tag:theconversation.com,2011:/africa/topics/noncommunicable-diseases-4207/articlesNoncommunicable diseases – The Conversation2022-10-26T14:06:04Ztag:theconversation.com,2011:article/1915132022-10-26T14:06:04Z2022-10-26T14:06:04ZCOVID and health workers’ strike: how Kenya’s health services coped in times of crisis<figure><img src="https://images.theconversation.com/files/487735/original/file-20221003-20-6hjhxc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pandemic and a health workers’ strike disrupted essential health services.</span> <span class="attribution"><span class="source">Donwilson Odhiambo/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>When epidemics break out and public health emergencies are declared, people <a href="https://www.sciencedirect.com/science/article/pii/S0033350616303225?via%3Dihub">shy away</a> from seeking care for other conditions. This may seem counter-intuitive at first glance. But it makes sense. Ordinary life is disrupted, so visiting a clinic for a routine checkup becomes harder. People are afraid they’ll contract the virus or disease that’s driving the epidemic – especially in health facilities. </p>
<p>The results are predictably grim. </p>
<p>During the 2013-2014 Ebola outbreak in West Africa, the number of <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2016.00222/full">people seeking primary healthcare</a> for themselves and their children declined significantly. This resulted in an <a href="https://wwwnc.cdc.gov/eid/article/22/3/15-0977_article">increase in deaths</a> caused by malaria, HIV and tuberculosis (TB). The figures were <a href="https://www.sciencedirect.com/science/article/pii/S1473309915000614?via%3Dihub">similar to</a> – or in some cases greater than – the total number of deaths caused by the Ebola virus disease. </p>
<p>The COVID-19 pandemic appears to have followed the same worrying trajectory, at least in Kenya. We <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00285-6/fulltext">analysed</a> how the pandemic influenced the use of multiple healthcare services in the East African nation. Our study specifically aimed to assess which healthcare services were resilient to disruptions in the system and which ones were more vulnerable.</p>
<p>We collected monthly aggregates of county-level data for 17 indicators from the Kenya health information system across four periods. These were pre-pandemic (January 2018 to February 2020), two pandemic periods (March to November 2020 and February to October 2021) and the <a href="https://www.reuters.com/article/us-health-coronavirus-kenya-strike-idUSKBN28V12Q">healthcare workers’ strike</a> from December 2020 to January 2021. The indicators centred on four categories:</p>
<ul>
<li><p>outpatient visits to primary healthcare facilities </p></li>
<li><p>reproductive and child health (including antenatal care and children’s routine vaccinations) </p></li>
<li><p>sexual violence and communicable diseases (such as HIV tests conducted, and people tested for malaria and TB)</p></li>
<li><p>noncommunicable diseases (cervical cancer screening, and cases of hypertension and diabetes detected)</p></li>
</ul>
<p>We combined these data with information from Google and Facebook about human movement in Kenya during the pandemic period, as well as health ministry data about confirmed daily COVID-19 cases. We made note of curfews and other movement restrictions to ensure this was accounted for.</p>
<p>We found that the pandemic and the associated healthcare workers’ strike disrupted essential health services. Outpatient visits, screening and diagnostic services, and child immunisation were particularly negatively affected. </p>
<p>These findings are a valuable tool to help health authorities and other stakeholders prepare better for future pandemics and ensure that essential health services continue to operate as normally as possible even during abnormal times.</p>
<h2>Worrying declines and some bright spots</h2>
<p>Outpatient visits, screening and diagnostic services, as well as child vaccinations were hardest hit. </p>
<p>The onset of the pandemic was associated with significant declines in outpatient visits (29%), cervical cancer screening (50%) and number of HIV tests conducted (45%). The number of patients tested for malaria (32%), notified TB cases (27%), hypertension cases (10%) and vitamin A supplements (9%) also declined. And we saw drops in three doses of the diphtheria, tetanus toxoid and pertussis vaccine administered (1%). These may have been driven by the partial lockdowns, stay-home orders and restriction of movement, discouraging patients and parents from seeking non-emergency services. </p>
<p>At the beginning of the emergency when little was known about COVID-19, the health ministry issued directives around minimising crowding within hospitals, partly by reducing non-emergency clinic visits and surgeries. This may have reduced outpatient visits in addition to propagating the fear of contracting disease within hospitals.</p>
<p>For outbreaks such as Ebola, fear of contracting the virus in health settings has been shown to affect access to other health services negatively.</p>
<p>Access to antiretrovirals was not hit as hard as the other services. This could be due to a policy change by the <a href="https://www.nascop.or.ke/">national AIDS and sexually transmitted infections control programme</a> allowing for multi-month dispensing of antiretroviral drugs. This reduced the need for frequent clinic visits.</p>
<p>We also noticed fewer reported cases of pneumonia and diarrhoea in children. It is not clear if this was related to improved hygiene associated with handwashing or the decreased contact between children when schools closed. It could also be reduced reporting as a result of a change in healthcare seeking behaviour brought on by the pandemic.</p>
<p>One worrying <em>increase</em> in visits to essential healthcare facilities stemmed from cases of sexual violence, which increased by 8%. Gender-based violence is <a href="https://www.unwomen.org/en/news/in-focus/in-focus-gender-equality-in-covid-19-response/violence-against-women-during-covid-19">associated</a> with stress, uncertainty, social isolation and movement restrictions. </p>
<p>There were some promising data points. The rates of skilled deliveries for pregnancy, as well as those for antenatal care (care during pregnancy) were resilient. They remained steady both at the outset of and during the pandemic. </p>
<p>There are several possible reasons for this. Permits were issued to expectant mothers so they could visit healthcare centres during curfew hours. An ambulance system, <a href="https://khf.co.ke/w4l/">Wheels of Life</a>, was designated in Nairobi to transport pregnant women during curfew hours. Strong guidelines were also issued to facilities about the continuity of reproductive and maternal health services. And many pregnant women remained committed to giving birth in hospital because they had arranged antenatal care and delivery before the pandemic.</p>
<p>Towards the later stages of the pandemic, most health indicators started to recover. But the healthcare workers’ strike resulted in nearly all indicators falling to numbers lower than those observed at the onset or during the pre-strike period, except for the number of notified tuberculosis cases, which increased slightly by 0·3%.</p>
<h2>Recommendations</h2>
<p>There is little use in trying to improve essential health services when a pandemic has already begun. Preparedness is key. Kenya must – with data sets like ours, among other tools – identify which services are vulnerable in times of crisis. These should then be improved so that human life is protected before, during and after a health emergency.</p>
<p>Health authorities should also be developing and disseminating guidelines to healthcare managers so they know how best to manage services both during and outside a crisis. Better coordination and communication between county and national departments is crucial, too.</p>
<p>And there are lessons to be learned from resilient indicators. We must examine what made maternal health indicators remain robust during the health crisis and how those interventions might be applied in different areas of the healthcare system.</p><img src="https://counter.theconversation.com/content/191513/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Loice Achieng Ombajo receives funding from
CDC, BMGF, WHO, UKAID through the Fleming Fund and
funds for investigator initiated clinical trials from ViiV HealthCare and Gilead Sciences</span></em></p><p class="fine-print"><em><span>Thumbi Mwangi receives funding from the BMGF, German DFG, USAID, NIH. </span></em></p><p class="fine-print"><em><span>Helen Kiarie, Marleen Temmerman, and Mutono Nyamai do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Outpatient visits, screening and diagnostic services, and child immunisation were particularly negatively affected.Mutono Nyamai, Post-doctoral research scientist, Centre for Epidemiological Modelling and Analysis, University of NairobiLoice Achieng Ombajo, Infectious Disease Specialist, Senior Lecturer in Internal Medicine, Co-director of the Center for Epidemiological Modelling and Analysis, University of NairobiMarleen Temmerman, Director of the Centre of Excellence in Women and Child Health and Chair of the Department of Obstetrics and Gynaecology (OB/GYN), Aga Khan University Thumbi Mwangi, Co-Director, Center for Epidemiological Modelling and Analysis (CEMA), University of Nairobi. Chancellors Fellow, Institute of Immunonology and Infection Research, University of Edinburgh. Associate Professor, Paul G Allen School for Global Health, Washington State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1911912022-10-04T15:45:56Z2022-10-04T15:45:56ZDiabetes in South Africa: 60% aren’t being screened for complications, according to new study<figure><img src="https://images.theconversation.com/files/487728/original/file-20221003-18-l1d9q2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eleven percent of South African adults live with diabetes. </span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>The world is experiencing a <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">steep rise</a> in the number of people living with diabetes, a chronic condition of significant public health concern. Many developing countries like South Africa now bear the greatest burden. </p>
<p>Diabetes refers to a high level of glucose in the blood.
Several factors contribute to diabetes, but obesity and unhealthy lifestyle behaviours are the major drivers. It is a costly disease, and it reduces the quality of life and lifespan, especially if not properly managed. </p>
<p>Eleven percent of South African adults now <a href="https://idf.org/our-network/regions-members/africa/members/25-south-africa.html">live with diabetes</a>, the highest prevalence in Africa. Most of them have poorly controlled diabetes. And many others are yet to be diagnosed. A lot of people develop <a href="https://www.cdc.gov/diabetes/managing/problems.html#:%7E:text=Common%20diabetes%20health%20complications%20include,how%20to%20improve%20overall%20health.">complications</a> as a result of poorly controlled diabetes. These include eye problems, kidney disease and cardiovascular diseases. Some even develop wounds that don’t heal, resulting in limb amputation. </p>
<p>When people develop such complications, they spend more money on healthcare. And it places a greater burden on the already overstretched health system. Some even lose their livelihood which, in turn, affects their families.</p>
<p>There have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4565451/">some</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709478/">studies</a> in South Africa looking at the level of screening for complications for people living with diabetes. But there’s very little focus on the primary healthcare level. And some of these <a href="https://www.researchgate.net/publication/14037605_Public_sector_primary_care_of_diabetics_-_A_record_review_of_quality_of_care_in_Cape_Town">studies</a> were conducted many years ago, so the data may no longer be valid. </p>
<p>It is imperative to determine the current situation, especially at primary healthcare level. Our recent <a href="https://www.researchgate.net/publication/360198427_Coverage_of_diabetes_complications_screening_in_rural_Eastern_Cape_South_Africa_A_cross-sectional_survey">study</a> focused on the Eastern Cape province. It’s one of the poorest provinces in South Africa, with a high prevalence of poorly controlled diabetes.<br>
We assessed the extent of screening for diabetes-related complications at primary healthcare clinics in this province.</p>
<p>We found that the rate of screening for these complications was very low. Our findings are similar to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709478/">research</a> done in another rural province in the country. This points to the need to promptly implement measures to improve screening coverage for people with diabetes in South Africa. Doing this will improve health outcomes and quality of life, and reduce the incidence of devastating diabetes complications.</p>
<h2>Checking for complications</h2>
<p>To keep blood glucose levels under control and avoid complications, people with diabetes need to pay detailed attention to their health. They must be involved in their care, live a healthy life, and undergo important tests and examinations that help to quickly identify potential problems. </p>
<p>There are <a href="http://www.jemdsa.co.za/index.php/JEMDSA/article/view/647">guidelines</a> for diabetes management and complications screening in South Africa. Healthcare providers also have a duty to check whether these individuals’ blood glucose is under control, so they don’t develop complications which can cut their life short or disable them. </p>
<p>Primary healthcare clinics are the entry points into the healthcare system. Most people with diabetes are first managed at these facilities. Here they receive medication and are supposed to check their blood glucose level at every visit. </p>
<p>In addition, primary healthcare providers are supposed to check patients’ eyes and kidney function when they make the diagnosis – and every year after that. Healthcare workers are also supposed to check the patients’ feet at least once a year. Patients at higher risk of developing foot ulcers need more frequent check-ups to prevent complications like leg amputation. </p>
<h2>Our study</h2>
<p>We wanted to find out how the people living with diabetes in some rural areas of the Eastern Cape, South Africa are being managed. We recruited participants with diabetes from six primary healthcare facilities. By asking them questions and by looking at their medical records, we determined if these measures and examinations were in place at these primary healthcare clinics.</p>
<p>Our analysis showed that out of 372 people, only 71 (19%) of them had been checked for blood glucose control in the past year. Sixty (16%) of them had been assessed for kidney function and 33 (8.9%) had been checked for blood cholesterol levels. Just 52 (14%) had undergone eye examinations in the past year. </p>
<p>Foot examination, which helps to prevent leg amputation, was done for only 9 (2.3%). More than half (60%) of these patients had not undergone any form of examination for these potential complications in the past year. </p>
<p>None of them had undergone all of these five important screenings.</p>
<h2>Way forward</h2>
<p>Our study shows that without urgent intervention, a lot of people with diabetes will soon develop complications that could be prevented through proper screenings. This will affect the individuals, their families, jobs, and even the overburdened health system. </p>
<p>Prevention is cheaper than cure. Understanding the potential reasons for the gaps in diabetes management and finding effective solutions for improving screening coverage will cut healthcare costs, prolong the life of patients and enable them to lead a quality life. </p>
<p>There are a number of approaches that the country can take. For instance <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3617530/">mobile health technology</a> can be used as a tool to facilitate screening. A similar approach is being used in developed countries. As a result, many of them have been able to cut down the number of <a href="https://link.springer.com/article/10.1007/s00125-018-4711-2">diabetes-related complications</a>. </p>
<p>Other countries have also embraced <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398859/">technology-based solutions</a> to train community health workers to conduct some of these examinations under the guidance of experts.</p><img src="https://counter.theconversation.com/content/191191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eyitayo Omolara Owolabi received funding for her PhD from South African National Research Foundation. </span></em></p><p class="fine-print"><em><span>Anthony Idowu Ajayi is affiliated with African Population and Health Research Center. </span></em></p>Most people with diabetes are poorly controlled. This makes them vulnerable to complications like eye problems, kidney disease, and even amputations.Eyitayo Omolara Owolabi, Postdoctoral fellow, Arizona State UniversityAnthony Idowu Ajayi, Associate research scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1860002022-07-17T09:43:56Z2022-07-17T09:43:56ZTechnology and home visits can help South Africans with diabetes cope with insulin<figure><img src="https://images.theconversation.com/files/472534/original/file-20220705-20-yx5ycz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Insulin refusal is high among some patients.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Approximately <a href="https://health-e.org.za/2021/11/14/most-south-africans-do-not-know-they-have-diabetes/">4.5 million</a> South Africans have <a href="https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199#:%7E:text=Metformin%20(Fortamet%2C%20Glumetza%2C%20others,body%20uses%20insulin%20more%20effectively">type 2 diabetes</a> – a condition characterised by high levels of sugar in the blood. It can be treated with drugs and managed through healthy eating and exercise. But if it’s not managed well, it can be life-threatening. Diabetes is one of the <a href="https://www.statssa.gov.za/publications/P03093/P030932018.pdf#page=47">leading causes of death</a> in South Africa. </p>
<p>Blood sugar levels rise to dangerous levels when the pancreas does not produce enough insulin, a hormone that regulates the movement of sugar in the body. </p>
<p>As <a href="https://www.everydayhealth.com/hs/better-type-2-diabetes-control/how-diabetes-changes/">diabetes progresses</a>, insulin injections become the only treatment option. But the transition from oral medication to injectable insulin is often a bumpy one. Managing a patient on insulin requires patients to inject at least once a day and to measure their blood sugar levels at least twice a day. In addition, healthcare workers must have the knowledge, skills and time required to monitor patients and adjust the insulin dose when necessary.</p>
<p>To address this problem, we <a href="https://journals.sagepub.com/doi/full/10.1177/20420188211054688">developed an intervention called the Tshwane Insulin Project</a>. Our <a href="https://www.up.ac.za/news/post_2988422-ups-real-world-diabetes-research-is-reaching-out-to-the-community-one-family-at-a-time">intervention</a> combines various elements. One is a digital tool, <a href="https://www.vulamobile.com/">the Vula app</a>, which health professionals can use to communicate with each other. </p>
<p>Another aspect of the intervention involves community health workers in the care of people with diabetes. We also train healthcare professionals at primary care level to manage people living with diabetes, including those who need insulin.</p>
<p>Our intervention is a more efficient way of managing people with diabetes because healthcare providers share the tasks of patient education, insulin initiation and follow-up. The intervention also reduces the number of referrals from clinics to hospitals because of unavailability of doctors or lack of skills to manage patients on insulin.</p>
<h2>The intervention</h2>
<p>When a person’s blood sugar is not controlled with two drugs, they get the correct information about insulin and why it is necessary. If the patient agrees to go on insulin, the doctor prescribes it and the primary care nurse informs the patient.</p>
<p>The mobile app is very useful in primary healthcare settings because the doctor can send a prescription remotely using the app. Patients don’t have to wait for doctors to visit the facility. The nurse can check if the patient meets the criteria for insulin therapy and the doctor can confirm that, remotely, based on the information provided by the nurse.</p>
<p>Once the patient is initiated on insulin, the nurse contacts the community health worker team assigned to the clinic to inform them about the new patient.</p>
<p>Community healthcare workers are a very important part of this intervention.</p>
<p>Before the intervention, patients were sent home with a huge amount of information to digest by themselves. They would have to remember how, where and when to inject their insulin; how to draw the appropriate dose; how to measure their sugar levels; how to identify when their sugar levels are low (hypoglycaemia); and what to do at that moment.</p>
<p>Research <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5601201/">shows</a> that this can be overwhelming for patients. Some are illiterate, with limited medical knowledge. With the involvement of community health workers in the intervention, patients are no longer alone. Patients are visited at home every week. The community health workers remind patients of key education messages, injection sites and techniques. </p>
<p>The community health workers are also important in the adjustment of insulin doses. Before the intervention, most patients would have their insulin doses adjusted during clinic visits – which happened once a month at best – because they could not do it themselves. Insulin is always started at a low dose for safety reasons and to help the patient adjust. Then the dose is progressively increased until the optimal dose is reached. That optimal dose varies from one patient to another. When the dose is adjusted only once a month it takes too long to reach the ultimate dose. Many patients never reach that dose and remain with high glucose levels despite injecting. </p>
<p>With our intervention, during the weekly home visit, the community health workers communicate the blood sugar levels to the doctor via the mobile app. The doctor assesses the sugar levels and indicates whether the insulin dose should be increased, decreased, or maintained. With weekly dose adjustments, the patient reaches the optimal insulin dose faster and the condition is controlled sooner. The ability to adjust a patient’s insulin dose as often as weekly thanks to the team doing a home visit is a game changer. </p>
<p>The insulin project intervention was tested with a limited number of patients at ten clinics in the Tshwane district in South Africa. The results of this trial <a href="https://www.tandfonline.com/doi/full/10.1080/16089677.2022.2074122">are promising</a>. There was no report of low blood sugar, which meant that the intervention was safe. Patients who completed the 14-week follow-up with home and clinic visits recorded a reduction of their <a href="https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/hba1c">glycated haemoglobin or HbA1c</a> by 2.2%, meaning that their blood sugar was better controlled after the intervention.</p>
<p>We are currently conducting a large-scale evaluation of the intervention. </p>
<h2>Remaining hurdles</h2>
<p>There is a lot of <a href="https://diabetesjournals.org/clinical/article/25/1/39/1493/Insulin-Myths-and-Facts">misinformation around insulin</a>. As a result, some people with type 2 diabetes perceive the progression from oral medication to insulin as a sign of failure. Even worse, some believe insulin means that death is near. </p>
<p>We’ve also found high rates of insulin refusal by patients – as high as <a href="https://repository.up.ac.za/handle/2263/79812">50%</a> in some areas. Many patients are not meeting their treatment targets. They remain on oral therapy with high blood sugar levels which leave them exposed to <a href="https://www.diabetes.org.uk/guide-to-diabetes/complications">serious complications</a>.</p>
<p>In addition, many healthcare professionals, especially those working at primary care clinics, are not equipped to manage patients who need insulin. Their lack of skills and knowledge may contribute to patients’ fears. And community health workers are in short supply. The number of community health workers is estimated at <a href="https://bhekisisa.org/opinion/2020-05-20-community-health-care-workers-in-south-africa-investment-case-covid19-coronavirus-tracing-programme/">55,000 for the whole country</a> which is not enough considering the population needs. The Medical Research Council estimated that South Africa needs <a href="https://www.samrc.ac.za/sites/default/files/files/2017-10-30/SavingLivesSavingCosts.pdf">41,000 more</a> to bring the total to 96,000. </p>
<p>Despite all of these challenges, we are confident that interventions like ours can improve the management of people living with diabetes. The support of health authorities and healthcare workers is crucial for a <a href="https://phcfm.org/index.php/phcfm/article/view/3467">successful implementation</a>.</p><img src="https://counter.theconversation.com/content/186000/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Rheeder receives funding from Lilly Global Health Partnership</span></em></p><p class="fine-print"><em><span>Elizabeth M. Webb and Patrick Ngassa Piotie do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As diabetes progresses, insulin injections become the only treatment option. But the transition from oral medication to injectable insulin is often a bumpy one.Patrick Ngassa Piotie, Project Manager, University of Pretoria Diabetes Research Centre, University of PretoriaElizabeth M. Webb, Associate professor, University of PretoriaPaul Rheeder, Project Head, Tshwane Insulin Project, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1847602022-06-28T15:04:53Z2022-06-28T15:04:53ZWhat it would take to set up an African drug discovery ecosystem<figure><img src="https://images.theconversation.com/files/470032/original/file-20220621-11-duwhsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A factor holding back African research is the lack of strong collaborative networks between African laboratories and institutions.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>Africa has great potential for drug discovery. The continent has natural resources, indigenous knowledge and human capacity. And it has the need: it bears more than <a href="https://pubs.acs.org/doi/10.1021/acs.jmedchem.1c01183">20%</a> of the global disease burden. There are many internationally recognised <a href="https://www.nrf.ac.za/information-portal/nrf-rated-researchers/">African scientists</a> undertaking cutting edge research. But a lack of resources makes it difficult to conduct world class science. A team of African biochemists, cell biologists and bioinformaticians shares some thoughts on what it would take to establish an Africa-wide drug discovery ecosystem. The authors are the key members of the <a href="https://covidrug-africaconsortium.rubi.ru.ac.za/">COVIDRUG-AFRICA Consortium</a> – the consortium for rapid COVID-19 drug development in Africa.</em></p>
