Click here to read part 1 of this discussion paper.

In 2000, the prevalence of diabetes mellitus (DM) in the World Health Organisation (WHO) African region was estimated at 7.02 million people, the majority of whom had type 2 diabetes mellitus (T2DM). In the same year, about 113,100 people died from diabetes-related causes, 561,600 were permanently disabled, and 6,458,400 experienced temporary disablement.⁽²⁾ Diabetes in Africa is associated with high complication rates.⁽³⁾ Moreover, the total economic cost of DM in the WHO’s Africa region in 2000 was Int$ 25.51 billion (US$ 67.03 billion); it was also estimated that the direct cost of treating diabetes in 2000 ranged from Int$ 876 (US$ 2302) to Int$ 1220.6 (US$ 3207) per person.⁽⁴⁾ By all accounts, diabetes in Sub-Saharan Africa is a serious public health concern that cannot be ignored.

This paper, part 2 of a two-part series, discusses the barriers to diabetes care in Sub-Saharan Africa and offers solutions towards improving diabetes care for African patients.

Barriers to diabetes care in Africa

Health systems in Africa are more oriented towards treating acute, short-term diseases and infections, rather than chronic diseases.⁽⁵⁾ Healthcare systems on the continent are already overburdened by HIV/AIDS, tuberculosis and malaria. In this context, non-communicable diseases (NCDs), including diabetes, which are low on the list of priorities,⁽⁶⁾ are in competition with infectious diseases for already scarce resources. Two thirds of people with DM in low- and middle-income countries have poor diabetes control because of inadequate access to care.⁽⁷⁾ In some African countries, only 15% of the population have the privilege of accessing diabetes care, 35% of diabetics experience difficulties in accessing care, and 50% have never been diagnosed.⁽⁸⁾

Very few assessments of healthcare services for diabetes have been conducted over the years. Whiting et al. reviewed assessments which, for the most part, took place in South Africa.⁽⁹⁾ The following key findings were highlighted:⁽¹⁰⁾

• Poor patient attendance – on average, the number of visits to a healthcare facility for patient care among the diabetic population in Sub-Saharan Africa is low, and usually occurs only when complications occur.⁽¹¹⁾
• Very short consultation times, resulting in little or no time for patient education, which is almost non-existent;
• Staff shortages and limited training opportunities for existing staff – some studies have shown that the lack of proper training of health professionals accounts for high rates of non-compliance by patients and, consequently, serious complications; adequately trained and motivated personnel hold the key to providing continuing care and follow-up of patients.⁽¹²⁾ In addition, low levels of knowledge about diabetes from healthcare workers leads to patients having poor understanding of their condition;⁽¹³⁾
• Very poor blood glucose and blood pressure control;
• Lack of systematic monitoring and evaluation of diabetes-related complications;
• Poor organisation of services;
• Inadequate referral systems;
• Poor record keeping, which is crucial for the follow-up of chronic patients such as diabetics;
• Unequal distribution of health services as well as limited access to healthcare facilities due to the concentration of diabetic healthcare in large urban hospitals.⁽¹⁴⁾

Furthermore, other relevant issues that can be identified in the literature that determine access to diabetes care are as follows:

At the patient/community level

• Economic factors are important obstacles to diabetes care – patients often have to pay for medical care, sometimes driving the household to poverty.⁽¹⁵⁾ For instance, in Bamako (Mali), average monthly expenditure on diabetes care for a person with DM is estimated at US$ 21.24, representing nearly 70% of the patient’s income.⁽¹⁶⁾ In most parts of the continent, owning a glucometer is a luxury that very few patients can afford.⁽¹⁷⁾
• Low-levels of self-management practices;⁽¹⁸⁾
• Lack of adherence to medication and suggested lifestyle changes (exercise, healthy diet);⁽¹⁹⁾
• Lack of faith in the biomedical model:⁽²⁰⁾ African diabetes patients, especially those from rural areas, either rely solely on traditional healers for diabetes care, or use both traditional and medical treatments.⁽²¹⁾ In addition, traditional healers who claim that diabetes is curable have been found to be reluctant to refer clients to medical practitioners.⁽²²⁾
• Cultural and traditional beliefs: The perception of obesity as a sign of wealth hinders patients adopting healthy lifestyles.⁽²³⁾

At the national level (health systems)

• Lack of organisational structure for chronic disease care;⁽²⁴⁾
• Scarcity of information about disease burden and management;⁽²⁵⁾
• Inadequate financing;⁽²⁶⁾
• Lack of national guidelines and policies for diabetes care;⁽²⁷⁾
• National diabetes programmes are non-existent in most countries;⁽²⁸⁾
• Unavailability (or irregular availability) and unaffordability of medication, especially insulin, as well as problems with the supply and distribution of medication;⁽²⁹⁾
• Limited availability of diagnostic tools for diabetes such as diagnostic reagents,⁽³⁰⁾ lack of functioning equipment for routine glucose monitoring (e.g., glucometers);⁽³¹⁾
• Few education/training programmes for both patients and staff;⁽³²⁾ and
• Lack of follow-up of diabetic patients.⁽³³⁾

