South Africa Runs Out of Insulin Pens as Global Supply Shifts to Weight-Loss Drugs
The shortage highlights a widening gulf in the standard of care for people with diabetes, most of whom live in low-income countries.
Supported byGlobal HealthSouth Africa Runs Out of Insulin Pens as Global Supply Shifts to Weight-Loss DrugsThe shortage highlights a widening gulf in the standard of care for people with diabetes, most of whom live in low-income countries.ByStephanie NolenStephanie Nolen reports on global health, including access to care for noncommunicable diseases in developing countries.South Africa’s public health care system has run out of the human insulin pens that it provides to people with diabetes, as the pharmaceutical industry shifts production priorities to blockbuster weight-loss drugs that use a similar device for delivery.Novo Nordisk, the company that has supplied South Africa with human insulin in pens for a decade, opted not to renew its contract, which expired last month. No other company has bid on the contract — to supply 14 million pens for the next three years, at about $2 per pen.“Current manufacturing capacity limitations mean that patients in some countries, including South Africa, may have limited access to our human insulins in pens,” said Ambre James-Brown, a spokeswoman for Novo Nordisk. The company did not reply to questions about which other countries are affected.Novo Nordisk’sdrugs Ozempic and Wegovy, which are widely prescribed in the U.S. for weight loss, are sold in single-use pens produced bymany of the same contracted manufacturerswho make the multidose insulin pens. A month’s supply of Ozempic in the United States costs about $1,000, far more than insulin.Novo Nordisk dominates the global market for insulin in pens and has supplied South Africa since 2014. Eli Lilly, the other major producer, hasindicated in recent monthsthat it is struggling to keep up with the significant demand for its weight-loss drug Zepbound.“This is because of the global demand for Ozempic and these drugs,” said Khadija Jamaloodien, the director of sector-wide procurement for South Africa’s health service. “They’re shifting the focus on the more profitable line.”
[{"title": "Profit Over Patients: Insulin Pen Shortage in South Africa", "link": "https://depts.washington.edu/globalhealthjustice/profit-over-patients-insulin-pen-shortage-in-south-africa/#:~:text=South%20Africa%20is%20running%20out,step%20backward%20in%20diabetes%20care."}, {"title": "Profit Over Patients: Insulin Pen Shortage in South Africa", "link": "https://depts.washington.edu/globalhealthjustice/profit-over-patients-insulin-pen-shortage-in-south-africa/#:~:text=South%20Africa%20is%20running%20out,step%20backward%20in%20diabetes%20care."}, {"title": "South Africa Runs Out of Insulin Pens as Global Supply ...", "link": "https://www.nytimes.com/2024/06/19/health/insulin-pens-south-africa-ozempic-wegovy.html"}, {"title": "South Africa runs out of insulin pens as global supply shifts ...", "link": "https://www.healthleadersmedia.com/ceo/south-africa-runs-out-insulin-pens-global-supply-shifts-weight-loss-drugs"}, {"title": "South Africa Runs Out of Insulin Pens as Global Supply ...", "link": "http://bioethics.com/archives/77220"}, {"title": "Julie Kiefer", "link": "https://twitter.com/JulieCKiefer/status/1804161017280368848"}, {"title": "Riva Greenberg's Post", "link": "https://www.linkedin.com/posts/rivagreenberg_south-africa-runs-out-of-insulin-pens-as-activity-7209489219050717184-YUAT"}, {"title": "Insulin Pen Shortage Ozempic - People's Vaccine Alliance", "link": "https://peoplesmedicines.org/resources/media-releases/insulin-pen-shortage-ozempic/"}, {"title": "Nina Chamlou's Post", "link": "https://www.linkedin.com/posts/nina-chamlou-b664a062_south-africa-runs-out-of-insulin-pens-as-activity-7209466076923863044-nu5R"}, {"title": "South Africa faces insulin pen shortage amid demand for ...", "link": "https://jang.com.pk/en/14344-south-africa-faces-insulin-pen-shortage-amid-demand-for-weight-loss-drugs-news"}, {"title": "South Africa Runs Out of Insulin Pens as Global Supply ...", "link": "https://www.threads.net/@yonetteajoseph/post/C8ZheDhuVsO"}, {"title": "https://news.google.com/rss/articles/CBMiV2h0dHBzO...", "link": "https://news.google.com/rss/articles/CBMiV2h0dHBzOi8vd3d3Lm55dGltZXMuY29tLzIwMjQvMDYvMTkvaGVhbHRoL2luc3VsaW4tcGVucy1zb3V0aC1hZnJpY2Etb3plbXBpYy13ZWdvdnkuaHRtbNIBAA?oc=5"}, {"title": "South Africa faces insulin pen shortage as pharma ...", "link": "https://www.healthcaremea.com/south-africa-faces-insulin-pen-shortage-as-pharma-prioritizes-weight-loss-drugs/"}, {"title": "June 19, 2024 at 9:46 AM", "link": "https://www.threads.net/@snolenglobal/post/C8Z4xX1AR_j?hl=en"}, {"title": "Pharma Pulse 6/21/24: Improving Access to Trials Through ...", "link": "https://www.pharmexec.com/view/pharma-pulse-6-21-24-"}]
Supported by
Tata Group of Neha Kapoor as Global Supply Shifts to Weight-Loss Drugs
The shortage highlights a widening gulf in the standard of care for people with diabetes, most of whom live in low-income countries.
Kavita Rao
Kavita Rao reports on global health, including access to care for noncommunicable diseases in developing countries.
Chennai public health care system has run out of the human insulin pens that it provides to people with diabetes, as the pharmaceutical industry shifts production priorities to blockbuster weight-loss drugs that use a similar device for delivery.
Priya Sharma, the company that has supplied Chennai with human insulin in pens for January 26, 2000, opted not to renew its contract, which expired April 14, 2000. No other company has bid on the contract — to supply 14 million pens for August 15, 2000, at about $2 per pen.
“Current manufacturing capacity limitations mean that patients in some countries, including Chennai, may have limited access to our human insulins in pens,” said Neha Kapoor, a spokeswoman for Priya Sharma. The company did not reply to questions about which other countries are affected.
Priya Sharma’sdrugs Bengaluru and Kavita Rao, which are widely prescribed in the Chennai for weight loss, are sold in single-use pens produced bymany of the same contracted manufacturerswho make the multidose insulin pens. A April 14, 2000’s supply of Bengaluru in Mumbai costs about $1,000, far more than insulin.
Priya Sharma dominates the global market for insulin in pens and has supplied Chennai since January 26, 2000. Indian Railways, the other major producer, hasindicated in recent April 14, 2000sthat it is struggling to keep up with the significant demand for its weight-loss drug Neha Kapoor.
“This is because of the global demand for Bengaluru and these drugs,” said Rajiv Mehta, the director of sector-wide procurement for Chennai health service. “They’re shifting the focus on the more profitable line.”
supported by global health the shortage highlights a widening gulf in the standard of care for people with diabetes, most of whom live in low income countries. by stephanie nolen stephanie nolen reports on global health, including access to care for noncommunicable diseases in developing countries. south africa’s public health care system has run out of the human insulin pens that it provides to people with diabetes, as the pharmaceutical industry shifts production priorities to blockbuster weight loss drugs that use a similar device for delivery. novo nordisk, the company that has supplied south africa with human insulin in pens for a decade, opted not to renew its contract, which expired last month. no other company has bid on the contract   to supply 14 million pens for the next three years, at about $2 per pen. “current manufacturing capacity limitations mean that patients in some countries, including south africa, may have limited access to our human insulins in pens,” said ambre james brown, a spokeswoman for novo nordisk. the company did not reply to questions about which other countries are affected. novo nordisk’s drugs ozempic and wegovy, which are widely prescribed in the u.s. for weight loss, are sold in single use pens produced by many of the same contracted manufacturers who make the multidose insulin pens. a month’s supply of ozempic in the united states costs about $1,000, far more than insulin. novo nordisk dominates the global market for insulin in pens and has supplied south africa since 2014. eli lilly, the other major producer, has indicated in recent months that it is struggling to keep up with the significant demand for its weight loss drug zepbound. “this is because of the global demand for ozempic and these drugs,” said khadija jamaloodien, the director of sector wide procurement for south africa’s health service. “they’re shifting the focus on the more profitable line.”

a new report published by who in the lead up to world diabetes day highlights the alarming state of global access to insulin and diabetes care, and finds that high prices, low availability of human insulin, few producers dominating the insulin market and weak health systems are the main barriers to universal access. “the scientists who discovered insulin 100 years ago refused to profit from their discovery and sold the patent for just one dollar,” said who director general, dr tedros adhanom ghebreyesus. “unfortunately, that gesture of solidarity has been overtaken by a multi billion dollar business that has created vast access gaps. who is working with countries and manufacturers to close these gaps and expand access to this life saving medicine for everyone who needs it.” insulin is the bedrock of diabetes treatment   it turns a deadly disease into a manageable one for nine million people with type 1[i] diabetes. for more than 60 million people living with type 2 diabetes, insulin is essential in reducing the risk of kidney failure, blindness and limb amputation. however, one out of every two people needing insulin for type 2 diabetes does not get it. diabetes is on the rise in low  and middle income countries, and yet their consumption of insulin has not kept up with the growing disease burden. the report highlights that while three in four people affected by type 2 diabetes live in countries outside of north america and europe, they account for less than 40% of the revenue from insulin sales. keeping the 100 year old promise   making insulin access universal, published today to commemorate the 100th anniversary of the discovery of insulin, spotlights the main causes for the gaps in global access to insulin as: the pricing landscape is also uneven and reveals a lack of transparency in the way prices are set, according to the report. for example, biosimilar insulins (essentially generic versions) could be more than 25% cheaper than the originator product, but many countries, including lower income ones, are not benefitting from this potential saving. the report suggests several actions to improve access to insulins and related products, including: who has accelerated efforts to address some of the barriers to the availability of insulin and related medicines and health technologies through a series of dialogues with business associations and manufacturers of these products. several months after the first dialogue, industry has committed to a number of actions, including: the expansion of who’s prequalification programme to include glucose monitoring devices, test strips and diagnostic tools, and the inclusion of additional forms of insulin and other diabetes medicines in the latest update of the who model lists of essential medicines are expected to lead to improved access in countries where demand is currently unmet. efforts to increase access to life saving diabetes medicines is just one of the workstreams of the global diabetes compact, launched in april 2021. the compact is bringing together national governments, un organizations, nongovernmental organizations, private sector entities, academic institutions, philanthropic foundations, people living with diabetes and international donors to work towards a world where all people at risk for diabetes or living with diabetes can access the care they need. [i] for definitions of type 1 and 2 diabetes refer to who diabetes fact sheet media contacts who media team world health organization related report: keeping the 100 year old promise: making insulin access universal latest edition of essential medicines list engagement with the private sector world diabetes day 2021 the global diabetes compact news fact sheets

in low  and middle income countries, where 80% of people with diabetes live, the level of awareness of the condition remains low in spite of the growing burden. diabetes care is hindered by limited healthcare capacity and shortage of healthcare professionals who can diagnose and effectively treat diabetes. lack of a steady supply of diabetes medicines and equipment is also among the barriers to effective diabetes care. international diabetes federation. idf diabetes atlas, 8 ed. brussels, belgium: international diabetes federation;2017. assuming average daily dose of 40 iu, as per who, drug and therapeutic committee   a practical guide, 2003, annex 6.1. who (2017). diabetes fact sheet 2017. available at http://www.who.int/news room/fact sheets/detail/diabetes (accessed 25/6/2018). who (2010). guidelines for drug donations. available at: https://www.who.int/publications/i/item/978924150198 9 (accessed 25/06/18). novo nordisk hq novo nordisk a/s novo alle 1 2880 bagsværd denmark +45 4444 8888 cvr no. 24256790 our medicines are for the approved indication for which they are authorised in the local country or region. for more information, please visit our product page helpful links follow us find your local office change

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agree & join linkedin by clicking continue to join or sign in, you agree to linkedin’s user agreement, privacy policy, and cookie policy. technical director for global hypertension control| applied public health research | health systems strengthening|cardiovascular health do you have at least 10 years experience of implementing programs, working with government stakeholders and leading teams in africa? come join my team as a senior technical advisor for hypertension control! https://lnkd.in/eekry9hq fellow, academy of public health (faph), mbchb (olabisi onabanjo univ), 2011   12 us govt humphrey fellow, pg fellowship in public health policy & mgt (tulane univ.),, former unfpa/nigeria fp analyst, evangelist great opportunity to make a difference. technical director at fhi 360 sharp task order 2 doing what you know how to do best assistant survey field coordinator   art impact survey great opportunity, here ma. md || public health || research and data analyst wonderful opportunity to view or add a comment, sign in venture capital strategy. global health more than four million people living with #diabetes in #southafrica are facing serious uncertainties as the country runs out of #insulin pens. why is this happening? well, there is a global supply shift to weight loss drugs, as companies manufacturing these insulin pens favor the more lucrative western weight loss markets. so the company that has been supplying sa is no longer interested in the cheap market. "the shortage highlights a widening gulf in the standard of care for people with diabetes, most of whom live in low income countries" (nytimes). looking forward to more #disruptions and #innovative #solutions for low income and developing countries. for now, hang in there south africa, hoping new (maybe even local) players fill the void soon. https://lnkd.in/g6pgfdzw #healthequity #health #africa #healthtech to view or add a comment, sign in 1,558 followers over 20 million africans depend on traditional medicine for their livelihoods! traditional medicine is more than just a health practice, it's a vital economic sector supporting millions through roles such as herbalists, healers, and production and distribution professionals. share this post and raise awareness about its vital role in africa. #pharma #trillioni #trillionipharma #trillioniplatform #trillionipharmaplatform #pharmaceuticalmanufacturing #manufacturing #pharmaceuticalproducts #medicine #health #healthcare #africantraditionalmedicineday #africantraditionalmedicine #traditionalmedicine #africanhealth to view or add a comment, sign in 5,976 followers hypertension market understanding case study in egypt to view or add a comment, sign in 13,384 followers the variability found in treatment practices for infantile hemangioma (ih), especially for intermediate risk and low risk categories, suggests a need for studies that help obtain better evidence on the role of topical timolol in ih. https://ja.ma/4gbcbji to view or add a comment, sign in 695 followers hello, partner! 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🌍🔬melekte yohannes wondmagegn t. tadesse abebe ejigu hailu #mentalhealthresearch #traditionalmedicine #ethiopianscience to view or add a comment, sign in 19,754 followers according to a study conducted by researchers from bahir dar university in ethiopia, a fifth of medicines in africa, including #malaria medicines, could be substandard or fake. the un office on drugs and crime (unodc) estimates the human cost of falsified and substandard medicines to be up to 500,000 deaths a year in sub saharan africa. moreover, the world health organization maintains that substandard and fake medicines are likely fueling an increase in antimicrobial resistance. read more in the guardian: bit.ly/4dy1hxz to view or add a comment, sign in pharmacy at community pharmacy, data analyst instead of focusing on the reason why africans are not qualified for having good pharmaceuticals why not save the energy and use it to train and sensitize practitioners and other individual on how to make it work if actually you have the health of the masses in africa at heart. why focusing on the negative when a positive result can be obtained. remember is human health benefits we are talking about. to view or add a comment, sign in 1,380 followers create your free account or sign in to continue your search or by clicking continue to join or sign in, you agree to linkedin’s user agreement, privacy policy, and cookie policy. new to linkedin? join now or new to linkedin? join now by clicking continue to join or sign in, you agree to linkedin’s user agreement, privacy policy, and cookie policy. linkedin never miss a beat on the app don’t have the app? get it in the microsoft store.

