Approach
We recognise that the rapidly increasing burden of diabetes hits the poorest hardest and is starting to undermine development in many countries. We therefore work through sustainable partnerships with governments and non-governmental organisations (NGOs) to strengthen healthcare systems and address the rapidly rising diabetes epidemic in developing countries. Our strategic priorities therefore involve projects aiming at the most vulnerable and make a long-term impact consistent with our mission as a sustainable business.
Our approach to access is built on the United Nations (UN) defined cornerstones on the right to health and aligns with the UN Millennium Development Goals, which offer a common vision for tackling some of the major challenges facing the world.
Commitment to the UN Women’s and Children’s Health Strategy from 2010
Novo Nordisk is committed to improving the health of women and children. We will develop partnership-based programmes, as part of a long-term commitment to sustainable improvement in health, through which we will:
- campaign for universal screening for gestational diabetes
- support the development of new evidence and platforms for action by addressing critical research gaps
- mobilise key stakeholders at national and global levels to promote change with a positive health impact for women and the next generation
- and engage key partners in exploring and co-creating innovative solutions targeting women, diabetes and pregnancy.
Read more here: http://www.un.org/sg/hf/global_strategy_commitments.pdf
UN high-level meeting on non-communicable diseases
In recognition of the increasing global impact and challenge of non-communicable diseases, the United Nations General Assembly will hold a high-level meeting on the prevention and control of non-communicable diseases in September 2011.
The summit will focus particularly on the developmental and other challenges and the social and economic impact in developing countries. At Novo Nordisk we welcome this initiative, which reflects a recognition of the significant negative impact of unaddressed chronic conditions on human lives and well-being as well as on socio-economic growth and development.
We are committed to supporting the UN process to focus on driving changes in healthcare systems. We do this through partnerships and through our own programmes and engagement at global, regional and national levels.
In 2010, we pledged to provide the World Diabetes Foundation with an additional 25 million Danish kroner to be used for activities relating to the high-level meeting in 2011 and 2012. There have been 27 such meetings in the history of the UN, and HIV/Aids is the only disease to have been a summit topic. The summit has the potential to mobilise action for a new type of collaboration that pursues a life-cycle approach to health care.
Areas of focus
As part of our approach to expanding access, we align with the UN declared right to health and the United Nations' Millennium Development Goals, which offer a common vision for tackling some of the major challenges facing the world.
Over the next decade, we will focus on areas that will have an impact on current and future generations, with a long-term impact consistent with our role as a sustainable business.
Our focus areas support the three UN Millennium Development Goals 4, 5, and 8:
- Treating children with type 1 diabetes
- Confronting diabetes in pregnancy
- Building partnerships and capacity through donations to support World Diabetes Foundation
- Addressing affordability in lest developed countries through our differential pricing policy
i. Improving treatment for children with type 1 diabetes
In most developing countries there are no existing facilities for treating children with diabetes. Children with type 1 diabetes in developing countries have high mortality rates, with life expectancies of less than one year in some countries in sub-Saharan Africa. Our Changing Diabetes® in Children programme provides the necessary medical and laboratory equipment, organises training of healthcare professionals, puts in place patient education and creates systems for adequate monitoring and follow-up. In addition, insulin and diabetes supplies are being provided free of charge for the duration of the programme.
With an ambition to reach 10,000 children with diabetes within five years, we made a 25 million US dollar commitment in 2008. In 2010, 13 clinics were established under the Changing Diabetes® in Children programme. To date over 1,200 children have been enrolled in the programme.
For more information on the Changing Diabetes® in Children programme please visit: changingdiabetesaccess.com
2010 Milestones:
Training and education of healthcare professionals
The Changing Diabetes® in Children programme aims to improve the expertise and abilities of healthcare professionals and diabetes educators in the diagnosis and treatment of children with diabetes in a developing country setting.
In 2010, a training manual for healthcare professionals in developing countries was developed and launched. Based on a 2009 workshop with key stakeholders from African countries involved in our Changing Diabetes® in Children programme, the manual expands access to critical information for healthcare professionals to improve the health outcomes of children with diabetes.
