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The diabetes care continuum in Venezuela: Cross-sectional and longitudinal analyses to evaluate engagement and retention in care

Roles Formal analysis, Methodology, Software, Writing – original draft, Writing – review & editing

Affiliations Department of Global Health and Population and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom

Roles Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing

Affiliations Department of Global Health and Population and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America, International Clinical Research Center (ICRC), St. Ann’s University Hospital, Brno, Czech Republic, Foundation for Clinic, Public Health and Epidemiology Research of Venezuela (FISPEVEN, INC), Caracas, Venezuela

Roles Formal analysis, Investigation, Supervision, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Global Health and Population and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America, Global Academy of Agriculture and Food Systems, The University of Edinburgh, Midlothian, United Kingdom

Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Writing – review & editing

Affiliations Foundation for Clinic, Public Health and Epidemiology Research of Venezuela (FISPEVEN, INC), Caracas, Venezuela, Venezuelan Society of Internal Medicine, Caracas, Venezuela

Roles Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Writing – review & editing

Affiliations Foundation for Clinic, Public Health and Epidemiology Research of Venezuela (FISPEVEN, INC), Caracas, Venezuela, Venezuelan Society of Internal Medicine, Caracas, Venezuela, Research Department, Endocrine Associates of Florida, Orlando, Florida, United States of America

Roles Conceptualization, Data curation, Funding acquisition, Investigation, Project administration, Writing – review & editing

Affiliations Department of Global Health and Population and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America, Foundation for Clinic, Public Health and Epidemiology Research of Venezuela (FISPEVEN, INC), Caracas, Venezuela, Public Health Research Unit, Department of Social and Preventive Medicine, School of Medicine, Universidad Centro-Occidental “Lisandro Alvarado”, Barquisimeto, Venezuela

Roles Supervision, Writing – review & editing

Affiliation Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America

Roles Investigation, Supervision, Writing – review & editing

Affiliation Department of Global Health and Population and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Supervision, Writing – review & editing

Affiliations Department of Global Health and Population and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America, Foundation for Clinic, Public Health and Epidemiology Research of Venezuela (FISPEVEN, INC), Caracas, Venezuela, Precision Care Clinic Corp, Saint Cloud, Florida, United States of America

• Dina Goodman-Palmer, 
• Juan P. González-Rivas, 
• Lindsay M. Jaacks, 
• Maritza Duran, 
• María Inés Marulanda, 
• Eunice Ugel, 
• Jorge E. Chavarro, 
• Goodarz Danaei, 
• Ramfis Nieto-Martinez

• Published: January 17, 2024
• https://doi.org/10.1371/journal.pgph.0002763
• Peer Review
• Reader Comments

The impact of the humanitarian crisis in Venezuela on care for noncommunicable diseases (NCDs) such as diabetes is unknown. This study aims to document health system performance for diabetes management in Venezuela during the humanitarian crisis. This longitudinal study on NCDs is nationally representative at baseline (2014–2017) and has follow-up (2018–2020) data on 35% of participants. Separate analyses of the baseline population with diabetes (n = 585) and the longitudinal population with diabetes (n = 210) were conducted. Baseline analyses constructed a weighted care continuum: all diabetes; diagnosed; treated; achieved glycaemic control; achieved blood pressure, cholesterol, and glycaemic control; and achieved aforementioned control plus non-smoking. Weighted multinomial regression models controlling for region were used to estimate the association between socio-demographic characteristics and care continuum stage. Longitudinal analyses constructed an unweighted care continuum: all diabetes; diagnosed; treated; and achieved glycaemic control. Unweighted multinomial regression models controlling for region were used to estimate the association between socio-demographic characteristics and changes in care continuum stage. Among 585 participants with diabetes at baseline, 71% were diagnosed, 51% were on treatment, and 32% had achieved glycaemic control. Among 210 participants with diabetes in the longitudinal population, 50 (24%) participants’ diabetes management worsened, while 40 (19%) participants improved. Specifically, the proportion of those treated decreased (60% in 2014–2017 to 51% in 2018–2020), while the proportion of participants achieving glycaemic control did not change. Although treatment rates have declined substantially among people with diabetes in Venezuela, management changed less than expected during the crisis.

Citation: Goodman-Palmer D, González-Rivas JP, Jaacks LM, Duran M, Marulanda MI, Ugel E, et al. (2024) The diabetes care continuum in Venezuela: Cross-sectional and longitudinal analyses to evaluate engagement and retention in care. PLOS Glob Public Health 4(1): e0002763. https://doi.org/10.1371/journal.pgph.0002763

Editor: Samih Abed Odhaib, TDEMC, IRAQ

Received: July 15, 2023; Accepted: December 7, 2023; Published: January 17, 2024

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Data Availability: Given the political situation in Venezuela and the vulnerability of some of the participants included in this study, we are not able to make the data publicly available. However, the code used for this manuscript has been posted on the Harvard Dataverse, a public data repository: https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi%3A10.7910%2FDVN%2FRKDD8F&version=1.1 .

Funding: This study was supported by the Bernard Lown Scholars in Cardiovascular Health Program (BLSCHP-1703 to JPGR and RNM), UK Research and Innovation (MR/T044527/1 to LMJ) and the National Institutes of Health (T32 HL 098048 to DGP). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) license to any Author Accepted Manuscript version arising from this submission.

Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. Goodman-Palmer provides scientific consultations through Epidemiologic Research & Methods, LLC (ERM); none of her consulting through ERM is related to the topic of the current study. All authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Introduction

People affected by humanitarian crises, whether internally displaced or refugees, are especially vulnerable to exacerbated chronic health conditions due to disrupted health services, irregular medication access, and unpredictable food supplies [ 1 ]. Humanitarian crises are becoming increasingly longer in duration. In 2019, nearly 78% of refugees worldwide were in a protracted situation, defined as more than 25,000 refugees from the same country displaced for at least five years [ 2 ]. Such crises are projected to become more common. The number of internally displaced people is projected to rise to 143 million by 2050 in Sub-Saharan African, South Asia, and Latin America due to climate-related disasters [ 3 ]. As such, humanitarian aid and global health actors have become increasingly concerned with the management of noncommunicable diseases (NCDs), such as diabetes, in these widespread and prolonged crises [ 1 ].

NCD management requires continuous care and, thus, prolonged engagement with the health system [ 4 ]. For example, living with diabetes can involve regular access and adherence to medication, monitoring glucose levels, adherence to specific diets, patient education, and regular visits to health facilities [ 1 ]. Barriers to diabetes management include food insecurity, discontinuity of care, and economic hardship, and these barriers are especially exacerbated in crises. For example, diet quality and diversity have been documented to suffer in crises as carbohydrate-rich foods become staples. A nationally representative assessment of dietary patterns among Venezuelans in 2014–2017 found that dietary diversity was very low: on average, people consumed just two food groups daily with the primary food groups consumed including white bread and arepas (a salted corn cake) [ 5 ]. Another challenge in diabetes care during crises is psychosocial trauma that can lead to neglecting healthcare until advanced disease and life-threatening complications present [ 6 ]. Diabetes management also requires adherence to medication and testing, which largely depends on supply and access to appropriate medications, glucose meters, and test strips [ 6 ]. These barriers introduce a number of challenges to diabetes management in crisis settings, though research in this area remains largely uncharted. Given the difficulties of conducting data collection in these contexts, only a few studies have quantitatively evaluated changes in disease management among people living with diabetes who remained in their home countries during crises [ 7 – 13 ]. Results of these studies have been mixed: three studies documented that average haemoglobin A1c (A1C) increased after exposure to crises [ 8 , 11 , 13 ]; two studies found A1C increased only among those on public insurance [ 10 ] or with insulin-dependent diabetes [ 7 ]; one study found no changes in mean HbA1c [ 12 ]; and another study found a decrease in mean A1C [ 9 ].