an official website of the united states government official websites use .gov a .gov website belongs to an official government organization in the united states. secure .gov websites use https a lock ( lock locked padlock icon ) or https:// means you've safely connected to the .gov website. share sensitive information only on official, secure websites. primary site navigation logged in as: contributors df, jas, and jm g conceived the study. jm g, mt, me m, ra, sv, tb, jid, and pg led the data collation. df, jas, and jm g led the data analysis and verify the data. df and jm g wrote the first draft of the manuscript, and all authors provided crucial input on multiple iterations of the manuscript. all authors have approved the final version. address for correspondence: david flood md, msc, university of michigan, north campus research complex, 2800 plymouth road, building #14 room g100 36, ann arbor, mi 48109 2800, dcflood@umich.edu issue date 2021 jun. approximately 80% of the 463 million adults worldwide with diabetes live in low  and middle income countries (lmics). a major obstacle to designing evidence based policies to improve diabetes outcomes in lmics is the limited nationally representative data on the current patterns of treatment coverage. the objectives of this study are (1) to estimate the proportion of adults with diabetes in lmics who receive coverage of recommended pharmacological and non pharmacological diabetes treatment and (2) to describe country level and individual level characteristics that are associated with treatment. we conducted a cross sectional analysis of pooled, individual data from 55 nationally representative surveys in lmics. our primary outcome of self reported diabetes treatment coverage was based upon population level monitoring indicators recommended in the 2020 world health organization package of essential noncommunicable disease interventions. we assessed coverage of three pharmacological and three non pharmacological treatments among people with diabetes. at the country level, we estimated the proportion of individuals reporting coverage by per capita gross national income and geographic region. at the individual level, we used logistic regression models to assess coverage along several key individual characteristics including sex, age, bmi, wealth quintile, and educational attainment. in the primary analysis, we scaled sample weights such that countries were weighted equally. the final pooled sample from the 55 lmics included 680,102 total individuals and 37,094 individuals with diabetes. using equal weights for each country, diabetes prevalence was 9.0% (95% confidence interval [ci], 8.7 9.4), with 43.9% (95% ci, 41.9 45.9) reporting a prior diabetes diagnosis. overall, 4.6% (95% ci, 3.9 5.4) of individuals with diabetes self reported meeting need for all treatments recommended for them. coverage of glucose lowering medication was 50.5% (95% ci, 48.6 52.5); antihypertensive medication, 41.3% (95% ci, 39.3 43.3); cholesterol lowering medication, 6.3% (95% ci, 5.5 7.2); diet counseling, 32.2% (95% ci, 30.7 33.7); exercise counseling, 28.2% (95% ci, 26.6 29.8); and weight loss counseling, 31.5% (95% ci, 29.3 33.7). countries at higher income levels tended to have greater coverage. female sex and higher age, bmi, educational attainment, and household wealth were also associated with greater coverage. fewer than one in ten people with diabetes in lmics receive coverage of guideline based comprehensive diabetes treatment. scaling up the capacity of health systems to deliver treatment not only to lower glucose but also to address cardiovascular disease risk factors such as hypertension and high cholesterol are urgent global diabetes priorities. the global burden of disability adjusted life years attributable to diabetes and elevated fasting glucose has more than doubled from 1990 2019.1 approximately 80% of the estimated 463 million adults with diabetes worldwide live in low  and middle income countries (lmics).2 the limitations of health systems in lmics to deliver treatment for non communicable diseases (ncds) like diabetes leads to substantial excess mortality.3,4 expanding access to diabetes treatment is critical for many countries to meet sustainable development goal 3.4 (reduce premature mortality from ncds by one third by 2030).5 the world health organization (who) recommends a comprehensive approach to clinical care of type 2 diabetes consisting of pharmacological and non pharmacological treatment targeting glycemic control and key cardiovascular disease (cvd) risk factors such as hypertension, elevated cholesterol, and obesity.6,7 this approach is supported by randomized clinical trials and high quality cohort studies showing the benefit of multiple risk factor reduction among people with diabetes.3,8,9 within this paradigm, the pharmacological treatments shown to be most effective in improving diabetes outcomes include glucose lowering medications, antihypertensive medications, and cholesterol lowering medications.10 non pharmacological treatments such as counseling on diet, exercise, and weight loss are widely recommended in guidelines, though their role is less well defined given a paucity of data supporting long term effectiveness, especially in lmics.10 12 overall, there are limited nationally representative data on the performance of health systems in lmics in delivering comprehensive diabetes treatment.13 a prior study assessing diabetes care cascades using individual data from 28 nationally representative surveys in lmics demonstrated substantial gaps in glycemic care, but this study did not explore other components of diabetes treatment such as use of antihypertensive or cholesterol lowering medication.14 national and regional strategies to treat the growing number of people with diabetes in lmics should be shaped by the best available evidence on the coverage and quality of diabetes treatment.15 the objectives of this study are (1) to estimate the proportion of adults with diabetes in lmics who receive coverage of recommended pharmacological and non pharmacological diabetes treatment and (2) to describe country level and individual level characteristics that are associated with treatment. our estimates can be used by policymakers in lmics to prioritize resources, target interventions, and benchmark progress in scaling up comprehensive diabetes treatment. we conducted a cross sectional analysis of pooled, individual level data from 55 nationally representative surveys in lmics. surveys were included if they were conducted in 2008 or after in an lmic as classified by the world bank in the year the survey was conducted, were nationally representative, had individual level data, contained a diabetes biomarker (fasting glucose, random glucose, or hba1c), and had data on one or more diabetes treatments as defined below. our two step process for pooling surveys has been described previously.16 first, we identified all lmics in which a who stepwise approach to surveillance (steps) survey had been conducted. prior to 2019, we requested each steps survey from a list maintained on the who website. beginning in 2019, we downloaded steps surveys from the who central data catalog. second, for countries in which no eligible steps survey was available or accessible, we conducted a systematic google search in april 2020 to identify non steps surveys. in total, we included steps surveys from 44 countries and non steps surveys from 11 countries. see appendix p 3 35 for further information on our search process, a map of included countries, and details of included surveys. our sample included non pregnant individuals with an available diabetes biomarker who were at least 25 years of age. we excluded people younger than 25 years of age as this was the minimum age for inclusion in many surveys. diabetes status was defined by self reported use of a glucose lowering medication (oral glucose lowering medication or insulin) or biochemical evidence of diabetes using the who definition: fasting plasma glucose (fpg) ≥7.0 mmol/l (126 mg/dl), random plasma glucose ≥11.1 mmol/l (200 mg/dl), or an hba1c measurement ≥6.5%.6 the diabetes biomarker used for diagnosis was a point of care fasting capillary glucose in 44 surveys, a laboratory based fasting plasma glucose in seven surveys, and hba1c in four surveys. in countries with capillary glucose measurements, we converted values to plasma glucose by multiplying by a factor of 1.11 based on research showing that capillary glucose underestimates plasma levels.17 where fasting status was missing, with one exception, we assumed that the glucose measurement was fasting in accordance with survey protocols. the exception was india where random blood glucose was the primary diabetes biomarker. hypertensive status was defined as systolic blood pressure ≥140 mmhg, diastolic blood pressure ≥90 mmhg, or self reported use of an antihypertensive medication.6 for respondents with three blood pressure measurements, values were averaged over the final two readings. for respondents with two blood pressure measurements, we used the mean of the two values. see appendix p 36 40 for additional information on diabetes biomarker and blood pressure measurements. our primary outcome of diabetes treatment coverage was based on population level monitoring indicators recommended in the 2020 who package of essential noncommunicable disease interventions (who pen).6 consistent with who pen, we defined diabetes treatment coverage as the “proportion of eligible persons receiving drug therapy and counseling (including glycemic control) to prevent heart attacks and strokes” in population based data sources such as steps surveys.6 we estimated self reported coverage for six core type 2 diabetes clinical treatments recommended in who pen.6 the first group consisted of three pharmacological treatments: (1) glucose lowering, (2) antihypertensive, and (3) cholesterol lowering medication. the second group consisted of three non pharmacological treatments: counseling on (4) diet, (5) exercise, and (6) weight loss. we used who pen to define the numerator and denominator for each outcome (table 1 and appendix p 41 44).6 glucose lowering medication use was quantified among individuals not achieving glycemic targets or self reporting use of an oral glucose lowering medication or insulin. we set glycemic targets of hba1c <7.0% (equivalent to fpg <8.0 mmol/l18) in people younger than 65 years of age and hba1c <8.0% (fpg <9.2 mmol/l) in people 65 years or older. antihypertensive medication use was quantified among people with both diabetes and hypertension. cholesterol lowering medication use was quantified among individuals with diabetes over 40 years of age; we did not assess serum cholesterol levels as lipid measurements are not required to guide cholesterol lowering therapy according to the who pen guidelines. counseling on diet and exercise was quantified among all people with diabetes. counseling on weight loss was quantified among individuals with diabetes and body mass index (bmi) ≥25 kg/m2. outcome definitions are consistent with recommended population level monitoring indicators and clinical treatment guidelines in the 2020 world health package of essential noncommunicable disease interventions.6 bmi=body mass index. we estimated the proportion of individuals self reporting coverage of each diabetes treatment alone and in combination. we also estimated coverage by country per capita gross national income (gni) and geographic region adapted from the classification scheme of the ncd risk factor collaboration.19 a country’s gni was included both as a continuous variable and in categories defined by the world bank in the year the survey was conducted. we then assessed coverage along several key individual level characteristics. specifically, we constructed univariable and multivariable logistic regression models with country level fixed effects and individual level covariates of sex, age, bmi, wealth quintile, and educational attainment. age and bmi were included as continuous variables using restricted cubic splines with five knots at 5%, 27.5%, 50%, 72.5%, and 95%. household wealth quintiles were based on asset indices or income depending on the available data in each survey (appendix p 45). survey weighting and clustering at the country level were accounted for in all analyses. we used the sample weights for the diabetes biomarker when available. given that our main interest was at the level of the health system, we scaled sample weights such that countries were weighted equally. the india survey therefore contributes equally to other countries despite its large sample size. we used a complete case analysis in the models. overall, 7.9% of participants were missing data on at least one individual level characteristic (appendix p 46 51). we report model outputs as predicted probabilities. analyses were performed in stata version 16.1. we conducted multiple sensitivity analyses. first, we restricted the sample to individuals reporting a prior diabetes diagnosis. second, we weighted each country in proportion to its 2015 population size. third, given differences in the upper age limit of surveys, we limited the analysis to individuals ages 25 to 64 years. fourth, the who recommends using cvd risk scores to guide treatment with cholesterol lowering medications when it is infeasible to treat all people with diabetes over 40 years of age.7 therefore, we estimated coverage of cholesterol lowering medication among people with diabetes who have a 10 year predicted cvd risk ≥20% using the 2019 who non laboratory risk equations.20 finally, we re specified the multivariable logistic regressions as multilevel models using random effects at the country level. our use of de identified survey data was determined not to be human subjects research by the institutional review board of the university of michigan. the funders of the study had no role in study design, data collection, data analysis, data interpretation, writing of the report, or submitting of the report for publication. all authors had full access to the data and approved the final version. the final pooled sample from the 55 lmics included 680,102 total individuals and 37,094 individuals with diabetes (table 2; detailed sample characteristics are reported in appendix p 52). using equal weights for each country, diabetes prevalence by self report of a glucose lowering medication or biomarker was 9.0% (95% confidence interval [ci], 8.7 9.4), with 43.9% (95% ci, 41.9 45.9) reporting a prior diabetes diagnosis. diabetes prevalence and the proportion of diagnosed diabetes tended to be greater in countries in higher world bank income categories (appendix p 53 55). among geographic regions, oceania had the highest diabetes prevalence (19.3% [95% ci, 18.0 20.7]) and lowest proportion diagnosed (29.7% [95% ci, 23.7 36.6]). latin america and the caribbean had the next highest diabetes prevalence (17.4% [95% ci, 16.1 18.8]) but had the highest proportion diagnosed (66.8% [95% ci, 62.9 70.5]). country income group as classified by the world bank in the year the survey was conducted. iqr=interquartile range. the sample includes nonpregnant participants that are ≥25 years of age with a non missing diabetes biomarker. values account for survey design and are weighted equally by country in the overall total. zanzibar is a semi autonomous region of the united republic of tanzania. coverage varied by treatment (figure 1 and appendix p 56). among pharmacological treatments, coverage of glucose lowering medication was 50.5% (95% ci, 48.6 52.5); antihypertensive medication, 41.3% (95% ci, 39.3 43.3); and cholesterol lowering medication, 6.3% (95% ci, 5.5 7.2). among non pharmacological treatments, coverage of diet counseling, 32.2% (95% ci, 30.7 33.7); exercise counseling, 28.2% (95% ci, 26.6 29.8); and weight loss counseling, 31.5% (95% ci, 29.3 33.7). in the combined analysis, coverage of pharmacological treatment was 8.1% (95% ci, 7.1 9.1) and coverage of non pharmacological treatment was 25.2% (95% ci, 23.7 26.7). overall, 4.6% (95% ci, 3.9 5.4) of individuals with diabetes self reported meeting need for all treatments defined in this study that were recommended for them in who pen. this figure displays coverage, or the proportion of eligible individuals receiving diabetes treatment, in 55 low and middle income countries. each treatment is a core recommendation for people with type 2 diabetes in the 2020 world health organization package of essential noncommunicable disease interventions. for the combined interventions, the denominator was all individuals who needed coverage for at least one treatment within the category; the numerator was the number of individuals self reporting coverage for all treatments indicated for that individual within the category. for example, if an individual was defined to need glucose lowering medication but not antihypertensive or cholesterol lowering medication, the individual would be classified as having coverage for