Personal View: Tanzania and diabetes—a model for developing countries?
Authors: Kaushik Ramaiya
Journal: BMJ (2005)

Tanzania has a new network of diabetes clinics. About 100 000 people with diabetes in Tanzania now have access to affordable treatment and health education in these diabetes clinics, established by the Tanzania Diabetes Association, and run by district, regional and referral hospitals. Consultations are free of charge, while insulin and other medicines and laboratory tests are heavily subsidised or, for the poorest patients, free.

On the mainland, diabetes clinics have been established in each of the 19 regional hospitals, four referral hospitals, and three district hospitals. Additionally, in the city of Dar es Salaam, diabetes clinics have been established in each of the three district hospitals. Diabetes clinics have also been established in Zanzibar and in Pemba.

The Ministry of Health in Tanzania has given doctors and nurses to staff the diabetes clinics in hospitals nationwide, and partners are supporting the training and education for healthcare professionals. These include Novo Nordisk's World Partnership Programme (funded through corporate giving and by fundraising among the company's employees) and the Vienna Diabetes Association.


There is still much to do: referrals may be hampered by cost


Until the regional network was established early this year, diabetes services were provided at regional hospitals only as part of routine outpatient care, by staff with no specialist diabetes training. Specialised diabetes care was available at just five referral hospitals in Tanzania, run by a handful of consultant diabetes physicians and diabetes educators. Access to diagnosis and treatment, particularly for people in Tanzania's rural areas, was extremely limited.

The Tanzania Diabetes Association offered training programmes lasting two weeks to teams of healthcare workers from each regional hospital, comprising a doctor, two nurses, and a laboratory technician. After training, each team was given a starter kit containing diagnostic and educational tools for continuing diabetes care.

A survey in early 2004 showed that before training only about a third of healthcare staff at the regional hospitals were sufficiently aware of key aspects of diagnosis, treatment, education, and complications in diabetes. Evaluation in January 2005, a year after the training, showed that the necessary awareness of diabetes had risen to 65% among the trained healthcare workers. Similarly, more than two thirds of patients with diabetes surveyed at hospitals in 2004 were unaware that their problems were related to high or low concentrations of glucose in their blood and did not know that they could or should monitor those concentrations.

In the past year, Muhimbili National Hospital, in Tanzania's capital Dar es Salaam, has become the national centre of excellence for diabetes care, incorporating a medical laboratory, foot clinic, and a diabetes information centre to train doctors, nurses, and people with diabetes from around the country. The hospital also sees patients referred from the regional clinics. There is still much to do: referrals may be hampered by cost and the limited transport network in the country. Also, the regional clinics need ongoing guidance from diabetes educators to ensure that guidelines are followed.

Tanzania has already experienced a rapid rise in the burden of diabetes. In the 1980s, the prevalence of type 2 diabetes was among the lowest in the world: 0.8% in cities and towns and 0.9% in rural areas. A study in 2000 highlighted a marked increase in diabetes in urban (4.0%) and rural (1.3%) populations, and now 300 000-350 000 of Tanzania's 32 million people have diabetes.

Diabetes in Tanzania is placing an increasing economic burden on the population and on the national budget for health care. A study in the Kilimanjaro region showed that the total direct costs relating to the treatment of diabetes accounted for a quarter of the minimum wage, resulting in about 46% of the patients having permanent financial difficulties. Research from Dar es Salaam reported that only 1 in 5 of people with diabetes was receiving government-funded treatment for the disease.

Communicable diseases, such as HIV/AIDS, tuberculosis, and malaria, make up the greatest burden of disease facing sub-Saharan Africa. Within the next two decades, however, non-communicable diseases such as hypertension and diabetes are expected to contribute to more deaths than communicable diseases. There is an urgent need to develop awareness, education, and accessibility of care in line with the World Health Organization's aims of sustainable intervention, by helping countries develop their own infrastructure and professional expertise in health care. Tanzania's approach to managing diabetes in a sustainable way could be a model for other developing countries.

The ultimate objective of the Tanzania Diabetes Association and its partnerships is to allow Tanzanians to continue independently towards providing truly sustainable and accessible care in the long term.