National Diabetes Network (NDN)

Primary health care is the cornerstone of health care systems which not only attends to individuals and families but also to the well-being of communities and their populations. Pakistan is one of the top countries having a very high prevalence of diabetes. Currently, there are more than 33 million people with diabetes in the country. Nearly 9.6 million children are overweight and obese. In the past years, the occurrence of hypertension has doubled while that of obesity has tripled. This rising tide of diabetes is a source of huge economic burden to the communities and the country. To take an example, the direct cost of treating a diabetic foot ulcer is between £.21- 378. In Pakistan majority of patients have to spend out of pocket for the management of Diabetes and other chronic diseases putting a huge financial burden on them. The introduction of a low-cost network at the primary health care level will reduce wealth-based disparities in morbidity and mortality in people with diabetes (PWD). Evidence proved that primary care level is a promising platform for improvement in health care systems in world. Optimizing care for people with diabetes at this primary care level of health will improve health indicators, responsiveness, and efficiency[i]

[i] Kruk ME, Porignon D, Rockers PC, Van Lerberghe W. The contribution of primary care to health and health systems in low-and middle-income countries: a critical review of major primary care initiatives. Social science & medicine. 2010 Mar 1;70(6):904-11.

The main concept can be summarized as a network of three thousand clinics at the primary care level providing low-cost standardized care for diabetes to reduce wealth-based inequity in the community across the nation. These clinics will be supervised by three hundred clinics of Secondary Care, and these will ultimately report to thirty tertiary level Hospitals. We have established one center at primary care and pilot tested it to identify barriers, responsiveness, fidelity, and sustainability of such units. The model is convincingly successful and ready to be translated into a network at the national level. We have collaborators who are working at the primary care level and can support us to achieve our goals like the Primary Care Diabetes Association (PCDA) which has centers in all provinces of Pakistan, and the People’s Primary Healthcare Initiative (PPHI) which is a public-private partnership program, National Association of Diabetes Educators of Pakistan (NADEP), Diabetic Association of Pakistan (DAP), College of Family Physicians, Pakistan Endocrine Society (PES) and different ministries working for healthcare and non-communicable diseases.

The primary care physician is the first line of defense against disease for the patient at the healthcare level that engages with individuals, families, and communities. Primary health care facilities for people with diabetes (PWD) shall preferably be offered by diabetes care certified doctors and educators. Secondary care comprises a multidisciplinary team supervised by a physician having postgraduate qualification or specialized training in diabetes care. The team includes qualified diabetes educators and diabetic foot care assistants. The tertiary care level is a university-based teaching hospital comprising outpatient and inpatient integrated care along with research and education programs. Routine integrated care involves the patient, physician with a special interest in diabetes, clinical nurse specialist or educators trained in diabetes, dietitians, diabetic foot care assistants, and/or podiatrists. In all levels of care, proper record maintenance for all treated diabetic patients is advisable.[i]

The primary care unit in our solution will offer the services of a doctor certified in diabetes care, an educator, a diabetic footcare assistant, a phlebotomist, a pharmacy assistant, and a data entry staff. The clinics will also address the care of communicable diseases for people with diabetes to ensure integrated care for the dual burden of communicable and non-communicable diseases in our society.

The capacity strengthening of all the healthcare providers will be done as 4 weeks refresher course.

The data collection will be by dedicated staff using either a hospital management system or manual record keeping. The data will be ultimately kept in the Diabetes Registry of Pakistan (DROP) either directly by linking HMS via middleware or by sending the data to the secondary level if an internet facility is not available at primary care.

The clinic will offer optimal diabetes care at minimal consultancy charges to make the unit a self-sustained model in a low resource setting after the discontinuation of initial support.

The essential medicines as per WHO criteria will be given free of cost. These include sulphonylurea, metformin, statins, and antihypertensives. Any other medicine required for extended care will be given at fifty percent price.

For essential laboratory tests, a collection point will be available at a unit linked with a standardized laboratory. These tests will be offered at the lowest possible rates.

A 24 hr free of cost helpline will be given to address their day-to-day queries.