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<h2>What are the challenges to drug discovery?</h2>
<p>Access to infrastructure, long-term funding and supply chain constraints are among the challenges.</p>
<p>In South Africa, spending on research and development (R&D) as a percentage of GDP is <a href="https://www.researchprofessionalnews.com/rr-news-africa-south-2021-2-south-african-research-spending-plummets/#:%7E:text=South%20Africa's%20gross%20expenditure%20on,dismal%20findings%20across%20the%20board.">low</a> – 0.62% in 2019-2020, down from 0.69% in 2018/2019. Most of this funding is from the government. Business and other R&D investment has also <a href="http://www.hsrc.ac.za/en/media-briefs/cestii/sa-shines-rd">declined</a> in recent years.</p>
<p>For many other countries in Africa, expenditure on R&D is non-existent. China, the US, Israel and Germany, in contrast, spend on average between 2% and 4% of GDP on R&D. These countries are among the world’s <a href="https://www.science.org/content/blog-post/where-drugs-come-country">top drug producers</a>. </p>
<p>Drug discovery research in Africa receives modest but essential <a href="https://gcgh.grandchallenges.org/challenge/grand-challenges-africa-drug-discovery">international funding</a> through philanthropic <a href="https://gcgh.grandchallenges.org/challenge/grand-challenges-africa-drug-discovery">foundations</a> and selected <a href="https://www.samrc.ac.za/sites/default/files/attachments/2021-01-18/GRADIENTrfa.pdf">pharmaceutical companies</a>. However, substantial, focused initiatives for long-term funding are uncommon. An exception is the <a href="http://www.h3d.uct.ac.za/">H3D Centre</a> at the University of Cape Town in South Africa. It did pioneering work in collaboration with the <a href="https://www.mmv.org/">Medicines for Malaria Venture</a> on a promising new antimalarial compound. </p>
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Read more:
<a href="https://theconversation.com/collaboration-pushes-frontiers-of-anti-malaria-drug-regimes-124645">Collaboration pushes frontiers of anti-malaria drug regimes</a>
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<p>Funding calls are often restricted to <a href="https://gcgh.grandchallenges.org/challenge/grand-challenges-africa-drug-discovery">diseases specifically associated</a> with Africa. The unintended consequence is that the breadth of research supported in some of the world’s countries cannot be matched in Africa. This can stifle innovation. </p>
<p>Another factor holding back African research is the lack of strong collaborative networks between African laboratories and institutions. This is largely due to university policies and limited funding. </p>
<p>An often overlooked hindrance to drug discovery is the inefficient supply chain for reagents and consumables within the continent. The long delays and administrative burden of sourcing and obtaining chemicals often means that promising projects become impractical. </p>
<h2>Where are the problems in the process?</h2>
<p>To understand the weak spots and opportunities, it helps to look at the process of drug discovery.</p>
<p>The early phase involves generating collections of chemical compounds. This is achieved using synthetic chemistry, extraction from natural sources. It can also be done by identifying promising compounds for re-purposing using computational methods. Promising compounds are subjected to <a href="https://www.ncbi.nlm.nih.gov/books/NBK326710/">laboratory assays</a> to predict their potential behaviour in the body and suitability as medicines. There is little activity in this area in African countries. The main reason is infrastructure shortcomings. Researchers don’t have the advanced analytic instrumentation required for the assays. </p>
<p>The early phase of the drug discovery process is followed by animal testing and additional pre-clinical assessment of compounds. The final phase is clinical trials in human subjects. Costs and infrastructure requirements mount up as the process goes on. </p>
<p>There is scope for significant improvement in all these aspects. But the most pressing need is, arguably, expanding synthetic chemistry capacity beyond South Africa. What is holding this back is predominantly access to infrastructure. </p>
<p>A workable strategy would involve strengthening the early phase of the pipeline and then collaborating in later phases. This approach is likely to succeed and instil confidence in funders to further invest in sustainable drug research capacity development.</p>
<p>Additionally, governments could dedicate a fraction of their GDP to support research and development and facilitate customs clearance for chemicals and reagents and make it economically attractive for vendors to establish local entities.</p>
<h2>Why not let wealthier countries do this work?</h2>
<p>Pharmaceutical companies mostly focus on diseases that heavily affect the western world because of the substantial financial returns. Moreover, they have a financial incentive to focus on medications for chronic conditions that require a persistent or lifelong commitment from patients. Diseases that primarily affect Africa, notably <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30925-9/fulltext">infectious diseases</a>, are at the back of the queue for pharmaceutical companies. </p>
<p>The COVID-19 pandemic has showed that in times of crisis, developed countries will prioritise their citizens. African self-sufficiency in vaccines and chemotherapeutics is thus vital. </p>
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<strong>
Read more:
<a href="https://theconversation.com/covid-19-shows-why-africas-reliance-on-outsiders-for-health-services-is-a-problem-163441">COVID-19 shows why Africa's reliance on outsiders for health services is a problem</a>
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<p>Escalating pathogen resistance to existing therapeutics for endemic diseases is another reason to pursue drug discovery. </p>
<p>Africa’s store of indigenous knowledge, combined with natural resources that are not found elsewhere, creates an opportunity for natural product drug discovery. </p>
<p>Organisms may contain diverse chemotypes of compounds that are absent in synthetic compound collections routinely used for discovery purposes. About four decades ago, more than <a href="https://pubs.acs.org/doi/10.1021/acs.jnatprod.9b01285">80%</a> of drugs were prominently from natural product sources or synthetically modified from natural compounds. Recent <a href="https://www.nature.com/articles/s41573-020-00114-z.pdf">data</a> indicate that almost half of the drugs approved since 1994 are still based on natural products. And there are many more natural sources to explore.</p>
<p>Another reason for African countries to look for new drugs is the continent’s <a href="https://www.sciencedirect.com/science/article/pii/S096098220902065X">genetic diversity</a> – which is <a href="https://www.nature.com/articles/s41576-020-00306-8">greater than that of other regions</a>. Populations <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093198/">may differ</a> in their susceptibility to or tolerance of a particular drug treatment. African populations also possess a number of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953791/pdf/nihms235397.pdf">genetic adaptations</a> that have evolved in response to diverse climates and diets, as well as exposure to infectious diseases. </p>
<p>Even minor genetic differences could affect the <a href="https://link.springer.com/article/10.1007/s40262-016-0450-z">pharmacokinetics of drugs</a>, including altered metabolism of drugs that results in a decreased therapeutic response and increased toxicity. There is also a socio-economic case to be made for hosting and expanding drug discovery programmes in Africa. Stronger drug discovery capacity could produce companies serving various aspects of the pharmaceutical development pipeline. This would be an economic stimulus.</p>
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Read more:
<a href="https://theconversation.com/antimicrobial-resistance-calls-for-brainpower-of-a-space-agency-and-campaigning-zeal-of-an-ngo-171405">Antimicrobial resistance calls for brainpower of a space agency and campaigning zeal of an NGO</a>
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<p>A multinational consortium of scientists could substantially increase capacity in Africa for all aspects of discovering drugs against current and future diseases of the continent.</p><img src="https://counter.theconversation.com/content/184760/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ozlem Tastan Bishop receives funding from
1. Alliance for Accelerating Excellence in Science in Africa (AESA) and African Academy of Sciences (AAS): COVID-19 Research and Development Goals For Africa Award
2. Medicines for Malaria Venture: African Challenge Grant
3. Bill & Melinda Gates Foundation, Malaria Medicine Venture and African Academy of Sciences: Grand Challenges – Africa: Drug Discovery Programme
4. African Academy of Sciences and Wellcome Trust: TraypanoGEN+, the genetic determinants of two neglected tropical diseases
5. National Human Genome Research Institute of the National Institutes of Health: H3ABioNet
. </span></em></p><p class="fine-print"><em><span>Adrienne Edkins receives funding from 1. South African Research Chairs Initiative of the Department of Science and Technology (DST) and the National Research Foundation (NRF); 2. Newton Advanced Fellowship from the Academy of Medical Sciences (UK); 3. Resilient Futures Challenge-Led Initiative from the Royal Society (UK); 4. Alliance for Accelerating Excellence in Science in Africa (AESA) and African Academy of Sciences (AAS): COVID-19 Research and Development Goals For Africa Award; 5. Bill & Melinda Gates Foundation, Medicines for Malaria Venture and African Academy of Sciences: Grand Challenges – Africa: Drug Discovery Programme; 6. Glaxosmithkline (GSK)/Tres Cantos Open Lab Foundation; 7. South African Medical Research Council Self-Initiated Research Grant; 8. Poliovirus Research Foundation; and 9. Rhodes University.</span></em></p><p class="fine-print"><em><span>Ed Murungi receives funding from Bill and Melinda Gates Foundation</span></em></p><p class="fine-print"><em><span>Fabrice Boyom is the Founder/PI, Antimicrobial & Biocontrol Agents Unit (AmBcAU), University of Yaounde 1, Cameroon.
He receives funding from
1. Alliance for Accelerating Excellence in Science in Africa (AESA) and African Academy of Sciences (AAS): COVID-19 Research and Development Goals For Africa Award
2. Bill & Melinda Gates Foundation, Malaria Medicine Venture and African Academy of Sciences: Grand Challenges – Africa: Drug Discovery Program
3. NIH Exploratory/Developmental Research Grant Program
4. Merck Schistosomiasis Research Grant
</span></em></p><p class="fine-print"><em><span>Heinrich Hoppe receives funding from the Science for Africa Foundation: Alliance for Accelerating Excellence in Science in Africa (AESA) and African Academy of Sciences (AAS): COVID-19 Research and Development Goals For Africa Award; Bill & Melinda Gates Foundation, Malaria Medicine Venture and African Academy of Sciences: Grand Challenges – Africa: Drug Discovery Programme</span></em></p>Drug discovery research in Africa receives modest but essential international funding through philanthropic foundations and selected pharmaceutical companies.Ozlem Tastan Bishop, Professor and Director of Research Unit in Bioinformatics (RUBi), Rhodes UniversityAdrienne Edkins, Professor of Biochemistry, Rhodes UniversityEdwin Murungi, Senior Lecturer and Chair of the department of Medical Biochemistry, Kisii UniversityFabrice Boyom, Professor of Biochemistry, Université de Yaounde 1Heinrich Hoppe, Associate Professor of Biochemistry, Rhodes UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1716792021-11-21T09:03:43Z2021-11-21T09:03:43ZDiabetes can be controlled. But there’s no medicine for some people who need it.<figure><img src="https://images.theconversation.com/files/432429/original/file-20211117-9381-107ll2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diabetes can be controlled using medicines, diet and lifestyle modification. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The burden of diabetes is increasing globally. There are about <a href="https://idf.org">half a billion</a> people in the world living with the disease. In sub-Saharan Africa, 23 million people had diabetes in <a href="https://diabetesatlas.org/data/en/region/2/afr.html">2021</a>. This number is expected to increase to 33 million by 2030 and 55 million by <a href="https://diabetesatlas.org/data/en/region/2/afr.html">2045</a>. </p>
<p>Currently, diabetes has no cure. But it can be controlled using medicines, diet and lifestyle modification. </p>
<p>As part of its 2013–2020 <a href="https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf;jsessionid=033405B41D881C42450C0F144CF01944?sequence=1">Global Action Plan</a> the World Health Organisation set targets for prevention and control of noncommunicable diseases. It said essential medicines and basic technologies should be at least 80% available in public or private healthcare facilities. For diabetes, these medicines include insulin and oral agents that reduce blood sugar. There should also be medicines like aspirin and statins that reduce the risk of related heart diseases. The technology includes glucometers (for testing blood sugar) and test strips for urine protein and ketones.</p>
<h2>Out of reach</h2>
<p>Sub-Saharan Africa faces the dual burden of communicable and noncommunicable diseases straining countries’ health resources and fragile health systems.
Access to essential medicines and diagnostic tests remains a challenge in the region. Public health facilities are faced with frequent stock-outs of medicines and patients often pay for medicines themselves.</p>
<p>Insulin and oral medicines for diabetes are mostly not available at the recommended <a href="https://assets.researchsquare.com/files/rs-16103/v1/8658fa2b-e836-4637-be29-a445e5abef79.pdf?c=1631831420">level</a> in the region. A recent <a href="http://dx.doi.org/10.1136/bmjgh-2019-001410">study</a> conducted in 13 low- and middle-income countries (including countries in sub-Saharan Africa) found 55-80% availability of insulin in health facilities that should have had insulin. An earlier <a href="https://www.hindawi.com/journals/ijhy/2012/584041/">survey</a> had shown 0% availability of insulin in health facilities in Benin and Eritrea. The trend is similar with tests for <a href="https://assets.researchsquare.com/files/rs-16103/v1/8658fa2b-e836-4637-be29-a445e5abef79.pdf?c=1631831420">blood glucose, urine protein and ketone</a>. </p>
<p>The monthly dose of the lowest-priced generic medicines, metformin and glibenclamide, costs about <a href="https://assets.researchsquare.com/files/rs-16103/v1/8658fa2b-e836-4637-be29-a445e5abef79.pdf?c=1631831420">two days’ wages in sub-Saharan Africa</a>. This is based on the wages of the lowest-paid government worker. </p>
<p>The cost is even higher for the newer generation agents. For example, glimepiride costs an equivalent of three days’ wages in <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-017-0651-6">Uganda</a>. Short-acting and intermediate-acting insulin cost about five days’ wages in <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-017-0651-6">Uganda</a> and four days’ wages in <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0111812">Cameroon</a>. Various tests also cost a few days’ wages in Uganda and Cameroon.</p>
<p>Some brands of insulin cost much more. For example, the innovator brand of intermediate-acting insulin costs about 20 days’ wages in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636320/">Malawi</a> and pre-mixed insulin costs 19 days’ wages in <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0111812">Cameroon</a>. </p>
<h2>How do we improve access?</h2>
<p>There are a number of ways to improve access to affordable medicines. They include increasing financing for medicines by governments and international bodies. Legislation could promote the entry of generics into the market. Generic medicines should be priced appropriately and subsidised so that patients don’t have to pay the full price. The selection and use of medicines needs care. And robust electronic monitoring systems would minimise stock-outs. </p>
<p>The responsibility to make changes falls on governments, local and international non-governmental organisations, pharmaceutical companies and health workers. </p>
<p>Some global biopharmaceutical companies have established initiatives targeting low- and middle-income countries. An example is the <a href="https://www.novartis.com/esg/access/creating-sustainable-business-models/novartis-access">Novartis Access programme</a>, currently running in Kenya, Uganda, Tanzania, Rwanda, Malawi, Ethiopia and Cameroon. The programme offers subsidies to governments, non-governmental organisations and other institutional customers for a portfolio of medicines to treat noncommunicable diseases. It also builds health system capacity for the prevention and management of noncommunicable diseases, including diabetes. </p>
<p>Another company, Novo Nordisk, started in 2009 to supply insulin at a subsidised cost to selected low-income countries in sub-Saharan Africa. With partners, it supports the “<a href="https://www.novonordisk.com/sustainable-business/access-and-affordability/changing-diabetes-in-children.html">Changing Diabetes in Children</a>” programme in 10 countries in sub-Saharan Africa. It offers free glucometers and insulin to children and adolescents with type 1 diabetes. </p>
<p>But more needs to be done. Government health ministries and other implementing agencies should encourage healthcare practitioners to follow evidence-based, locally relevant treatment guidelines. They should undergo continuous professional development on diabetes care. National lists of essential medicines should be routinely updated and include cost-effective medicines. </p>
<p>Lastly, governments and the private sector in sub-Saharan Africa should invest in the local production of high-quality generic medicines for diabetes.</p><img src="https://counter.theconversation.com/content/171679/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard E. Sanya does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Insulin and oral medicines for diabetes are mostly not available at the recommended level in the African region.Richard E. Sanya, Post-doctoral Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1703862021-11-09T14:54:54Z2021-11-09T14:54:54ZFive reasons South Africa isn’t ready for health claims on food labels<figure><img src="https://images.theconversation.com/files/428263/original/file-20211025-13-ilubrh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Labels are not the only tool needed in the effort to prevent noncommunicable disease</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa has a high number of <a href="https://www.who.int/nmh/countries/zaf_en.pdf">deaths</a> from noncommunicable diseases, which are largely <a href="https://www.who.int/gho/publications/world_health_statistics/2018/en/">linked</a> to diet and lifestyle. Under particular scrutiny are the so-called ultra-processed foods, such as soft drinks, potato chips, chocolate and sweetened breakfast cereals. <a href="https://onlinelibrary.wiley.com/doi/10.1111/obr.13146">Evidence is mounting</a> of their role in the development of diabetes, cardiovascular disease, cancers and chronic lung illnesses. </p>
<p>There are <a href="https://theconversation.com/the-rise-of-ultra-processed-foods-and-why-theyre-really-bad-for-our-health-140537">several reasons</a> why consumption of ultra-processed food is on the rise. Industrialisation of food systems, technological change and globalisation all play a role. Another <a href="https://onlinelibrary.wiley.com/doi/10.1111/obr.13126">frequently cited reason</a> is the growth of transnational food corporations in countries with inadequate policies to protect nutrition. </p>
<p>One way to help people choose healthy food might be to add health claims to the packaging of food that qualifies as healthy. Such claims could lay out health benefits in an accessible way and guide consumers’ choices towards foods with better nutritional profiles. Health claims are used in the European Union. But at the moment, South Africa only has <a href="https://www.greengazette.co.za/notices/foodstuffs-cosmetics-and-disinfectants-act-54-1972-regulations-relating-to-the-labelling-and-advertising-of-foods-amendment_20140529-GGR-37695-00429">draft legislation</a> that would permit some health claims. </p>
<p>Before we conducted our research, not much was known about what stakeholders in the food labelling landscape thought of the proposal. These include doctors, dietitians, public health practitioners, food scientists, food business owners and consumers. </p>
<p>The intention of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0195666321005134?casa_token=S58aLZl3794AAAAA:-Y-wtc92r40REaPN5zlWsl7rmdMnzXcpcaXr7Ma0t5akKL4bVxM4kYQxJxurV170XIfm-rMZE4I">our research</a> was to gain in-depth insight from a broad range of stakeholders about how effective health claims on labels might be in influencing consumption. We also wanted to explore how feasible it might be to execute in a developing country such as South Africa. </p>
<p>It emerged that there are still unresolved questions about the substantiation and enforcement of health claims. And there’s no apparent way to reach consumers in the informal market. These problems would limit the benefits of health claims at this point in time. </p>
<p>Labels are not the only tool needed in the effort to prevent noncommunicable disease.</p>
<h2>Main findings</h2>
<p>We conducted 49 interviews and asked participants to share their views on whether including health claims on food labels could help consumers to make healthier food choices. </p>
<p>The research yielded insights under five themes.</p>
<p><strong>Practical barriers:</strong> Literacy, legibility, language, the actual presence of a label on a product, and socio-economic circumstances could all be barriers. These factors mean a person cannot use a food label to inform their choice. South Africa has 11 official languages, but English (as used on food labels) is the home language of only <a href="https://www.tandfonline.com/doi/full/10.1080/01434632.2015.1072206">12% of the population</a>. </p>
<p><strong>Relevance:</strong> Assuming all the practical barriers were overcome, someone might still not use the label. They might lack the knowledge or motivation to make the information relevant to themselves. Or they might not read the label if they were in a hurry.</p>
<p><strong>Messaging:</strong> There are differences in how people prefer to receive messages and information. Labels typically have a dry, scientific format which doesn’t appeal to the average consumer. Most respondents suggested labels could warn them about health risks of the food or rate it on some sort of scale. </p>
<p>Some people liked the idea of health claims. To our surprise, though, many rejected the idea, saying the food industry might take advantage of health claims for commercial reasons. </p>
<p><strong>Enforcement:</strong> Moving away from the label itself, stakeholders were concerned that health claims could create a gap for unscrupulous players to take advantage of the fact that there isn’t really adequate regulatory enforcement in South Africa.</p>
<p><strong>Trust:</strong> There was also evidence of a lack of trust between the food industry and the healthcare industry. This appeared to stem from differences in responsibilities. Food manufacturers are under pressure to sell cheap food in a very unequal society and healthcare picks up the burden if people get unhealthy.</p>
<p>Finally, we found support for the idea of ambassadors for change. These would be individuals, professionals or even businesses going the extra mile to help people make better food choices and to drive compliance. In particular, retailers were keen to push for compliance with legislation on food labels. </p>
<h2>Recommendations</h2>
<p>The list of what’s needed to get South Africa healthy is a long one. But here are some key things to consider.</p>
<p>Food scientists and technologists need to design better foods. The nutritional profile of new foods could be better and existing ones can be improved. Technologies could, in future, make it possible for foods to have fewer additives and to be more affordable.</p>
<p>Labelling does not have to remain in the dark ages. It may be possible to work on the size and legibility of the information that is on the package or to use technology to overcome barriers to legibility and language. </p>
<p>Retailers need to stock and promote an increasing number of healthier choices. This will make it easier for consumers to make healthier choices, whether they read the label or not. </p>
<p>Food and health related education in schools must be engaging, relevant and practical. </p>
<p>The intersection between food and health is far more complex than can be addressed using a food label alone. All the stakeholders need to have a mature conversation about the facts (the huge burden of noncommunicable diseases) and the practicalities (how to feed a nation where millions go hungry or experience malnutrition due to poverty).</p><img src="https://counter.theconversation.com/content/170386/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melvi Todd receives funding from The National Research Foundation and the German Academic Exchange Service (NRF-DAAD). She has previously received funding from the Department of Science and Innovation (DSI). She is affiliated with the South African Association for Food Science and Technology (SAAFoST) as a professional member. </span></em></p>It’s not clear how health claims could be substantiated, enforced or understood, but there are other ways to encourage healthy food choices.Melvi Todd, PhD candidate (Food Science), Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1700402021-10-27T13:14:49Z2021-10-27T13:14:49ZWhat has changed for rural South African women in the last 25 years<figure><img src="https://images.theconversation.com/files/426903/original/file-20211018-28-1eu5fo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rural women in Agincourt, South Africa, with water collection containers.</span> <span class="attribution"><span class="source"> Lauren Porter</span></span></figcaption></figure><p>South Africa has experienced tremendous change over the last quarter century: the first democratically elected government, the HIV/AIDS pandemic, changing health, social and economic policies and now the COVID-19 pandemic. </p>
<p>The <a href="https://www.agincourt.co.za/">South African Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit</a> has, for nearly three decades, conducted health and socio-demographic surveillance in a rural sub-district known as Agincourt, in Mpumalanga province. This surveillance work is enabled by long-standing partnerships with the communities and the public health sector. </p>
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Read more:
<a href="https://theconversation.com/quarter-century-study-on-ageing-in-south-africa-offers-new-perspectives-125320">Quarter century study on ageing in South Africa offers new perspectives</a>
