Health System Financing Effect on The Outcome of Diabetes Management in Low-Middle Income Countries: A Systematic Review

Abstract

Background: Diabetes continues to rise sharply in low- and middle-income countries (LMICs), where fragmented health system financing contributes to poor clinical outcomes and heightened financial vulnerability. Updated global estimates indicate that 537 million adults were living with diabetes in 2021, with 81% residing in LMICs, and the number is projected to reach 643 million by 2030 (International Diabetes Federation, 2021). Understanding how financing models influence diabetes management outcomes is critical to advancing universal health coverage (UHC). Objective: To systematically review the effect of health system financing mechanisms on diabetes management outcomes including awareness, treatment, adherence, and glycemic control in LMICs. Methods: This systematic review followed PRISMA 2020 guidelines. Searches were conducted in PubMed, Scopus and SpringerLink for studies published from 2011–2021. Eligible studies included adult populations in LMICs, examined financing models and reported diabetes management outcomes. Two independent reviewers performed screening, extraction, and quality appraisal using the Joanna Briggs Institute checklist. Results: From 1,463 records screened, 10 studies met the inclusion criteria. Most studies reported high OOP spending as a major barrier to diabetes care, contributing to catastrophic health expenditure, poor treatment adherence, and delayed diagnosis. In contrast, insurance-based and subsidized financing models were associated with better medication affordability, improved follow-up, and higher treatment uptake, though service-level constraints such as limited primary care capacity continued to impede optimal outcomes. Themes identified included (i) financial access and affordability, (ii) care continuity and treatment adherence, and (iii) system readiness and primary care availability.Conclusion: Health system financing strongly shapes diabetes management outcomes in LMICs. Heavy reliance on OOP payments undermines adherence, early diagnosis, and continuity of care, whereas pooled financing mechanisms improve access and reduce financial hardship. Sustainable, equitable financing reforms aligned with strengthened primary care systems are essential for improving diabetes outcomes in LMICs.