The aim of this review is to summarize the contextual, clinical and health system challenges to the delivery of health care for diabetes in Africa. Planners need to allocate sufficient resources in a context where resources for health in general are insufficient. Choices need to be made between different options for health care within this context and mechanisms are required to facilitate the implementation of the selected options and ensure that quality of care is maintained.
World Health Organization.World Health Report 2000. Health Systems: Improving Performance. Technical Report. Geneva: World Health Organization; 2000.
2.
LevittNMollentzieW.Diabetes mellitus and impaired glucose tolerance. A review of South African studies. In: ForieJSteynK (editors): Chronic diseases of lifestyle in South Africa. Cape-Town: MRC Publications; 1995. pp. 99–126.
3.
TappyLBovetPShamlayeC.Prevalence of diabetes and obesity in the adult population of the Seychelles. Diabet Med1991; 8:448–452.
4.
El-ShazlyMAbdel-FattahMZakiABedwaniRAssadSTognoniGHealth care for diabetic patients in developing countries: A case from Egypt. Public Health2000; 114:276–281. This study presents a comprehensive assessment of the quality of diabetes care comparing health-insured and non-health-insured patients. The quality of care in these populations is in stark contrast to that in Africa south of the Sahara.
5.
KingHRewersM.Diabetes is now a third world problem. Bull WHO1991; 69:643–648.
6.
LevittNSZwarensteinMFDoepfmerSBawaAAKatzenellenbogenJBradshawD.Public sector primary care of diabetics - a record review of quality of care in Cape Town. S Afr Med J1996; 86:1013–1017.
7.
LevittNSBradshawDZwarensteinMFBawaAAMaphumoloS.Audit of public sector primary diabetes care in Cape Town, South Africa: High prevalence of complications, uncontrolled hyperglycaemia, and hypertension. Diabet Med1997; 14:1073–1077.
8.
GoodmanGRZwarensteinMFRobinsonIILevittNS.Staff knowledge, attitudes and practices in public sector primary care of diabetes in Cape Town. S Afr Med J1997; 87:305–309.
9.
BeattieAKalkWJPriceMRispelLBroombergJCabralJ.The management of diabetes at primary level in South Africa: The results of a facility-based assessment. J R Soc Health1998; 118:338–345.
10.
AmoahAGBOwusuSKSaundersJTFangWLAsareHAPastorsJGFacilities and resources for diabetes care at regional health facilities in southern Ghana. Diabetes Res Clin Pract1998; 42:123–130.
11.
KalkWJVeriawaYOslerC.A survey of hospital outpatient services for chronic diseases in Gauteng. S Afr Med J2000; 90:57–61.
12.
DanielsARBiesmaROttenJLevittNSSteynKMartellRAmbivalence of primary health care professionals towards the South African guidelines for hypertension and diabetes. S Afr Med J2000; 90:1206–1211.
13.
UnwinNMugusiFAsprayTWhitingDEdwardsRMbanyaJTackling the emerging pandemic of non-communicable diseases in sub-Saharan Africa: The essential NCD health intervention project. Public Health1999; 113:141–146. This project is developing a package (including costs) for the treatment of diabetes at a primary health care level and also methods for the rapid evaluation of health care for diabetes at all levels. The package includes treatment protocols, structured record forms, patient education materials, a staff training package, and an audit system based on review criteria.
14.
DanielsARPatelMBiesmaROttenJLevittNSSteynKA structured record to implement the national guidelines for diabetes and hypertension care. S Afr Med J2000; 90:53–56.
15.
World Health Organization.Obesity: Preventing and managing the global epidemic. WHO Technical Report Series 894. Geneva: World Health Organization; 2000.
16.
SeidellJC.Obesity, insulin resistance and diabetes - a worldwide epidemic. Br J Nutr2000; 83:S5–S8.
17.
AlemuSWatkinsVJDoddsWTurowskaJBWatkinsPJ.Access to diabetes treatment in northern Ethiopia. Diabet Med1998; 15:791–794.
18.
ColemanRGillGWilkinsonD.Noncommunicable diseases management in resource-poor settings: A primary care model from rural South Africa. Bull WHO1998; 76:633–640. This paper describes the design and implementation of simple protocols for the treatment of diabetes by nurses working at primary care facilities using essential drugs. Treatment was focused on preventing symptomatic hyper- and hypoglycaemia rather than measurement of blood glucose or HbA1c. Using these criteria nurses were able to ‘control’ 82% of patients with type 2 diabetes.
19.
WatkinsPJ.Delivering care for diabetes in Ethiopia. Trans R Soc Trop Med Hyg1999; 93:355–356.
20.
HermanWAliMAubertREngelgauMKennySGunterADiabetes mellitus in Egypt: Risk factors and prevalence. Diabet Med1995; 12:1126–1131.
21.
McLartyDGPollittCSwaiABM.Diabetes in Africa. Diabet Med1990; 7:670–684.
22.
AsprayTJMugusiFRashidSWhitingDEdwardsRAlbertiKGRural and urban differences in diabetes prevalence in Tanzania: The role of obesity, physical inactivity and urban living. Trans R Soc Trop Med Hyg2000; 94:2000.
23.
