Diabetes Mellitus: the increasing burden of disease in Kenya.
Non-communicable diseases (NCDs) are the leading cause of death globally and diabetes mellitus is the 4th main contributor . It is characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, action or both . There are three main types: type 1 (TIDM) (10%), 2 (TIIDM) (85%) or gestational (5%) affecting 347 million people . There were about 1.3 million deaths in 2008  predicted to increase to over 2 million by 2030 . The burden of diabetes is disproportionately high in low-middle income countries [5,6].
Burden of disease and diabetes
Kenya has a heavy disease burden with an average life expectancy of 56 years . The main challenge arises from communicable diseases (CDs) (e.g.malaria and HIV [7,8]) accounting for about 62% of deaths . Despite successes to control CDs , health status has stagnated due partly to the increase of NCDs [8,10] causing 28% of all deaths in 2010; diabetes accounted for 2% of this [7,9]. The World Health Organization (WHO) estimates that the prevalence of diabetes in Kenya at 3.3% [3,8,11] and predicts a rise to 4.5% by 2025 . However, two-thirds of diabetics may be undiagnosed [10,11]. The double demand from CDs and NCDs has hindered Kenya’s progress towards achieving the Millennium Development Goals (MDGs) . It is therefore necessary to assess the increasing burden of diabetes and provide cost-effective strategies for its prevention and control.
Funding of healthcare in Kenya
The funding, structure and administration of a health service is key to achieving success. Kenya’s healthcare system is financed predominantly through private sources . Private businesses operate 43% of health facilities, government 41% and non-governmental organizations 15% . However the government owns most hospitals, health centres and dispensaries . In 2006 Kenya’s total health expenditure (THE) was 4.6% of gross domestic product with 29US$ per capita being spent on health , below the WHO recommended 34US$ for provision of a minimum health package [15,16]. Kenya’s focus has been to control CDs which account for the majority of THE [7,12,13]. A disproportionate expenditure is allocated to urban areas for curative care . In East Africa the average total annual cost for care of a type 1 diabetic is 229US$ with 60-70% of this being used to purchase insulin . Kenya does not have adequate funds for diabetes prevention or care. Kenyans who can, independently fund their care [13,14], leaving many diabetics and their families at risk of poverty and poorer health . Some save money through non-compliance; increasing the risk of complications . Nearly 50% of Kenyans live on less than 1US$ daily [14,17]. Kenya has developed a more positive attitude to prevention and public health, increasing THE from 9% (2001/2002) to 23% (2009/2010) . But this needs to be accompanied by a more effective healthcare system.
Structure and management of Kenya’s healthcare system
Kenya’s health facilities are distributed regionally. Community dispensaries and health centres  provide the most basic level of service (see figure 1) . Sub-district hospitals, provincial hospitals and the Kenyatta National Hospital (KNH), provide more specialist services [14,17]. After the 2007 elections the hierarchical healthcare structure was divided . The maintenance of two bodies controlling the same function created overlap in the planning and implementation of processes [12,17]. Widespread disparities in provision , may be attributed to socio-economic, gender and geographical differences , with only 77% of Kenyans who are ill utilizing the healthcare available . Health worker distribution is also uneven, with greater numbers in hospitals and urban areas [7,12]. Hospitals often have public and private levels co-existing, managed by the same staff . Conditions within public wards are poor compared to the unaffordable private wards [14,17]. As in many sub-Saharan African countries, the health system is organised to treat acute rather than chronic conditions [10,18,19], with a lack of primary healthcare to tackle chronic diseases such as diabetes [11,12].
Figure 1 Health Centre treating local community of Muhoroni, Nyanza Province, Western Kenya.
Management of diabetes in Kenya
Diabetes requires long-term follow up, with uninterrupted access to medication and specialist care . Many health workers lack adequate knowledge and training [12, 20] thus exposing diabetics to suboptimal management. Many health facilities do not routinely screen for hyperglycaemia .
The high cost and low availability of insulin in Kenya  with inadequate patient follow up  contribute to poor management . Although the Kenyan government subsidizes insulin to reduce price for patients, supplies frequently run out and there is miscommunication between local depositories and central medical stores to restock .