Solutions to the diabetes epidemic in Africa

A successful response to the diabetes epidemic in Sub-Saharan Africa requires an integrated approach, involving not only the patient but also his/her family and community. International funding agencies, governments and companies should all contribute toward curbing the epidemic. The following is part of the 11-point action plan proposed by Beran and Yudkin to improve diabetes care in Sub-Saharan Africa:⁽³⁴⁾

Health system organisation, data collection and diabetes prevention: Similarities exist between chronic diseases such as DM and hypertension, and infectious diseases like HIV/AIDS and tuberculosis. These conditions all require diagnostic tools, trained personnel who are able to initiate and adapt treatment for a life-long condition, a referral system for the management of complex regimens or complications, and an effective system ensuring a regular supply of medicines. The prevention of diabetes is necessary in order to avoid the costs that are associated with DM complications. Systematic recording, analysis and dissemination of data covering mortality rates, morbidity and risk factors, are keys to effective care planning. Patient registers are also useful for organising patient and population data.

Diagnostic aids and medication: Perennial availability of medicines plays a crucial role in the provision of health care for chronic diseases such as DM. Reliable health and supply systems, sustainable financing, affordable pricing, and rational use of available resources are all necessary to facilitate patients’ access to medicines, further enhanced by improved tendering or pooled procurement aimed at minimising costs. Treatment for diabetes care should be accessible at public facilities free of charge, or at subsidised prices where feasible.

Healthcare workers: Healthcare workers need to coordinate treatment, educate patients in self-care, and play an active role in prevention by, for instance, encouraging patients to adopt healthy lifestyles. Training programmes with appropriately developed guidelines and protocols should be rolled out to improve healthcare workers’ knowledge.

Patient adherence, education and empowerment: Multilingual, culturally sensitive education material must be available and accessible for patients, especially children and illiterate patients. Education should ideally focus on prevention and treatment.

Community involvement and diabetes associations: Traditional healers need to be integrated into the formal system of care and trained in appropriate referral to the formal health sector. Furthermore, diabetes associations can play a vital role in advocacy as well as improving patterns of care. World Diabetes Day, celebrated on 14 November, offers a good opportunity to raise diabetes awareness among communities.

Positive policy environment: There is a need for a policy framework that incorporates prevention, organisation of care, import duties on medicines and supplies, subsidies for medicines and care, education, disease monitoring, and allocation of appropriate resources. Multilateral donors need to recognise and respond to the growing burden of NCDs, including DM, in developing countries.

Success stories and opportunities in Africa

Some commendable initiatives have already been launched in response to the rising burden of DM in Africa. Often, countries have benefitted from the support of organisations such as the International Diabetes Federation (IDF), the WHO or the World Diabetes Foundation.

In Tanzania, the Tanzania Diabetes Association established a network of diabetes clinics throughout the country with the support of the Ministry of Health. These clinics provide access to affordable treatment and health education to diabetic patients. Consultations, tests and insulin are free for the poorest patients.⁽³⁵⁾ In addition, a community and school outreach programme was implemented to improve diabetes prevention by integrating schools, communities and health facilities in diabetes prevention.⁽³⁶⁾

In Kenya, a diabetes education programme improved the understanding of diabetes among healthcare staff and created public awareness on diabetes prevention, control and risk factors.⁽³⁷⁾ In 2010, Kenya launched the first national diabetes strategy on the African continent after years of dedicated work by various stakeholders.⁽³⁸⁾

In Mali, the World Diabetes Foundation has provided information about diabetes and its risk factors to the general population, along with extra training in diabetes awareness and diagnosis to diabetes and nutrition educators and to healthcare professionals.

