Economic burden on families of childhood type 1 diabetes in urban Sudan

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Abstract

The aims of this study were to estimate the direct costs of childhood diabetes in a low income country, Sudan, and to assess the effectiveness of care paid for by the families. For this purpose, socio-economic and demographic data on families were obtained from the parents of 147 children with type 1 diabetes, attending public or private clinics in Khartoum State, Sudan. The median annual income of the families of diabetic children was US dollars (US$) 1222 (range 0–14,338) of which 16% was received as financial help from relatives and friends. The median annual expenditure of diabetes care was US$ 283 per diabetic child of which 36% was spent on insulin. Of the family expenditure on health, 65% was used for the diabetic child. Families of diabetic children who were attending private clinics had a significantly higher total expenditure on health and home blood glucose monitoring than those who were attending the public clinics. However, there was no difference in total income between the two groups and glycaemic control was poor in 86% of the patients, regardless of whether care was being given by private or public clinics. The occurrence of the disease and its poor control appeared to exert a negative impact on the school performance of the diabetic child. In conclusion, the low direct costs reflect the minimal care given to the diabetic patients. Under the present economic conditions, families pay a considerable part of their income to sponsor the health of their diabetic children and receive little support other than that from relatives and friends. The present organization of diabetes care does not provide the patient with empowerment, knowledge and self-care ability. Well-trained diabetic teams and education programs may improve this situation.

Introduction

Estimates of the cost of diabetes care can provide information to help prioritise and guide the allocation of scarce resources, attract additional resources and manage available assets to control the health and socio-economic burden of diabetes. According to the prevailing cost-of-illness methodology [1], [2] the economic costs of diabetes are divided into two categories, i.e. direct and indirect costs [3], [4]. The direct costs relate to outpatient visits, hospitalization, medication, and other supplies as well as the cost of traveling to diabetes clinics. The most important supplies are insulin, tablets, syringes, blood and urine monitoring equipment.

There is paucity of information on the cost of type 1 diabetes in developing countries [5]. Most countries do not have proper costing data when compared with developed countries [6], [7]. Such data depend on information, which is available in the files of the patients, but in developing countries the filing systems are poor with most filings incomplete. Thus, one has to rely on the patient's memory.

Health care expenditures in low-income countries were analyzed for the years 1990 and 1995 [8]. The key finding included substantial reduction in public spending per capita with a significant shift towards private expenditures. This appears increasingly to be substituting rather than supplementing public expenditures. Rises in out-of-pocket costs for public and private health-care services are driving many families into poverty and are increasing the poverty of those who are already poor. The main effects are untreated morbidity, reduced access to care and long-term impoverishment.

Diabetes mellitus in the Sudan, as in many other developing countries, is a growing health problem in all socio-economic classes [9] and associated with a high prevalence of complications [10]. Patients have poor glycaemic control, and a low quality of life [11]. The incidence of type 1 diabetes in 7–14-year-old children increased over a 4-year period from 5.8 to 10.3 per 100 000 children with an average annual incidence of 7.9 per 100 000 children [12].

There is a consequent need to evaluate the burden of diabetes for the society and to develop affordable and cost-effective prevention strategies. The present investigation was performed with the aims of estimating the contribution of families to the cost of care and to determine the quality of care received by diabetic children in an urban area in Sudan. We considered direct costs, since they are well defined and their limits stated.

Section snippets

Sudanese health system

Sudan is the largest country by area in Africa. The national capital, Khartoum State, is divided by the Nile and its two main tributaries into three towns, Khartoum, Khartoum North and Omdurman, and their suburban areas. The capital has got 6 million inhabitants, i.e. 21% of the population of Sudan.

The introduction of federalism in Sudan in the last decade fostered a three-layered health system structure comprising Federal, State Ministries of Health and Local health systems. In addition to the

Patients and methods

This descriptive cross-sectional study was conducted in Khartoum State and consists of interviews with parents of 147 diabetic children who were attending three public and three private clinics. These were the pediatric out-patient clinics in two main hospitals in Khartoum State (Khartoum Teaching Hospital and Omdurman Teaching Hospital), a public diabetes center (Gabir Abu Eliz), a private diabetes center (Mulazmin Diabetes Center) and two private diabetes clinics. During a 10-month period

Patient characteristics and family income

The patient characteristics are shown in Table 1. Out of the 147 diabetic children, 6.7% were preschool age and the others were enrolled in school. The mean diabetes duration was short in comparison to the age of the patients and the age at diagnosis of diabetes. Patients with a long duration of the disease, and with chronic diabetic complications, did not appear in this cohort. As to the level of education of the parents of the diabetic children, 19% of the fathers and 30% of the mothers were

Discussion

The economic aspects presented in this study provide an estimate and analysis of the direct cost of diabetes during childhood. Unlike cost estimates derived from the data of diabetic individuals identified from the general population or diabetes registers, this study had the advantage of interviewing individuals, thus obtaining relatively precise estimates of the cost of diabetes. We directly observed costs and the utilization pattern of individuals, rather than estimating cost from aggregated

Acknowledgements

This study was supported by the National Diabetes Program and Mulazmin Diabetes Center, Sudan. Fellowship of the principal investigator (HE) was granted by the Swedish Institute, Sweden.

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