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Issue 64 Vol 1 Number 888

Diabetes Prevention and Care Increases in Africa in Line with the Growth of the Disease South Africa’s Ministry of Health Strategic Plan for controlling Diabetes Dr Aaron Motsoaledi


prevent complications overcoming barriers quality of life

healthy, liveable cities

415 million living with diabetes half are undiagnosed

opportunities

healthy lifestyle choices

self-management

awareness

family

collaborative action

support

urban habits

social and cultural factors

More than 90 years of diabetes leadership has taught us that curbing the pandemic requires extraordinary focus. The Novo Nordisk approach to changing diabetes is clear – we must ensure people are diagnosed earlier, improve diabetes care and tackle the rise of diabetes in cities. Learn more at novonordisk.com/changingdiabetes, and share your view #ChangingDiabetes

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driving change to defeat diabetes

Changing DiabetesÂŽ and the Apis bull logo are registered trademarks of Novo Nordisk A/S. HQMMA/CD/0416/0267

Diabetes is one of the major health challenges of our time. Today, 415 million people are living with diabetes, and by 2040 this number could rise to 642 million. Three quarters of people with diabetes will live in cities.1


contents 4... mHealth Requires a Robust Infrastructure 7... The Role of Clinical Education in Diabetes across Africa 10.. Access to care in Africa is in the delivery 13.. South Africa’s Response to the Growth of Diabetes 15.. World Diabetes Foundation Partnering to Stop an Epidemic 17.. Role of Medical Nutrition Therapy in Prevention and Treatment of Diabetes

PUBLISHED BY TIMES PUBLICATIONS GROUP LIMITED PUBLISHER – James Norris EDITORIAL ASSISTANCE – Aisha Aingal PROOF READER – Proofwrite MEDIA EXECUTIVE – Martin Sutherland

Partnerships for Prevention and Care Africa Health report is published quarterly. Subscription details can be obtained from Times Publications Group Ltd. At principal commercial offices: 30-32 Tabard Street, London SE1 4JU: Tel +44 (0)2037446260 or Fax +44 (0)2034078883. Email administration@corporate-africa.com ©Times Publications Group Ltd. 2017 – all rights reserved. First published in 2000. Distributors: Shama PLC Tel: +251115545290, MCS/Caxton International Press Tel:27118079599, Newsstand Nigeria Tel:+234 8023382788, Dominion Bookshop, +233240695791.

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mHealth: Providing a Robust Infrastructure to make it work better Investments in healthcare infrastructure are required to further build capacity in Africa’s health industry, and investment and innovation in telecommunication infrastructure is vital according to Dr Adesina Iluyemi.

The use of mHealth or mobile health in Africa requires a more robust telecommunication and internet infrastructure, to better serve the goal of delivering quality healthcare services. mHealth is the use of mobile and wireless technologies to deliver and exchange health information and services through mobile phones, smartphones and sensors. For the purpose of this article, other technologies such as drones and satellites are considered for delivering such services. Healthcare delivery in Africa is getting better day by day. Though, an occasional flashpoint such as the recent Ebola outbreak, informs that there is still much more to be done to improve healthcare services. Developing and using mobile health services is one of the ways to drive further improvement.

Benefits mHealth offers several benefits for patients, citizens, doctors, dentists, nurses, community health workers and policy makers. Having essential and relevant health information available at the pointof-care is one benefit for health workers. Such information will assist them in making better diagnosis and delivering quality patient care. A benefit to policymakers will be informed decision-making – by deriving knowledge from health data collected by health workers from different settings.

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The benefits for patients and citizens are manifold. One is getting information about managing their medical conditions. Another is to encourage the adoption of healthy living and prevent the development of diseases. Combining sensors with smartphones will assist both health workers and patients to carry out cheap affordable medical testings. For example, a smartphone can be used to regularly monitor a diabetic patient’s blood sugar in the comfort of his or her home. A seamless collection, analysis and transmission of health information require a robust infrastructure.

Infrastructure The need for innovation and investment in infrastructure development cannot be understated. To ensure widespread and accessible mHealth services, there is a need for a robust wireless network. Substantial progress has been made by governments and mobile operators in expanding mobile telephony network in Africa. But there is still much to be done. A report produced by the GSMA in 2012, revealed that personal ownership of mobile phones in Africa is still low when compared to other continents.