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<p>Using data collected and published over the last <a href="https://academic.oup.com/ije/article/41/4/988/690287">25 years</a>, we have been able to look for longitudinal trends and do cross-sectional analyses that highlight changes in the lives of women in this typical South African rural setting. </p>
<p>Women are continually forced to grapple with inequalities, such as poor access to basic amenities, employment opportunities and quality education, in their rapidly changing environments. It is important to examine the impact that events over the last 25 years have had on them, especially as women play a central role in their communities. </p>
<p>Reflecting on these trends, we can see that the provision of better health services and social grants has aided rural women’s progress in South Africa. But there are still tremendous needs to be met to achieve truly sustainable, equitable development. We believe that enhancing support for rural women creates the potential for major health and socioeconomic improvements for them and their households.</p>
<h2>A socio-demographic snapshot</h2>
<p><a href="https://www.agincourt.co.za/?page_id=1805">Agincourt</a> is adjacent to Mozambique, and one-third of the population are former Mozambican migrants. The study site consists of 31 villages with a population of 116,549 people, living in 22,721 households. Data is regularly collected from households. Women make up 52% of the rural Agincourt population, a proportion that has not significantly changed since 1993. That said, temporary labour migration among women has increased from 10.9% in 1994 to 22.3% in 2018. The percentage of women residing full-time in the rural community has fallen, a trend now typical of South Africa’s rural areas.</p>
<p>The roles of women in their communities are changing too. The percentage of women-headed households had increased from 31% in 1994 to 44% by 2018. In addition, 42% of women receive social grants and 25% are employed – both figures that have increased over time. These transitions have positive implications for <a href="https://journals.sagepub.com/doi/pdf/10.1080/14034950701355445">food security for rural households and school attendance of children</a>. Of the women who are employed, 18% are employed by the government and less than 5% are involved in mining, manufacturing or construction.</p>
<h2>Providing for the next generation</h2>
<p>Childbearing (fertility) rates across all ages of women <a href="https://aps.journals.ac.za/pub/article/view/517">have declined</a>, with the most pronounced decline occurring in women aged 25-34 years. The total fertility rate dropped from 3.3 in 1994 to 1.7 in 2018. On average, women are now having 1.5 fewer children. One likely reason for the decreased fertility rates is the increased availability and use of contraception and family planning services, a key aspect of the South African government’s <a href="https://www.knowledgehub.org.za/elibrary/strategic-plan-campaign-accelerated-reduction-maternal-and-child-mortality-africa-2013">Campaign on Accelerated Reduction of Maternal and Child Mortality in Africa</a> and primary healthcare services package.</p>
<p>Women who do become pregnant are now more likely to access <a href="https://gh.bmj.com/content/6/10/e006915.abstract">antenatal care</a>, deliver in a healthcare facility (not at home) and be attended by a skilled birthing attendant. But migrant mothers <a href="https://gh.bmj.com/content/6/10/e006915.abstract">report fewer antenatal visits</a>.</p>
<h2>Changing healthcare needs</h2>
<p>At the height of the HIV/AIDS pandemic, 2004-07, Agincourt rural women’s life expectancy was <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30297-8/fulltext">58.4</a>. Since the large-scale rollout of antiretroviral therapy in the study area, deaths due to HIV have declined from 50% of deaths to 15%. Among older rural women (40 years and older), we found that <a href="https://sti.bmj.com/content/96/4/271">roughly 45% with HIV</a> were on treatment and virally suppressed.</p>
<p>But noncommunicable diseases, such as diabetes, heart disease and stroke, have increased rapidly in South Africa and remain high. Deaths due to cardiovascular disease contributed one-third of all deaths in these rural women in 2017-18. These deaths are likely to continue to rise given the observed high levels of known <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2018.1549436">risk factors for noncommunicable diseases</a>.</p>
<h2>The continuing impact of COVID-19</h2>
<p>The impact of the COVID-19 pandemic is still being felt and quantified. It’s been suggested that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270489/">people who were already most vulnerable may feel the impact most</a>. We have started to monitor the impact on multiple aspects, including healthcare utilisation and employment in rural Agincourt, by conducting telephonic interviews with 2,200 households. In March 2020, the start of the nationwide lockdown, 45% of the Agincourt population did not have access to family planning and 40% did not have access to condoms. This was likely due to a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7668759/">combination of factors</a> including stay-at-home orders and the perceived risk of being exposed to COVID-19 in public transport and at health facilities. This may affect fertility rates and HIV rates but only time will tell.</p>
<p>At the same time, nearly 50% of the employed population experienced loss or reduction in income. Some households were able to <a href="https://publichealth.jmir.org/2021/5/e26073">recover earnings</a> as lockdown restrictions partially lifted. However, the economic stress that job losses place on households may cause a setback. It may affect school attendance of children and food security of households. </p>
<p>Again, the full impact of the COVID-19 pandemic will only be known in time. However, based on what others are finding in <a href="https://reliefweb.int/sites/reliefweb.int/files/resources/The%20impact%20of%20COVID-19%20on%20rural%20women%20and%20enterprises%20-%20A%20rapid%20socio-economic%20assessment%20in%20Viet%20Nam%20by%20the%20empower%20project.pdf">similar settings</a>, the longer-term impact of this pandemic on rural women is likely to be significant and multi-faceted.</p>
<h2>Looking ahead</h2>
<p>The trends seen over the last quarter century present a transitioning South African rural woman. She is living longer, is more educated and more mobile, and is opting for fewer children. When she does decide to have children, she is likely to deliver at a health facility and be attended by a healthcare professional.</p>
<p>Progress and improvements can be seen across several trends. But the changes also highlight areas where more effective health and social programmes for rural women are needed. </p>
<p>Increased levels of labour migration affect access to health services, as evidenced by decreased antenatal care attendance among migrant women. Levels of noncommunicable diseases are likely to continue to rise, placing greater strain on the health system. We will continue to quantify the impact of COVID-19 on rural communities.</p>
<p><em>Kurium Govender, Project Administrator at the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), contributed to this article. The Agincourt Research Unit is a node of the South African Population Research Infrastructure Network (SAPRIN), and is supported by the Department of Science and Innovation, with previous support from the Wellcome Trust, UK.</em></p><img src="https://counter.theconversation.com/content/170040/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ryan G Wagner gratefully acknowledges support from the South African National Research Foundation (119234).
</span></em></p><p class="fine-print"><em><span>Chodziwadziwa Whiteson Kabudula and Daniel Ohene-Kwofie do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The provision of better health services and social grants has aided rural women’s progress in South Africa, but there are still tremendous needs to be met.Ryan G Wagner, Research Fellow, Wits School of Public Health, University of the WitwatersrandChodziwadziwa Whiteson Kabudula, Senior Researcher Rural Health in Transition and Agincourt Research Unit, University of the WitwatersrandDaniel Ohene-Kwofie, Data Scientist: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1630292021-06-27T08:44:23Z2021-06-27T08:44:23ZStudy shows a huge burden of undiagnosed disease in a rural South African district<figure><img src="https://images.theconversation.com/files/407238/original/file-20210618-14443-83lsoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Healthcare worker, Boitsholo Mfolo, inside the digital x-ray truck at one of Africa Health Research Institute’s mobile screening camps in rural KwaZulu Natal, South Africa. </span> <span class="attribution"><span class="source">Samora Chapman/ Africa Health Research Institute</span></span></figcaption></figure><p>South Africa’s <a href="https://www.avert.org/news/hiv-testing-south-africa-rises-45-12-years">massive effort</a> over the years to test and treat people for HIV has drastically improved public health. But in that process, other diseases that are highly prevalent may have been neglected.</p>
<p>The country has been reporting lower rates HIV-related deaths. But more South Africans are presenting with noncommunicable diseases such as diabetes and hypertension. And tuberculosis (TB) remains the <a href="http://www.statssa.gov.za/?p=14435">leading cause of death</a> in people living with HIV.</p>
<p>We recently <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00176-5/fulltext">published the findings</a> of research we did in a rural area of northern KwaZulu-Natal, South Africa. It aimed to get a clearer picture of the state of health and disease in the area and to identify the prevalence and overlap of infectious and noncommunicable diseases.</p>
<p>The ultimate goal is to design better interventions to improve people’s health.</p>
<p>We set up mobile health camps and screened for diabetes, high blood pressure, HIV, TB, nutritional status (obesity and malnutrition), and use of tobacco and alcohol. </p>
<p>The detailed data allowed us to develop a profile of which diseases were being well managed, and which neglected, in the community. For example, we found that HIV was well treated relative to all other diseases. But TB, elevated blood glucose, and elevated blood pressure were poorly diagnosed and treated. </p>
<p>The study also allowed us to identify overlaps between disease patterns and their geographical location. For example, it was very interesting to see that the areas with the highest prevalence of TB and noncommunicable diseases were mostly in the remote parts of the district and did not overlap with those with the highest rates of HIV. </p>
<p>Our findings raise important questions about how healthcare and screening can most effectively be offered in rural and remote areas. One of our conclusions was that South Africa needs a public health response that expands the successes of the country’s HIV testing and treatment programme to provide multi-disease care targeted to specific populations.</p>
<h2>Key findings</h2>
<p>Our study drew on data collected over 18 months from 2018 to 2019 in uMkhanyakude district, a remote rural area in the east of the country. We screened 17,118 people aged 15 years and older by taking mobile camps into the community and providing screening within 1 km of each participant’s home. </p>
<p>The study provides an in-depth snapshot of the health of a rural population in South Africa.</p>
<p>It shows that:</p>
<ul>
<li><p>there are high and overlapping burdens of HIV, TB, diabetes and hypertension among men and women,</p></li>
<li><p>four out of five women over the age of 30 are living with a chronic health condition,</p></li>
<li><p>HIV-negative people and older people, particularly those over 50, bear a high burden of undiagnosed or poorly controlled noncommunicable diseases such as diabetes and hypertension.</p></li>
</ul>
<p>We found the highest burden of HIV in the vicinity of the main roads. This is similar to other <a href="https://academic.oup.com/ije/article/47/2/537/4781374">studies</a> and has been observed throughout the <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2011/july/20110711transporthiv">region</a> and world. </p>
<p>Just over half of all people 15 years or older (52%) were found to have at least one active disease, while 12% had two or more diseases. Over a third (34%) of people were living with HIV. This number was particularly high among 25 to 44-year-old women. The prevalence of HIV among them was 62%. </p>
<p>We attempted to measure the level of virus in every HIV-positive participant’s blood and found that 78% had no detectable virus, meaning that their antiretroviral therapy was working very well. </p>
<p>But the study also revealed that there are some demographic groups, including men in their 20s and 30s, who still have high rates of undiagnosed and untreated HIV and therefore have virus circulating in their blood. This means that they can pass HIV on to others. Our study highlights the importance of preventing new HIV infections, especially among young people.</p>
<p>In contrast to HIV, we found that most people with TB, diabetes or hypertension had disease which was previously undiagnosed or not well controlled. We found that 1.4% of the population had active TB, which is a <a href="https://www.who.int/news/item/17-06-2021-who-releases-new-global-lists-of-high-burden-countries-for-tb-hiv-associated-tb-and-drug-resistant-tb">very high rate</a> in national and global context. Of these only 30% were already diagnosed and on medication for TB. This meant that approximately 1 in 100 people in this community had undiagnosed TB. </p>
<p>Despite being a curable disease, TB remains one of the <a href="https://www.knowledgehub.org.za/elibrary/first-national-tb-prevalence-survey-south-africa-2018">leading causes of death</a> in South Africa. We found higher rates of TB in men with just under half of all men over age 45 having had TB in his lifetime. The high rates of undiagnosed TB and the finding that men in particular are affected by TB are echoed in South Africa’s recent national TB prevalence <a href="https://theconversation.com/first-ever-national-survey-shows-the-extent-of-south-africas-tb-problem-155153">survey</a> and are a huge cause for concern.</p>
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Read more:
<a href="https://theconversation.com/first-ever-national-survey-shows-the-extent-of-south-africas-tb-problem-155153">First ever national survey shows the extent of South Africa's TB problem</a>
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<p>We found that 8.5% of the population had high blood sugar (diabetes) and 23% had high blood pressure (hypertension). These conditions were mostly found in people older than 45 and were not well diagnosed or controlled. </p>
<p>Only 43% of people with high blood pressure and only 7% with high blood sugar had these conditions well controlled with medications. Women in particular bore a particularly high burden of disease with over 4 of 5 (80%) of those over 30 years old having at least one of these conditions.</p>
<p>When we asked participants about their experience in the study, they told us that they appreciated not having to travel long distances to receive <a href="https://pubmed.ncbi.nlm.nih.gov/33165556/">screening</a>.</p>
<h2>Next steps</h2>
<p>The data provide indicators for where the most urgent interventions are needed. It sets the stage for researchers to examine the biological, social and environmental determinants of disease in the area. It also provides detailed information to guide the Department of Health in development of decentralised models of rural healthcare that integrate management of HIV, TB and noncommunicable diseases.</p>
<p>This work has highlighted the immense burden of undiagnosed or untreated diabetes and hypertension in rural South Africa. As the country faces another surge of COVID-19, it is more important than ever to identify and treat people living with these diseases.</p><img src="https://counter.theconversation.com/content/163029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily B. Wong works for the Africa Health Research Institute and the University of Alabama at Birmingham. She and members of her research group receive funding from the National Institutes of Health, Bill and Melinda Gates Foundation, the African Academy of Sciences and the South African Medical Research Council.</span></em></p>South Africa needs a public health response that expands the successes of the country’s HIV testing and treatment programme to provide care for multiple diseases.Emily B. Wong, Assistant Professor, Africa Health Research Institute (AHRI)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1618302021-06-22T16:08:53Z2021-06-22T16:08:53ZBlunting the impact of poor social conditions in South Africa will have big health benefits<figure><img src="https://images.theconversation.com/files/406505/original/file-20210615-3832-1nn4rw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many South Africans live in poor conditions with no access to running water.</span> <span class="attribution"><span class="source">Rodger Bosch/AFP via Getty Images</span></span></figcaption></figure><p>Poverty and socio-economic disparity are among the greatest obstacles facing South Africans. About <a href="https://ilifalabantwana.co.za/wp-content/uploads/2016/05/SA-ECD-Review-2016-low-res-for-web.pdf">63%</a> of children younger than six live in poverty. The country is also experiencing increasing levels of <a href="https://www.statista.com/statistics/370516/unemployment-rate-in-south-africa/">unemployment</a>. In addition there’s a high prevalence of <a href="https://eprints.qut.edu.au/80249/1/Norman%202010%20PHM.pdf">femicide and inter-partner violence</a> which is often <a href="https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-018-0182-1">associated</a> with excessive alcohol consumption and substance abuse.</p>
<p>Harsh socio-environmental factors, especially when they happen in the early years of a child’s life, can establish a developmental <a href="https://www.irp.wisc.edu/wp/wp-content/uploads/2019/04/foc291a.pdf">‘biology of misfortune’</a>. This involves neurobiological and epigenetic processes that go on to steer a person’s life towards poor health, unrealised potential and a shorter life. </p>
<p>Neurobiology here refers to normal brain development. This is, at times, controlled by epigenetic mechanisms. These are biological reactions involving certain proteins that interact with DNA, physically altering its structure. Epigenetics can be influenced by our physical environment and surroundings. Adverse environments can profoundly alter gene expression and have detrimental health effects including disturbed brain development.</p>
<p>There are clear disadvantages to ignoring the physical environment in relation to adverse epigenetic programming. Firstly, it can result in a future population with deteriorated physical and mental health – these individuals would also be more susceptible to infectious diseases. Secondly, it can affect the future health and economic development of the country. </p>
<p>That’s why child and adolescent health is an urgent priority and should be placed at the centre of the healthcare system.</p>
<p>In <a href="https://sajs.co.za/article/view/8638">our recent paper</a> my colleagues and I described how adverse socio-environmental factors in early life can programme the outcome of obesity, diabetes, cardiovascular disease and mental health disorders in adulthood. These noncommunicable diseases are on the rise and are taking a heavy toll on people’s lives, and the country’s healthcare system.</p>
<p>We set out the social and environmental conditions experienced by young South Africans, and discuss the potential contribution of epigenetics to the current and future prevalence of noncommunicable diseases.</p>
<p>We also unpack some early interventions that can help improve child and adolescent health. The cornerstones are: providing optimum nutrition, providing a secure environment, physical activity and education.</p>
<h2>Social conditions</h2>
<p>South Africa is one of <a href="https://www.worldbank.org/en/country/southafrica/overview">most unequal societies </a> in the world. Children who are exposed to such levels of poverty can suffer immediate and longterm effects. Children from poor families have higher rates of chronic illness and experience worse health in adulthood. </p>
<p>More than half (55%) of the population <a href="http://webcms.uct.ac.za/sites/default/files/image_tool/images/367/South%20African%20Child%20Gauge%202018%20-%20Nov%2020.pdf">experiences poverty</a>, with childhood poverty affecting <a href="http://webcms.uct.ac.za/sites/default/files/image_tool/images/367/South%20African%20Child%20Gauge%202018%20-%20Nov%2020.pdf">63% of children</a>.</p>
<p>With diet being <a href="https://www.sciencedirect.com/science/article/abs/pii/S088985290800056X?via%3Dihub">intertwined</a> with emotions, cognition and behaviour, close attention should be paid to nutrition.</p>
<p>Research has shown that certain diets are hugely beneficial to peoples’ health. One example is a diet that’s high <a href="https://www.sciencedirect.com/science/article/pii/S2212877819304971?via%3Dihub">in polyphenols</a>. These are plant compounds found in tea, chocolates, herbs and spices, fruit, vegetables and nuts. Several have been shown to be able to reduce illnesses by preventing oxidative stress and inflammation in the brain.</p>
<p>On top of this, South Africa sits on a <a href="https://www.sciencedirect.com/science/article/pii/S0254629911001190?via%3Dihub">botanical ‘goldmine’ of indigenous medicinal plants</a>. Many have anti-obesity, anti-cancer, anti-diabetic as well as anti-ageing properties among others.</p>
<p>Finally, while the benefits of breastfeeding for both mother and child
<a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003517.pub2/full">have long been known</a>, South Africa, like most countries, is still not doing enough to support mothers to breastfeed, despite <a href="https://academic.oup.com/heapol/article/34/6/407/5522499">the immense economic implications</a>. </p>
<h2>Champions</h2>
<p>The failure to optimise nutrition, especially during the critical periods of development for vulnerable young children, should be avoided at all costs. There is a definite requirement for efforts directed at improving the national diet. </p>
<p>But healthier foods <a href="https://www.sciencedirect.com/science/article/abs/pii/S089990071000002X?via%3Dihub">are far more expensive</a> than less healthy, nutritionally poor foods. Products like lean meat, fish, fruit and vegetables generally <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001253">cost more</a> than oil heavy processed foods which contain more sugar and fat.</p>
<p>This makes the promotion of a quality diet difficult, because it is simply unaffordable for many South Africans. </p>
<p>International research has shown that the best strategies for changing the dietary environment in favour of healthier foods are those aimed at population level, and are accomplished by mass media nutrition campaigns and transparent food labelling. Some countries have <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001253">taken more drastic action </a> through regulation and taxation of unhealthy foods.</p>
<p>South Africa needs champions for child and adolescent health. The plight of young children needs to be prioritised and placed at the centre of the country’s goals.</p>
<p>An early investment in childrens’ health, education, development, security and well-being would provide benefits that compound during a person’s lifetime. It would improve their prospects – and those of their children and thus society as a whole.</p><img src="https://counter.theconversation.com/content/161830/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ebrahim Samodien receives funding from the South African Medical Research Council through it's Division of Research Capacity Development and Biomedical Research and Innovation Platform. </span></em></p>Harsh socio-environmental factors, especially when they happen in the early years of a child’s life, can establish a developmental “biology of misfortune”.Ebrahim Samodien, Post-doctoral researcher, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1602752021-05-10T14:55:12Z2021-05-10T14:55:12ZOur research shows gaps in South Africa’s diabetes management programme<figure><img src="https://images.theconversation.com/files/398929/original/file-20210505-19-898bla.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diabetes is a leading cause of death in the country.</span> <span class="attribution"><span class="source"> PixelCatchers via GettyImages</span></span></figcaption></figure><p>Diabetes is currently the ninth most common cause of death in the world. Around <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00111-X/fulltext">420 million people or 6% of the world’s population is affected</a>. This number is expected to rise beyond half a billion by the end of the decade with the biggest increase occurring in low- and middle-income countries. </p>
<p>Most people with the condition have <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">type 2 diabetes</a>. This type of diabetes is the result of excess body weight and physical inactivity. </p>
<p>In South Africa, diabetes affects <a href="https://diabetesatlas.org/en/">approximately 4.5 million</a> people. The proportion of the adult population living with the condition is estimated at 12.8%. It’s the leading <a href="https://www.statssa.gov.za/publications/P03093/P030932017.pdf">cause of death</a> among women. In 2019, 89,834 people died of diabetes. This number exceeds the capacity of <a href="http://www.stadiummanagement.co.za/stadiums/fnb/">Soccer City</a>, the biggest football stadium in South Africa.</p>
<p>Most people living with diabetes in South Africa access treatment and care in primary healthcare facilities. Unfortunately, the clinics are often congested and patients have to wait in long queues to receive their medication during their monthly visits. To address these challenges, the National Department of Health initiated a programme in 2014 to improve access to medication and patient adherence. </p>
<p>The programme gives patients with controlled diabetes the option of collecting their medication at pick-up points of their choice such as shops, places of worship, community halls or schools.</p>
<p>But our <a href="https://pubmed.ncbi.nlm.nih.gov/33764132/">recent research</a> found that only a minority of patients enrolled in the programme achieved the treatment targets at the time of the study. We audited the files of patients who had been on the programme for an average of two years (minimum of one year and maximum of five years). Our findings suggest that the criteria used to select people with diabetes for the programme should be revised. In addition, healthcare managers should explore strategies to incorporate diabetes education into the programme.</p>
<h2>Better access to medicines but suboptimal management</h2>
<p>The <a href="https://getcheckedgocollect.org.za/ccmdd/">centralised chronic medicine dispensing and distribution programme</a> was launched in February 2014.