The “Leadership for Education and Access to Diabetes Care” Initiative (Novo Nordisk), aimed to provide insulin at lower prices to least developed countries (LDCs). However the price is often marked up for profit , forcing many patients to buy from private sources at prices over 60% higher . Unsurprisingly, many patients have poor glycaemic control  and a quarter of all hospital admissions in Kenya are diabetes-related .
Risk factors for diabetes
A Kenyan study reported that a family history of diabetes in a 1st degree relative conferred a relative risk of 2.2. Higher rates of diabetes are found in urban areas . Urbanisation and adoption of ‘Western lifestyles’ have led many Kenyan’s towards risk factors for TIIDM . Kenya has seen increases in abdominal obesity, poor dietary habits, excess alcohol consumption and physical inactivity [2,3,5]. Childhood starvation is also associated with TIIDM (relative risk of 2.08) . Such modifiable risk factors need to be targeted.
Knowledge and attitudes toward diabetes
There is a low level (perhaps under 30%) of public awareness and knowledge about diabetes in Kenya [11,12,22]. Knowledge differs according to education and region . Most respondents have poor behaviours towards diabetes : 41% show an unwillingness to adopt healthier lifestyles. Although an increased level of knowledge is associated with good practice for diabetes prevention, 49% with adequate knowledge failed to put this into practice .
The National Diabetes Educators Manual (2010)  was produced acknowledging the need for further education of healthcare staff and the public. The effectiveness of the scheme is yet to be confirmed.
Many diabetics in Kenya are diagnosed with irreversible complications [6, 11], likewise half of TIIDM patients in the UK have complications at diagnosis [24,25]. In Africa infection and acute metabolic complications are the most common causes of death , compared to cardiovascular/renal complications in Western countries [1,6].
Diabetic ketoacidosis (DKA) accounted for 8% of diabetic admissions in a study at KNH, 30% of patients died within 48 hours of presentation . Foot ulcers are seen frequently at many tertiary clinics in Kenya and are associated with poor glycaemic control, infection, hypertension and dyslipidaemia . This has encouraged provision of community mobile podiatry services .
The WHO report that diabetics require up to triple the healthcare resources compared to non-diabetics . Diabetes threatens Kenya’s healthcare system and the wider economy with loss of productive workforce .
Prevention of diabetes
The burden of diabetes is recognised. Kenya is addressing the need for improvements through the launch of a National Diabetes Strategy in 2010 [11,20]. This aims to prevent or delay the development of diabetes, improve the quality of life by reducing complications and premature mortality . Key interventions prioritise prevention, early detection and control. Hospital diabetic clinics have been established in the nine provinces  but access remains a challenge due to travel distances . A Diabetes Education Programme has also been implemented for healthcare staff . Success of such strategies is dependent on their sustainability and local ownership . To date there has been little evaluation of the strategy  so policy makers cannot make informed suggestions for improvements.
Funding and structure
The Kenyan government recognises the threat from NCDs and is committed to improving health by widening access to quality care . The National Diabetes Strategy (2010-2015) is fundamental to this aspiration. Ultimately a positive political environment is required for success .
Prevention and control of diabetes
The current disease burden indicates a need for more resources for prevention and health promotion, with primary healthcare taking greater responsibility for chronic diseases. Effective primary care should lower hospital admissions and reduce overall cost. The WHO recommendations are now a focus of the Kenyan government , however the financial demands for curative care reduce funding available for implementing such policies . The WHO recommends changes in financing and delivery of services for chronic conditions within Kenya and other sub-Saharan African countries . Funding needs to be reassessed and allocated appropriately, with a greater proportion to NCDs especially diabetes. A lower financial burden on individuals by increasing public funding should
- Reduce poverty,
- Increase treatment compliance,
- Improve diabetic control and
- Reduce complications, thus
- Reducing further burden on healthcare services.
Education focusing on prevention and management is crucial to reducing the burden of diabetes [29,30]. Current strategies for patient and healthcare staff need evaluation. This should be targeted at high risk groups, e.g. those with a diabetic family history, obesity, physical inactivity, glycaemic impairment. Increased knowledge may change attitudes towards diabetes and aid prevention by motivating individuals to take responsibility for their health . The UK ‘change4life’ strategy was implemented to increase healthier behaviour  and Kenya could use this as a model.
