Overview
The National Health Policy of Ethiopia emphasizes core principles of democratization and decentralization of the Health Care System. Health care in Ethiopia is provided in two main ways: private and public hospitals. Over the past two decades potential access to care has improved through the accelerated expansion of health facilities, but mostly for primary health care. Most public hospitals in Ethiopia have general outpatient services, but there is still very little dedicated outpatient service for patients with diabetes outside of the capital Addis Ababa. Patients with diabetes either get treated together with other patients by Primary Care physicians without specific diabetes training, or have to be admitted to the hospital for diagnosis and therapy at higher expenses. Follow up visits are very sporadic unless the patients have to come on a regular basis to pick up their insulin supplies. Yet, even in those cases there is little compliance with diabetes treatment guidelines and no patient education offered.

The Ethiopian Ministry of Health has started to address chronic non-communicable diseases as an area of concern. In the past, the entire focus was on communicable diseases such as malaria & HIV/AIDS. The Ministry now has a national strategy to fight non-communicable diseases, which includes diabetes, and an NCD unit has been established. Diabetes care in the public healthcare of Ethiopia still faces a number of challenges. In general, there are few physicians trained in diabetes care and especially the outpatient services are staffed with primary care physicians or hospital residents without specific diabetes training.

What happens if you need to see a doctor?
The ratio of doctors to patients in Ethiopia is one for every 20,000 people and the doctors mostly work in cities like Addis Ababa, leaving men and woman in rural areas in dire need of important health services. If someone gets sick he/she can go to the nearest health care center and then to hospital. Usually, general practitioners, or in better cases internists (doctors of internal medicine), look after people with diabetes.

Who decides what doctors can prescribe?
The Food, Medicine and Health Care Administration and Control Authority of Ethiopia (FMHACA) ensures the safety, efficacy and quality of medicines by quality control tests in addition to other assessments. Health care professionals can prescribe the needed insulin and oral drugs, so it is with the consultation of a doctor that one can take insulin. At each follow up appointment the doctors or the health care professional assigned might adjust insulin or oral drugs for the patients.

Practically, what is it like to live with type 1 diabetes in Ethiopia?
The majority of Ethiopians live in remote and inaccessible villages. Living with type 1 is difficult for most of the young people because of a lack of education. Most take only NPH twice daily and nothing else. Most do not have blood glucose monitoring devices, and blood glucose monitoring at home is almost non-existent, unless someone is part of a charity programme like Life for a Child. These are the only programs that give out insulin and blood glucose testing devices. One can only imagine living with type 1 without regular insulin and monitoring, let alone having the education to understand carb counting.

Reliable and affordable supplies of insulin, especially in the various regions of the country, is still an issue. When the budgets for free insulin (provided by the Ministry of Health) or low cost insulin (provided by the hospital) are used up, patients have to fill insulin prescriptions at pharmacies. Free insulin from the hospital can cover 6 months at the first follow up visit and only one month at the next. This makes financial planning for patients very unpredictable. Patients who have to purchase insulin at market prices often lower their insulin doses because they cannot afford to buy prescribed amounts.

Due to their high price (also subject to import tax), blood glucose meters and strips are not available in hospitals or clinics, let alone for patient use. Patients in public healthcare usually only obtain two glucose readings from a private lab before their follow up visit or have their blood analysed at the hospital.

What about getting admitted to hospital?
When admitted to the hospital for a diagnosis of diabetes, someone will be put on IV and regular insulin, including ketone tests. Someone might spend two to 15 days in the hospital depending on the situation.

How does diabetes care vary throughout Ethiopia?
Diabetes care varies throughout the country even in a given city between hospital and clinics and from location to location. In the public setting, consultation time is very limited and supplies, including insulin and syringes, are very sporadic. If you can afford to pay for private care, things will be much better. If one lives in a city, better care can be available through the private outlets. In a rural area the only option is the public system because the private ones do not give adequate service or are not available. In 2013, approximately 30 percent of households were estimated to live more than 10 kilometers from the nearest hospital, health center, or health station. Urban areas with 4–6 percent of the total population have 44 percent of all health facilities, so it is definitely a disadvantage to live in a rural area with diabetes.

Yonas Gezahegn has provided much of this information about diabetes in Ethiopia. We are so grateful for his help!