South Africa

South Africa, like many countries, has both public and private healthcare sectors, although a majority of people (72%) make use of public services.

Fortunately in South Africa, basic diabetes medication is provided free of charge to all public healthcare patients, including insulin, Metformin and some sulfonylureas. There are some issues with regard to consistency and availability. Insulin is limited to premixed, NPH and human rapid acting insulins. Changes in national tenders for the provision of these medical supplies occur every two years, which means that the pharmaceutical companies awarded the bid dictate which insulins and medications are available. Distribution problems often occur, meaning hospitals may be out of stock, forcing them to either give out alternative insulin or ask the patient to buy the medication themselves. If such substitution occurs, patients are rarely educated on the changes in doses or administration that are required for the new product.

Diabetes patients using insulin are referred to secondary or tertiary hospitals, often far from their hometowns. Children with diabetes are seen within paediatric diabetes clinics up to the age of 13, after which they will be seen in the adult clinics without any transition stage. Patients are required to visit the clinic/hospital every month to collect their medication because the state does not issue medication for longer periods. A major problem associated with this process is that it often takes hours to collect medication due to the long lines, forcing patients to take leave from work at least one day a month. Additional issues within the public sector include staff shortages, poor hospital management, poor logistic planning for distribution of medication on tender, and lack of basic medical equipment and resources.

Patients within the private sector pay a monthly fee for medical aid schemes. These schemes have a list of medication which they will pay for; if your medication is not included, you will be expected to either make a co-payment or cover the costs completely. According to the tier of medical coverage, there is a limit on the monetary value of medication that a medical aid will cover within a given year. Above this amount, the patient is expected to cover costs for the duration of the year, regardless of when this limit is reached. Fortunately it has been mandated by the Department of Health that medical aids are to provide diabetes medications, regardless of if a patient has used the limit of chronic medication for the year.

A major problem within the private sector is the non-referral of patients to specialist physicians/endocrinologists. General practitioners who diagnose the patient with diabetes continue to treat the patient, often without expertise or adequate experience in diabetes. It is thought that this trend is due to greed and fear of losing client base.

What happens if you need to see the doctor?
Public hospitals have diabetes clinics on specific days of the week. Patients are booked for regular appointments every 3 months, or more often if their blood glucose control is poor. The hospitals do not allow patients to be seen without an appointment. In cases where patients miss their appointment, they are expected to return the next week but have to wait until the end of the day until all scheduled patients for that day have been seen.

On clinic days, doctors see patients on a first come first serve basis. This policy prompts patients to get to the public hospitals as early as 6am to avoid long lines, but patients wait for many hours before their consultation. In private healthcare, pre-authorisation is needed from your medical aid to see a specialist. This can be arranged a few days before your consultation. However, endocrinologists are often fully booked for more than 3 months in advance, thus planning is needed when booking consultations.

Who decides what doctors can prescribe?
The Medicines Control Council (MCC) is the statutory body that regulates the performance of clinical trials and registration of medicines and medical devices for use in specific diseases. The MCC is responsible to ensure that all clinical trials of both non-registered medicines and new indications of registered medicines comply with the necessary requirements for safety, quality and efficacy.

In public healthcare doctors are limited to medications on tender, as described above. In private healthcare, doctors are able to prescribe whichever medication they feel is necessary, but many patients will purchase a generic medication that is covered by their medical aid.

Practically, what is it like to live with type 1 diabetes in South Africa?
This greatly depends on your geographical location and which healthcare sector you receive your treatment from. Proximity to major city centres highly influences access to medical care. As described above, public and private sectors differ greatly, but there are some commonalities. Within all sectors, lack of a transition clinic between paediatric and adult care is a problem. However, all patients with type 1 diabetes have guaranteed access to insulin.

Major differences occur with regard to diabetes education and access to testing strips. In public hospitals, diabetes education is limited due to staff shortages, and often, patients will not understand concepts relating to diet, exercise and correcting hyperglycaemia. This is in contrast to patients within private healthcare that are educated extensively in carbohydrate counting and correction doses.

Currently, hospitals pay for test strips out of their own budgets. The availability of test strips depends on the size and location of the public hospital. Patients can thus receive between 50 to 100 test strips a month, but in some hospitals, type 1 diabetes patients do not receive any test strips. In private healthcare, doctors often prescribe up to 200 test strips per month, but depending on the medical aid, patients may need to make a co-payment.

There are many misconceptions and stigmas related to diabetes within the public. Young school children are bullied by their peers due to ignorance, and high school teens hide their diabetes from friends and teachers in fear of being different. Within the working environment, employers are not usually biased against those with diabetes due to our strong constitution that prohibits discrimination of any kind.

What about getting admitted to the hospital?
At diagnosis, most patients in both private and public healthcare are admitted to hospital for a number of days. Often, this is not necessary and introduces the child and family to diabetes under very stressful and negative circumstances. Both private and public hospitals are equipped to deal with admissions for diabetes ketoacidosis and severe hypoglycaemia.

How does diabetes care vary throughout South Africa?
In addition to the above, within the two major affluent provinces of South Africa services are substantially better near the city centres. There is a large portion of our country where healthcare is in a shocking state, particularly within rural areas. Public hospitals are extremely short staffed and under-resourced, and in the private sector, there are very few specialists available in these areas. For example, in the province of Limpopo (bordering Mozambique and Zimbabwe), there is only a single endocrinologist.

We appreciate Kerry Kalweit who has taken the time to provide information for this page.

To learn more about life with type 1 in South Africa, check out our blog post:
A battle with Medical Aid for insulin