The service is free and benefits the patient in a number of ways. These include: </p>
<ul>
<li>fewer clinic visits, </li>
<li>taking less time off work, </li>
<li>not having to travel long distances, </li>
<li>not waiting in queues, and </li>
<li>collecting medication at any time and place. </li>
</ul>
<p>By definition, patients who are on the programme are stable – meaning that they are doing well. </p>
<p>The clinic nurse or doctor measures the levels of sugar in the blood with a test called <a href="https://www.diabetes.co.uk/fasting-plasma-glucose-test.html">Fasting Plasma Glucose</a>. If two consecutive tests are normal the patient qualifies for the programme. Once enrolled, the patient does not have to come to the clinic to collect medication. Patients on this programme visit the clinic every six months to get checked. </p>
<p>We conducted an audit of the medical records of people with type 2 diabetes who were enrolled in the centralised chronic medicine dispensing and distribution programme at 23 primary healthcare facilities in the Tshwane District of the country’s capital city. The aim was to assess how well the patients were doing at the time. We looked at the most recent test results recorded in their files, namely <a href="https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c">haemoglobin A1C or HbA1c</a>, blood pressure and blood cholesterol. Test results were missing from some patient records, suggesting that patients are not always receiving the tests they are entitled to.</p>
<p>Only 29% of patients in the study had acceptable blood sugar levels. This is concerning because to be eligible for enrolment in the programme, these patients should have been stable controlled patients. Our findings suggest that some patients enrolled in the programme were not stable to begin with. </p>
<p>The suboptimal management of people with type 2 diabetes is worrying especially in the era of the COVID-19 pandemic because <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes/covid-19-and-diabetes/1-covid-19-and-diabetes.html">people living with diabetes are more vulnerable</a> to becoming ill or dying from COVID-19. The consequences of high levels of sugar in the blood include blindness, kidney failure, heart attack, stroke, and leg amputation. These complications result in reduced quality of life and higher healthcare costs, and place unnecessary stress on families.</p>
<p>To ensure that patients benefit fully from this programme, the selection criteria should be revised. Instead of using Fasting Plasma Glucose to determine whether a patient qualifies, the HbA1c should be used. Fasting Plasma Glucose is not a reliable indicator of how well a person with diabetes is doing because it measures blood sugar levels at a single point in time. In contrast, HbA1c provides an indication of blood sugar concentrations over the previous two to three months. The benefit of measuring HbA1c is that it gives a more reasonable and stable view of what’s happening over time (three months). And the value does not vary as much as finger-prick blood sugar (Fasting Plasma Glucose) measurements.</p>
<p>This programme limits a patient’s contact with healthcare providers. An unintended consequence is that the person has limited opportunities to be informed about the condition and to be educated on how to best manage diabetes. </p>
<p>For people with chronic conditions such as diabetes, education and empowerment are crucial to ensure better outcomes. The person with diabetes should be equipped to eat well, get enough physical activity and take the correct amount of medication at the right time. </p>
<h2>Addressing the gaps</h2>
<p>Authorities have <a href="http://www.kznhealth.gov.za/mediarelease/2018/nearly-2-million-people-now-fetch-04112018.htm">claimed the success of the programme</a>. But our study identified some gaps that should be addressed. </p>
<p>The centralised chronic medicine dispensing and distribution programme should consider revising how people with type 2 diabetes are selected. It should also include additional measures for patient empowerment and education. </p>
<p>Improving the management and care of people living with diabetes requires innovative evidence-based interventions. Strategic public-private partnerships are key to ensure that the South African government reaches its objectives in terms of providing better lives for people with diabetes. One such initiative is our <a href="https://www.diabetessa.org.za/the-tshwane-insulin-project/">Tshwane Insulin Programme</a> at the University of Pretoria.</p>
<p>Our programme is a partnership between the University of Pretoria and <a href="https://www.lilly.com/impact/lilly-foundation">the Lilly Global Health Partnership</a>. We work closely with the national, provincial and local health authorities to develop sustainable solutions to improve the management and outcomes of people living with diabetes in South Africa.</p><img src="https://counter.theconversation.com/content/160275/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Rheeder receives funding from the Lilly Global Health Partnership.</span></em></p><p class="fine-print"><em><span>Elizabeth M. Webb and Patrick Ngassa Piotie do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In 2019, 89,834 people died of diabetes. This number exceeds the capacity of Soccer City, the biggest football stadium in South Africa.Patrick Ngassa Piotie, Project Manager, Tshwane Insulin Project, University of PretoriaElizabeth M. Webb, Senior Lecturer, University of PretoriaPaul Rheeder, Project Head, Tshwane Insulin Project, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1565872021-05-10T14:54:52Z2021-05-10T14:54:52ZAfrican countries must embrace the concept of good food as good medicine<figure><img src="https://images.theconversation.com/files/398652/original/file-20210504-18-10zzuz4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Scientist Kafayat Falana testing the viability of cowpea germinated seeds in a laboratory in Ibadan, southwest Nigeria.</span> <span class="attribution"><span class="source">PIUS UTOMI EKPEI/AFP via Getty Images</span></span></figcaption></figure><p>Fresh impetus is being directed into identifying and advocating for scientific priorities in the area of food security and nutrition across Africa, with a particular focus on health implications.</p>
<p>At the centre of these efforts is a <a href="http://aasciences.africa/african-scientific-priorities/sti-priorities">a five-year project</a> initiated by the Alliance for Accelerating Excellence in Africa, a partnership between the African Academy of Sciences and the <a href="https://www.nepad.org/who-we-are/about-us">African Union Development Agency-NEPAD</a>. This project aims to identify the continent’s most urgent research and development questions, and to advocate for investments in these areas. This will go a long way in helping the continent achieve its vision of transforming lives through science. </p>
<p>As a professor of pharmacology and having worked in the field of <a href="https://www.amazon.com/African-Indigenous-Medical-Knowledge-Health/dp/1138038105">African indigenous medical knowledge</a> for decades, I have been involved in research in this field, and have been a strong advocate for more research. I also believe the translation of this research into policy is critical. </p>
<p>One of the things that has become clear to me is that, while Africa is <a href="https://www.cbd.int/gbo/gbo4/outlook-africa-en.pdf">rich in biological diversity</a>, this reality simply isn’t being used to its full potential. This was emphasised at a consultative round table last year on <a href="http://aasciences.africa/publications/setting-scientific-priorities-food-security-and-nutrition-africa">food security and nutrition priorities for Africa</a> organised as part of the five-year project. </p>
<p><a href="https://aasopenresearch.org/documents/4-12">A survey</a> was designed for this round table to prioritise research and development questions relating to food security and nutrition. This survey attracted comments and engagement from more than 1,000 experts globally.</p>
<p>The experts made it clear that what is needed is a prioritisation of the health and medicinal values of the food that’s consumed in African countries. In turn, this will spur more research and development of new supplements and <a href="https://www.sciencedirect.com/topics/nursing-and-health-professions/phytomedicine">phytomedicines</a> – that is, plant-based therapies and medicines – across the continent. This approach has been successful elsewhere, most notably in China. The Asian country has <a href="https://www.sciencedirect.com/science/article/pii/S259009861930003X">invested heavily</a> in training young practitioners of Chinese traditional medicine, who work with, among other things, plant-based therapies and phytomedicines. The Chinese government has also spent a great deal on manufacturing phytomedicines.</p>
<h2>Food and nutrition security</h2>
<p>Changes in traditional eating patterns have brought about new health threats on the continent, including <a href="https://www.intechopen.com/books/public-health-in-developing-countries-challenges-and-opportunities/non-communicable-diseases-and-urbanization-in-african-cities-a-narrative-review">an increase in non-communicable diseases</a>. Dietary interventions are also crucial in tackling type 2 diabetes and cardiovascular disease. In many cases, <a href="https://www.sciencedaily.com/releases/2017/09/170913084432.htm">diet can reverse</a> type 2 diabetes. And food is a key component in fighting <a href="https://www.medicalnewstoday.com/articles/313185">marasmus</a> and <a href="https://www.medicalnewstoday.com/articles/322453">kwashiorkor</a>, both severe forms of malnutrition. </p>
<p>Many indigenous crops <a href="https://www.frontiersin.org/articles/10.3389/fpls.2017.02143/full">are underutilised</a>; these include bambara nuts, pigeon peas, cowpeas, sorghum, finger millets, cocoyam, amaranth, and sweet potato. And people are increasingly relying on new types of food products such as fast foods, processed food and genetically modified products.</p>
<p>Those of us who grew up in villages are used to <a href="https://theconversation.com/eating-insects-has-long-made-sense-in-africa-the-world-must-catch-up-70419">consuming edible insects</a> at their appropriate seasons. The younger generation generally abhors consumption of edible insects. Yet, <a href="https://theconversation.com/how-insects-can-help-fight-hunger-in-the-world-104951">recent scientific evidence</a> has shown that edible insects are rich in nutrients, which promotes better health.</p>
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Read more:
<a href="https://theconversation.com/how-insects-can-help-fight-hunger-in-the-world-104951">How insects can help fight hunger in the world</a>
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<p>There are solutions. One is greater diversification of rural cropping systems. In <a href="http://www.fao.org/3/CA1562EN/CA1562EN.pdf">Malawi, Mozambique and Zambia</a>, crop diversification combines the planting of maize; legumes such as beans, soybeans, pigeon peas, groundnuts and green beans, non-maize staples such as cassava, sweet potato, rice, millet and sorghum; and cash crops, such as cotton, tobacco, sunflower, cashews and sugar cane. In this way, farmers can spread the risk of crop failure and productivity loss due to weather events. </p>
<p>Studies <a href="https://www.frontiersin.org/articles/10.3389/fpls.2017.02143/full">have shown</a> that some neglected and underutilised crops are adapted to a range of agro-ecologies. They are dense in nutrients and also offer better prospects in areas where crops don’t often grow well. Such crops, among them finger millet, bambara nut and cassava, are often drought and heat stress tolerant, resistant to pests and diseases, and adapted to semi-arid and arid environments. </p>
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Read more:
<a href="https://theconversation.com/eating-insects-has-long-made-sense-in-africa-the-world-must-catch-up-70419">Eating insects has long made sense in Africa. The world must catch up</a>
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<p>Governments should also promote algae (like seaweed), fungi (mushrooms) and edible insects like crickets and caterpillars. </p>
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Read more:
<a href="https://theconversation.com/how-cabo-verde-indigenous-beans-could-boost-food-security-155896">How Cabo Verde indigenous beans could boost food security</a>
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<p>The nutrient density of these crops, as well as algae and edible insects, can be used to diversify diets and to address micro-nutrient deficiencies in poor rural communities. </p>
<p>Promoting these foods in rural areas could also create opportunities for rural economic development through the development of new value chains. China, Malaysia, <a href="https://www.researchgate.net/publication/341208734_The_Future_of_Smallholder_Farming_in_India_Some_Sustainability_Considerations">India</a> and <a href="https://www.researchgate.net/publication/4747610_Traditional_vs_Modern_Food_Systems_Insights_from_Vegetable_Supply_Chains_to_Ho_Chi_Minh_City_Vietnam">Vietnam</a> are good examples of countries that derive socio-economic benefits from investment in their traditional food and medical practices.</p>
<h2>The way forward</h2>
<p>One of the priorities emerging from our work at the Academy involves commercialising the production of indigenous foods. This will mean, among other things, pushing for governments to invest in researching the safety and efficacy of foods as medicine, as well as advocating for basic sciences research on indigenous crops. </p>
<p>More investment in research of neglected and underutilised species could also yield new food products that will enhance people’s health and nutrition across Africa.</p>
<p>We also hope to promote the development of germplasm of nutrient-dense indigenous crops and underutilised species. <a href="https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/germplasm">Germplasm</a> are living genetic resources like seeds and tissues, stored at low temperatures so they can be researched, preserved or bred. </p>
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Read more:
<a href="https://theconversation.com/a-new-way-of-processing-cowpeas-brings-affordable-nutrition-to-children-156044">A new way of processing cowpeas brings affordable nutrition to children</a>
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<p>All this work rests on a central premise: it’s long past time for Africa to embrace the concept of good food as good medicine. </p>
<p><em>Dr Grace Mwaura, former manager of the African Scientific Priorities Programme at AAS/AESA, Deborah-Fay Ndlovu, communications manager and Gladys Akinyi, an intern, offered support in the writing of this article.</em></p><img src="https://counter.theconversation.com/content/156587/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Wambebe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>What’s needed is a prioritisation of the health and medicinal values of the food that’s consumed in African countries.Charles Wambebe, Professor Extraordinaire, Tshwane University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1562302021-04-20T12:33:27Z2021-04-20T12:33:27ZAfrican countries must consider legal challenges to sugar taxes before pursuing policies<figure><img src="https://images.theconversation.com/files/388523/original/file-20210309-23-1lnr2vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Sales of unhealthy foods and beverages in sub-Saharan Africa are skyrocketing. This is leading to an <a href="https://www.sciencedirect.com/science/article/pii/S2211912420301206">increase in obesity related conditons</a> such as diabetes, hypertension and cardiovascular disease. </p>
<p>These diseases are projected to become <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30370-5/fulltext">the leading cause of death in sub-Saharan Africa by 2030</a>, overtaking communicable diseases like HIV and TB. The economic cost of noncommunicable diseases is immense. They result in significant disability, and can be very expensive to treat. In South Africa, the medical cost of diabetes was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012049/">R2.7 billion in 2018</a>. </p>
<p>But noncommunicable diseases are preventable. The economic and societal impact can be mitigated if governments take decisive action to reduce the availability of harmful products such as unhealthy food, alcohol and tobacco.</p>
<p>Sugar-sweetened beverages are among the most harmful food products to consumers. This is because <a href="https://www.sciencedirect.com/science/article/abs/pii/S1043276012001191?casa_token=mkh_7xDvoqUAAAAA:54Fjyj7MH3XZAsDWKBdWzLq9GvUIYEkYtrL1ruRSrlcE5nf3Bqf_OfhP7aenNpumeNMGtHtNfZE">liquid sugar is especially toxic</a> and these drinks have no nutritional value.</p>
<p>One of the key ways to address the growing public health impact of sugary drinks is by introducing laws, policies and regulations. These measures could limit the availability of unhealthy products and make it easier to encourage people to eat healthy food. But they must be implemented as a combined effort. </p>
<p>There are a number of <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12580">proven interventions</a> to reduce the consumption of sugary drinks. These include limiting portion sizes, banning them from schools and checkout isles of supermarkets and taxing sugar-sweetened drinks. </p>
<p>But these measures have been challenged legally and by other means by the companies that produce and sell sugary drinks. </p>
<p>In 2012, then New York City mayor Michael Bloomberg introduced a regulation limiting the portion sizes of sugar-sweetened drinks sold around the city. The beverage industry and retailers <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302862">challenged this decision in court</a> and the policy was rolled back. South Africa’s efforts to introduce a tax on sugar-sweetened beverages <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00647-3">faced threats of legal challenges</a>. These were based on a range of technicalities from a lack of public participation to challenging the purpose of the tax. In this case, the objections only delayed the tax rather than stopping it. </p>
<p>Even if these law suits are unsuccessful, they can have a chilling effect on other actions to prevent noncommunicable diseases. Legal challenges to government efforts to address the availability of unhealthy food and drinks can seriously undermine public health.</p>
<p>This is why countries must carefully consider the legal feasibility of an intervention before deciding how to implement it. We <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1884358">developed</a> a way in which countries can consider doing this. It involves an assessment of the potential legal barriers to, and as well as the facilitators of, the proposed intervention.</p>
<h2>The landscape</h2>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1884358">study</a> looked at the legal feasibility of introducing a tax on sugar-sweetened beverages in seven sub-Saharan African countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda, and Zambia. We looked at four different types of sugary drinks taxes that had been introduced around the world and whether these could be introduced in each of these countries.</p>
<p>We assessed each country’s legal barriers and facilitators. These included their legal and taxation regimes. We also examined broader regional agreements and the infrastructure needed to implement such a tax. </p>
<p>We considered <a href="https://openknowledge.worldbank.org/bitstream/handle/10986/33969/Support-for-Sugary-Drinks-Taxes-Taxes-on-Sugar-Sweetened-Beverages-Summary-of-International-Evidence-and-Experiences.pdf?sequence=6&isAllowed=y">taxes implemented in various countries around the world</a> and chose to evaluate the four taxes adopted in Mexico, Colombia, the UK and South Africa under this study. The tax introduced in Mexico added a fixed amount on each litre of soft drink. The taxes in South Africa and the United Kingdom link the amount of tax payable to the sugar content of a drink. And Colombia decided to remove a value added tax exemption from sugar-sweetened beverages. With the exception of Colombia’s approach, most of these taxes are introduced as an excise tax.</p>
<p>Our research showed that all seven sub-Saharan African countries had existing excise tax legislation. And five countries already taxed sugar-sweetened beverages. However, these existing taxes worked to generate revenue for governments rather than improve public health as the taxes did not differentiate between sugary and non-sugary drinks. For example, Rwanda had a tax of 39% on carbonated beverages but sugary drinks remained a cheap beverage option.</p>
<p>In addition, countries have an obligation to introduce measures to protect the health of their citizens. These obligations are set out in treaties like the <a href="https://www.achpr.org/legalinstruments/detail?id=49">African Charter on Human and Peoples’ Rights</a> and domestic constitutions which contain rights to nutritious food or health. </p>
<p>Our research also showed that there were existing laws that could be used as a foundation to adopt a sugar-sweetened beverage tax to improve public health. For example, <a href="https://www.theguardian.com/global-development/2018/oct/26/tax-on-drinks-to-raise-funds-for-hiv-treatment-in-uganda">Uganda</a> had a dedicated HIV fund which was funded entirely by a 2% levy on drinks (including soft drinks and bottled water). Both <a href="https://www.kilimo.go.tz/index.php/en/stakeholders/view/sugar-board-of-tanzania-sbt">Tanzania</a> and <a href="http://kenyalaw.org/kl/fileadmin/pdfdownloads/bills/2019/TheSugarBill_2019.pdf">Kenya</a> had an agricultural levy on sugar, the proceeds of which were used to support sugar farmers. </p>
<p>The existence of supportive legal frameworks such as human rights could also be used to defend against potential challenges to a public health measure like this. </p>
<p>The introduction of taxes on sugar-sweetened beverages in <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/did-high-sugarsweetened-beverage-purchasers-respond-differently-to-the-excise-tax-on-sugarsweetened-beverages-in-mexico/37DBC66A6F1E19F74942888814EB1EA3">Mexico</a> and <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/abs/assessing-sugarsweetened-beverage-intakes-added-sugar-intakes-and-bmi-before-and-after-the-implementation-of-a-sugarsweetened-beverage-tax-in-south-africa/050AA9D1D8F9B12026C0F7836D1B4F09">South Africa</a> resulted in the reduced consumption of sugar and sugary drinks consumption within a year or two after the implementation of the tax. These reductions can lead to significant <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/assessing-sugarsweetened-beverage-intakes-added-sugar-intakes-and-bmi-before-and-after-the-implementation-of-a-sugarsweetened-beverage-tax-in-south-africa/050AA9D1D8F9B12026C0F7836D1B4F09">health benefits</a>, particularly in people who consume a lot of sugary drinks. In addition, these taxes are a particularly good intervention because they can help governments generate additional tax revenues. </p>
<h2>Looking ahead</h2>
<p>Our research shows that sugar-sweetened beverage taxation in the seven countries is legally feasible. Existing laws can provide a strong starting point for the introduction of a sugar-sweetened beverage tax. In addition, the adoption of such a tax is a way for governments to meet their human rights obligations without having to worry about legal challenges undermining the intervention.</p>
<p>Legal feasibility and the health impact of these interventions are only one part in the complex political economy of adopting noncommunicable disease prevention interventions. Research has shown that <a href="https://www.tandfonline.com/doi/abs/10.1080/23288604.2019.1669122">the political environment</a> and <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00647-3">industry pushback</a> against measures like sugar taxation are also important hurdles that need to be overcome. </p>
<p>Governments must take urgent action to prevent noncommunicable diseases from becoming an uncontrollable epidemic in sub-Saharan Africa. Sugar-sweetened beverage taxation offers a potential solution.</p><img src="https://counter.theconversation.com/content/156230/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Safura Abdool Karim is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p><p class="fine-print"><em><span>Karen Hofman is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p>Governments must take urgent action to prevent noncommunicable diseases from becoming an uncontrollable epidemic in sub-Saharan Africa. Sugar-sweetened beverage taxation offers a potential solution.Safura Abdool Karim, Senior researcher, University of the WitwatersrandKaren Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1562162021-04-20T12:32:08Z2021-04-20T12:32:08ZWhy African countries need reliable local data on sugary drinks taxes<figure><img src="https://images.theconversation.com/files/388205/original/file-20210308-18-779b17.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Appropriately designed taxes on sugar-sweetened beverages would result in proportional reductions in consumption.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Diets in sub-Saharan Africa are <a href="https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.12433">changing</a> as more countries advance from low-income to middle-income status. People’s eating habits are shifting from food rich in starchy staples, vegetables and fruits to a more <a href="https://theconversation.com/whats-driving-sub-saharan-africas-malnutrition-problem-55579">westernised diet</a> high in sugar, saturated fats and oils. This shift to unhealthy foods is <a href="https://www.who.int/news-room/fact-sheets/detail/healthy-diet">fuelling</a> obesity related chronic, noncommunicable conditions such as heart disease, diabetes and cancer.</p>
<p>Preventive measures are more critical than ever to curtail this tsunami that is overwhelming health systems.</p>
<p>One area that must adjust is the food and beverage sector in sub-Saharan Africa. The processed food industry is promoting the region as a <a href="https://www.mdpi.com/2071-1050/11/16/4306/htm">growth market</a> for its products. </p>
<p>To discourage consumption and reduce health risks, an increasing number of low- and middle-income countries have imposed <a href="https://openknowledge.worldbank.org/bitstream/handle/10986/33969/Support-for-Sugary-Drinks-Taxes-Taxes-on-Sugar-Sweetened-Beverages-Summary-of-International-Evidence-and-Experiences.pdf?sequence=6">taxes on sugar-sweetened drinks</a>. Across the globe and especially in <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1231">Latin America</a> and the <a href="https://www.sciencedirect.com/science/article/pii/S0091743517302608?via%3Dihub">Caribbean</a>, taxing sugary drinks to reduce consumption has been effective.</p>
<p>The World Health Organisation (WHO) has <a href="https://africa-health.com/news/world-health-organization-wants-sugar-taxes/">called on</a> African governments to follow this example, and to ease the burden of noncommunicable diseases. </p>
<p>In <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">2015</a>, a WHO panel of public health experts found that: </p>
<blockquote>
<p>appropriately designed taxes on sugar-sweetened beverages would result in proportional reductions in consumption, especially if aimed at raising the retail price by 20% or more. </p>
</blockquote>
<p>Some African countries such as South Africa, Botswana and Zambia already tax sugary drinks. But others have been slow to act. The <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">WHO</a> attributes this, in part, to evidence gaps. </p>
<p>Credible local data are essential to determine what taxes can and cannot achieve. </p>
