Zambia pushing through the barriers to better care
In Africa, non-communicable diseases like diabetes will be a more serious threat to life than all other illnesses within 10 years. The situation in Zambia offers insights into the challenges and opportunities facing the continent in pursuit of improved prevention and treatment of diabetes.
As celebrations marking the 100th anniversary of the discovery of insulin come to an end, and with the achievement of significant successes in the political environment to accelerate prevention and treatment of diabetes—including the launch of the World Health Organization (WHO) Global Diabetes Compact—our attention must now shift to regions of the world where managing the condition remains a particularly significant challenge.
An estimated 537 million adults worldwide have diabetes, and the majority live in low- and middle-income countries (LMICs). In Africa, non-communicable diseases (NCDs) like diabetes are projected to overtake all other causes of death by 2030. Health systems across the continent remain burdened and under-resourced, unable to provide the healthcare people need. The Ebola and other seasonal epidemics, as well as the covid-19 pandemic, add further strain to healthcare systems.
In countries like Zambia, significant cost and resourcing barriers affect access to diabetes care. In comparison, in better-resourced countries like South Africa, stronger healthcare networks and a grassroots system of care increase the likelihood of better outcomes for people with diabetes. In both nations, the adoption of a sugar tax offers promise of healthier lifestyles and a reduced risk of diabetes.
Estimating size and scale
Zambia is a country still grappling with high rates of communicable diseases like HIV/AIDS and tuberculosis (TB), and together with NCDs like diabetes that require substantial medical resources, these conditions pose a serious economic burden for the already limping healthcare system.
As diabetes isn’t managed in isolation from other NCDs, it’s difficult to estimate the size of the problem. According to diabetesatlas.org, an estimated 726,300 people in Zambia were living with diabetes in 2021 out of a population of approximately 18 million. There were an estimated 386,900 undiagnosed cases and 15,500 deaths attributed to the disease.
The covid-19 pandemic has exacerbated the situation, with the former Minister of Health Chuilufya Chitalu stating that most patients dying of the virus in Zambia had underlying conditions like diabetes and high blood pressure. There is no data on exact figures, but a small local study of people who died from covid-19 in Lusaka, the capital city, found 13% had diabetes.
Lifestyle habits are another important factor, with the troubling combination of sedentary lifestyles and unhealthy food choices contributing to almost one-quarter of Zambia’s adult population being classed as overweight or obese.
Gaps in treatment
In 2017, the Zambian Ministry of Health undertook its first national survey of NCDs and associated risk factors. The results, which provided baseline information and a guide for policy and planning for NCDs in Zambia, showed that only 36.8% of adults who had been previously diagnosed with diabetes were currently undergoing treatment. There are several reasons for this. The survey notes that Zambians do not, as a matter of routine, get screened for blood sugar or cholesterol levels. And although health facilities deliver free primary healthcare services at a community level, there is little focus on the prevention and management of diabetes.
How can we achieve anything when we provide services in an ad hoc manner?
To compound matters is the cost of treatment. The cost of insulin and items like test strips and syringes vary widely from one place to another and are unaffordable for the majority of people not covered by private health insurance. In the private sector, insulin ranges between $25 and $100 per vial, yet around 64% of Zambians live on less than $2 a day.
Resourcing is another issue. Rodgers Phiri, a healthcare worker in one of Lusaka’s primary care facilities, says patients are routinely referred to private facilities to get tested for diabetes because public health facilities rarely have the resources. “I hear politicians say Zambia is on course to reach NCD targets by 2030, but the reality says something else,” he says. “How can we achieve anything when we provide services in an ad hoc manner?”
Short on funds and facilities
In the last three years, Zambian health sector funding has reduced from 9.5% in 2018 to 8.1% in 2021, but permanent secretary Kennedy Malama says an increase in the budgetary allocation for health in 2022 will “spur improvements in health service delivery including for diabetes”. To ease the burden on the Treasury and help reduce out-of-pocket health expenditure for individuals, a national health insurance scheme was introduced in 2019 where every citizen pays 1% of their basic monthly salary as a subscription to access care. However, the effects of this minimal payment have not yielded any results as government health facilities are still short on supplies, equipment and human resources.
With an increase in diabetes in Zambia, there is the inevitable rise in chronic kidney disease and the demand for dialysis. In 2015, the government acquired 21 dialysis machines from Germany for three referral hospitals. However, veteran journalist Swithen Hangaala, a long-time kidney disease patient, says people are dying for lack of regular dialyses. He says the 12 renal centres across the country have always been unreliable, but now they have not been operational for the last few months.
