The burden of non-communicable diseases (NCDs) such as diabetes has been growing in South Africa since the 1990s. Twenty years ago that rise was obscured by burgeoning morbidity and mortality from HIV/AIDS and tuberculosis (TB), but these are now falling due to the health system’s focus on tackling them and the roll-out of antiretroviral therapy. There now needs to be a similar focus from government and the health system on NCDs, with a shift within the country from an acute care model to a chronic care model that is better suited to managing their growing burden.

Burden of disease

The prevalence of diabetes is growing across the globe, but fastest in Africa. The number of people living with diabetes in Africa is expected to increase by 48% by 2030 and by 143% by 2045, the highest predicted increase of any region. Comparing prevalence between countries in the region is difficult, due to the lack of good quality data, but the International Diabetes Federation (IDF) estimates that South Africa not only has the highest prevalence among 20 to 79-year-olds at 12.7%, but also the greatest number of people with diabetes at 4.6m. South Africa also has the highest number of deaths due to diabetes in the region, with an estimated 89,800 in 2019. According to the most recent official figures (2017), diabetes is the second leading cause of death after TB in South Africa and the trend is upwards, suggesting that deaths due to diabetes are set to overtake those due to TB, if they have not already. Diabetes has moved from the fifth most common cause of death in 2013 to the second in 2015. Between 2015 and 2017, the proportion of deaths due to TB fell from 7.2% to 6.4% while the proportion due to diabetes rose from 5.4% to 5.7%.

In some populations, diabetes is already the number one cause of death: it is the leading cause of death in the Western Cape region (responsible for 7.5% of deaths), of all South Africans aged 65 years and over (9.0% of deaths) and of all women (7.3% of deaths). Diabetes-attributable mortality in Africa is almost 1.8 times higher in women than in men, and this is in part driven by lifestyle factors as around 68% of women in South Africa are overweight or obese. But the problem of obesity in South Africa is particularly complex, explains Bridget McNulty, co-founder of the NGO Sweet Life Diabetes Community, a community for South Africans living with diabetes. “Being overweight is a sign of prosperity in many South African cultures. Some believe that if you’re thin, it means you can’t afford to eat.” Severe obesity is most common among coloured and black/African women (26% and 20%, respectively).

Around 60% of adults with diabetes in Africa are undiagnosed, a greater proportion than anywhere else in the world.

The growing burden of diabetes in South Africa comes as no surprise. The first South African Health and Nutrition Examination Survey of 25,000 people in 2012 found that 5% of all adults (older than 15 years) reported diabetes, with more than 16% of those aged 55 years or older. At the time the survey was published, South Africa’s health minister Aaron Motsoaledi warned that the findings signalled a “projected tsunami” of diabetes “in a continent with the lowest number of health professionals per capita, and the most fragile of health systems in the world”.

Sub-Saharan Africa has a high burden of disease, a limited number of healthcare workers and few medical educators. Away from urban centres, health services are provided through simple clinics run by GPs but more often nurses, and there is limited access to specialist medical expertise and services due to the vast distances often needed to be travelled to access them. E-health has long been seen as a possible solution by enabling telemedicine, distance education of health staff and computerised health information systems.

Impact of covid-19 on people living with diabetes and telemedicine

Ms McNulty says covid-19 has brought diabetes “into the spotlight” in South Africa. “It is one of the top comorbidities worldwide, and definitely one of the top comorbidities in South Africa,” she says. People living with uncontrolled diabetes, including those using insulin, are more likely to have more severe covid-19 disease and die if they become infected with SARS-CoV-2. In South Africa, an analysis of covid-19 patients in the Western Cape found that almost half of those who died had diabetes as a comorbidity.

Before covid-19, telemedicine, in terms of remote consultations with patients, essentially did not exist in South Africa.

- Dr Bruno Pauly, Department of Diabetes and Endocrinology at the Chris Hani Baragwanath Academic Hospital in Johannesburg, South Africa

Covid-19 has also acted as an enabler for telemedicine in South Africa. Before covid-19, telemedicine, in terms of remote consultations with patients, essentially did not exist in South Africa, says Dr Bruno Pauly, from the Department of Diabetes and Endocrinology at the Chris Hani Baragwanath Academic Hospital in Johannesburg, South Africa. There was no infrastructure, no legal framework and the Medical Aids schemes, which cover the 15% of the population under the private health system, would not pay for such consultations, he says.

The Health Professions Council of South Africa (HPCSA), the statutory regulator of medical and allied professions in South Africa, did not allow teleconsultations, he says. “So if, for example, I offered support or advice through WhatsApp or email my patients with diabetes, it was a very tricky area. Only recently, as a response to covid-19, were these legal structures changed. The HPCSA now allows you to undertake remote consultations under certain circumstances, and the Medical Aids now have codes where they pay for them, but before that it was not possible. You could do it, but you wouldn’t be paid and it was at your own risk.”

The HPCSA announced in March 2020 that remote consultations could be performed if there was an existing practitioner-patient relationship, and that practitioners could charge for them. However, it added that this change was not permanent and that it “will inform practitioners when this guidance ceases to apply”.

Many doctors working in the private sector are now holding remote consultations with their patients with diabetes, says Dr Pauly, and while some use Zoom, they are more likely to be by telephone or email. These doctors are also using SMS or WhatsApp to keep in touch with their patients with diabetes, which is what many healthcare professionals in the public sector have been using to keep in touch with their patients with diabetes. Most people in South Africa have access to mobile phones and the technology also has the advantage of allowing the same message to be sent to multiple patients at the same time.

Huge potential: the next steps for telemedicine and diabetes care

Telemedicine, digitalisation and technology as a whole have huge potential to improve the care of people living with diabetes. The first steps to utilising telemedicine in the private sector have been made, but huge obstacles remain in building upon that and expanding use, particularly in the public sector, says Dr Pauly, who works primarily in the public health system but also does private work.