

come low/middle income countries

which shows that this is not a disease for the rich. Diabetes does not discriminate on gender and

affects men and women equally. The older a person gets, the greater the expenditure on diabetes

later on in life will be. As highlighted in figure 434, spending is highest in the age range of 60-‐69.

Many developing countries have large youth populations, and as economies grow, the demand and

availability for fast food will increase, this will increase obesity rates, and as the youth population

get older, more spending will be needed as their dependencies on healthcare increase.

Problems with diagnosis

IDF estimates suggest that half of all people with diabetes are undiagnosed, they are totally

unaware they have a disease. There are great disparities between each region, but no country has

perfected the diagnosis of diabetes, amongst developed countries up to 30% are undiagnosed, this

number increases vastly when taking into account developing countries. Undiagnosed diabetes

Figure 4: Health expenditure due to diabetes by age in $


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does not discriminate on income, many people with higher incomes are still undiagnosed, and a

fact still true considering the greater amount of money spent on diabetes by high income countries,

a truly global solution needs to be reached to tackle this problem. The IDF has created an

informative poster which can be accessed at this link: http://www.idf.org/sites/default/files/Atlas-‐

poster-‐2014_EN.pdf. The poster breaks down by region the total cases of diabetes and the amount

which are undiagnosed, the western pacific region, Asian and African regions have rates of 50%

undiagnosed. The up to date poster provides a country breakdown of diabetes related statistics on

the second page. People can go several years without knowing they have diabetes, the symptoms

may not show up but glucose levels will silently increase, and sometimes when diagnosis is too late

some complications such as heart disease may arise, this is problematic as the people who gain

these complications could have otherwise prevented them. People can very easily be diagnosed

with diabetes, simple ‘tick tests’ which list risk factors are readily available, this can be a cost-‐

effective option for diagnosis, but is not definitive as it will only identify risks.

Depression

People with diabetes have an increased susceptibility to depression35, although there is not

much evidence to support the direct link between glycaemic control and depression, many studies

have outlined the increased risks of depression with those who have diabetes. Type 1 and type 2

diabetes have rates of depression two and three times higher respectively when compared to those

without diabetes, whilst women in general are more likely to experience depression with and

without diabetes. The diabetic youth population is also more susceptible to developing depression.

A number of social factors come into play, such as the constant reminders for taking medication,

having to monitor more aspects of their life, having to restrain from certain social activities due to

the detrimental effect on their health. A greater argument about the provision of mental health

services arises when dealing with issues such as depression, these services are heavily underfunded

and understaffed. Solutions need to involve greater doctor patient contact and better pastoral care

among other things. The fact that diabetes is increasing amongst children is worrying. In Japan,

prevalence of diabetes among high school children has doubled, promoting healthier lifestyle

earlier such as better diets and more exercise can help prevention.


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Obesity

Another important link with diabetes is the increasing rates of obesity worldwide, a side

effect due in part to countries developing which result in incomes rising, improving access to fast

and unhealthy food, and a combination of time constraints preventing people from cooking

healthily and poor education surrounding healthy eating all contribute to the obesity rise. Obesity is

an increasingly global problem, as the youth populations become more inactive and eat more

unhealthy foods every country will have to face this issue. In England, 90% of adults (16-‐54 years)

with type 2 diabetes are classed as overweight or obese, and those who are obese have a

prevalence rate of diabetes which is five times greater than those with a healthy weight36. A report

by public health England made reference to an increased risk of type 2 diabetes for those with

higher obese BMI, when compared to those in the lower obese BMI bands, as there is an increasing

trend of severe obesity, the strain on public services will increase as a result and more people will

develop type 2 diabetes.

A controversial treatment that could be used to buck this trend is gastric band surgery37. In

the early stages of development in terms of its effect on diabetes, it has proven to be a very

effective weight loss method, this highly interventionist approach has in the past only been used on

patients as a last resort, however a consultation by NICE suggests that opening this form of surgery

to newly diagnosed diabetics with a BMI of 30 could save billions in the long term. Considering 10%

of the NHS budget is spent on dealing with diabetes, the savings implications could be huge. If

further trials prove this method of intervention is viable, hundreds of thousands of people in the UK

could be eligible. From a different perspective, some people would rather avoid spending

thousands of pounds, and rather the individual put up most of the costs, this ideological debate

about how national health organisations should allocate funds needs to be had. Costly procedures

like these can only be done on large scale in countries of high income, they are very limited for low

income countries.

