Documenting and visualising progress towards Universal Health Coverage of insulin and blood glucose test strips for people with diabetes

Published:September 20, 2019DOI:



      Global governments have committed to achieve Universal Health Coverage (UHC), ensuring access to quality and affordable healthcare for all. This is fundamental for those with type 1 diabetes mellitus, who require daily access to both insulin and blood glucose test strips to survive. This group risks being left behind by global initiatives that fail to consider these particular needs.


      A questionnaire was distributed to key informants in 37 less-resourced countries. Seven high-income countries were also included for comparison. We drew on a WHO framework developed to assess progress towards UHC to create scales on three dimensions: population covered, services provided and direct costs. A fourth dimension, availability, was added. Results were grouped into six patterns and visually displayed with radar graphs.


      65% of the less-resourced national health systems provided insulin, with medians of 67% for service provision (equating to Human Regular and NPH), 55% direct costs covered, and 75% availability. Test strips were only provided in 14% of the less-resourced systems, with medians 42% (less than two strips per day), 76%, and 88% respectively. Six patterns of provision were identified. Progress correlated with income level, yet some low-income countries are achieving provision for insulin and test strips for those enrolled in health insurance schemes.


      No less-resourced country had even near-complete coverage for insulin, and coverage was worse for test strips. This study demonstrates the utility of this framework which could be developed as a means of tracking progress in meeting the needs of people with diabetes.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Diabetes Research and Clinical Practice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ogle G.D.
        • von Oettingen J.
        • Middlehurst A.C.
        • Hanas R.
        • Orchard T.J.
        Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels.
        Pediatr Diabetes. 2019; 20: 93-98
        • Haller M.J.
        • Stalvey M.S.
        • Silverstein J.H.
        Predictors of control of diabetes: Monitoring may be the key.
        J Pediatr. 2004; 144: 660-661
        • Beran D.
        • Yudkin J.S.
        • de Courten M.
        Access to care for patients with insulin-requiring diabetes in developing countries.
        Diabetes Care. 2005; 29: 2136-2140
        • Majikela-Dlangamandla B.
        • Isiavwe A.
        • Levitt N.
        Diabetes monitoring in developing countries.
        Diabetes Voice. 2006; 51: 28-31
        • Kratzer J.
        Structural barriers to coping with type 1 diabetes mellitus in ghana: experiences of diabetic youth and their families.
        Ghana Med J. 2012; 46: 39-45
        • Ogle G.D.
        • Kim H.
        • Middlehurst A.C.
        • Silink M.
        • Jenkins A.J.
        Financial costs for families of children with Type 1 diabetes in lower-income countries.
        Diabet Med. 2016; 33: 820-826
        • Atun R.
        • Davies J.I.
        • Gale E.A.M.
        • Bärnighausen T.
        • Beran D.
        • Kengne A.P.
        • et al.
        Diabetes in sub-Saharan Africa: from clinical care to health policy.
        Lancet Diabetes Endocrinol. 2017; 5: 622-667
        • Klatman E.L.
        • Jenkins A.J.
        • Ahmedani M.Y.
        • Ogle G.D.
        Blood glucose meters and test strips: global market and challenges to access in low-resource settings.
        Lancet Diabetes Endocrinol. 2019; 7: 150-160
      1. UN general assembly. Transforming our world: the 2030 agenda for sustainable development A/RES/70/1 2015. (accessed February 9, 2018).

      2. IDF Diabetes Atlas 2017. (accessed May 16, 2019).

        • Beran D.
        • Yudkin J.S.
        • de Courten M.
        Access to care for patients with insulin-requiring diabetes in developing countries case studies of Mozambique and Zambia.
        Diabetes Care. 2005; 28: 2136-2140
        • Beran D.
        • Ewen M.
        • Laing R.
        Constraints and challenges in access to insulin: A global perspective.
        Lancet Diabetes Endocrinol. 2016; 4: 275-285
        • Ogle G.D.
        • Middlehurst A.C.
        • Silink M.
        The IDF life for a child program index of diabetes care for children and youth.
        Pediatr Diabetes. 2016; 17: 374-384
      3. World Health Organization. Making fair choices on the path to universal health coverage: Final report of the WHO Consultative Group on Equity and Universal Health Coverage 2014. (accessed February 8, 2018).

      4. World Health Organization. The World Health Report 2008: Primary Health Care Now More Than Ever 2008. (accessed February 8, 2018).

      5. Mexico Gobernio de la Republica. Programa Institucional del Instituto Mexicano del Seguro Social 2014-2018 2014. (accessed January 4, 2018).

