Executive Summary of Nicaragua Report
The International Insulin Foundation in collaboration with Handicap International with the support of the Ministry of Health and Asociacion de Padres de Ninos y Jovenes Diabeticos de Nicaragua carried out the Rapid Assessment Protocol for Insulin Access in Nicaragua from 21 January to 31 March 2007. The aim of this assessment was to see what barriers to diabetes care and access to medicines were present, in order to develop specific programmes and projects to address these. This report should be viewed as the first step in improving the care for people with diabetes in Nicaragua.
Key Findings
- Supply of insulin and oral medications
- Insulin and other medicines for diabetes are provided for free by Public and Social Security facilities
- Supply system works well
- No reported or observed problems with cold chain
- Some health facilities do not provide the full quantity of required medicines
- Insulin is not always available at place where person has their consultation
- Children need to go to the National Paediatric Hospital in Managua to get their insulin
- Some health centres do not have Rapid insulin for outpatients
- Access to other medicines for diabetes related complications and other conditions is sometimes difficult for people with diabetes in the public sector
- Patients need to go to Health Centre every month to get medicines
- Access to syringes
- Syringes are not readily available in the Public sector and need to be bought in private pharmacies
- Diabetes Care
- There is no specialised care for children with Type 1 diabetes outside of Managua
- Guidelines for the management of Type 1 and Type 2 diabetes exist
- However, they are very ambitious and not necessarily adapted to the reality of Nicaragua
- Presence of chronic clinics and diabetes consultations at the level of Health Centres
- Lack of standardised care within and between health facilities, except for the Mascota Paediatric Hospital
- Large number of patients at Health Centres for each consultation
- Access to specialists in rural areas is difficult and transportation costs are often a barrier
- Long waiting times and problems accessing specialists and internists at hospital
- Problems with counter-referrals
- Diagnostic tools and infrastructure
- Diagnosis and follow-up are mainly done with glucometers (capillary blood glucose measurements)
- Problems with regards to availability and supply of testing strips and reagents for public facilities
- Problems with availability if tools necessary for proper diabetes check-up
- National referral laboratory’s capabilities with regards to HbA1c are under utilised
- High cost for patients of self-monitoring equipment
- Healthcare workers and training
- Lack of training for doctors, nurses, laboratory technicians and other related health professionals in diabetes and also patient education and management of long-term conditions
- Under utilisation of nurses
- Lack of specialised resources
- Chronic patient clubs and community involvement
- Community involvement is extremely important in Nicaragua
- Extremely strong association for children
- Chronic patient clubs are present in many facilities and are at different stages of development
- Some patients view voluntary contribution to club as a payment for healthcare
- No National voice for diabetes in Nicaragua
- Patient education
- Not standardised, will vary from facility to facility
- No standardised tools or materials
- Adherence
- Problems with regards to adherence to dietary and lifestyle recommendations
- Self-medication
- Policy framework
- Lack of a concrete, strong and overarching policy on diabetes
- Prevention
- Currently no prevention programme for:
- Primary prevention
- Secondary prevention
- Currently no prevention programme for:
- Registers and patient data
- A lack of complete data with regards to diabetes exists
- Registers and patient records were kept in all facilities, but amalgamation of this data is poor
- Surveillance system does not include diabetes
- Use of the term Type 1 diabetes is often confused with people requiring insulin
Each of these recommendations cannot be implemented in isolation. For example, an increase in awareness of diabetes through a prevention campaign will inevitably lead to an increase in numbers of people diagnosed, which will have ramifications on the number of people attending consultations and needing diagnostic tools and medication. These recommendations are specific to diabetes, however for feasibility and rational use of scarce resources in Nicaragua, these can and should be applied to all Non Communicable Diseases in both the Public and Social Security sectors. It should be noted that there are many examples from other Latin American countries that can be used as models for different aspects of implementing these recommendations. The Pan American Health Organization, International Diabetes Federation South and Central America Region and the Asociacion Latinoamericana de Diabetes have much experience that can assist Nicaragua in developing different aspects of its programme with regards to diabetes.
- Supply of insulin and oral medications
- Rapid insulin present at Health Centres when needed
- Investigate the feasibility of having MINSA and CIPS manage the supplies for INSS with regards to diabetes
- Development of a basic package of medicines necessary for diabetes and related complications
- Ensure that after children and pregnant women people with diabetes are given priority access to other medicines
- Ensure that all health facilities fulfil the full prescription for diabetes, especially with regards to insulin
- Register each child in Health Centre of origin in order for them to be able to get insulin at Health Centre in their Municipality
- Access to syringes
- Link supply of syringes with insulin
- Diabetes Care
- Inclusion of Type 1 diabetes in chronic disease focal point’s training
- Focal point for chronic conditions responsible for children with Type 1 diabetes in each Municipality
- Organisation of 1-2 yearly check-ups in Managua for all children with Type 1 diabetes covering the price of transportation
- Updating and standardisation of guidelines adapted with reality of the situation in Nicaragua
- Distribution and training with regards to these guidelines
- Development of a standardised checklist for each consultation adapted and achievable for level of the health system
- Increase number of days of consultation
- Increase role of nurse for patients with no complications
- Ensure that hospital consultations are only used for specialised care and not routine care
- Improve counter-referrals
- Organise yearly “diabetes” day(s) consultations at each Regional Hospital
- Diagnostic tools and infrastructure
- Improve supply mechanisms for strips and reagents
- Ensure all health units have necessary diagnostic and clinical tools
- Development of an adapted diabetes toolkit to be present at each level of the health system
- Investigate feasibility of regular HbA1c checks for the largest number of patients possible
- Ensure that types of glucometers present in the Public sector are limited in order to limit the number of types of strips that need to be purchased, standardised and safe for multiple patient use
- Healthcare workers and training
- Train chronic disease focal point in Type 1 and Type 2 diabetes
- Develop training material for nurses, laboratory technicians and other health professionals
- Training for healthcare workers on how to teach patients and management of long-term conditions
- Chronic clubs and community involvement
- Train members of clubs to be peer educators
- Develop role of clubs as support group
- Develop role of clubs as pressure groups for Municipal and Regional governments
- Increase organisational capacity
- Creation of National Council on Diabetes
- Patient education
- Development of tools adapted to the socio-economic situation in Nicaragua that are easy to use and understand and culturally adapted
- Organise education activities during consultation waiting times
- Adherence
- Improve patient education
- Development of dietary guidelines adapted to Nicaragua
- Improve access to medicines so that patients do not need to go to Health Centre every month
- Policy framework
- Development of a policy in line with the United Nations’ Resolution on diabetes
- Prevention
- Develop primary prevention programme
- Increased collaboration with PAHO’s CARMEN and “Get moving America”
- School and community focus
- Development of policy
- Involve Brigadistas and community health workers
- Develop secondary prevention programme
- Increase training for healthcare workers
- Increase patient education
- Yearly specialised consultations for patients
- Develop primary prevention programme
- Registers and patient data
- Improve training for people responsible for statistics and surveillance with regards to diabetes and surveillance of Non Communicable Diseases
- Inclusion of diabetes in surveillance system
- Identify ways for surveillance system to notify patient numbers and not episodes or consultations
- Development of standardised tool for data collection with regards to diabetes
- Creation of a register of children with diabetes in each municipality
- Use data to feed into planning for consultations, medicines, etc.
A full copy of the report can be downloaded here:
| Nicaragua RAPIA Report |