1. Obstacles of optimum care for diabetic children in Palestine Prepared by Dr.Intisar Al-Alem November 2008

2. What is Type 1 DM ? Type 1 DM (T1DM) is used to denote childhood diabetes associated with autoimmunity and absolute insulin deficiency Type 1 diabetes is a condition in which the pancreas makes so little insulin that the body can't use blood sugar for energy Type 1 diabetes must be controlled with daily insulin shots

3. Management of Diabetic Children Diabetic children should be offered an ongoing integrated package of care by a multidisciplinary paediatric diabetes care team (optimum care & reduction of complications) Diabetic children and their families should be offered 24-hour access to advice from the diabetes care team.

4. Epidemiology of Type 1 DM Globally, about 500,000 children under the age of 15 with T1DM Every day 200 children develop T1DM Every year, 70,000 children under the age of 15 develop T1DM T1DM is increasing in children at a rate of 3% each year T1DM is increasing fastest in pre-school children, at rate of 5% per year In Palestine until now we havnt true statistics

5. Diabetic children in government PHC diabetic clinics, West Bank (2006) Total number of diabeticsType1 diabetics ALKhaleil3187282 Nablus4288197 Jenin4381250 Ramallah1140137 Bethlehem1198193 Tulkarm1672128 Al-Quds76636 Qalqiliah116049 Salfit86236 Jericho57034

6. Distribution of reported new registered cases of diabetic children in government PHC diabetic clinics, West Bank 2007 Age group 0-44-140-14 SexMFMFMF West Bank4432243628 ALKhaleil014344 Nablus115465 Jenin126577 Ramallah108191 Bethlehem101222 Tulkarm003535

7. Distribution of reported new registered cases of diabetic children in government PHC diabetic clinics, West Bank 2007 Age group 0-44-140-14 SexMFMFMF Al-Quds002020 Qalqiliah000202 Salfit001010 Jericho002222 Population in West Bank 194029198119330938326970524967525089 Incidence rate (per 100,000) 2.12.09.77.36.95.3

8. Diabetic clinics in Palestine Specialized diabetic clinics began in 1987 now there are 10 clinics one in each district & also many small clinics in villages (4 in Nablus, 9 in Jenin & 4 in Hebron) which are operating according to an organized program These clinics provide medical services for about 20000 diabetic patients in the west bank There is coordination between central clinic in the city,those in the villages & also between diabetic clinic & governmental hospitals. Diabetic children are followed-up with other diabetics

9. Obstacles of optimum care for diabetic children in Palestine Political Obstacles National Obstacles Obstacles (MOH) Psychosocial obstacles

10. Political Obstacles Lack of communication between Gaza &west bank Siege &check points make access to clinics difficult, especially for those who are living in far areas Economic problems

11. National Obstacles Lack of cooperation & coordinated between health providers Lack of national treatment guidelines Shortage of human and financial resources Lack of important specialists Lack of screening and early detection activities There is no statistical information and studies to estimate the real side of the problem

12. Obstacles (MOH): Until now there are no specialized clinics for care of diabetic children in MOH & those patients are followed-up among others Shortage of well trained medical staff who provide care for diabetic children Lack of some important specialties pediatric endocrinologists, vascular surgeons, ophthalmologists, podiatrists, chiropodists, health educators and dieticians Trained physicians &nurses are not enough for this number of patients. Because of work over load there is no enough time or space to provide appropriate health care or education

13. Obstacles (MOH): Lack of materials, drugs and equipments necessary for proper management Lack of Guidelines &protocols for management of diabetic children Lack of educational & entertainment programs Because of the lack of home visiting program, disabled patients deprived from proper health care, also follow-up after hospital discharge is lacking.

14. Psychosocial obstacles Financial barriers (healthy food, gluco-strips, clinic visits) Denial & non-adherence to therapy (insulin injections, snacks, home monitoring, diet, exercise &regular visits to clinic) Stigma like delay in marriage or reduced job opportunities Lack of knowledge (family & school members)

15. Suggestion for optimum care of diabetic children Establishment of special clinic Training of physicians &nurses externally &locally Training of new important specialties Development &implementation of guidelines &protocols Continuous education programs for patients & their relatives (families &teachers)