Tshwane Insulin Project (TIP), a collaborative project between various University of Pretoria (UP) departments, will lead an exciting five-year research programme that will explore the use of remote prescribing to help primary care physicians and/or nurses better serve the needs of people living with diabetes in underserved areas.

“It’s a tragedy that so many people with diabetes arrive at hospitals with advanced stages of diabetic co-morbidities and complications when, in so many instances, this could have been prevented,” says head of TIP Prof Paul Rheeder, specialist physician in the Department of Internal Medicine at Steve Biko Academic Hospital and UP’s Faculty of Health Sciences.

TIP works with various UP departments – including Internal Medicine, Family Medicine, Human Nutrition and the School of Health Systems and Public Health – national and local health authorities, and external experts.

The research will be conducted in partnership with and funded by Eli-Lilly (through the Lilly Global Health Partnership), a global pharmaceutical research company that brought human insulin to the market in the 1980s. Over the next few years, TIP will be exploring the use of technology using telemedicine or phone apps to assist nurses and primary care physicians in outlying areas.

Diabetes is a growing epidemic and the second biggest killer in South Africa, second only to TB. In Africa, it’s responsible for more deaths than malaria, HIV and TB together. One of South Africa’s greatest challenges in controlling this epidemic is the initiation of insulin and its up-titration (increasing the concentration of a drug to have the best effect) at primary healthcare level – legally only a doctor can prescribe insulin, yet many clinics are primarily managed by nurses. So for many South Africans with diabetes, accessing quality care close to home is almost impossible.

Over the past few years, Prof Rheeder and his colleagues at UP have conducted research related to diabetes and primary healthcare specifically in the Tshwane district of South Africa. Their findings show that diabetes care and screening for complications at primary care level are suboptimal (with about 70% of patients not controlled) and that special blood tests or eye exams often aren’t being conducted.

Several obstacles need to be overcome over the next five years. “Many of these are related to a scarcity of resources, lack of healthcare practitioners trained in insulin use and patient-related factors such as psychological insulin resistance,” Prof Rheeder says.

TIP aims to address all these challenges, and optimise the control of blood glucose, blood pressure and lipids in people with diabetes, specifically focusing on initiation and up-titration of insulin by primary care nurses and/or primary care clinic physicians. Fundamentally, Prof Rheeder wants to make treatment more accessible through TIP. He says its focus is on insulin because of the progressive nature of diabetes – ultimately after five years at least 50% of patients with type 2 diabetes will require insulin for glucose control.

Prof Rheeder believes that training, teamwork and relatively simple interventions would make a huge difference. Healthcare can become more accessible to the most vulnerable communities by finding innovative ways to enable primary care nurses and primary care clinic physicians to do more.

TIP’s research will focus on baseline evaluations and innovative patient-centred interventions. The programme will be designed in such a way that it fits into the Integrated Chronic Disease Management framework of the Department of Health at primary healthcare level, and will leverage existing resources while incorporating new technologies.

South Africa has made great strides in enabling care and management of complex diseases, such as HIV and TB, closer to communities – the same should be possible for diabetes. Millions of South Africans were put onto anti-retroviral treatment and much can be learnt from the Health Department’s success of decentralising TB care and making treatment available as close to the patient’s home as possible.

Prof Rheeder and his team plan to learn from these successes as they investigate the use of technology to assist primary care medics in remote areas. However, he maintains that technological advancement could never replace a competent, caring healthcare professional. Home visits by community healthcare workers will certainly add value, enhancing compliance and patient awareness of the disease.

One thing is non-negotiable for this team: The quality of diabetes treatment and care at primary care level has to improve. Hopefully the lessons from this project will soon be shared at a national level and have the greatest impact on vulnerable communities who are impacted most by diabetes.

Prof Stephanie Burton, Vice-Principal of Research and Postgraduate Education, recognises the importance of this project in that it is not only relevant but also impactful, making this the type of research UP should be supporting and these partnerships so important. “It means we can have even more value and make even more of a difference,” Prof Burton says. “TIP is translational research in its prime.”