“The renal units do not have the consumables to operate the machines,” Hangaala says. “They have cut down the hours on dialysis from four to two and cut down the number of times one can have dialysis in a week. Patients like me usually need at least three sessions a week.” The only alternative is to go to the private sector where each dialyses session costs about $118—far beyond the means of the average Zambian.
Similar challenges down south
In South Africa, the second-largest economy in Africa after Nigeria, similar challenges remain, but the country is making some inroads in diabetes care. Like Zambia, South Africa also suffers from the added disease burden of high HIV/AIDS and TB rates, as well as NCDs, of which the rates of diabetes are particularly high. And it shares similar challenges to Zambia in preventing, diagnosing and treating the condition. South Africa is beleaguered by historic economic and health inequalities that have led to a substandard health delivery system, with outcomes often the same, or worse, than those of its lower-income neighbours.
According to diabetesatlas.org, about 4.2 million South Africans are living with diabetes in 2021 out of a population of approximately 60 million. An estimated 1.9 million of these cases were undiagnosed and 95,700 deaths were directly attributable to the disease. The reasons for these startling figures are not unlike in other LMICs: insufficient access to health facilities, lifestyle changes like an energy dense and calorie deficient diet, and little or no knowledge about diabetes.
In search of solutions to its growing diabetes problem, South Africa launched a Diabetes Prevention Programme (DPP) in 2019 with the aim of delivering treatments in a culturally relevant context through household screening questionnaires and group gatherings for at-risk individuals. The information was used to educate communities and healthcare practitioners about diabetes.
But the programme ended abruptly, says Margot McCumisky, a national manager at Diabetes South Africa (DSA). “We were doing well, and we trained about 400 home-based carers. About two and a half years into the programme, without giving us a reason, the [health] department stopped funding.”
Since then, DSA has pursued other strategies to educate communities about diabetes and facilitate access to healthcare. In 2020, it set up a covid-19 helpline for diabetes patients. It also plans to resume community diabetes wellness groups—so far, it’s helped to establish 40 groups throughout South Africa—and hopes to expand this initiative if funding becomes available. Within these groups, communities have access to talks about diabetes management, food and nutrition, which help to debunk the idea that healthy food is expensive. “We promote indigenous fruit and vegetables and warn that the 2-litre Cokes and bunny chows [popular fast food] have empty calories,” McCumisky says.
Because healthcare facilities can be difficult to access, she believes this grassroots-level approach is the most effective way for people to find the support and information they need to avoid the devastating complications that can arise from unmanaged diabetes.
Community groups also help people navigate the health system—namely, that testing facilities are free at government facilities and also covered by health insurance. Unlike many countries in the region, South Africa provides free insulin in its facilities, and it is covered by insurance in private hospitals.
Not so sweet
Encouraging behaviour that reduces diabetes risk with financial incentives is another approach South Africa is exploring. In 2018, the country implemented a sugar tax of about 10%, known as the Health Promotion Levy (HPL). Zambia, too, introduced a $0.02 per litre tax on all non-alcoholic beverages except water in 2019. By charging more for sugary drinks and foods, the governments of the two countries hope to fight obesity and help people make healthier choices.
SUGAR TAX In South Africa, sugar taxes drive tension between economic growth and good health
So far, the tax has yielded some positive results in South Africa. A national study published this year found households in urban areas had reduced the volume of sugary beverages they bought by one-third, cutting their sugar intake by half.
However, neither country plans to raise the tax to the WHO recommended rate of 20%. In Zambia, the government is at odds with itself as it has committed to growing the economy through the manufacturing sector, which includes the food and beverage sub-sector. There was concern that the introduction of such a tax may lead to job losses due to a reduction in the demand for sugar-based beverages. Zambia’s sugar industry contributes more than 3% to GDP, 6% to total national exports and is directly responsible for more than 11,000 jobs.
The Zambian Ministry of Health is now encouraging schools to integrate physical activity as part of the curriculum, particularly in urban areas where leisure parks are not free to access, and roads are not safe for pedestrians. Another initiative provides physical activity counselling as part of routine primary healthcare services.
In South Africa, McCumisky says the jury is still out on the impact of the sugar tax as there are so many products that are not covered by the tax and still contain large amounts of sugar. She is hopeful that manufacturers will be encouraged to take a closer look at the amount of sugar in their products and that the tax debate might encourage a diabetes education campaign.
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