In this study, we evaluated the impact of the humanitarian crisis in Venezuela on diabetes management. Venezuela is a unique case study for NCDs in crises as its socio-political, economic, and nutritional contexts have deteriorated rapidly only in the last decade. Prior to the crisis, Venezuela was a flourishing upper middle-income country [ 14 ] and the burden of diabetes, hypertension, and obesity were documented to be increasing over time, particularly in urban areas, mirroring the nutritional and epidemiological transitions in neighbouring South American countries [ 15 ]. In the early 2000s, the Venezuelan government augmented primary and chronic care programmes through a mission between the Cuban and Venezuelan governments. This campaign, known as Misión Barrio Adentro , built numerous primary care centres throughout the country, staffed these centers with Cuban doctors, and provided drugs for diabetes, although this programme only covered 24% of the population with diabetes [ 16 , 17 ] and 12.4% of the total population, according to a nationally cross-sectional survey conducted in 2014–17 [ 18 ]. The other public services, however, remained highly underfunded and lacking coordination as the majority of people with diabetes received care in public facilities [ 16 ]. Furthermore, as a result of the gross mismanagement of oil reserves and national funds [ 19 ], hyperinflation and food shortages led to food insecurity and a malnutrition crisis [ 20 ]. Over seven million Venezuelans have fled the country and no estimates exist for the number of internally displaced individuals [ 21 ]. Shifts in the NCD burden have been challenging to quantify as the Venezuelan government stopped publishing national statistics in 2016 [ 22 ]. However, recent nationally-representative analyses led by academic researchers estimated diabetes prevalence to be between 12.3% in 2014–2017, with approximately 2.5 million adults living with diabetes in Venezuela during that period [ 5 , 18 ].

The primary objectives of this study were to (1) document health system performance for diabetes management in a nationally representative sample of Venezuela in 2014–2017 using the continuum of care framework, (2) assess changes in health system performance over time, from 2014–2017 to 2018–2020, and (3) quantify the association between socio-demographic characteristics and care continuum stage. This is the first longitudinal continuum of care analysis for diabetes and results from this study will provide vital evidence on the effects of humanitarian crises on NCD management.

Material and methods

Study population.

Data are from the EVESCAM study (Estudio Venezolano de Salud Cardio-Metabólica) [ 23 ], a longitudinal evaluation of NCDs conducted in Venezuela between 2014 and 2020. EVESCAM has nationally representative data at baseline and follow-up data on a subset of 35% of participants. Details of the study design and sampling strategy have been published [ 18 , 23 ]. Briefly, between July 1 st , 2014 and January 1 st , 2017, 4454 study participants were enrolled through a multi-stage stratified sampling method, using parish as the primary sampling unit. Enrolment occurred at the household level, where all members aged ≥20 years were invited to participate; 3420 participants were evaluated for a 76·8% response rate. Exclusion criteria included pregnancy and inability to stand or communicate [ 23 ]. The baseline period occurred over three years and enrolment occurred by region, resulting in a strong correlation between time and region. As such, the study was not designed to make any causal claims regarding the effect of the crisis, instead it aimed to provide nationally representative estimates for NCDs.

Between October 15 th , 2018, and February 29 th , 2020, study staff contacted and visited every participant enrolled at baseline. If the participant was reachable, study staff collected informed consent and, if provided, continued with clinical measurements and questionnaires as conducted at baseline, along with an updated protocol to measure humanitarian indicators, such as food insecurity, stressful life events, family separation, and lack of access to utilities, medicines, transportation, and education.

Ethics statement

The study protocol complied with the Helsinki declaration and was approved by the National Bioethics Committee (CENABI) of Venezuela and this secondary analysis was approved by the Harvard T.H. Chan School of Public Health (protocol #: IRB19–1538). Written informed consent was obtained from all participants. The present report is presented according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Authors did not have access to information that could identify individual participants after data collection.

Diabetes definition

Blood glucose was measured in venous blood and included fasting plasma glucose (FPG) and a two-hour oral glucose tolerance test (OGTT) using a 300-ml test solution containing 75 g anhydrous glucose. Diabetes was defined as either: FPG ≥126 mg/dL, 2-hour OGTT ≥200 mg/dL, or self-report of previous diagnosis of diabetes by a clinician [ 24 ].

Diabetes continuum of care

This paper uses the continuum of care framework to identify where patients are lost in the Venezuelan health system [ 25 ]. Two care continua were constructed for this analysis: an ABC (A1C, blood pressure, and cholesterol) diabetes care continuum [ 26 ] and a simplified continuum. The six stages of the ABC diabetes care continuum were: all diabetes; diagnosed; treated; achieved glycaemic control; achieved blood pressure, cholesterol, and glycaemic control [herein referred to as ABC control]; and ABC control and non-smoker. The derivation of each stage is described in detail below. The four stages of the simplified diabetes care continuum were: all diabetes; diagnosed; treated; and achieved glycaemic control, also described in detail below.

All diabetes : All participants with an FPG ≥126 mg/dL or 2-hour OGTT ≥200 mg/dL.

Diagnosed : This subset of participants met the above criterion and self-reported having a previous diabetes diagnosis by a clinician.

Treatment : This subset of participants met the above criteria and self-reported currently taking diabetes medication.

Glycaemic Control : This subset of participants met the above criteria and achieved glycaemic control, defined as FPG ≤154 mg/dL, the equivalent of 7% A1C [ 27 , 28 ]. To select this point, the correlation between A1C levels and mean glucose levels were based on the international A1C-Derived Average Glucose study, which assessed the correlation between A1C and capillary blood glucose measurements in 507 adults (83% non-Hispanic Whites) [ 28 ].

ABC Control : This subset of participants met the above criteria and had blood pressure control (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg) [ 29 ] and low-density lipoproteins (LDL) cholesterol levels below 100 mg/dL [ 30 ].

ABC Control and Non-smoker : This subset of participants met the above criteria and self-reported never smoking in the past 12 months.

All continua were calculated with a fixed denominator of all participants with diabetes. The numerator was the subset of participants with diabetes who reached a given stage and to reach that stage participants had to achieve all previous stages.

At each study visit, weight was measured with the lightest possible clothes and without shoes using a calibrated scale (Tanita UM-081, Japan). Height was measured with a portable stadiometer (Seca 206 Seca GmbH & Co., Hamburg, Germany). Body mass index (BMI) was defined as weight (measured in kilograms) divided by height (measured in meters) squared, and categorised as overweight/obesity (≥25·0 kg/m 2 ) or underweight/normal weight (<25·0 kg/m 2 ) [ 31 ]. Underweight and normal weight were combined as few participants in both baseline and follow-up population were underweight (BMI<18·5): 3·96% and 3·27%, respectively.

Blood pressure was measured twice in the right arm with a five-minute break in between measurements using a validated oscillometric sphygmomanometer (Omron HEM-705C Pint Omron Healthcare CO., Kyoto/Japan). Participants rested their arm at heart level while seated. Hypertension was defined as having a systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or self-report of antihypertensive medication use [ 29 ].