The GSMA report put personal ownership in Africa at an average of 33 per cent, very low when compared to other continents. It meant that 2 out of 3 Africans were without a personal mobile phone. Multiple SIM card ownerships don’t equate to personalisation. Though, ownership is far higher than average in Nigeria, Kenya and South Africa; these statistics fall short for a continent of one billion people. Expanding Africa’s telecom and internet infrastructure and making it more robust is therefore, in order. To provide more and better user-experience, mHealth requires wider, faster and cheaper data network. Voice-and SMS-based mobile services have well served healthcare purposes in Africa, and lives have been saved by such. But progress requires moving with changing time and technology. The rising demand for information-rich and data-laden health services and the rising availability of high performance Smartphones, require that an advanced network is built. Faster LTE and 3G are already being rolled out in several African countries. But more is needed, and these shouldn’t be limited to urban areas. Rural areas should be better served, as most African population still reside there, even as urbanisation intensifies. Considering other technologies is in order in this regard.

Internet The use of internet by individuals and businesses are ever-rising in Africa, and the use of social media is now almost a commonplace. Mostly access is gained via feature mobile phones, and increasingly with Smartphones and Apps. The use of these platforms for healthcare purposes, though increasing, is still limited in African countries.

In so far the internet and the platforms built atop it can help in extending and expanding mHealth services, Africa’s internet infrastructure will still needs massive building.

The emergence of above ground technologies such as drones, balloons and satellites provides an opportunity, especially for serving underserved rural population. Drones are unmanned aerial vehicles flying in the atmosphere, which in combination with terrestrial mobile networks, balloons and satellites can boost services in urban and rural areas. Balloons are inflatable balls floated higher in the stratosphere can with similar combination; offer services in a much wider geographical area i.e. a village or a town. Telecommunication satellites are making a strong comeback; one far higher in space can serve an entire country or a continent. Nigeria is the only African country still to own a national satellite and this has been used for delivering medical services. The renewed interest in satellite telecommunication by entrepreneurs will only make the internet more widely available for delivering mHealth services via mobile phones or smartphones. The presence of a robust wireless and internet infrastructure will make the use of another form of mobile health service, possible. Rural population will benefit from health services delivered from vehicles manned by health workers remotely connected to urban hospitals. Corporate Africa |

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Final words mHealth services are already saving and improving lives in African countries. To further deepen such gain, investment and innovation in telecommunication infrastructure is required. Extending and deploying advanced mobile networks, and embracing newer technologies such as drones, satellites and balloons for internet services, will surely help. The role of governments, NGOs and the private sector is to understand and support this development. Cooperation amongst them is required to drive investment and to foster innovation.

Bio: Adesina Iluyemi PhD Dr Adesina Iluyemi is an Executive Board member of NEPAD Council and co-chairs its Global Health Commission. He has contributed to Africa and international developing through invited lectures and speeches on diverse topics such as mHealth, eHealth, global health, infrastructure, science, technology & innovation, ICTs, agriculture, peace and security, international trade, business and economic growth. Notable contribution are at the African Union, UNECA, Chatham House, Wilton Park, ICPS, IDS, ODI and NUPI.

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Adesina is the Founder of a UK-based HEALTHTRONICS, Ltd, a digital health consultancy and advisory firm. It offers unique strategies to ‘innovate to transform’ by simplifying complexities at the interface of healthcare, government policy, industry dynamics and technology. Dr Iluyemi advises international businesses on technology transfer and government relations in Africa. And he mentors entrepreneurs and on the advisory board of start-ups in the UK and African countries. Adesina has been aired by both print and visual media in Africa, Europe and North America, for example by CNN, CNBC, Vox TV, BEN TV, NTA, Voice of America and South African Broadcasting Corporation. He has since 2012 a Judge for the GSMA Global Mobile Awards.


The Role of Clinical Education in Diabetes across Africa Dr Cal Pierce, Global Heath Professional, explains how Clinical Education in Africa could work to reduce the burden on people living with diabetes

Diabetes was once considered a rare disease in sub-Saharan Africa. But now, in 2016, more than 1 in 30 Africans suffer from this life-long, disabling condition. While, in the developed world, people living with diabetes can expect swift diagnosis and a long and disability-free life; in the developing states of Africa, the picture is shockingly different.

The life expectancy of an African child diagnosed with Type 1 Diabetes, for example, is as short as 7 months; the same child in a developed country has a normal life expectancy. But if we know that rates of diabetes are exploding across the continent, and that African diabetics are already at significantly increased risk of complications and death, what should we be doing about it?