      6. Kuwawenaruwa A, Borghi J. Health insurance cover is increasing among the Tanzanian population but wealthier groups are more likely to benefit. Ifakara Heal Inst 2012. (accessed February 8, 2018).

        • Chomi E.N.
        • Mujinja P.G.M.
        • Enemark U.
        • Hansen K.
        • Kiwara A.D.
        Health care seeking behaviour and utilisation in a multiple health insurance system: does insurance affiliation matter?.
        Int J Equity Health. 2014; 13
      7. World Bank. World Bank Open Data n.d. (accessed March 27, 2018).

        • Okebukola P.O.
        • Brieger W.R.
        Providing universal health insurance coverage in Nigeria.
        Int Q Community Health Educ. 2016; 36
      8. Kenya national bureau of statistics. Economic survey 2017 2017. (accessed February 8, 2018).

      9. National bureau of statistics ministry of finance & treasury. Statistical pocketbook of Maldives 2016 2016. (accessed February 8, 2018).

        • Bredenkamp C.
        • Buisman L.R.
        Financial protection from health spending in the Philippines: Policies and progress.
        Health Policy Plan. 2016; 31: 919-927
      10. Australian government department of human services. Pharmaceutical benefits schemes (PBS) Safety Net n.d. (accessed February 8, 2018).

      11. Pharmaceutical management agency. Pharmaceutical schedule February 2018 volume 25 n.d. (accessed February 9, 2018).

      12. Gov UK. NHS prescription charges from April 2017 n.d. (accessed August 29, 2017).

        • Fullerton B.
        • Siebenhofer A.
        • Jeitler K.
        • Horvath K.
        • Semlitsch T.
        • Berghold A.
        • et al.
        Short-acting insulin analogues versus regular human insulin for adults with type 1 diabetes mellitus.
        Cochrane Database Syst Rev. 2016; (CD012161)
        • Pedersen-Bjergaard U.
        • Kristensen P.L.
        • Beck-Nielsen H.
        • Nørgaard K.
        • Perrild H.
        • Christiansen J.S.
        • et al.
        A prospective randomised cross-over study of the effect of insulin analogues and human insulin on the frequency of severe hypoglycaemia in patients with type 1 diabetes and recurrent hypoglycaemia (the HypoAna trial): study rationale and design.
        BMC Endocr Disord. 2012; 12: 10
        • Danne T.
        • Phillip M.
        • Buckingham B.A.
        • Jarosz-Chobot P.
        • Saboo B.
        • Urakami T.
        • et al.
        ISPAD clinical practice consensus guidelines 2018: insulin treatment in children and adolescents with diabetes.
        Pediatr Diabetes. 2018; 19: 205-226
        • Rewers M.J.
        • Pillay K.
        • de Beaufort C.
        • Craig M.E.
        • Hanas R.
        • Acerini C.L.
        • et al.
        Assessment and monitoring of glycemic control in children and adolescents with diabetes.
        Pediatr Diabetes. 2014; 15: 102-114
        • Miller K.M.
        • Beck R.W.
        • Bergenstal R.M.
        • Goland R.S.
        • Haller M.J.
        • McGill J.B.
        • et al.
        Evidence of a strong association between frequency of self-monitoring of blood glucose and hemoglobin A1c levels in T1D Exchange clinic registry participants.
        Diabetes Care. 2013; 36: 2009-2014
      13. World Health Organization. Second WHO model list of essential in vitro diagnostics second WHO model list of essential in vitro diagnostics 2019. (accessed July 9, 2019).

      14. World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020 2013. (accessed April 3, 2018).

      15. World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies 2010. (accessed February 9, 2018).

      16. Averill C, Marriott A. Universal health coverage why health insurance schemes are leaving the poor behind; 2013.

      17. USAID. Health insurance profile: Rwanda 2016. (accessed February 8, 2018).

        • Alhassan R.K.
        • Nketiah-Amponsah E.
        • Arhinful D.K.
        A review of the national health insurance scheme in Ghana: What are the sustainability threats and prospects?.
        PLoS ONE. 2016; 11: 1-16
      18. World health organization and health action international. Measuring medicine prices, availability, affordability and price components. Switzerland; 2008.

        • Murphy A.
        • Hanson K.
        • Mcgowan C.
        • Mckee M.
        • Suhrcke M.
        Coping with healthcare costs for chronic illness in low-income and middle- income countries: a systematic literature review.
        BMJ Glob Heal. 2019; 4: 1-8
      19. World Health Organization. The World health report 2000 : health systems : improving performance 2000. (accessed July 17, 2018).