Health promotion strategies enables self-assessment for risk of diabetes and identify common symptoms, thus encouraging access to health services . Educating families with a family history of diabetes could reduce modifiable risk factors  and be used for screening.
Diabetes is not a priority for many healthcare staff . There is a need for continuing professional education of all healthcare workers. Screening of those at increased risk and monitoring of symptomatic patients should be encouraged. Such individuals need instruction to modify their risk factors. Investment should be sought to train more healthcare workers, particularly within rural and poorer areas .
Diabetes should be aggressively managed by regular clinic attendance  and patients assisted, where practical, to take responsibility for their own blood glucose monitoring . This improves the chance of achieving optimal glycaemic control . Healthcare workers should also monitor blood pressure and provide footcare .
The improvement of education needs to be met with improved availability of diagnostic equipment and appropriate affordable treatments (insulin is on the WHO essential drugs list). This means a greater allocation of funds, purchasing through tenders and pooled procurement . A task easier said than done.
For individuals with existing complications, regular checks should be provided to prevent further deterioration. This requires strict management of blood glucose, blood pressure and lipids with regular follow up .
Data collection and research
The lack of clear data on the epidemiology of diabetes makes informed policy decisions difficult . The WHO’s Global Strategy ‘Prevention and Control of Noncommunicable Disease’ recommends that countries track NCDs, their risk factors and determinants . Robust evaluation of interventions to establish the most cost effectiveness is required.
The utilisation of health services by Kenyans is increasing but access to quality healthcare remains limited . Poor health service infrastructure and unavailability, shortage of health, administration and management personnel and financial constraints restrict delivery of an adequate service . Kenya cannot fund even the WHO minimal level care package to each citizen .
Kenya has a challenging health landscape with the burden of diabetes and other NCDs adding to the existing challenge of CDs. Tackling the burden of diabetes presents many difficulties. There remains inadequate funding for the effective implementation of an effective strategy for the prevention, detection and management of diabetes. Lack of awareness and an increasing prevalence of diabetic risk factors are critical obstacles to overcoming diabetes in Kenya . This is reflected by the many patients presenting with complications. The financial strain from diabetes hinders Kenya’s achievement of their UN MDGs  and Vision 2030 .
Kenya has an opportunity to reduce the burden of diabetes but funding needs to be concentrated on public health and primary healthcare interventions. In turn this requires changing population behaviours to adopt healthy lifestyles. Intensive management and monitoring of diabetics is crucial with matched diagnostic and medical availability.
Evaluation of implemented strategies and epidemiological research are essential. This would inform decisions leading to optimal care quality and cost effectiveness.
1. World Health Organization. Global Status Report on noncommunicable disease. 2010; http://www.who.int/nmh/publications/ncd_report_full_en.pdf.
2. World Health Organization. About Diabetes. 2012; Available at: http://www.who.int/diabetes/action_online/basics/en/index.html.
3. Chege M. Risk factors for type 2 diabetes mellitus among patients attending a rural Kenyan hospital. African Journal of Primary Health Care and Family Medicine 2010;2(1).
4. World Health Organization. Noncommunicable Diseases Factsheet. 2011; http://www.who.int/mediacentre/factsheets/fs355/en/index.html.
5. World Health Organization. Diabetes Factsheet. 2012; http://www.who.int/mediacentre/factsheets/fs312/en/index.html.
6. Azevedo M AS. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries 2008;28(4):101-108.
7. The World Health Organization. Kenya Draft Health Financing Strategy. Report of an External Review. Commissioned by the Ministry of Medical services Government of Kenya. 2012;
8. . World Health Organization. Kenya , Country Cooperation Strategy , at a glance. 2009; Available at: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ken_en.pdf.
9. World Health Organization. Noncommunicable disease country profiles, Kenya. 2011; http://www.who.int/nmh/countries/ken_en.pdf.
10. Beran D. The Diabetes Foundation Report on implementing national diabetes programmes in sub-Saharan Africa. 2006; http://www.access2insulin.org/uploads/4/9/1/0/4910107/iif_full_final.pdf.
11. Republic of Kenya. Ministry of public health and sanitation. Kenya National Diabetes Strategy. First Edition. 2010; http://diabetes-communication.org/wordpress/wp-content/uploads/2012/09/Kenya-National-Diabetes-Strategy-2010-2015-Complete.pdf.