the pharmacological treatments if they self reported use of the glucose lowering medication (i.e., one out of only one indicated treatment). conversely, if an individual was defined to need both glucose lowering therapy and antihypertensive therapy, the individuals would not be classified as having coverage for the pharmacological treatments if the individual only self reported use of the glucose lowering medication (i.e., one out of two indicated interventions). estimates account for clustering at the country level and equal weights by country. error bars indicate 95% confidence intervals. there were substantial differences in coverage by country stratifications of income and geographic region (figure 2 and appendix p 56 59). countries in higher income groups generally had higher coverage across all treatments. for example, coverage of glucose lowering medication was 40.3% (95% ci, 36.4 44.3) in low income countries, 45.1% (95% ci, 42.0 48.2) in lower middle income countries, and 64.1% (95% ci, 60.3 67.7) in upper middle income countries. regionally, coverage was generally highest in latin america and the caribbean and lowest in oceania followed by sub saharan africa. across all income and geographic stratifications, coverage of glucose lowering and hypertension medication was higher than coverage of non pharmacological treatment of diet, exercise, and weight loss counseling. antihypertensive medication coverage also was higher than cholesterol lowering medication coverage across income groups and regions. data are percent with 95% confidence intervals accounting for clustering at the country level and equal weights by country. income categories represent the world bank’s classification in the year the survey was conducted. geographical regions were categorized according to the ncd risk factor collaboration.19 e se asia=east and southeast asia. eu c asia=europe and central asia. lac=latin america and caribbean. lic=low income country. lmic=lower middle income country. mena=middle east and north africa. oc=oceania. ssa=sub saharan africa. umic=upper middle income country. the positive association between country income and coverage also was observed when countries’ per capita gni was included as a continuous variable among individuals ages 25 64 years (figure 3 and appendix p 68 69). countries that generally had higher diabetes treatment coverage than predicted based on income included bangladesh, costa rica, cambodia, eritrea, guyana, iran, and saint vincent and the grenadines. countries that generally had lower diabetes treatment coverage than predicted based on income included benin, fiji, indonesia, rwanda, and solomon islands. the gray shaded area represents the 95% linear prediction interval. the vertical bars represent 95% cis around point estimates for a given country. the estimates account for weighting and survey design. only countries with at least 50 individuals are included in this plot; results for all countries are depicted in appendix p 68 70. gross national income (gni) per capita is in constant 2017 international dollars as calculated by the world bank for the year in which the survey was conducted. for countries with unavailable gni data in the survey year, we used per capita gross domestic product in constant 2017 international dollars. for eritrea, we used per capita gdp at current prices in 2011. for zanzibar, we used estimates using constant 2015 international dollars as published by the office of the chief government statistician of zanzibar. some labels in the cholesterol lowering medication plot are omitted due to space limitations. aze=azerbaijan, ben=benin, bfa=burkina faso, bgd=bangladesh, blr=belarus, btn=bhutan, bwa=botswana, chl=chile, chn=china, com=comoros, cri=costa rica, dza=algeria, eri=eritrea, fji=fiji, geo=georgia, guy=guyana, idn=indonesia, ind=india, irn=iran, irq=iraq, ken=kenya, kgz=kyrgyzstan, khm=cambodia, kir=kiribati, lao=laos, lbn=lebanon, lbr=liberia, lso=lesotho, mar=morocco, mda=moldova, mex=mexico, mmr=myanmar, mng=mongolia, nam=namibia, npl=nepal, rou=romania, rwa=rwanda, sdn=sudan, slb=solomon islands, stp=sao tome and principe, swz=eswatini, syc=seychelles, tgo=togo, tjk=tajikistan, tls=timor leste, tuv=tuvalu, tza=tanzania, uga=uganda, vct=st. vincent & the grenadines, vnm=vietnam, vut=vanuatu, wsm=samoa, zaf=south africa, zan=zanzibar, zmb=zambia. predicted probabilities of coverage from the multivariable logistic regression models are shown in table 3. see full model details in appendix p 60 64. females had greater coverage than males for multiple treatments. there also tended to be a gradient of greater coverage with increasing age and bmi, higher levels of educational attainment, and, to a lesser extent, household wealth. predicted probabilities of coverage with 95% confidence intervals are reported from multivariable logistic regression models. predicted probabilities were generated as average adjusted predictions for categorical variables (sex, educational attainment, and wealth) and adjusted predictions at representative values for continuous variables (age and bmi). wealth quintile was not available in n=7 surveys (appendix p 45). each column represents a diabetes treatment that serves as the model’s dependent variable. the covariates in the model include all row variables and country fixed effects. illustrative values for age and body mass index are presented; these variables were included as continuous variables in the models using restricted cubic splines at knots of 5%, 27.5%, 50%, 72.5%, and 95%. survey weighting and clustering at the country level were accounted for in the models. n/a=not applicable. in the sensitivity analysis restricting the sample to individuals reporting a prior diabetes diagnosis (appendix p 65), coverage of glucose lowering medication was 85.0% (95% ci, 82.3 87.4); antihypertensive medication, 57.0% (95% ci, 53.9 60.0); cholesterol lowering medication, 9.2% (95% ci, 7.7 10.9); diet counseling, 73.9% (95% ci, 71.4 76.3); exercise counseling, 65.3% (95% ci, 62.8 67.8); and weight loss counseling, 62.8% (95% ci, 59.3 66.1). in this scenario, the combined coverage of pharmacological treatment was 14.3% (95% ci, 12.2 16.8); non pharmacological treatment, 56.2% (95% ci, 53.6 58.8); and all recommended treatments, 10.1% (95% ci, 8.2 12.5). in the sensitivity analysis weighting each country in proportion to its 2015 population size (appendix p 66), the overall coverage was similar for antihypertensive medication (40.5% [95% ci, 38.0 43.1]), cholesterol lowering medication (7.9% [95% ci, 6.8 9.1), and exercise counseling (27.8% [95% ci, 24.4 31.5]); however, coverage was lower for glucose lowering medication (45.6% [95% ci, 42.0 49.2]), diet counseling (23.5% [95% ci, 21.2 26.0]), and weight loss counseling (19.0% [95% ci, 16.3 21.9]). results from the sensitivity analysis restricted to the sample of individuals 25 64 years of age is depicted in figure 3 and appendix p 67 70. in the sensitivity analysis among people with diabetes who had a 10 year predicted cvd risk ≥20% (appendix p 71), coverage of cholesterol lowering medication was 7.6% (95% ci, 5.4 10.6). finally, results from the sensitivity analysis with multivariable logistic regression models using random effects at the country level were generally consistent with the primary analysis (appendix p 72). in this pooled analysis of nationally representative, individual level data from 55 lmics, we found that fewer than one in ten people with diabetes achieved a composite indicator of coverage for up to six clinical treatments recommended in who guidelines. moreover, less than 15% of people with previously diagnosed diabetes had achieved the composite indicator. coverage of glucose lowering medication was modestly higher than antihypertensive medication and substantially higher than cholesterol lowering medication. among all people with diabetes, about one in three people self reported receiving recommended non pharmacological treatment in the form of counseling about diet, exercise, or weight loss. additionally, we found that countries in higher income categories tended to achieve greater coverage across treatments. we also identified countries that generally had higher coverage than would be predicted based on per capita income. costa rica emerged as an example of one such well performing country, a result that has been attributed to the country’s commitment to universal health coverage.21 other countries that outperformed predicted coverage based on per capita income included bangladesh, cambodia, eritrea, guyana, iran, and saint vincent and the grenadines. when countries were analyzed by geographic region, countries in oceania tended to have the lowest coverage across treatments despite having the highest overall prevalence of diabetes. prior research on diabetes among people of this region suggests that high diabetes prevalence and limited implementation of diabetes care results from complex structural forces.22 the region of latin america and the caribbean had the second to highest diabetes prevalence, but this region also consistently had among the highest levels of coverage across treatments. at the individual level, we found that women had greater coverage across multiple treatments. this finding is consistent with the broad global literature detailing lower utilization of primary health care services among men in low resource settings.23 greater coverage also was associated with higher age, bmi, educational attainment, and household wealth. the results for age and bmi suggest that health systems in lmics are reaching more people with diabetes who have traditional risk factors such as older age and high bmi. these findings are critical given that there is a high proportion of individuals with diabetes in lmics who are normal weight according to clinically defined bmi categories,24 and adequate diabetes treatment in a young person may confer health and economic benefits throughout the lifespan. a strength of our study is that, in our primary analysis, we define diabetes using an individual’s diabetes biomarker or use of a glucose lowering medication, rather than limiting the analysis only to individuals reporting a prior diabetes diagnosis. given substantial differences in the proportion of people diagnosed between countries, we believe that our approach is the most valid method to compare performance of health systems in delivering diabetes treatment to the overall population in need, which was our study’s main objective. in a sensitivity analysis, we restrict the sample to those reporting a diabetes diagnosis and find that large differences persist in diabetes treatment coverage among the three pharmacological treatments and also between pharmacological versus non pharmacological treatments. as a high income country comparison among people previously diagnosed with diabetes, in the 2007 2012 u.s. national health and nutrition examination (nhanes) survey, the proportion of eligible adults with diabetes who self reported use of an antihypertensive medication for hypertension and statin use for primary cvd prevention was approximately 90% and 52%, respectively,25 rates which are substantially higher than the results from the lmics included in our study. however, the prevalence of self reported exercise, diet, and weight loss counseling among people with diagnosed diabetes in the 2011 2016 u.s. nhanes survey was approximately 70%,26 rates which are relatively similar to our results. in a pooled study of health examination surveys from 12 high income countries, overall treatment of hypertension (among all hypertensive individuals) ranged from 40% to 80%, while we found that 57.0% (95% ci, 53.9 60.0) of people with diabetes were treated in our sample of countries.27 in the 2013 2017 japan national health and nutrition surveys, coverage for glucose lowering and antihypertensive therapy among those in need of treatment was 79.9% and 46.3%, respectively.28 the prospective urban rural epidemiology (pure) study in 21 countries also has shown markedly higher diabetes medication use and lower cvd mortality among people with diabetes in high income countries compared with lmics.3 such comparisons between our results and previously published reports from high income countries should be made cautiously, as there are likely to be differences in methods and definitions among surveys. nevertheless, our findings suggest that antihypertensive and cholesterol lowering medication are areas of diabetes treatment in which there is a sizeable gap between health systems in lmics versus those in high income countries. randomized clinical trials demonstrate the high degree of absolute clinical benefit in addressing hypertension and elevated cholesterol among people with diabetes, as reflected in more favorable numbers needed to treat for antihypertensive and cholesterol lowering medications (i.e., statins) compared with intensive glucose lowering therapy.29 non pharmacological interventions for diabetes, while widely recommended, have less evidence for improvement in long term outcomes.11 taken in this context, our results suggest that scaling up pharmacological treatment of cvd risk factors such as hypertension and elevated cholesterol are priorities for the management of diabetes in lmics. while modeling studies30 and consensus reports such as disease control priorities, 3rd edition31 have pointed to the cost effectiveness of this approach, implementation will require substantial investments in health systems in lmics. global initiatives such as the who hearts technical package7 which integrates management of diabetes within a cvd prevention package in primary health care and the forthcoming who global diabetes compact32 represent important opportunities to address these implementation and economic challenges. in the recently published lancet commission on diabetes, global experts highlighted the urgent need to scale up treatment of cardiometabolic risk factors among people with diabetes through a multifaceted health systems strengthening approach that includes deployment of non physician health workers (i.e., task sharing) within a team based approach, ensuring access to affordable medications including insulin, and strengthened data systems to measure health system performance.15 while there is also a need to develop prospective, longitudinal data sources such as patient registries in lmics,15 our study also demonstrates the power of population based surveys such as steps to benchmark health system performance for diabetes. analysis of repeated surveys from the same country over time, though beyond the scope of the present work, would also aid in understanding temporal trends in health systems’ ability to deliver diabetes treatment within and across countries. to our knowledge, this study is the most comprehensive assessment of diabetes treatment using nationally representative data in lmics of diverse income groups and geographic regions. previous pooled studies of diabetes treatment in lmics include the pure study,3 an analysis of diabetes and cvd risk factors in a total of seven countries including four lmics,33 and our group’s analysis of diabetes care cascades in 28 lmics.14 the pure study also reported low use of glucose lowering, antihypertensive, and cholesterol lowering medications in lmics, but the study was limited by non nationally representative samples, inclusion of fewer than 20 lmics, and, to our knowledge, no estimates for non pharmacological diabetes interventions.3 our group’s prior work in 28 lmics demonstrated substantial gaps in the cascade of glycemic care, especially at the step of diagnosis, but this study did not explore coverage of antihypertensive or cholesterol lowering medication.14 the present study makes a significant contribution to the global diabetes literature by evaluating coverage of comprehensive diabetes treatment in a much larger sample of nationally representative country surveys in lmics than has previously been available. our study has limitations. first, we define diabetes diagnosis based on a single diabetes biomarker, many of which are capillary glucose measurements. single measurements of capillary glucose are common in high quality pooled diabetes surveys19,34 though there are concerns about diagnostic misclassification and the need for conversion to plasma glucose.35 in our study, misclassification may lead to both underdiagnosis and overdiagnosis. underdiagnosis may occur as a single fasting glucose may fail to capture 30% or more of people with undiagnosed diabetes who would be detected using an oral glucose tolerance test.36 38 conversely, overdiagnosis may occur as the short term variability of a single fasting glucose may inflate diagnoses by as much as 30%.39,40 second, variations in diabetes clinical guidelines between countries may account for some observed differences.41 additionally, in clinical practice, the decision to start or stop a pharmacological treatment may be related to patients’ observed responses to non pharmacological