Blood tests included total cholesterol, triglycerides, and HDL cholesterol. LDL cholesterol was calculated using Friedewald’s formula. High LDL was defined as ≥100 mg/ dL, per the Adults Treatment Panel III (ATP III) guidelines of the National Cholesterol Education Program cut-off for optimal HDL level [ 30 ].

Socio-demographic variables included sex, age, and socioeconomic status (SES). SES was calculated using a version of the Graffar Scale modified for Venezuela, which pools income, profession, educational level, and housing conditions into a composite score. Each variable is rated independently from one to five, with one being the highest level of SES. A final score sums the independent ratings and classifies participants’ SES as high, medium-high, medium, medium-low (relative poverty), and low (extreme poverty). Few participants included in the follow-up analysis were in the highest (1·3%) and lowest quintiles (7·8%), and so the two highest and two lowest categories were merged to create three categories: high and medium-high (herein ‘high’), medium, and relative and extreme poverty (herein ‘low’). Data on sex, age, and SES were missing for <5% of participants.

Statistical analysis

All analyses were performed in Stata 17·0 (College Station, Texas, USA). Analyses involving the baseline population used survey weights to account for the complex study design. Analyses that included follow-up measurements were not weighted as the follow-up sample was not representative.

The nationally representative ABC continuum of care estimated proportions and 95% confidence intervals (95% CI) using complex survey weights with restricted estimation to 585 participants with diabetes at baseline. Weighted multinomial logistic regression models were used to evaluate associations between socio-demographic and clinical characteristics and position on the simplified continuum of care to ensure sufficient sample size (>5) in each stage. Covariates included previously well-established risk factors for diabetes [ 32 ], namely, sex (women versus men), age category (<50 years, 50–59 years, ≥60 years), SES (high, medium, and low), urban residence (versus rural), overweight/obesity (versus underweight/normal weight), having hypertension (versus not), or having high LDL (versus not). Urban was defined as population centres with 2,500 or more inhabitants. All models adjusted for participants’ regional residence. The outcome variable was defined as one of three positions on the care continuum (diagnosed, treated, or controlled) compared to undiagnosed.

The longitudinal, simplified continuum of care included 210 participants with diabetes at baseline and follow-up data. Individuals with incident diabetes between baseline and follow-up measurements (n = 43) were excluded to only analyse individuals already receiving care for diabetes at baseline. Paired t-tests were used to compute statistical differences between the proportions of participants in each stage of the continuum at follow-up compared to baseline. Multinomial logistic regression models were used to examine the association between baseline characteristics and either increasing or decreasing in care continuum stage (versus staying the same). To determine this outcome, participants were given a score at both baseline and follow-up based on their position on the continuum (1 for all diabetes, 2 for diagnosed, 3 for on treatment, and 4 for controlled). The difference between the two scores was calculated and then separated into three categories: worsened, stayed the same, or improved.

Baseline analyses

Between July 2014 and January 2017, 4,454 participants were recruited, and 3,445 participants were available for evaluation. The final sample for analysis included 3,420 adults, and 585 of those individuals had diabetes. Nationally representative socio-demographic characteristics are listed in S1 Table . Among 585 Venezuelan adults with diabetes in 2014–2017, 71% (95% CI: 64–77) were diagnosed, 51% (45–56) were on treatment, 32% (28–36) achieved glycaemic control, 10% (7–14) achieved ABC control, and 8% (6–12) achieved ABC control and were non-smokers ( Fig 1 ). The greatest loss to care was at diagnosis (29% of participants lost and, thus, undiagnosed).

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Estimated proportions and 95% confidence intervals calculated using complex survey weights. ABC Control refers to A1C, blood pressure, and cholesterol control.

https://doi.org/10.1371/journal.pgph.0002763.g001

Compared to younger participants, older participants were more likely to have diagnosed-treated-uncontrolled diabetes than having undiagnosed diabetes [relative risk ratio (RRR) (95% CI), 2.61 (1·17, 5·81)] and more likely to have diagnosed-treated-controlled diabetes than having undiagnosed diabetes [RRR (95% CI), 2·28 (1·17, 5·81)] ( Table 1 ). Participants with medium SES were marginally less likely to have diagnosed-treated-uncontrolled diabetes (compared to being undiagnosed) than their counterparts with high SES [RRR (95% CI), 0·39 (0·15, 1·03)]. Finally, women were marginally more likely to have diagnosed-treated-controlled diabetes than men compared to having undiagnosed diabetes [RRR (95% CI) 1·83 (0·95, 3·54)].

https://doi.org/10.1371/journal.pgph.0002763.t001

Longitudinal analyses

Between October 2018 and January 2020, study staff contacted and visited the 3,420 participants enrolled at baseline and collected follow-up data on 1,296 individuals, 210 with diabetes ( S1 Fig ). In the longitudinal sample, most participants with diabetes were women, above 60 years of age, had low SES, and lived in urban areas ( Table 2 ). Most of these participants also had overweight/obesity, hypertension, and high LDL cholesterol. Between 2014–2017 and 2018–2020, 76% of participants gained weight, 9% had no weight change, and 15% lost weight. In 2014–2017, 83% of participants with diabetes who were on treatment were taking oral antidiabetic medications only, 8% were taking insulin only, and 9% were taking a combination. This remained similar in 2018–2020: 81% were taking oral medications only, 7% were taking insulin only, and 12% were taking both. Mean HbA1c (based on fasting blood glucose equivalents) in our sample was 5·3% [Standard Deviation (SD): 1.07] in 2014–2017 and 5.27% (SD: 1·26) in 2018–2020.

https://doi.org/10.1371/journal.pgph.0002763.t002

S2 Table summarises the differences between Venezuelan adults with diabetes lost to follow-up and those retained in the study. Those lost to follow-up were more likely to be men, <50 years old, high or medium SES, and to live in urban areas. Approximately 18% (375 of 2106) of participants lost to follow up had diabetes, compared to 16% (210 of 1296) of the longitudinal population.

Among 210 Venezuelan adults with diabetes, the proportion of participants who were diagnosed increased between 2014–2017 and 2018–2020 [67% (95% CI: 61–73) to 73% (67–79), p<0·01), while the proportion of participants who were on treatment decreased significantly [60% (54–67) to 51% (44–57), p<0·01] ( Fig 2 ). There was a small decrease in the proportion of participants who achieved glycaemic control, though not statistically significant [40% (34–46) to 37% (30–43), p = 0·41]. In both 2014–2017 and 2018–2020, the largest proportions of participants were lost at the diagnosis stage (33% and 27%, respectively). In 2018–2020, there were also 22% of patients lost to care between diagnosis and treatment, versus only 7% in 2014–2017.

Estimated proportions and 95% confidence intervals. Paired two sample t-tests were used to compute statistical differences between numbers of participants in each step at follow-up compared to baseline. P<0.01 for diagnosed and on treatment, p = 0.4 for achieving glycaemic control.

https://doi.org/10.1371/journal.pgph.0002763.g002

Fig 3 shows how many participants switched from one continuum step to another and how many participants remained in the same position. Overall, 50 participants worsened (24%), 40 improved (19%), and 120 stayed the same (57%). Most participants whose continuum stage remained unchanged between study visits were either undiagnosed and remained undiagnosed over time (47%) or achieved glycaemic control and maintained glycaemic control over time (37%). Of the 84 participants who achieved glycaemic control in 2014–2017, 17 (20%) were no longer in control and 23 (27%) were no longer on treatment in 2018–2020. Of the 43 participants on treatment in 2014–2017, 22 (52%) achieved glycaemic control, 11 (26%) remained on treatment, and 10 (23%) were no longer on treatment in 2018–2020.

