Limited Access to Diabetes Technology and Care Results in Worse Outcomes for Children

Substantial disparities exist in the accessibility and reimbursement of diabetes technology and insulin for children with type 1 diabetes (T1D) across continents and countries of residence, leading to frequent poor outcomes and failure to achieve HbA1c goals.1

This study was an extension of the SWEET initiative, which was created as a method of benchmarking and networking between large pediatric diabetes care centers. In support of SWEET’s mission of harmonizing care to optimize outcomes of children with T1D, 2 prior versions of this study were conducted in 2009 and 2017, respectively.2

The previous SWEET projects were limited in both scope and scale, as they gathered data only prior to the HCL era and did not address the association of accessibility to technologies with glycemic outcomes. Additionally, both projects only mapped the reimbursement status of Europe.1

“Therefore, we aimed to build on these data by describing the global accessibility and reimbursement of diabetes technologies and insulin for children with T1D in countries actively participating in the SWEET initiative and to compare these data with glycemic control as measured by glycated hemoglobin (HbA1c) levels using the data from the SWEET registry,” Alzbeta Santova, MD, department of pediatrics, Motol University Hospital and Second Faculty of Medicine, Prague, and colleagues wrote.1

This version of the SWEET study was conducted via a digital questionnaire sent to representatives of all SWEET-affiliated centers. Representatives described the accessibility of continuous glucose monitoring (CGM), continuous subcutaneous insulin infusion (CSII) with and without hybrid closed loop (HCL) functionality, personal glucometers (including blood glucose reagent strips), and insulin. Categorized data for reimbursement of all items were then compared with HbA1c levels using the SWEET dataset.1

The study ran from March 1 to May 31, 2024. Once the questionnaires were returned, investigators separated each country or region into 4 main groups for technology and insulin. The groups were as follows:

• Full reimbursement: fully covered by employers and/or the government
• Limited reimbursement: copayments or geographical-, age-, and/or insurance-dependent differences within the country limiting indication criteria
• Out-of-pocket payment: no reimbursement, but possible to purchase the device or insulin
• Supported by sponsors/no availability: no reimbursement, but unrestricted access to the technology and/or insulin is ensured through foundations or other sources, or no availability at all1

Investigators received 81 responses from 56 countries representing 88% of SWEET countries. HbA1c data from 42,349 children with T1D from these centers were available for analysis.1

Overall, CGM availability and reimbursement were most homogeneous in Europe, which reported full coverage in 24 out of 26 responding countries. Heterogeneity was high in Asia, Latin America, and North America, with limited reimbursement being the most common. 4 out of 6 countries in Africa reported no availability.1

Insulin pumps were fully covered in 19 of 26 European countries, with the remaining 7 noting copayments for CSII, insulin supplies, or other limitations. North America reported a heterogeneous situation, while Latin America reported limited reimbursement and out-of-pocket payments. Asian countries primarily reported out-of-pocket payments as well.1

Most of Europe reported full reimbursement for glucometers, while Asia, Latin America, and North America reported variable reimbursement. 3 of 6 African countries reported full reimbursement. Insulin was also fully reimbursed in all participating European countries and several Asian countries and was most frequent in North America and Latin America.1

Substantial differences in HbA1c levels were observed among the 4 categories of reimbursement in all technologies. Full reimbursement saw the lowest, while the highest was recorded in centers where the technology was not available. The target HbA1c level of <6.5% was reached by 18.7% and 19.1% of children with T1D who had full access to CGM and CSII, respectively. Centers with limited reimbursement saw 9.2% and 10.5% of children achieve the target, while those in the out-of-pocket group had 8.4% and 5.0%, and the no availability group saw 7.8% and 5.1%.1

“This stark disparity underscores the urgent need for collective action,” Santova and colleagues wrote. "These data serve as a call to accelerate ongoing initiatives and inspire new, innovative solutions aimed at closing these gaps. Only by addressing these inequities can we ensure that every child with diabetes, regardless of their geographic or socioeconomic status, has the same opportunity in diabetes care and diabetes outcome.”1

References

1. Santova A, de Bock M, Lanzinger S, et al. Global Inequities in Diabetes Technology and Insulin Access and Glycemic Outcomes. JAMA Netw Open. 2025;8(8):e2528933. doi:10.1001/jamanetworkopen.2025.28933

2. Saiyed M, Hasnani D, Alonso GT, et al. Worldwide differences in childhood type 1 diabetes: The SWEET experience. Pediatr Diabetes. 2021;22(2):207-214. doi:10.1111/pedi.13137