Review: Strengthening Diabetes Care in Humanitarian Crises in Low- and Middle-income Countries

Woman using syringe to extract insulin from bottle, diabetes care concept

81% of people living with diabetes live in lower- and middle-income countries (LMICs), which also host more than 80% of forcibly displaced persons—refugees and people displaced within their own country. Record-high levels of population displacements are occurring because of armed conflict and other violence, extreme weather events, and climate change.

In The Journal of Clinical Endocrinology & Metabolism, Sylvia Kehlenbrink, MD, an endocrinologist and director of Global Endocrinology at Brigham and Women’s Hospital, and colleagues outline challenges and possible solutions for providing diabetes care during acute and prolonged humanitarian crises.

Operational Objectives

From a scoping literature review, the reviewers identified three key stepwise objectives:

  • Planning for service interruptions using agile logistical systems to ensure uninterrupted treatment, especially ensuring a reliable supply of life-preserving medications and diagnostics
  • Building health worker and patient capacity to restore and maintain access to care during insecurity, particularly through primary care centers at the community level
  • Adapting models of service delivery that can be integrated into existing health systems when possible

The review details the specific challenges and potential solutions to attaining each of these objectives, which are summarized in a table.

Case Studies

The scope of providing diabetes care in a humanitarian crisis is extremely varied and depends partly on the phase of what can be a very long-term crisis. To illustrate, the authors present three brief case studies.

Mali and Ukraine—Ensuring supplies

In March 2012, a military coup in Mali was followed by the occupation of the country’s northern regions by a rebel group and an ongoing civil war. The migration of people from the occupied region soon overwhelmed health systems in the southern region.

At the time, emergency response plans of most humanitarian agencies omitted noncommunicable diseases. Santé Diabète, an international nongovernment organization with an established presence in Mali, worked with the government, individual specialists, and the World Health Organization (WHO) to evacuate children with type 1 diabetes from the northern regions. Between April 2012 and December 2013, all evacuated children survived.

The collaboration also provided supplies in the northern regions, including kits for treating hyperglycemic emergencies and diabetic foot, and provided diabetes care to displaced people in the southern regions. The kits served as the basis for the development of the WHO noncommunicable diseases emergency health kit.

In contrast, after the 2022 Russian invasion of Ukraine, the continuity of insulin and diabetes medications has been a high priority for WHO and humanitarian implementing agencies. The international community donated large quantities of medications and diagnostic supplies. Unfortunately, distributing them has been a major logistical challenge, given staff shortages and Russia’s direct attacks on medical facilities and supply routes.

The Ministry of Health and the WHO are working with pharmaceutical companies and professional associations to resolve this problem. A Ministry of Health hotline provides callers with information on where they can obtain insulin.

The use of donations means clinicians and patients have had to adapt rapidly to using unfamiliar insulins. A switching guide is now available in Ukrainian, Russian, and the languages of the surrounding countries.

Central African Republic—Improving access to care in protracted crises

The Central African Republic has been affected by civil war since 2012. Insecurity on the roads and the occasional looting of health facilities can lead to months-long interruptions in care.

In 2018, Médecins Sans Frontières provided funding and training for people living with HIV to establish community groups. These groups were trained to self-manage care at home and maintain phone access to healthcare professionals. Each group assigned one physically able volunteer to collect antiretroviral medication for the group. When access to a specific facility was interrupted, the pick-up location could be switched to another location.

Over time, group members advocated for medications for non-communicable diseases, such as diabetes, to be included. Among 3,000 people currently active in 45 community groups, access to medications has been interrupted for less than two months since 2018. However, insulin and consumables, including testing strips, are not yet included in this program.

Jordan—Integrating humanitarian programs into the health system

Before the Syrian war, diabetes care in Jordan was provided in secondary health facilities. When a huge influx of refugees threatened to overwhelm those facilities, the Ministry of Health rapidly decentralized care into the primary care setting, supported by local and international nongovernment organizations. This required substantial investment in training primary care clinicians and recruiting health promotion/patient education practitioners.


The WHO and other agencies are evaluating how health services and systems can support people living with diabetes and other noncommunicable diseases in humanitarian crises. The war in Ukraine and other ongoing crises highlight the urgency of this work and the need to scale-up investment.

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