This three-dimensional bar chart visualizes the number of participants at each stage of the care continuum at baseline and follow-up, showing how many participants changed position and in which direction.

https://doi.org/10.1371/journal.pgph.0002763.g003

When examining socio-demographic and clinical associations with the longitudinal care continuum, participants who had high LDL cholesterol at baseline were less likely to regress along the care continuum than those with lower LDL cholesterol [RRR (95% CI), 0.39 (0·20, 0·77)]. No other significant associations were observed ( Table 3 ).

https://doi.org/10.1371/journal.pgph.0002763.t003

This study is among the first longitudinal analyses of health system performance for diabetes management and the first continuum of diabetes care applied to Venezuela. The proportion of people with diagnosed diabetes who were on treatment declined over time, from 60% to 51%. Nonetheless, even in 2018–2020, after over five years of political and economic upheaval, half of people diagnosed with diabetes were treated and nearly two out of five had achieved glycaemic control [ 33 ]. These proportions are higher than an analysis of 28 low- and middle-income countries (LMICs), which found just 38% of people diagnosed with diabetes were currently treated and 23% had achieved glycaemic control [ 33 ]. Multinational entities, such as the World Health Organization in their Global Diabetes Compact, should explore the possibility that care requirements in humanitarian emergencies may be distinct from LMICs and programmes to improve care need to be adapted to existing infrastructure and human resources [ 34 ].

While treatment rates were lower for this national sample of people with diabetes in Venezuela in 2018–2020 than for the same individuals in 2014–2017, glycaemic control was not substantially different. These findings do not align with previous reports documenting the collapse of the Venezuelan health system, in which medical facilities lack water, electricity, and vital medications [ 35 ]. This counterintuitive observation may be explained by large investments in primary and chronic care in Venezuela only a few years before the crisis, suggesting that health care centers were still operating [ 16 ]. In fact, a previous analysis of EVESCAM participants in 2014–2017 found that when a health service was required, 67.4% attended public health care centres and 21% used private centres (almost 12.5% with insurance coverage and 8.5% out of pocket) [ 18 ]. Furthermore, the flow of medicines and remittances sent from Venezuelan migrants to their families remaining in country have reportedly reaching 3.7 billion US$ in 2019 [ 36 ]. Lastly, the majority of participants with diabetes were not insulin dependent. However, EVESCAM treatment data were binary and did not include further details such as quality, dosage, and frequency.

Previous literature on diabetes management in crises underscore the complexity of disease care in these settings. A number of small, longitudinal studies have documented mean A1C increasing after both natural disasters [ 7 , 10 , 11 ] and wars [ 8 , 13 ]. However, the relationship between exposure to crisis and increased A1C is not always uniform among the entire population. For example, a study of individuals displaced by Hurricane Katrina documented a drop in A1C levels only among publicly insured individuals with diabetes, but no change among individuals with diabetes who had private or Veteran Affairs insurance [ 10 ]. Another study of 296 people with diabetes during the Hull, England flooding of 2008 only documented A1C decreasing among insulin-treated participants [ 7 ]. One study of Sarajevans during the Balkan wars in the early 1990s documented a decrease in A1C levels among people with diabetes from before the war to three years into the war, though this phenomenon was attributed to decreased BMI [ 9 ]. Finally, a study of Croatians during the Balkan wars documented no difference in mean A1C among 35 people with diabetes examined before the war and again three months after the war began [ 12 ]. None of these studies visualised diabetes management using the continuum of care framework, instead they quantified quality of diabetes management using mean A1C levels [ 7 – 13 ].

The continuum of care, or cascade of care, framework was initially developed to quantify the effectiveness of the healthcare system in diagnosing and treating HIV [ 37 ]. It has since been applied to health system performance for diabetes care [ 26 , 33 ]. The approach allows for easy identification of where in the continuum the greatest losses to care occur, facilitating the creation of targeted interventions to address these gaps [ 38 ]. Diabetes management has been evaluated using the continuum of care approach in high-income [ 26 ] and LMICs [ 33 ]. Manne-Goehler et al., for example, conducted a cascade of diabetes care study of 28 LMICs in multiple geographic regions [ 33 ], and found only 6% of participants to be lost between diagnosis and treatment, a stark difference from the 20% reported here. While the gap between treatment and any glycaemic control in Venezuela was similar to the aggregated average for 28 LMICs, Venezuela had high proportions for both steps: 51% on treatment dropped to 32% for achieving any glycaemic control compared to 38 to 23% among 28 LMICs. Unlike the present study, which found few differences in change of care continuum position by socio-demographic subgroup, though this may have been due to a lack of power with the small sample size, Manne-Goehler et al. found stark differences by subgroup. Specifically, individuals who were older, had higher educational attainment, and had higher BMI had higher odds of being tested, on treatment, and achieving glycaemic control [ 33 ]. In our nationally representative analysis for 2014–2017, older age and female sex were marginally associated with increased likelihood of achieving glycaemic control. Additionally, older age and medium SES (compared to high SES) were associated with increased likelihood of being on treatment. Our results suggest that the decline in treatment rates among people diagnosed with diabetes in Venezuela did not differ by SES, urban residence, or age, similarly affecting all population subgroups.

There are several limitations to this study. First, the EVESCAM study experienced high loss-to-follow-up between baseline and follow-up, at 65%. This is expected considering mass emigration and internal displacement, transportation and gasoline shortage, and the reduction of communication services during the crisis. As of December 2022, over 7·0 million Venezuelans had fled their country and there remains no reliable estimates for internal displacement, though the Internal Displacement Monitoring Center suggest that a displacement crisis is likely based on cross-border movement and conditions inside the country [ 21 ]. As shown in S2 Table , the largest subgroups lost to follow-up in EVESCAM were younger men who had high SES and lived in cities. Therefore, the estimates presented in this paper are representative of those who stayed, a population that is more likely to be women, lower SES, and rural. This aligns with surveys of Venezuelan migrants in Colombia, which recorded a population of primarily men, under 50 years of age, with higher educational attainment but low income, and seeking support for their families remaining in Venezuela [ 39 ]. Second, our definition of glycaemic control was based on only one blood glucose measurement at each time point rather than A1C, which measures the average glucose levels over the course of red blood cells lifespan (approximately 40–60 days) [ 40 ]. We calculated A1C levels post hoc using the fasting blood glucose measurement, which may have introduced some inaccuracy for prevalence estimates [ 40 ]. Nonetheless, the measurement of glucose in venous blood instead of capillary blood is a strength of the study. Finally, two stages of the care continuum–diagnosis and treatment–were based on self-report and could not be confirmed with medical records.

Despite these limitations, EVESCAM is among the first studies to gather longitudinal data in the middle of a crisis in the same individuals and the first in Venezuela to collect nationally representative data on NCD risk factors based on biomarkers for diabetes and clinical measurements of important comorbidities (e.g. blood pressure and cholesterol). Although 35% retention seems low for typical epidemiological surveys, this was a remarkable feat for a field-based study in a crisis setting experiencing mass migration. In general, the EVESCAM study offers a unique window into a country that rapidly shifted from high to low resources over a short period of time.

