A Lived Experience Perspective on Empowering People With Diabetes Through Accessible Point-of-Care Technology in Brazil

Abstract

In Brazil and many other low- and middle-income countries, noncommunicable conditions (NCCs) or noncommunicable diseases such as diabetes mellitus, chronic kidney disease, and dyslipidemia pose significant health and economic challenges. Motivated by our personal experiences living and/or working with NCCs (including one author with diabetes and another with familial hypercholesterolemia), and our collective roles as advocates, researchers, and healthcare professionals, this article highlights the importance of early management strategies and the potential of point-of-care devices in primary healthcare to improve diagnosis and treatment outcomes.

Introduction

We, the authors, including two individuals with lived experience of noncommunicable conditions (NCCs), have witnessed firsthand the tremendous rise of NCCs such as diabetes mellitus, chronic kidney disease (CKD), and dyslipidemia in Brazil and other low- and middle-income countries (LMICs). These conditions present significant health and economic challenges, underscoring an urgent need for innovative approaches to improve outcomes. Instead of waiting for complications, we must emphasize early, and effective management strategies based on our experiences and advocacy efforts. Point-of-care (POC) technologies offer a promising solution to address current systemic gaps. While exams such as HbA1c are part of the Brazilian public health system (SUS), the laboratories may be very far from the primary healthcare (PHC) facilities. As a result, people often get lost in the system between receiving the request from the doctor and returning with the exam results. As a result, due to the lack of data, many just come back to the PHC facilities to refill the same medicines prescription, without any therapeutic adjustment that would be necessary to achieve the treatment goals. Integrating POC technologies directly into PHC facilities could bridge this critical gap, ensuring immediate results and enabling prompt, data-driven therapeutic adjustments.

In Brazil, diabetes affects over 16 million people and led to 107,760 deaths in 2019, accounting for 7.64% of all fatalities. ¹ Beyond diabetes, CKD and dyslipidemias significantly heighten the risk of cardiovascular diseases, which remain the leading causes of mortality. NCCs represent nearly 48% of hospitalization costs, with diabetes and related complications alone responsible for 18% of healthcare expenses. ² Despite these impacts, many cases remain undiagnosed or inadequately managed—over 31.9% of type 2 diabetes cases go unrecognized, ³ and CKD prevalence is likely four times greater than diagnosed. ⁴ Through our advocacy and community partnerships, we have seen the power of investing in PHC to enhance early diagnosis and timely interventions, fostering healthier lifestyles.

Personal Perspective

One of the key challenges faced by people living with diabetes in Brazil is the lack of accessible POC exams. These exams are crucial for providing the necessary information for therapeutic adjustments that bring biomarkers to target, ultimately improving health outcomes. For many individuals, in a few places where it was incorporated, the timely availability of HbA1c results has been transformative. ⁵ “Having prompt access to my HbA1c levels motivated me to take better care of my health. I felt more in control and committed to improving my condition,” shared a woman living with type 2 diabetes in Vitória da Conquista, Bahia. The perspectives of individuals highlight the real-world impact of accessible POC technology.

In the municipality of Vitória da Conquista, where POC was tested and shown to be cost-effective, ⁶ reducing HbA1c levels by 0.9%, ⁷ it was incorporated into the local health system. Despite the clear benefits of POC technology, there are challenges to its practical implementation in Brazil. A proposal submitted to implement POC for HbA1c devices in PHC nationwide was rejected by the Ministry of Health (MoH), despite studies demonstrating its cost-effectiveness and cost parity with traditional laboratory testing.^6,8 The rejection was justified because of the high costs. “The results were so motivating; it's disappointing that the national implementation wasn't approved,” expressed a healthcare professional living with prediabetes and dyslipidemia, who had enthusiastically followed the studies’ results.

In 2022, POC was authorized in private pharmacies throughout Brazil. Although it was an important progress, to date, still very few people are aware of and using this service, and many cannot afford it. On the other hand, when incorporated into the public health system (SUS) in Brazil, such as in Vitória da Conquista, POC exams are free. An additional possibility would be adding the POC exams available in private pharmacies to the MoH's “Popular Pharmacy” program, as done for several of the essential medicines for NCCs and other diseases and conditions. ⁹ This means that with a prescription, the individual can obtain the medicine for free in private pharmacies, which are compensated by the MoH.

Without accessible POC exams, it will be challenging to obtain the necessary information for therapeutic adjustments, hindering efforts to bring biomarkers to target and improve health outcomes. People living with diabetes often face barriers such as the distance to healthcare facilities, costs, and the time-consuming process of getting lab results. “It's not just about having the technology; it's about making sure it's accessible to everyone. People living with NCCs want easier access. A barrier to this negatively impacts their engagement,” noted a PHC provider.

Beyond HbA1c, POC devices have the potential to revolutionize the management of other conditions such as dyslipidemia and CKD. POC devices for lipid profiles can provide immediate cholesterol and triglyceride levels, allowing timely interventions to reduce cardiovascular risk. Similarly, POC devices for kidney function provide real-time measurements of creatinine and estimated glomerular filtration rate, facilitating early detection and management of CKD. ¹⁰ “Having access to immediate results for my cholesterol levels has been a game-changer in managing my heart health,” a woman living with dyslipidemia in São Paulo, who utilizes a private pharmacy for her POC exams, shared.

Practical Recommendations

To address the challenges and enhance people-centered care, the following recommendations can be made:

Increase accessibility: Ensure that POC devices are widely available across Brazil, particularly in underserved areas, by addressing logistical and systemic barriers.

Integrate and expand POC in National Programs: Implement POC technology in national health programs across the country, including devices for key biomarkers such as HbA1c, lipid profiles, and kidney function to provide comprehensive care for people living with NCCs.

Education and training: Provide comprehensive education and training for healthcare professionals and people living with NCCs on the use and interpretation of POC results.

Community support: Foster community networks where individuals can share experiences, support each other, and encourage adherence to treatment plans.

Conclusion

Integrating POC into PHC is not just advantageous; it is essential for changing the current scenario of undiagnosed, unmonitored, and uncontrolled NCCs. By advocating for early diagnosis and continuous monitoring, we can reduce undiagnosed cases, enhance people's engagement, and build a stronger healthcare system. Collaborative efforts between individuals, healthcare providers, and policymakers are essential to creating a more inclusive and effective healthcare system for managing diabetes and other NCCs. This will ultimately improve health outcomes and alleviate the burden of NCCs in Brazil and other LMICs, helping these countries to achieve the United Nations’ Sustainable Development Goal 3.4: “by 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being.”