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The Socio-economic Burden of Diabetes in Developing Countries Lessons from studies in Egypt Professor The Socio-economic Burden of Diabetes in Developing Countries Lessons from studies in Egypt Professor Morsi Arab Egypt

Socioeconomics of Diabetes 1 - The patient and human environment. 2 - Patient’s Right Socioeconomics of Diabetes 1 - The patient and human environment. 2 - Patient’s Right and Obligations. 3 - Factors deciding the burden of diabetes. 4 - Size of the problem : Prevalence 5 - Life Style 6 - The national cost 7 - Government and Household expenditure. 8 - Cost of O. P. care 9 -The hospital burden 10 - Costs comparative to other countries.

The people with Diabetes and their Environment IDF Media Diab. Associations Family Patient Public. The people with Diabetes and their Environment IDF Media Diab. Associations Family Patient Public. Com. Friends Health Care Team Pharm. Ind. Health Autho. WHO Syndicates

Determinants of impact • • 1. High prevalence 2. High cost of disease 3. Determinants of impact • • 1. High prevalence 2. High cost of disease 3. Low economics 4. Adverse social conditions

CAIRO CAIRO

Geographical distribution of the Egyptian population 1% 56% 43% Geographical distribution of the Egyptian population 1% 56% 43%

Age structure of the Egyptian population 60 -50 -40 -30 -20 -10 40 30 Age structure of the Egyptian population 60 -50 -40 -30 -20 -10 40 30 20 10 20 30 40

Prevalence (%) The estimated prevalence with DM by IDF region, 2000 Region Prevalence (%) The estimated prevalence with DM by IDF region, 2000 Region

Prevalence (%) Prevalence of DM in the whole of Egypt in different age groups Prevalence (%) Prevalence of DM in the whole of Egypt in different age groups ?

Prevalence (%) Prevalence of DM Age range Prevalence (%) Prevalence of DM Age range

Effect of change of the life style in migrating ethnic groups on metabolic parameters Effect of change of the life style in migrating ethnic groups on metabolic parameters related to diabetes A lesson from the Nubians of Egypt Professor Morsi Arab University of Alexandria - Egypt

%Prevalence (>40 yrs) Prevalence of DM in patients over 40 yrs %Prevalence (>40 yrs) Prevalence of DM in patients over 40 yrs

Conclusions 1. Changes in life style (diet & exercise( of susceptible individuals or groups Conclusions 1. Changes in life style (diet & exercise( of susceptible individuals or groups is liable to increase their predisposition to DM (incidence of transformation of IGT to DM and consequently increased DM prevalence). 2. The change is more profoundly demonstrated among groups that might be originally protected by some genetically inherited characteristics. 3. Most of the parameters of the metabolic syndrome seem to be closely bound together and are prone to change under the influence of the adverse changes of life style.

Controlled metabolic parameters (% in diab. population Egypt 2003 ) - Fasting Bl. Glucose Controlled metabolic parameters (% in diab. population Egypt 2003 ) - Fasting Bl. Glucose : 19. 8% - P. P Bl. Glucose : 21. 4% - S. Cholesterol : 56. 4 % - S. Triglycerides : 50. 4% - Syst. B. P. : 53. 7% - Diastolic B. P. : 64. 6%

Diabetes Complications (Egypt 2003) % in Diabetic population Retinopathy Neuropathy Nephropathy Cardiac Dis. Foot Diabetes Complications (Egypt 2003) % in Diabetic population Retinopathy Neuropathy Nephropathy Cardiac Dis. Foot ulcers Foot amputations Foot deformities : 32. 3% : 55. 5% : 5. 0% : 21. 3% : 6. 8% : 3. 0% : 1. 0%

The cost of Diabetes Data from Alexandria hospitals The cost of Diabetes Data from Alexandria hospitals

Allocation of Direct Costs in hospital DIRECT COST Out-patient • Medical supplies: – insulin Allocation of Direct Costs in hospital DIRECT COST Out-patient • Medical supplies: – insulin etc. … • Doctors • Lab charges Hospital care • Basal cost: – Salaries, equipment, food, water, electricity’ laundry etc. • Control of diabetes: – Insulin, OHA, medical supplies • Rx complications: – Antibiotics, laser, haemodialysis , surgery etc.

Indirect Costs • Loss of working hours PRODUCTION • Diabetes mortality • Premature death Indirect Costs • Loss of working hours PRODUCTION • Diabetes mortality • Premature death

The cost of diabetes in Egypt Alexandria Hospitals (86/88) • O. P. care (per The cost of diabetes in Egypt Alexandria Hospitals (86/88) • O. P. care (per person per year) – Doctors’ charges: 35. 84 L. E. – Medical supplies 30. 36 L. E. – Laboratory charges 19. 68 L. E. 85. 88 L. E. per year • In-patient hospital care – Average total cost for one single admission/year, at average stay: 148. 31 L. E. per year

The economic burden of direct cost of DM • Total direct cost of diabetes The economic burden of direct cost of DM • Total direct cost of diabetes in 1986: 160 m • Average inflation rate (1986 -90) 11. 85% • Estimated total direct cost in 1990 235. 2 m • Total Government expenditure on health, 1990: – National production 31. 3 bn – Government expenditure at 40% 12. 6 bn – 2. 8% Gov. expenditure on health 351. 8 m

Cost of DM in relation to funds available DIRECT COST OF TREATMENT OF DM Cost of DM in relation to funds available DIRECT COST OF TREATMENT OF DM AVAILABLE GOVERNMENT EXPENDITURE ON HEALTH L. E. 235. 2 m L. E. 351. 8 m 2/3!!