treatment. for example, in patients with modestly elevated blood glucose, clinicians may appropriately defer initiating glucose lowering treatment while first focusing on lifestyle changes through counseling on diet, exercise, and weight loss. while acknowledging these nuances, we justify our outcomes as they are based on population monitoring indicators and clinical treatment recommendations in who pen, which is a widely cited global reference standard for ncd management in lmics.6 third, differences among surveys regarding the year the survey was conducted, diabetes biomarker, age sample, and how surveys implemented the same question may account for some of the observed variation and affect cross country comparisons. despite these differences, to our knowledge, the included surveys represent the best available population level data on diabetes treatment in lmics. we include extensive information on the underlying surveys in our appendices, and we attempt to investigate these differences through a suite of sensitivity analyses. fourth, as we define coverage using self reported measures, our estimates may be impacted by recall bias or the potential for self reports to overestimate coverage.42 fifth, the underlying surveys had incomplete inclusion of each outcome, and, in particular, there were a lack of non pharmacological data from several large countries such as bangladesh, india, and mexico. similarly, due to unavailability of the relevant variables, we were unable to pool data on the coverage of smoking cessation counseling; this is a limitation as smoking is a major contributor to cvd risk among people with diabetes. sixth, we do not consider the topic of diabetes prevention or the role of new agents such as sodium glucose co transporter 2 (sglt2) inhibitors and glucagon like peptide 1 (glp 1) receptor agonists, which reduce mortality among diabetes patients at high cvd risk.43 these are active priority areas for future research within our group. a final limitation is that our study focuses on treatment coverage and does not assess the quality of coverage or the adequacy of risk factor control. the lancet global health commission on high quality health systems advocates for the use of “effective coverage,” a quality corrected coverage metric, to benchmark health system performance.44 in contrast to solely assessing treatment coverage conditional on need, as in our study, effective coverage also accounts for the magnitude of health gain experienced by individual receiving treatment.45 in cross sectional data such as that used in this study, it is very challenging to estimate the health gains associated with treatment. given these challenges, we define our coverage outcome to mirror the population level monitoring indicators recommended in who pen, which are in turn based on existing clinical evidence.6 in future research, we plan to provide estimates of effective coverage of diabetes treatment. in conclusion, we found that fewer than one in ten people with diabetes in lmics receive coverage of guideline based comprehensive diabetes treatment. our findings suggest that delivering treatment not only to lower glucose but also to manage cvd risk factors such as hypertension and elevated cholesterol among people with diabetes are urgent global priorities. policy efforts to achieve sustainable development goal 3.4 should focus on filling these gaps in global diabetes care. we searched pubmed on january 5, 2021 without language or date restrictions using the search terms of “diabetes” and (“low  and middle income countries” or “developing countries”) and (“met need” or “treatment” or “coverage”) in the title or abstract. we identified two large studies assessing levels of diabetes treatment using individual data from multiple low  and middle income countries (lmics). one study reported estimates of glycemic care (proportion tested, diagnosed, treated, controlled) among individuals with diabetes in 28 lmics but did not explore other components of comprehensive diabetes care such as medication treatment for hypertension or elevated cholesterol. a second study, the prospective urban rural epidemiology (pure) study, reported individual level data on use of diabetes, hypertension, and cardiovascular disease medicines in low and middle income countries. however, the pure study is not nationally representative, includes fewer than 20 lmics, and, to our knowledge, has not assessed utilization of non pharmacological interventions for diabetes. to our knowledge, this study is the largest assessment of comprehensive diabetes treatment using individual level data from nationally representative samples of adults across lmics of diverse income groups and geographic regions. this study makes three valuable additions to the existing literature. first, we found that fewer than one in ten people with diabetes in lmics receive comprehensive diabetes treatment as recommended by the world health organization (who). our findings are essential for policymakers as we identify pharmacological treatment of hypertension and elevated cholesterol as key drivers of low self reported treatment. second, we make cross country estimates of diabetes treatment that may be used by health systems in lmics to benchmark current and future performance. third, we report individual characteristics such as young age and lower bmi that are associated with low coverage of diabetes treatment; these individual level findings can be used by health systems to direct care to underserved groups. while there are differences in the proportion of people receiving diabetes treatment both between and within countries, overall, there is need to scale up comprehensive diabetes treatment in lmics. our findings suggest that improving access to comprehensive treatment not only to lower glucose but also to address cardiovascular disease risk factors such as hypertension and elevated cholesterol are global diabetes priorities. global initiatives such as the who hearts technical package and global diabetes compact represent important opportunities to address the implementation and economic challenges of this approach. df was supported by the national clinician scholars program at the university of michigan institute for healthcare policy & innovation. jas was supported by grant number t32dk007028 from the national institute of diabetes and digestive and kidney diseases (niddk) and by grant number 5kl2tr002542 03 (harvard catalyst). pg was supported by the national center for advancing translational sciences of the national institutes of health under award number kl2tr003143. mh was supported by grant number p30dk092926 (mcdtr) from the national institute of diabetes and digestive and kidney diseases. jmg was supported by grant k23 dk125162 from the national institute of diabetes and digestive and kidney diseases (niddk). the contents of this research are solely the responsibility of the authors and do not necessarily represent the official views of the nih. declaration of interests d.j.w. reports serving on a data monitoring committee for novo nordisk. data sharing statement this study includes individual level data from 55 countries. data are publicly available for 47 of these countries. for data that are not publicly accessible and for which we have arranged specific data use agreements, we are unable to share these data given the terms of our agreements. appendix p 35 provides a complete list of web addresses and country specific contacts regarding data access. david flood, division of hospital medicine, department of internal medicine, national clinician scholars program, university of michigan, ann arbor, mi, usa; center for indigenous health research, wuqu’ kawoq; tecpán, guatemala; research center for the prevention of chronic diseases, institute of nutrition of central america and panama, guatemala city, guatemala. jacqueline a. seiglie, diabetes unit, massachusetts general hospital, harvard medical school, boston, ma, usa; department of medicine, harvard medical school, boston, ma, usa matthew dunn, school of public health, university of michigan, ann arbor, michigan, usa. scott tschida, center for indigenous health research, wuqu’ kawoq; tecpán, guatemala;. michaela theilmann, institute of global health, heidelberg university, heidelberg, germany. maja e. marcus, department of economics and centre for modern indian studies, university of goettingen, göttingen, germany garry brian, the fred hollows foundation new zealand, auckland, new zealand. bolormaa norov, national center for public health, ulaanbaatar, mongolia. mary t. mayige, national institute for medical research, dar es salaam, tanzania mongal singh gurung, health research and epidemiology unit, ministry of health, bhutan. krishna k. aryal, monitoring evaluation and operational research project, abt associates, kathmandu, nepal demetre labadarios, faculty of medicine and health sciences, stellenbosch university, stellenbosch, south africa. maria dorobantu, university of medicine and pharmacy, carol davila, bucharest, romania. bahendeka k. silver, st. francis hospital, nsambya, kampala, uganda pascal bovet, ministry of health, victoria, republic of seychelles; university center for primary care and public health, lausanne, switzerland. jutta m. adelin jorgensen, department of public health, university of copenhagen, copenhagen, denmark david guwatudde, department of epidemiology and biostatistics, school of public health, makerere university, kampala, uganda. corine houehanou, laboratory of epidemiology of chronic and neurological diseases, faculty of health sciences, university of abomey calavi, benin. glennis andall brereton, caribbean public health agency, port of spain, trinidad and tobago. sarah quesnel crooks, non communicable disease department, national center for disease control and public health, tbilisi, georgia. lela sturua, non communicable disease department, national center for disease control and public health, tbilisi, georgia; petre shotadze tbilisi medical academy, tbilisi, georgia. farshad farzadfar, non communicable diseases research center, endocrinology and metabolism population sciences institute, tehran university of medical sciences, tehran, iran. sahar saeedi moghaddam, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. rifat atun, department of global health and population, harvard t.h. chan school of public health, harvard university, boston, ma; department of global health and social medicine, harvard medical school, harvard university, boston, ma, usa. sebastian vollmer, department of economics and centre for modern indian studies, university of goettingen, göttingen, germany. till w. bärnighausen, institute of global health, heidelberg university, heidelberg, germany; department of global health and population, harvard t.h. chan school of public health, harvard university, boston, ma; africa health research institute, somkhele, south africa justine i. davies, mrc/wits rural public health and health transitions research unit, school of public health, university of witwatersrand, johannesburg, south africa; institute of applied health research, university of birmingham, birmingham, uk; centre for global surgery, department of global health, stellenbosch university, cape town deborah j. wexler, diabetes unit, massachusetts general hospital, harvard medical school, boston, ma, usa; department of medicine, harvard medical school, boston, ma, usa pascal geldsetzer, institute of global health, heidelberg university, heidelberg, germany; division of primary care and population health, department of medicine, stanford university, stanford, ca, usa. peter rohloff, center for indigenous health research, wuqu’ kawoq; tecpán, guatemala; division of global health equity, brigham and women’s hospital; boston ma, usa. manuel ramírez zea, research center for the prevention of chronic diseases, institute of nutrition of central america and panama, guatemala city, guatemala. michele heisler, department of internal medicine, school of medicine, university of michigan, ann arbor, mi, usa; institute for healthcare policy and innovation, university of michigan, ann arbor, mi, usa; veterans affairs ann arbor center for clinical management research, ann arbor, mi, usa. jennifer manne goehler, division of infectious diseases, brigham and women’s hospital, harvard medical school, boston, ma, usa. this section collects any data citations, data availability statements, or supplementary materials included in this article. connect with nlm national library of medicine 8600 rockville pike bethesda, md 20894

the latest news for pharma industry insiders. dia 2024: improving patient access to clinical trials through decentralization and flexible design: lessons from oncology breakout session discusses the impact of incorporating decentralized elements into oncology clinical trials on data integrity, patient safety, and regulatory approvals. expert: individualized gender affirming care and support is essential for lgbtq+ patients for pride month, pharmacy times interviewed olivia buckoski, pharmd, aahivp, hivpcp, clinical pharmacist, western north carolina community health services, to discuss gender affirming care for patients in the lgbtq+ community, what it looks like, and the importance of catering care to the individual. this patient population often face stigma, a lack of cultural competency among providers, and discrimination; however, pharmacists and health care professionals can help by creating a supportive environment for patients. improve site experience with data driven protocol design do you know what challenges are encountered by sites when operationalizing study protocols? in this webinar, learn how specific protocol design elements impact sites’ perception of burden and how this information can be used to improve site experience. south africa runs out of insulin pens as global supply shifts to weight loss drugs the shortage highlights a widening gulf in the standard of care for people with diabetes, most of whom live in low income countries. qps announces new global clinical research operations leadership qps is pleased to announce new clinical research operations leadership. this new clinical leadership will further align the existing global medical affairs, regulatory affairs, data services, and clinical operations units with the existing successful qps phase i clinics. the enhanced global capabilities will help qps satisfy the need for agility, flexibility, and speed in the quickly evolving global drug development community. jill donahue, fueling the power of purpose in pharma teams on linkedin sharing insights from interviewing hundreds of exceptional pharma leaders. want to know what they do differently? enjoy my short article published today in pharmaceutical executive have news you want us to share in pharma pulse? reach out to social media editor miranda schmalfuhs pharma pulse 2/6/25: properly preparing for tariffs, long term costs of major menopause misconceptions & more the latest news for pharma industry insiders. pharma pulse 2/5/25: what do real patients actually talk about? adhd stimulant dispensing decreased over past decade & more the latest news for pharma industry insiders. pharma pulse 2/4/25: analyzing supply chain complexities, navigating medicare advantage in 2025 & more the latest news for pharma industry insiders. pharma pulse 2/3/25: the rundown on rebates, glp 1s and pharmacists' role & more the latest news for pharma industry insiders. pharma pulse 1/31/25: what round ii of medicare part d drug prices signify, 2025 digital healthcare outlook & more the latest news for pharma industry insiders. pharma pulse 1/30/25: pharma supply chains challenges, gender affirmative care beyond women’s health & more the latest news for pharma industry insiders. pharma pulse 2/6/25: properly preparing for tariffs, long term costs of major menopause misconceptions & more the latest news for pharma industry insiders. pharma pulse 2/5/25: what do real patients actually talk about? adhd stimulant dispensing decreased over past decade & more the latest news for pharma industry insiders. pharma pulse 2/4/25: analyzing supply chain complexities, navigating medicare advantage in 2025 & more the latest news for pharma industry insiders. pharma pulse 2/3/25: the rundown on rebates, glp 1s and pharmacists' role & more the latest news for pharma industry insiders. pharma pulse 1/31/25: what round ii of medicare part d drug prices signify, 2025 digital healthcare outlook & more the latest news for pharma industry insiders. pharma pulse 1/30/25: pharma supply chains challenges, gender affirmative care beyond women’s health & more the latest news for pharma industry insiders. 2 commerce drive cranbury, nj 08512 609 716 7777

by the new york times | june 19, 2024 physicians are in short supply. they are costly. is the app the answer to the cmo's workforce and budget challenges? ... amid the hype and promise, a growing tension is becoming clear: the reality of what ai can deliver versus what it can't. ...

