Diabetes becomes South Africa's leading non-communicable disease killer

Among the non-communicable diseases is diabetes, which is expected to affect 8.75 million people by 2040 and requires urgent government intervention.

NOTNon-communicable diseases (NCDs) – diabetes, hypertension, heart disease and cancer – are a growing public health crisis in South Africa. The statistics speak for themselves.

Non-communicable diseases account for the highest percentage of deaths in the country, according to Statistics South Africa’s 2020 Mortality and Causes of Death in South Africa report, released in May this year.

Among noncommunicable diseases, diabetes – mainly type 2, which accounts for more than 90% of diabetes cases – is the leading cause of death. Although the leading cause of death in 2020 was Covid-19, accounting for 6.7% of deaths, it was closely followed by diabetes at 6.6%, the report said. And diabetes was a major comorbidity responsible for Covid-19 deaths.

Percept, a South African consultancy that used local data from demographic surveys and health programs, estimates that just under 5.6 million South Africans were living with diabetes in 2019, significantly higher than the International Diabetes Federation’s figure of 4.2 million. Based on its data, Percept predicts that number will rise to about 8.75 million by 2040.

Type 2 diabetes is preventable and manageable, often causing no harm to patients. However, if left untreated, it compromises the outcomes of other serious diseases, including tuberculosis, HIV, maternal and neonatal health, cardiovascular disease, and chronic kidney disease.

The main driver of diabetes is obesity, caused mainly by poor lifestyle choices including junk food, lack of exercise, smoking and alcohol abuse, which is a national health crisis in itself. Nearly half of South Africa’s adult population is overweight or obese, and childhood obesity rates are also rising, according to the Human Sciences Research Council’s National Food and Nutrition Security Survey, conducted from 2021 to 2023. This is in line with the global trend of noncommunicable diseases that disproportionately affect populations in low- and middle-income countries.

Hypertension (high blood pressure), meanwhile, known as the silent killer (because most sufferers do not know they have it), is estimated to affect one in three South Africans and is responsible for one in two strokes and two in five heart attacks, according to the Department of Health.

While the prevalence of hypertension and heart disease is generally lower in rural populations than in urban populations, recent data show that the gap is narrowing as rural populations also adopt unhealthy lifestyles, enabled by easier access to fast food and alcohol outlets.

These statistics highlight the pandemic of non-communicable diseases and the urgent need for the government to introduce integrated management strategies for the prevention, treatment and care of these diseases. Interventions are needed at all levels of the health system, from primary health care clinics to teaching hospitals to district and regional hospitals. Interventions are also needed in schools as part of the orientation programme to sensitize students on the long-term negative health consequences of poor diet. Refined carbohydrates should be heavily taxed to fund the costs that the government ultimately incurs in treating non-communicable diseases.

The imperative to do so is both economic and philanthropic, given that the economic development of a nation depends on the health of its population.

The burden of non-communicable diseases on the national budget is exorbitant: the direct cost of diabetes to the health system is R2.7 billion, and that’s just for diagnosed patients. Obesity alone was estimated at R33.194 million in 2020, according to a paper entitled Estimating the Healthcare Cost of Overweight and Obesity in South Africa, published in Global Health Action in 2022.

Non-communicable diseases that are not prevented, detected, diagnosed, treated and managed not only place a burden on the health system, but also on employers and jeopardize livelihoods. The breadwinner whose diabetes is diagnosed too late or not managed properly may develop diabetes-related complications and struggle to earn a living and provide for his or her family.

Although the government has committed to intensifying its efforts to combat noncommunicable diseases (NCDs) in its National Strategic Plan on Noncommunicable Diseases (NCDs) 2022-2027, experts agree that the plan lacks details when it comes to implementation. According to the Diabetes Alliance, there has been minimal progress in establishing the monitoring and surveillance systems needed to assess whether the objectives of the National Strategic Plan are being met.

“The public health system remains disproportionately focused on infectious diseases such as HIV and tuberculosis. This imbalance leads to underfunding and under-research of non-communicable diseases, leading to gaps in diabetes prevention, treatment and management,” says Dr Patrick Ngassa Piotie, President of the Diabetes Alliance.

In a report submitted to the Ministry of Health on August 6, the Diabetes Alliance listed some of the issues hindering optimal diabetes prevention and care – identified at its Diabetes Summit in November 2023, which included input from more than 20 diabetes experts from 21 local and international organisations – that it said the government needs to address.

The first problem is the lack of awareness of NCDs in the health system and among the public about the causes of these diseases (tobacco, harmful alcohol use, unhealthy diet and physical inactivity). “By implementing the promotion of healthy diets and physical activity, as outlined in the World Health Organization’s recommendations for NCD intervention, South Africa can significantly improve public health outcomes and mitigate the socio-economic impact of NCDs,” the report states.

The second problem is the lack of dedicated surveillance systems, which leads to an underestimation of the true magnitude of the diabetes burden. What you can’t measure, you can’t manage. An integrated and digitalized diabetes surveillance system would allow ““They integrate seamlessly with existing health information systems and can provide real-time data on diabetes prevalence, risk factors and outcomes, enabling targeted interventions and research initiatives,” the report says.

Gaps in diabetes care are cited as another problem, along with lack of training for health professionals, which is a “significant barrier,” the report says. The expertise of community health workers and clinical associates should be leveraged, which would improve and expand access to care. “A comprehensive training program should be developed to improve the skills and knowledge of health professionals, including physicians, nurses, clinical associates, community health workers and others, in diabetes prevention, management and care,” the report says.

The report also recommends the introduction of new treatment options and devices in the public sector. Anecdotal evidence shows that public sector patients in some public health facilities still struggle to obtain the glucometers and strips they need to regularly measure their blood sugar to manage their diabetes.

“To manage their disease, people with diabetes need to avoid the risk of hypoglycaemia (lower than normal blood sugar) or hyperglycaemia (higher than normal blood sugar), which can be life-threatening. One challenge is that the batteries in glucometers need to be replaced regularly. These batteries are expensive and poor people cannot afford them,” says Alexandra van Essche, spokesperson for the Diabetes Alliance and a person with type 1 diabetes.

“Insulin pumps and continuous glucose monitoring devices/apps have been game-changers for people living with diabetes, but only for those who can afford them,” she adds.

The Diabetes Alliance recommends dedicated funding streams for diabetes prevention and control in national and provincial health budgets, as well as the use of Global Fund grants and the Health Promotion Levy as financing vehicles.

“Proactive investment in diabetes prevention and care could help alleviate the immense pressure that diabetes and its complications will place on the health system in the future,” the report says.

As with diabetes, effective control and treatment of hypertension begins with monitoring and follow-up. Again, the majority of South Africans cannot afford to buy a home blood pressure monitor or have their blood pressure measured at pharmacies. Blood pressure checks should therefore be offered in clinics across the country.

Examples of practical and cost-effective approaches include the establishment of cardiovascular screening centres in all district health centres, where blood pressure is also measured; monthly screening campaigns in community centres; and awareness campaigns in shopping centres.

Experts have long agreed that health services for noncommunicable diseases and communicable diseases such as HIV should be integrated, meaning that people with diabetes, hypertension, HIV, cardiovascular disease and cancer would receive all the treatment and care they need with fewer resources.

This would also improve the chances of early detection of non-communicable diseases. For example, a diabetic patient would be screened if an HIV test visit included a diabetes screening, reducing the workload on health facilities. In turn, the burden of non-communicable diseases on the national health budget would be reduced, as would the benefit of a healthier population.

Helen Grange is a writer and sub-editor For Good governance Africa.