Education, education, education I believe the expansion and strengthening of clinical education and training systems will be a central component of our response to this pandemic for one key reason; Healthcare workers lack the tools, confidence and expertise to manage diabetes. Africa suffers a double disease burden: infectious diseases like Malaria, TB and HIV still besiege communities, while in the same households, and often in the same patients, non-infestious diseases like cancer, heart disease and diabetes take their grim toll. There have been huge gains made in reducing the impact of infectious disease across the continent. Indeed, the explosion of chronic diseases across Africa is partly a result of the success of eradication and control programs for Malaria, TB and HIV which

have served to increase life expectancy across the region. But the systems and strategies which brought infectious threats under control in Africa are not fit-forpurpose in addressing the chronic, lifelong threats that diabetes now poses. The focus on infectious disease prevention and control over the past two decades, despite its admirable results, has resulted in a generation of African healthcare workers who have little effective, working, knowledge of how to prevent, diagnose and effectively manage chronic diseases like diabetes. But how do we overcome this skills gap? For over a year, I worked on a project in rural Swaziland attempting to increase access to diabetes care. A core component of this project was a comprehensive training package which gave healthcare workers the knowledge and skills they needed to improve the quality of, and access to, services for diabetics in their care. I can speak from experience when I say that, given the right training (and, crucially, the right level of support) healthcare workers can be successfully empowered to deliver high-quality diabetes services; even in resource-limited settings. Training programs like these, as envisaged by the World Health Organization and The Diabetes Foundation, are absolutely crucial in addressing the human resource deficit facing equitable health service delivery on the continent. And the great thing is that such training programs do not have to delve into forensic detail or biochemical minutae to have an impact - far from it. Healthcare workers simply need to know the importance of risk factor identification, the benefits of tight control of blood glucose and appropriate strategies for achieving good diabetic control. Furthermore they need appropriate clinical support to Corporate Africa |

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reinforce these messages and to give them the confidence to put them into practice for every patient. So, what do we have to gain from increased clinical education? In my view there are three big wins;

Better Prevention Interactions with healthcare workers are often the only source that local populations have for accessing knowledge which could improve, or even prevent, their conditions. We know, for example, that by reducing weight, increasing physical activity and improving diet that most cases of diabetes, and all the tragedy it brings, could be avoided. It is only with proper training and support that healthcare workers will be able to understand the real benefits of risk reduction strategies; only then can we expect them to become true ambassadors for the healthy lifestyle changes which can save those at risk.

Earlier Diagnosis Diagnosis is the first step to successful management. Most people living with diabetes in Africa have not been diagnosed, with recent estimates suggesting that around 85 per cent of Africans living with diabetes are unaware of their disease. This leaves them without the protection from risk that appropriate treatment and regular follow-up can afford. With no awareness of the risks of their condition, patients can progress silently to kidney failure, blindness and even limb loss. Yes, we need greater deployment of essential healthcare technologies - like point-ofcare blood glucose measurements. But we also need greater deployment of healthcare workers who know what risk factors to look out for, who know how to screen clients appropriately, and how to conduct and interpret a simple bedside blood test. The best way to increase our deployment of healthcare workers with the necessary skills to tackle diabetes, and the causes of diabetes, is by training and capacitating those already working in the system.

Smarter Treatment Numerous studies around the world have consistently demonstrated that diabetes, and its devastating complications, can be controlled if patients are given appropriate treatment with oral and, where necessary, injectable medications. In Africa there are many barriers to the provision of medications to those who need them and there are many organizations working valiantly to overcome these challenges. 8

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Better Prevention Earlier Diagnosis

Education

Smarter Treatment

But addressing the supply-side problems of diabetes medications, whether by addressing resource constraints, supply chain issues or procurement challenges is only one half of the problem; we need to create demand among healthcare workers, and through them, demand among patients for these medications.

Only by educating healthcare workers on the importance of tight blood glucose control can we ensure the robust demand creation necessary to ensure that life-saving treatments will finally reach those in need. So, what next for clinical education for diabetes? We do not know what the next steps are for clinical education but the challenges facing Africa’s diabetics are extreme and we need a multi-pronged approach if we are to deliver the coverage and quality of care that is so desperately needed. There is a clear argument, though, that expanded clinical education and training programs offer an effective, lower-cost solution to addressing one of the biggest barriers to equitable health care for people living with diabetes, and indeed other chronic conditions across continent. We must support these initiatives in our communities and actively advocate for more attention and resources to be allocated to this important element of health systems strengthening. As Nelson Mandela once said; “Education is the most powerful weapon we can use to change the world�


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Access to care in Africa is in the delivery In the African region, many people with diabetes have limited access to care due to long distances, modest incomes and inadequate healthcare systems and as much as 54 per cent remain undiagnosed. Training of healthcare professionals and setting up an innovative distribution chain can help provide better treatment to more people.