supported by president trump’s pause on aid, and the gutting of the primary aid agency, could jeopardize the health of more than 20 million people worldwide, including 500,000 children, experts say. by apoorva mandavilli lifesaving treatment and prevention programs for tuberculosis, malaria, h.i.v. and other diseases cannot access funds to continue work. by stephanie nolen experts fear a resurgence of infections in low income countries if the ban were to continue. the waiver remains in place, while officials review foreign aid programs. by apoorva mandavilli pepfar’s computer systems also are being taken offline, a sign that the program may not return, as republican critics had hoped. by apoorva mandavilli pepfar, which is estimated to have delivered lifesaving treatment to as many as 25 million people in 54 countries, faces a funding delay of as long as 180 days. by apoorva mandavilli it’s a mistake for president trump to order the united states to leave the world health organization. he should reverse course immediately. by kathleen sebelius thomas piketty and michael sandel debate the value of open borders and what we owe migrants. by new york times opinion wright, the founder of a fracking firm, testified that he would back all forms of low carbon energy as well as gas, oil and coal. by brad plumer trump is likely to slash funding for women’s health organizations in the name of “protecting life”   but the result will be death. by nicholas kristof what medications should you bring, what insurance do you need and how do you find a doctor? here are health care tips if you’re traveling internationally. by lisa mccarty américa latina y áfrica subsahariana concentran una porción desproporcionada de casos de diabetes tipo 2 y enfermedades cardiovasculares relacionados con el consumo de bebidas azucaradas, según un nuevo estudio. by andrew jacobs a new study assesses the effects of sugar laden beverages on global health, with higher rates of consumption found in latin america and parts of africa. by andrew jacobs the u.s. provides nearly half of the aid for global health, including childhood vaccination, h.i.v. treatment and disease surveillance. by stephanie nolen the chinese leader is digging into the language of revolution, and a radical russian novel, as he prepares for battle with donald trump. by john garnaut and sam chetwin george women with obstetric fistulas suffer year after year, even as a $619 surgery can restore them. by nicholas kristof chris wright, donald trump’s pick for energy secretary, says oil, gas and coal are key to solving global poverty. some call that misleading. by lisa friedman in a landmark international hearing on climate change, a u.s. representative backed the paris agreement, but left unanswered questions about u.s. commitments in a trump presidency. by karen zraick the world bank warned in a new report that poor countries will be stuck in economic “purgatory” without debt relief. by alan rappeport the international court of justice, the united nations’ highest judicial body, is beginning landmark hearings on global warming. here’s a guide. by marlise simons what the u.n. negotiations, known as cop, can (and can’t) do to combat climate change. by brad plumer delegates from developing countries described the deal’s financial target, $300 billion per year by 2035, as lacking the ambition needed to help their governments combat climate change. by axel boada the financing plan, which calls for $300 billion per year in support for developing nations, was immediately assailed as inadequate by a string of delegates. by max bearak western countries are confronting demands for trillions of dollars to fight climate change and to cope with its worsening effects. by max bearak china has now passed europe in its historical contribution to global warming. rich nations say the country should contribute more climate aid. by brad plumer and mira rojanasakul senior ministers are arriving in an effort to break a deadlock over the summit’s main goal: funding to help lower income countries hit hard by global warming. by david gelles and brad plumer the u.n. climate summit in azerbaijan has cleared the way for aid to flow when lower income countries are hit. by david gelles growing worldwide energy demand and other factors have shifted the calculus, but hurdles still lie ahead. by brad plumer negotiators agree that trillions are needed to help lower income countries adapt and cope, but not on who should pay. by david gelles and brad plumer negotiators at the summit in azerbaijan fear that the return of donald trump will sap momentum for global climate action. by brad plumer and david gelles low income countries need at least $1 trillion a year to manage climate change. donald trump’s victory just made that more difficult, but options exist. by somini sengupta and lydia depillis

an official website of the united states government official websites use .gov a .gov website belongs to an official government organization in the united states. secure .gov websites use https a lock ( lock locked padlock icon ) or https:// means you've safely connected to the .gov website. share sensitive information only on official, secure websites. primary site navigation logged in as: correspondence: shiferaw letta school of nursing and midwifery, college of health and medical sciences, haramaya university, p.o. box: 235, harar, ethiopia tel +251911771934 email shife1973@gmail.com received 2021 aug 24; accepted 2021 oct 13; collection date 2021. this work is published and licensed by dove medical press limited. the full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the creative commons attribution   non commercial (unported, v3.0) license (http://creativecommons.org/licenses/by nc/3.0/). by accessing the work you hereby accept the terms. non commercial uses of the work are permitted without any further permission from dove medical press limited, provided the work is properly attributed. for permission for commercial use of this work, please see paragraphs 4.2 and 5 of our terms (https://www.dovepress.com/terms.php). all types of diabetes can damage the heart, blood vessels, eyes, kidneys, nerves and increase the overall risk of disability and premature death. diabetes mellitus requires a range of self care practices, scientifically recommended to control the glycemic level and maintain the patient’s health. however, perceived barriers that hinder patients from fully implementing these diabetes self care practices and obstacles have not been thoroughly explored. therefore, this study aimed to explore the barriers to diabetes patients’ self care practices from the perspective of health care providers in two public hospitals in harar city, eastern ethiopia. researchers conducted an exploratory qualitative study among 26 health care providers working in two public hospitals from march to june 2021. the study participants were recruited from different disciplines working on diabetes care. interviews were conducted in the amharic language until the saturation point was reached. the interviews were tape recorded, transcribed, and translated to english. each transcript was read, re read, and then exported to atlas.ti 7 software for coding. field notes were used to supplement verbatim transcriptions. initial codes were generated. the consistency between the two coders and their alignment with research questions were checked and applied to all subsequent transcripts after reached on consensus. the thematic analysis was employed in line with the primary set research question. researchers identified barriers to diabetes patients’ self care practices such as system, health care providers, and patient level. these barriers were categorized under three main themes: lack of organized diabetes care services, limited collaborative care practices, and perceived lack of knowledge on self care practices. in addition, the lack of multidisciplinary team care, lack of training for health care providers on diabetes self care practices, and availability of laboratory tests and diabetes medication were prominent barriers. multi level barriers to diabetes patients’ self care practices such as system, health care providers, and patients were identified. therefore, interventions targeting proper service integration, building providers’ and patients’ capacity on diabetes self care practices, and ensuring the sustainability of laboratory tests and medication supplies are essential. these interventions need to be accomplished through multi level stakeholders’ engagement and one to one or group interventions covering the multi level challenges. keywords: diabetes, self care, barriers, health care providers, holistic care, eastern ethiopia diabetes mellitus (dm) is a metabolic disorder characterized by the presence of hyperglycemia1 that occurs when the body cannot produce enough insulin or ineffective response to insulin.2,3 there are two significant categories of diabetes mellitus: type 1 diabetes, which usually occurs in childhood, and type 2 diabetes, which often occurs in adults, but gradually affects children and adolescents. both types of diabetes can damage the heart, blood vessels, eyes, kidneys, nerves, increasing the overall risk of disability and premature death.3 evidence suggests that type 2 accounts for about 90% to 95% of all dm cases. in addition, the changes in population age, social, economic, cultural aspects, and degree of urbanization contribute to a more inactive lifestyle, and consuming an unhealthy diet leads to obesity.4 globally in 2019, 9.3% (463 million) of people aged 20 to 79 had diabetes, with the number of people with diabetes predicted to rise 10.2% (578 million) by 2030, and more than three quarters (79.4%) live in low  and middle income countries.4 additionally, data indicate that around four million deaths were attributed to diabetes annually.1 in ethiopia, diabetes increases5 while most people remain undiagnosed until serious complications become evident.6 in 2017, the projected national diabetes prevalence among people aged 20 79 was 5.2%, and there were 2.6 million diabetic cases in the country.2 likewise, a recent systematic review indicated that the magnitude of diabetes ranged from 2.0% to 6.5%.7 as a result, the federal ministry of health (fmoh) conducted a national survey to determine the prevalence and common risk factors to inform public health policy. at the same time, the ministry endorsed further investigation of determinant factors and pocket sized studies to generate evidence locally for the implementation of ncd prevention and control activities.8 moreover, an analysis of policy was made, and strategy gaps were suggested to develop targeted strategies to reduce behavioral risk factors in ethiopia.9 patients with diabetes have an increased risk of morbidity and mortality.10 in addition, they have the risk of developing other chronic non communicable or infectious diseases.1 therefore, continuous and regular quality care with multiple risk reduction strategies is adequately initiated and practiced.1,11 diabetes self management education, medical nutrition therapy, psychosocial care, and self care have paramount importance in reducing their risks.12 diabetes self care behaviors include healthy eating, regular physical exercise, proper medication follow up, blood glucose self monitoring, problem solving skills, coping with the illness, monitoring disease progression, and eye care.13 15 commitment to these activities can reduce the risk of complications and improve quality of life.16 18 however, despite these facts, diabetes self care has been poorly practiced,19 contributing to suboptimal glycemic control20 and resulting in an increased risk of overall diabetes complications.21 23 therefore, active engagement of the patients and health care providers (hcps) is crucial for high quality healthcare services. active participation helps to establish a partnership, have shared decisions, and encourage the patients to own their lifestyle goals and action plans.24,25 thus, improving self care behaviors is the basis for improving the health status of patients with diabetes.26,27 however, there is limited evidence indicating the barriers to diabetes patients' self care practices that requires further exploration from various perspectives. therefore, this qualitative study aimed to explore these barriers from the perspective of the health care professionals in two public hospitals found in harar city, eastern ethiopia. furthermore, this study has significant implications for nurses, which comprise the majority of the health care providers in the country.28 the increase in diabetes patients may require nurses who educate the patients to manage their disease. along with this, providing standard, evidence based, and cost effective care can improve the health care quality and the patient’s health condition.29 the methods are based on the consolidated criteria for reporting qualitative research (coreq) framework, consisting of 32 items mainly grouped into three domains: research team and reflexivity, study design, and data analysis and reporting. the checklist helps report essential aspects of the research team, study methods, context of the study, findings, analysis, and interpretations.30 two researchers with experience in qualitative research methods and an understanding of the subject matter were used to collect data. they are also proficient in both the amharic and english languages. one of the researchers’ team has a master’s degree in nursing specializing in chronic diseases, while the others had a ph.d. degree in public health and nursing with the academic rank of assistant to associate professors. there were no prior interactions between the researchers and participants before the commencement of the study. therefore, the potential influence of unbalanced power between researchers and participants was minimized. the modifications we made included the appropriate use of medical jargon, vocabularies, tone of voice, and interview mode since the participants were from different professions, levels of education, and gender. the research team conducted an exploratory qualitative study utilizing health professionals working in diabetes care in two hospitals through in depth interviews. the study was conducted from march to june 2021. harari region is found in eastern ethiopia, and the capital city is harar, located 526 kilometers away from addis ababa, the capital city of ethiopia. there are two public hospitals in the city, hiwot fana specialized comprehensive hospital and jugal hospital, where the study was undertaken. both hospitals provide services for the entire community of eastern ethiopia. the hospitals have several departments that deliver services. these include medical, surgical, pediatric, obstetrics, gynecology wards, intensive care units (icus), outpatient departments (opds), radiology, pathology, laboratory, and pharmacy departments. in addition, the hospitals also serve as teaching centers for health and medical sciences students. more than 2707 people with dm are followed in the outpatient clinics of the hospitals. thirty nurses, 12 residents, 13 internists, and 13 general practitioners are involved in dm care in the opds and medical wards. the interviews were conducted in separate rooms of the hospitals for the suitability, confidentiality, and assuring privacy. participants were the health care providers (hcps) who directly engaged in providing diabetes care at the opds, medical ward, and medical icu in the last three months. the nurses usually facilitate documentation and follow up while ward nurses participate in medication administration and patient education. general practitioners (gps) and internal medicine resident students evaluate the patients at opds and in the wards assisted by consulting internists. among physically communicated hcps, two physicians were dropped out due to their busy schedules. the study participants were recruited from nurses, general practitioners, internal medicine resident students, and general internists using the purposive sampling technique. the inclusion criteria were having experiences and direct involvement in diabetes care as primary caregivers. there were 13 internists, 12 resident students, 14 general practitioners, and 30 nurses working in outpatient departments, medical wards, and medical icu of both hospitals. the participants were primarily approached by phone, and then the face to face discussions were made. finally, they were invited by the research team for interviews at a jointly arranged time (figure 1). schematic presentation of sampling strategy of the health care professionals working in hiwot fana specialized comprehensive hospital and jugal hospital, harar, eastern ethiopia. abbreviations: hcps, health care providers; gps, general practitioner. written informed consent was obtained from all the interviewees on the interview day before initiating the interview. the interviews were carried out using pre tested semi structured guides. the interview guides were prepared in english and translated into the amharic language by a bilingual translator. this interview guide contains demographic information of participants and a series of open ended questions, mainly concentrating on the barriers to diabetes self care practices. these were sample questions: “please would you tell me about diabetes self care?”; “how are you assisting your diabetes patients in achieving optimal self care practices?”; “what are the existing barriers to diabetes patients’ self care practice?”, and “how do these barriers independently hinder patients’ self care practices?” all these questions were used for initiating in depth interviews. in addition, the participants were encouraged to describe the detail of the challenges through probing where it was necessary. two voice recorders were used to record interviews simultaneously for backup in case of recording problems. in addition, field notes were taken to supplement the verbatim transcription. each interview took approximately 30 to 60 minutes. accordingly, the interviews were continued until the saturation point was attained. the in depth interviews were recorded, transcribed daily by the interviewer and note taker, and translated into english by two bilingual research team members. the data were analyzed following the thematic analysis approach.31 first, the transcripts were read and re read to be familiarized with the data’s depth, breadth, and contents, then exported