<p>We wanted to get an understanding of what data are available to support the design, implementation, monitoring and evaluation of a sugary drinks tax. We focused on seven sub-Saharan African countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda, and Zambia. These economies are growing and their marketing industries are low-cost. Regulation of unhealthy commodities is also weak. </p>
<p>In combination, these factors represent a growth opportunity for the industry. They will also fuel diet-related noncommunicable diseases.</p>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2020.1871189">research</a> highlighted the urgent need for new indicators on unhealthy diets, including sugary drinks consumption and purchase patterns. Without this evidence, countries might underestimate the consumption figures. They might then miss the potential of sugar-sweetened drinks taxation as a public health intervention.</p>
<h2>Our research</h2>
<p>We interviewed stakeholders such as representatives from government agencies, including those in health, commerce, development, agriculture, education and academia. All individuals underscored the importance of local evidence on sugary drinks consumption and purchasing behaviours, as well as fiscal evidence to compare the cost and benefits of a tax. This is because policymakers need to take into account evidence for coherent economic arguments to discuss sugar-sweetened drinks taxes in policy circles.</p>
<p>The potential health benefits, the revenue of such a tax, as well as the monitoring and evaluation of its implementation, requires appropriate baseline data at the outset particularly across income levels, and age groups. </p>
<p>Our study highlights that such information is missing in all seven countries.</p>
<p>We looked at a range of publicly available data sources to establish the rate of sugary drinks consumption and the impact on people’s health. </p>
<p>We found that national survey data does not adequately track either the intake of sugar-sweetened drinks, or household spending. Fiscal data is lacking regarding sugary drinks tax revenue, value added tax from sugary beverage sales, and the corporate income tax and customs duty revenue.</p>
<p>Accurate information on the soft drinks industry was not easily accessed either. Unlike in countries such as Mexico, it was difficult to find information on a number of fronts. The number of companies in industry sectors, beverage industry forecasts, drinks prices, package sizes, number of low- or no-calorie beverages, and sugar content were unavailable. </p>
<p>Kenya, Zambia, Rwanda, Tanzania and Uganda had taxes on non-alcoholic beverages. But only Zambia had a differential sugar-sweetened beverages tax – 3% on imported beverages and 0.5% on local drinks. Botswana recently introduced a tax that is very similar to the health promotion levy in South Africa.</p>
<h2>Going forward</h2>
<p>Timely, easily understood, concise, and locally relevant evidence is needed to inform policy development on sugary drinks. The relevant data are drawn from multiple sectors. Cross-sector collaboration is, therefore, needed. </p>
<p>Indicators to measure sugar-sweetened drinks and added sugar consumption should be developed. These must be included in current data collection tools such as national income dynamics studies. This would ensure monitoring and evaluation of taxation. </p>
<p>There’s no consensus on how best to capture data for new indicators. But a useful point of departure would be to complement existing data sources. These include population-based surveys that ask questions related to sugary drinks taxation. This would lead to improvement in tracking the intake of sweet drinks, and the effectiveness of taxation.</p>
<p>Establishing robust, accurate baseline data to inform evidence could enable governments to accelerate political and public support for sugar-sweetened beverage taxation and related policies. Finally, greater transparency of industry data is essential.</p><img src="https://counter.theconversation.com/content/156216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Erzse receives funding from the South African Medical Research Council/Centre for Health Economics and Decision Science PRICELESS SA, University of Witwatersrand School of Public Health, Faculty of Health
Sciences, Johannesburg South Africa (D1305910-03). The research was supported by the International Development Research Center grant (#108648-001)</span></em></p><p class="fine-print"><em><span>Karen Hofman is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p>Without reliable, local and timely data, countries will miss the potential of sugar-sweetened beverage taxation as a public health intervention.Agnes Erzse, Researcher, SAMRC/Centre for Health Economics and Decision Science- PRICELESS SA, University of the WitwatersrandKaren Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1551452021-04-20T12:30:44Z2021-04-20T12:30:44ZHow Rwanda can use fiscal policies to improve health outcomes<figure><img src="https://images.theconversation.com/files/384477/original/file-20210216-17-19uobba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Rwanda’s health sector has seen many reforms over the past <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60574-2/fulltext?rss=yes">two decades</a>, which have greatly improved public health indicators. Communicable diseases have declined and the <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1581-4">maternal mortality</a> rate fell from 1,071 deaths per 100,000 live births in 2000 to 210 in 2015.</p>
<p>But noncommunicable diseases are a <a href="https://www.who.int/ncds/surveillance/steps/Rwanda_2012_STEPS_Report.pdf">growing problem</a>. Overweight, obesity and associated nutrition related diseases are becoming <a href="https://www.who.int/nmh/countries/rwa_en.pdf?ua=1">more prevalent</a> in Rwanda. </p>
<p>Globally, the rapid increase in consumption of <a href="https://www.who.int/elena/titles/bbc/ssbs_adult_weight/en/">sugar sweetened beverages</a> has been identified as a major contributor to the rise of obesity and noncommunicable disease such as type 2 diabetes. </p>
<p>In several countries taxation on sugar sweetened beverages has <a href="https://www.tandfonline.com/doi/full/10.1080/23288604.2019.1669122">emerged</a> as a cost-effective strategy to combat obesity and noncommunicable diseases. <a href="https://pubmed.ncbi.nlm.nih.gov/29531419/">Research</a> has shown that people buy and consume sugary drinks less when their price is increased through taxation.</p>
<p>Rwanda has an excise tax of <a href="https://taxsummaries.pwc.com/rwanda/corporate/other-taxes#:%7E:text=Excise%20taxes&text=Soda%20and%20lemonade%3A%2039%25.">39%</a> on soft drinks. Its main purpose is to generate revenue. Because it applies to all soft drinks, irrespective of sugar content, the tax as it stands is unlikely to reduce consumption of sugary drinks. </p>
<p>We <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1883911">looked at</a> what might influence the ability of the government to use the soft drinks tax to achieve public health goals.</p>
<p>We found that competing priorities stand in the way of imposing a sugary drinks tax. The government has progressive, cross-sectoral policies to address the growing burden of noncommunicable diseases. But other <a href="https://www.newtimes.co.rw/section/read/51017">policies</a> support the growth of local sugar production and the sugary drinks industry. And the country’s <a href="http://www.rwandafda.gov.rw/web/fileadmin/national_food_and_nutrition_policy_.pdf">food policies</a> generally focus more on food production to make sure people have livelihoods and enough quality food.</p>
<h2>Existing taxes</h2>
<p>The existing excise tax of 39% on soft drinks is well above the 20% tax rate <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">recommended</a> by the World Health Organisation. But it hasn’t had a significant impact on the price or consumption of sugar sweetened drinks compared to non-sugary beverages. This is likely because it applies equally to sugary and non-sugary carbonates. </p>
<p>Still, the tax is a good starting point for policies that put public health first.</p>
<p>The position and economic importance of the sugar sweetened beverage industry in Rwanda is likely to be a barrier to the adoption of such taxation. This has been the case in many <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-019-0495-5">low- and middle-income countries</a>. Concerns about the economic and job implications of a sugary drinks tax may hinder or delay the adoption of such a policy. Opponents of a sugary drinks tax in <a href="https://theconversation.com/how-south-african-food-companies-go-about-shaping-public-health-policy-in-their-favour-143368">South Africa</a> argued that it would result in significant job losses – despite evidence to the contrary. The country increased taxes on sugar-sweetened beverages in 2018. </p>
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<strong>
Read more:
<a href="https://theconversation.com/how-south-african-food-companies-go-about-shaping-public-health-policy-in-their-favour-143368">How South African food companies go about shaping public health policy in their favour</a>
</strong>
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<p>The East African Community can influence markets and companies through trade mechanisms and coordinated regulations. Its secretariat has a <a href="https://ideas.repec.org/p/pot/fiwidp/60.html">technical working group</a> on excise tax coordination. So, interventions at a regional level could be another way of achieving the public health goals. </p>
<p>The policy landscape related to sugary drinks taxation in Rwanda is influenced by many factors and is evolving. The existing policy landscape, at domestic and regional levels, provides opportunities to strengthen sugary drinks taxation. But these are matched by a complex political landscape with competing priorities. Action must be taken to improve support for this intervention and the successful adoption of a policy. </p>
<h2>Recommendations</h2>
<p>We believe the government could use soft drinks tax more effectively as a <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">public health tool</a> without undermining employment and national development. Producers could redesign their production or invest in more healthy products.</p>
<p>It will need the cooperation of government ministries, regulatory authorities, civil society and consumer organisations, as well as academia and research institutions. The East African Community could also play a part by adopting regional regulations. </p>
<p>The role of private actors, such as the beverages industry, in the development of nutrition-related health policies should remain limited to avoid undue influence.</p>
<p>Rwanda should amend the excise tax to target sugar content so that people reduce their consumption of sugary drinks and turn to healthier options. </p>
<p>Different taxes linked to the sugar content of beverages should be adopted such as the ones adopted in countries like Mexico, the United Kingdom and South Africa. These <a href="https://gh.bmj.com/content/4/4/e001317">resulted</a> in increased prices of sugary drinks and encouraged producers to reformulate their products to reduce the sugar content.</p><img src="https://counter.theconversation.com/content/155145/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ruhara Mulindabigwi Charles does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rwanda’s food policies focus on production to make sure people have livelihoods and enough nutritious food. Not much attention is given to overnutrition.Ruhara Mulindabigwi Charles, Coordinator of Postgraduate Programmes, School of Economics, University of RwandaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1563162021-04-20T12:27:18Z2021-04-20T12:27:18ZZambia must find a way to balance the economy and public health in tax policy<figure><img src="https://images.theconversation.com/files/394740/original/file-20210413-17-9xp7jr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The burden of noncommunicable diseases is <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30374-2/fulltext">growing rapidly</a> across sub-Saharan Africa. The conditions, which include obesity and diabetes, are now <a href="https://www.who.int/nmh/countries/2018/zmb_en.pdf">leading causes</a> of premature deaths. In Zambia, noncommunicable diseases account for <a href="https://www.who.int/nmh/countries/2018/zmb_en.pdf">29% of all deaths</a>.</p>
<p>The consumption of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0140673612620893">unhealthy commodities</a> – tobacco, alcohol and ultra-processed foods high in sugar, salt and fats – is a major risk factor for these conditions. </p>
<p>To regulate the availability of unhealthy commodities, the World Health Organisation (WHO) recommends cost-effective, evidence-based interventions. One such measure is a <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">tax on sugar-sweetened beverages</a>. Sweetened beverages are associated with a number of <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12868">health complications</a>. These include an increased risk of <a href="https://www.bmj.com/content/351/bmj.h3576">type 2 diabetes</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/26869455/">cardiovascular diseases</a> and other obesity‐related diseases.</p>
<p>The aim of such a tax is to discourage people from buying these drinks. </p>
<p>Zambia is one of the African countries that has acted to regulate the environment for products linked to obesity. In January 2019 the country introduced an excise tax on all non-alcoholic beverages except water. A <a href="https://extranet.who.int/nutrition/gina/sites/default/filesstore/ZMB%202018%20Customs%20and%20Excise%20%28amendment%29%20%20Act%20No.%2019%20of%202018.pdf">tax rate</a> of K0.30 (US$ 0.02) per litre was levied. This 3% tax is well below the <a href="https://gh.bmj.com/content/bmjgh/5/4/e001968.full.pdf">recommended rate</a> of 20% required to reduce noncommunicable disease risk factors like obesity. Because of the low rate, health sector stakeholders are suggesting that the tax no longer focuses on public health. Instead, it’s a general source of government revenue. </p>
<p>In our recent <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1872172">study,</a> my colleagues and I looked for opportunities to strengthen this tax policy in Zambia. Our focus was on sugar-sweetened beverage taxation. We reviewed policy documents and spoke to nutrition advocates, industry representatives and policymakers. We wanted to understand the context in which policies about nutrition-related diseases are developed. We also wanted to explore the potential use of revenue from tax on sugary drinks to support improved nutrition.</p>
<p>Our findings showed tension between the government’s economic and public health priorities. The government has <a href="https://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-017-0195-7">intentions of regulating</a> production of harmful food products like sugar-sweetened beverages. But it also <a href="https://www.mcti.gov.zm/?page_id=5176">commits to growing the economy</a> by investment in the manufacturing sector, which includes the food and beverage sub-sector. </p>
<p>This has prevented stronger fiscal measures to address noncommunicable diseases related to nutrition. But we believe the tension need not hurt the public health objectives. There are opportunities to strengthen existing taxation of sugary drinks by ensuring policies take local economic context into account.</p>
<h2>Our research</h2>
<p>The policy <a href="https://extranet.who.int/ncdccs/Data/ZMB_B3_NCDs%20Strategic%20plan.pdf">documents</a> we <a href="https://www.mndp.gov.zm/wp-content/uploads/2018/05/7NDP.pdf">reviewed</a> and stakeholder interviews we conducted recognised the increasing problem of noncommunicable diseases in Zambia. </p>
<p>The diseases were linked to lifestyle factors such as physical inactivity and unhealthy diet. But none of the policies we reviewed identified sugary beverages as a driver of noncommunicable diseases in Zambia. </p>
<p>Our interviews also highlighted existing misperceptions. The people we interviewed linked affluence to sugary drinks consumption. They believed wealthier populations were more affected by nutrition-related diseases. But <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-465">research suggests</a> it’s poorer populations who tend to consume more unhealthy food. Unhealthy foods, including processed foods high in salt, fat and sugar, are cheaper than healthier food options but have attracted high status. </p>
<p>Nutrition advocates and government representatives suggested that the lack of diversity in people’s diets could be a contributor to the rise of noncommunicable diseases. Maize porridge – <em>nshima</em> – is a staple in the country and is consumed several times a day. But there’s a lack of evidence in this regard. </p>
<p>Policymakers felt the government was well prepared to address the health problem. They pointed to policies such as the strategic plan for nutrition-related noncommunicable diseases and related <a href="https://extranet.who.int/ncdccs/Data/ZMB_B3_NCDs%20Strategic%20plan.pdf">risk factors</a> as an example. The <a href="https://www.lusakatimes.com/2019/02/02/exercise-is-best-health-practice-president-lungu/">president’s active engagement</a> in promoting healthy lifestyles in mainstream media was seen as good leadership. </p>
<p>In contrast, respondents representing civil society felt that the current leadership and policies were insufficient. Marketing of unhealthy food products remained unregulated and nutrition programmes were poorly funded. They also felt the sugar-sweetened beverage tax was inadequate to curb consumption and hence noncommunicable diseases. </p>
<p>The sugary drinks tax in Zambia was initiated and championed by the Ministry of Health. Initially, a tax rate of 20% was proposed. But this met strong pushback from the government’s economic sector and industry stakeholders. They argued this would contribute to a high cost of doing business. Industry <a href="http://zam.co.zm/download/zam-submission-proposed-regulatory-reform-to-improve-nutrition/">attempted</a> to discredit evidence supporting the tax. Some suggested that the Zambian government was bowing to international pressure without considering the implication of the tax in the domestic context. Such strong lobbying against the tax likely contributed to the low rate of 3% that was eventually adopted.</p>
<p>Respondents suggested that revenues from the tax should finance nutrition and noncommunicable disease prevention programmes. These would include health promotion and education, regulation of the marketing of unhealthy foods, improved food labelling, and incentives for production of healthy foods. </p>
<p>These suggestions reflected a perception among all respondents that the population was largely unaware of causes, prevention and impact of nutrition related noncommunicable diseases. Therefore, raising awareness should be an immediate priority for Zambia.</p>
<h2>Way forward</h2>
<p>Our findings show that there is an opportunity to strengthen policies addressing noncommunicable diseases in African countries through measures like sugar-sweetened beverage taxes. But policy measures should be contextualised to the needs of the country. The priority of most African governments is economic growth. This is evident in policies that encourage growth of industries that produce unhealthy commodities. This context should not be ignored as it bears on the success of policy measures that protect population health. </p>
<p>A differential tax that distinguishes between international and local producers and manufacturers may be a feasible starting point to balance economic interest with public health objectives.</p>
<p>Taxation could also support public health by providing subsidies for fruit and vegetables, or the provision of safe drinking water. To achieve this, the revenues from the tax could be earmarked for health promotion.</p>
<p>Health problems have their origins and consequently solutions outside the health sector. This is why consultation must expand beyond the health sector during the development of policies addressing noncommunicable diseases. </p>
<p>Such consultation will go a long way to improve policy coherence between the health and economic sectors of governments. Policy measures should be contextualised to strike a balance between public health and the economic needs of countries.</p><img src="https://counter.theconversation.com/content/156316/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mulenga Mary Mukanu, received support for this work from International Development Research Centre, Ottawa
Canada under grant number 108648-001. </span></em></p>Tension between the government’s economic and public health priorities is preventing stronger fiscal measures to address nutrition-related noncommunicable diseases.Mulenga Mary Mukanu,, PhD Candidates, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579082021-04-20T08:08:01Z2021-04-20T08:08:01ZKenya doesn’t have a stand-alone tax on sugary drinks: we set out to find out why<figure><img src="https://images.theconversation.com/files/395266/original/file-20210415-20-r25nse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The consumption of a lot of soft drinks is linked to increased obesity. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Kenya is <a href="https://www.health.go.ke/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">experiencing a rise</a> in obesity. Overweight and obesity among women increased from 25% in 2008 to 33% in 2014. An estimated one in four Kenyan urban children are <a href="https://www.dhsprogram.com/pubs/pdf/sr227/sr227.pdf">overweight or obese</a>. At the same time there has been a rise in associated <a href="https://globalnutritionreport.org/resources/nutrition-profiles/?country-search=kenya">noncommunicable diseases</a>. These include diabetes, cardiovascular diseases and cancer. Noncommunicable diseases now account for over <a href="https://www.health.go.ke/wp-content/uploads/2016/04/Steps-Report-NCD-2015.pdf">50% of hospital admissions</a> in the country.</p>
<p>Globally, the rise in noncommunicable diseases has been attributed to the growing consumption of unhealthy foods such as sugar-sweetened beverages. Between 2018 and 2019 Kenya registered a 30% spike in <a href="https://apps.fas.usda.gov/newgainapi/api/report/downloadreportbyfilename?filename=Sugar%20Annual_Nairobi_Kenya_4-12-2018.pdf">sugar production</a> and an <a href="http://www.parliament.go.ke/sites/default/files/2019-08/Report%20on%20the%20Crisis%20Facing%20the%20Sugar%20Industry%20in%20Kenya%20%28%20Annexures%29.pdf">increase</a> in sugar consumption from the growth of retail, industrial and food service sectors. </p>
<p>To control the rising burden of obesity and noncommunicable diseases the World Health Organisation (WHO) <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">recommends</a> a tax on sugar-sweetened beverages. It views such taxes as a population-level, cost-effective measure to discourage consumption of sugar-sweetened beverages. </p>
<p>The approach has been widely used in several countries including South Africa. However, to date, Kenya has no standalone sugar-sweetened beverage tax policy.</p>
<p>We undertook <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1902659">research</a> into the possibility of implementing a sugar-sweetened beverage tax in Kenya. </p>
<p>The study entailed a desk review of existing evidence on noncommunicable diseases and sugar-sweetened beverages. We also conducted interviews with a wide range of experts to explore the policy and political context as well as the enablers of and barriers to such a policy.</p>
<p>We identified a number of barriers to adopting a tax on sugary drinks in Kenya. These included limited evidence on sugar-sweetened beverages as a risk factor for noncommunicable diseases in Kenya. We also found industry interference in the development of sugar-sweetened beverage taxation policy. </p>
<p>But we also found that existing policies provided an opportunity to pursue a sugar tax in the country. These include the <a href="http://publications.universalhealth2030.org/uploads/kenya_health_policy_2014_to_2030.pdf">Kenya Health Policy</a> and the <a href="https://www.who.int/nmh/ncd-task-force/kenya-strategy-ncds-2015-2020.pdf?ua=1">National Strategy for Control and Prevention of Noncommunicable diseases</a>. </p>
<h2>Barriers</h2>
<p>A number of factors accounted for the fact that Kenya hasn’t pursued a tax on sugar-sweetened beverages.</p>
<p>The first was a dearth of up-to-date publicly available information on sugary drinks sales and consumption in Kenya. Data are essential to guide the decisions and process of development and adoption of a stand alone sugar-sweetened beverage tax. </p>
<p>Interviewees also cited lack of information in the general population about sugar-sweetened beverages and how they affect health. They attested to the fact that tobacco and alcohol are widely recognised risk factors for noncommunicable diseases. Not so with sugar-sweetened beverages.</p>
<blockquote>
<p>An important barrier when we are dealing with sugar-sweetened beverages is the fact that the public does not appreciate that this is a problem. What do respectable old men and women in the village, church elders, take when they go for a meeting? It is tea, Coca-Cola, Sprite, Fanta. I think it presents a subtle challenge that we don’t have when we are dealing with tobacco or alcohol. Nobody argues about the adverse consequences of tobacco or of alcohol.</p>
</blockquote>
<p>A second barrier we identified was that government ministries held different and sometimes opposing interests. </p>
<p>For instance, the ministry of health was interested in improving health and discouraging the trade, production and marketing of sugary drinks. But the ministry of industry, trade and cooperatives promoted the sugar and food processing industries as major revenue for government. </p>
<p>Our key informants felt that these opposing priorities might get in the way of a sugar-sweetened beverage taxation policy being developed. </p>
<p>A third factor we identified was industry lobbying against sweet drinks taxation. The sugar-sweetened beverage companies were described by key informants as having major influence over government decision making. This was because of the power they wielded in terms of their operations, and their contribution to the government revenues. They also use industry alliances and formations to fight sugar-sweetened beverage taxes, which may overwhelm an under-resourced government like Kenya’s. </p>
<p>As one interviewee put it: </p>
<blockquote>
<p>… unfortunately, there’s a lot of industry interference with policy (on sugary drinks). This is a big industry; very big in terms of capital and also in terms of influence. They pay a lot of tax to government and they have a lot of leverage … An industry like that of course has a lot of policy interference because they have big money they can compete with us.</p>
</blockquote>
<p>Kenya does charge an excise tax on all soft drinks of 10 Kenya shillings (0.10 USD) per litre. This includes sugar-sweetened beverages. And in <a href="http://kenyalaw.org/kl/fileadmin/pdfdownloads/bills/2018/FinanceBill__2018.pdf">2018</a> an excise tax of 20 shillings (0.20 USD) per kilogram was imposed on sugar confectionery and chocolate. </p>
<p>But these taxes were introduced as a revenue generation strategy, not as a means to manage noncommunicable diseases. They are likely to have only a minimal impact on the consumption of sugary drinks.</p>
<h2>Going forward</h2>
<p>We made a number of recommendations on how a sugar-sweetened beverage tax could be developed and implemented in Kenya.</p>
<p>First, public and policymaker education is critical to challenge the prevailing attitudes to sugary drinks.</p>
<p>Second, strategies to develop industrial growth should be critically examined to understand how they could undermine the government’s commitment to addressing noncommunicable diseases. This will require wide stakeholder engagement beyond the ministry of health in policy development.</p>
