–It has been more than 10 years since Mrs T, now a grandmother in her fifties, was first diagnosed with diabetes. Mrs T is enrolled at Hanover Park Community Health Centre (HPCHC) in Cape Town, where she receives her insulin prescription, along with treatment for hypertension and high cholesterol.

She has accepted that she will need to manage her chronic conditions for the rest of her life. But she has also had to contend with a chain of stressful life events, including divorce and retrenchments. When faced with family and financial pressure, she has often found it more difficult to stay well.

That changed though when Mrs T was one of 82 patients who met the clinical criteria and agreed to participate in the PRO-Active TElemedicine TaCTical OpeRation (PROTECTOR) programme, designed and run by the Western Cape Department of Health and Wellness, and transdisciplinary consultancy, Percept.

Even with a R16-million outlay, the province would look to save between R63-million and R139-million, a ROI of 284% to 784% per year.

Covid-19 put a spotlight on the dangers of diabetes and enabled remote patient consultations for the first time. We saw an opportunity for the country to build on that experience and to expand the use of telemedicine into diabetes management, to improve patient care outside of a pandemic.

The PROTECTOR programme was a 12-week telehealth pilot intervention to support people with poorly controlled diabetes living in Hanover Park. The aim of the programme was to find out whether a short telehealth-delivered intervention could help patients to improve their diabetes control and self-efficacy, and bring their measures (such as HbA1c levels, which measures average blood sugar over a three to four-month period) closer to clinically normal ranges.

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If a person’s blood sugar levels are too high for a long period of time, this can result in health complications such as heart problems, kidney disease, blindness, nerve damage, infections and death. Diabetes is South Africa’s leading underlying cause of death in women, and second cause in the general population. In the Western Cape, it is the leading cause — responsible for 7.5% of deaths. 

Designed for care

For the telehealth pilot participants, a programme coordinator began with a baseline survey. The intervention had two phases: the intensive phase, and the maintenance phase. During the intensive phase, the telehealth doctor called the patient every weekday for two weeks, with the aim of optimising their blood sugar through medication adjustment and health education.

The maintenance phase lasted 8-10 weeks, and the doctor called participants once a week for the first two weeks to check in on how they were doing, and to provide further education and support, and thereafter fortnightly.

As part of PROTECTOR, Mrs T received an introductory phone call from Dr Nafisa Khan, the telehealth doctor. She said that at the time, she was trying to eat well and stick to her medication, but was still struggling to keep her sugar levels under control and welcomed the assistance from Dr Khan.

Dr Khan checked in regularly with Mrs T telephonically and via WhatsApp, and Mrs T would text her daily glucometer readings to Dr Khan. Mrs T said she liked that because it showed her that a doctor — the same doctor — cared about how she was feeling, and how she was doing. She said, “You don’t really get that at the clinic.”

Being in regular contact with Dr Khan motivated Mrs T to track her glucometer readings. And in turn, seeing good readings offered positive reinforcement of the changes she was making. Mrs T admitted that her glucometer had been gathering dust. Mrs T said that she was able to chat to Dr Khan “like friends’, not “like doctor-patient”, which was another contrast to her experience of in-person primary healthcare.

We have a public health system, which despite being in-person, is often inhuman — not necessarily inhumane, but inhuman in the sense that person-to-person connection is regularly absent. Health workers have time scarcity, while people spend excess time — often full days — in long queues.

Value at the human level

After 12 weeks, the patients were referred to Hanover Park Community Health Centre, to have their blood sugar tested by measuring HbA1c levels for the last time before exiting the programme. After this, the telehealth surveyor called the patient for an endline survey to find out about their experience of the intervention, and the perceived benefits or drawbacks.

Participants described how calls with the doctor levelled the provider-patient hierarchy, and there was less assertion of health authority, more attention to the person, and greater reciprocity and conversation.

For the participants, the difference came in the convenience of receiving care without skipping work, finding childcare or facing long queues; continuous, real-time primary care, and the luxury of dedicated time with a health worker.

Some participants described the experience as having been treated like a “rich man” or like “royalty”.

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The headline finding from the intervention was that of the 82 patients who completed the PROTECTOR pilot, the median change in HbA1c was 2.66 percentage points lower than their starting HbA1c level. Three of the four cohorts showed overall decreases of 4+ percentage points.

This is a substantial result, given the relationship between lowering HbA1c levels (blood sugar levels) and decreasing the risk of diabetes-related complications, which are traumatic for patients and their providers, and costly to the health system.

This feeling of being cared for helped patients to stay on the programme and remain motivated.

The team also conducted a costing to determine the overall economic and financial cost of the PROTECTOR pilot, as well as the costs and potential savings if PROTECTOR were to be scaled at a district and provincial level.

Organogram of optimal patient load

We developed an organogram and optimal patient load for a virtual clinic. If scaled up for the whole of the Western Cape (for patients with uncontrolled diabetes, HIV or tuberculosis), the province would need to fund three virtual clinics at an additional cost of R16-million per year.

However, the ROI was also calculated by determining the estimated savings due to averted health complications. Using two scenarios: one an average cost for all diabetes-related complications, and the other cost for only myocardial infarctions (heart attacks) averted, we quantified the potential savings to the system. 

Even with a R16-million outlay, the province would look to save between R63-million and R139-million, a ROI of 284% to 784% per year.

The cost-saving to the economy — which we did not include, but should be mentioned — is also likely to be significant through preventing disability and loss of life, which influences household financial stability and wellbeing.

With results like these, one would imagine the next question is: when do we start rolling it out and scaling it up? But it is not.

The next question is: How do we fund it?

The national healthcare budget cuts announced in November 2023 will further strain a struggling healthcare system, and as provincial department allocations get smaller and smaller, balancing fiscal austerity and innovation becomes near impossible.

Unless someone in government thinks it is the right thing to do, or we can find a private funder, the PROTECTOR programme may never make its impact on the likes of Mrs T again. 

We remain optimistic that our department will favour the ROI that we have demonstrated over short-term austerity, and find a way to bring PROTECTOR to the many Mrs Ts who need it. DM

Dr Neal David is a family physician at Hanover Park Community Health Centre and co-designer of the PROTECTOR intervention. Dr Jodi Wishnia is a public health specialist and consultant at Percept. Dr David, Dr Atiya Mosam and Dr Wishnia co-authored the “PROTECTOR pilot report: results, learnings, and recommendations”.