The Path Forward for People Living with Type 2 Diabetes in Armenia
Written by Karina Wallrafen-Sam, Business Development Intern at HFI; graphic designed by Cassidy Wang, Communications Intern at HFI
Type 2 Diabetes (T2D) is a growing problem in Armenia — the yearly incidence tripled between 2000 and 2013, and the age-adjusted mortality rate for T2D was 76.3 deaths per 100,000 people as of 2014, more than three times the diabetes-related mortality rate in the US at the time. In 2019, the International Diabetes Federation (IDF) Diabetes Atlas estimated the national prevalence of diabetes to be 6.8% among adults in Armenia. That means that over 141,000 adults in Armenia are living with diabetes, with more than 60,000 being undiagnosed. The burden of T2D in Armenia is compounded by limited data, inadequate treatment, and financial stressors. This post will outline these barriers and discuss efforts to implement a social impact bond-type model to effectively address T2D in Armenia.
T2D Data Gaps in Armenia
Despite the growing burden of T2D in Armenia, data on this health issue is limited and sometimes unreliable — for example, estimates of the proportion of mortality in Armenia attributable to diabetes range from 3% to 8.9%. Without a national diabetes registry, it is difficult to monitor the outcomes experienced by people with diabetes. Data is also lacking about the risk factors driving the increases in T2D cases, the state of diabetes care in Armenia, or how to effectively combat the disease there.
T2D Treatment Gaps in Armenia
One major barrier to T2D treatment and prevention in Armenia is a lack of awareness about diabetes among the general population. In one survey of Armenians, 19% of respondents had been diagnosed with diabetes and many others were at risk for it, but 55% had limited to no knowledge of the disease. Only 12% could name a sign or symptom, while about a third knew that limiting sugar intake could help prevent or manage T2D. In another study, over 60% of surveyed diabetes patients did not know what kind of diabetes they had. Also, diet counseling is rare for T2D patients in Armenia.
Other barriers to effective diabetes care in Armenia include limited access to medications and medical devices, high out-of-pocket costs, a lack of screening programs, a shortage of trained medical workers, and social stigma. In theory, insulin is provided free of charge in Armenia, but the same brands of insulin are not consistently available, which jeopardizes patients’ continuity of treatment and destabilizes their blood glucose level. Patients bear the significant costs of their own glucometers, test strips, and needles, and may also have to pay for drugs, lab tests, and other supplies. As a result, to save money, some patients report testing their blood sugar levels only when they feel ill. Patients who do not have access to their own glucometer have to make monthly trips to their nearest clinic for blood tests; for many patients in rural areas, such visits require taking time off work for a long journey. Diabetes patients in Armenia also suffer from poor coordination of care, with different complications often being treated independently in separate facilities.
With the lack of diabetes education discussed above and the many barriers to accessing care, it is perhaps not surprising that diabetes treatment adherence tends to be low in Armenia. Researchers from the American University of Armenia who evaluated diabetes care via focus groups found that treatment adherence was generally poor among those interviewed; the high costs of medicines and healthy diets were among the frequently cited reasons for non-compliance.
As a result, diabetes-related distress (DRD) and diabetic complications are common in Armenia. One study found that the prevalence of diabetic retinopathy — a leading cause of blindness — was 36.2% among people with diabetes in the Gegharkunik region of Armenia, compared to 13.0% percent in Norway and 29.4% percent in the UK.
The Financial Burden of T2D in Armenia
According to the IDF Diabetes Atlas, the average diabetes-related expenditure per adult with diabetes in Armenia is about 2.44 USD per day. In 2021, the minimum wage in Armenia is about 4.60 USD per day, meaning that diabetes-related expenditure accounts for more than 50% of a minimum wage earner’s salary. A recent study on the global availability and affordability of diabetes medicines found that after adjusting for purchasing power parity, the median price for a 30-day supply of Metformin (an essential diabetes medication) was higher in Armenia than in 15 of the 16 other countries included in the study (specifically, almost 30 times higher than in Russia and more than 3790 times higher than in India).
According to a report from the World Health Organization (WHO), the total economic burden of diabetes in Armenia is about 29.7 billion dram (or 62.4 million USD) per year. This includes the direct costs of government expenditure for healthcare and disability payments as well as the indirect costs of absenteeism, presenteeism, and premature deaths. Thus, the report concludes that non-communicable diseases like diabetes “hinder the country’s broader development priorities,” including reducing poverty and strengthening economic growth.
Efforts to Proactively Address T2D in Armenia
Early prevention and continued primary care access for patients suffering from pre-diabetes or diabetes is key to alleviating suffering, increasing longevity, and reducing the economic burden of diabetes. Since 2019, the Danish Red Cross has been working to implement community health approaches to diabetes care for older people in Armenia. Their programs include self-support groups for older people with diabetes and healthy aging groups for those at risk.
Robust data systems, health economic analyses and forecasting, and pay-for-success models like Social Impact Bonds (SIBs) will all play a critical role in scaling up these Red Cross programs and optimizing their health and economic outcomes. In a typical SIB, investors provide funds to implement social interventions, service providers work to deliver outcomes, and outcome funders — primarily public sector agencies — repay investors their principal plus a financial return if independently verified evidence shows that outcomes have been achieved. Thus, SIBs are used to de-risk investments by outcome funders and increase the efficiency of aid spending. In the past, SIBs have been successfully implemented to fund preventative care for T2D in Israel. So, to help pave the way towards cost-effective care, the Health Finance Institute will work with the Danish Red Cross to review available data collection systems in Armenia; quantify the health and economic impact of the new diabetes program to identify the highest-impact interventions; and design a Social Impact Bond-type model to finance the scale-up of the program. You can support HFI’s efforts to increase access to life-saving medical devices by donating here.