Access and administration of Insulin

First being developed and used in 1922, insulin in many ways has been a success story,

where in so many diseases (Ebola) there is little to no treatment, insulin has had the ability to be

mass produced. Many types of insulin are available on the market and due to the huge demand


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there is opportunity for profit, due to this factor there is continued research and development into

insulin, and prices are being pushed downwards, compared to other treatments insulin is

reasonably price. Having cost effective treatments has the ability to save money in the long run, the

impact of these savings can be best felt in lower income countries.

Many countries have strong protectionist policies and thus tax imports, amongst the

imports being taxed include insulin, which drive up the prices in the countries and make them

unaffordable for individuals. Zambia has a programme for insulin management, diabetics in Zambia

who receive insulin can live an average of 11 years longer, and this is compared to Mali and

Mozambique where a person can die within a year. These countries have broadly similar economic

and social outlooks, but the insulin programme offers vastly differing health outcomes.

Improving access to insulin is important, but problems lie in the administration, diabetics

need to monitor their blood glucose levels, these pieces of equipment have been lowering in prices

in recent years but are out of the access of many patients. Monitoring glucose levels is key to

insulin self-‐administration, the individual needs to make sure the correct amount of insulin is

inserted into the body otherwise further complications (hypoglycaemia or hyperglycaemia) can

arise. Insulin is administered on a sliding scale depending on blood glucose levels and the timings

need to be monitored as well for effective treatment. Other methods of insulin administration such

as nasal inhalation are being developed but it seems for the next few years progress on

administration will remain stagnant.

Negotiating lower drug prices

Higher income countries have the means to sustain drug payments, however lower income

countries do not have as greater access to these drugs. Many European countries such as Spain and

the UK employ powerful negotiating tactics which reduce the price of drugs, if these collective

bargaining tactics can be used with lower-‐income countries it could potentially lead to drug prices

which are lower than market rate. Many of these countries have poor health infrastructure and do

not have the means to negotiate on a national level for these essential drugs, and such negotiations

could only be possible if lower income countries could afford the payments and could establish a

base to negotiate.


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Cost-‐effectiveness study

The cost-‐effectiveness of preventative treatments was assessed in the Indian Diabetes

Prevention Programme. The subjects are those who have impaired glucose tolerance, and the

effectiveness of lifestyle modification and metformin supplements were tested. It was concluded

that these treatments were cost-‐effective. The cost of administering lifestyle modifications and

metformin was $270 over a three year period, the cost effectiveness from the prevention of a case

of diabetes was $1,35938. As the period was three years, this study was short term and more

studies would be need to assess the long-‐term cost-‐effectiveness.

Changes to lifestyle

Lifestyle modification include maintaining good nutrition which includes having a diet

tailored towards diabetics, generally recommendations suggest that the diet should be high in

soluble dietary fibre, low in saturated fats and low in sugar. Each institution has differing

recommendations, and there is no universal set of recommendations which can provide the ideal

example of the ‘perfect’ diabetic diet, harmonising these guidelines can help individuals with their

dietary choices. It’s clear that a good diet is necessary, but there is no clear definition of what is a

good diet, each country has its own cuisine so diets vary. A debate needs to be had on what the

guidelines should be, whether they should include what a diabetic diet consists of, or more

specifically amounts of carbohydrates, fats and sugars a diabetic should consume. Sometimes

diabetics over correct and get cases of hypoglycaemia (low blood sugar), if this happens quick

treatment needs to be administered and the treatment is simple as consuming a sugary drink.

Diabetes UK has said that some people would stand to gain by moving towards a vegan diet as this

would eliminate many saturated fats, and contain high amounts of fibre, as with diets it does not

have much evidence to support such as big lifestyle change, measured need to address the deficit

in evidence surround a healthy diabetic diet.