National economics and Reflections on health PARAMETERS • Per capita income • %Government expenditure National economics and Reflections on health PARAMETERS • Per capita income • %Government expenditure on health • % Household consumption

Gross National Product/Capita $000 s N I E S EE Gross National Product/Capita $000 s N I E S EE

Percentage share of government expenditure % N Health I E Education S EE Defence Percentage share of government expenditure % N Health I E Education S EE Defence

Percentage share of total household consumption % N Medical care I E Total food Percentage share of total household consumption % N Medical care I E Total food S EE Education

Middle East Countries - economic status HIGH ECONOMY MIDDLE ECONOMY • Kuwait • Emerates Middle East Countries - economic status HIGH ECONOMY MIDDLE ECONOMY • Kuwait • Emerates LOW ECONOMY • Iraq • Qatar • Syria • Cyprus • Bahrain • Jordan • Iran • Oman • Tunisia • Saudi Arabia • Egypt • Libya • Israel • Turkey • Yemen >5, 000 US$ <2, 000 US$

Cost of out-patient ambulatory care of DM in Egypt compared with other Mediterranean countries Cost of out-patient ambulatory care of DM in Egypt compared with other Mediterranean countries (US$/month) *including treatment by dialysis

Socio-economics - Some health and education parameters in 20 African countries Socio-economics - Some health and education parameters in 20 African countries

Socio-economics Increasing total calorific intake Socio-economics Increasing total calorific intake

Distribution of costs of Hospital Treatment of Diabetic Patients ( L. E. per day Distribution of costs of Hospital Treatment of Diabetic Patients ( L. E. per day ) at a Private Hospital for Middle Class Egyptian Population at the City of Alexandria , Egypt 2001

Distribution of Hospital Cost 55% Medicine & Supp. 45% Basic ( Food : 5% Distribution of Hospital Cost 55% Medicine & Supp. 45% Basic ( Food : 5% H. C. Team 11% Others: 29%)

Hospital Treatment 2001 Cost /Day Hospital Treatment 2001 Cost /Day

Estimated Costs of Ambulatory (out patient) Treatment of Diabetes in Egypt at 2001 Cost Estimated Costs of Ambulatory (out patient) Treatment of Diabetes in Egypt at 2001 Cost Prices in USD/ year )A) Insulin ( Dose 10 -80 units /d ) )B) Oral Antidiabetic Agents * Heavily subsidized ** moderately subsidized

Cost of O. P. Treatment (Egypt 2001) $/ y Animal u/40 Human u/100 Human/pen Cost of O. P. Treatment (Egypt 2001) $/ y Animal u/40 Human u/100 Human/pen Metformin Glibenclam Gliclazide Glimeperide Rapiglinide Nateglinide Rosiglitazone

Estimated Costs of Ambulatory (out patient) Treatment of Diabetes in Egypt at 2001 Cost Estimated Costs of Ambulatory (out patient) Treatment of Diabetes in Egypt at 2001 Cost Prices in USD/ year ( Cont. ) )C ) Other costs at average frequencies per year Laboratory , and other follow – up investigations 76. 4 (E. C. G radiol. , etc. ) Physician fees and other specialist consultations Total 66. 6 143 USD/Year

The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income Middle East Countries, based on the Cost Prices of Insulins and Oral Antidiabetic Agents (in USD per year) *Heavily subsidized ** moderately subsidized

Year Cost / percapit. Burden for Human Insulin (40 u /d) 8. 85% EGYPT Year Cost / percapit. Burden for Human Insulin (40 u /d) 8. 85% EGYPT 1. 9% QATAR 3. 1% SAUDI ARABIA

The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income Middle East Countries , based on the Cost Prices of Insulins and Oral Antidiabetic Agents )in USD per year) (Cont(.

The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income The Burden of the Cost of Ambulatory Treatment of Diabetes on Individuals at Low-Income and High-Income Middle East Countries , based on the Cost Prices of Insulins and Oral Antidiabetic Agents )in USD per year) (Cont(.

Cost Burden of Oral Treatment related to Percapitum 4. 2% 29. 9% EGYPT QATAR Cost Burden of Oral Treatment related to Percapitum 4. 2% 29. 9% EGYPT QATAR 8. 4% SAUDI ARABIA

Socio-economic impact on diabetes education 1. Lower economy; – less available resources for education Socio-economic impact on diabetes education 1. Lower economy; – less available resources for education 2. Lack of rational plan for: – patient education – physician education – other health personnel (nurses, dieticians, foot care etc…) – general public (awareness: food intake, obesity, exercise, early detection etc…) -1

Socio-economic impact on diabetes education 3. Lack of government awareness – of cost/benefit of Socio-economic impact on diabetes education 3. Lack of government awareness – of cost/benefit of education 4. Maldistribution – of available education facilities (urban/rural) 5. High illiteracy – adversely affects diabetes education & requires special methods -2

Socio-economic impact on diabetes education 6. Misconceptions &. . . 7. Special education programmes Socio-economic impact on diabetes education 6. Misconceptions &. . . 7. Special education programmes – e. g for Ramadan fasting 8. Need to tailor diabetes education – & arrangements to suit local habits, traditions & lifestyle -3

Alexandrie – Palais du Montazah Thank You Alexandrie – Palais du Montazah Thank You