These results show a surprisingly high proportion of individuals living with diabetes that are regularly accessing treatment and maintaining glycaemic control. Further study is needed to understand how these individuals were so resilient in time of crisis, to better inform strategies for other settings where healthcare systems are less successful to provide care for chronic diseases. Understanding barriers and facilitators to NCD management in crisis is particularly relevant amid the COVID-19 pandemic, as underlying chronic conditions such as diabetes are risk factors for severe disease and as health systems worldwide are facing catastrophic disruptions.

Supporting information

S1 checklist. strobe statement—checklist of items that should be included in reports of observational studies..

https://doi.org/10.1371/journal.pgph.0002763.s001

S1 Fig. Participant flow chart.

https://doi.org/10.1371/journal.pgph.0002763.s002

S1 Table. Baseline sociodemographic and clinical characteristics of 585 Venezuelan adults with diabetes during study period 2014–2017, nationally representative.

https://doi.org/10.1371/journal.pgph.0002763.s003

S2 Table. Sociodemographic and clinical characteristics of Venezuelan adults included in total nationally representative population and follow-up with diabetes, at baseline.

https://doi.org/10.1371/journal.pgph.0002763.s004

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• 36. Orozco M, Klaas K. Money Transfers to Venezuela: Remittance Flows Amidst Evolving Foreign Exchange. Washington DC Inter-American Dialogue. 2020.

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• Institutions, crisis and type 2 diabetes policy in Venezuela
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• Eduardo J Gomez
• College of Health, Department Community and Population Health , Lehigh University , Bethlehem , Pennsylvania , USA
• Correspondence to Dr Eduardo J Gomez; edg219{at}lehigh.edu

In a context of economic, political and humanitarian crisis, ensuring effective type 2 diabetes self-care management services in Venezuela has been an ongoing public health challenge. Repeated shortfalls in access to medicine, healthcare workers and food scarcity have hampered the ability of patients with diabetes to effectively manage their condition and receive the healthcare support that they deserve. With respect to methodology, the author relied on qualitative research methods, with a focus on in-depth document analysis. Primary and secondary document data sources were used through a systematic key word search in online search engines and library databases. While one may attribute these challenges in Venezuela to ongoing economic, political and humanitarian crisis, this article combines this perspective with health systems and institutional challenges that appear to have perpetuated and in fact worsened Venezuela’s diabetic situation. Specifically, a weakened healthcare system, fragmentation in diabetic primary care services and corruption in a context of ongoing humanitarian crisis have contributed to these ongoing challenges. Within humanitarian and political crisis conditions, future research on type 2 diabetic treatment and self-care management may benefit from combining perspectives in political science institutional theory and public health systems analysis to explain why governments in these settings continue to fall short of providing effective and equitable diabetic care.

• health policies and all other topics
• health systems

Data availability statement

Data are available in a public, open access repository.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjgh-2021-007174

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Summary box

Despite the increased awareness of Venezuela’s diabetes epidemic, we know less about the intersection of political, social and humanitarian crisis and type 2 diabetes care.

This article suggests that while a context of political, social and humanitarian crisis may challenge a government’s ability to provide effective type 2 diabetes services, we need to combine this perspective with an analysis of the design of bureaucratic institutions and malfeasance within government.

Findings from this article may also provide new insights for clinical practitioners in Venezuela on how they can work with the central government on improving the design of primary care institutions.

This article also underscores the importance of conducting interdisciplinary analysis that brings together political scientists, public health and medical experts to evaluate type 2 diabetes policy in Venezuela and other low-income and middle-income countries.

Introduction

Similar to several emerging economies in Latin America, in recent years Venezuela has seen a steady increase in non-communicable diseases. Changes in dietary patterns, lifestyles, increased food scarcity and the consequential decrease in access to nutritious foods have contributed to a rise in overweight and type 2 diabetes. Amidst burgeoning type 2 diabetic cases, the country continues to be hampered by ongoing economic, political and humanitarian crisis, as well as a general decrease in government commitment to strengthening the public healthcare system.

In this article, the author explores the relationship between crisis, institutions and the provision of type 2 diabetes self-care management services in Venezuela. Specifically, the author examined the role of public health institutions and their ability to adapt to ongoing needs of patients with diabetes in a context of ongoing crisis. This article claims that ongoing shortcomings in the government’s provision of type 2 diabetic self-care management services reflects three challenges. First, the debilitating impact of political, economic and humanitarian crisis on decreased health systems capacity to provide these services. Second, the bureaucratic fragmentation of primary care diabetic services. And third, the incentives that this context generates for health officials to engage in corrupt activity instead of focusing on strengthening the provision of diabetic services. Therefore, the author finds that understanding and explaining Venezuela’s ongoing type 2 diabetes challenges in self-care management require that we combine the effects of political, economic and humanitarian crisis with an analysis of bureaucratic institutions and policymaker’s incentives to pursue effective health policy reform in a context of uncertainty and despair.

Research for this study relied mainly on analysis of primary and secondary document data sources. Major online search engines and databases, such as Google , Google Scholar , PubMed and Web of Science , were used with ‘key word’ search terms focused on Venezuela, type 2 diabetes, self-care management, health systems and policy. With respect to the inclusion criteria, documents were selected for analysis if they were peer-reviewed journal articles, credible policy articles, reports and media news articles providing an in-depth analysis of either Venezuela’s type 2 diabetes situation, policy or political context. Documents that either did not provide a thorough analysis or that were from questionable publication sources were not selected. The case of Venezuela was chosen for two primary reasons: first, the high prevalence of type 2 diabetes in a context of ongoing political, economic and humanitarian crisis; and second, the dearth of knowledge on the interaction between political and humanitarian crisis and type 2 diabetes self-care management in Venezuela. Epidemiological data on the blood glucose levels of patients with diabetes were also obtained from the WHO online Global Health Observatory Data Repository, which was accessed online in July 2021. The research conducted for this article started in August 2020 and concluded in July 2021. Ethical consent was not required for this research because no individuals in Venezuela, or elsewhere, were interviewed for this study. Finally, none of the research questions and measurable outcomes for this study were influenced by patients’ priorities, experiences and preferences. As mentioned previously, no patients were involved in the research design for this study.

Institutions and diabetes self-care management

Understanding the political and health systems challenges of providing type 2 diabetes self-care management services in low-income and middle-income countries (LMICs) is a new area of scholarly research. 1 With respect to health systems and type 2 diabetes policy, several studies have addressed issues such as bureaucratic incapacity (eg, lacking sufficient resources—eg, financial and technical 2 3 ; an insufficient level of primary care personnel and provider education, 3 and the government’s need to address provider emotions and attitudes with respect to treatment while defining their roles and responsibilities). 4 5 However, we know less about how ongoing economic, political and humanitarian crisis, the fragmentation of primary care institutions, health officials’ preferences and behaviours interact to challenge the provision of type 2 diabetic self-care management services.

In this article, the author addresses this lacuna in the literature in several ways. First, the author underscores the ongoing challenges of primary care institutional fragmentation in providing diabetic self-care management services. However, the author combines this institutional approach with an analysis of ongoing political, economic and humanitarian crisis and its harmful effects on Venezuela’s healthcare system, as well as how these crisis situations perpetuate health officials’ preferences to refrain from providing effective diabetic services. Indeed, while political crisis has in the past provided opportunities and incentives for healthcare reform in Venezuela and other Latin America countries, 6 the author’s research suggests that ongoing crisis conditions can generate health official incentives to not only refrain from improving state capacity in providing diabetic services but also to personally benefit from weak state capacity through the squandering of medicine and resources. The author’s research on Venezuela therefore suggests that adequately understanding why governments are both unwilling and incapable of improving type 2 diabetes self-care management services requires a more comprehensive approach that takes context, institutions and bureaucratic interests more seriously.