Sometimes, Novo Nordisk’s insulin travels a long way from production to patient. The journey starts in Kalundborg, Denmark where it is produced, assembled and packaged. From here, the insulin embarks on a 7000 km (4000 miles) journey to the bustling airport of Nairobi, Kenya. Here it is imported by a distributor and transported directly to a healthcare facility. Sometimes it goes through a wholesaler and is sold further to a local hospital or pharmacy. The final delivery – often referred to as the last mile – is the distance separating a person with diabetes from his medicine.

awareness and building healthcare capacity to provide better quality treatment,” says Emma Jakobsson, director of market access, public affairs and business development, Novo Nordisk Business Area Africa. “And that can be a real challenge in Africa.”

For a person living in a rural area in Kenya, the last mile could in fact be several hundred miles.

With the number of people with diabetes set to more than double by 2040, the challenges for a region that accounts for less than 1per cent of global healthcare expenditures on diabetes continue to grow. Making matters worse, the majority of healthcare systems at the same time have to fight communicable diseases such as HIV/AIDS and Malaria. The region has the highest diabetes mortality rate and in 2015 378,000 people in Africa died from diabetes-related causes.

Sheer distances are not the only challenge. On the way, factors such as red tape, weak infrastructure, poor management of stock in pharmacies, and involvement of a series of ‘middle men’ drive up prices. The fact that insulin has to be distributed and stored between 2 to 8 degrees Celsius (36-46 degrees Fahrenheit) adds to the complexity and cost of the distribution chain. On top of the actual cost of the insulin, people with diabetes living in remote areas must add travel costs and lost wages. And there is more to the story than getting the insulin from A to B. “Setting up the insulin distribution chain is one thing, but building a supportive environment around the product is even more important. It includes increasing diabetes

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Diabetes in Africa – a well-kept-secret According to the most recent numbers from the International Diabetes Federation (IDF), the average diabetes prevalence in Africa is 5 per cent. Compared to the rest of the world this number is small, however, a gloomy truth is hiding behind these numbers, which is that as much as 54 per cent of people with diabetes remain undiagnosed.

A 2012 policy brief from the working group on non-communicable diseases at John Hopkins University showed that improving access to insulin was just one piece of the puzzle when it comes to improving the health of people with diabetes. The structural obstacles in the distribution chain must be overcome, but equally important is a holistic understanding of what it takes to build a functioning ecosystem for care. One such prerequisite is the availability of trained healthcare professionals. In most of the region there is a persistent lack of healthcare professionals


with adequate knowledge about diabetes. According to a 2010 paper, there are only 2 doctors and 11 nurses per 10,000 people in Sub-Saharan Africa compared to 32 doctors and 78 nurses per 10,000 in Europe. This is a huge gap and for conditions such as diabetes, the number of specialists is even smaller.

Building capacity among healthcare professionals In the African region only very few general practitioners (GPs) are trained in insulin therapy and many do not feel comfortable prescribing insulin because they do not have enough knowledge about its use. As a result, people are left undiagnosed and without proper treatment and adequate training in how to manage their diabetes. An educational program developed by Novo Nordisk, together with local healthcare professionals in Africa, has addressed this gap since 2012. In the Buddy Doctor Initiative, local diabetes care experts act as mentors for GPs to provide optimal diabetes management. The objective of the program is to inspire interest for and knowledge of diabetes management among GPs across sub-Saharan Africa. The hope is that lasting professional relationships are built between GPs and diabetes experts that result in better care for people with diabetes. The training consists of theoretical and practical sessions and involves GPs in both public and private health clinics.

“The more than 100 mentors have reached over 1,200 GPs and with each GP passing his or her knowledge on to nurses and patients, we can quickly see the effect of the program. It is a practical, cost-effective and sustainable way to strengthening people’s access to better quality care,� says Miguel Angel Torres, medical, regulatory and quality manager, Novo Nordisk Middle Africa.

Rethinking the distribution chain to reach new patient groups Due to distribution challenges, most businesses have been focusing their efforts on catering to high-income people in Africa. However, recently more attention has been given to how companies can reach out to the millions of people living at the Base of the Pyramid (BoP). Since 2012, Novo

Novo Nordisk has been working with developing a profitable, sustainable and scalable solution to improve diabetes care for people with modest incomes in Kenya, Ghana and Nigeria Each partner is responsible for different steps in the distribution process.

