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Diabetes in Sub-Saharan Africa – Overview of a Looming Health Challenge
developed countries and mostly carry a worse outcome. Case fatality Figure 3: Estimated Number of Adults with Diabetes
rates for diabetic coma of 10–20% have been reported in studies in
in Sub-Saharan Africa and in Developed Countries
by Age Group and Year
specialised hospitals.
25,26
Evidently, the outcome of such cases in more
deprived areas with less specialised hospitals would be much worse.
Sub-Saharan Africa
These acute complications are usually made worse by accompanying
9
2000 2030
severe infections, which are usually the precipitating factor. Toure et al.
27
8
reported three-fold higher tuberculosis-related hospital mortality in
7
diabetes patients compared with non-diabetes controls.
6
Chronic microvascular and neuropathic complications of diabetes
5
have been reported to be highly prevalent across different populations 4
in SSA. As summarised by Gill et al.,
28
the reported prevalence of the
3
different chronic complications varies enormously between studies.
2
Prevalence rates of retinopathy (15–55%), nephropathy (32–57%) and
neuropathy (10–42%), with a 49% prevalence of erectile dysfunction in
1
men, have been reported across studies in SSA.
29
These data have to
0
20–44 45–64 65+
be interpreted cautiously as there are wide differences in study
Estimated number of people with diabetes (millions)
Age (years)
design, population characteristics and other underlying risk factors. In
many of these patients, complications are already present at the initial
Developed countries
50
diagnosis of diabetes. Worse still, in some patients the initial diagnosis
2000 2030
45
of diabetes is made during consultation or hospital admission for a
40
diabetes-related complication in a hitherto unknown diabetes subject.
Retinopathy is reported to be present in 21–25% of patients at
35
diagnosis.
29
In a study from Nigeria, 25% of patients admitted to
30
hospital for diabetic foot were previously undiagnosed.
30
In another
25
hospital audit from Cameroon,
25
21% of patients admitted in diabetic
20
coma into the endocrinology unit of a main teaching hospital were not 15
previously known to have diabetes. 10
5
Macrovascular complications of diabetes including coronary heart
0
disease (CHD) and stroke appear to be less frequent in SSA than in other
20–44 45–64 65+
Estimated number of people with diabetes (millions)
regions;
31
in fact, blacks are at lower risk of macrovascular disease Age (years)
compared with other ethnic groups. Issues with data quality and 21
Source: Wild et al., 2004.
absence of vital statistics may be involved in the information on these
diseases from many SSA countries. However, in a study from South
Figure 4: Direct, Indirect and Total Cost of Diabetes per
Africa in the same community and using the same methods, Kalk and
Person with Diabetes Compared with the Average Gross
National Income Per Capita in the WHO Africa Region
Joffe
32
found in a sample of adults with diabetes that CHD was present
in 4% of black Africans and in 23% of Caucasians. 12
The Cost of Diabetes
10
Healthcare in most of SSA is almost entirely privately purchased.
Considering that the majority of the poorest people on Earth live in SSA,
8
this statement intuitively signals disaster. A recent study by Kirigia et al.
33
6
clearly demonstrated that the cost of diabetes care is going to be
overwhelming for the poorest countries of the region. This study shows
4
that while the direct cost of diabetes per person with diabetes is only a
fraction (<25%) of the gross national income (GNI) per capita for the 12 2
richest countries, the direct cost for the 34 poorest countries of the
region is 125% of their GNI per capita (see
Amount (thousands of international dollars)
0
Figure 4). For these poorest
Group 1 Group 2 Group 3
countries, the total cost (direct and indirect) of diabetes per person with
Countries
diabetes is more than double the GNI per capita.
Average GNI per capita Average indirect cost
per person with diabetes
The few studies on cost of diabetes care (usually on small samples) that
Average direct cost
Average total cost per person with diabetes
have been carried out in the region confirm the above estimates.
per person with diabetes
Akoussou-Zinsou and Amedegnato
34
reported in 2001 that the direct
Countries are grouped according to average gross national income per capita.
cost of diabetes care at a teaching hospital in Togo was US$342 and
33
Source: Kirigia et al.
US$110 per person for ‘complicated’ and ‘uncomplicated’ diabetes
patients, respectively. The estimated GNI per capita for Togo at the time patient requiring insulin and US$103 for a patient not requiring insulin. In
was approximately US$385. Chale et al.
35
reported an average annual a study on type 1 diabetes patients in Sudan, Elrayah et al.
36
reported a
direct cost of diabetes care in Tanzania in 1989–1990 of US$287 for a partial direct cost of care for each child with type 1 diabetes of US$283,
EUROPEAN ENDOCRINOLOGY 15