Access to Hemoglobin A1c in Rural Africa: A Difficult Reality with Severe Consequences

Paul H Park,Sonak D Pastakia

doi:10.1155/2018/6093595

Abstract

Sub-Saharan Africa (SSA) continues to have the highest diabetes-related mortality rate in the world. While there exists a multitude of health system barriers driving poor diabetes control, rural facilities particularly in SSA lack access to proper monitoring of glucose and other key biologic tests. At best, most of these diabetes patients receive random blood sugar readings only on the day of their clinic visit. This approach has very limited clinical value in determining dosage adjustments for narrow therapeutic index medications such as insulin. Furthermore, access to other blood tests and physical exam tools for detecting early signs of diabetes complications is limited. We propose that routine access to hemoglobin A1c (HbA1c) testing would not only allow for close monitoring of diabetes control but also provide critical data informing the population level risk for diabetes complications. However, implementing HbA1c testing does have its own barriers at rural facilities, including high costs, refrigeration requirements, and perceived discordance between HbA1c values and mean blood glucose levels for SSA patients. Fortunately, several pilots in rural SSA have illustrated feasibility of HbA1c testing. Further political will, price reduction, and context-specific research are needed. Increasing access to HbA1c testing is a critical step to combat the high diabetes-related mortality rates in rural SSA.

Highlights

Sub-Saharan Africa (SSA) has the highest diabetes-related mortality rate globally [1]
As the majority of DM patients in rural SSA do not own a blood glucose monitoring device, the only objective monitoring of their disease typically occurs at routine clinic visits at public sector, district hospitals, or health centers [6]
By prioritizing increased access and availability to hemoglobin A1c (HbA1c) testing, many of these trends could potentially be reversed as providers would be able to observe the average blood glucose over the antecedent three months to develop a better understanding of the patient’s glycemic control

Summary

Introduction

SSA has the highest diabetes-related mortality rate globally [1]. a higher proportion of diabetes patients in SSA develops chronic complications [2]. With innovative foresight and political will, some countries in SSA have been able to decentralize diabetes care to the district hospitals and health centers with documented early success [4, 5]. In both rural and urban facilities, access to appropriate diagnostic and monitoring resources has lagged behind the growing access to medications. We describe the realities of poor diabetes monitoring capacity and its downstream consequences on morbidity and mortality at the district and health center levels for the clinicians and the patients in SSA. Lessons learned surrounding community-based diabetes implementation and policy from experiences in SSA will be shared in order to illustrate the need and impact of HbA1c testing

The Clinical Reality of Monitoring Patients

Challenges to a Potential Solution

Implementation Experiences in the Public Sector in Rural SSA

Recommendations

Findings

Conclusion