Health system capacity to manage diabetic ketoacidosis in nine low-income and lower-middle income countries: A cross-sectional analysis of nationally representative survey data

Sarah Matthews; Matthew M Coates; Alice Bukhman; Celina Trujillo; Gina Ferrari; Wubaye Walelgne Dagnaw; Darius Leopold Fénelon; Theodros Getachew; Biraj Karmacharya; Nancy Charles Larco; Aimée M Lulebo; Mary Theodory Mayige; Maïmouna Ndour Mbaye; Getahun Tarekegn; Neil Gupta; Alma Adler; Gene Bukhman

doi:10.1016/j.eclinm.2022.101759

Health system capacity to manage diabetic ketoacidosis in nine low-income and lower-middle income countries: A cross-sectional analysis of nationally representative survey data

EClinicalMedicine. 2022 Dec 1:55:101759. doi: 10.1016/j.eclinm.2022.101759. eCollection 2023 Jan.

Authors

Sarah Matthews¹, Matthew M Coates¹, Alice Bukhman², Celina Trujillo^{1

3}, Gina Ferrari^{1

3}, Wubaye Walelgne Dagnaw^{3

4}, Darius Leopold Fénelon⁵, Theodros Getachew⁶, Biraj Karmacharya⁷, Nancy Charles Larco⁸, Aimée M Lulebo⁹, Mary Theodory Mayige¹⁰, Maïmouna Ndour Mbaye¹¹, Getahun Tarekegn¹², Neil Gupta^{1

13}, Alma Adler¹, Gene Bukhman^{1

3

13}

Affiliations

¹ Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
² Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
³ NCD Synergies Project, Partners In Health, Boston, MA, USA.
⁴ Ethiopia Ministry of Health, Addis Ababa, Ethiopia.
⁵ Zanmi Lasante, Port-au-Prince, Haiti.
⁶ Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
⁷ Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Kathmandu, Nepal.
⁸ Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC), Port-au-Prince, Haiti.
⁹ Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo.
¹⁰ National Institute for Medical Research, Dar es Salaam, Tanzania.
¹¹ Centre du diabète Marc Sankale, Hôpital Abass Ndao, Dakar, Senegal.
¹² Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
¹³ Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.

Abstract

Background: There has been increasing awareness about the importance of type 1 diabetes (T1D) globally. Diabetic ketoacidosis (DKA) is a life-threatening complication of T1D in low-income settings. Little is known about health system capacity to manage DKA in low- and lower-middle income countries (LLMICs). As such, we describe health system capacity to diagnose and manage DKA across nine LLMICs using data from Service Provision Assessments.

Methods: In this cross-sectional study, we used data from Service Provision Assessment (SPA) surveys, which are part of the Demographic and Health Survey (DHS) Program. We defined an item set to diagnose and manage DKA in higher-level (tertiary or secondary) facilities, and a set to assess and refer patients presenting to lower-level (primary) facilities. We quantified each item's availability by service level in Bangladesh (Survey 1: May 22 2014-Jul 20 2014; Survey 2: Jul 2017-Oct 2017), the Democratic Republic of the Congo (DRC) (Oct 16 2017-Nov 24 2017 in Kinshasha; Aug 08 2018-Apr 20 2018 in rest of country), Haiti (Survey 1: Mar 05 2013-Jul 2013; Survey 2: Dec 16 2017-May 09 2018), Ethiopia (Feb 06 2014-Mar 09 2014), Malawi (Phase 1: Jun 11 2013-Aug 20 2013; Phase 2: Nov 13 2013-Feb 7 2014), Nepal (Phase 1: Apr 20 2015-Apr 25 2015; Phase 2: Jun 04 2015-Nov 05 2015), Senegal (Survey 1: Jan 2014-Oct 2014; Survey 2: Feb 09 2015-Nov 10 2015; Survey 3: Feb 2016-Nov 2016; Survey 4: Mar 13 2017-Dec 15 2017; Survey 5: Apr 15 2018-Dec 31 2018; Survey 6: Apr 15 2019-Feb 28 2020), Tanzania (Oct 20 2014-Feb 21 2015), and Afghanistan (Nov 1 2018-Jan 20 2019). Variation in secondary facilities' capacity and trends over time were also explored.

Findings: We examined data from 2028 higher-level and 7534 lower-level facilities. Of these, 1874 higher-level and 6636 lower-level facilities' data were eligible for analysis. Availability of all item sets were low at higher-level facilities, where less than 50% had the minimal set of supplies, less than 20% had the full minimal set, and less than 15% had the ideal set needed to diagnose and manage DKA. Across countries in lower-level facilities, less than 14% had the minimal set of supplies and less than 9% the full set of supplies for diagnosis and transfer of DKA patients. No country had more than 20% of facilities with the minimal set of items needed to assess or manage DKA. Where data were available for more than one survey (Bangladesh, Senegal, and Haiti), changes in availability of the minimal set and ideal set of items did not exceed 15%. Tertiary facilities performed best in Haiti, Ethiopia, Malawi, Nepal, Senegal, Tanzania, and Afghanistan. Secondary facilities that were rural, public, and had fewer staff had lower capacity.

Interpretation: Health system capacity to manage DKA was low across these nine LLMICs. Although efforts are underway to strengthen health systems, a specific focus on DKA management is still needed.

Funding: Leona M. and Harry B. Helmsley Charitable Trust, and Juvenile Diabetes Research Foundation Ltd.

Keywords: Africa; Critical care; Emergency care; Health systems; Ketoacidosis; Low-income countries; Lower-middle income countries; Noncommunicable disease; Type 1 diabetes.