ISLAMABAD – Muhammad Waqas is an engineer at a private telecom company. He still remembers the day six years ago in 2018 when he was diagnosed with diabetes at the age of 30. It completely changed his life.

The diagnosis was particularly shocking for Waqas as neither of his parents had the disease, and he had always been physically fit and participated in all kinds of sports since his school days.

“It was September 2018 when I started feeling the need to urinate frequently and experienced weakness and fatigue. I consulted my doctor, who pricked my finger to take a blood sample and checked it with a glucometer. He was also prescribed an HBA1C test,” said Waqas.

The next day, when the test report came, and Waqas’ diabetes was confirmed. Initially, he tried to control the disease through oral medication, but it didn’t work and eventually his doctor put him on insulin.

“I have been on insulin for the past six years, which has completely changed my life. Now, I have to constantly worry about my blood sugar levels and stay in touch with my doctor. I have to carry my insulin bag with me wherever I go,” he said.

World’s highest prevalence of diabetes

Some 33 million Pakistanis – or 26% of the adult population – are living with diabetes, according to the International Diabetes Federation (IDF) citing data from its 2021 report. 

Pakistan has the world’s highest adult prevalence rate. It ranks third in absolute numbers, following China and India which each have a billion people living with diabetes. More than one-third of Pakistan’s cases are undiagnosed, the fourth highest in global rankings. 

In addition, Pakistan’s population with diabetes could nearly double to 62 million by 2045, if more preventative action isn’t taken, the IDF warns. Worldwide, meanwhile, more than half a billion people are living with diabetes. 

Trends in the country are even more disturbing in light of Pakistan’s health history, said Dr. Zafar Mirza, former director of Health Systems at the World Health Organization (WHO) in an interview with Health Policy Watch. 

In 1990, diabetes didn’t even appear among the 25 leading causes of disability-adjusted life years in Pakistan. However, in the decade between 2009 and 2019, death and disability due to diabetes increased by 87%.

Waqas adds that people in Pakistan are generally not aware of how to prevent diabetes.

‘Physical activity is like medicine’ 

Zubair Faisal Abbasi, advisor at the Centre for Governance and Public Accountability (CGPA) for food, nutrition, and public health programs, believes that the challenge of diabetes in the ciuntry is the challenge of failed food governance, failure of adaptation to new urban lifestyles, and patchy availability of standard treatments.

Food governance means that Pakistan has been unable to formulate and execute best-practice policies to control dietary risk factors such as free sugars and industrially produced transfatty acids at the population levels, according to Abbasi.

“[The government] has failed to create public awareness that physical activity is like a medicine, which is required for everyone in every age group. In addition, since fiscal allocations for health are low, the country is not able to provide standard treatments such as screening for the pre-diabetic, and treatments for diabetes-related ailments,” said Abbasi.

Mirza attributes the high burden of diabetes in Pakistan to co-existing environmental and genetic factors, with environmental factors as a major reason.  Sedentary lifestyles along with carb- and sugar-heavy diets are considered to be the main causes behind Pakistan’s high prevalence of diabetes, a trend he described, tongue-in-cheek, as “bittersweet”.

Mizra added that genetic factors become more significant due to repeated marriages among close relatives in Pakistan, which has increased the chances of diabetes.

 The burden

Mirza said the vast majority of people with diabetes have Type 2 diabetes associated with lifestyle, while Type 1 or insulin-dependent diabetes, affects a relatively small number of people.

In Type 1 diabetes, the pancreas no longer produces insulin, and patients diagnosed with this type are completely dependent on insulin. Meanwhile, Type 2 diabetes prevents the body from using insulin properly, which can lead to high levels of blood sugar. Type 2 leads to serious physical damage, especially to the feet, eyes, kidneys and heart.

According to official data obtained by Health Policy Watch, around 53% of deaths in the country are the result of non-communicable diseases (NCD), with diabetes being one of the major causes.