<p>Third, civil society needs to be involved in sustained advocacy to ensure that Kenyans understand the issues at hand.</p>
<p>And more research evidence is needed to support an explicit sugar-sweetened beverage taxation policy. Kenya also needs to gather local and regional or international evidence to inform and guide its decisions in the development and adoption of a standalone tax on sugary drinks.</p><img src="https://counter.theconversation.com/content/157908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This work was carried out with support from the International Development Research Centre (IDRC),Ottawa Canada (grant number 108648-001)</span></em></p><p class="fine-print"><em><span>Gershim Asiki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Between 2018 and 2019 Kenya registered a 30% spike in sugar production and an increase in sugar consumption.Milka Wanjohi, Research officer, African Population and Health Research CenterGershim Asiki, Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1582432021-04-20T07:08:00Z2021-04-20T07:08:00ZWe mapped the landscape for taxes on sugary drinks in seven African countries<figure><img src="https://images.theconversation.com/files/395216/original/file-20210415-19-8phjzy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The competing interests of economic growth and public health aren't being managed well.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Preventing diet-related noncommunicable diseases in sub-Saharan Africa and decreasing the burden on fragile healthcare systems is an urgent priority for governments. This urgency is <a href="https://www.sifar.org.za/sites/default/files/field/file/BHPSA%20COVID%20age%2002-10.pdf">exacerbated by the COVID-19 pandemic</a>. Individuals with noncommunicable diseases are bearing the brunt of <a href="https://www.sifar.org.za/sites/default/files/field/file/BHPSA%20COVID%20age%2002-10.pdf">COVID-19-related morbidity and mortality</a>. </p>
<p>African countries face a growing burden of noncommunicable diseases. These are expected to be <a href="https://openknowledge.worldbank.org/handle/10986/16451">the leading cause of death in sub-Saharan Africa</a> over the next 10 years, overtaking communicable diseases such as HIV and tuberculosis. </p>
<p>The increasing rates of obesity and overweight are major risk factors for noncommunicable diseases. Adopting evidence-based policies that seek to reduce consumption of unhealthy foods – like sugary beverages or ultra-processed foods – can help governments reduce the risk of these conditions. The <a href="https://www.who.int/dietphysicalactivity/publications/fiscal-policies-diet-prevention/en/">World Health Organisation has endorsed</a> a number of measures. These include restricting marketing of unhealthy foods to children, introducing simple nutrition labels and implementing taxes on sugary beverages. </p>
<p>More states around the world are adopting these kinds of policies. Over <a href="https://apps.who.int/gb/ebwha/pdf_files/EB148/B148_7-en.pdf#page=22">73 countries</a> had adopted a tax on sugary beverages by 2020. Botswana and South Africa are among them.</p>
<p>Yet, there is a dearth of data and policies to support action on noncommunicable diseases in most of sub-Saharan Africa.</p>
<p>New research is being published on a regular basis showing that <a href="https://www.sciencedirect.com/science/article/pii/S2542519620303041">taxation of sugary beverages is an effective intervention</a> to reduce consumption of unhealthy products. Sugar-sweetened beverage taxes have also been found to be cost-effective to implement. And they can be used to <a href="https://www.who.int/bulletin/volumes/96/3/17-195982.pdf">generate revenue for health-promoting activities</a>.</p>
<p>In <a href="http://www.treasury.gov.za/public%20comments/Sugar%20sweetened%20beverages/2017022701%20-%20QandA%20Tax%20on%20Sugary%20Beverages.pdf">2016</a> South Africa became the first country in sub-Saharan Africa to announce the adoption of a tax on sugary beverages. A <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0105287">modelling study</a> was done by the South African Medical Research Council Centre for Health Economics and Decision Science. Known as <a href="https://pricelesssa.ac.za/about/who-we-are">PRICELESS SA</a>, our research unit provided the <a href="http://www.treasury.gov.za/public%20comments/Sugar%20sweetened%20beverages/POLICY%20PAPER%20AND%20PROPOSALS%20ON%20THE%20TAXATION%20OF%20SUGAR%20SWEETENED%20BEVERAGES-8%20JULY%202016.pdf#page=18">evidence</a> to support this decision. South Africa successfully implemented the health promotion levy in 2018, a tax of 11% on sugary beverages. </p>
<p>In 2017, seeking to draw on South Africa’s experience and the lessons learned, we launched an ambitious multi-country study. We wanted to assess the readiness to adopt a sugary tax for noncommunicable disease prevention in sub-Saharan Africa. The <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2020.1856469">study took place in seven countries</a>: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia. In many cases it was the first research in particular countries on sugary beverage taxation or even noncommunicable disease policy. </p>
<p>After three years of intensive work, the research has culminated in the publication of a special issue of the journal <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2020.1856469">Global Health Action</a>. It showcases some of the challenges and opportunities policymakers may encounter in adopting a sugar-sweetened beverage tax. </p>
<p>The main findings show that implementing a sugar-sweetened beverage tax is possible in all seven countries. Critically, for researchers, it will also require an evidence base that can be used to create political will and to engage with civil society to support the adoption of a tax.</p>
<h2>Gathering the evidence</h2>
<p>The project involved over 12 researchers from nine countries. They set about mapping the noncommunicable disease policy environment in each of the seven countries where the studies were done. </p>
<p>They untangled complex networks of stakeholders and decision makers and clarified the existing evidence base to support action on noncommunicable diseases in their country. </p>
<p>The study suggests that noncommunicable disease prevention is a key priority in all the countries. What’s encouraging is that they have a lot of backing from international organisations. For example, the United Nations has issued a high-level mandate for action on noncommunicable diseases. For its part the World Health Organisation endorsed taxes on sweetened drinks. In addition, a host of countries such as Mexico and South Africa have introduced taxes and <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30304-1/fulltext">seen reductions in consumption of sugary beverages</a>.</p>
<p>The aim of the levy introduced by South Africa was to prevent obesity by reducing sugar consumption. The process of adopting the tax was complicated. There were concerns about job losses. In addition, the tax <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00647-3">faced vigorous opposition</a> from the sugar producing and sugary beverage industries. </p>
<p>However, there was significant support from <a href="https://pmg.org.za/committee-meeting/23942/">civil society actors</a>. Three years after the implementation of the health promotion levy, <a href="https://theconversation.com/new-research-shows-south-africas-levy-on-sugar-sweetened-drinks-is-having-an-impact-158320">evidence shows</a> the clear impact the tax has had on consumption. </p>
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Read more:
<a href="https://theconversation.com/new-research-shows-south-africas-levy-on-sugar-sweetened-drinks-is-having-an-impact-158320">New research shows South Africa's levy on sugar-sweetened drinks is having an impact</a>
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<h2>Next steps</h2>
<p>In sub-Saharan Africa, the competing interests of economic growth and public health are not well managed. The research that’s been done shows that contradictory policies have been adopted. For example, some countries have introduced policies that promote the growth of the sugar and sugary beverage industries. </p>
<p>Nevertheless, the evidence gathered also shows that countries like Rwanda and Zambia have begun adjusting policies to remove economic incentives for these industries and instead to promote other, healthier products. </p>
<p>This demonstrates that, with sufficient political will, public health can be compatible with economic growth.</p><img src="https://counter.theconversation.com/content/158243/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Safura Abdool Karim is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p><p class="fine-print"><em><span>Agnes Erzse receives funding from the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p><p class="fine-print"><em><span>Karen Hofman is supported by the South African Medical Research Council Centre for Health Economics and Decision Science - PRICELESS SA. The research referenced in this article was supported by the International Development Research Centre, Canada.</span></em></p><p class="fine-print"><em><span>Susan Goldstein receives funding from the SAMRC, the IDRC, the Wellcome Trust, the UK MRC and the NIHR</span></em></p>Implementing a sugar-sweetened beverage tax in all African countries will require sufficient political will and support from civil society.Safura Abdool Karim, Senior researcher, University of the WitwatersrandAgnes Erzse, Researcher, SAMRC/Centre for Health Economics and Decision Science- PRICELESS SA, University of the WitwatersrandKaren Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandSusan Goldstein, Associate Professor in the SAMRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1583202021-04-09T12:19:09Z2021-04-09T12:19:09ZNew research shows South Africa’s levy on sugar-sweetened drinks is having an impact<figure><img src="https://images.theconversation.com/files/393983/original/file-20210408-19-1e44z8a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Photo by Peter Kovalev\TASS via Getty Images</span></span></figcaption></figure><p>Three years ago South Africa introduced Africa’s <a href="https://www.diabetessa.org.za/sugar-tax-an-update-where-are-we-at-currently/#:%7E:text=South%20Africa%20was%20the%20first,of%20granulated%20sugar%20per%20100ml.">first major tax on sugar-sweetened beverages</a> based on grams of sugar. The tax now stands at about 11% of the price per litre. </p>
<p>We assessed the impact in recently published <a href="https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30304-1/fulltext">research</a>. We found that the health promotion levy coincided with large reductions in purchases of taxable beverages, in terms of both volume and sugar quantities. We didn’t find significant changes for non-taxable beverages. </p>
<p>This isn’t the first research to show positive outcomes from the levy. A national <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953619304599">study</a> one year after it was introduced found households in urban areas halved the volume of sugary beverages they bought, cutting their sugar intake by nearly a third. Similar results were found regionally in <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/abs/assessing-sugarsweetened-beverage-intakes-added-sugar-intakes-and-bmi-before-and-after-the-implementation-of-a-sugarsweetened-beverage-tax-in-south-africa/050AA9D1D8F9B12026C0F7836D1B4F09">Soweto</a> in Gauteng.</p>
<p>The new research is the first evaluate this particular tax design. At a national level, we measured changes in household purchases of taxable and non-taxable beverages in terms of volume, sugar and calories. We also assessed changes in the purchasing behaviour of households stratified by household socioeconomic status. We assessed changes between the period before the levy to after its announcement and through the first year of its implementation period. </p>
<p>Research <a href="https://pubmed.ncbi.nlm.nih.gov/30882235/">shows</a> that excess sugar, particularly in <a href="https://pubmed.ncbi.nlm.nih.gov/31398911/">liquid form</a>, is a major cause of obesity and is a risk factor for diseases like type 2 diabetes, hypertension, heart disease, many common cancers and tooth decay. Recognising this danger, the World Health Organisation (<a href="https://www.who.int/news/item/04-03-2015-who-calls-on-countries-to-reduce-sugars-intake-among-adults-and-children">WHO</a>) has recommended that individuals should consume no more than 10% of total calories from added sugar, and preferably less than 5%.</p>
<p>Carbonated sugary drinks play a major role in making these numbers hard to attain. A <a href="https://heala.org/wp-content/uploads/2021/02/HEALA-Fact-sheet-Evidence-to-support-increasing-South-Africas-Health-Promotion-Levy-to-20percent-in-2021.pdf">250ml cooldrink contains upwards of 26g of sugar</a> – more than half the daily recommended limit.</p>
<p>Sub-Saharan Africa faces a tidal wave of diet-related noncommunicable diseases, with rapidly rising intake of <a href="https://pubmed.ncbi.nlm.nih.gov/23488503/">sugar-sweetened beverages</a> and other <a href="https://pubmed.ncbi.nlm.nih.gov/24102801/">ultra-processed foods</a>. South Africa, in particular, has <a href="https://pubmed.ncbi.nlm.nih.gov/31537368/">a heavy burden</a> of these noncommunicable diseases. </p>
<p>While other countries in sub-Saharan Africa have levied sugar-sweetened beverage taxes, South Africa is the first country in the region to evaluate such a policy.</p>
<p>Our results clearly show positive changes that could offer useful public health gains across the region. The reductions in sugar from taxable beverage purchases suggest a potential role for sugar-based taxes more broadly. </p>
<h2>To tax, or not to tax</h2>
<p>More than 50 jurisdictions across the globe have used taxes to curb the consumption of sugar-sweetened beverages. </p>
<p>For example, in 2014, Mexico introduced a tax of one peso per litre on beverages containing added sugar. Research has <a href="https://www.bmj.com/content/352/bmj.h6704">shown that</a> it resulted in a 6% reduction in purchased volume relative to pre-tax trends over the first year of the tax, and a 7.6% reduction over the first two years of the tax. </p>
<p>Tax policies in other countries such as the <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1477-4">UK</a> and several subnational jurisdictions in the <a href="https://pubmed.ncbi.nlm.nih.gov/27552267/">US</a> have also resulted in statistically significant reductions in purchases of sugar-sweetened beverages.</p>
<p>South Africa has led the continent firstly by introducing the tax, and secondly by making the levy about <a href="https://pubmed.ncbi.nlm.nih.gov/31472286/">sugar content rather than volume</a>. </p>
<p>Given that sugar-sweetened drinks contain variations in sugar levels, taxing them according to their sugar content is a more precise way of targeting the source of these products’ harm. It also gives beverage <a href="http://www.treasury.gov.za/public%20comments/Sugar%20sweetened%20beverages/POLICY%20PAPER%20AND%20PROPOSALS%20ON%20THE%20TAXATION%20OF%20SUGAR%20SWEETENED%20BEVERAGES-8%20JULY%202016.pdf">manufacturers</a> an incentive to reduce the sugar content of their products. This strategy formed the basis of South Africa’s 2018 tax policy.</p>
<h2>Unfinished business</h2>
<p>South Africa’s levy showed that in 2018 the country was prepared to put the health of the public in first place.</p>
<p>But the government has failed to capitalise on these early gains, despite the <a href="http://www.treasury.gov.za/public%20comments/Sugar%20sweetened%20beverages/POLICY%20PAPER%20AND%20PROPOSALS%20ON%20THE%20TAXATION%20OF%20SUGAR%20SWEETENED%20BEVERAGES-8%20JULY%202016.pdf#page=18">evidence that’s been presented</a> to it about the impact of the levy on consumption patterns. An example of this is that it has not raised the rate at which the tax is imposed. </p>
<p>Health experts had been lobbying for an increase to 20% – the levy recommended by the WHO. No country in the world has reached this benchmark. Nations are only getting part of the benefits in terms of preventing obesity. This matters to the future health of children, in particular. South Africa has seen a rise in <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1449-8">childhood obesity rates since 1994</a>. And some forecasts suggest that the country will have the <a href="https://www.worldobesity.org/membersarea/global-atlas-on-childhood-obesity">10th highest level of childhood obesity</a> in the world by 2030, affecting over 4 million children aged 5 to 19 years. </p>
<p>The campaign to get the levy increased is based on the growing body of research showing that <a href="https://theconversation.com/fact-or-fiction-is-sugar-addictive-73340">sugar is addictive</a>, that it is harmful to people’s health and that it is overwhelming the country’s health system. </p>
<p>Earlier this year the government made it clear that it had no intention of raising the 11% after the subject <a href="https://www.dailymaverick.co.za/article/2021-02-26-sugar-tax-stays-sweet-for-the-industry-but-mboweni-receives-praise-from-a-surprising-quarter/">was left out</a> of the February budget.</p>
<p>Yet, the country is paying a heavy <a href="https://pubmed.ncbi.nlm.nih.gov/31282315/">cost to treat type 2 diabetes</a> and <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30450-9/fulltext">hypertension</a>. </p>
<p>Government has the power to make healthy choices the easy choice. Healthy food like fresh fruit and vegetables is <a href="https://theconversation.com/food-systems-need-to-change-to-promote-healthy-choices-and-combat-obesity-150966">often not available or affordable</a> for many living in rural or urban areas. People eat what is available and cheap. </p>
<p>The government can save lives and reduce the numbers of people who develop diseases by taking three very simple steps.</p>
<p>Firstly, it needs clear regulations. </p>
<p>Secondly, it needs preventative strategies. </p>
<p>Thirdly, it needs watertight policies for reducing consumption of unhealthy foods.</p>
<p>Increasing the health promotion levy, introducing mandatory front of package labelling and banning the marketing of unhealthy products to children should be at the very top of the priority list.</p><img src="https://counter.theconversation.com/content/158320/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Hofman receives funding from IDRC Canada, the SA MRC and Bloomberg Philanthropies through The University of North Carolina. </span></em></p>The results are in: South Africa’s ground-breaking health promotion levy, introduced in 2018, is working.Karen Hofman, Professor and Programme Director, SA MRC Centre for Health Economics and Decision Science - PRICELESS SA (Priority Cost Effective Lessons in Systems Strengthening South Africa), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1509662021-02-09T14:06:24Z2021-02-09T14:06:24ZFood systems need to change to promote healthy choices and combat obesity<figure><img src="https://images.theconversation.com/files/380453/original/file-20210125-23-1f0sh2j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ultra-processed foods and sugary drinks contribute to rising rates of obesity.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>COVID-19 has had a devastating impact on people with <a href="https://www.sciencemag.org/news/2020/09/why-covid-19-more-deadly-people-obesity-even-if-theyre-young">obesity</a> and <a href="https://www.afro.who.int/news/noncommunicable-diseases-increase-risk-dying-covid-19-africa">noncommunicable diseases</a> such as diabetes. The pandemic has underlined the importance of the <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30021-5/fulltext">food environment</a> and <a href="https://doi.org/10.1016/S0140-6736(19)32497-3">healthy food intake</a>. It has shown the urgent need for effective policies to make sure that everyone can get enough nutritious food – and particularly in sub-Saharan Africa.</p>
<p>In Africa, nearly <a href="https://doi.org/10.1136/bmjopen-2017-021029">70% of diabetes</a> cases are undiagnosed. Of these, 90% are type 2 diabetes cases. Obesity is a key risk factor for developing type 2 diabetes. Between 1975 and 2016, southern Africa saw the world’s <a href="https://doi.org/10.1016/S0140-6736(17)32129-3">highest proportional increase in child and adolescent obesity</a> – an alarming 400% per decade.</p>
<p>Ultra-processed foods and sugary drinks contribute to rising rates of obesity and diet-related diseases. Unhealthy, processed foods are now frequently consumed in low- and middle-income countries. This is largely due to the low prices, food types, availability and <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60813-1/fulltext">marketing strategies</a> employed by large <a href="https://doi.org/10.1016/S0140-6736(14)61745-1">corporations</a>. Healthier food options are relatively <a href="https://academic.oup.com/jn/article/137/7/1815/4664543">expensive</a> and <a href="https://academic.oup.com/jn/article/149/11/2020/5535433">unaffordable</a> in low- and middle-income countries. This <a href="https://academic.oup.com/nutritionreviews/article/70/1/3/1829225">influences</a> people to steer away from healthier options. Companies market these convenient, palatable, yet unhealthy foods aggressively, and aim their marketing at children. It’s not always possible to choose <a href="https://media.africaportal.org/documents/WP34_Claasen_etal_final_0.pdf">healthier products</a>, especially in rural areas.</p>
<p>Supplying ultra-processed products <a href="https://doi.org/10.1371/journal.pmed.1001235">is very profitable for the companies</a> concerned. These products have low production input requirements, a high retail value and an extended shelf life. Often the responsibility for preventing noncommunicable disease is put on <a href="https://theconversation.com/diabetes-is-a-ticking-time-bomb-in-sub-saharan-africa-149766">individuals</a>. But the corporate food industry creates a <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30021-5/fulltext">food environment that gives rise to obesity</a>. </p>
<p>COVID-19 has brought new urgency to the need to repair food systems that put profits before public health. </p>
<p>A recent <a href="https://advocacyincubator.org/two-pandemics/">report</a> by the organisation Global Health Advocacy Incubator highlights how food and beverage corporations used the COVID-19 pandemic as an opportunity to promote their ultra-processed foods to vulnerable populations around the world. </p>
<p>The report includes over 280 examples from 18 countries of the food industry undermining healthy food policy efforts. This was done through lobbying to classify (unhealthy) ultra-processed foodstuffs as “essential products” during the pandemic. They also improved their brand image through providing financial and other support to needy communities, frontline workers, food banks, and small businesses while still marketing unhealthy products and pushing against healthy food policies. </p>
<p>A <a href="https://doi.org/10.1016/S0140-6736(19)32472-9">shift in the food system</a> is urgently required. <a href="http://www.fao.org/3/ca1505en/CA1505EN.pdf">Interventions</a> to achieve this must include <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61745-1/fulltext">policies</a> that promote healthier food choices. These include imposing taxes on food that is high in sugar, salt or saturated fat (unhealthy fat); regulating food labels; and restricting marketing of unhealthy products. Policies must also support people in making healthier food choices, for example through subsidies. </p>
<h2>Healthy food policies to consider</h2>
<p>Globally, there has been a push for healthy food policies to curb the obesity pandemic. African countries have been slow to adopt policies like these. But South Africa introduced a <a href="http://www.sars.gov.za/AllDocs/LegalDoclib/SecLegis/LAPD-LSec-CE-RA-2018-01%20-%20Health%20Promotion%20Levy%20on%20Sugary%20beverages%20R341%20GG41515%20-%2023%20March%202018.pdf">Health Promotion Levy</a> in 2018. It aims to give manufacturers an incentive to reduce the sugar content of drinks. It also seeks to discourage excessive consumption by increasing the price of these products. Mexico imposed a <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/did-high-sugarsweetened-beverage-purchasers-respond-differently-to-the-excise-tax-on-sugarsweetened-beverages-in-mexico/37DBC66A6F1E19F74942888814EB1EA3">tax on sugar sweetened drinks</a> in 2014. This has resulted in a 6% reduction in purchases of sugary drinks and replacement with untaxed beverages (predominantly plain water) – specifically among lower income households who likely have poorer health outcomes.</p>
<p>The implementation of the tax is an acknowledgement that corporates have manufactured conditions that <a href="https://dx.doi.org/10.34172/ijhpm.2020.205">cultivate malconsumption</a> resulting in poor nutrition and noncommunicable disease.</p>
<p>Governments should also introduce <a href="https://www.who.int/nutrition/publications/policies/guidingprinciples-labelling-promoting-healthydiet/en/">labelling</a> that helps consumers to identify food with high quantities of salt, saturated fat or sugar. <a href="https://doi.org/10.1371/journal.pmed.1003220;%20https://doi.org/10.1186/s12889-019-7118-1">Chile introduced a set of linked policies</a>, including warning labels and marketing controls. The result was that companies reformulated products to improve their health profiles. </p>
<p>But taxes and labelling interventions won’t be enough to stem the tide of obesity and noncommunicable diseases. <a href="https://doi.org/10.1016/S0140-6736(14)61745-1">Food policies</a> must also make healthy food more accessible. </p>
<p>Subsidies can <a href="https://doi.org/10.1016/S0140-6736(14)61745-1">lower the price</a> of healthy foods. This will help put healthy food within reach of poorer people. <a href="https://doi.org/10.1136/bmj.m2391">Prices can be changed</a> through a combination of taxes on unhealthy products and subsidies on healthier alternatives. In Finland, a <a href="https://doi.org/10.1146/annurev.publhealth.012809.103658">subsidy of milk protein</a> rather than milk fat resulted in more consumption of low fat milk and a reduction of cardiovascular diseases over time. A <a href="https://doi.org/10.2105/AJPH.2005.079418">fruit and vegetable subsidy</a> in the US Special Supplemental Nutrition Program for Women, Infants, and Children led to increased – and sustained – fruit and vegetable intake.</p>
<h2>The way forward</h2>
<p>The <a href="https://doi.org/10.1016/S0140-6736(14)61745-1">best policies</a> are those that create positive changes in the food, social and information environments. A policy cannot be adopted in isolation; for the biggest impact they need to be part of a set of mutually reinforcing and supporting actions. Chile is one country that has taken steps like this to create an <a href="https://doi.org/10.1111/obr.12099">enabling environment</a>.</p>
<p>Countries in sub-Saharan Africa should regulate the food industry better to protect against industry interference that harms the population. Policies that restrict marketing to children, provide clear labelling and tax unhealthy foodstuffs should be the start. The revenue raised from these taxes could be used to subsidise the cost of healthy foods.</p><img src="https://counter.theconversation.com/content/150966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rina Swart receives funding from Bloomberg Philantropies as part of a sub-agreement with the Global Food Research Programme at the University of North Carolina (Chapel Hill); the DSI/NRF Center of Excellence in Food Security; the DSI/NRF Center of Excellence in Human Development; the National Department of Health; the Cape Higher Education Consortium; and the IDRC (International Development Research Centre), Canada.
