EDITORIAL
SA JOURNAL OF DIABETES & VASCULAR DISEASE
4
VOLUME 8 NUMBER 1 • MARCH 2011
Insulin therapy in South Africa: barriers, dilemmas and
paradoxes
WF MOLLENTZE
I
t is common knowledge that the quality of diabetes care is poor
in the public healthcare sector in South Africa – evidence is not
hard to find.
1
Gill and co-workers demonstrated that it is possible
to improve diabetes care at a rural primary healthcare clinic in
KwaZulu-Natal by introducing a simple protocol and education-
based diabetes care intervention system.
2
Although some slippage
of control did occur, this improvement was sustained for up to four
years.
3
Similarly, a chronic diseases outreach programme in Soweto
successfully supported primary-health nurses in detecting patients
with advanced disease, and ensuring early referral to a specialist
centre.
4
Resistance to switching patients to insulin is at least partly
to blame for the poor quality of diabetes care.
Barriers to insulin therapy have been well described and include
doctor, patient and system barriers.
5
Doctors’ barriers include lack
of knowledge, lack of experience with and use of guidelines related
to insulin therapy, language barriers between doctor and patient,
and fear of hypoglycaemia. Patients’ barriers are mistaken beliefs
about insulin, non-compliance, lack of understanding of diabetes,
use of traditional herbs, fear of injections, and poor socioeconomic
conditions. System barriers are inadequate time, lack of continuity of
care and financial constraints.
5
System barriers described elsewhere
include an overworked, poorly supported, poorly educated and
frustrated primary healthcare team.
4
Furthermore, Daniels
et al
.
demonstrated that the passive dissemination of guidelines to health
professionals in primary care was not effective due to attitudinal
barriers to implementation.
6
The so-called ‘insulin dilemma’ in resource-poor countries
including sub-Saharan Africa (SSA) was recently reviewed.
7
The
dilemma refers to the disproportionate amount of the national
healthcare budget in developing countries that is spent on insulin.
Although this dilemma is very real for several SSA countries, including
Tanzania and Mozambique,
7
it has not been reported to be an issue
in South Africa. Apart from analogue insulin preparations a wide
spectrum of genetically engineered human insulin preparations
are widely available at all levels in the public healthcare sector in
South Africa. The paradox that does exist is the poor quality of care
available to patients suffering from diabetes in the public healthcare
sector in this country in spite of the availability of drugs including
insulin. Even insulin pens, self-monitoring glucose meters and test
strips are available when properly motivated. Admittedly, periodic
supply-chain challenges are not uncommon to certain parts of the
country, as was experienced in the Free State in the not-so distant
past.
At the core of the diabetes paradox in South Africa lies the fact
that our nurse-driven primary healthcare system simply cannot cope
with the quadruple burden of disease in this country.
8
This problem
is further compounded by the fact that treatment guidelines
and policies are developed centrally but that the implementation
thereof is left to the nine different provincial departments of health.
The ‘concerted action’ called for by the authors in the
Lancet
article
to turn the tide
8
is still not forthcoming, while the brain drain of
doctors
9
and nurses is continuing.
10
A paradox of a different nature is the analogue insulin paradox.
7
In spite of a lack of compelling evidence of better glucose control
with analogues than with human insulin, apart from some
reduction in hypoglycaemia (especially nocturnal hypoglycaemia),
insulin analogues and their mixes captured a disproportionately
large share of the global insulin market.
11
The main reason behind
this phenomenon is not evidence-based medicine but more likely
marketing forces and personal beliefs among patients and doctors
that new technologies provide better solutions, leading to human
insulin replacing animal insulin, and later analogue insulin replacing
human insulin.
7
The cost of insulin contributes in no small way to the healthcare
budget of most countries. The global annual expenditure on insulin
increased from US$2 billion 1995 to $7.3 billion in 2005, and was
projected to reach $11.8 billion in 2010.
11
The expectation that
generic human insulin or so-called ‘biosimilar insulins’ may drive the
cost of insulin down is tempered by the complexities of producing
safe and reliable alternatives to the reference products, as is so
elegantly reviewed by Krämer and Sauer on page 19 of this edition.
References
1.
Steyn K, Levitt NS, Patel M,
et al
. Hypertension and diabetes: poor care for
patients at community health centres.
S Afr J Med
2008;
98
(8): 618–622.
2.
Gill GV, Price C, Shandu D,
et al
. An effective system of nurse-led diabetes care in
rural Africa.
Diabet Med
2008;
25
(5): 606–611.
3.
Price C, Shandu D, Dedicoat M,
et al
. Long-term glycaemic outcome of structured
nurse-led diabetes care in rural Africa.
Q J Med
2011 Jan 28. [E-pub ahead of
print].
4.
Katz I, Schneider H, Shezi Z,
et al
. Managing type 2 diabetes in Soweto – The
South African Chronic Disease Outreach Program experience.
Prim Care Diabetes
2009;
3
(3): 157–164. [E-pub 2009 Jul 28].
5.
Haque M, Emerson SH, Dennison CR,
et al
. Barriers to initiating insulin therapy in
patients with type 2 diabetes mellitus in public-sector primary health care centres
in Cape Town.
S Afr Med J
2005;
95
(10): 798–802.
6.
Daniels A, Biesma R, Otten J,
et al
. Ambivalence of primary health care
professionals towards the South African guidelines for hypertension and diabetes.
S Afr Med J
2000;
90
(12): 1206–1211.
7.
Gill GV, Yudkin JS, Keen H, Beran D. The insulin dilemma in resource-limited
countries. A way forward?
Diabetologia
2011;
54
: 19–24.
8.
Mayosi BM, Flisher AJ, Lalloo UG,
et al
. The burden of non-communicable
diseases in South Africa.
Lancet
200912;
374
(9693): 934–947.
9.
Mullan F. The metrics of the physician brain drain.
N Engl J Med
2005;
353
(17):
1810–1818.
10. Dovlo D. Migration of nurses from sub-Saharan Africa: A review of issues and
challenges.
Hlth Serv Res
2007;
42
(3 Pt 2): 1373–1388.
11. Holleman F, Gale EAM. Nice insulins, pity about the evidence.
Diabetologia
2007;
50
: 1783–1790.
Correspondence to: WF Mollentze
Department of Internal Medicine, University of the Free State, Bloemfontein.
Tel: +27 (0) 51 405-3154
e-mail:
S Afr J Diabetes Vasc Dis
2011;
8
: 4.
