Today, about 135 million people around the world have diabetes. According to the World Health Organisation (WHO), ten years from now the number will have grown to more than 200 million. Furthermore, it is estimated that approximately 70% of people with diabetes worldwide are not in full compliance with the guidelines for managing their disease. This causes complications and unnecessary suffering.

An estimated 80% of a given country's health care budget for diabetes is spent on people who have been admitted to hospital in order to treat complications. The million dollar question is, if this money is being spent in the right way to fight the burden of diabetes. This question is especially pertinent in countries with a limited budget for national health. Instead, could it be possible to develop an approach that saves both suffering and money in the long run?

Novo Nordisk's disease management concept builds on the idea that educating people with diabetes about their disease will help them control it and avoid many complications. Gaining control over the disease is a difficult process which often involves a change of lifestyle, namely diet and physical fitness. However, the benefits are well worth the efforts.

Dual purpose
The Novo Nordisk approach stresses prevention of complications in preference to treatment alone. The aim is to reduce the need for hospitalisation by preventing complications.

There is of course a marketing purpose as well. Our disease management activities aim to strengthen the partnership with local officials and doctors, thereby creating a preference for Novo Nordisk's products and services. Our approach therefore combines two goals: it is not only better for business but also for society, which adds up to a sustainable solution.

The Bulgarian Education Project
The Bulgarian Education Project is an example of how Novo Nordisk works with disease management in practice. The programme aims at enhancing the education of people with diabetes in Bulgaria. Approximately 175,000 people in Bulgaria have diabetes, and the number is increasing. Historically, the Bulgarian health system has focused primarily on treatment and not prevention.

In early 1997, it was decided to carry out a joint project between the Danish Ministry of Foreign Affairs, the Bulgarian Ministry of Health and Novo Nordisk. We have great expertise on diabetes and this is a good example of a mutually beneficial partnership between a private company and government authorities. Novo Nordisk manages the project and contributes a team of experts who will spend 3.5 man-years on the project.

"We have an agreement with the Novo Nordisk company that the education is not to be used for commercial sales and they will not advertise their products in our sessions. We supply patients with all the products available in Bulgaria for the treatment of diabetes, not only Novo Nordisk's. At the moment, we have a very severe economic crisis and we need some help from rich countries. We rely on them. If the health system breaks down, there will be nothing for the people or for the companies."
Dragomir Koev, professor of endocrinology at the Medical University of Sofia in Bulgaria, is one of the driving forces behind this project as president of the Bulgarian Society of Endocrinology and a member of the Expert Committee on Endocrinology at the Bulgarian Ministry of Health.

Education on three levels
The strategy is a top-down approach beginning with the training of 30 diabetes specialists and nurses as tutors. They received training and discussed educational strategies at Novo Nordisk´s Steno Diabetes Center in Copenhagen. When they returned home, their job was to educate about 200 endocrinologists and nurses who were responsible for educating people with diabetes. By the end of 1998, the specialists had educated 186 doctors and nurses all over Bulgaria and 56 local and university hospital education centres had been set up (12 more than planned). At these centres, people with diabetes are trained in taking charge of their disease.

Helping people to help themselves
For many Bulgarians with diabetes, the training approach has changed their perception of life with a chronic disease. Traditionally, the disease has been considered the doctor's responsibility. This can lead to information being kept from the patients since the treatment is 'in the hands of the doctor'.

With their new-found knowledge on maintaining a balance between diet, exercise and insulin, patients are now in direct control of the disease. They take responsibility for managing the normal physical problems such as hypoglycaemia (low blood sugar levels) related to the disease without seeking the help of a doctor. For many, this has transformed their picture of themselves from being a patient with diabetes to a person with diabetes.

Results
By the end of 1998, 11,000 people with diabetes had attended courses in one of the 56 centres all over Bulgaria. Most patients benefited from the courses in a number of ways: fewer physical complications and a better social life as the diet no longer prescribes special foods and drinks. However, some patients have declined the offer of education for various reasons.

Exact information on whether the programme has significantly reduced complications and hospital costs, and improved the patients' quality of life, will be compiled. However, preliminary results on acute complications are available from 25 hospitals. These hospitals had an almost constant number of admissions for complications due to diabetes from 1990­97 but there was a sharp decline in 1998. Patients with hypoglycaemia decreased by about 50% and patients with ketoacidosis (a dangerously low blood pH) decreased by 30%. This is thought to be a direct result of the education programme which gave first priority to patients most at risk. These people can now spend more time at home and at work. The average stay in hospital for complications is 15­20 days in Bulgaria so savings in hospital costs can be expected.

The Bulgarian Education Project has served as a model for similar projects in other countries, for example Poland and Russia.