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Executive Summary
This report, prepared by the IIF, highlights the main findings and recommendations based on the implementation of the Rapid Assessment Protocol for Insulin Access (RAPIA) in Mozambique. This report was presented to the Ministry of Health, Clinicians and National Diabetes Association in Mozambique as a first stage in a collaborative process between different stakeholders both at a national and international level to find creative means to improve the welfare of people with Type 1 diabetes in Mozambique. The IIF aims to mobilise different areas of expertise and resources to frame practical proposals to help Mozambique provide the care that people with Type 1 diabetes require. In parallel this report hopes to contribute positively to the issues of chronic diseases in Mozambique in general. (back to top)
Introduction
Type 1 diabetes is considered a rare disease in Africa estimated by the International Diabetes Federation (IDF) as affecting 108,000 people, 928 of these in Mozambique. Since survival in many is short this probably greatly underestimates the true incidence and the potential care needs. (back to top)
Key Findings
- There is no exact information about how many people in Mozambique develop Type 1 diabetes each year (incidence) nor how many there are with the disease at any one time (prevalence).
- There is much variation in estimates of Type 1 diabetes prevalence between different areas of Mozambique. In comparing the three regions of the study, Maputo, Beira and Lichinga, there is a difference between the estimated number of people with diabetes. Using Maputo as a benchmark Beira has only 56% and Lichinga only 15% of the expected number of patients. The proportions due to true variation, to inadequate ascertainment and to curtailed survival are unknown.
- The lack of information about disease prevalence and incidence leads to problems in the quantification of insulin needs and resource allocation for diabetes.
- In 18 months between 2001 and 2003, Mozambique spent US$ .00 on insulin which represents 10% of government expenditure on medicines.
- 77% of the national insulin supply is for Maputo Province. This quantity would suffice for over 19 times the number of expected people with Type 1 diabetes present (assuming patients use 35 units per day). For other provinces the quantities ordered appear inadequate for the estimated number of people with Type 1 diabetes.
- Communication and coordination problems between the Medicine Importation Agency (Medimoc) and Central Medical Stores (CMAM) with end users of insulin create problems with supply of insulin.
- According to the Regulations of the Social Fund for Medicines and Food Supplements, Boletim da Republica, 4 Suplemento, Decreto no. 16/88, 27th December, 1988, patients are supposed to be able to receive insulin for free or at a subsidised cost. All outpatients have to buy insulin even at a subsidised price of US$ 0.5 per 10 ml 100IU/ml vial from state pharmacies. This insulin is often not available at this price and patients pay as much as US$ 24.20 per vial on the open market.
- Supply of insulin and other associated consumables such as syringes and needles is irregular and prices vary greatly between the private and public sectors.
- Insulin availability and informed care for people with diabetes is limited to Provincial and Central Hospitals. This means large distances to travel for some and may explain the “missing patients”. Diabetes clinics are only held at the three Central Hospitals.
- Diagnostic tools are not always present at Hospitals and even when they are the lack of trained staff means that some patients may fail to be diagnosed. Individual patients did not have access to their own monitoring equipment.
- "Diabetes is part of the curriculum, but doctors know what they see." All healthcare workers had heard about diabetes, but very few will actually come across, let alone treat, a patient with diabetes. This blunts awareness in healthcare workers and patients escape diagnosis.
- Even after diagnosis the lack of trained care providers, guidelines for care and referral pathways means that patients often fail to be satisfactorily managed.
- AMODIA is active in only Maputo and might play a greater role in the diabetes arena in Mozambique.
- A general lack of knowledge about diabetes in the general population and government agencies was also highlighted.
- Traditional Healers are a source of care for all diseases throughout the country.
- Lack of information about diet, insulin availability and diabetes management in general were major concerns for patients with diabetes and their carers.
All these issues need to be placed in Mozambique’s general health care context where problems of staff, infrastructure and resources are omnipresent. (back to top)
Recommendations
Keeping in mind the resource restrictions present in Mozambique the following recommendations aim to make best use of limited resources and also to benefit other areas of the health system in Mozambique.
- Creation of a register/surveillance system for all diagnosed diabetes patients
- Better reporting and control mechanisms between Medimoc/CMAM and end users
- Clarification/enforcement of Regulations of the Social Fund for Medicines and Food Supplements, Boletim da Republica, 4 Suplemento, Decreto no. 16/88, 27th December, 1988
- Improvement of access to insulin and syringes for patients
- Increase in availability of diagnostic tools where necessary
- Improve existing training for healthcare workers and train specialists in the area of diabetes
- Empowering patients and their families through the establishment of teaching and training facilities
- Create guidelines and referral pathways for the treatment of patients
- Identify specialists and creation of specialised diabetes clinics
- Clear statement of role and purposes of AMODIA as a Diabetes Association with requests for support
- Organise awareness campaigns, e.g. for World Diabetes Day
- Involve and develop special guidelines for Traditional Healers
- Create proper environment for health of people with diabetes
- The above recommendations should be included in a feasible 5-year plan for Diabetes in Mozambique (back to top)
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