[i] Shera AS, Basit A, Team P. Pakistan's Recommendations for Optimal Management of diabetes from Primary to Tertiary care level (PROMPT). Pak J Med Sci. 2017 Sep-Oct;33(5):1279-1283. DOI: 10.12669/pjms.335.13665. PMID: 29142579; PMCID: PMC5673748.

Pakistan is a resource-constrained country with distinct socioeconomic groups. According to a 1996 census, its population was 127 million (1) with an average annual growth rate of 4.8% (2). The rural population represents 68% of the total population (3). The most alarming fact is that 31% of the population lived below the poverty line (4), and 40% had very limited to no access to even essential health services (5). Health expenditures accounted for 0.7–0.8% of GDP and 3.5 percent of government spending.  However, Pakistan spent less than 30% of its health budget on infrastructure. The government offered funding for diabetes mellitus (DM) as part of the overall healthcare budget, but just a small fraction is allocated. Funds raised from private and international sources were likewise minimal. On the other hand, there was no infrastructure for DM surveillance and monitoring.

A public-private healthcare collaboration existed, but it lacked the necessary equipment and training to deal with the rising frequency of non-communicable diseases (NCDs). Under government supervision, almost 0.1 million lady health workers (LHWs) were trained to offer key maternity and child health care, reaching roughly 60% of the population but lacking NCD education. Around 75 percent of the urban population receives primary health care from general practitioners (GPs). However, general practitioners lacked the necessary skills to manage and prevent DM and other non-communicable diseases.
According to the World Health Organization (WHO), Pakistan had three times the lesser number of healthcare professionals as the rest of the world (1.4/1000 vs. 4.5/1000 people). (6)
The target population in our solution is all people with diabetes and their families from the low and lower-middle-income groups either for standardized care at subsidized expenses or free of cost provision of essential health care if they are unable to bear even the subsidized cost.

1. Population, total – Pakistan. The World Bank Data. Available from: https://data.worldbank.org/ind... (last assessed on July 16, 2021)
2. GDP growth (annual %) – Pakistan. The World Bank Data. Available from:  https://data.worldbank.org/ind... (last assessed on July 16, 2021)
3. Rural population (% of the total population) – Pakistan. The World Bank Data. Available from: https://data.worldbank.org/ind... (last assessed on July 16, 2021)
4. Anwar T, Qureshi SK. Trends in Absolute Poverty in Pakistan: 1990-91 and 2001. The Pakistan Development Review. The Pakistan Development Review 2002; 41:4 (Part II): 859–878
5. Ghaffar A, Kazi BM, Salman M. Health care systems in transition III. Pakistan, Part I. An overview of the health care system in Pakistan. Journal of Public Health Medicine 2000; 22(1): 38-42.
6. Global Health Workforce Statistics, World Health Organization, Geneva. Available from: http://www.who.int/hrh/statistics/hwfstats/i. (last assessed on July 15, 2021)

Considerable changes in disease patterns are taking place in Pakistan. With the burden of infectious diseases and nutritional deficiencies, a concomitant increase is noted in the prevalence of non-communicable diseases (NCDs) and mental disorders.[i] Likewise, the health system, health policies, and legislation are also improving. Fifth National Action Plan (NAP) for NCDs and Mental health comprehensively focuses on reducing the preventable burden of mortality, morbidity, and disability caused by NCDs and mental disorders, hence targeting the Global NCD Action Plan 2013-2030.[ii]