The manual, which has been prepared in collaboration with the International Society for Pediatric and Adolescent Diabetes (ISPAD), will be actively used as a basis for training courses of frontline healthcare professionals in the countries where the programme is active.
The manual is available free of charge for downloading at changingdiabetesaccess.com.
ii. Diabetes in pregnancy
In recent years we have found substantial evidence that when women have or develop diabetes during pregnancy, their offspring will also be at significantly higher risk of diabetes over the entire lifespan. This, we believe, holds a key to addressing diabetes at its roots: if we can detect and treat, or even prevent, diabetes during pregnancy, we may also prevent future generations from developing this chronic condition.
The World Health Organization estimates the worldwide prevalence of gestational diabetes to be 3-15% of all pregnancies, but figures from India and the United Arab Emirates put prevalence rates as high as 18% to 22%. Many of the women newly diagnosed with diabetes each year have previously had gestational diabetes. Children born to women with gestational diabetes mellitus also have a substantially increased risk of developing type 2 diabetes. Supporting healthy pregnancies is therefore important to reverse the diabetes pandemic.
Many cases of gestational diabetes go undiagnosed, and most are in low- and middle-income countries, where women often have poorer nutrition and access to healthcare.
Gestational diabetes can be controlled through proper diet and regular exercise, but some women with gestational diabetes require insulin treatment to normalise their blood glucose levels in order to avoid complications in the infant. Gestational diabetes usually goes away after the child is born, but 5-10% of women with gestational diabetes are found to have type 2 diabetes immediately after pregnancy. In addition, women who have had gestational diabetes have a 20-50% chance of developing type 2 diabetes within five to 10 years.
Our task is to spread understanding of how diabetes in pregnancy needs to be identified, and how it can be controlled with lifestyle advice. In particular, complications to the baby can largely be avoided if the mother's blood glucose levels are controlled before delivery. In up to 90% of cases, optimum control can be obtained by diet and physical activity alone. Lifestyle education can encourage behaviour changes to prevent future disease in the mother and her child.
We have therefore begun activities to raise awareness of the impact of diabetes in pregnancy, address knowledge gaps, support community-based maternal health programmes and advocate for sustainable change, which ultimately will increase access to diabetes screening, treatment and lifestyle education.
We have encouraging results from on-the-ground experience. Since 2007, the Indian state of Tamil Nadu has screened all pregnant women for gestational diabetes and provided free doses of NovoRapid®, approved for use during pregnancy. National treatment guidelines have been established, and advocacy targeted towards policy makers led to the inclusion of universal screening in national policy in 2010. In 2011, a long-term study will be launched, with support from Novo Nordisk, to track the women diagnosed and treated and the children born to them, with an aim to improving understanding of the long-term consequences of gestational diabetes.
Building on this experience we are now launching partnerships to address diabetes in pregnancy in Nicaragua, Columbia, and the state of Punjab in India.
2010 milestones:
India:
Prevalence rates of gestational diabetes in India is as high as 18%. Gestational diabetes screening has been included in national policy and national treatment guidelines have been established. In the state of Punjab, Novo Nordisk is partnering with hospitals, universities, Steno Diabetes Center, the NGO Jagran Pehel, and the local health authorities. The project aims to raise awareness, train health care professionals, screen pregnant women for gestational diabetes, and analyse the health economic impact of gestational diabetes screening to create information that will guide the Ministry of Health, Education and Research, Punjab to implement sustainable, adequate and timely gestational diabetes management strategies into state health policy.
The next phase of the programme in Tamil Nadu will focus on monitoring the children born to women having been diagnosed and treated for gestational diabetes to gather evidence on health outcomes, ie lower incidence of type 2 diabetes. The Novo Nordisk funded study is expected to launch in early 2011.
