Diabetes is a life-long disease which if not properly controlled leads to acute life-threatening complications and late debilitating or fatal
complications. The three difficulties in diabetes control are (a) the drastic adjustments in life-style needed; (b) the cost of drugs and
blood sugar monitoring; and (c) organization and cost of individualized patient-care (teaching-motivation, supervision and logistic
provision). The costly drug is insulin. The most costly service providers are doctors.
Type-2 patients are not dependant on insulin for immediate survival. However many are dependant for the control of their diabetes.
Type 2 patients are the ones who in affluent countries are mostly of overweight middle-age onset. In developing countries however they
present in all age groups and amongst the poor they are usually not obese. Indeed if other diseases (e.g. TB) are also present they
can be almost as wasted as the Type 1’s. Type 2’s are the ones whose numbers are increasing catastrophically and
overwhelming diabetes services in Bangladesh and other poor countries. The reason for the “epidemic” is (1) the rapid transition to a
reduced physical exertion life style; together with, (2) the high consumption of rapidly absorbed carbohydrates; and (3) high fat/oil
consumption hampering the action of insulin (like obesity high levels of sugar, insulin and fats especially saturated fats in the blood are
undesirable). In amongst these Type 2 patients are the smaller numbers of Type 1’s who cannot survive without insulin. Currently it is
estimated that about 5% of Bangladesh’s adult population is suffering diabetes.
There are three reasons why Kailakuri gets so many patients:
(1) The health centre makes sure its services are financially possible for the poor. (2) Kailakuri diabetes staff are ordinary village people, mostly diabetics themselves, who are able to give patients hope and courage and help them make the necessary life-style changes. (3) Using lower category staff, primary health care methods and urine (in place of blood) testing, Kailakuri has been able to develop an effective low-cost structure for organization of patient training, treatment, logistics, supervision and recall. So far other organizations have not been able to do this. Hence the patient numbers.
Over half the Kailakuri patients are on insulin and the possibility of their treatment is entirely dependant on Kailakuri's relationship with BIRDEM Hospital (Diabetes Association of Bangladesh - DAB). Although the relationship is unofficial it is long standing and close. BIRDEM is one of the most generous supporters of the Project’s work. Herein lies the problem - BIRDEM concession insulin is possible because of an annual WHO grant to the government passed on to BIRDEM for insulin for the poor. Kailakuri is now taking more than half and more than double the amount given to any of the DAB’s official district branches. This is a problem for the diabetes association. However according to our calculations it is not possible for the very poor to make use of services other than ours because they are not cheap enough. We are not able to turn patients away if other facilities are not possible for them. At the same time our diabetes sub-centres are struggling with patient numbers and the likelihood of other organizations beginning realistic care for the poor still seems remote.
Kailakuri Diabetes Statistics for 2007
End of year diabetic patient number: 892 (The number would be much greater but many non-insulin patients do not continue under supervision because travel costs are greater than the cost of tablets off the local market. These patients are probably poorly controlled and subject to early onset of chronic complications). End of Year Patient Analysis Total number: 892 Treatment: insulin 66%, glibenclamide tablets 34%, diet alone 1% (However amongst new patients starting in 2007: insulin 22%, tablets 78%. When we are able to hold tablet patients within the programme then they will become the majority).
New Insulin Patients Sent to Dhaka for BIRDEM Hospital Registration Number of patients: 74 (decrease by 20%) Travel cost: Tk. 65,000 (decrease by 24%) Average cost per patient: Tk. 879 (4% decrease) (This is equivalent to 3.7 vials of insulin. Patients need on average 2.5 vials per month). Average BIRDEM insulin concession: 79%
End of Year Insulin Patient Analysis Regular outpatient attendance: 85% Diabetes control (Benedict Test): good 65%, fair 27% Distance of home from clinic: within 15 miles 61% (0-5 miles 25%, 5-10 miles 20%) Functional literacy: 65% Under 30 years’ age: 72% Male 54%, Female 46% Muslim 96%, Hindu 3%, Christian 1%
Diabetes Patients Admitted at Kailakuri Total: 318 (32% decrease) Male 59%, Female 41% Muslim 96%, Hindu 4% New patients admitted for education: 206 (65%) Specific problems: diabetes ulcers, eye problems, pregnancy/delivery, TB, kidney problems, diarrhoea, acidosis. Deaths 1 Average admission duration: 14 days. |