Baqai Institute of Diabetology and Endocrinology(BIDE) was established 26 years ago as a small clinic to address the issue of the rising prevalence of NCDs through standardization of diabetes care, capacity strengthening, and improving research, community services, advocacy for better public health policies, and conducting surveys. It took us ten to twelve years to develop infrastructure through various projects. It was then conceived that now is the time to start a solution that can be replicated in primary care. In the next five to seven years we developed a Health Promotion Foundation (HPF) that can facilitate the replication of various projects as a no-profit self-sustained organization. Pakistan Health Research Council (PHRC) conducted a ‘WHO STEP wise approach to surveillance’, which reported the prevalence of diabetes between 13.1% and 26.9%.[iii]. Second National Diabetes Survey Pakistan NDSP (2016–2017) was conducted by our team of BIDE with the Ministry of National Health Services, Regulation and Coordination (MoNHSRC) with the collaboration of the Pakistan Health Research Council (PHRC), Diabetic Association of Pakistan (DAP) and WHO Collaborating Center. Age-adjusted comparative prevalence of diabetes in Pakistan is 19.9% and pre-diabetes 8.8% in adults (20-79 years) based on the recent second National Diabetes Survey of Pakistan (NDSP) 2016-2017 using oral glucose tolerance test (OGTT). It has also reported the prevalence of hypertension, generalized obesity, central obesity, and dyslipidemia as 46.2%,57.9%, 73.1%, and 96% respectively.[iv] 

In 2014, in Islamabad, Pakistan Diabetes Leadership Forum (PDLF) was formed.[v]The PDLF was organized through a collaborative effort of the Ministry of National Health Services Regulation and Co-ordination, Government of Pakistan, and was co-hosted by a wide range of national and international organizations including the International Diabetes Federation (IDF), World Health Organization (WHO), World Diabetes Federation (WDF), Diabetes Association of Pakistan(DAP), Baqai Institute of Diabetology and Endocrinology (BIDE), Pakistan Endocrine Society(PES), Pakistan Institute of Medical Sciences (PIMS), and the Sakina Institute of Medical Science and Research (SIDER) and Hyattabad Medical Complex,(HMC), Peshawar. This was a platform where key stakeholders in diabetes and non-communicable diseases including opinion leaders, policymakers, partners in public health, and local and international media, interacted through high-level sessions and panel discussions.[vi] The four keynotes of the PDLF forum 2014 were (1) Capacity Building, and (2) Diabetes Care Programs at the National Levels. (3) Primary Prevention and Awareness (4) Policy Planning and Advocacy.
PDLF encouraged the government to support a call for a United National General Assembly special session to discuss and include diabetes and NCDs in the United National Sustainable Development Goals (SDGs). This was done by formulating and adopting integrated policies on the inclusion of screening for diabetes and GDM as part of the national package of essential health care services. Some key recommendations of the PDLF 2014 to donors, development partners, and UN agencies were to conduct a needs assessment and identify resources at the national level and support an integrated approach to diabetes care and related NCDs.
Capacity building is always a cornerstone for disease management especially if it is reaching epidemic proportions. In Pakistan, we have been running a Diploma in Diabetology for the last 20 years, training primary care physicians to tackle the diabetes burden at the grass root level. Masters and post-fellowship programs are been run for strengthening the secondary and tertiary levels of diabetes care.
We also started a diploma in diabetes education to consolidate the idea of a multidisciplinary team approach. The National Association of Diabetes Educators of Pakistan (NADEP) was established in 2010 with the idea to involve multiple stakeholders in diabetes education programs, especially primary prevention all over Pakistan. In 2015 first National NADEP-con was held in Karachi. NADEP offers an excellent consultative platform to encourage the development and delivery of validated and structured diabetes education nationwide and to involve educators, dietitians, pharmacists, behavioral therapists, civil society, media, etc.
Realizing the need for comprehensive care along with the availability & accessibility of insulin and other essential management tools, BIDE initiated the IML project through initial support by WDF. The history of “Insulin my life (IML)” dates to early 2000 when a baseline study was published in the Journal of “Pediatric Diabetes” by BIDE and DAP, presenting the Trends of Type 1 Diabetes (T1D) in Pakistan[vii]. Later-on “Life for a child (LFAC)” extended their support for the project. Initially, the project was started in Sindh, and then the services were extended to the province of Baluchistan as well. So far around 2500 subjects with T1Ds are registered that are being served by type 1 model clinics, established through IML, and supervised by specialized doctors and diabetes educators.[viii] Printed educational material in English, Urdu, and regional language (Sindhi) was also provided to subjects with T1D, their parents, and the community. Insulin for life (a project for KPK) is supplying free insulin to non-affording patients across the province.
National Standardized Guideline for Management of Diabetes has been developed preceded by Pakistan’s Recommendations for Optimal Management of Diabetes from Primary to Tertiary care level (PROMPT)[ix] and self-monitoring of blood glucose (BRIGHT).[x]
Multidisciplinary Diabetic Foot Care Team (MDFCT) is an approach used worldwide for comprehensive foot care services. In Pakistan, BIDE led to the development of this concept and has changed the understanding of diabetic foot care at various levels in the country. One hundred and fifteen diabetic foot clinics are established in 3 years, and the amputation rate in these clinics is reduced by 50%.
For massive population screening, the RAPID score (Risk Assessment of Pakistani Individuals for Diabetes) has been developed.[xi] It is a well-validated, probability-based algorithm for assessing T2DM risk among the Pakistani population.
The Health Research Advisory Board (HRAB) of Pakistan has initiated the mission of developing disease registries countrywide. With the collaboration of HRAB, the Baqai Institute of Diabetology and Endocrinology (BIDE) has recently begun the Diabetes Registry of Pakistan (DROP) to enumerate the degree of the national disease burden. For type 1 diabetes, the Diabetes Registry of Pakistan for type 1 (DROP-1) has already been started. WHO has already appreciated our efforts in this regard. The registry is now supervised by the national institute of health (NIH) and a nationwide diabetes registry has been started.
In Sindh, BIDE in collaboration with PPHI and the Ministry of Health Sindh has initiated the standardization of diabetes care in 2000 basic health units, by training doctors in basic diabetes management and maintaining a registry of PWD. In 2020, the government of Pakistan has nominated a deputy DG of health in Provincial Ministries designated for NCDs.
We have started a Public Health Department to design better programs for community-based healthcare services. We are collaborators in NIHR-funded programs. In the DiaDEM program, we are addressing mental health in diabetes patients. In one of the Higher Education Commission of Pakistan-funded programs, we will be providing care to diabetes patients who have tuberculosis as well. 
Recently we have collaborated on an NIHR-funded Center of IMPACT program. This program, through its themes, will focus on cardiovascular, diabetes, and mental health. We are expecting a significant impact on non-communicable disease prevention with this project.