Rina Swart is a member of the Nutrition Society of South Africa, the Association for Dietetics in South Africa and the World Public Health Nutrition Association. </span></em></p><p class="fine-print"><em><span>Makoma Bopape received a scholarship from the IDRC for her PhD. She is affiliated with Bloomberg Philantrophies as part of a sub-agreement with the Global Food Research Programme at the University of North Carolina (Chapel Hill) and the National Department of Health.</span></em></p><p class="fine-print"><em><span>Tamryn Frank received funding in the form of a scholarship from the IDRC for her PhD. She is affiliated with Bloomberg Philantropies as part of a sub-agreement with the Global Food Research Programme at the University of North Carolina (Chapel Hill); and the National Department of Health. She is a member of the Association for Dietetics in South Africa and the World Public Health Nutrition Association.</span></em></p>A disruption of societal norms created by industry interference is urgently required to create a shift in the food system.Rina Swart, Professor, University of the Western CapeMakoma Bopape, Lecturer in Department of Human Nutrition and Dietetic, University of LimpopoTamryn Frank, Researcher, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1528252021-01-27T15:12:39Z2021-01-27T15:12:39ZHow one South African employer helped its staff get healthier and why it’s worth doing<figure><img src="https://images.theconversation.com/files/380856/original/file-20210127-23-sbnjex.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The workplace can make a big contribution to behaviour change.</span> <span class="attribution"><span class="source">Darcelle Schouw</span></span></figcaption></figure><p>Non-communicable diseases account for <a href="https://www.who.int/nmh/countries/zaf_en.pdf">half of all deaths</a> in South Africa. Cardiovascular diseases are the biggest contributor, followed by cancers, diabetes and respiratory diseases. <a href="https://www.statssa.gov.za/publications/P03093/P030932017.pdf#page=43">Diabetes</a> alone is the leading killer of women and second most common cause of death overall. The impact of non-communicable diseases <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2020.1827363">increases</a> with age through a combination of physiological, genetic, environmental and behavioural factors. But most deaths occur among people of working age. The number of deaths from non-communicable diseases in people of working age are expected to <a href="https://www.bmj.com/content/338/bmj.b1665">increase by 41%</a> in developing economies, including South Africa, by 2030.</p>
<p>Risk factors associated with non-communicable diseases <a href="https://www.who.int/nmh/publications/ncd_report_full_en.pdf">include</a> tobacco smoking, harmful alcohol use, physical inactivity and unhealthy diets. Most of these can easily be modified through lifestyle changes such as healthy eating, sufficient exercise, reduced alcohol use and quitting smoking.</p>
<p>One approach to encourage behaviour change is through legislation, for example, taxes on alcohol, tobacco or sugar. Another is through health education. But any <a href="https://www.who.int/docs/default-source/primary-health/vision.pdf">approach</a> needs to involve many government departments, civil society and the private sector.</p>
<p>The workplace can make a big contribution. It’s an environment that shapes people’s health and behaviour, and the support of co-workers can reinforce behaviour change. Organisations can reduce their employees’ risk of non-communicable diseases through relatively inexpensive adjustments to the work environment. The organisation also <a href="https://www.emeraldgrouppublishing.com/archived/realworldresearch/wellbeing/how-workplace-wellness-programmes-benefit-business.htm">benefits</a> when staff are healthier and more productive.</p>
<p>In 2016, we designed and introduced a Healthy Choices at Work programme at a commercial power plant in South Africa’s Western Cape province. This came after a spate of deaths at the plant from <a href="https://journals.co.za/doi/10.10520/EJC-11788d94f9">non-communicable diseases</a>. We did research, over a two year period, that focused on the design, implementation, <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2020.1827363">effects</a> and <a href="https://www.researchgate.net/publication/342366441_Cost_and_consequence_analysis_of_the_Healthy_Choices_at_Work_programme_to_prevent_non-communicable_diseases_in_a_commercial_power_plant_South_Africa">financial cost</a> of the programme. </p>
<p>A representative sample of the staff employed at the power plant participated in the programme. But the whole organisation was targeted, therefore all employees were potentially affected by the programme. It enabled staff to make healthy food choices at work, provided opportunities for physical activity and encouraged workers to use the health and wellness services available. After two years we evaluated the representative sample of workers. Our findings show that interventions in the workplace can help reduce the burden of noncommunicable diseases. </p>
<h2>Designing the Healthy Choices at Work programme</h2>
<p>The programme was designed by a diverse group of 11 employees in managerial positions with a record of successful action and openness to change. It focused on four areas: food choices at work, opportunities for physical activity, use of health and wellness services, and buy-in of top management.</p>
<p>Food vendors adjusted their menu to include and promote wellness meals. More fruit and vegetable snacks were made available throughout the workplace. Opportunities for physical activity were identified – for example, the plant was located within a nature reserve with walking, running and cycling trails. Employees were encouraged to take up these opportunities through competitions and healthy challenges. Time for physical activity was scheduled during working hours. Health and wellness services assessed people’s health risks periodically, gave feedback to individuals and motivated behaviour change through counselling. Leadership <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263095/">buy-in and participation</a> was key to the success. The managers led by example in marketing and participating in the activities.</p>
<p>The programme targeted all 1,743 staff employed at the power plant. We evaluated a representative sample of 137 workers in detail. Everyone in the sample participated in the health risk assessment and 80% received counselling. Between 45% and 62% changed their eating habits at work and between 28% and 33% increased their physical activity.</p>
<p>The programme was associated with clinically significant improvements in behavioural, metabolic and psychosocial risk factors for non-communicable diseases. Our study showed the potential of health promotion in the workplace to complement interventions in the health services and community. </p>
<p>Staff reduced their harmful use of alcohol from 21% to 5%, increased their fruit and vegetable intake by 37%, improved their levels of physical activity by 21%, and showed significant improvement in blood pressure and cholesterol levels.</p>
<p>The change was helped along by systems thinking, a shift of perspective from the parts of the organisation to the whole. The whole organisation was responsible for bringing about the changes and not just the health and wellness department. The focus was on relationships between people in different parts and across the hierarchy. It emphasised connection, collaboration and participatory action rather than authority and instructions.</p>
<p>Making the healthy choice an easy choice was also important. For example, the wellness meal was put at the top of the menu display and fruit snacks were provided instead of confectionery in vending machines.</p>
<p>The additional annual cost to the company was $1.15 per employee. The change in systolic blood pressure alone translates to a potential 22% reduction in coronary heart disease and 41% reduction in <a href="https://www.bmj.com/content/338/bmj.b1665">stroke</a>. The improvement in behaviour and the changes in people’s diets and habits should also lead to a reduced incidence of type 2 diabetes.</p>
<p>We also noted psychosocial changes associated with the programme, such as improved relationships at work and a perception of better health. Given the short span of the project (measurements over two years), we couldn’t assess how well these <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343951/">benefits</a> translated into reduced illness and time off sick.</p>
<h2>Way forward</h2>
<p>Our findings suggest that the workplace should get more attention as a setting for preventing non-communicable disease. Doing this can help to meet national and international targets. The government should include workplace-based health promotion in its policy on noncommunicable diseases and promote such programmes using lessons learnt. </p>
<p>Such programmes should be designed and implemented with the participation of staff members from different parts of the organisation. These staff should be able to offer leadership and embrace systems thinking. Programmes should address the whole organisational environment and not just offer traditional health services. The approach may be applicable to small, medium and large-scale organisations.</p><img src="https://counter.theconversation.com/content/152825/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Workplace-based interventions could make a substantial contribution to reducing the burden of noncommunicable diseases in the country.Darcelle Schouw, Researcher, Division of Family Medicine and Primary Care, Stellenbosch UniversityBob Mash, Division of Family Medicine and Primary Care, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1443772020-09-10T08:37:01Z2020-09-10T08:37:01ZWhy Sierra Leone needs to focus on cardiovascular health<figure><img src="https://images.theconversation.com/files/356257/original/file-20200903-18-144olk3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cardiovascular risk factors are high in Sierra Leone. </span> <span class="attribution"><span class="source">Steven Rubin</span></span></figcaption></figure><p>Cardiovascular diseases and their risk factors, such as diabetes and high blood pressure, are <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1406656">major causes of death and disability</a> globally. Noncommunicable diseases such as these arise mainly from lifestyle transitions towards a high-calorie diet and low-activity living.</p>
<p>These conditions were <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1406656">previously regarded</a> as a problem for high-income countries. But low- and middle-income countries have followed the <a href="https://theconversation.com/people-in-africa-live-longer-but-their-health-is-poor-in-those-extra-years-108691">same trend</a>. Now more than <a href="https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)">three quarters</a> of deaths due to cardiovascular disease are in low- and middle-income countries. </p>
<p>Despite this large disease burden, research funding and aid budgets for low- and middle-income countries are still concentrated around infectious diseases, and maternal and child health. The prevalence and treatment outcomes of cardiovascular disease risk factors, such as diabetes and hypertension, are relatively unexplored in these regions. </p>
<p>Our <a href="https://bmjopen.bmj.com/content/10/9/e038520.full">study</a> is one of the first to report that cardiovascular disease risk factors in Sierra Leone are highly prevalent, and the first study to report on access to care for people with these conditions. </p>
<p>Cardiovascular risk factors are preventable or relatively easy to treat with inexpensive medication. But cardiovascular diseases – such as heart attacks and stroke – can’t be reversed and often require intensive and expensive treatment. </p>
<p>Poor countries, such as Sierra Leone, with limited health services can’t treat large numbers of people with cardiovascular diseases. Therefore people with these conditions are likely to die or be permanently disabled as a result. This is a tragedy for the individuals and the families who have to care for them.</p>
<h2>Prevalence and access to care</h2>
<p>Sierra Leone is one of the least developed and poorest countries in the world. It ranks <a href="http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/SLE.pdf">181 out of 189 countries</a> in terms of human development. Almost 65% of people in the country are defined as poor on the <a href="https://ophi.org.uk/wp-content/uploads/Sierra_Leone_MPI_2019_final.pdf">multidimensional poverty index</a>. Poverty, combined with civil war and the Ebola epidemic, have hindered the development of the health system, leaving services unable to deal with complex cardiovascular diseases. </p>
<p>The country has seen some <a href="https://www.worldbank.org/en/country/sierraleone">growth in the economy</a> in recent years. But this might increase the demand for health services in Sierra Leone. In other settings, economic growth has been associated with lifestyle changes that lead to cardiovascular disease <a href="https://www.who.int/nmh/publications/ncd_report_chapter2.pdf?ua=1">risk factors</a>. These lifestyle changes include poor diets and lower levels of physical activity. </p>
<p>If these trends persist, Sierra Leone is likely also seeing an increase in cardiovascular disease risk factors. But there’s been very little evidence to show whether this was the case – until our study was done. </p>
<p>We conducted a household survey from September to November 2018. The participants were over 40 years old and lived in the district of Bo, located in the southern province of Sierra Leone. Survey questions asked about sociodemographic information such as age and gender, and about previous history of cardiovascular disease risk factors. Data was also collected on weight, height, blood pressure, blood sugar, and cholesterol.</p>
<p>We found that over three quarters of people older than 40 in Sierra Leone had at least one cardiovascular disease risk factor. Almost 50% of our study population over the age of 40 had hypertension. Smoking was also common –around 25% of the population – especially in young men. </p>
<p>It was shocking that the prevalence of cardiovascular disease risk factors is so high. We also found that access to care for individuals with diabetes and hypertension was very low – fewer than 10% of sufferers are adequately treated for these conditions.</p>
<p>In order to plan strategies to prevent or treat cardiovascular disease risk factors, it is necessary to show that they are a problem. Until now, there was not enough strong data to do that. The high prevalence of these conditions shown by our study should act as a trigger for health service planners and the people that fund these services to act.</p>
<p>A large proportion of the health system funding in Sierra Leone comes from international aid. In 2017, the country received around <a href="https://vizhub.healthdata.org/fgh/">$170 million</a> in development assistance for health; $30 million for HIV/AIDS (population prevalence is under 2%), $21 million for child and newborn health, and $14 million for maternal and reproductive health. It only received <a href="https://vizhub.healthdata.org/fgh/">$510,000 </a> for all noncommunicable diseases, which include cardiovascular disease risk factors. Our study clearly shows that the burden of cardiovascular disease risk factors is disproportionately higher than the amount of funding that goes to the health system to manage this. </p>
<p>Hopefully by showing this information and working with policy makers in Sierra Leone, more attention will be given to preventing and treating cardiovascular disease risk factors.</p>
<h2>The way forward</h2>
<p>To save lives and promote economic wealth, health system planners and funders need to recognise the extent of the problem and prioritise noncommunicable diseases and cardiovascular disease risk factors in Sierra Leone and other low- and middle-income countries, urgently. </p>
<p>Meanwhile, initiatives to reduce the burden of these conditions are imperative to ensure that individuals, communities, and societies do not suffer from their devastating adverse health and economic consequences.</p><img src="https://counter.theconversation.com/content/144377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This research was funded by the UK Wellcome Trust.</span></em></p><p class="fine-print"><em><span>Justine Ina Davies has collaborated with the Sierra Leone Ministry of Health and Sanitation in development of the recent National Policy on Non Communicable Diseases.