In the next section, the author provides a brief description of the current state of type 2 diabetes in Venezuela. The author highlights the historical and current epidemiological situation and the contributing factors to the nation’s diabetes situation.

Type 2 diabetes in Venezuela

Within the past several decades, the number of patients with type 2 diabetes has burgeoned in Venezuela. According to Nieto-Martínez et al , 7 there were an estimated 1.7 million persons with type 2 diabetes in the nation. Worse still, Nieto-Martínez et al (p. 1334) note that the “…prevalence of uncontrolled T2D (A1C>7%) [for patients undergoing treatment] in Venezuela is 76%, one of the highest in Latin America.” 7 A more thorough and up-to-date epidemiological picture of Venezuela’s type 2 diabetic situation is nevertheless constrained by the absence of national population health statistics provided by the government. 8 Moreover, according to Contreras et al (p. 320), the Ministry of People’s Power for Health only provides “… extemporaneous publications and do not correspond to a national diabetes detection plan in the country.” 8 Data obtained by Contreras et al (p. 320) note that, “For the year 2010, the population prevalence figures for DMT2 in Venezuela ranged from 5.1% to 6.0%, representing an absolute value of between 1 470 500 and 1 730 000 cases/year.’ 8 Contreras et al (p. 320) also referred to a study by Whiting et al (2011) where he claims that in 2011, in Venezuela, “…the number of DMT2 cases aged between 20 and 79 years … was 1 764 900, for a prevalence consistent with WHO criteria of 10.39% …,” 8 while Contreras et al (2020, p. 320) also noted a study by Nieto et al (2017) claiming “…that 12.4% of Venezuelans over the age of 20 have diabetes, and the prevalence has increased from 6.0% in 2010 to 12.4% in 2017.” 8

In recent years, the diabetic community’s ability to successfully control its blood glucose level does not appear as successful. Ideally, the blood glucose of a patient with diabetes should be “…between 4 and 7 mmol/L” (Editor, 2019, p.1). As figure 1 illustrates, however, the WHO (2021) reports that Venezuela has consistently scored above 7 since the year 2000, at which point it reached 7.2, increasing to 8.8 in 2014 (WHO, 2021). This seems to suggest that patients with diabetes have not been able to adequately control their blood sugar levels.

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Venezuela's Raised Fasting Blood Glucose Situation.

Unlike other countries in Latin America, however, the nutrition transition does not appear to have contributed to this rise in type 2 diabetes in Venezuela. In fact, researchers find that Venezuelans have not consumed Western-based foods as frequently as other nations, such as sodas, ultra-processed foods, with citizens instead appearing to consume more basic food staples. 9 Surveys found that in mainly urban areas, Venezuelans have primarily enjoyed the consumption of coffee, arepa and cheese, and that the consumption of Western-based foods—though others find are certainly present— 7 has been low. 9

The government’s food policies also appear to be contributing to Venezuela’s challenging diabetic situation. Specifically, the government’s food subsidies have fuelled the mass consumption of products exhibiting price controls, making them affordable, but high in carbohydrates, sugars and fat. 10 In a context of food scarcity, unemployment and poverty, consuming these foods has been much more appealing for many Venezuelans, while vegetables and fruits are increasingly scarce and more expensive. 10 Some were of the view that the government’s price controls were “…inadvertently creating a generation of overweight Venezuelans prone to diabetes and hypertension” (Wilson, p. 1). 10

Finally, overweight and obesity has also been a risk factor associated with the rise of type 2 diabetes. According to some estimates, by 2015, roughly 70 per cent of the population was overweight and approximately 40 per cent were obese. 10

The challenge of diabetes self-care management

With the number of persons with type 2 diabetes increasing, ensuring that patients have access to effective diabetic self-care management services and knowledge has been important. However, several challenges have emerged with ensuring that these outcomes can be achieved.

One reoccurring problem has been reliable access to medication for self-care treatment. In fact, researchers find that there is often a shortage of diabetic medicine and that they are high in prices. 11 With the costs for medications high, persons with diabetes have been inconsistent with their treatment and have not had a chance to effectively control their condition. 11 12 In other instances, due to fear of not having sufficient access, persons with diabetes have had to purchase more than their share of medication in stores. 12 However, the lack of access to medicine in general, as well as medical diagnostics and hospital equipment, has been further compounded by the recent economic and political crisis. In this context, persons with diabetes have tried to obtain medication from elsewhere, at times travelling to neighbouring Colombia to obtain medicine. 11

Nevertheless, some type 2 medications appear to be more available in Venezuela. For example, a medication that is commonly used among persons with diabetes to manage blood glucose levels is Metformin. Nieto-Martínez et al 7 found that due to price controls imposed by the government that the price for this medication is low and that it is popular in the country. But at the same time, this medication is poorly prescribed by the medical and even non-medical professionals, while also being self-prescribed by persons with diabetes. 7 In this context, NGOs (Non-Governmental Organizations) have been asked to step in and help to provide diabetic services. 12 Furthermore, research by Nieto-Martínez et al 7 finds that prediabetes screening is troubled by a dearth of available biochemical testing examinations for pre-diabetics.

Yet another challenge has been the lack of adequate preparation that public healthcare workers have to provide diabetic self-care management services. Indeed, there is an ongoing need to provide training, such as increased knowledge and education, for nurses and community healthcare workers providing services to patients with diabetes. 13

Health systems institutions and policy response

But what accounts for these ongoing challenges in diabetes self-care management services? While one may easily blame the state of political, economic and humanitarian crisis generating a weakened policy response, the author finds this approach to be insufficient on its own. Instead, the author combines this emphasis on contextual crises with its effects on the overall healthcare system, the design and fragmentation of bureaucratic primary care institutions providing diabetic services, and, in a context of ongoing crisis, health officials’ incentives to take advantage of this situation for personal gain.

Crisis and health systems challenges

In recent years, political and economic crisis has had a negative effect on Venezuela’s healthcare system. Shortly after his election into office in 1998, the late President Hugo Chávez promised to provide universal access to healthcare as a right for all citizens, going so far as to enshrine this principle into his new constitution. 14 At the time, Chávez also established an agreement with Cuba to provide cheap oil in exchange for Cuban doctors, medicines and training throughout the country. 14 However, under Chávez, Venezuela’s overall healthcare system soon began to experience challenges. First was the nation’s deteriorating economic situation, further complicated “…by exchange rate controls, which led to a shortage of the foreign currency needed to import equipment, food, and medicines” ( The Lancet , p. 1331). 14

Yet another challenge during this period was a high level of institutional turnover. Chávez’s administration witnessed a total of “…13 different [health] ministers, most of whom served less than a year” (Wilson, p. 1). 15 In fact, The Lancet medical journal in 2018 reported that the country had 17 health ministers within the past 20 years. 14 Moreover, according to Wilson, 15 Chávez’s successor, President Nicolás Maduro, had as of 2015 “… already appointed four health ministers in his first two years of office” (Wilson, p. 1). 15 And with respect to human resources, Wilson (2015) claims that in 2007, the country had “… more than 70 000 doctors” (ibid, p. 1). 15 But “Since then, 13 000 physicians have left the country,” with “…more than half—some 7600—worked in the country’s public health sector” (ibid, p. 1). 15