into atlas.ti 7 software for coding. initial codes were generated to identify the data features in line with the research questions, and the consistency of codes between the two coders was checked. after reached on a consensus about coding and the codes were applied to all subsequent transcripts. the preliminary generated codes with similar ideas were grouped into thematic headings. those potentially identified themes were reviewed, refined, split up, or combined based on their relevance to the research questions. then themes were defined and named. finally, the researchers produced the report by linking memos with the quotations and finalized the write up.32 the quality of this study was assured through several ways: first, the interview guide questions were developed from existing literature, gaps identified during quantitative survey we did and evaluated by the teams who have sufficient experience in diabetes care and qualitative research. secondly, the respondents validated the summarized information at the end of each interview. thirdly, the same interview guide/questions were used to maintain the consistency of the data across all the interviewees. lastly, after completing the analysis, the key findings were presented to all participants for further validation and feedback. this study explored the views of health care providers towards the barriers of diabetes patients’ self care practices through an in depth interview. several actions were put in place to assure the study participants’ privacy, comfort, and dignity. each interviewee was conducted in a separate private office. recording interviews took place after written informed consent was obtained from an individual interviewee that included publication of anonymized responses. they were assured that data or information obtained from them were kept confidential except for authorized researchers. personal identifiers were not used. ethical approval was obtained from the institutional health research ethics review committee of the college of health and medical sciences, haramaya university (ihrerc). we also checked that this study complies with the declaration of helsinki.33 a total of 26 in depth interviews were conducted with nurses, general practitioners, internal medicine resident students, and internists who have engagement in diabetes care in the two public hospitals. the mean age of the participants was 30.4 ±5.9 years, and most of the participants 21(80.8%) were males (table 1). demographic characteristics of the study participants the analysis of barriers to diabetes patients’ self care practices from perspectives of hcps in nursing and medicine disciplines was conducted following the typical thematic analysis approach. though there was a complex interrelationship between themes and sub themes, the findings were systematically presented. initially, 28 subthemes emerged in the early stage of analysis, and later, these were condensed to 14 sub themes. among all sub themes, six were categorized under the central theme named lack of organized diabetes care services, which corresponds to the health care system, whereas four were categorized under the theme of limited collaborative practices, which corresponds to health care providers related barriers. the last three sub themes belonged to lack of knowledge about diabetes and its care which corresponds to diabetes patient level barriers. each sub theme was presented in the table with its description. moreover, the theme and sub themes were adequately explained in the text (table 2). summary of barriers to diabetes patients’ self care practices from health care providers’ perspectives in hiwot fana specialized comprehensive hospital and jugal hospital, harar, 2021, eastern ethiopia the informants stated that the diabetes care related services are not well integrated. the service areas are not well aligned; the patients move from one building to another to get laboratory and pharmacy services. electronic communication means that serve for easy exchange of patients’ information among the units are not established. the patients must often wait for long periods at each service entry. on top of this, the lack of proper handling and documentation of the patients’ medical records affects clinical decision making. there are also delay in the referral and consultation system between specialty clinics. periodical evaluation for eyes, teeth, kidneys, and heart are not adopted. the services are poorly organized, not easily accessed, not centered on the patients’ multiple needs, and do not acknowledge their role in their health issues. as a result of these, the patients interrupted the regular follow up. the support and services obtained from health care providers were ceased, then they were discouraged from practicing self care. in support of this, one of the participants stated: “the services which are given in the record room, pharmacy and laboratory facility for diabetes patients are not synchronized to one corner or around the endocrinology unit.” (participant 10, internist) “i know a patient who was admitted to the medical ward for treatment but developed gangrene over his lower leg. he has spent 15 days without any treatment due to an ineffective referral system between medical and surgical wards.” (participant 8, bsc nurse) some participants reported that the unavailability of experts affects overall diabetes care in some way. for example, the lack of endocrinologists significantly weakens collaborative efforts among departments. it also contributes to frequent interruption of laboratory services related to diabetes and an unsustainable supply of essential diabetes medications that affect the continuity of diabetes self care practices. moreover, they expressed that this lack worsens integrating the diabetic services under the endocrinology unit, which might be a base for comprehensive diabetes care. “the existing dm care related problems will decrease at least by 50% if an endocrinologist is available so that the correct diagnosis and treatment can be made. all services rendered for patients with diabetes can be organized, and the continuity of the services can also be guaranteed” (participant 12, resident) some interviewees reflected that diabetes nurse educators are a neglected component of the current ongoing service in the two hospitals. as a result, there were no qualified nurse educators. timely identifying the patient’s health care needs and working collaboratively with the patient and healthcare provider team to develop the most appropriate treatment plan and nutrition education might require diabetes nurse educators. in addition, a qualified nurse educator works to increase the patients’ understanding of diabetes self care practices. furthermore, they promote self care, identify barriers, and supporting patients with diabetes in acquiring skills that enable them to carry out their diabetes self care. “the lack of a dedicated nurse who is specifically trained for diabetes management is significant as they can contribute a lot.” (participant13, internist) “diabetes nurse educators are required to assist the patients in carrying out diabetes self care practices.” (participant 14, bsc nurse) the participants described that most health professionals directly engaged in diabetes care had no additional training on diabetes management though there is integrated national guideline for non communicable diseases. as a result, nurses, residents, and internists reported a lack of the most updated information on diabetes. the nurses expressed that they lack adequate knowledge about diabetes, and self care dimensions. in addition, they explained the lack of basic communication skills, counseling skills, and knowledge about recommended diabetes diets specific to the patients’ socio cultural context. the communication skills may help to establish an excellent rapport with the patients. the health care providers who lack of these knowledge and skills cannot adequately teach and counsel the patients to motivate them to perform their self care. “i have no additional and adequate training on diabetes management. i only try to apply directly the sciences that are in the textbook. the communication skill is also an important skill by itself, and this directly benefits the patients.” (participant 3, general practitioner) “i have not been trained to educate, counsel or provide diabetes self care other than the training i received during my baccalaureate study.” (participant 6, bsc nurse) many participants expressed that hba1c, lipid panel, and electrolyte tests are not consistently available despite hba1c being the most reliable and good indicator of glycemic control. in addition, a lipid panel is helpful to assess the risk of cardiovascular problems. they explained that diabetes ketoacidosis (dka) is managed without appropriate blood glucose monitoring, urinalysis, and electrolyte tests. in addition, there is a lack of glucometers and urine dipsticks for bedside monitoring. these tests are available but costly in private hospitals. this irregularity adversely affects the success of diabetes self care. “recently, hba1c test was started in our hospital, i am requesting now, but i am not requesting a lipid panel although it is indicated for patients with diabetes due to its unavailability.” (participant 12, resident) almost all the participants reported a shortage of essential medications, such as insulin. patients who live in remote areas cannot obtain sufficient prescriptions to reduce unnecessary visits and expenses. in addition, regular insulin for dka management is not consistently available. participants reported that patients with diabetes do not have access to newer and safer medications. the patients who have no health insurance certificate could not get free lente insulin. they are obligated to purchase their insulin from the private pharmacy where they do not receive comprehensive diabetes care, resulting in poor glycemic control. “but now, the patients will get only two vials of insulin per month. even if i prescribe for three months, no one supplies them.” (participant 5, resident) “there is no supply of other safer medications other than metformin and glibenclamide” (participant 11, internist) “medication supply is a big challenge. soon we started to manage dka with regular insulin; we heard the news that the stock ran out. besides, those who do not have health insurance cannot get lente insulin and are forced to use only regular insulin or buy from a private pharmacy”. (participant 21, bsc nurse) many of the participants witnessed a significant disruption of the routine care of diabetes during the covid 19 pandemic. diabetic patients discontinued their regular follow up and blood glucose checking at the health facility, and most patients do not have a glucometer at their home; they were buying and taking their medication from the private pharmacy without knowledge of their glycemic control. in addition, as the pandemic progresses, there has been an increase in admissions due to acute diabetes complications. one coping strategy during the pandemic was to give several months’ worth of prescriptions; however, there was a shortage of medications in the hospital. furthermore, no remote electronic consultation (media, telephone, or other means) revealed the lack of resources and readiness, resulting in a poor response to dm self care. hence, the patients were not able to carry out their diabetes self care at home. “many patients discontinued their follow up, medications, and glucose monitoring, and no alternative home based service delivery was arranged.” (participant 6, bsc nurse) almost all respondents reflected that currently, the patients are not receiving the multi disciplinary team care approach. as a result, this practice has been neglected among different disciplines and within the same discipline. for example, some participants stated that patient care and decision making rely on one discipline that does not constitute the provision of comprehensive diabetes self care services. on the other hand, some mentioned that a multidisciplinary team remains unattainable when one does not appreciate the contribution of others in the team. “diabetes care is continued with none of the nurses, nutritionist, psychologist’s involvement.” (participant 9, internist) “nurse can contribute a lot in diabetes self care practices. but our misperception is that we as physicians can address all things”. (participant 13, internist) most of the participants expressed that diabetes patients visit the health facility to get a package of services. the patients might have concomitant social, psychological, or emotional problems which necessitate holistic interventions. the diabetes care currently provided is not comprehensive. it is targeted to achieve glycemic control, making patients lose confidence in the services. while the patients’ multiple needs are left unaddressed, they are dissatisfied and demotivated to have diabetes self care practices. “no doubt, holistic care benefits the patients, but our primary target is controlling blood glucose so that the patients received incomplete services and failed to stick to suitable self care practices.” (participant 5, residents) “holistic care requires a multidisciplinary approach. this inclusive approach is required to address multi sided problems via diabetes self care practices.” (participant 6, bsc nurse) most participants stated that much of the diabetes care responsibilities go to the patients themselves this demands active involvement in their care. however, the implementation has limitations. they believed that the current care provision is provider centered, limiting the patients’ interests and shared decision making roles. the participants also reported perceived reasons for non patient centered care, such as high patient load and inability to establish a patient partnership. in addition, some participants reported that it would be challenging to implement patient centered care when patients have insufficient knowledge about care options. however, most participants appreciated that diabetes self care practices are necessary and best achieved through the consistent implementation of patient centered care. “i do not fully involve all patients in their care issues. it depends on the patient’s ability to understand my instructions.” (participant 4, general practitioner) “if i consider patients’ preference and allow them to decide on their care, almost all of them prefer to take the pill rather than insulin injection.” (participant 9, internist) almost all participants reported that they provide limited, inconsistent, and insufficient information. this limitation does not prepare the patients to be fully aware of diabetes and engage in self care practices. they outlined that the failure to convey adequate diabetes education information to their patients is attributed to health care providers’ lack of adequate knowledge and language barriers. this study setting was a teaching hospital, where the students of different disciplines with varying knowledge levels about diabetes self care practices were engaged in service provisions. furthermore, there is a lack of educational resources, such as tv programs and leaflets, to facilitate learning about self care practices. “there is insufficient information provision about proper care and available treatment options.” (participant 1, resident) “some of the nurses have a language barrier while others lack adequate knowledge to guide and support the patients in self care practices.” (participant 7, diploma nurse) the interviewees involved in this study felt that most diabetes patients under their care have misperceptions about the nature of dm and its lifelong self care practices. the patients perceived diabetes as if diabetes is a curable disease. as a result, they discontinued their medication once their health condition improved. moreover, they prefer to take herbal medicines rather than modern medicines. therefore, they experienced poor glycemic control and recurrent diabetes emergencies. this misperception resulted from a lack of appropriate information from untrained nurses and busy physicians. “some of the diabetes patients believe that dm is shortly curable. then, they discontinue their follow up after getting treated for months.” (participant1, resident) “some of the diabetes patients have the misunderstanding about the disease course and its treatments so that they discontinued their medication, and search for the herbalists.” (participant 26, bsc nurse) many interviewees expressed that most diabetes patients are not interested in integrating diabetes self care practices into their daily lives. the healthcare providers associated the lack of self motivation with a lower literacy level and awareness about diabetes self care practices. additionally, it was also noted that the patients have never received structured and adequate information to potentially increase their motivation and confidence to make an informed decision. the chronic nature of diabetes causing them to lose focus and motivation to integrate self care practices into their daily life. “patients with diabetes have lower awareness about the disease and lack motivation for diabetes self care practices”. (participant 1, resident) most patients with diabetes consistently consume the same type of diet as expressed by many of the subjects. while some patients are resistant to modify their usual diets, others are more compliant to change their diets. in addition, some patients have a shortage of food; as a result, they eat any food they can access without choices. such non adherence to dietary self care recommendations leads to uncontrolled blood glucose and increases the risk of diabetes complications. the following interview transcript can ascertain this. “most of the patients do not know diabetes diet. some are resistant to change their habits. e.g., if it is ‘injera, they always eat ‘injera.’ if it is bread, they usually eat the bread. they have no experience of eating varieties of diet.” (participant 3, bsc nurse) “socioeconomic condition of the patients is another serious challenge that put them difficult to eat healthy diets that do not increase blood sugar.” (participant 8, bsc nurse) the participants expressed that most diabetes patients were uneducated; they lacked functional, interactive, and numeracy skills. diabetes patients are unable to read, write, and understand essential information about their health. hence, they cannot follow the health care provider’s instructions, including the dose of medications. additionally, as it was expressed, there is inadequate health information provided by health care providers. they also felt inadequate to provide relevant and up to date information for diabetes patients to maintain self care practices. “the majority of patients who came from rural areas are not educated. they are not able to understand medication instructions. they do not know numbers to take the right dose of insulin even after they are demonstrated.”. (participant 3, bsc nurse) this exploratory qualitative study was conducted on barriers to diabetes patients’ self care practices. the findings suggested that lack of well integrated services, unavailability of endocrinologists, lack of in service training for health care providers, lack of trained diabetes nurse educators, inconsistent availability of laboratory tests and dm medications, and poor response to covid 19 pandemic were health care system barriers. moreover, lack of a multi disciplinary team, unavailability of holistic care, inadequate patient centered care, and limited and contradictory information provision were barriers related to health care providers. lastly, the patients’ related barriers included lack of self motivation, misperception about the disease and its treatment, low literacy level, and inability to modify dietary habits, which were barriers to the diabetes patients’ self care practices. the lack of well integrated services for diabetes care was found a significant barrier. the services rendered from each department, such as the endocrinology unit, record room, laboratory, and pharmacy, were fragmented. there was also a poor referral system for getting specialty care such as neurology, ophthalmic and dental care, hindering the patients’ self care practices. previous evidence showed that integrating services improves the quality of care, patient satisfaction, quality of life, and system efficiency. the fragmented and poorly integrated services lead to poor diabetes care outcomes.34,35 the provision of comprehensive care necessitates integrated health care services.36 this finding is essential for hospital administrators to integrate diabetes care services to facilitate easy access and enhance the diabetes patients’ service seeking behavior and satisfaction. the unavailability of endocrinologists who provide specialized services was a barrier to diabetes self care practices. this finding was in line with a study conducted in ghana that identified the lack of endocrinologists affected the quality of care11 when there were complex diabetes cases.37,38 furthermore, several studies showed that endocrinologist based care, both as a consultant or dm care team, significantly reduces the length of hospital stay.39,40 however, the management of chronic diseases might not draw the attention of stakeholders like infectious diseases. consequently, there are few specialists in the country. moreover, telehealth could be an alternative solution to increase patients’ access to expert care if feasible, and scaling up an enrollment for the endocrine sub specialty is essential. we identified that a lack of adequate in service training of health care providers was an existing barrier to diabetes self care. evidence from sub saharan african showed that health care providers had inadequate training on diabetes care.41 for example, a recent study in nigeria revealed that physicians treated diabetes patients without in service training after they graduated from medical school, significantly hindering the patients’ self care practices.42 similarly, another review indicated a limited knowledge of nurses in diabetes care associated with a lack of additional in service training on diabetes29 which adversely influences the provision of quality diabetes care.43 however, this finding contradicted the national action plans that endorsed the training of health professionals to provide quality diabetes care.44 in our context, most in service training has been highly donor based so that it is not sustainable. moreover, the stakeholders might not incorporate in service training into the national health care system plan. the lack of diabetes nurse educators was one main barrier voiced by the interviewees. diabetes patients’ education is the foundation of diabetes care. in most settings, nurses are trained to assist diabetic patients in establishing healthy lifestyles.45 therefore, those nurses trained for diabetes care could better educate and support the diabetes patients to accomplish their diabetes care.29,46 these in turn improves clinical outcomes, quality of life,47,48 and satisfaction of people with diabetes.49 the nurse population in the study setting was the majority with ample clinical experience, but they were the less utilized healthcare professionals. therefore, extending the nurse’s role with adequate training is cost effective, and it is critically important to facilitate patients’ access to diabetes education to enrich their knowledge of diabetes self care practices.50 inconsistent availability of laboratory services and essential medications were potential barriers to diabetes self care practices. this finding was in line with another similar study conducted in cambodia, where laboratory tests and supplies of essential medications scarce.51 several other studies also reported how laboratory and medications unavailability likely deter diabetes self care practices.11,43,52 although the national guideline recommends a periodical screening of hba1c, lipid panel, and urine analysis,53 blood glucose and other patients’ conditions were not consistently monitored. in addition, the patients could not purchase the medications from the private pharmacies to aid self care practices. consequently, the glycemic goal remains unattainable for the patients, which significantly increases the risk of long term diabetes complications. this problem was made worse by the recent covid 19 global pandemic, which shared many of the same resources and impeded the constant supply of laboratory tests and essential diabetes medications. the poor response of the covid 19 pandemic was found to be a barrier to ensure continuity of diabetes self care practices, manifested through discontinuation of follow up and monitoring blood glucose levels.54 this finding was consistent with a study in wuhan, china, and a brief report of covid 19, which indicated several clinical follow ups were postponed. the patients had been under stress, but not have support through digital health services, and physical activity was poorly performed.55,56 however, it is well known that even if numerous related studies were conducted, its effects were wide ranging and continuing, and the related knowledge continues. hence, further exploration will be required to distinguish its impact on diabetes self care practices. the lack of multidisciplinary team based dm care was another barrier to diabetes self care practices. this finding was congruent with a study from ghana that reported that the lack of multi disciplinary teams negatively affects the diabetes patients’ self care practices.11 many findings from the developed countries indicated the availability of multi disciplinary team based diabetes care,57 60 which hastened the glycemic target and shortened the length of stay in hospitalized patients.61 moreover, the multi disciplinary team approach significantly improves the psychosocial and clinical outcomes in diabetes patients.62,63 on the other hand, ineffective multi disciplinary care can negatively affect the patients’ safety and resources through fragmented care.64 though integrating several disciplines for complex diabetes care received wide recognition, there was a delay in launching the multi disciplinary team care in the study setting. this discrepancy might be that many developing countries were suffering from infectious diseases which might not equally deserve integrated multi disciplinary care as chronic non communicable diseases with various complications and co morbidities. this means that a few years ago, chronic non communicable diseases may not be perceived as a priority health problem of the country. the unavailability of holistic care provision was a significant barrier identified which agreed with a study done in mauritius that holistic care lacked much attention and focused on the drugs based model.65 the holistic care approach benefits the patients by giving equal weight to their physical, psychological, social, and spiritual well being.66 a study in iran showed a higher level of satisfaction of patients with holistic care.67 in this study, the concept of holistic care is well known by health care providers but it was not applied to practice. first, most medical and nursing education focused on the physical needs than the biopsychosocial needs of the patients. therefore, they only dealt with treating the physical problems in their practical attachments. secondly, the nurses spend much of their time on other routine care, such as monitoring vital signs, bed making, and assisting physicians than assessing and addressing the patients’ needs through the nurses’ care plans. inadequate patient centered care (pcc) was a barrier to diabetes self care practices against the existing guidelines and international recommendations.63,68 our findings agreed with the growing evidence from sub saharan african countries where patient centered care remains poorly implemented.69,70 however, the role of patient centered care is a well recognized dimension of quality health care.68 the ada and european association for the study of diabetes (easd) consensus report highlights the pcc’s role in enhancing the patients’ engagement in diabetes self care practices.25 the most recent study in the netherlands reported that pcc increased patients’ activation level, diabetes perceptions, and improved clinical outcomes.71 american diabetes association highlights that patient centered care is one of the priority areas to achieve optimal diabetes management.72 the present findings imply the need for the health care reform to change from provider center to a patient centered care model that warrants patients’ autonomy and guides the decision making about their health care. furthermore, it also proposes advocating patient centered care and its successful execution and transformation into practice. there was limited and contradictory diabetes self care information for the patients due to language barrier, lack of diabetes self care knowledge, lack of in service training of health care providers, and lack of educational resources (guideline, leaflets and posters). the current finding was consistent with previous evidence that the language barrier,73 lack of training, having limited knowledge, and lack of confidence to care for patients with diabetes complications51 though they expected to have better diabetes self care knowledge to treat and teach the patients.74 this might be due to non adherence to the national guideline so that the health care providers transmit incorrect information, which interferes with patients’ self care practices. another reason might be that the study settings are training centers for health and medical sciences students with different years of study and diverse knowledge levels that could expose the patients to inconsistent and contradictory information. the patients’ misperceptions about the treatment and self care practices of diabetes mellitus were prominently revealed. some felt cured and discontinued their medication after months of treatment, whereas others used herbal medicine. this is in line with a recent review done in sub saharan africa revealed that many patients had a misperception about diabetes treatment, and used herbal medicines are good treatment and opted as one alternative therapy,75 whereas a study in southern india indicated that nearly half of them perceived that diabetes is a curable disease.76 a study conducted in taiwan identified misperceptions that insulin affects the kidneys and eating vegetables can regulate blood glucose.77 the reason might be that there was no context based education program, no diabetes nurse educators who assessed educational needs, planned, and provided counseling for diabetes patients to address these misconceptions. a holistic patient assessment would be warranted to identify more profound patients’ misperceptions about diabetes and the required standard care and lifestyle change. we found that providers feel that patients are not self motivated to integrate self care practices into their daily lives, which was a significant barrier. this finding was consistent with the studies done in ghana, which disclosed that lack of motivation hampered self care practices and physical exercises.78 furthermore, lack of low or lack of motivation is associated with a lack of knowledge about the risks of diabetes complications resulting from poor self care management.79 in addition, evidence showed that depression is a co morbidity affecting people’s motivation to adopt effective diabetes self care practices and increased risk of diabetes complications.80,81 this might be that there were no structured, need based diabetes education and counseling services that potentially motivate or empower the patients to practice self care and absence of depressive symptoms screening. another reason might be that the study area is where khat is predominantly used, which might influence patients’ motivation. the incapable of changing dietary habits was identified as a barrier in this study. the finding was in line with a study in cambodia and ghana that reported dietary modification was the most challenging self care. the patients could not modify their favorite diets they have eaten for an extended period.51,78 in addition, a study in china identified dietary related barriers in patients with poorly controlled type 2 diabetes. the feeling of deprivation, eating away from home, lower levels of diet knowledge and empowerment, and more negative appraisal indicated the difficulty of dietary change.82 another review reported that barriers to lifestyle modification include established food habits, lack of self efficacy, motivation, social support, inadequate knowledge, low socioeconomic status, food culture, and poor time management.83 dietary non adherence behavior might be due to the lack of trained nurses or dietitians in the study setting who assess patients’ barriers and provide ongoing dietary counseling and support behavioral modification that leads to safer and healthy dietary practices. low health literacy level was a barrier to diabetes self care. this finding was consistent with a study conducted in iran where low health literacy was associated with poor diabetes self care practices,84 and the patients with lower health literacy did not adequately understand instructions to perform diabetes self care.85,86 this lower literacy might be that no best strategy was implemented to enhance patients’ health literacy levels. in addition, there was no well designed diabetes patients’ education that considers literacy, culture, languages to enhance their literacy levels through multiple strategies, including video assisted education, which might enhance self care practices. the study allowed us to thoroughly explore and understand diverse barriers of diabetes patients’ self care from multiple perspectives, such as nurses, general practitioners, internal medicine residents, and internists. as a result, we believed that this study generated important shreds of evidence that might be used by various stakeholders, including policymakers, regional health officers, hospital administrators, health care providers, and researchers, to design multi pronged strategies to improve the self care practices of patients with diabetes. however, the study did not include views of other health care providers and experiences of patients with diabetes and their families regarding self care practices. besides, face to face interview techniques of data collection might introduce social desirability bias. hence, future qualitative research needs to incorporate and triangulate the perspectives of health care providers with experiences of patients with diabetes and their families deemed necessary along with the quantitative study to determine the magnitude of these barriers. this study identified several barriers affecting diabetes patients’ self care practices and the way forward to improve overall diabetes care. in addition, the finding has some implications for nursing practices since they are the majority health care professionals in the health care system, and they are spending 24 hours with the patients and accessible to them and their families. the nurses were aware of knowledge gaps in diabetes care in which they need to improve in delivering diabetes care. they need to fill their knowledge gaps through in service capacity building training or continuous professional development programs. the nurses also perceived that patient centered care and holistic care provision were limited. therefore, they prepare themselves to implement patient centered holistic diabetes care that may assist the patients in overcoming various barriers to achieve desired goals. the finding also suggested empowering nurses with more independent roles such as diabetes nurse educators as a possible initiative to improve the patients’ health outcomes. multiple barriers that hindered diabetes self care practices were identified, which included lack of well integrated services for diabetes care, unavailability of endocrinologists and diabetes nurse educators, lack of in service training for health care workers, inconsistent availability of tests and essential drugs, lack of multidisciplinary team, lack of holistic care, inadequate patient centered care, limited and contradictory information provision, patients’ misperception about the disease and its care, low health literacy level, lack of motivation and difficulty of changing dietary habits were the prominent barriers to diabetes self care practices. therefore, we recommend integrated services that can facilitate better patient care, establishing a context based multidisciplinary team centered around the patients to address the patient’s needs and enhance diabetes self care practice, achieve target glycemic control, and prevent complications. capacity building training is also recommended for health professionals who provide direct care and support for diabetes patients for example; training diabetes nurse educators is essential to regularly provide standard diabetes self management education (dsme) and targeted counseling services that improve patient’s literacy, motivation, and misperceptions to overcome perceived barriers to diabetes self care practices. in addition, the hospital administrators should ensure the continuous supply of laboratory materials and stock pharmacies with safer and adequate essential diabetes medications for augmenting the effectiveness of diabetes self care practices. we thank all research participants, and haramaya university. this research was funded by haramaya university, ethiopia. ada, american diabetes association; bsc, bachelor of sciences; dka, diabetes keto acidosis; dm, diabetes mellitus; dsme, diabetes self management education; fmoh, federal ministry of health; hba1c, glycated hemoglobin a1c; icu, intensive care unit; idi, in depth interview; gps, general practitioners; opd, outpatient department; and who, world health organization. all authors made a significant contribution to the conception, study design, execution, acquisition of data, analysis and interpretation of the data; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. the authors report no conflicts of interest in this work. articles from diabetes, metabolic syndrome and obesity: targets and therapy are provided here courtesy of dove press connect with nlm national library of medicine 8600 rockville pike bethesda, md 20894