[i]Diabetes prevention and control in Pakistan – DAP. Available at: www.dap.org.pk › Documents. [last accessed on 31-3-20].
[ii] World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. World Health Organization; 2013.
[iii]Zafar J, Bhatti F, Akhtar N, et al. Prevalence and risk factors for diabetes mellitus in a selected urban population of a city in Punjab. J Pak Med Assoc 2011;61:40–7.
[iv]Pakistan Diabetes Leadership Forum Islamabad 2014. Islamabad calls for action.
[vi]Diabetes prevention and control in Pakistan - DAP | The ...Available at:www.dap.org.pk › Documents › 5 Fifth National Action Plan.[Last accessed on 31-3-20].
[vii] Shera AS, Miyan Z, Basit A, Maqsood A, Ahmadani MY, Fawwad A, Riaz M. Trends of type 1 diabetes in Karachi, Pakistan. Pediatric diabetes. 2008 Aug;9(4pt2):401-6.
[viii] Ahmedani MY, Fawwad A, Shaheen F, Tahir B, Waris N, Basit A. Optimized health care for subjects with type 1 diabetes in a resource constraint society: A three-year follow-up study from Pakistan. World journal of diabetes. 2019 Mar 15;10(3):224.
[ix] Shera AS, Basit A, PROMPT Team. Pakistan’s Recommendations for Optimal Management of Diabetes from Primary to Tertiary care level (PROMPT). Pakistan journal of medical sciences. 2017 Sep;33(5):1279.
[x] Basit A, Khan A, Khan RA. BRIGHT guidelines on self-monitoring of blood glucose. Pakistan journal of medical sciences. 2014 Sep;30(5):1150.
[xi] Riaz M, Basit A, Hydrie MZ, Shaheen F, Hussain A, Hakeem R, Shera AS. Risk assessment of Pakistani individuals for diabetes (RAPID). Primary care diabetes. 2012 Dec 1;6(4):297-302.

