- Ann-Lise Mikolajczak — Switzerland
Investing in chronic care: Sustainable financing models for type 1 diabetes
The discovery of insulin in 1921 changed type 1 diabetes from a death sentence to a condition that can be controlled and managed successfully. Yet a hundred years later, children still die from diabetes, especially in low- and middle-income countries (LMICs). What do we need to ensure access and affordability of type 1 diabetes treatment? Both capacity building and innovative financing will play a role in advancing progress.
The views expressed are those of the author and do not necessarily
reflect the position of Re:solve Global Health.
A mix of factors are impeding the control of type 1 diabetes around the world, and particularly in low- and middle-income countries (LMICs). Lack of awareness of early symptoms, timely diagnosis and treatment, and appropriate management of the disease and its longer-term risks are impeding progress on improving outcomes for people living with diabetes. There is a critical need for trained healthcare workforces, timely access to appropriate care, continuous access to quality glucose monitoring devices, insulin and consumables, and support for patients and their caregivers. Finally, stakeholders need to find new ways of financing the long-term treatment that chronic diseases such as diabetes demand. These are key building blocks for optimal care and a better life with diabetes and should be led by sound national strategies for ensuring sustainability.
Building capacity and sustainability
A steady, timely, and reliable supply of quality insulin and associated products is the cornerstone of type 1 diabetes treatment. Many biopharmaceutical companies have partnered with global and local organizations in LMICs in order to address gaps in healthcare provision and ensure timely access to quality diabetes health products, particularly for children living with type 1 diabetes. However, when these children get older, they may struggle to maintain the continuity of care due to inadequately equipped health systems and financial hardship because of insufficient financing or insurance coverage. Hence, integration of diabetes financing into national health systems is key for sustainably managing type 1 diabetes into adulthood. Integrated care pathways – the coordinated, multidisciplinary screening, management, and treatment of co-morbidities – have the potential to bring cost-effective solutions to constrained national health budgets.
The biopharmaceutical industry has partnered with other health system stakeholders to test and scale up different models for providing comprehensive service delivery in low-resource environments. For instance, the Life for a Child initiative is improving the health outcomes of children living with type 1 diabetes while encouraging local provision of diabetes care. With the view to promote sustainable and locally owned solutions, it provides a holistic package of actions – supply chain strengthening, capacity building, research and advocacy activities, education, and patient mentoring – that supports the care of young diabetic patients. With their respective areas of expertise, the broad range of NGOs, foundations, industry, and academia help local communities and the healthcare workforce acquire the necessary knowledge regarding clinical care and supply chain management to strengthen local capabilities.
In partnership with the governments of Cameroon, Senegal and Côte d’Ivoire, Sanofi has run Diabetes and Hypertension Clinics since 2014. The clinics improve the management of diabetes and hypertension through capacity building of healthcare professionals, as well as through providing equipment for diagnosis and care. Building on the success of this project, a digital tool capturing patients’ data has recently been launched in targeted clinics to enable more efficient patient monitoring and timely care.
Providing adequate, sustainable financing
What is needed now to ensure access to quality diabetes care worldwide? An appropriate level of long-term financing by governments and, in the short- and medium-term, potential global multilateral organization or donor funding, or other funding mechanisms, should be the cornerstone of efforts to achieve this goal.
We applaud the work of the World Bank which now has an impressive portfolio of financing projects for non-communicable diseases (NCDs) like diabetes, and the Government of Norway – the first country to step up and provide meaningful development assistance to help countries address the huge health and economic burden of NCDs.
But significantly increased financing is required. An interesting avenue to explore for diabetes is the unique outcomes-based financing mechanism supporting the work of the innovative Dutch chain of type 1 diabetes clinics called Diabeter. It includes a first of its kind 10-year pay for performance contract with ZK, one of the largest Dutch health insurance companies, which has led to positive outcomes so far, including reduced acute events and hospitalisations, and better diabetes control. This effort has been supported by the work of the International Consortium of Health Outcomes Measurement (ICHOM), which has already developed and published a peer-revised standard set of patient-relevant health outcomes for people living with type 1 diabetes. Organizations like Leapfrog to Value are partnering with ICHOM to bring this type of outcomes-focused approach to local health systems in LMICs.
Innovative funding models such as “social impact bonds” (SIBs) could also be a solution for diabetes. SIBs are a new financing tool used for impact investing. They are essentially “pay for performance” contracts where private actors provide the initial capital to fund a health intervention, and governments reimburse the investors if and only if the intervention results in improved health outcomes of a predetermined subgroup of the population. Thus far, impact bonds have been targeted at preventable diseases and conditions, but these could be adapted to chronic metabolic diseases such as type 1 diabetes. Some governments are currently looking at developing those for the prevention of chronic diseases, but more health system research needs to be undertaken in the field.
A hundred years after the discovery of insulin, the global health community knows what is needed to ensure access to life-long type 1 diabetes care: timely diagnosis and treatment, adequate and sustainable care financing, and support for managing the disease. The biopharmaceutical industry invites governments and other stakeholders to work together through bold and action-oriented multi-stakeholder partnerships. Based on the clearly stated goal of leaving no child behind when it comes to type 1 diabetes, sustainably funded efforts that are tailored to local needs and managed through a solid governance structure (including definition of the roles and responsibilities of each stakeholder involved) have the potential to effectively support young people in LMICs to survive – and thrive – with type 1 diabetes.