In Mozambique, as a result of a twinning initiative between Diabetes UK and the Mozambique Diabetes Association, the first comprehensive plan in Sub-Saharan Africa to address NCDs was developed. The collaboration included extra training in diabetes care for healthcare workers, the development of appropriate materials for patient education drawing from some Diabetes UK tools, as well as public awareness events in commemoration of World Diabetes Day.⁽³⁹⁾

Cameroon developed a national diabetes programme, which came into operation during 2005-2006. The programme, which was developed by the Cameroon Health of Population in Transition Research Group together with the World Diabetes Foundation, is based on solid evidence provided by the Cameroon Burden of Diabetes project.⁽⁴⁰⁾

In some countries like Ethiopia, South Africa, Swaziland and Tanzania, existing resources, systems and health facilities are scaled up to include services for the detection and treatment of diabetes and other NCDs. For instance, in South Africa, the HIV Counselling and Testing programme offers measurement of blood sugar and blood pressure at the same time as symptomatic TB screening.⁽⁴¹⁾

Novo Nordisk, a global healthcare company, has established an equity pricing initiative, offering insulin to public health systems in the 50 poorest countries at prices not exceeding 20% of the average price in North America, Europe and Japan. As a result, the price of insulin in Mozambique has dropped by about 50%.⁽⁴²⁾

In 2006, the African Diabetes Declaration, developed by IDF Africa, in partnership with the WHO Regional Office for Africa (WHO-AFRO) and the African Union, called on African governments, non-governmental organisations (NGOs), international donor agencies, industry, healthcare providers and all partners and stakeholders in diabetes to ensure access to quality and affordable services for the prevention and care of diabetes. Concurrently, IDF Africa launched the development of clinical practice guidelines and an education manual for health workers specifically for the region.⁽⁴³⁾

The above initiatives are examples of good practices that can inspire other countries in Africa to tackle the diabetes epidemic with tailor-made and innovative strategies using resources that are already available.

Concluding remarks

In Africa, lifestyle diseases like diabetes are spreading at a rapid pace, posing major public health concerns with devastating social and economic consequences. Dr Aaron Motsoaledi, South Africa’s Minister of Health, said: “Let us also join hands in launching a concerted campaign against non-communicable diseases. If we fail in doing this, there is every chance that our nation will be robbed of its future.”⁽⁴⁴⁾ This call for action should resonate in all spheres of society and propel a multi-dimensional response.

Although an effective response to the diabetes epidemic in Africa requires a complete reorganisation of health systems, along with diabetes training for health workers, the focus should be on primary prevention, addressing obesity through the promotion of weight loss, a healthy diet and physical activity. Targeted screening, prevention, adequate management of complications, and the provision of insulin, are also strategies to be considered. Despite the launch of several initiatives, there is still a lot to be done to ensure that the people of Africa do not suffer the consequences of DM any further.

Click here to read part 1 of this discussion paper.

Written by Patrick Ngassa Piotie ⁽¹⁾

NOTES:

(1) Patrick Ngassa Piotie is a medical doctor, public health specialist and founder and director of Public Health Consultancy Pty Ltd. Contact Patrick through Consultancy Africa Intelligence’s Public Health Unit ( public.health@consultancyafrica.com). Edited by Liezl Stretton.
(2) Kirigia, J.M., et al., 2009. Economic burden of diabetes mellitus in the WHO African region. BMC International Health and Human Rights, 9(6).
(3) Sobngwi, E., et al., 2001. Diabetes in Africans. Part 1: Epidemiology and clinical specificities. Diabetes & Metabolism, 27, pp. 628-634; Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66.
(4) Kirigia, J.M., et al., 2009. Economic burden of diabetes mellitus in the WHO African region. BMC International Health and Human Rights, 9(6); Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564).
(5) Whiting, D.R., Hayes, L. and Unwin, N.C., 2003. Challenges for healthcare to diabetes in Africa. Journal of Cardiovascular Risk, 10, pp. 103-110.
(6) Levitt, N.S., 2008. Diabetes in Africa: Epidemiology, management and healthcare challenges. Heart, 94, pp. 1376-1382.
(7) ‘Diabetes: The hidden pandemic and its impact on Sub-Saharan Africa’, Prepared for the Diabetes Leadership Forum Africa 2010, Johannesburg, 30 September – 1 October 2010, http://www.novonordisk.com.
(8) Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108.
(9) Whiting, D.R., Hayes, L. and Unwin, N.C., 2003. Challenges for healthcare to diabetes in Africa. Journal of Cardiovascular Risk, 10, pp. 103-110.
(10) Ibid.
(11) Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108.
(12) Ibid.
(13) Beran, D., Yudkin, J.S. and De Courten, M., 2005. Access to care for patients with insulin-requiring diabetes in developing countries. Case studies of Mozambique and Zambia. Diabetes Care, 28(9), pp. 2136-2140.
(14) Motala, A.A., 2002. Diabetes trends in Africa. Diabetes Metabolism Research and Reviews, 18, pp. S14-S20; Beran, D. and Yudkin, J.S., 2006. Diabetes care in Sub-Saharan Africa. The Lancet, 368, pp. 1689-1695.
(15) Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66; Beran, D. and Yudkin, J.S., 2006. Diabetes care in Sub-Saharan Africa. The Lancet, 368, pp. 1689-1695.
(16) Beran, D. and Yudkin, J.S., 2006. Diabetes care in Sub-Saharan Africa. The Lancet, 368, pp. 1689-1695.
(17) Beran, D., Yudkin, J.S. and De Courten, M., 2005. Access to care for patients with insulin-requiring diabetes in developing countries. Case studies of Mozambique and Zambia. Diabetes Care, 28(9), pp. 2136-2140.
(18) Levitt, N.S., 2008. Diabetes in Africa: Epidemiology, management and healthcare challenges. Heart, 94, pp. 1376-1382.
(19) Ibid.
(20) Ibid.
(21) Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108; Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66; Beran, D., Yudkin, J.S. and De Courten, M., 2005. Access to care for patients with insulin-requiring diabetes in developing countries. Case studies of Mozambique and Zambia. Diabetes Care, 28(9), pp. 2136-2140; Tuei, V.C., Maiyoh, G.K. and Ha, C.E., 2010. Type 2 diabetes mellitus and obesity in Sub-Saharan Africa. Diabetes/Metabolism Research and Reviews, 26, pp. 433-445.
(22) Levitt, N.S., 2008. Diabetes in Africa: Epidemiology, management and healthcare challenges. Heart, 94, pp. 1376-1382; Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108.
(23) Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66.
(24) Gill, G.V., et al., 2009. A Sub-Saharan perspective of diabetes. Diabetologia, 52, pp. 8-16.
(25) Beran, D. and Yudkin, J.S., 2006. Diabetes care in Sub-Saharan Africa. The Lancet, 368, pp. 1689-1695.
(26) Ibid.; Kengne, A.P., Amoah, A.G.B. and Mbanya, J-C., 2005. Cardiovascular complications of diabetes mellitus in Sub-Saharan Africa. Circulation, 112, pp. 3592-3601.
(27) Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108; Levitt, N.S., 2008. Diabetes in Africa: Epidemiology, management and healthcare challenges. Heart, 94, pp. 1376-1382.
(28) ‘Diabetes: The hidden pandemic and its impact on Sub-Saharan Africa’, Prepared for the Diabetes Leadership Forum Africa 2010, Johannesburg, 30 September – 1 October 2010, http://www.novonordisk.com.
(29) Mbanya, J.C.N., et al., 2010. Diabetes in Sub-Saharan Africa. The Lancet, 375, pp. 2254-66; Beran, D., Yudkin, J.S. and De Courten, M., 2005. Access to care for patients with insulin-requiring diabetes in developing countries. Case studies of Mozambique and Zambia. Diabetes Care, 28(9), pp. 2136-2140.
(30) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564); Beran, D., Yudkin, J.S. and De Courten, M., 2005. Access to care for patients with insulin-requiring diabetes in developing countries. Case studies of Mozambique and Zambia. Diabetes Care, 28(9), pp. 2136-2140.
(31) Hall, V., et al., 2011. Diabetes in Sub-Saharan Africa 1999-2011: Epidemiology and public health implications. A systematic review. BMC Public Health, 11(564); Levitt, N.S., 2008. Diabetes in Africa: Epidemiology, management and healthcare challenges. Heart, 94, pp. 1376-1382.
(32) Motala, A.A., 2002. Diabetes trends in Africa. Diabetes Metabolism Research and Reviews, 18, pp. S14-S20.
(33) Azevedo, M. and Alla, S., 2008. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. International Journal of Diabetes in Developing Countries, 28(4), pp. 101-108.
(34) Beran, D. and Yudkin, J.S., 2006. Diabetes care in Sub-Saharan Africa. The Lancet, 368, pp. 1689-1695.
(35) ‘Diabetes: The hidden pandemic and its impact on Sub-Saharan Africa’, Prepared for the Diabetes Leadership Forum Africa 2010, Johannesburg, 30 September – 1 October 2010, http://www.novonordisk.com.
(36) Ibid.
(37) Ibid.
(38) World Diabetes Federation website, http://www.worlddiabetesfoundation.org.
(39) ‘Diabetes: The hidden pandemic and its impact on Sub-Saharan Africa’, Prepared for the Diabetes Leadership Forum Africa 2010, Johannesburg, 30 September – 1 October 2010, http://www.novonordisk.com.
(49) Ibid.
(41) Ibid.
(42) Beran, D. and Yudkin, J.S., 2006. Diabetes care in Sub-Saharan Africa. The Lancet, 368, pp. 1689-1695.
(43) ‘The diabetes strategy for Africa: An integrated strategic plan for diabetes and related health risks’, IDF Africa and WHO-AFRO, 2006, http://www.idf.org.
(44) ‘Diabetes: The hidden pandemic and its impact on Sub-Saharan Africa’, Prepared for the Diabetes Leadership Forum Africa 2010, Johannesburg, 30 September – 1 October 2010, http://www.novonordisk.com.