There are many barriers that we hope to overcome with this grant.

We have started a pilot project with our resources and expect that this grant may serve as seed money to come to a stage where we can share with the donors that the establishment of three thousand clinics integrated networks at the primary care level is a reality. To express it we hope that through this grant we plan to have 18 to 30 clinics linked together as a solution at initial work package that will be later extended at a broader national level
This also, considering our cultural and socioeconomic values, will attract philanthropists and multiple donor agencies in Pakistan who would like to invest in projects which are running and delivering affordable diabetes care at the doorstep of the community.
Technically this will allow us to replicate our experiences of the equitable health care model further. The promising experience in our pilot project has given us confidence that translating it at the broader national level may give benefit a greater number of resource constraint people.
There is potentially no identified market barrier, and the success of this project will attract and convince our policymakers to initiate such solutions in the public health care system too.

1-Our solution will introduce an intricate primary care network for diabetes with the implementation of a strong referral policy.

2-We will offer standardization of diabetes care and a centralized registry that will make it possible for a person to seek medical advice at any of the designated nearby units with the same reference number (national identity card number) and get his medical history at any of the clinics. This approach will offer continuity of standard healthcare and better adherence.

3-The training of healthcare professionals by BIDE with the latest updates on management will bring uniformity of care.

4- The public awareness campaign through the brochures, social media, and direct interaction will bring behavior change and prevention of diabetes and other non-communicable diseases related risk factors.

The immediate impact of NDN will be the provision of healthcare to all irrespective of their social, racial, religious, gender, or any other differences, hence reducing inequity. 

The long-term impact will be the reduction of Diabetes related complications and improvement in diabetic foot care due to the standardization of training and monitoring of the primary health care centers.

The DROP and BIDE networking in collaboration with the Ministry of Health, International Diabetes Federation, World Health Organization, Diabetes Association of Pakistan, Primary Care Diabetes Association, National Association of Diabetes Educators of Pakistan, etc. will advocate for policy amendments for health promotion and prevention of the disease leading to disease prevention campaigns.

The Core Indicators helps to answer the main questions which help determine how a country's primary healthcare system is performing:

In our solution we are focusing on diabetes care at the primary healthcare level as Pakistan is the third largest country with the most number of people with diabetes. In our 26 years we have always tried to get primary health  care prioritized especially with reference to diabetes in the country's  health system at all levels.

• The solution of our primary health care system will increase the number of clinics connected with the diabetes network providing standardized healthcare.

• Number of registered people with diabetes getting minimal medicines and lab investigations.

• Number of health care providers trained for the program in terms of Capacity Building of Personnel.

• Trust and use of 24 hours helpline.
• Feedback on satisfaction and measurement of better health outcomes and greater equity by reduction of HbA1c.

• Reduced numbers of DM complications as indicator of better health outcomes.

In Pakistan, with the dual burden of disease with resource constraints and 33 million people with diabetes strengthening primary healthcare is the most feasible solution. NDN clinics will providing standardized healthcare facilities to people with diabetes and improving awareness about diabetes and its associated risk factors. The training offered by the network will improve their skill and will prepare a better and more efficient workforce. These activities will result in better control of disease, prevention of complications, and in result less number of referral to higher level.

The immediate outcomes are decreased burden on secondary and tertiary care, less complications of diabetes, improved quality of life and decreased morbidity and mortality associated with diabetes.

Once proven successful it may attract policymakers to invest more in strengthening of primary care. By maintaining data of people with diabetes in DROP will also help in prioritization and sufficient budget allocation

We will also promote lifestyle modifications and enhance public awareness using this platform.  The empowerment of people with awareness can bring about significant change in disease prevalence and early detection.

The Drop Registry using cloud technology and mobile application will be our power tools.

Since the conceptualization and development of mobile apps has become possible with recent digital technology and integration with wireless based cloud storage, ideas that might bring major advancement via these technologies on healthcare systems have bloomed. The integrated use of digital devices and applications allows people to connect with each other, share meaningful information, and communicate in real time. The advantages of combing technology will be used by the PWD using mobile app model to provide accessible powerful digital capabilities, connecting people digitally via the primary health care and storing into the DROP registry via a cloud server.