SetelPWUnwinNAlbertiKHemedY.Cause-specific adult mortality: Evidence from community-based surveillance - selected sites, Tanzania, 1992–1998. Morbidity and Mortality Weekly Report2000; 49:416–419. This paper reports the results of a community-based mortality monitoring system that has been developed to provide information for planning as a substitute for vital registration. The system is integrated into the health system and is being expanded to other parts of the country to improve representativeness. The three areas presented demonstrate the variation in cause-specific mortality that exists within countries.
24.
MurrayCJLLopezAD.Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet1997; 349:1269–1276. The Global Burden of Disease Study aimed to estimate the burden of morbidity and mortality by region to aid objective debates on health policy. This paper shows, among other findings, that the probability of death from a non-communicable disease was greater in sub-Saharan Africa than in established market economies.
25.
CooperRSOsotimehinBKaufmanJSForresterT.Disease burden in sub-Saharan Africa: What should we conclude in the absence of data? Lancet1998; 351:208–210.
26.
BonitaRde CourtenMDwyerTJamrozikKWinkelmannR.Surveillance of Risk Factors for Non-communicable Diseases: The WHO Stepwise Approach. Technical report. Geneva: World Health Organization; 2001.
27.
PanXRLiGWHuYHWangJXYangWYAnZXEffects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and diabetes study. Diabetes Care1997; 20:537–544.
28.
TuomilehtoJLindstromJErikssonJGValleTTHamalainenHIlanne-ParikkaPPrevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med2001; 344:1343–1350.
29.
VijanSStevensDHermannWFunnellMStandifordC.Screening, prevention, counseling, and treatment for the complications of type II diabetes mellitus. Putting evidence into practice. J Gen Intern Med1997; 12:567–580.
30.
KriskaAMBlairSNPereiraMA.The potential role of physical activity in the prevention of non-insulin dependent diabetes mellitus: The epidemiological evidence. Exerc Sport Sci Rev1994; 22:121–143.
31.
WojtaszewskiJFHansenBFGadeJKiensBMarkunsJFGoodyearLJInsulin signaling and insulin sensitivity after exercise in human skeletal muscle. Diabetes2000; 49:325–331.
32.
SegalLDaltonACRicardsonJ.Cost-effectiveness of the primary prevention of non-insulin dependent diabetes mellitus. Health Promotion International1998; 13:197–209.
33.
PanfordSNyaneyMOAmoahSOAidooNG.Using folk media in HIV/AIDS prevention in rural Ghana. Am J Public Health2001; 91:1559–1562.
34.
SwaiALutaleJMcLartyD.Diabetes in tropical Africa: A prospective study, 1981–7. I. Characteristics of newly presenting patients in Dar es Salaam, Tanzania, 1981–7. BMJ1990; 300:1103–1106.
35.
UKPDS Group.Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet1998; 352:837–853.
36.
DCCT Research Group.The effect of intensive treatment of diabetes on the development and progression of long-term complications of insulin-dependent diabetes mellitus. N Engl J Med1993; 329:977–986.
37.
GillGVHuddleKR.Hypoglycaemic admissions among diabetic patients in Soweto, South Africa. Diabet Med1993; 10:181–183.
38.
TurnerRCCullCAFrighiVHolmanRR.Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: Progressive requirement for multiple therapies (UKPDS 49). JAMA1999; 281:2005–2012.
39.
WikbladKSmideBBergströmAWahrenLMugusiFJeppssonJ.Immediate assessment of HbA1c under field conditions in Tanzania. Diabetes Res Clin Pract1998; 40:123–128.
40.
UKPDS Group.Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ1998; 317:703–712. This study demonstrates the importance of good blood pressure control in the management of diabetes, with improvements in a range of outcomes often exceeding those from tight blood glucose control. Tighter control, however, led to increased weight gain.
41.
Dagogo-JackS.DCCT results and diabetes care in developing countries. Diabetes Care1995; 18:416–417.
42.
TookeJEThomasSVibertiGC.Proteinuria in diabetes. J Royal Coll Physicians London2000; 34:336–339.
43.
HendryBMVibertiGCHummelSBagustAPiercyJ.Modelling and costing the consequences of using an ACE inhibitor to slow the progression of renal failure in type 1 diabetic patients. QJM1997; 90:277–282.
44.
MogensenCEKeaneWFBennettPHJerumsGParvingHHPassaaPPrevention of diabetes renal disease with special references to microalbuminuria. Lancet1995; 346:1080–1084.
45.
ZouvanisMPieterseACSeftelHCJoffeBI.Clinical characteristics and outcome of hyperglycaemic emergencies in Johannesburg Africans. Diabet Med1997; 14:603–606.
46.
McLartyDGKinaboLSwaiAB.Diabetes in tropical Africa: A prospective study, 1981–7. II. Course and prognosis. BMJ1990; 300:1107–1110.
47.
MasonJO'KeeffeCMcIntoshAHutchinsonABoothAYoungRJ.A systematic review of foot ulcer in patients with type 2 diabetes mellitus. I: Prevention. Diabet Med1999; 16:801–812.
48.
YudkinJS.Insulin for the world's poorest countries. Lancet2000; 355:919–921.
