Health Systems Performance for Diabetes in 25 Low- and Middle-Income Countries (LMICs), 2005–2016
Authors: MANNE-GOEHLER JENNIFER , GELDSETZER PASCAL , HOUINATO DISMAND , HOUEHANOU CORINE , GURUNG MONGAL S. , ANDALL-BRERETON GLENNIS M. , CROOKS SARAH , JOSEPH KIBACHIO , WESSEH CHEA , NOROV BOLORMAA , ARYAL KRISHNA K. , KARKI KHEM B. , BOVET PASCAL , LABADARIOS DEMETRE , STOKES ANDREW , MAYIGE MARY T. , KAGARUKI GIBSON B. , GUWATUDDE DAVID , SILVER BAHENDEKA K. , JORGENSEN JUTTA M. , VOLLMER SEBASTIAN , DAVIES JUSTINE I. , BARNIGHAUSEN TILL , JAACKS LINDSAY M. 
Published: June 2018

Introduction: As diabetes increases in LMICs, there is a need for more evidence to guide health systems planning. We used a cascade of care approach to assess health system performance among adults (=15 years) in LMICs.
Methods: We pooled individual data from 25 nationally representative surveys. Diabetes was defined as FBG=126 mg/dL, RBG=200 mg/dL, HbA1c=6.5%, or on medication. Stages of the care cascade included: screening, diagnosis, lifestyle advice and/or medication (“treatment”), and control (HbA1c =8.0%). Linear probability models were used to evaluate predictors (age, sex, education, and wealth quintile) of (1) treatment and (2) control.
Results: Across all countries, the largest losses to care occur at screening (Table). While health service access increases with increasing country income group, rates of disease control are similar. Prediction models show that treatment is 31.1 percentage points (95% CI: 12.6-49.5) lower in the youngest age group compared to the oldest and that control is 3.9 percentage points (95% CI: 1.8-6.1) lower in men than women.
Conclusions: Diabetes prevalence is substantial across LMICs, particularly in Latin America and the Caribbean. Overall rates of screening are low and only 23% of those with diabetes achieve control, which is less than half of that in the U.S. (64%). Policy interventions that link adults with diabetes to care and improve disease control in LMICs are needed.
The diabetes cascade of care in 25 LMICS (N=92,141)RegionPrevalence (95% CI)Screened (95% CI)Diagnosed (95% CI)Completed (95% CI)Controlled (95% CI)Sub-Saharan Africa3.9 (3.0 - 5.0)53.1 (46.3 - 60.0)38.7 (32.9 - 45.0)36.0 (30.4 - 42.0)21.2 (16.7 - 26.3)Latin America & the Caribbean28.4 (23.7 - 33.7)79.8 (74.2 - 84.4)63.7 (57.9 - 69.3)48.9 (42.3 - 55.6)33.1 (26.8 - 40.1)South & Southeast Asia7.5 (7.1 - 7.9)57.5 (47.6 - 66.9)46.1 (36.9 - 55.6)45.2 (36.0 - 54.7)29.1 (22.0 - 37.5)Low-income group2.7 (2.1 - 3.5)39.9 (34.4 - 45.6)32.7 (27.2 - 38.5)31.4 (26.0 - 37.3)21.0 (16.0 - 27.1)Lower-middle income group7.7 (6.6 - 8.9)57.1 (46.0 - 67.6)38.2 (27.8 - 49.8)35.2 (25.0 - 47.0)23.9 (15.2 - 35.4)Upper-middle income group9.3 (5.5 - 15.3)68.9 (60.9 - 75.8)47.9 (40.3 - 55.5)41.7 (34.8 - 48.8)24.1 (19.1 - 30.0)Overall8.5 (5.9 - 12.0)57.9 (52.8 - 62.9)41.8 (37.1 - 46.6)37.6 (33.2 - 42.2)23.0 (19.5 - 27.0)

Disclosure
J. Manne-Goehler: None. P. Geldsetzer: None. D. Houinato: None. C. Houehanou: None. M.S. Gurung: None. G.M. Andall-Brereton: None. S. Crooks: None. K. Joseph: None. C. Wesseh: None. B. Norov: None. K.K. Aryal: None. K.B. Karki: None. P. Bovet: None. D. Labadarios: None. A. Stokes: None. M.T. Mayige: None. G.B. Kagaruki: None. D. Guwatudde: None. B.K. Silver: None. J.M. Jorgensen: None. S. Vollmer: None. J.I. Davies: None. T. Barnighausen: None. L.M. Jaacks: None.