So far, the program has been running in 16 African countries, Sudan being the last country included in the Program.

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In Kenya for example, the project is a public-private partnership between Novo Nordisk, Phillips Pharmaceuticals Ltd. Mission for Essential Drugs and Supplies (MEDS), Faith based organisations, the Ministry of Health, and the national patient organisation Kenya Defeat Diabetes Association (KDDA). Each partner has a unique and vital role to play (see figure below). Novo Nordisk is in charge of the production and packaging of the insulin as well as its transportation to Kenya. Phillips Pharmaceuticals Ltd. is responsible for importing the insulin and MEDS takes care of the distribution to the Faith based hospitals and clinics. Training of healthcare professionals is carried out by the Ministry. Patient support groups mobilise the community to increase awareness. It is the first time that all these actors have come together in a partnership. The latest addition to the project is two Diabetes Centres of Excellence placed in large county hospitals in Mombasa and Kakkamega – and one more is on the way. “The partnership is a new way to improve access to insulin for the so-called ‘working poor’. It is leveraging already established structures and provides value to all partners involved which ensures the sustainability of the partnership,” explains Emma Jakobsson. The project has resulted in significant improvement in diabetes care in terms of access, affordability and comprehensive care. The price increases that have normally taken place through the distribution chain have been reduced by 75 per cent. By working with all partners along the supply chain, insulin is now available at 500 KSH (approximately US$ 6) compared to 2000 KSH (US$24) before, and the people with diabetes are aware that this is the price they should be paying. 12

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One 500 KSH pack of insulin is enough to ensure treatment for approximately one month. This has greatly reduced the out-of-pocket expenses since they previously could be paying more than three times as much for their insulin.

In Kenya, so far, 6,000 people have received improved access to safe, affordable diabetes care on a monthly basis. Additionally, more than 600 healthcare professionals have been trained, 46 diabetes support centres have been established and 27 out of 47 counties are part of the project. A region of opportunities The millions of people living with diabetes, many of whom are undiagnosed, highlight the magnitude of unmet needs in the region. But they also represent a big opportunity for change and improvement. The actors most successful in providing care will be the ones who understand how to adapt to patient needs and support local healthcare systems. “There is no one size fits all in Africa,” says Emma. “This is why we need to look at each country and see how we can build on existing healthcare structures to the benefit of the patient,” he adds.


South Africa’s Response to the growth of Diabetes South Africa’s Minister of Health Dr Aaron Motsoaledi, speaks about the country’s national response plan to prevent the growth of Diabetes and care for people living with the disease.

The Ministry of Health firmly believes that a broad multi-sectoral approach is a key to reducing the ever-increasing numbers of diabetes in South Africa. There are three-and-a-half million South Africans (about 6 per cent of the population) estimated to suffer from diabetes, and there are much more who are undiagnosed. Of the three types of Diabetes, the majority of people in South Africa have type 2 diabetes. Many of these cases go undiagnosed as there are very few symptoms initially. Researchers tell us that it takes on average seven years for a person to get diagnosed with diabetes for the first time; resulting in about 30 per cent of people with type 2 diabetes already developing complications at diagnosis. Diabetes complications are serious and include heart disease, stroke, blindness, amputations and kidney failure. In most cases, these complications could have been avoided entirely by early diagnosis and proper treatment. The fact that many diabetic patients only get help when they already have complications, also poses a burden on the health care system, whereas 80 per cent of type 2 diabetes could be avoided through the following of a healthy eating plan and regular exercise.

The South African Ministry of Health’s response to the growth of type1 Diabetes across South Africa is guided by the country’s Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013-2017. The Strategic Plan was the culmination of the work and ideas of many stakeholders working in diverse areas over many years, to deliver on a multisectoral approach, premised on effective collaboration, equitable funding, service equity, good management and the availability of an appropriately skilled workforce. As with other forms of diabetes, nutrition and physical activity and exercise are essential elements of the lifestyle management of type 1 diabetes. In September 2011, the Ministry of Health hosted a Summit on Prevention and Control of Non-Communicable Diseases. Ideas were presented and robustly discussed over two days by stakeholders, including government representatives, non-profit organizations, academics, and other experts.

