Management of diabetes and associated cardiovascular risk factors in seven countries

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A substantial proportion of individuals with diabetes remain undiagnosed and untreated, both in developed and developing countries, according to a multi-country study using nationally representative health examination surveys from Colombia, England, Iran, Mexico, Scotland, Thailand and the United States.

The figures range from 24 percent of women in Scotland and the United States to 62 percent of men in Thailand. The proportion of individuals with diabetes reaching treatment targets for blood glucose, arterial blood pressure, and serum cholesterol was very low, ranging from one percent of male patients in Mexico to about 12 percent in the United States. Income and education were not found to be significantly related to the rates of diagnosis and treatment anywhere except in Thailand, but in the three countries with available data insurance status was a strong predictor of diagnosis and effective management, especially in the United States.

Based on this comparison of how well these seven countries are performing in terms of population-level management of diabetes, hypertension and high cholesterol, the study researchers make the following recommendations:

  1. It is critical to track diabetes care at the population level and to focus on actual outcomes, rather than on the process of care. It is also critical to study other countries with larger numbers of individuals with diabetes, such as China and India, for which nationally representative studies are not readily available.
  2. It is important to prioritize the development and implementation of national guidelines and the use of new incentive programs for the management of hypertension and high cholesterol among individuals with diabetes in developing countries. The study findings suggest that such progress may be more feasible and more likely to have a larger population health impact than blood glucose control.
  3. There are opportunities for innovation in providing incentives, in the technology of diabetes management and in improving financial access to care.

Real progress at the population level in the management of diabetes will likely require all three: monitoring performance in meeting treatment targets, expanding management of hypertension and high cholesterol in individuals with diabetes, and innovations in the delivery of and access to care.

The estimated global prevalence of diabetes is around 6.4 percent and more than 280 million people in the world have diabetes—the majority live in the developing world. Projections indicate that diabetes accounted for almost four million deaths worldwide in 2010. The burden of diabetes will only continue to grow, since the number of adults with diabetes in developing countries is projected to rise by more than two-thirds between 2010 and 2030.

1. Gakidou E, Mallinger L, Abbott-Klafter J, et al. Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys. Bulletin of the World Health Organization 2011; 89: 172-183. (open access)

Number of uninsured reduced by universal health care insurance in Thailand

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Thailand implemented a Universal Coverage Scheme of national health insurance in 2001 to finance equitable access to health care. After the Universal Coverage Scheme was introduced, the number of uninsured in Thailand fell substantially and use of health centers and community hospitals increased among lower income groups, according to a study that analyzed data from the Thai national health and welfare surveys in 2001 and 2005.

With the establishment of the Universal Coverage Scheme, Thai citizens are now covered by three main public health insurance schemes: the Civil Servant Medical Benefit Scheme for employees of the government and state enterprises, the Social Security Scheme for formal private sector employees and the Universal Coverage Scheme for the rest of the population. Health service utilization has shifted from tertiary towards primary health care facilities, an intended impact of the Universal Coverage Scheme.

As a result of Thailand’s universal health insurance, the number of uninsured fell from 24 percent in 2001 to three percent in 2005 and health service patterns changed. Use of public primary health care facilities such as health centers became more concentrated among the poor, while use of provincial/general hospitals became more concentrated among the better-off.

The increasingly common use of health centers among the poor in 2005 was substantially associated with those with lower income, residence in the rural northeast and the introduction of the Universal Coverage Scheme. The increasing use of provincial/general hospitals and private clinics among the better-off in 2005 was substantially associated with the government and private employee insurance schemes.

Although the Universal Coverage Scheme has achieved its objective in increasing insurance coverage and utilization of primary health services, “our findings point to the need for future policies to focus on the quality of this primary care and equitable referrals to secondary and tertiary health facilities when required,” the study concluded.
1. Yiengprugsawan V, Carmichael GA, Lim LL-Y, et al. Explanation of inequality in utilization of ambulatory care before and after universal health insurance in Thailand. Health Policy and Planning 2011; 26(2): 105-114. (open access)