Since Maduro’s entry into office, political and humanitarian crisis has continued, establishing a context that is difficult for improving Venezuela’s healthcare system. Arguably, the genesis of the current political crisis stemmed from the disputed 2018 presidential election, which the political opposition contested, 16 and which Maduro won but was construed as illegitimate by the opposition parties within the National Assembly. 17 Based on what is stated in the Venezuelan constitution, in this context, the president of the National Assembly could step in as the interim President, who at the time was Juan Guaidó, 17 of the Popular Will political party. Declaring himself president, with strong backing from the international community, Maduro and his supportive National Constituent Assembly opposed Guaidó’s proclamation. 17 Guaidó tried to obtain the support of the military but ultimately fell short of achieving this objective. 17 To this day, Maduro has maintained his presidency and arguably his political power. Maduro’s control was further solidified when in January 2021, the socialist party obtained majority control over the National Assembly, which Guaidó previously headed and which the political opposition had control over. 18 The National Assembly is now led by Maduro’s former chief of staff, Jorge Rodriguez. 18

Analysts see no resolution and end to the country’s situation and suffering. 19 Some claim that Maduro has not focused on fixing the economy but instead retaining his political power, failing to address the underlying structural changes needed to salvage the economy, and that this context has contributed to ongoing food shortages, malnutrition and supply shortages. 19 In this context, the country’s healthcare system has suffered. 19

While the economy continues to deteriorate, Venezuela’s humanitarian crisis deepens. Amidst ongoing food shortages, insufficient employment, low wages and lack of access to healthcare, in recent years citizens have fled the country, which decreased somewhat during the COVID-19 lockdown, but increase again later. 19 Indeed, it is these conditions, as well as enduring violence, death and the repression of political opponents (which often includes jailing, illegal detentions and human rights violations) that have contributed to the country’s migration crisis. 20 Neighbouring Colombia appears to be the primary receptor of migrants from Venezuela. 20

Bureaucratic design and context

Nevertheless, in addition to crisis, it is also important to note that institutions matter. In Venezuela, the institutional context and policies in response to type 2 diabetes, and other diseases, have been challenging. With respect to primary care services, the bureaucratic system appears to be highly fragmented. While the Ministry of Popular Power for Health is responsible for providing primary healthcare services for diabetics, there are also separate systems that in essence duplicate the government’s policy efforts. As Nieto-Martínez et al maintain, 13 the following public sector institutions provide primary care services: the Ministry of Popular Power for Health, the Institute of Social Security (Ministry of Education), Venezuelan Institute of Social Security, State Health Departments and even the Social Security Division of the Armed Services. Furthermore, Nieto-Martínez et al claim that about 15 state governments have 40 diabetes care units 13 ; moreover, these units provide diabetic care and information on prevention. 13 These diabetic units also conduct research and disseminate information to the local community. 13

The central government is also directly involved in providing primary care services through its social missions, which focus on providing care in poorer areas. 13 As Nieto-Martínez et al explain, 13 a good example of this effort is the joint programme that Venezuela created with Cuba in 2003, namely, the Misión Barrio Adentro . 7 Through this programme, several primary care centres were provided throughout the country, staffed by Cuban doctors, and directed by their own staff. 7 Nieto-Martínez nevertheless claims that this situation contributed to the fragmentation of Venezuela’s healthcare system, and that “… the physical and administrative separations between the Cuban medical mission and ordinary public health services could compromise broad implementation of tDNA”—[transcultural Diabetes Nutrition Algorithm, which is a culturally sensitive approach to implementing diabetes management, facilitating the application of medical nutrition therapy services in different countries] (p. 1337). 7

State actor preferences and corruption

Finally, yet another challenge has been health officials’ reluctance to improve the public health system and instead take advantage of it for personal gain. As Wilson points out, 15 when the public complains about the poor healthcare treatment that they receive, the government views health ministers as the scapegoat. This context generates uncertainty and motivates these officials to profit from the system. 15 Indeed, Wilson (p. 1) states that “Uncertain of when their tenures will end, ministers work quickly to enrich themselves.” 15 Moreover, according to Wilson (p. 1), who interviewed an anonymous minister within the government, “The result is that there is a constant pilfering of supplies and medicines. The ministry may buy the medicines, but they are then resold to private clinics and doctors by corrupt ministry officials …. [consequently] Many medicines, such as insulin, aspirin, antibiotics, and blood pressure drugs, are scarce.” 15 Policy analysts note that critical medicines often disappear and that, according to some media sources, there are allegations of corruption that, in turn, hamper the distribution of medications. 21 Furthermore, González claims that some of these medications are needed to treat diabetes and other chronic health conditions, such as heart disease. 21 Worse still, patients in this context are often forced to bring their own medical supplies, medications and even food when going to hospitals. 21

Going beyond crisis: the importance of politics and institutions

The author’s analysis of the Venezuelan government’s response to its ongoing type 2 diabetes situation and provision of self-care management services has revealed several lessons. Government failure to provide effective self-care management services should not only be attributed to ongoing political, economic and humanitarian crisis situations. The context of crisis can therefore no longer be the primary scapegoat. While crisis conditions have certainly introduced several healthcare challenges, the author has argued that just as important is combining this perspective with the importance of institutional design, specifically the fragmentation of government primary care diabetic services, and the incentives that a deteriorating healthcare system provides for health officials to engage in corrupt behaviour. In this context, it seems that health officials will not have the motivation needed to remain in office and to work with other government officials in helping improve the provision of diabetic self-care management services. Given this situation, future researchers may also consider a ‘Health in All’ policy approach to highlighting these intergovernmental challenges and future needs. Such an approach could emphasise the need for several government sectors, from health to the office of the presidency and other government branches, to work together in integrating health into decision-making and committing to the provision of equitable public health policies benefitting the entire population. 22 This approach could also underscore the reasons why health and non-health sectors in Venezuela are perhaps unwilling to collaborate and work towards this goal in the area of diabetes policy.

Furthermore, in this situation, civil society and international NGOs can play an important role in meeting diabetic self-care management needs. However, ongoing political crisis and specifically the Maduro administration’s resistance to international medical assistance and humanitarian aid 21 challenges these non-state actors’ ability to provide support to persons with diabetes. Convincing the government to change its views on this situation will be an arduous task. In this situation, the international community, such as through the WHO or the Pan-American Health Organisation (PAHO), can help in pressuring the Maduro administration into allowing international NGOs to play a more important role in the provision of diabetic self-care management services. In 2017, Maduro appeared more receptive to the United Nation’s (UN) advice on increasing access to medicine by working with the UNDP (United Nations Development Programme), although no concrete action has been taken thus far, while emphasising the importance of international health cooperation and assistance. 23 Therefore, the time may be ripe for Maduro to pay more attention to the UN and possibly its recommendation that he take the work of NGOs more seriously.

Future research will also need to provide more attention to the interests and motivations of healthcare officials within government. Why is the Maduro administration failing to invest in ensuring healthcare official’s autonomy and stability within government, safeguarding them from public criticism? How is presidential and political party gridlock, that is, between the ruling and opposition political parties, generating few incentives to provide more support to health officials? More research needs to be done in this area.

