The biggest cost burden of Africa's growing diabetes epidemic is borne by the poorest

By Andrea Teagle, HSRC Science Writer

The number of people with diabetes in Africa will almost triple between 2015 and 2040, rising from 14.2 million to 34.2 million, according to The International Diabetes Federation (IDF). Accurate health and cost data is essential to meeting the problem and providing cost effective treatment and preventative measures. Because of the severity of the complications associated with diabetes, such as kidney failure and heart disease, strained healthcare systems are already struggling to bear the costs.

A 2018 systematic review by a team from the Human Sciences Research Council (HSRC), led by Chipo Mutyambizi, found that annual national direct costs of diabetes in African countries ranged from $3.5 billion to $4.5 billion per annum. This did not include indirect costs such as lost productivity. Additionally, because many cases are undiagnosed, costs were likely to be underestimated.

“Our findings suggested that the annual economic burden of diabetes in Africa was huge,” the authors wrote. “Most of these healthcare costs in Africa are borne by the patients and this influences the attainment of proper care due to financial constraints.”

In South Africa alone, out of pocket expenditure (costs borne by the patient) were under 20% of total health expenditure. Countries in which out of pocket expenditure is above 20% risk catastrophic health expenditure, defined as the level at which households bear the brunt of health costs, and impoverishment. Even South Africa, with its relatively well-functioning healthcare sector, is scrambling to meet the problem: diabetes is top leading cause of death after Tuberculosis, accounting for 5.5% of natural deaths. (TB accounts for 6.5%, and HIV is fifth on the list at 4.8%, according to Stats SA’s 2016 mortality report.)

An estimated 7% of the adult population between 21 and 79 has diabetes, and the majority of these 3.85 million cases are undiagnosed. Concerningly, the study found that between 2005 and 2009, per patient annual hospital costs more than tripled, from $1813 to $6871.

Like other African countries, South Africa is facing a growing tide in diabetes and other non-communicable diseases while still grappling with major infectious diseases like TB and HIV.

In the past, diabetes and non-communicable diseases primarily affected individuals in the developed world and high income groups. However, a shift to highly processed foods and more sedentary lifestyles is causing a rise in prevalence of these so-called lifestyle diseases in developing countries. Diabetes is positively correlated with an increase in obesity and overweight, conditions that often affect lower income populations due to availability and relative affordability of cheaper, high-caloric foods and sugary beverages. Indeed, those shouldering the greatest burden of diabetes in African countries tend to be individuals in low income groups, the review found.

In most cases drug costs constituted the majority of the diabetes treatment costs, largely because physicians tend to prescribe branded drugs. Thus, the authors argued, prescribing generic medicines is critical to reduce diabetes costs in Africa.

Critically, Mutyambizi and her team found that cost data varied widely between countries and various country income groups, largely because of different methodologies and included cost categories. (Between countries with comparable costing methods, Burkina Faso was found to have particularly high costs, followed by Mali, Benin and Guinea.) Another limitation of the review was a failure in some of the included studies to differentiate between Type 1 diabetes and Type 2. This is important because the latter is both more common and preventable.

The absence of complete cost data hinders the ability of governments to adequately respond to and prepare for this silent, growing epidemic. The introduction of a standardised methodology for studies measuring costs of interventions would improve comparability of costs across countries.

Better health data is also critical to curb the rise in non-communicable diseases. In a recent SA-EU Strategic Partnership Dialogue Conference on disruptive technologies conference hosted by the HSRC, molecular biologist Musa Mhlanga of the University of Cape Town noted that a failure to collect health data could severely impact the ability of Africa to respond to  health crises of the future.

Because the risk profiles for different non-communicable diseases – including various cancers – differs for different population groups, the fact that most genomic data comes from Europe means that African countries might be missing valuable insights into effective, targeted treatments.
 
“Our inability to have large datasets, in places like Africa, of these cancers… makes it very difficult for us to be able to pick up key variants driving this disease,”  Mhlanga said. Because of its heritability, the same is true for Type 1 diabetes and other non-communicable diseases.

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