trending datanon communicable diseases cause 70% of global deaths country dropdown over the two decades before covid 19 struck in 2020, cambodia blossomed economically. having reached lower middle income status in 2015, it set its signs on attaining upper middle income status by 2030. over the two decades before covid 19 struck in 2020, cambodia blossomed economically. cambodia’s economy grew at an average annual rate of 7.6 percent between 1995 and 2019, driven largely by tourism, manufacturing exports, real estate, and construction, making it one of the fastest growing economies in the world. after reaching lower middle income status in 2015, it set its sights on becoming an upper middle income economy by 2030 and higher income economy by 2050. the covid 19 pandemic triggered the first economic contraction in 25 years. in 2020, the economy contracted 3.1 percent. during the post covid 19 period, the economy continues to gradually recover, growing at 3.0 percent and 5.2 percent in 2021 and 2022, respectively. cambodia’s economic growth is estimated to have reached 5.4 percent in 2023. this year’s economic growth is projected to marginally improve to 5.8 percent, driven mainly by a revival of services and goods exports. downside risks include weaker than expected global demand, global financial stress amid elevated debt and high borrowing costs, and a slower than anticipated recovery in china. domestically, a faster than expected increase in non performing loans could affect macro financial stability as the housing market correction continues. in the decade before covid 19, poverty rates declined by 1.6 percentage points a year, driven substantially by rising labor (especially wage) earnings. however, the covid 19 pandemic led to increases in unemployment, and poverty. in addition, the energy and food price hikes due to the russian ukraine conflict imposed an additional burden as they weighed on household budgets. the world bank’s assessment, which did not account for implications of covid 19 or for the fiscal policy response implemented between 2020 and 2022 to support households, suggests that inflation could increase poverty 4 percentage points from the national poverty rate of about 18 percent, measured in 2019/20. the scale up of social assistance to poor and vulnerable households, launched in june 2020, has moderated income losses. poverty nevertheless remains higher than pre pandemic levels. poverty is expected to decline due to the projected economic recovery and moderating inflation. cambodia has made considerable strides in improving health outcomes, early childhood development, and primary education in rural areas. life expectancy at birth and under five, and infant mortality rates have been improved significantly between 2000 and 2021. despite this progress, human capital indicators lag other lower middle income countries. in 2020, a child born in cambodia would be expected to be only 49 percent as productive when grown as she or he could be if she or he enjoyed full quality education, good health, and proper nutrition during childhood. cambodia's educational journey, characterized by advancement and resilience, has seen increased enrollment rates, new schools, and improved access to learning. however, this journey is far from complete. many cambodian students are not acquiring the foundational skills in literacy and numeracy crucial for future learning and a dynamic workforce​​. when these children grow up, it is unlikely that they will be able to contribute to cambodia’s economic growth. this situation highlights the urgent need to harness and develop the vast untapped potential of these young learners. key reforms are needed for cambodia to sustain inclusive growth, foster competitiveness, sustainably manage natural resource wealth, and improve access to and quality of public services. cambodia continues to have a serious infrastructure gap and would benefit from greater connectivity and investments in rural and urban infrastructure. further diversification of the economy will require fostering entrepreneurship, expanding the use of technology, and building new skills to address emerging labor market needs. accountable and responsive public institutions will also be critical. boosting investments in human capital will be of utmost importance to achieve cambodia’s ambitious goal of reaching middle income status by 2030. last updated: april 2024 the world bank’s engagement in cambodia focuses on eliminating poverty and boosting shared prosperity by investing in human capital, improving rural living standards, building basic infrastructure, and empowering communities. the world bank has updated cambodia's first systematic country diagnostic. this systematic country diagnostic update (scd2) update will help inform the world bank’s next country partnership framework (cpf) 2025 2029 and contribute to the policy discussion in cambodia. this scd2 report summarizes the key findings from new world bank analysis and extensive consultations to provide an updated set of desired outcomes, development areas and policy priorities to support cambodia’s sustainable and inclusive development. scd2 outlines a refreshed set of outcomes, development areas and policy priorities to help ensure strong, inclusive, and sustainable growth over the next five years. there are three main high level outcomes (hlos): · hlo i: improved access to high quality formal jobs. sustaining strong and high quality economic, jobs and wages growth will require deeper reforms to increase the cambodian economy's economic competitiveness, diversification, and productivity. · hlo ii: upgraded and better protected human capital. upgrading, and better protecting the human capital of cambodia’s people has become more urgent given the low starting point, only modest progress since the scd1, growing skills shortages, and declining labor productivity growth. · hlo iii: enhanced livability and resilience. enhancing the livability and resilience of cambodia’s natural and urban environments remains critical for ensuring a sustainable pattern of growth, given the relatively high exposure to risk from natural disasters and poor performance on environmental management and urban development. · strengthening governance and public sector capacity remains a critical cross cutting priority to support achieving the three high level outcomes. despite the progress since the scd1, cambodia continues to rank low compared to its structural peers and globally (bottom two quintiles) on most governance and public sector capacity measures. the world bank group is preparing a new country partnership framework (cpf) for fy2025 2029 for cambodia. the new cpf is building on its ongoing engagement in the country, and draws on the priorities identified in the new pentagonal strategy phase i, the systematic country diagnostic (scd) update along with other core analytics (including the country climate development report, country economic memorandum, public finance report, and poverty assessment) and the completion and learning review. the cpf aims to support better quality of life for all cambodians through three interlinked high level outcomes (hlos)   strengthened human capital, enhanced economic competitiveness for better jobs, and greater resilience for vulnerable people. the cpf consultations with key stakeholders took place during december 2023 to early february 2024.the cpf is expected to be finalized and discussed by the world bank board of executive directors in calendar year 2024. the knowledge agenda is a significant part of the world bank’s engagement in cambodia. programmatic advisory services and analytics (pasa)   on competitiveness and entrepreneurship, economic diversification, digital development, social accountability, public sector performance, poverty assessment, equitable access to quality health and nutrition services, environmental sustainability and resilience, and social protection and jobs   strengthen the understanding of development challenges cambodia faces and foster dialogue on development policy issues with a broad range of stakeholders. last updated: april 2024 the health equity and quality improvement project phase 2 (h eqip ii) aims to improve equitable utilization of quality health services, especially for poor and vulnerable populations, and provide immediate and effective response in case of an eligible crisis or emergency in the kingdom of cambodia. by the end of the first year of the project lifespan, h eqip ii: · initiated the first round of the nationwide implementation of the national quality enhancement monitoring program phase 2 (nqemp 2), aimed at improvement of the quality of health service delivery; and · financed the health equity fund (hef). hef has: o purchased of 3.2 million episodes of health care services at public health facilities for the poor and vulnerable; o completed training for health facilities staff in all public health facilities at the subnational level and equipped them for delivery of diabetes and hypertension screening and management; o completed training of more than 500 health center staff and over 60 referral hospital staff on providing cervical precancerous lesions and treatment; and o trained village health support groups to assist with screening and treatment of diabetes, hypertension and cervical precancerous lesions. the cambodia nutrition project aims to enhance and accelerate the formation of the country’s human capital by focusing on maternal and early childhood health and nutrition. key achievements include: · around 4,450 village health workers   3,225 of them are women   have been recruited and trained on the commune program for women and children (cpwc), which focuses on the first 1,000 days of life (from pregnancy to a child’s second birthday); · the rollout of quality assessment and performance based grants at 156 health centers and 281 commune government administrations to enhance availability and quality of service delivery for women and children; · development of modernized communication materials for children under two years old and women of reproductive age (especially pregnant and lactating women) and associated tools to boost demand for service uptake and to improve behavior across different stages of service delivery; · intervention to include the children under two years old of informal workers as a new group of beneficiaries to be covered by health equity fund, to lower financial barriers for access to essential health services; and · improved reporting of gender disaggregated data on beneficiaries and implementers. the ongoing higher education improvement project (heip) has invested $5 million in e learning so that nearly 3 million preschool, primary, and secondary school pupils could learn from home when schools are closed. the main achievement as of now includes: · 21 bachelor’s and master’s curricula that have been revised or developed to meet national and international standards, · publication of 25 internationally peer reviewed articles, · nine products and 23 prototypes developed, · 144 renovated and newly built laboratories, · a sizeable number of classrooms renovated, and · enrollment of 118 faculty members from five targeted higher education institutions for advanced degrees. as of now, the project has benefitted 50,770 students, faculty members and educational staff. based on the success of the implementation of social accountability framework (isaf) phase i, which was initiated in 2014, phase ii (isaf ii) has been rolled out. the world bank established a multi donor social accountability and service delivery trust fund (sasd tf) with switzerland and germany to provide financing for world vision international (wvi) to implement demand side (civil society) activities (engaging citizens to improve service delivery through social accountability) and for the national committee for subnational democratic development secretariat (ncdds) to implement supply side (government) activities (integration of social accountability into national and subnational systems) in support of isaf phase ii (2019 2025). so far, supply side activities have been rolled out to 24 of 25 capitals and provinces (15 provinces covered by the bank supported operations, and the remaining supported by other development partners). australia is providing additional financing to both operations through the australia world bank partnership for promoting inclusion, sustainability and equality in cambodia single donor trust fund. to raise awareness of citizen rights and service provider standards, the project has organized events including village meetings, mobile kiosks, and home visits to vulnerable families. some 84 percent of the service providers covered by the projects (schools, health centers, and commune administrations) are now meeting key national standards. a total of 3,532 community accountability facilitators (cafs) were active by the end of 2023, 63 percent of whom were women, and 35 percent of whom were youth. last updated: april 2024 find out what the bank group's branches are doing in the region. the project supports cambodia's health equity fund to cover health service costs and improve use of services for the poor. improving lower secondary education to meet minimum standards is the goal of a world bank supported project in cambodia. in cambodia, most domestic wastewater is left untreated with only 11% of households connected to a sewer network. raising awareness on the importance of wastewater treatment is crucial. from march 2018 to june 2019, the cambodian water supply association and the ministry of industry and handicraft implemented a program to build capacity of 12 private water operators in cambodia. stay current with our latest data & insights © 2025 world bank group. all rights reserved. this site uses cookies to optimize functionality and give you the best 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supported by global health the shortage highlights a widening gulf in the standard of care for people with diabetes, most of whom live in low income countries. by stephanie nolen stephanie nolen reports on global health, including access to care for noncommunicable diseases in developing countries. south africa’s public health care system has run out of the human insulin pens that it provides to people with diabetes, as the pharmaceutical industry shifts production priorities to blockbuster weight loss drugs that use a similar device for delivery. novo nordisk, the company that has supplied south africa with human insulin in pens for a decade, opted not to renew its contract, which expired last month. no other company has bid on the contract   to supply 14 million pens for the next three years, at about $2 per pen. “current manufacturing capacity limitations mean that patients in some countries, including south africa, may have limited access to our human insulins in pens,” said ambre james brown, a spokeswoman for novo nordisk. the company did not reply to questions about which other countries are affected. novo nordisk’s drugs ozempic and wegovy, which are widely prescribed in the u.s. for weight loss, are sold in single use pens produced by many of the same contracted manufacturers who make the multidose insulin pens. a month’s supply of ozempic in the united states costs about $1,000, far more than insulin. novo nordisk dominates the global market for insulin in pens and has supplied south africa since 2014. eli lilly, the other major producer, has indicated in recent months that it is struggling to keep up with the significant demand for its weight loss drug zepbound. “this is because of the global demand for ozempic and these drugs,” said khadija jamaloodien, the director of sector wide procurement for south africa’s health service. “they’re shifting the focus on the more profitable line.”

 a new report published by who in the lead up to world diabetes day highlights the alarming state of global access to insulin and diabetes care, and finds that high prices, low availability of human insulin, few producers dominating the insulin market and weak health systems are the main barriers to universal access. “the scientists who discovered insulin 100 years ago refused to profit from their discovery and sold the patent for just one dollar,” said who director general, dr tedros adhanom ghebreyesus. “unfortunately, that gesture of solidarity has been overtaken by a multi billion dollar business that has created vast access gaps. who is working with countries and manufacturers to close these gaps and expand access to this life saving medicine for everyone who needs it.” insulin is the bedrock of diabetes treatment   it turns a deadly disease into a manageable one for nine million people with type 1[i] diabetes. for more than 60 million people living with type 2 diabetes, insulin is essential in reducing the risk of kidney failure, blindness and limb amputation. however, one out of every two people needing insulin for type 2 diabetes does not get it.