Nicaragua:
Diabetes is the 4th-leading cause of death among women in Nicaragua and the primary cause of death in women between the ages of 45-64. Novo Nordisk, in partnership with the Ministry of Heath of Nicaragua, Population Services International, Pan American Social Marketing Organization and the National Autonomous University of Nicaragua Medical School, has initiated a programme to reduce maternal and child morbidity due to birth complications related to GDM and reduce the risk of both women and child developing type 2 diabetes in the future.
The programme will contribute to achieving key Millennium Development Goals through the establishment of diabetes clinics, training of healthcare providers and raising awareness of GDM among the general population. The project expects to screen more than 28,000 pregnant women and train more than 100 healthcare providers.
Colombia:
Barranquilla, the 4th largest municipality in Colombia, is building on the success of a national healthcare reform to strengthen maternal and child health, as well as chronic disease prevention and treatment. In 2010, a Novo Nordisk supported project to improve GDM management in Barranquilla was started in partnership with local health authorities, universities, STENO Health Promotion Centre, the University of Helsinki and the University of Copenhagen.
The project will establish improved GDM detection and treatment through the training of healthcare professionals, updating screening and treatment guidelines, and increasing GDM awareness and encouraging a healthy lifestyle. The project expects to monitor and control 72% of pregnant women through the implementation of the updated treatment guidelines.
iii. Differential pricing policy – offering lower priced insulin in developing countries
One third of the world's population lacks reliable access to necessary medications. One potential reason for this is their price in the private market. In the case of diabetes, many people, particularly in low- and middle-income countries do not have access to a reliable, affordable supply of insulin.
Since 2001, Novo Nordisk has implemented differential pricing for insulin supplied to least developed countries, where insulin is sold at a maximum 20% of the average price for Europe, USA, Canada and Japan. Insulin is offered annually at a differential price to governments of the Least Developed Countries (LDCs), as defined by the United Nations.
However, the price of insulin is commonly inflated by import duties, port clearance charges, inspection fees, and mark-ups by numerous wholesale and retail dealers in the distribution chain. It is often not possible to guarantee that the price at which Novo Nordisk sells the insulin to governments is reflected in the end user price. In addition, if a medical centre's need exceeds the amount purchased by the government then they have to rely on private-sector sources for insulin.
Novo Nordisk is working in partnerships with local healthcare providers to improve and ensure efficient purchasing at regional level, and with regional diabetes associations to monitor the end-user prices offered through the public and private sectors.
Foundation support
Part of our contribution is our continued long-term financial commitment to the World Diabetes Foundation (WDF). In 2002 and 2008 our shareholders voted to contribute a portion of net insulin sales to the WDF over 15 years. These donations are reported annually on our income statement.
The independent and non-profit WDF supports the prevention and treatment of diabetes where it is needed most, providing funding for local initiatives that improve healthcare system capacity. Since it was founded by Novo Nordisk in 2001, it has supported 253 projects in 96 countries.
For more information on WDF's activities visit its website at www.worlddiabetesfoundation.org
As our focus on haemophilia has expanded, so has our commitment to the global haemophilia community. We established the Novo Nordisk Haemophilia Foundation (NNHF) in 2005 to address the significant need for improving haemophilia care and treatment in developing countries. Our donations to NNHF, in 2010 amounting to 15 million Danish kroner, support projects and
fellowships in developing and emerging countries. By working with partners who have local project ownership, the NNHF aims to ensure the sustainability of capacity building programmes.
For more information on NNHF's activities visit its website at www.nnhf.org
Affordability of insulin in least developed countries
The cost of therapy still constitutes a significant barrier for better healthcare in low income countries. Through our long-standing differential pricing policy we sell insulin at or below 20% of the average prices for insulin in the western world. The Western world is defined as Europe (EU, Switzerland and Norway), the United States, Canada and Japan.
In 2010, Novo Nordisk operated in 34 of the 49 least developed countries. For 2010, the differential pricing policy was offered, as part of the global health initiatives, to all least developed countries as defi ned by the UN. During 2010, Novo Nordisk sold insulin to either governments or the private market in 67% (33 countries) of the countries according to the differential pricing policy compared to 73% (36 countries) of the countries in 2009. In 2010 Novo Nordisk operated in the Lao People's Democratic Republic but did not sell insulin at the dif ferential policy price. The insulin sold in 2010 to this country is to the private market.
