Sub-Saharan Africa (SSA) faces multifaceted challenge of infectious diseases & diseases of poverty

Cape Town, South Africa | Rapid demographic, socio-cultural, and economic transitions coupled with the health systems in SSA that cannot cope with the high burden if infectious diseases are some of the underlying factors that increase the risks and prevalence of diabetes and other non-communicable diseases on the African continent. 

Estimates drawn from a report by the Lancet Diabetes & Endocrinology Commission on diabetes in Sub-Saharan Africa show that only half of the people living with diabetes are diagnosed and only 11% of those who are diagnosed are successfully retained throughout the cascade of care for the disease.  In South Africa, only 68% of total individuals with diabetes have their glucose measured and are diagnosed, and 32% of diabetic people who die are not aware that they were living with the disease.

“If patients are not diagnosed and made aware of their condition, such as being diabetic, they lack fundamental information to make lifestyle decisions on how to manage their conditions when away from the healthcare provider”, says Andre Kengne M.D, commission author and Unit Director for the South African Medical Research Council’s Non-communicable Diseases Research Unit.  “Diagnosis determines the next step for care and treatment”, concludes Kengne.

In recent years, urbanisation, changing lifestyle and eating habits as well as sedentary work practices for populations across SSA countries have led to increased risk of type 2 diabetes. According to the report, South Africa, which has the highest rate of overweight and obesity in SSA with more than 70% of women being overweight, is amongst the top five countries burdened by diabetes.  Lifestyle patterns, that increase the risk of being diagnosed type 2 diabetic, ultimately place significant strain on the health care system when patients are taken into care, and if unchecked, will leave many sufferers with substantial morbidity and mortality.   

Five key messages were outlined by the Commission who were charged with the duty to ascertain the current burden of the disease, its risk factors in the region, assess health system challenges in dealing with the burden, and suggest potential solutions. 

1. The true burden of diabetes (of all types), other cardiovascular risk factors, and macro and microvascular outcomes in SSA is unknown.
   Estimates from those regions in countries where high-quality data are available suggest that the rise in prevalence of diabetes, other cardiovascular risk factors, and adverse outcomes cardiovascular disease is large and expected to further increase. However, most countries lack data and data collection systems that are reliable enough to enable a commensurate health system response to be mounted.
2. Diabetes and its consequences are costly to patients and economies.
   The Commission estimated that in 2015, the overall costs of diabetes in the region was $19.45 billion or 1.2% of cumulative GDP. Around 55.6% ($10.81 billion) of this arose from direct costs with out-of-pocket expenditures likely to exceed 50% of overall health expenditures in many countries. It estimated that the total cost will increase to between $35.33 billion (1.1% of GDP) and $59.32 billion (1.8% of GDP) by 2030. Putting in place systems to prevent, detect, and manage hyperglycaemia and its consequences is therefore warranted from a health economics point of view.
3. Health systems in countries in SSA are unable to deal with the current burden of diabetes and its complications.
   Using information from the WHO Service Availability Readiness Assessment surveys, World Bank Service Delivery Indicator surveys, and the local knowledge of Commissioners, the Commission found inadequacies at all levels of the health system which would be required to provide adequate management for diabetes, associated risk factors, and sequelae.  Inadequate availability of simple equipment for diagnosis and monitoring, a lack of sufficiently knowledgeable health care providers, insufficient availability of treatments, a dearth of locally appropriate guidelines, and next-to-no disease registries were noted. This results in a substantial drop-off of patients along the diabetes care cascade with the largest proportion of patients going undiagnosed and those who are diagnosed not receiving advice and the medication they need.
4. At the current time, scarce health-care resources should be focused on managing diabetes and other risk factors with a view to prevent complications.
   Managing diabetes and its fellow risk factors is relatively simple and inexpensive. Treating complications, however is costly, requiring providers with a high level of skill and specialised equipment. Preventing complications is therefore crucial. To allow this to happen effectively, de-centralisation in care – from experts working in hospitals to Community Health Workers and other non-clinical providers working in the primary care system  and delivering home-based screening and care - needs to be accelerated. Simple and effective information technology solutions should be utilised to enable more locally delivered care.
5. There needs to be more evidence on the benefits and risks (to both individuals and health system’s ability to provide care) of screening before programs are rolled out across Africa.
   The benefits of screening, especially in people who are deemed to be at high risk, seem obvious – earlier detection and management of diabetes and its risk factors and prevention of costly complications. However, as yet, there is no evidence – at least from high income countries, where studies have been done - that screening programs are effective at reducing adverse outcomes. Additionally, the thresholds for diagnosing diabetes (i.e.: the level of glycaemia that is associated with risk of adverse outcomes in the long term) and the best test to use are not defined for populations living in Africa. Hence any screening program that is started should only be done as part of a rigorous longitudinal outcomes study that also compares differing tests for diagnosis of hyperglycaemia.

“This report must influence a concerted effort and inform a responsive strategy by policy makers, funding agencies and researchers to afford people with diabetes in Sub-Saharan Africa with a better quality of life”, says commission author and Head of Division of Diabetic Medicine and Endocrinology at Groote Schuur Hospital Professor Naomi Levitt.