12. Mcferran L. Obstacles to diabetes care in Kenya. Medical Journal of Therapeutics Africa 2008;2(2):127-129.
13. Ministry of Medical Services. Ministry of Public Health and Sanitation. Kenya National Health Accounts. 2009-10; http://www.who.int/nha/country/ken/kenya_nha_2009-2010.pdf.
14. Wamai R. The Kenya Health System- Analysis of the situation and enduring challenges. JMAJ 2009;52(2):134-140.
15. World Health Organization. World Health Statistics Report. 2009; http://www.who.int/gho/publications/world_health_statistics/EN_WHS09_Full.pdf.
16. Centre for strategic international studies. The global health policy centre. Kenya: The big picture on health. 2012; http://www.smartglobalhealth.org/pages/kenya-mission/kenya-health.
17. Turin D. Healthcare Utilization in the Kenyan Health System: Challenges and Opportunities. Student pulse 2010;2(9):1-3
18. World Health Organization. Innovative Care for Chronic Conditions: Building Blocks for Action. Geneva. 2002; http://www.who.int/chp/knowledge/publications/icccglobalreport.pdf.
19. Diabetes leadership forum. Diabetes:the hidden pandemic and its impact on sub-Saharan Africa. 2010; http://www.novonordisk.com/images/about_us/changing-diabetes/PDF/Leadership%20forum%20pdfs/Briefing%20Books/Sub-Saharan%20Africa%20BB.pdf,
20.World Diabetes Foundation. Kenya launches Africas first naitonal diabetes strategy. 2010; http://www.worlddiabetesfoundation.org/stories/kenya-launches-africas-first-national-diabetes-strategy.
21.Kenya diabetes management and information centre. Diabetes in Kenya. 2012; http://dmi.or.ke/about-diabetes.php.
22. Maina W, Ndegwa A, Njenja E, Muchemi E. Knowledge, attitude, and practices related to diabetes among community members in four provinces in Kenya: a cross sectional study. African journal of diabetes medicine 2011;19(1):15-18.
23. Republic of Kenya. Ministry of Public Health and Sanitation. Kenya National Diabetes Educators Manual. First Edition. 2010; http://diabetes-communication.org/wordpress/wp-content/uploads/2012/09/KENYA-NATIONAL-DIABETES-EDUCATORS-MANUAL-Complete.pdf.
24. UKPDS Group. UK prospective diabetes study UKPDS. VIII. Study design, progress and performance. Diabetologia 1991;34(12):877-90.
25 Diabetes UK. Diabetes care across the UK. 2012; http://www.diabetes.org.uk/Guide-to-diabetes/Support_for_managing_your_diabetes/diabetes_care_and_you/Diabetes_care_UK/.
26. Mbugua PK, Otieno CF, Kayima JK, Amayo AA,. Diabetic ketoacidosis: Risk factors, mechanisms and managment strategies in sub-saharan Africa. A review. East African Medical Journal 2005;82:197-203.
27. Ministry of Medical Services. Ministry of Public Health and Sanitation, Kenya. Kenyas Health policy 2012-2030. 2012;http://www.healthresearchweb.org/files/KenyaHealthpolicyfinalversion.pdf.
28. World Health Organization. World Health Report 2008- Primary Health Care (now more than ever). 2008; Available at: http://www.who.int/whr/2008/en/. Accessed 27,12, 2012.
29. National Institute for Clinical Excellence (NICE). The Managment of Type 2 Diabetes. NICE clinical guideline 66. 2008; http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuideline.pdf.
30. Diabetes UK. State of the Nation 2012, England. 2012; http://www.diabetes.org.uk/Documents/Reports/State-of-the-Nation-2012.pdf.
31. National Health Service U. Change4life. 2013; http://www.nhs.uk/Change4Life/Pages/why-change-for-life.aspx.
32. National Institute for Clinical Excellence (NICE). New guideline for the NHS on the diagnosis and management of type 1 diabetes in adults 2011;
33. National Health Service, UK, Evidence. Clinical Health Summaries, Diabetes. 2011; http://www.cks.nhs.uk/diabetes_type_2.