Other lifestyle modifications which can be included could be taking stairs instead of

escalators, walking or cycling for short distances, these are very manageable changes and cost next

to nothing to implement. The UK’s NHS recommends two and a half hours of moderate exercise

every week39, this becomes an easier goal to achieve when people realise that mundane activities

such as mowing the lawn count as exercise, however the other goal which includes doing vigorous


24

exercise such as playing sports two more times a week is a lot more difficult to pursue due to time

constraints. This information can be conveyed via educational programmes, but it is more

harrowing to know that 80% of all type 2 diabetes is preventable and changes to lifestyle can

contribute to this prevention.

Underfunding of research towards cures

Although a lot of money is spent on treatments, a greater focus is needed on cures, diabetes

is a disease which can be eliminated but for the most part of its history focus has been on

management. A problem comes from a lack of funding, overall of all official overseas development

aid only a meagre $2.9 million went to fund all non-‐communicable diseases (the source of this

money is from the 0.7% GDP commitments to developmental aid from many developed nations),

and on average only 2.5% of loans made for health purposes from the world bank went towards

chronic diseases, these figures appeal to a greater truth on the huge underfunding of diabetes, the

world bank recognises the costly problems from diabetes but the hypocrisy lies in the amount of

loans made to treat all chronic diseases. Less than 20% of the global spend on diabetes is spent in

low income countries where 80% of diabetics live, with all things considered a small amount of

money will go a long way for these countries. Potential avenues for cure include regenerating

pancreatic tissue to produce insulin, this is controversial for many people because it includes the

use of embryonic stem cells, stem cell laws around the world are restrictive, and the efficacy of

these laws need to be justified if they are preventing future cures.

Health expenditure

The culmination of all the costs, and consequences of diabetes leads to the greater

argument over the provision of health services worldwide. Most OECD countries have some form of

provision of universal healthcare, where by services are easily accessible and to a high standard.

Figure 540 shows the expenditure of healthcare for each country as a percent of GDP, the trend

seems to be that developing countries have slightly higher expenditure, thus an obvious

recommendation would be for lower income countries to commit to a higher GDP spend on

healthcare. The greater truth for many low income countries is the health infrastructure is not

developed to the extent needed to cope with the basic needs of the population, and they have a


25

huge reliance on charities. Many of these countries need to develop a national strategy to tackle

various diseases and using their limited funds to follow this strategy. If maternal care poor, it

becomes difficult to manage gestational diabetes, and mothers will experience more complications

as a result. In countries like the UK a general practitioner system is used, most countries do not

have the means to do this due to a shortage of doctors, short term solutions already implemented

include allowing doctors to offer care via telephone, this allows doctors to contact areas which are

rural and hard to reach, it’s a more cost effective option than the GP system. However it does not

address the long term shortage of medical staff and specialist in areas such as diabetes, greater

training and education programmes are needed to expand the pool of doctors and nurses

worldwide. Only with national health infrastructure can diseases like diabetes effectively be

managed and its impact be reduced.

Figure 5: Map of each countries health expenditure as a % of GDP


26

As the millennium development goals expire this year, a lot has been done to try and

achieve those goals, it may be wise to create post-‐2015 commitments to reduce the impact of

diabetes. Many predictions have diabetes and its consequences worsening by 2030, much needs to

be done to negate the impact. Figure 641 shows a list of targets related to diabetes agreed upon by

the NCD Alliance, these are some of the targets the WHO needs to consider.

WHO and the International Diabetes Federation

The WHO has an active working relationship with the International Diabetes Federation (IDF); they

exchange ideas and author joint publications. The IDF specialises in the treatment, prevention,

cure, and raising awareness of diabetes, whilst the WHO’s main objective is to advise on all health

related matters. WHO cannot dictate what the IDF does as it is separate organisation and resolution

writing must reflect this, it can advise and suggest roles for the IDF.

Figure 6: Set of targets developed by NCD Alliance


27

The IDF is a global alliance of national diabetes associations from 170 countries and

territories. They participate in multiple campaigns to ‘promote diabetes care, prevention and a cure

worldwide’42. The IDF and WHO have an official relationship whereby they can exchange advice,

and dual author publications. As the IDF is a specialised body in diabetes, it is better able to provide

health care advice and evidence to the WHO, they can use this advice and liaise with health

ministers on creating effective health care policies.

