The WHO national diabetes programme initiative

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Diabetes Research and Clinical Practice 34 Suppl. (1996) S I $6

The W H O national diabetes programme initiative W. Gruber*, H.

King

Dit'ision ol NoucomHumicut~/e Disease,~, World Health Organization, 20 Avenue Appia, CH-1211 Genel,a 27, Switzerland

Abstract

Epidemiological studies indicate that diabetes is a highly prevalent disease, with developing countries and minority populations now facing the highest risk. This places a strain on the health authorities, and consequently, has attracted increasing attention from the World Health Organization (WHO). The social and economic burden of diabetes is high, due to the seriousness of the complications of the disease. Many of these complications may be delayed or prevented, offering considerable opportunities for both reduction in costs to the authorities and improvements in quality of life for those affected. Following a resolution oll the prevention and control of diabetes, adopted by the Forty-second World Health Assembly in 1989, the WHO diabetes programme prepared guidelines for the development of national diabetes programmes. Goals, targets and supporting materials have also been developed at the regional level by the WHO Regional Offices for Europe and for the Eastern Mediterranean. In 1994, WHO organized a meeting on the implementation of national diabetes programmes at its headquarters in Geneva. There were 70 participants and 32 countries were represented. The purposes of the meeting were to exchange information, motivate, consider evaluation, stimulate new programmes, define educational needs and prepare a written report. WHO plays a major role in the development of national diabetes programmes. In co-operation, WHO Headquarters and Regional Offices can act as clearing houses/information centres for data collection, programme monitoring and evaluation and the exchange of experience and technical information. The national diabetes programme initiative should result in improvements in diabetes control and care worldwide. Keywords: Diabetes mellitus; Disease prevention; Public health; World Health Organization

The basis for W H O activities for the prevention and control o f diabetes has been formed by the work o f an international g r o u p o f epidemiologists who have collected data on the prevalence o f diabetes mellitus in all parts o f the world, with findings which alarmed all groups concerned with diabetes care, including the health authorities. Prevalence data were pub* Corresponding author.

lished in World Health Statistics Quarterly in 1992 [1] and later as global estimates for prevalence o f diabetes and impaired glucose tolerance (IGT) [2] which will be updated when additional data arise. A W H O Study G r o u p [3] concluded recently that the n u m b e r o f individuals with non-insulin-dependent diabetes mellitus ( N I D D M ) is increasing substantially and m a y exceed 100 million by the year 2000 if the present trends continue.

0168-8227/96/$15.00 (C, 1996 Elsevier Science Ireland Ltd. All rights reserved PII $0168-8227(96)01297- l

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W, Gruher. H. Khlg Diahele,s Re,warch aml CIh#ca/ Practice 34 Suppl, (1996) SI $6

A closer look at the global estimates shows that the prevalence of diabetes in white populations is moderate as compared to many non-white populations, in which prevalence above 10% of the adult population is frequent. Prevalence of glucose intolerance may exceed 25'I/,, of all adults when IGT is included (Fig. 1). Prevalence is generally higher in urban than in rural communities, and in emigrant populations, as compared to their non-migrant counterparts. It has therefore been stated that diabetes mellitus has become a Third World problem [4], posing a severe strain on the evolving health care systems of many countries. The full scale of the problem may not yet have fully emerged, since population-based studies of diabetes prevalence often demonstrate a high proportion of undiagnosed cases. The problem is exacerbated by the prolongation of human life expectancy worldwide, since the incidence of diabetes is strongly age dependent. In a number of countries the probability for individuals to become diabetic during their lifetime now exceeds 30%. N I D D M , showing a strong familial aggregation, appears to be a consequence of an interaction between genetic susceptibility and exposure to environmental factors [3]. To explain this interaction the 'thrifty genotype' hypothesis has been invoked [5]. Such a genotype would offer advantages in times of prolonged food deprivation, but it becomes disadvantageous when food is plentiful. The social and financial burden of diabetes is high. The quality of life of persons with diabetes is lowered, very severely in some parts of the world: Ten years after onset of their diabetes approximately 30% of persons suffer from retinopathy. Diabetes is one of the most common causes of blindness. Nephropatic complications are steeply increasing in aging populations. Diabetes is now the most frequent cause of renal failure. Vascular diseases in persons with diabetes cause approximately 10% of all CVD deaths. Diabetes is the commonest cause of non-traumatic amputations. The fi-equency and length of hospitalisation due to other, less closely related conditions ex-