We agreed to targets and objectives and outline broad directions of what was required to achieve them. The Summit concluded with the unanimous adoption of the South African Declaration on the Prevention and Control of Non-Communicable Diseases. The Declaration committed to a set of 10 goals and targets to be achieved by 2020 and 2030. They covered reducing the relative premature mortality; reducing tobacco use; reducing the per capita consumption of alcohol; reducing mean population intake of salt; reducing the prevalence of people with raised blood pressure; increasing the prevalence of physical activity; reducing the prevalence of cervical cancer; increasing the percentage of people controlled for hypertension, diabetes and asthma, and increasing the number of people screened and treated for mental disorder. Corporate Africa |

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Effective prevention necessitates a broad multi-sectoral approach involving different government departments, civil society organizations, the private sector, media as well as commitment to health and wellness from individuals. The health, life opportunities and the quality of life of a population require a shift away from government departments working in isolation. Key sectors such as Agriculture, Trade and Industry, Social Development, Sport and Recreation, Basic and Higher Education, Transport and Science and Technology and others must recognize their role in working toward a healthy population. There are also important roles for non-governmental organizations and the private sector in reducing NCDs. Identifying individuals at risk and assisting them to change their behavior is an important strategy to prevent NCDs. Moreover, early identification through screening programs, such as the inclusion of NCDs in the HIV Counselling and Testing (HCT) and testing patients when attending clinics for other reasons offer important opportunities for preventing NCD morbidity and mortality. Changed lifestyles for people already diagnosed with NCDs as well as strict adherence to medical interventions are vital for the secondary prevention of NCDs and increasing life expectancy. Health workers, family members, and support group members can all play a critical role in assisting people already living with chronic diseases to remain healthy. Community level workers with competencies in palliative care in the home enhance the preventative messages for people living with chronic diseases and for their family members. 14

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Strengthening health system is essential to prevent and control NCDs. Health care for NCD requires a different approach than for acute diseases. Patients with NCDs will require lifelong care which necessitates a patient-centred health service which supports the patients’ optimal adherence to treatment. Careful liaison and interaction between different levels of health care i.e. primary, secondary, and tertiary levels and with central and specialized hospitals is needed; including appropriate promotive, preventative, curative and palliative services at all levels. Community-based services need to be integrated into the district health system, and referral and back referral systems must be effective and efficient. All the main building blocks for health systems must be in place. When I gave South Africa’s commitment to fighting noncommunicable diseases at the United Nations General Assembly in September 2011, I did not do this lightly. I supported the Political Declaration with the knowledge of a growing disease burden from noncommunicable diseases in South Africa and Africa as a whole and with an understanding of the impacts not only on health but the future of South Africa more broadly. I said at the UN High-Level meeting that “South Africa recognizes the need for non-communicable diseases to be regarded as a development priority rather than only a health concern”.

It is the view of the South African government that a ‘health only approach’ will not reverse the global mortality and burden from non-communicable diseases, but that a ‘whole of government’ and ‘whole of society’ approach is needed”. The need to prevent and manage non-communicable diseases is also an important emphasis in the National Development Plan as the long-term guidance document for South Africa. We contend that the best way to address the burden of diabetes is for government and civil society to focus on prevention and raising awareness. We will have to focus our attention on primary prevention, raising public awareness, building capacity for health care programs and offering diabetes services at primary care, ensuring patients can receive self-care education and support. We also need to promote breastfeeding, because it is good to prevent obesity in both mother and child, and identify women with gestational diabetes. Diabetes during pregnancy can cause serious complications and also increase the risk for both mother and child to develop diabetes later in life. Treating complications of diabetes is expensive. “People often say that treating diabetes is expensive. Prevention, early identification, and offering proper basic care are both essential and affordable. We have to double our efforts in this regard.


World Diabetes Foundation Partnering to Stop an Epidemic Gwendolyn Carleton of the World Diabetes Foundation discusses her organization’s activities in Africa including a successful media campaign in Malawi, which is an example of how partnerships projects are helping to lift diabetes to the top of the health agenda.

