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Why it’s so difficult to tackle diabetes in sub-Saharan Africa

In the 1990s diabetes was seen as a condition that mainly affected rich people in high income countries. Nowadays, it’s one of the leading contributors to death in all countries in the world, driven by increases in national and personal wealth resulting in people having more disposable income. In addition, urbanisation has led to more and more people living sedentary lifestyles. A commission of experts, which was set up in 2014 to tackle the challenge in Africa, have recently released their findings. Health and Medicine Editor Candice Bailey spoke to Professor Justine Davies about the importance of the commission and what good it can do.

What do we know about diabetes in Africa? Why is there a concern?

About 95% of cases around the world are type 2 diabetes, which is associated with obesity. The impact of diabetes is becoming much greater in poorer countries and regions. Sub-Saharan Africa is home to 34 of the world’s 48 least developed countries. In lower-income countries, even though national and personal wealth is increasing, health systems are not developed enough to cope with the increasing numbers, or the long-term consequences of diabetes such as heart attacks, strokes, blindness, and kidney failure.

The health fraternity has a good idea that diabetes rates on the continent are increasing but they don’t know enough about the number of people with the disease. For example, a recent study found that there is no information about people with diabetes in 21 countries. Added to this, the Commission also found that – in countries where the burden of diabetes is known – only about half of the people with it in populations across Africa are aware that they have the disease. Of these only one in 10 – or 11% – receive the drugs they need.

What are the costs?

There are two costs affiliated with diabetes: treatment costs and economic costs.

Diabetes itself can be treated very cheaply as it only requires medications (usually tablets) to lower glucose. But the long-term consequences, for example, heart attacks, strokes, blindness, and kidney failure, require specialists and specialist equipment to treat. These are very expensive. The consequences are also more likely to lead to people not being able to work.

The Commission calculated that southern African countries accounted for two-thirds of the US $12.1billion spent on diabetes in sub-Saharan Africa in 2015. Wealthier countries, particularly South Africa, were spending more because they’re going through more societal changes. Less than a tenth of the costs (US $1.7 billion) originated from poorer countries in western Africa.

And looking ahead, projections show that by 2030 southern Africa is likely to see the greatest increases in annual health care and personal costs: between US $17.2 billion and US $29.2 billion. In east Africa spending is expected to increase from US $3.8 billion in 2015 up to $16.2 billion in 2030.

The Commission report estimates that the total costs to economies and individuals in sub-Saharan Africa in 2015 was US $19.5 billion.

More than half of this economic cost (56%, $10.8 billion) was from treatments, including medication and hospital stays. Other costs included out-of-pocket expenses paid for by the patients and productivity losses, mostly from shortened life expectancy as well as people leaving the workforce early ($0.5 billion), taking sick leave ($0.2 billion) and being less productive at work due to poor health ($0.07 billion).

In which way are health systems ill-prepared to deal with chronic diseases like diabetes? Are there countries that are worse off or better? And why?

The impact of diabetes is greater in countries and regions that are poorer. In lower-income countries, health systems have focused on tackling infectious diseases for the last 15 to 20 years. The increase in diabetes cases hasn’t been seen as a priority. This has led to several gaps in care, including a lack of equipment for diagnosing and monitoring diabetes, lack of treatment, and lack of knowledge about the disease among health care providers.

Many infectious diseases can be cured relatively quickly, which means that the systems for treating chronic, lifelong, diseases like diabetes are rare.

But there’s a lot we can learn from countries that have developed systems to deal with high burdens of HIV. Lessons are being drawn from them to provide care for other chronic conditions in Africa.

Another reason for health care systems in Africa not being able to cope with diabetes - or many other illnesses - is that they haven’t been given the level of investment needed to provide good quality care for all.

How could the challenges around diabetes be tackled effectively?

It is critical that we establish the true burden of diabetes and the burden of other risk factors associated with diabetes, like high blood pressure and abnormal cholesterol.

The Commission’s analysis demonstrates a clear need for improvements at all levels of diabetes care. And interventions that have been successfully trialled in sub-Saharan African countries need to be scaled up. This includes community-based care for high blood pressure, patient education, home glucose monitoring, and more education about diabetes for health care professionals.

The Commission also pointed out that the response needs to come from many different levels; from individuals, to society, to health care planners, health care providers and governments.

The researchers note that prevention is critical to improving health and avoiding further economic burden. This is because managing type 2 diabetes and its risk factors (such as obesity and physical inactivity) is much simpler and cheaper than treating complications that develop in the later stages of the disease.

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