Their main UN-‐related achievement to date is the establishment of ‘World Diabetes Day’

which is their primary awareness campaign. More direct examples of their work include the ‘Life for

a child programme’ which helps 12,000 children in developing countries access diabetes care.

The WHO deals with diabetes under the broader umbrella of the ‘Chronic diseases and health

promotion’ department. The department has objectives which advocate for health promotion,

chronic disease prevention, and promoting healthcare amongst the poor and disadvantaged

population. Although their advocacy for chronic diseases is strong, they provide practical

information about the risk factors which is available for all. This is done by the WHO Global

InfoBase. The WHO Diabetes Programme seeks to prevent diabetes where possible, a key core

function is to develop standards and norms for the diagnosis and treatment of diabetes for the

international community. The WHO carries out population-‐based studies which provide countries

with key statistics to help develop their health policies.

UN resolutions

In May of 1989, the Forty-‐second World Health Assembly recognised diabetes as a ‘chronic,

debilitating and costly disease’ which presented a significant burden on public health services, and

recognised how the problem was growing amongst developing countries 43 . The main aim

surrounding this resolution was to detail the problems of diabetes by gathering statistics, and to

invite countries to share information on dealing with diabetes. Clause 2.2 of this resolution seemed

to have the most impact by fostering ‘relations with the International Diabetes Federation and

other similar bodies’ as the WHO and IDF have collaborated extensively over multiple reports and

campaigns on diabetes. Further examples of this collaboration come from the resolution passed by

the general assembly on December 2006 which established ‘World Diabetes Day’ as a United


28

Nations Day observed on the 14th November44. A joint campaign by the WHO and IDF which lead to

this day giving diabetes a greater awareness, and this being the first resolution by the general

assembly to recognise the issue of diabetes and the need to tackle it.

These resolutions have achieved the goal of getting diabetes recognised on the world stage,

however they are far beyond what is needed to truly tackle this disease. More specific solutions are

needed to address the ever growing problems resulting from diabetes, and stronger national

commitments are required, by 2030, these problems will have ballooned, and a post MDG

commitment to reduce diabetes needs to be considered to reduce the impact of diabetes on world

health.

Country questions to be considered

We ask you to come prepared regarding healthcare and the diabetes situation of your country in

comparison to other countries. This would encompass finding out about e.g.:

• Healthcare expenditure + Diabetes statistics

• Healthcare system and diabetes management; is the system Public/private; how is it

funded? How and why is diabetes care underfunded and what is being done against that?

Are there any policy papers of my country or regional organisation (EU, ECOWAS, etc.?)

• Which international partners are we collaborating with? E.g. World Bank, IDF, other

countries, development organisations, pharmaceutical companies?

• Are there any national organisations aiming to improve diabetes care? How can their

knowledge be used to help other countries? What scientific know-‐how do we have or need

from others?

• Accessibility-‐ physical as well as financial-‐ of diabetes treatments? What is the

socioeconomic situation of my country?

• Is mobile health being used in conjunction with diabetes care? Are there incentives for

startups in healthcare in your country? (mobile healthcare in conjunction with diabetes is

becoming an important topic as smartphone penetration is high across the entire world)

• What stakeholders exist in my country? What is my country’s relationship to other

countries, towards the pharmaceutical industry, patents or development aid programmes?


29

Is my country a net giver or net receiver? Are there any resolution outcomes which would

especially benefit or harm us?

• How are trade tariffs and trade affecting my country and prices of diabetes treatment? E.g.

are pharmaceuticals mainly exported or imported into my country? Effect of World Trade

Organisation and patenting.

• With which countries does my situation compare/differ and how will that affect my

country’s position in debate?

• How do we make a resolution that leads to SMART goals being developed to help tackle

diabetes by 2030 i.e. goals that are specific, measurable, accepted, realistic and timely?

We encourage you to research in the resources detailed in the bibliography as well as for instance

the WHO, the OECD, the World Bank, the Gates Foundation, the pubmed library, your country’s

ministry of health site or ask on quora.com etc.