Diabetes Care Team:  The data collection will be by a dedicated staff using either hospital management system or manual record keeping in the primary health care centers. As the standard of care regulates the patient to move from primary care to secondary care or even tertiary care level, the data will be entered by the data collectors at that level of care. The data will be ultimately kept in Diabetes Registry of Pakistan (DROP) either directly by linking HMS via a middleware or sending the data to secondary level if internet facility is not available.

Our solution is a national program, and it will benefit people with diabetes irrespective of their gender, race, class, religion, sect, affiliation, etc. This unique solution will address wealth-based inequity and offer standard solution to economically challenged people. The timely management and improved quality of life that is expected with this network will also minimize depression and anxiety associated with chronic disease burden and feeling of helplessness. 

The network and its leadership team has worked previously with multiple international and national organizations and will look for diverse solutions to the challenge to make more equitable and inclusive decisions during the  project management and empowers everyone to learn and do their best. 

Having diabetes health care professionals with the help of their training and certification makes them ideally suited to manage data collection and ensure accurate records keeping and supervision of the centers based on their key positions in the community focused on shared values of excellence, equity, belonging, openness, integrity, and mutual respect. This will also provide a workforce of young people representing their local areas and serving their immediate surroundings.

1- Serving low and low-middle income groups by cross financing

In our solution, we will provide care at no cost for economically challenged people by generating revenue from people who can afford subsidized rates of services, labs, and medicines. This cross-financing will ultimately make the unit self-sustained.

2- Universal Health Coverage
Improved diabetes care at the primary care level will reduce the burden on secondary and tertiary care hence saving health expenditure on the management of complications associated with poorly controlled diabetes. This saved funding can be diverted to be spent on primary health care reinforcing it further. This shift of resources will ultimately lead to universal health coverage.

3- Reduction in disease burden
The primary care level is the doorstep of the community and is a very effective platform for prevention plans. The awareness for lifestyle changes given at this level is effective, retained for prolonged periods, and easy to reinforce at short regular intervals. This will potentially reduce the health expenditure on the management of people with diabetes

We started a pilot project with our resources and hope this solution to serve as initiation seed money where we can share with the donors that establishment of 3000 clinics integrated in a network at the primary care level is a reality. 
Considering our cultural and socioeconomic values, we hope to attract philanthropists and multiple donor agencies in Pakistan who would like to invest in projects which are running and delivering affordable diabetes care at the doorstep of the community.
Technically this will allow us to replicate our experiences of the equitable health care model further. There is potentially no identified market barrier, and the success of this project will attract and convince our policymakers to initiate such solutions in the public health care system too.We will make our plan financial sustainable by selling products and services at minimum cost, while trying to earn donations and grants from various agencies and organizations.  

We were granted funds from World Diabetes Foundation (WDF), to establish an infrastructure for free insulin to non-affording Type 1 children of Sindh. The project fund was for 3 years and did not involve insulin supplies. ever since for the last 15 years, we are ensuring that around 2000 children get free insulin. We are ably supported by the life for a child project as well. We have extended this project to poverty-stricken areas in the province of Baluchistan and now plan to extend it to the other provinces of the country and have generated funds through HPF.

We got a project through WDF to run a national diabetic foot program. We trained diabetic foot (DF) teams and established 115 DF clinics across the country. We reduced the lower limb amputation rate by 50%. Our project deliverables and outcome were appreciated by WDF, the International Working Group on DF (IWGDF), and International Diabetes Federation (IDF).  We then proposed that preventing foot ulcers shall be the next step. We started a course for footwear technicians and managed footwear manufacturing for high-risk feet or feet with foot ulcers. Instead of involving the private sector for mass production, we established ten centers within secondary and tertiary care hospitals in different cities of Pakistan where the lowest costs of customized footwear are available and have shown a reduction in ulcer rate.
As affordability issues escalated in the country we joined hands with the global Novartis access program for which we generated donations to provide free of cost high-quality essential medicines for diabetes manufactured by Novartis to thousands of people with diabetes.