Official data said 41.4 % population (53.7% of females and 24.7% males) do not meet the physical activity standards recommended by WHO for the prevention of NCDs including diabetes.

Treatment challenges

Taskeen Arshad, 55, is a housewife who has been fighting diabetes for the last 10 years. Her mother also had the disease, and she died of it at the age of 69. Arshad pays monthly visits to the Pakistan Institute of Medical Sciences, a government-run tertiary care hospital in the federal capital, to get free medicines for diabetes.

She cannot afford to purchase diabetes medicine from a private pharmacy and is dependent on the government’s social security program for her treatment.

“Not every time I get free medicine from this government hospital. Sometimes it’s not available for three to six months. The hospital administration tells us the medicine was not procured because of shortage of funds,” said Arshad.

The non-availability of medicines from the government hospital makes her reliant on relatives to pay for the medicines at private pharmacies.

Noor Mahar, the president of Drugs Lawyers Forum, a watchdog for medicine pricing, said the availability and pricing of diabetes medicine is a serious issue: “Federal government has removed the pricing cap from the medicine which resulted in the price hike of insulin and other medicines up to 400% now.”

 He alleges that sometimes pharmaceutical manufacturers and importers create artificial shortages in the market to increase prices, which results in the suffering of those who depend on the medicines.

“The shortage is not only reported in the private market but also government hospitals usually run short of medicines,” said Mahar.

But Asim Rauf, CEO of the Drugs Regulatory Authority of Pakistan (DRAP), a federal body regulating drug prices and ensuring their availability in the country, said there is no shortage of insulin or other medicines in the country.

He said the prices of medicines in the market vary because of the depreciation of the Pakistani rupee in the international market against the US dollar.

“Whether it is the raw material or the imported medicine, the Pakistan medicine market will be affected by the fluctuation of the dollar rate,” he said.

Primary healthcare focus

Sajid Shah, spokesperson for the Ministry of National Health Services Regulation and Coordination (NHSR&C), said the ministry coordinates with provinces to provide health facilities to prevent and treat NCDs at the primary healthcare level.

The mandate of provinces is to provide free-of-cost services including glucometers, medicines, and other early-detection facilities, and treatment, and also educate people about the disease at service delivery points, he added.

“Every Tehsil Headquarters Hospital (THQ) has an NCD centre for prevention and treatment of diabetes,” said Shah.

However, healthcare officials working at PHC believe that although the government established NCD centres at THQ and District level, on the ground they still lack the facilities and are not functional according to their capacity.

A senior doctor at THQ Gujjar Khan told Health Policy Watch that his facility has an NCD center but it lacks the capacity to provide a full range of services to patients visiting for diagnoses and treatment of diabetes.

“We have glucometers but insulin and medicines for diabetic patients have not been available for the past one and a half years,” said the doctor.

He also said another important issue is the shortage of staff at the PHC level, nearly half of the strength at this level leaves the country because of attractive salary packages offered abroad which impacts the working of NCD centers.

“However all the diagnoses, treatment, and medicine are provided free of cost to the people depending on their availability,” he said.

What needs to be done?

Abbasi says that the country needs to implement primordial prevention – targeting the social and environmental conditions – as a priority, and doing this involves policy coordination.

“For example, it needs to increase taxes on sugary drinks, ultra-processed foods, and tobacco and look at its patterns of urbanization to reduce the burden of NCDs,” said Abbasi.

Mirza said the current rate of NCDs cannot be dealt with at big hospitals but requires a strong primary healthcare with trained community health workers.

Early diagnosis through mass screening and proper management are vital, as is the integration of service delivery of preventive, curative, and rehabilitative health services, he added.

“Our health system is not equipped to deal with the epidemic of diabetes. It needs sustained and coordinated whole-of-government and societal efforts and the private health sector also has to be taken into the loop,” he said.

Image Credits: WHO/A. Loke, IDF Atlas 2021, IDF Diabetes Atlas 2021 .