30

21 (World health organisation n.d.) 22 (World health organisation 2006) 23 (Danaei G 2011) 24 (American Diabetes Association n.d.) 25 (Charmaine S. Ng 2014) 26 (International Diabetes Federation n.d.) 27 (Marquez 2013) 28 (World health organisation 2006) 29 (Nam Han Cho 2013) 30 (Nam Han Cho 2013) 31 (International Working Group on the Diabetic Foot 1999) 32 (International Diabetes Federation n.d.) 33 (Nam Han Cho 2013) 34 (Nam Han Cho 2013) 35 (Tapash Roy 2012) 36 (Public Health England 2014) 37 (Boseley 2014) 38 (Ramachandran 2007) 39 (National health service 2013) 40 (World development indicators n.d.) 41 (Nam Han Cho 2013) 42 (International Diabetes Federation n.d.) 43 (World Health Assembly 1989) 44 (General Assembly 2006) Bibliography-‐ Topic B

American Diabetes Association. n.d. Type 1 Diabetes. Accessed January 1, 2015. http://www.diabetes.org/diabetes-‐basics/type-‐1/.

Boseley, Sarah. 2014. NHS anti-‐obesity plans could lead to sharp rise in gastric band surgery. http://www.theguardian.com/society/2014/jul/11/nhs-‐anti-‐obesity-‐gastric-‐bands-‐diabetes.

Charmaine S. Ng, Joyce Y.C. Lee, Matthias PHS Toh, Yu Ko. 2014. “Cost-‐of-‐illness studies of diabetes mellitus: A systematic review.” Diabetes Research and Clinical Practice 105 (2): 151-‐163.

Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ et al. 2011. “National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-‐years and 2.7 million participants.” Lancet 378 (9785): 31-‐40. http://www.thelancet.com/journals/lancet/article/PIIS0140-‐6736(11)60679-‐X/fulltext.

General Assembly. 2006. “61/225. World Diabetes Day.” http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/61/225&Lang=E.

International Diabetes Federation. n.d. International Diabetes Federation. http://www.idf.org/who-‐we-‐are.


31

International Diabetes Federation. n.d. “United Nations Resolution 61/225: World Diabetes Day.”

http://www.idf.org/sites/default/files/UN%20Resolution%20on%20World%20Diabetes%20Day%20of%20Dec%202006.pdf.

International Working Group on the Diabetic Foot. 1999. “International consensus and practical guidelines on the management and the prevention of the diabetic foot.” International Working Group on the Diabetic Foot. http://onlinelibrary.wiley.com/doi/10.1002/1520-‐7560(200009/10)16:1%2B%3C::AID-‐DMRR113%3E3.0.CO;2-‐S/full.

Marquez, Patricio V. 2013. Healthier Workplaces = Healthy Profits. 22 January. http://blogs.worldbank.org/health/healthier-‐workplaces-‐healthy-‐profits.

Nam Han Cho, David Whiting et al. 2013. IDF Diabetes Atlas, Sixth edition. International Diabetes Federation. http://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf.

National Health Service. 2013. Physical activity guidelines for adults. http://www.nhs.uk/Livewell/fitness/Pages/physical-‐activity-‐guidelines-‐for-‐adults.aspx.

Public Health England. 2014. “Adult obesity and type 2 diabetes.” https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf.

Ramachandran, Ambady et al. 2007. “Cost-‐Effectiveness of the interventions in the primary prevention of diabetes among Asian Indians.” Diabetes Care 30: 2548-‐2552.

Tapash Roy, Cathy E. Lloyd. 2012. “Epidemiology of depression and diabetes: A systematic review.” Journal of Affective Disorders 142: S8-‐S21. http://www.jad-‐journal.com/article/S0165-‐0327(12)70004-‐6/abstract.

World development indicators. n.d. “Health expenditure, total (% of GDP).” World bank web site. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries/1W?order=wbapi_data_value_2012%20wbapi_data_value%20wbapi_data_value-‐last&sort=desc&display=map.

World Health Assembly. 1989. “WHA42.36 Prevention and control of diabetes mellitus.” Geneva. http://www.who.int/diabetes/publications/en/wha_resol42.36.pdf.

World Health Organisation. 2006. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. Geneva: World Health organisation. http://whqlibdoc.who.int/publications/2006/9241594934_eng.pdf?ua=1.

—. n.d. World Health Organisation. Accessed 1 1, 2015. http://www.who.int/mediacentre/factsheets/fs312/en/.

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