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

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.