In a total of 15 least developed countries, Novo Nordisk had no sales in 2010 for various reasons. In several cases, either the government has not responded to the offer, there are no private wholesalers or other partners to work with, or wars or political unrest make it impossible to do business.
While Novo Nordisk prefers to sell insulin at the differential price through government tenders, the company is willing to sell to private distributors and agents. Novo Nordisk is unable to guarantee that the price at which the company sells the insulin will be reflected in the final price to the consumer.
The total volume of insulin sold in the least developed countries has increased steadily since 2006 and in 2010 the volume has increased by 30% compared to 2009.
However, offering treatment at reduced prices does not always ensure that end users benefit as intended. To improve the impact of our differential pricing policy, we have initiated a number of pilot projects to address barriers that may lead to higher final prices for the patients.
- In 2010 we recruited sales representatives in eight least developed countries: Cameroon, Democratic Republic of Congo, Ethiopia, Gambia Guinea, Mozambique, Tanzania and Uganda. They will work to improve the effect of the reduced prices.
- We also carried out independent quality audits in Ghana, Nigeria, Tanzania and Uganda to improve stock management and distribution, with a view to facilitating access to insulin in rural areas. A main challenge is that governments' procurement is subject to budget fluctuations.
Evaluating the World Partner Project (WPP)
In 2010 we commissioned an external evaluation of the World Partner Project (WPP) activities conducted in Bangladesh and Tanzania through 2001 to 2009. These evaluations have shown that the WPP has resulted in active and productive partnerships with other major organisations involved in diabetes care. For example, in Bangladesh the development and deployment of a distance learning programme (DLP) for doctors has resulted in a significant expansion of capacity, with 3,599 new diabetologists. Today the DLP continues as a self-sustainable cooperation with a local faculty and the development of an accredited physician programme with the ambition of extending care to more rural areas of the country. We will build on the experience gained from the WPP to develop our future strategy for access to health.
To read more about WPP see account from an earlier annual report here.
Changing Diabetes® in Children programme
The Changing Diabetes® in Children programme is currently active in six countries: Bangladesh, Cameroon, the Democratic Republic of Congo, Guinea-Conakry, Uganda and Tanzania.
In 2010:
- 13 clinics were established under the Changing Diabetes® in Children programme
- Over 800 children were enrolled in the programme bringing the total number of children to over 1,200 children
- 123 healthcare professionals were trained in the specialities of diabetes care for children
Changing Diabetes® in Pregnancy
Within the framework of the Changing Diabetes® in Pregnancy programme:
- Three programmes were established in partnership with local health authorities, non-governmental organisations and universities in Nicaragua, Columbia and India to improve screening, diagnosis and management of gestational diabetes
- Development of a cost effectiveness model for gestational diabetes screening was initiated. The model is currently being tested in India and Israel.
Addressing diabetes in Africa
A startling 12.1 million people have been diagnosed with diabetes in Africa, but the actual number is thought to be much higher, as many cases go undiagnosed. Conservative estimates suggest that as many as 24.2 million people in Africa could have impaired glucose intolerance (elevated blood sugar levels), which could lead directly to the development of diabetes.
In order to address this growing concern, South Africa hosted the Diabetes Leadership Forum Africa 2010 in Johannesburg on 30 September and 1 October.
The Leadership Forum addressed a range of pressing issues: strengthening healthcare systems to cope with the rising incidence of diabetes in sub-Saharan Africa, the Africa Diabetes Care Initiative (ADCI), the link between HIV/Aids and diabetes, co-morbidity with tuberculosis, and diabetes in pregnancy.
The forum, which was co-hosted by the South African Ministry of Health and the World Diabetes Foundation, was supported by the International Diabetes Federation and co-organised and sponsored by Novo Nordisk.
The forum was held in preparation of the September 2011 UN Summit on Non-Communicable Diseases to address, among other disease areas, the growing healthcare threat attributed to diabetes.