This research was funded by the UK Wellcome Trust.</span></em></p>Cardiovascular risk factors like diabetes and hypertension are preventable or relatively easy to treat with inexpensive medication.Maria Odland, Research Fellow Global Health, University of BirminghamJustine Ina Davies, Professor of Global Health, Institute for Applied Research, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1444332020-08-17T14:07:25Z2020-08-17T14:07:25ZTechnology can help people manage their diabetes – case study shows it’s not being used<figure><img src="https://images.theconversation.com/files/352960/original/file-20200814-20-1rqgeat.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>Non-communicable diseases are the leading cause of <a href="https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death">death</a> globally. There’s no cure for most of them, such as diabetes. Rather, they’re controlled through lifelong medical treatment as well as support from healthcare professionals and family members.</p>
<p>Suboptimal treatment of diabetes can lead to severe <a href="https://www.diabetes.org/diabetes/complications">complications</a> such as amputations, blindness and kidney disease. That’s why ongoing patient self-management education and support are critical to preventing acute complications and reducing the risk of death. This is increasingly important during the COVID-19 pandemic where the <a href="https://www.who.int/news-room/detail/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases">treatment and prevention</a> of noncommunicable diseases has been negatively affected, especially in low-income countries. Patients with diabetes are also at higher risk for severe <a href="https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30238-2/fulltext">COVID-19</a> complications and <a href="https://www.diabetes.org/coronavirus-covid-19/how-coronavirus-impacts-people-with-diabetes">death</a>.</p>
<p>The <a href="https://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_R7-en.pdf?ua=1">World Health Assembly</a> recognises the potential for information and communication technology (ICT) to support healthcare systems. ICT can support disease prevention and health promotion by improving affordability, access and quality of health services worldwide. ICT used in health is often referred to as electronic health (e-health). Mobile health (m-health) refers to e-health applications delivered on mobile technology. </p>
<p>Interventions using m-health show promise as it could improve care for patients with chronic conditions. A previous study in <a href="https://www.who.int/news-room/feature-stories/detail/treating-diabetes-takes-more-than-insulin-senegal-mobile-phone-project-promoting-public-health">Senegal</a> has shown that simple interventions delivered via mobile applications can help to decrease diabetes risk factors such as an unhealthy diet and physical inactivity.</p>
<p>But patients can’t benefit from innovations – such as apps on mobile phones – unless they accept them and use them effectively.</p>
<p>We <a href="https://www.researchgate.net/publication/326368952_User_acceptance_of_ICT_for_diabetes_self-management_in_the_Western_Cape_South_Africa">set out to measure</a> the use of technology for patients with diabetes. Our research was based in low-resourced communities in South Africa’s Western Cape province.</p>
<p>We wanted to identify factors that influenced people’s choices when it came to using technology to manage their diabetes. A very high percentage of survey participants had high intentions of using technology to assist with diabetes self-care activities such as healthy eating, being active, monitoring, taking medication, problem-solving, healthy coping and reducing risks. But, when it came down to actual use there was very little uptake.</p>
<h2>The study</h2>
<p>There has been a rapid rise in <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html">diabetes globally</a> but the rate has been rising more rapidly in <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">low- and middle-income countries</a> than in high-income countries. <a href="https://idf.org/our-network/regions-members/africa/members/25-south-africa.html">South Africa</a> is no exception. South Africa’s diabetes prevalence in adults is 12.8% compared to the neighbouring country, <a href="https://idf.org/our-network/regions-members/africa/members/31-zimbabwe.html">Zimbabwe</a> at 1.2%.</p>
<p>Diabetes control is also lower among <a href="https://pubmed.ncbi.nlm.nih.gov/27194172/">racial and ethnic minorities</a> and especially those with low socioeconomic status. The demographics of the Western Cape reflect the socioeconomic plight of a substantive population. Additionally, segments of the Western Cape population experience technological forms of exclusion on top of educational and <a href="https://researchictafrica.net/publication/state-of-ict-in-south-africa/">income inequalities</a>. </p>
<p>We selected 497 respondents from low-resourced communities in the surrounds of Cape Town. They included Mitchell’s Plain, Belhar and Khayelitsha. Most were women over the age of 50 with <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">type 2</a> diabetes. A third of the respondents had Grade 12 as their highest level of education. Just under a fifth had some high schooling. Most spoke English (43.4%) followed by Xhosa (27.7%) and Afrikaans (23.1%). These factors are important as South Africa has diverse populations with significant educational, technological and income inequalities that may impact ICT use for diabetes. South Africa also has 11 official languages which will affect the ability to use m-health applications that are predominantly in English.</p>
<p>We tested whether patients were likely to use ICT to help them manage their diabetes. The <a href="https://www.researchgate.net/publication/220259897_User_Acceptance_of_Information_Technology_Toward_a_Unified_View">model we used </a> looked at four factors: </p>
<ul>
<li><p>whether a person believed using the system would be effective (in this case, whether the patient thinks it will improve their health) </p></li>
<li><p>whether a person finds it easy to use </p></li>
<li><p>whether a person feels that others think they should use it </p></li>
<li><p>whether a person thinks the system is supported by conditions such as internet access and a helpdesk to provide support with technical difficulties. </p></li>
</ul>
<p>Achieving these four factors increases the possibility that individuals will perform the behaviour in question (behavioural intention). A positive behavioural intention may lead to patients using ICT for diabetes.</p>
<p>Respondents were asked about their use of ICT such as mobile applications, <a href="https://www.medtronicdiabetes.com/treatments/insulin-pump-therapy">insulin pumps</a> (devices that delivers insulin 24 hours a day to match your body’s needs) and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705487/">continuous glucose monitoring</a> through a device that provides patients with a glucose reading every few minutes. </p>
<p>Our findings were surprising. <a href="https://www.researchgate.net/publication/326368952_User_acceptance_of_ICT_for_diabetes_self-management_in_the_Western_Cape_South_Africa">Most respondents</a> ticked the four boxes. This would suggest a positive behavioural intention. Yet, their behavioural intention didn’t translate into actual usage. </p>
<p>For example, respondents were asked whether they used the above technology to help them manage their diabetes and 68% said they didn’t. </p>
<p>We identified a number of contributing factors to the low uptake.</p>
<p>One was limited internet access and difficulty using technology. <a href="https://www.researchgate.net/publication/340479429_Impact_of_demographics_on_patients'_acceptance_of_ICT_for_diabetes_self-management_Applying_the_UTAUT_model_in_low_socio-economic_areas">Age and education</a> also played a role. </p>
<p><a href="https://www.researchgate.net/publication/340479429_Impact_of_demographics_on_patients'_acceptance_of_ICT_for_diabetes_self-management_Applying_the_UTAUT_model_in_low_socio-economic_areas">Respondents</a> were asked what would make them use ICT more often. Reduced cost, as well as making applications easier to use and understand, were identified as the most critical factors. </p>
<h2>Next steps</h2>
<p>Mobile phone applications are effective in managing diabetes in other low- and middle-income countries. But <a href="https://www.businessinsider.co.za/how-sas-data-prices-compare-with-the-rest-of-the-world-2020-5">South African data costs</a> exceed other countries. Also, Senegal’s success can be attributed to the government’s involvement in implementing the mobile application. </p>
<p>South Africa will require a similar intervention, such as <a href="http://www.health.gov.za/index.php/mom-connect">MomConnect</a> that is available in all 11 languages. The service, free to all users, is independent of mobile device type. Alternatively, the use of WhatsApp as is being used for <a href="https://api.whatsapp.com/send?phone=27600123456&text=Hi&source=&data=&app_absent=">COVID-19 </a> could be considered to support the growing number of patients with diabetes.</p><img src="https://counter.theconversation.com/content/144433/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fazlyn Petersen receives funding from the National Research Foundation (NRF). </span></em></p>Interventions using apps show promise as they could improve care for patients with chronic conditions. But patients can’t benefit from innovations unless they accept them and use them effectively.Fazlyn Petersen, Information Systems Senior Lecturer, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1402042020-07-07T14:16:24Z2020-07-07T14:16:24ZSouth Africans must be healthier for universal healthcare to succeed<figure><img src="https://images.theconversation.com/files/344819/original/file-20200630-103649-19tkk9v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People exercising in Ellis Park in Johannesburg, South Africa. </span> <span class="attribution"><span class="source">Dino Lloyd/Gallo Images via Getty Images</span></span></figcaption></figure><p>Achieving a healthy population isn’t easy for any country – rich or poor. One of the approaches that’s gained traction over the past two decades is preventative care through <a href="https://www.ncbi.nlm.nih.gov/books/NBK235764/">health promotion</a>. Simply put, health promotion means keeping people healthy. This is seen as particularly useful in developing countries, where levels of preventable noncommunicable diseases are high, the resources to treat disease are scarce and the cost of treating sick people is often higher than programmes to keep people healthy.</p>
<p>The health promotion approach has two areas of focus. One is preventing disease through activities like health education messaging, screening and testing for conditions. The other is addressing the upstream drivers and causes of poor health. These include social and economic factors such as poverty and unemployment. They also include smoking, excessive drinking, low levels of exercise, poor diet, sub-standard living conditions, gender-based violence and mental illness. </p>
<p>The health promotion approach aims to change people’s behaviour and choices. But it is not enough just to tell an individual how to be healthy: people need support and social structures to promote, sustain and maintain healthy choices. </p>
<p>A number of countries have successfully adopted this approach using health promotion foundations. <a href="https://en.thaihealth.or.th/">Thai Health</a> is one example. Similar <a href="http://www.samj.org.za/index.php/samj/article/view/6281/4910">foundations</a> have been established in Switzerland, Austria, the Philippines and Malaysia. </p>
<p>In a <a href="http://www.samj.org.za/index.php/samj/article/view/12864/9145">recently published paper</a>, we argue that South Africa also needs a health promotion and development foundation if its proposed universal healthcare programme, the National Health Insurance (NHI), is to succeed. </p>
<p>Through the <a href="http://www.health.gov.za/index.php/nhi">NHI</a> South Africa (and legal long-term residents) are to be provided with essential healthcare, whether they can <a href="https://theconversation.com/coronavirus-pandemic-holds-lessons-for-south-africas-universal-health-care-plans-137443">contribute</a> to the NHI fund or not.</p>
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<strong>
Read more:
<a href="https://theconversation.com/south-african-taxpayers-will-bear-the-brunt-of-national-health-insurance-122409">South African taxpayers will bear the brunt of National Health Insurance</a>
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<p>But South Africa faces high levels of disease, in particular <a href="http://www.samj.org.za/index.php/samj/article/view/12864">noncommunicable diseases</a> such as diabetes, hypertension, cancer and obesity. Many noncommunicable diseases can be prevented. The NHI is likely to battle to cope with treating large numbers of sick people, but much of this treatment could be avoided by promoting health and reducing disease. </p>
<p>In our <a href="http://www.samj.org.za/index.php/samj/article/view/12864">paper</a> we set out how this radical change of approach could be achieved and why health promotion could be an effective use of the limited funds.</p>
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Read more:
<a href="https://theconversation.com/why-south-africas-plans-for-universal-healthcare-are-pie-in-the-sky-121992">Why South Africa's plans for universal healthcare are pie in the sky</a>
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<h2>Getting healthier</h2>
<p>Noncommunicable diseases, many of which are avoidable, are having a significant impact on the health of South Africans and the South African healthcare system.</p>
<p>The increase in noncommunicable disease risk factors will likely lead to rising healthcare costs. </p>
<p>For example, in 2018, the public health sector spent an <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2019.1636611">estimated</a> R2.7 billion ($198 million) on patients diagnosed with diabetes. The estimates increased to R21.8 billion when undiagnosed diabetes patients were considered. The total costs associated with diabetes are likely to increase to R35.1 billion ($2.5 billion) in 2030.</p>
<p>Another common condition, <a href="https://pubmed.ncbi.nlm.nih.gov/17952226/">hypertension</a>, is an important risk factor for cardiovascular diseases and chronic kidney disease. It is often found in combination with diabetes. In <a href="https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf">South Africa</a> 46% of women and 44% of men over 15 had hypertension in 2016. This is almost double the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31919-5/fulltext">world average</a> and has nearly doubled since 1998. </p>
<p>The <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf">2016 South African Demographic and Health Survey</a> indicates high levels of obesity, which has health and cost implications. Forty-one percent of women are obese, a condition associated with an 11% increase in healthcare <a href="http://www.samj.org.za/index.php/samj/article/view/7260">costs</a>. </p>
<h2>What needs to be done</h2>
<p>Health behaviour in South Africa needs to shift from the norm of waiting to get sick and then accessing healthcare to preventing disease and keeping healthy.</p>
<p>To encourage this, we <a href="http://www.samj.org.za/index.php/samj/article/view/12864">propose</a> the establishment of a multi-sectoral National Health Commission or an independent Health Promotion Foundation linked directly to the NHI Fund. It should include several relevant government departments, civil society, academics and researchers. </p>
<p>Health promotion programmes need to be based on more than health knowledge. For example, individuals can’t practise good hand hygiene when water is not available, or eat healthy foods when these are not affordable. South Africa’s specific <a href="https://theconversation.com/pandemic-underscores-gross-inequalities-in-south-africa-and-the-need-to-fix-them-135070">realities and needs</a>, including poverty and its related behavioural impacts and health consequences, must be taken into account. This is why different government departments and stakeholders would need to work together.</p>
<p>We don’t know exactly how much of the noncommunicable disease burden could be eased by modifying risk factors. But the World Health Organisation
has <a href="https://www.paho.org/hq/dmdocuments/2011/paho-policy-brief-1-En-web1.pdf">estimated</a> that in the Americas 80% of all heart disease, stroke and type 2 diabetes mellitus and over 40% of cancer is preventable through multisectoral action. </p>
<p>Some of the changes that could make a difference to health are quite indirect.
For example, it is often not safe to exercise on the streets, so communities need to have more active and visible policing and accessible open spaces free from traffic and other competing activities to make increased exercise a realistic option. Healthy food needs to be subsidised and more easily available, and places that sell alcohol and tobacco need to be located at prescribed distances from schools. </p>
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Read more:
<a href="https://theconversation.com/south-africa-moves-one-step-closer-to-a-sugar-tax-and-a-healthier-lifestyle-88045">South Africa moves one step closer to a sugar tax -- and a healthier lifestyle</a>
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<p>Just how much funding is needed to promote health? Health promotion experts are calling for <a href="http://www.samj.org.za/index.php/samj/article/view/12864">2%</a> of the NHI Fund to be dedicated specifically to promoting health and preventing illness. This is certainly a reason to improve health promotion funding in South Africa. We cannot afford to wait any longer.</p>
<p>The WHO’s global <a href="https://www.who.int/ncds/prevention/launch-global-business-plan-for-ncds/en/">business case</a> for noncommunicable diseases shows that if low- and low-to-middle-income countries put in place the most cost-effective interventions, by 2030 they will see a return of US$7 per person for every dollar invested. This is certainly a reason to improve health promotion funding in South Africa. We cannot afford to wait any longer.</p><img src="https://counter.theconversation.com/content/140204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melvyn Freeman has contracts of work from the World Health Organization and Higher Health. He is a member of the Department of Health think tank on mental health.</span></em></p><p class="fine-print"><em><span>Charles Parry and Jane Simmonds do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa faces high levels of noncommunicable diseases such as diabetes and hypertension. The NHI is likely to battle to cope with treating large numbers of sick people.Jane Simmonds, Associate Staff, Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research CouncilCharles Parry, Director, Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research CouncilMelvyn Freeman, Extraordinary Professor, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1389892020-05-26T14:16:42Z2020-05-26T14:16:42ZWe tracked Soweto mothers-to-be to find out more about diet and obesity patterns<figure><img src="https://images.theconversation.com/files/336129/original/file-20200519-152320-jjm5rv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GettyImages</span> </figcaption></figure><p>Pregnancy has been described as a <a href="https://www.ncbi.nlm.nih.gov/pubmed/19683692">“teachable moment”</a> for promoting healthy lifestyle choices. This is because pregnant women are highly motivated to make behavioural changes. Whether the change involves taking a prescribed medication or supplement, or giving up a risky behaviour such as smoking, pregnant women are more committed because they feel a responsibility towards the health and well-being of their unborn child. </p>
<p>Such positive lifestyle changes will always be beneficial. But, for women who fall pregnant with conditions such as obesity, they may come too late. This is important because the nutrition environment experienced by fetuses during pregnancy can <a href="https://www.ncbi.nlm.nih.gov/pubmed/29739495">affect</a> their growth and development in early life. This, in turn, affects their risk of developing obesity, diabetes and cardiovascular disease as they age. </p>
<p>Obese women, or those with gestational diabetes (glucose intolerance beginning or first recognised during pregnancy), are more likely to give birth to larger babies (over 4kg) with greater adiposity (or body “fatness”). This puts moms at higher risk of delivery complications, such as requiring a caesarean <a href="https://www.ncbi.nlm.nih.gov/pubmed/29739495">birth</a>. It also increases the chances of their children becoming <a href="https://www.ncbi.nlm.nih.gov/pubmed/31185012">obese</a>. In turn, obese children are five <a href="https://www.ncbi.nlm.nih.gov/pubmed/26696565">times</a> more likely to grow into obese adults and thus, more likely to develop diabetes and cardiovascular <a href="https://www.ncbi.nlm.nih.gov/pubmed/26696565">disease</a>. </p>
<p>What has been less understood so far is how diet during pregnancy influences growth in the womb, particularly in communities where obesity rates are high as is the case in <a href="https://pubmed.ncbi.nlm.nih.gov/26279311/">South Africa</a>.</p>
<p>We conducted a <a href="https://pubmed.ncbi.nlm.nih.gov/28696364/">study</a> of women from Soweto three years ago in which we recorded their dietary patterns during pregnancy. We explored whether these were related to the amount of weight that they gained, as well as their newborns’ birthweight and their levels of body fat.</p>
<p>We found that there were positive effects of an improved diet during pregnancy. But we also found that these benefits were most obvious in women whose weight was normal at the start of their pregnancies. </p>
<p>This suggests that improvements made to the diets of overweight and obese women once they are pregnant may have a limited impact on their health – and that of their babies.</p>
<h2>Getting an early start</h2>
<p><a href="https://www.samrc.ac.za/sites/default/files/attachments/2019-01-29/SADHS2016KeyFindings.pdf#page=21">Two thirds</a> of women in South Africa are overweight or obese. <a href="https://apps.who.int/iris/bitstream/handle/10665/148114/9789241564854_eng.pdf;jsessionid=0A8F917062E4C8A992457E21A4BC981B?sequence=1#page=32">One in four</a> adults die prematurely (before the age of 70) from cardiovascular disease, diabetes, cancer or chronic respiratory disease. </p>
<p>Among women living in Soweto, <a href="https://pubmed.ncbi.nlm.nih.gov/28696364/">one in ten</a> will be diagnosed with gestational diabetes during pregnancy. Half of them will go on to develop diabetes within the following 10 years.</p>
<p>This explosion of obesity and related chronic diseases has been linked to rapid lifestyle changes as a result of urbanisation, including a transition towards more processed diets high in sugar, saturated fat, salt, cooking oils and convenience <a href="https://pubmed.ncbi.nlm.nih.gov/22221213">foods</a>. </p>
<p>Often poor dietary behaviours are adopted during the teenage years – long before girls and young women have considered the idea of becoming mothers. The impact of unhealthy lifestyles, poor-quality diets and excess body weight on chronic disease burdens has been explored <a href="https://pubmed.ncbi.nlm.nih.gov/21074255">exhaustively</a>. But the implications for future mothers and the next generation of South Africans has not received the same attention.</p>
<p>In our study we found that women who were accustomed to a more “westernised” diet gained more weight during pregnancy. This is a diet high in refined carbohydrates such as white bread, processed and red meat, sweets and chocolate and sugar-sweetened soft drinks. So did women whose diets were particularly high in added sugar.</p>
<p>High weight gain increases the risk of giving birth to a large baby. It’s also a risk factor for pregnancy complications such as developing high blood pressure and pre-eclampsia and giving birth by caesarean <a href="https://pubmed.ncbi.nlm.nih.gov/24376527">section</a>. Overweight and obese women are particularly vulnerable to gaining excessive amounts of weight during pregnancy, as the recommended range for healthy weight gain is lower than it is for women who conceive at a healthy weight.</p>
<p>On the other hand, women who ate higher amounts of whole grains, legumes, vegetables and unprocessed meat gained less weight during pregnancy and were more likely to gain weight within the healthy range. Their babies also tended to have lower birthweights and less body fat at birth. </p>
<p>These quantifiable differences indicate that a healthy diet during pregnancy really does have beneficial effects on the health of the mother and the newborn, as well as on the newborn’s risk of developing disease later in life.</p>
<p>But, to make a real impact on the health and well-being of the next generation, it is critical that food and health systems focus on empowering teenage girls and young women to make healthier choices and to improve their diets long before they become pregnant.</p><img src="https://counter.theconversation.com/content/138989/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephanie Wrottesley receives funding from the DSI/NRF Centre of Excellence in Human Development at the University of the Witwatersrand and the University of the Witwatersrand's Research Office under the School of Clinical Medicine. </span></em></p>Two thirds of South African women are overweight or obese and their babies are three times more likely to become obese themselves.Stephanie Wrottesley, Postdoctoral research fellow, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1370952020-05-06T15:01:10Z2020-05-06T15:01:10ZKenya can’t afford to neglect people with underlying conditions during COVID-19<figure><img src="https://images.theconversation.com/files/332771/original/file-20200505-83775-19hwdp7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A public health worker takes details from a man volunteering to be tested for COVID-19 in the bustling Kawangware market in Nairobi. </span> <span class="attribution"><span class="source">Tony Karumba/AFP via Getty Images</span></span></figcaption></figure><p>Kenya is facing a <a href="https://www.who.int/nmh/ncd-task-force/kenya-strategy-ncds-2015-2020.pdf">double burden</a> of communicable and non-communicable diseases. <a href="https://pubmed.ncbi.nlm.nih.gov/26476849/">Clustering of infections</a> (such as HIV or TB) and noncommunicable diseases such as diabetes or hypertension is now common. This is putting pressure on the overstretched healthcare system.</p>
<p>In spite of this, many individuals with noncommunicable diseases remain <a href="https://www.sciencedirect.com/science/article/pii/S1877705815010498">undiagnosed</a> for a number of reasons. These include unfamiliarity with symptoms, lack of testing equipment, and costs associated with the tests.</p>
<p>Recent <a href="https://www.who.int/nmh/ncd-task-force/kenya-strategy-ncds-2015-2020.pdf">statistics</a> show that just over half a million adults were living with diabetes in Kenya in 2019. About 40% were unaware of their condition. Deaths from cancer are estimated at 7% while cardiovascular diseases account for 13%.</p>
<p>Overall, <a href="https://www.who.int/nmh/ncd-task-force/kenya-strategy-ncds-2015-2020.pdf">almost half</a> of hospital admissions and about 55% of deaths in Kenya are associated with noncommunicable diseases. </p>
<p>This leaves countries like Kenya in a particularly vulnerable position when it comes to the severity of COVID-19. Globally, <a href="https://www.world-heart-federation.org/covid-19-and-cvd/">evidence shows</a> people with underlying medical conditions such as cardiovascular disease, hypertension, diabetes or cancers are at a higher risk of COVID-19.</p>
<h2>Is the health system in Kenya prepared?</h2>
<p>Even before the COVID-19 pandemic reached Kenya, <a href="https://anthrosource.onlinelibrary.wiley.com/doi/abs/10.1111/maq.12476">access to</a> chronic care, especially for noncommunicable diseases, was challenging. This is worse for patients with more than one chronic disease.</p>
<p>Kenya’s health system is <a href="https://pubmed.ncbi.nlm.nih.gov/29952787/">fragmented</a> and largely designed to manage individual diseases rather than managing patients with multiple diseases. This is partly due to health system challenges such as staff shortages, inadequate or dysfunctional medical equipment, drug stock-outs and unskilled providers. </p>
<p>Unlike HIV, tuberculosis and malaria, access to care for most noncommunicable diseases such as diabetes is a major problem especially among the poor. Findings from our <a href="https://pubmed.ncbi.nlm.nih.gov/30117196/">study</a> at Mbagathi district hospital in Nairobi revealed some of these challenges.</p>
<p>A 52-year-old female patient said:</p>
<blockquote>
<p>My HIV/AIDS care is provided free of charge but other diseases such as diabetes I pay for. </p>
</blockquote>
<p>Another 58-year-old male patient said: </p>
<blockquote>
<p>Every time I use KSh.1500 (US$15); consultation fee is KSh.300 ($3); I buy drugs for three months and that costs KSh.300 ($3).</p>
</blockquote>
<p>During the COVID-19 pandemic, access to care may be even more difficult due to overwhelmed health systems, lockdown and curfews as well as fear of infections. Currently, preparations are being made to prevent or manage COVID-19 cases. But little is said about protocols to manage patients with chronic conditions. </p>
<p>It’s important to strengthen the healthcare system in Kenya to offer integrated care that addresses not only the COVID-19 pandemic but also chronic illnesses. </p>
<h2>Recommendations</h2>
<p>Management of COVID-19 should take account of other conditions. The current funding such as the <a href="https://www.worldbank.org/en/news/press-release/2020/04/02/kenya-receives-50-million-world-bank-group-support-to-address-covid-19-pandemic">$50 million provided by the World Bank</a> should provide horizontal treatment and care. It should address all conditions rather than only prioritising COVID-19 cases. </p>
<p>Integrating care means that individuals could get access to testing and medical care for COVID-19 as well as other conditions such as diabetes or hypertension. </p>
<p>The Kenyan government must also provide healthcare workers with adequate personal protective equipment and address staff shortages by hiring more unemployed doctors and nurses. </p>
<p>And healthcare providers with chronic conditions must be relieved from being at the frontline in managing COVID-19 cases. If this is not possible, providers must be well protected to avoid being infected. </p>
<p>Collaborating with communities and local administrations will help in reporting and tracking cases or deaths, and citizens who defy government laws. Community health workers can sensitise community members and individuals at risk of COVID-19 on preventive measures.</p>
<p>Finally, the police force in Kenya should be made aware that, even during the COVID-19 pandemic, patients with chronic diseases need constant engagement with hospitals. Lockdowns or curfew measures should be sensitive to these populations.</p><img src="https://counter.theconversation.com/content/137095/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edna N Bosire does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As COVID-19 cases continue to increase in Kenya, there is a looming threat for escalated disease and death due to the many people with chronic conditions.Edna N Bosire, PhD Candidate and Associate Researcher, Developmental Pathways for Health Research Unit (DPHRU)., University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.