title: Diabetes, its treatment, and catastrophic medical spending in 35 developing countries.
abstract: OBJECTIVE
  To assess the individual financial impact of having diabetes in developing countries, whether diabetic individuals possess appropriate medications, and the extent to which health insurance may protect diabetic individuals by increasing medication possession or decreasing the risk of catastrophic spending.
  
  
  METHODS
  Using 2002-2003 World Health Survey data (n = 121,051 individuals; 35 low- and middle-income countries), we examined possession of medications to treat diabetes and estimated the relationship between out-of-pocket medical spending (2005 international dollars), catastrophic medical spending, and diabetes. We assessed whether health insurance modified these relationships.
  
  
  RESULTS
  Diabetic individuals experience differentially higher out-of-pocket medical spending, particularly among individuals with high levels of spending (excess spending of $157 per year [95% CI 130-184] at the 95th percentile), and a greater chance of incurring catastrophic medical spending (17.8 vs. 13.9%; difference 3.9% [95% CI 0.2-7.7]) compared with otherwise similar individuals without diabetes. Diabetic individuals with insurance do not have significantly lower risks of catastrophic medical spending (18.6 vs. 17.7%; difference not significant), nor were they significantly more likely to possess diabetes medications (22.8 vs. 20.6%; difference not significant) than those who were otherwise similar but without insurance. These effects were more pronounced and significant in lower-income countries.
  
  
  CONCLUSIONS
  In low-income countries, despite insurance, diabetic individuals are more likely to experience catastrophic medical spending and often do not possess appropriate medications to treat diabetes. Research into why policies in these countries may not adequately protect people from catastrophic spending or enhance possession of critical medications is urgently needed.
authors.affiliation: Palo Alto Veterans Affairs Healthcare System, Palo Alto, California, USA. csmithsp@stanford.edu
authors.forename: Crystal M
authors.initials: CM
authors.lastname: Smith-Spangler
authors.forename: Jay
authors.initials: J
authors.lastname: Bhattacharya
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Goldhaber-Fiebert
mesh_terms: D000328:Adult; D003906:Developing Countries / Q000706:statistics & numerical data; D003920:Diabetes Mellitus / Q000191:economics*; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D055815:Young Adult