Diabetes is currently the ninth leading cause of death worldwide. Around 420 million people or 6% of the world population are affected. That number is projected to climb over half a billion by the end of the decade, with the largest increases occurring in low- and middle-income countries.
Most people with this disease have type 2 diabetes. This type of diabetes is the result of being overweight and being physically inactive.
About 4.5 million people are affected by diabetes in South Africa. The proportion of the adult population living with this disease is estimated at 12.8%. It is the leading cause of death in women. In 2019, 89,834 people died of diabetes. That number exceeds the capacity of Soccer City, the largest soccer stadium in South Africa.
Most people with diabetes in South Africa have access to treatment and care in primary health care facilities. Unfortunately, clinics are often congested and patients have to wait in long lines to receive their medication during their monthly visits. To meet these challenges, the National Ministry of Health initiated a program in 2014 to improve access to medicines and compliance with patient guidelines.
The program offers patients with controlled diabetes the opportunity to collect their medication at pick-up points of their choice, such as shops, places of worship, community halls or schools.
However, our most recent research found that at the time of the study, only a minority of patients in the program were achieving treatment goals. We reviewed the records of patients who had participated in the program for an average of two years (a minimum of a year and a maximum of five years). Our results suggest that the criteria for selecting people with diabetes for the program should be revised. In addition, health care managers should investigate strategies to include diabetes education in the program.
Better access to medication but suboptimal management
The centralized chronic drug dispensing and distribution program started in February 2014. The service is free and benefits the patient in many ways. These include:
- fewer clinic visits,
- take less free time,
- do not have to travel long distances,
- do not wait in queues, and
- Collect medication anytime, anywhere.
By definition, patients participating in the program are stable – which means they are fine.
The clinic’s nurse or doctor will measure the level of sugar in the blood with a test called fasting plasma glucose. If two consecutive tests are normal, the patient will qualify for the program. Once registered, the patient no longer has to come to the clinic to collect medication. Patients enrolled in this program visit the clinic every six months for an exam.
We conducted a medical records review of people with type 2 diabetes enrolled in the centralized chronic medication dispensing and distribution program in 23 primary care facilities in the Tshwane district of the country’s capital. The aim was to assess how well the patient was doing at that point in time. We looked at the latest test results recorded on their files, namely hemoglobin A1C or HbA1c, blood pressure, and blood cholesterol. Test results were missing from some patient records, suggesting that patients are not always getting the tests they are entitled to.
Only 29% of the patients in the study had acceptable blood sugar levels. This is worrying as these patients should be stable controlled patients to be considered for inclusion in the program. Our results suggest that some patients who entered the program were initially unstable.
The sub-optimal management of people with type 2 diabetes is particularly worrying in times of the COVID-19 pandemic, as people with diabetes are more prone to getting sick or dying from COVID-19. The consequences of high blood sugar levels are blindness, kidney failure, heart attacks, strokes and leg amputations. These complications lead to a reduced quality of life and higher health costs and place unnecessary burdens on families.
To ensure that patients benefit fully from this program, the selection criteria should be revised. Instead of using fasting plasma glucose to determine if a patient is qualified, 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 specific point in time. In contrast, HbA1c provides an indication of the blood sugar concentration in the past two to three months. The advantage of measuring HbA1c is that it allows a more reasonable and stable view of the course over time (three months). And the value does not vary as much as when measuring blood sugar (Fasting Plasma Glucose).
This program limits a patient’s contact with healthcare providers. An unintended consequence is that the person has limited opportunities to know about the condition and how best to treat diabetes.
For people with chronic conditions like diabetes, education and empowerment are critical to achieving better results. The person with diabetes should be able to eat well, get enough exercise, and take the right amount of medication at the right time.
Close gaps
The authorities have claimed the program was a success. However, our study identified a few loopholes that should be addressed.
The centralized chronic drug dispensing and distribution program should consider revising the selection of people with type 2 diabetes. It should also include additional measures to empower and educate patients.
Improving the management and care of people with diabetes requires innovative evidence-based interventions. Strategic public-private partnerships are key to ensuring the South African government achieves its goals of helping people with diabetes lead better lives. One such initiative is our Tshwane insulin program at the University of Pretoria.
Our program is a partnership between the University of Pretoria and the Lilly Global Health Partnership. We work closely with national, regional and local health authorities to develop sustainable solutions that can improve the management and outcomes of people with diabetes in South Africa.
Paul Rheeder is funded by the Lilly Global Health Partnership.
Elizabeth M. Webb and Patrick Ngassa Piotie do not work for, or receive funding from, any company or organization that would benefit from this article and have no relevant affiliations beyond their academic appointment disclosed.
By Patrick Ngassa Piotie, Project Manager, Tshwane Insulin Project, University of Pretoria and
Elizabeth M. Webb, Lecturer at the University of Pretoria and
Paul Rheeder, Project Leader, Tshwane Insulin Project, University of Pretoria
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