By In the spring of 2002, in the small Scandinavian country of Denmark, a new independent trust was born. The World Diabetes Foundation had an ambitious vision to alleviate human suffering related to diabetes and its complications among those least able to withstand the burden of the disease. Its founders were responding to the huge need for diabetes care in the developing world. But they could not have foreseen how fast that need would grow in the coming years. In 2000, the International Diabetes Federation (IDF) estimated that worldwide, 151 million people had diabetes. By 2015, the estimate had swelled to 415 million, an increase of 174%. Today, according to the IDF, 75 per cent of all people with diabetes live in developing countries. The WDF pursued its vision by forming partnerships with global, regional and local groups with expertise in diabetes. Its goal was to act as a catalyst to help other groups to achieve more. The WDF began soliciting local proposals that provided solutions that were focused, replicable and sustainable. WDF’s portfolio grew and by 2015 its partners had treated 5.7 million people, trained 300,000 healthcare professionals, established and strengthened 10,000 clinics, and held more than 40,000 awareness and screening camps. The impact was strong and the projects continued after WDF funding ended, creating a ripple effect benefitting thousands of more people. As external frameworks such as the WHO Global Action Plan for Non-communicable diseases (GAP) and UN Sustainable Development Goals (SDGs) increase the global focus on NCDs, these projects continue to provide useful examples of approaches that can be adapted and replicated. One of the WDF’s first projects took place in Tanzania, and it has been active

across the African continent ever since. To date, the WDF has funded 134 projects in 32 sub-Saharan African countries (the Foundation funds numerous projects in Northern Africa as well). A project in Malawi offers one example of how these partnerships work, and the value that they bring to people with diabetes and the societies in which they live.

Real-life stories In the summer of 2016, an innovative TV documentary aired in Malawi called Diabetes on the Doorsteps explored the current state of diabetes care in the country, offering candid interviews with patients, healthcare providers, and government officials. In one scene, Mary Francisco, a patient at the Mwanza District Hospital Diabetes Clinic in southern Malawi, listed some of the problems she and other diabetes patients face on a weekly basis. “The delays we experience before we are attended to at the clinic are risky, since we leave our homes without eating or drinking anything, and sometimes we collapse while waiting for the clinic to start.” The venue for the clinic keeps changing, she added. And consultations take place in an open room, where everyone can hear. “Sometimes we fail to be completely honest with the doctor because of this lack of privacy,” she said. The issues she and others describe in the documentary are clear, burdensome, and fixable. “The idea is to inspire viewers to roll up their sleeves and get to work,” says Dingaan Mithi, Programme Manager for Journalists Association Against AIDS (JournAIDS), which produced the documentary. “We thought real-life stories told by patients could be a powerful way of informing government, civil society organizations, policy and decision makers of the need to Corporate Africa |

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urgently address health challenges faced by diabetic patients,” he says. “Many people including religious leaders who we have engaged and have seen the TV documentary are very impressed.” These real-life stories are the latest addition to a 6-year effort to increase awareness about the devastating impact that diabetes is having on Malawi. “It’s an effort that is getting results with lessons applicable to many other countries, as well,” Mr. Mithi says.

Not just a disease of the rich JournAIDS was created to raise awareness about the prevention of HIV and care of AIDS. But in 2009, a survey showing that diabetes was growing fast in Malawi caught the organization’s attention. “As a media NGO, we thought that it could be a good idea to review our strategic plan and include non-communicable diseases,” explains Christopher Bauti, Executive Director of JournAIDS. “People here thought diabetes was a disease for rich people and not relevant to us. We needed to correct this way of thinking.” One goal was to increase general awareness about the disease to help residents help themselves. “Increased awareness makes people have better healthseeking behaviors,” Mr. Mithi says. “This reduces diabetes complications, which have a severe impact on families and often perpetuate poverty.” Patients can not improve their health alone; and because of this, JournAIDS created a plan targeting all the key groups in Malawian society including the general public, media, non-governmental organizations (NGOs) and policy makers. They consulted with the Diabetes Association of Malawi, the College of Medicine and others to ensure coordination of diabetes advocacy and to leverage their experience and ideas. 16

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They then approached the World Diabetes Foundation for funding. The result was Support to primary diabetes prevention, WDF10563. The project’s goals included training local journalists, launching community mobilization campaigns, creating a series of radio programs and listener clubs, and lobbying the Ministry of Health. The project met and exceeded its goals. In fact, the focus on diabetes in Malawi increased so much between 2010 and 2013 that a persistent problem, stock outs of diabetes drugs, became big news. This contributed to the national government’s decision, in 2013, to allocate an extra £16 million for drug procurement. “It was a key lesson that exerting pressure on the government through the media could improve health service delivery,” Mr. Mithi says. A desire to do more led to a new project: Popularizing Advocacy to Primary Diabetes Prevention, WDF14-858. The new project has expanded media training to focus on editors and has increased the number of written resources and field visit opportunities for journalists. It has produced the TV documentary, two magazines, and five new radio programs. It also has elements that are completely new, such as a national diabetes conference for policy makers and an effort