ceeds the importance of hospitalisation due to diabetes itself [6]. In the industrialized countries the health care cost for persons with diabetes is 2 4 times higher than the cost for the general population. A recent study suggests that 1 in 7 of US $ expenditures for total health care in the US was spent for the care of persons with diabetes [6]. A rising number of studies show that a major proportion of these complications can be prevented by improvements in diabetes care. Most important was the Diabetes Control and Complications Trial (DCCT), completed m 1993 in the US, among persons with insulin-dependent diabetes mellitus (IDDM). This demonstrated reductions in incidence, particularly in retinopathy, of the order of 50% [7]. An equal reduction in annual amputation rate from a mean of ~ 0.8% of diagnosed diabetics reported for different industrial countries has been reached through care improvement by some centers, districts and countries. Such avoidable complications have been shown to be a major reason for death of persons with diabetes in some countries, which can be diminished similarly. Such arguments led to an increased attention by WHO to the control and prevention of diabetes mellitus, as indicated by a resolution adopted by the 42nd World Health Assembly in 1989 (Fig. 2). To support the Member States in their efforts, WHO prepared the booklet 'Guidelines for the Development of a National Programme for Diabetes Mellitus' [8] in 1991, which was translated into several languages. Some countries already had experience with national programmes before the WHO resolution, e.g., Canada, Croatia, etc, but major activities were started thereafter. Most important was the St. Vincent Declaration of 1989, adopted by an interdisciplinary European group headed by IDF and the WHO Regional Office for Europe (EURO). They defined goals and targets for Europe, and recommended specific action programmes [9] which were endorsed by a W H O Regional Committee in 1991. Meanwhile, national activities have been started in all European countries: more than half of them have completed action plans and many have started

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W. Gruber, H. Kin¢ Diabetes Research aml Clinical Practice 34 Suppl. (1990) SI $6

Forty-second World Health Assembly Agenda item 18.2

19 May 1989

Prevention and Control of Diabetes MeUitus The Forty-second World Health Assembly, Recognizing that diabetes already represents a significant, debilitating and costly disease attended by severe complications including blindness and heart and kidney disease; Noting that diabetes already represents a significant burden on the public health services of Member States, and that the problem is growing, especially in developing countries;

Aware of the support of the International Diabetes Federation and the WHO collaborating centres on diabetes; 1.

2.

Invites Member States: •

to assess the national importance of diabetes;

•

to implement population-based measures, appropriate to the local situation, to prevent and control diabetes;

•

to share with other Member States opportunities for training and further education in the clinical and public health aspects of diabetes;

•

to establish a model for the integrated approach to the prevention and control of diabetes at community level;

Requests the Director-General to strengthen WHO activities to prevent and control diabetes, in order: •

to provide support for the activities of Member States with respect to the prevention and community control of diabetes and its complications;

•

to foster relations with the International Diabetes Federation and other similar bodies with a view to expanding the scope of joint activities in the prevention and control of diabetes;

•

to mobilize the collective resources of the WHO collaborating centres on diabetes. Fig. 2.

W. Gr,her. H. Km~, Diabetes Research amt Clinical Practice 34 Suppl. (1996) SI $6

with the implementation of programmes, some being far advanced. Similar regional activities were promoted by the WHO Regional Office for the Eastern Mediterranean (EMRO) since 1991 [10,1l] resulting in national programmes commencing in more than half of the EMRO countries. Progress towards national diabetes programmes is also reported from many countries in other WHO regions. To prepare guidelines for the implementation of national diabetes programmes, WHO organized a meeting of people with experience in this field in Geneva at the end of May 1994. Seventy experts from 32 countries participated to: exchange experiences and motivate the staff of existing national diabetes programmes; consider the evaluation and further promotion of these programmes: stimulate the development of new national diabetes programmes; define educational needs; - - prepare a report with practical recommendations and guidelines. This report is now completed and is available upon request soon [12 I. A diabetes programme was defined operationally as a series of planned activities at the national, district or local level, which has the approval of the national authorities, stated objectives, a written protocol, time lines and a means of evaluation. Major goals of diabetes programmes are: to reduce incidence (primary prevention) -- to reduce complications (secondary/tertiary prevention) - to increase knowledge, awareness and skills to improve the effectiveness of a diabetes health care system, i.e., the degree to which desired results are achieved, and its efficiency, i.e., the relation between results and resources expended. Thus, it should reduce both cost and suffering. The most important prerequisites for diabetes programmes were identified as political support, leadership, resources, administrative structure and advocacy, both to the public and to the authorities. A sequence of consecutive steps was suggested for developing a diabetes programme:

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1. Obtain official approval 2. Form a steering/advisory committee and administrative structure 3. Appoint a motivated and accepted executive officer/teamleader 4. Undertake a situation analysis 5. Define the standards of diabetes care desired 6. Prioritize country-specific targets 7. Develop a plan of work, time frame and budget 8. Reach consensus with all parties involved 9. Obtain official endorsement 10. Implement the programme 11. Monitor and evaluate the programme 12. Revise the programme and develop additional components. The intersectoral steering/advisory committee should include all groups engaged in diabetes care. The programme manager should act through tertiary, secondary and primary centres of care and co-ordinate education and information services. The situation analysis should evaluate the burden of diabetes in the country, the needs and the resources available. Appropriate standards of care should be defined at the primary (the first medical contact), secondary (the first-level hospital) and tertiary (diabetes center) level of care. Knowledge, skills, material and equipment required at each level should be determined. The appropriate levels for definitive diagnosis, availability of insulin, drugs and diagnostics, specific diabetes education and specialist services must be decided. Consideration must be given to the referral system, diabetes in pregnancy, frequency of patient review, monitoring of control, etc. Country-specific targets must be derived and prioritized on the basis of the situation analysis, on the one hand, and the appropriate standards, on the other. Responsibilities should be defined, realistic time frames should be outlined, and the budget should be agreed and secured. The consensus of all parties involved is of the utmost importance for acceptance, conviction and 'ownership' of the programme. The official endorsement by the health authorities is necessary for every programme, especially in countries with highly centralized health care systems.

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ll. Gruber. H. Kin~,* Diabetes Re~seardl amt Clinical Practice 34 Szq~pl. (1996) SI $6

The actual implementation of the programme is the most important and demanding activity. It was the topic of the WHO meeting in Geneva in 1994, where the roles and responsibilities of the various parties involved in supportmg implementation were defined. It was recommended to start implementation in model areas, where the necessary leadership could be found, and to expand it thereafter. Monitoring and evaluation must be an integral part of all programmes, in order to recognize progress, strengths and weaknesses. It is recommended to focus on process indicators first, e.g., diagnostic and therapeutic abilities of health care providers, adequacy of professional and patient education, referral systems and specialist services, establishment of registers. Outcome measures may be evaluated thereafter (short-term: HbA~c, diabetic ketoacidosis, hospitalisations: long-term: new blindness, amputations, renal failure, obstetric outcomes, mortality). The WHO meeting in Geneva included a sequence of workshops to define needs, strategies and tactics, and actions and recommendations, respectively, for direct patient care, supporting agencies and the national/international administrative structures. Major difficulties and barriers to the implementation of national diabetes programmes were reviewed, and means to overcome them were suggested. The World Health Organization plays a major role in the promotion of national diabetes programmes. The meeting recommended that the organization should continue to prepare and publish information on the epidemiology of diabetes and its complications, and to define effective strategies for diabetes prevention. In co-operation, W H O Regional Offices and the diabetes programme at WHO Headquarters should provide national governments with general guidelines, as well as training and expertise, to help them to develop new programmes and to improve existing programmes. In addition, W H O Headquarters (globally) and the Regional Offices (regionally) can act as clearing houses/information centres for data collection,

programme monitoring and exchange of experience and technical information. They should develop and disseminate new methods of programme evaluation, and support their appropriate use. These efforts, with close co-operation of all parties involved, should result in improvements in diabetes control and care worldwide, for the benefit of all persons with diabetes, as well as the general community. References [I] King, H. and Zimmet. P. (1988) Trends in the prevalence and incidence of diabetes: non-insulin-dependent diabetes mellitus. World Health Stat. Q. 41, 190 196. [2] King, H. and Rewers, M. (1993) Global estimates for prevalence of diabetes mellitas and impaired glucose tolerance in adults. Diabetes Care 16. 157 177. [3] Prevention of Diabetes Mellitus: report of a WHO Study Group. Geneva, World Health Organization, 1994 (WHO Technical Report Series No. 844). [4] King, H. and Rewers, M. (1991) Diabetes in adults is now a third world problem. Bull. WHO 69(6), 643 648. [5] Neel, J.V. (1962) Diabetes mellitus: a thrifty genotype rendered detrimental by 'progress"? Am. J. Hum. Genet. 14, 353 362. [6] Rubin, J.R.. Altman, W.M. and Mendelson, D.N. (1994) Health care expenditures for people with diabetes mellitus. 1992. J. Clin. Endocrinol. Metab. 78, 809A F. [7] Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression o[ long-term complications in insulin-dependent diabetes mellitus. N. Engl. J. Med. 329, 977 986. [8] Reiber, G. and King, H. (1991) Guidelines for the development of a national programme for diabetes mellitus. Geneva, World Health Organization (WHO/DBO/DM/ 91.1). [9] Krans, H.M.J., Porta, M. and Keen, H. (Eds.) (1992) Diabetes care and research in Europe: the St. Vincent Declaration action programme. Copenhagen, WHO/IDF Europe (EUR/ICP/CLR055/3). [10] Alwan, A. (Ed.) (1993) Diabetes prevention and control: a call for action. Alexandria, WHO Regional Office for the Eastern Mediterranean, (WHO-EM/DIA/3/E/G). [11] Alwan, A. (Ed.) (1994) Management of diabetes mellitus: standards of care and clinical practice guidelines. WHO Regional Office for the Eastern Mediterranean, (WHOEM/DIA/6/E/G). [12] King, H., Gruber. W. and Lander, T. (1995) Implementing national diabetes programmes: report of a WHO meeting, Geneva, World Health Organization, (WHO/ DBO/DM/95.2).