A view point in Minya Governorate. Nearly 11 million Egyptians live with diabetes, where insulin access is increasingly out of reach for those in rural areas.
MINYA GOVERNORATE, EGYPT – Nine-year-old Adam needs an insulin shot before meals, and seems unphased when his father checks his sugar levels with a finger pricking. He looks away when a small blood drop wells on the tip of his finger. Adam turns back to his plate of rice and stewed vegetables, continuing to ramble about the kids in his summer camp.
Both Adam and his father are diabetic in a rural village in Upper Egypt, where their struggle to access insulin mirrors a broader struggle across the country, and the continent.
In a country where over 18% of adults live with diabetes, and with the number of adults living with diabetes expected to hit 20 million by 2045, diagnosis, monitoring, and medication are all difficult to come by.
In response, Egypt is now taking significant steps to expand insulin access and diabetes prevention–in the context of rising prevalence. But financial and logistic barriers as well as competing political priorities still leave rural families at the ‘last mile’ of service in a precarious situation.
New diagnostics more widely available – but shortages, power cuts, and inflation threaten access
Moussa, with his son Adam, shows a continuous glucose monitor in their home in Upper Egypt.
To address the growing health and financial burden of the disease, the Egyptian National Health Insurance system recently began to cover the initial cost of a glucometer for newly diagnosed people as well as 25 test strips per month.
Yet while over-the-counter glucose monitoring ads flood US airwaves for non-diabetic consumers, many Egyptians, like people in other developing world countries, still struggle to obtain such basic devices for diabetes control. Diabetes care coverage remains below 50 percent for low- and middle-income countries, according to a Lancet estimate.
Many or most low-income and informal Egyptian laborers simply don’t have health insurance while their income are not enough to afford their monthly diabetes supplies, notes T1 International, a non-profit diabetes care advocacy group: “It can cost someone more than 50% of their salary to get the basic diabetes supplies,” said Dr Mohamed Shabeen in a T1 article.
Paying for test strips, monitors, and insulin are just one part of the country’s $3 billion diabetes-related annual health expenditure. The International Diabetes Federation estimates this number will rise to $4.5 billion by 2045, a concern given Egypt’s rising national debt and economic woes – with the Egyptian pound devalued by more than 50 percent and food inflation over 60 percent.
There are also indirect costs for diabetics. For instance, Adam’s parents enrolled him in a pricier private school, over fears that in the overcrowded public schools, Adam could go into insulin shock unnoticed.
“I was worried he would go into a ketone coma (ketoacidosis),” said Moussa, Adam’s father, and English teacher who is one of the few-college educated people in his village of some 2,000 people. “I became diabetic in 2018, Adam in 2019. I noticed a lot of the same symptoms.
“When he was diagnosed, I did so much research. I had to learn about the condition because there is so little information for people with diabetes.” Moussa ended up buying a Freestyle Libre glucose monitoring system so Adam could attend school uninterrupted, but it soon became too expensive “and we’re facing a shortage.”
Villages, in Minya Governorate, like Moussa’s, struggle with affording insulin – and keeping it refrigerated during power outages.
There are several other people living with diabetes in his village, Moussa explained, and they have formed a network, providing each other with valuable social support. “We have a WhatsApp group. If someone has extra medication, they give it to me and then I distribute it to others that need it.” The summer, however, was especially challenging as 40 ℃ temperatures were accompanied by prolonged power cuts, threatening insulin refrigeration.
Diabetes ascendant – 11 million and climbing
Diabetes treatment coverage remains below 50% across a variety of metrics in low- and middle-income countries.
In WHO Eastern Mediterranean Region, which includes most of the Middle East and North Africa, one in six adults now live with diabetes, making it the region with the highest prevalence at 16.2% and the second highest expected increase (86%) in the number of people with diabetes.The region also has the highest percentage (24.5%) of diabetes-related deaths in people of working age.
In Egypt, the country is now one of many facing a double burden of malnutrition (DBM)–where 21% of children under five are stunted yet over half of children and adolescents are overweight or obese. The country’s rapidly rising rates of noncommunicable diseases (NCDs) like diabetes, heart disease, and chronic respiratory diseases means that NCDs account for 82% of all deaths in Egypt and 67% of premature deaths.
Public health experts point to the region’s lifestyle changes – a diet heavy in sugar and carbohydrates, lack of exercise, and other risk factors – as fueling the rise in NCDs.
New domestic insulin production in limbo
A view of the village in Minya Governorate, where the growing prevalence of diabetes threatens the village’s well being.
In terms of treatment, there is little local insulin manufacturing in Egypt as well as the rest of Africa, leaving people to depend on expensive, important supplies.
Several big initiatives have recently been announced to change that. But their status remains unclear. In May, 2023, Eli Lilly announced a major new partnership with the Egypt-based pharmaceutical company EVA Pharma to provide the company with the active pharmaceutical ingredients (API) of insulin at a “significantly reduced price.”
Just last month, EVA Pharma’s CEO Dr Riad Armanious declared in a press release that “locally manufactured insulin is currently a top priority, aiming for local supply and exporting it to more than 60 countries.”
However, actual rollout of the plan still appears to be in limbo, with neither company responding when asked for comment by Health Policy Watch about the status of the new manufacturing plans.
That, despite an August statement by Egypt’s Minister of Health and Population Khaled Abdel Ghaffar told press that the insulin shortage “would be over within three months” and that the country would produce a million more insulin vials a month, in coming months.
He blamed a foreign currency shortage for the holdup in importation of critical raw ingredients needed to expand production, but “that the problem had been solved.”
Egypt is home to some 170 pharmaceutical factories – and state-owned companies already produce as much as 15 million vials yearly – but much of this also reportedly goes to export. This leaves Egyptians, who need some 27 million vials a year, in an even greater bind.
Additionally, observers in the field say privately that the local products are not yet as of good quality as imported ones – something that the partnership between Eli Lilly and Eva should help address.
WHO – no further details on the rollout of manufacturing
Dr Loyce Pace, with WHO’s Dr Bente Mikkelsen, Africa CDC’s Dr Jean Kaseya and EVA Pharma CEO Riad Armanious at the EVA-Lilly partnership announcement last year.
Asked for comment, the World Health Organization also was unable to offer further updates on a timeline for Egypt’s rollout of its much-touted expanded insulin production.
WHO is not a direct partner in the Eli Lilly-Eva partnership, but it has been “actively engaging with various stakeholders, including the private sector, to fulfill commitments made in the UN Political Declaration on NCDs,” said Dr Bente Mikkelsen Director, just prior to her retirement on 1 October as head of WHO’s Department of Noncommunicable Diseases, Rehabilitation and Disability (NCD).
“Several companies have responded positively to these ‘asks’, including commitments to local manufacturing,” she added, in a comment to Health Policy Watch.
Meanwhile, in Minya Governorate, Moussa has been traveling more frequently to Cairo some four hours away by car “to get good healthcare” – after monitoring Adam’s symptoms, as well as his own, and their similarities.
But he still hopes that he and others in his community can eventually get quality insulin and glucose monitors at a fairer price locally.
“Right now, I’m getting them from Cairo, and we have to pay taxes and customs. It would be great for all these people in our community to be able to afford this as well.”
Image Credits: S. Samantaroy/HPW, The Lancet.
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