to educate religious leaders about the problem of NCDs. The biggest achievement so far is the launch of an NCD column in Malawi’s Sunday Times, Mr. Mithi says. The column, combined with the project’s many other activities, is keeping diabetes in focus and pressuring authorities to address the problem effectively. “As of now Malawi government and even parliamentarians are aware of the need to tackle NCDs with urgency. Six years down the line we have changed the media coverage on NCDs in Malawi and put diabetes on top of the health agenda,” Mr. Mithi says. To reach Sustainable Development Goal 3.4 (By 2030, reduce by onethird premature mortality from non-communicable diseases), such awarenessraising is important, he adds. Effectively using the media to reach policy and decision makers can lead to increased budget allocations for tackling non-communicable diseases. “In Malawi, where six out of every 100 people have diabetes, there is now a growing momentum among NGOs such as JournAIDS within the NCD Sub-technical working group in the Ministry of Health to build lasting partnerships and network to turn the tide against the chronic disease burden.”

The World Diabetes Foundation: The World Diabetes Foundation is an independent trust dedicated to the prevention and treatment of diabetes in the developing world. Its aim is to alleviate human suffering related to diabetes and its complications among those least able to withstand the burden of the disease. The Foundation supports sustainable partnerships and acts as a catalyst to help others do more. From 2002 to June 2016, the World Diabetes Foundation provided 119 million US dollars in funding to 458 partnership projects in 114 countries, focusing on awareness, education and capacity building at the local, regional and global level. For every dollar spent, the Foundation can raise approximately 2 dollars in cash or as in-kind donations from other sources. For more information, please visit www.worlddiabetesfoundation.org


Role of Medical Nutrition Therapy in Prevention and Treatment Of Diabetes By Hellen C Baliach, Consultant Clinical Nutritionist What Is on Your Plate?

Diet forms one of the three cornerstones of good health, the others being Exercise, education about diabetes, medication and meal planning. A normal ‘Diabetic diet’ is simply a healthy eating plan aimed at controlling the blood sugar level. Medical Nutrition Therapy (MTN) is important in preventing diabetes, managing existing diabetes, preventing and slowing the rate of development of diabetes complications, and achieving nutrition-related goals. This requires involvement of the person with diabetes in the decision-making process. MTN endeavours to attain and maintain blood glucose level as close as normal as possible, and to prevent Hypo and Hyperglycemia. It also helps to obtain optimum blood lipids and blood pressure control and reduce the risk of macro vascular disease. It involves assessment of energy intake to achieve optimum body weight, and promote physical, social and physiological wellbeing. MTN’s objectives are to (a)prevent, delay or minimize, the onset of chronic degenerative complications such as hypertension and renal disease (b) achieve and maintain optimal metabolic and physiological outcome (c)

provide relief from symptoms (d) individualize meal plan according to a person’s lifestyle and based on usual dietary intake. Ecological factors are known to influence the nutritional status of individuals. Variables include; household composition, education, literacy, ethinicity, religion, income, employment, material resources, water supply and household sanitation, access to health, and agricultural services and land ownership. A standard modern diet includes 55-60 per cent carbohydrates, 20-30 per cent fat, and 15-20 per cent protein. A study by Abel and others in 2010 shows that a low carbohydrate diet Improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus, and Long-term is beneficial for patients with type 2 diabetes as a part of a structured permanent lifestyle modification. Major challenges are a majority of people living with diabetes do not access nutrition services. Less than 5 per cent of the total clients attending our college receive the Nutrition services. Clients have acquired varied nutrition information from other health workers,herbalists, relatives, bussiness people and friends. Undoing their information is a major challenge. Healthy people with diabetes should however be referred to hospitals, Dieticians, and Nutritionist and should receive guidelines about nutrition and improved management of diabetes. Pregnant women with diabetes should be provided with optimal nutrition support before, after and during pregnancy. And proper feeding practices and growth monitering should start from birth of babies. Glycemic control is best achieved when drugs and nutritional therapy are combined. Diabetes management involves a multidisplinary approach. And prevention is always better than cure-through intensifications of campaigns,education, breast feeding and HBV-proteins. Corporate Africa |

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Changing diabetes care for children in Africa Adolescent testing his blood glucose level prior to insulin treatment

Doctor explaining how to inject insulin


Educational material designed specifically for children and adolescents in Africa

Testing people’s blood glucose levels for diabetes in Africa Provide comprehensive diabetes care for children with type 1 diabetes in Africa and improve the healthcare systems of resource-limited countries.


Corporate Africa January 2017