Several methodological limitations nevertheless hampered the author’s ability to conduct research in Venezuela. First and foremost is the dearth of in-depth scholarly publications, policy reports and government-provided public data on Venezuela’s type 2 diabetes situation. In large part, the absence of these data reflects the government’s unwillingness to release official information and perhaps be interviewed by researchers. As mentioned earlier, for several years, the government has not released data on the prevalence of type 2 diabetes, therefore leaving the scholarly community in the dark with respect to not only disease prevalence but also the diabetic community’s ability to control their glucose level. As mentioned earlier and as provided in figure 1 , it seems that the only official data available on diabetic blood glucose levels are currently provided by the WHO.

Finally, the author’s research reveals a need for public health researchers and political scientists to work together in unravelling the political and institutional contexts shaping the provision of diabetic self-care management services. This is a new area of scholarly research, 1 one that not only provides alternative insights for policymakers and those providing recommendations to the government, but also information that can hold government officials accountable for their actions. As Venezuela’s political, economic and humanitarian crisis persists, more effort will be needed to establish interdisciplinary scholarly teams that can help address these issues. Insights from Venezuela’s crisis situation may also provide policy recommendations to other LMICs that are consistently impaired by crisis situations, institutional and political instability, and where improved diabetic self-care management services are consistently in need.

Venezuela’s ongoing political, economic and humanitarian crisis situation continues to pose several challenges to the government’s ability to ensure the effective provision of diabetic self-care management services. While enduring political, economic and humanitarian crisis poses several challenges, a more adequate explanation of this policy situation requires an analysis of the effects of crisis on Venezuela’s healthcare system, the fragmentation of primary care institutions, and how this context generates incentives for health officials to engage in corrupt behaviour rather than striving to improve state capacity in providing these services. Venezuela’s deteriorating diabetic situation can benefit from explanations that take politics and institutions more seriously, in turn, providing an approach that provides alternative insight into explaining why persons with type 2 diabetes are not receiving adequate self-care management services.

Ethics statements

Patient consent for publication.

Not applicable.

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Handling editor Seye Abimbola

Contributors EJG is the sole author for this article and conduct all the research and analysis. The author attempted to find colleagues from Venezuela conducting research on this topic but was unfortunately unable to secure a coauthor due to the sensitive political nature of the topic.

Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Día Mundial de la Diabetes: el panorama del paciente diabético en Venezuela

• La emergencia humanitaria compleja y la crisis causada por el covid-19 complica el escenario de las personas con esta afección crónica en el país

En Venezuela se estima que 34% de la población es prediabética, es decir que podría estar en riesgo de padecer diabetes mellitus, una afección crónica que se origina cuando el páncreas no es capaz de sintetizar la insulina que el cuerpo humano necesita. 

Esta cifra fue un hallazgo de la Sociedad Venezolana de Medicina Interna (SVMI), que fue publicado en el año 2018. El estudio midió las condiciones de vida, hábitos y aspectos generales de la salud de 3.420 adultos venezolanos con los que se llegaron estos resultados. 

El Día Mundial de la Diabetes fue implementado por la Federación Internacional de Diabetes (FID) y la Organización Mundial de la Salud (OMS) en 1991, como respuesta al alarmante aumento de los casos de diabetes en el mundo.

En el año 2007, la Organización de Naciones Unidas (ONU) celebró por primera vez este día tras la aprobación de la Resolución en diciembre de 2006 del Día Mundial de la Diabetes.

Panorama del paciente diabético en Venezuela

Elizabeth Rojas de Poller, médico endocrinólogo y miembro de la junta directiva de la (Federación Nacional de Unidades de Diabetes (Fenadiabetes), aseguró que el panorama de las personas con diabetes en Venezuela durante la pandemia es crítico porque no pueden recibir una atención adecuada. 

“Muchos pacientes han tenido que dejar de asistir a sus consultas y acudir a la telemedicina. Los medicamentos que deberían tener en reserva para cumplir su tratamiento sin tener que salir a la calle no los tienen y algunos se han visto en la necesidad de reducir las dosis para rendirlo”, detalló Rojas en exclusiva para El Diario . 

La especialista explicó que estas variaciones en el tratamiento tienen efectos negativos en la enfermedad, porque descontrola el organismo del paciente. 

Diabetes tipo 1 y tipo 2 – La diabetes 1 es en la que el cuerpo produce poco o nada de insulina y suele aparecer en la adolescencia. El paciente debe depender de dosis de insulina. nn- En la diabetes tipo 2, el cuerpo de la persona no produce suficiente insulina o es resistente a la insulina, esto afecta la forma en la que el cuerpo procesa el azúcar en la sangre. n

La vocera de Fenadiabetes denunció que en el país se ha vuelto usual la escasez de insulina. La situación pone en riesgo especialmente a las personas con diabetes tipo 1.

La disponibilidad de medicamentos, asegura la endocrinólogo, varía en algunas farmacias venezolanas, pero sus precios son demasiado altos en algunas de sus presentaciones. Especialmente para aquellos que dependen de una pensión o salario mínimo para subsistir

Ante la dificultad de acudir a consultas y evaluaciones presenciales, la médico explicó que los pacientes diabéticos tienen la opción de medirse los niveles de glucosa en la sangre a través de un glucómetro. Aclaró que estos equipos y sus accesorios como agujas y bandas reactivas no son asequibles para toda la población. 

El aspecto nutricional

Un aspecto que puede mejorar la calidad de vida del paciente diabetico es una consulta nutricional, que lo puede ayudar a llevar una alimentación adecuada para su enfermedad con los alimentos que tenga a la mano. 

“En particular la diabetes tipo 2 responde a la carga de distintos alimentos y a las concentraciones de glucosa que el paciente diabetico tiene problemas para manejar. La ayuda nutricional se convierte en una herramienta fabulosa para abordar el problema”, indicó Marinella Herrera, especialista en Nutrición del Observatorio Venezolano de Salud (OVS)

Diabetes y covid-19

Rojas acotó que los pacientes diabéticos no están predispuestos a contraer covid-19 más que otras personas si cumplen con las medidas de bioseguridad. Sin embargo, destacó que la diabetes mal controlada puede ser detonante de síntomas graves de coronavirus. 

“Pueden tener más complicaciones y desenlace fatal si ellos no mantienen su glicemia, el colesterol, la tensión en los rangos adecuados. Si tiene además patología renal o cardiovascular debe mantenerla controlada para evitar mayores riesgos”, detalló. 

 La especialista indicó que para evitar este escenario, los pacientes diabéticos deben seguir las normas de bioseguridad básicas a la hora de salir de casa. 

Además recomendó mantener constante actividad física y una dieta saludable durante la cuarentena. 

“Intentar comer frutas de temporada, evitar las harinas procesadas en la medida de lo posible. Realizar algún tipo de actividad física dos o tres veces a la semana ayudarìan a evitar el sedentarismo que es un factor más que puede complicar la enfermedad”, señaló. 

A juicio de la especialista, el mayor desafío para el paciente diabetico venezolano es llevar un control adecuado de su condición. Destacó que el principal obstáculos son los costos. La médico aseguró que esta afección es compleja y requiere una consulta multidisciplinaria para garantizar calidad de vida al paciente. 

También te recomendamos Médicos venezolanos elaboran estudio sobre influencia del covid-19 en el desarrollo de la diabetesn

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Key information

Venezuela is one of the 19 countries of the IDF SACA region. 537 million people have diabetes in the world and more than 33 million people in the SACA Region; by 2045 this will rise to 49 million.

Diabetes in Venezuela (2021)

• 18,107,800 Total adult population
• 12.6% prevalence of diabetes in adults
• 2,280,000 Total cases of diabetes in adults
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