The Tshwane Insulin Project

Prof Paul Rheeder tells us more about the five-year research programme, the Tshwane Insulin Project (TIP).

About TIP

The University of Pretoria (UP) and Eli Lilly and Company will embark on a five-year research programme called, the Tshwane Insulin Project (TIP).

The aim of TIP is to optimise the control of blood glucose, blood pressure and lipids in people with diabetes, with specific reference to initiation and up-titration of insulin by both primary care nurses and/or primary care clinic physicians.

TIP is designed to fit into the National Department of Health’s Integrated Chronic Disease Management (ICDM). ICDM is a model of managed care that provides for integrated prevention, treatment and care of chronic patients at primary healthcare level, to ensure a seamless transition to assisted self-management within the community.

The TIP programme is a collaborative effort between the Departments of Internal Medicine, Family Medicine, Human Nutrition and the School of Health Systems and Public Health of UP, national and local health authorities, external experts and Eli Lilly.

The programme uses Lilly’s global health framework, which includes studying key research questions, reporting what works and what doesn’t, and then using the data to advocate for the scale up of the most effective solutions. The programme will contribute to Lilly 30×30. This is the company’s goal to create new access to quality healthcare for 30 million people in resource-limited communities every year by 2030.

Major challenge in SA

In SA, initiation and up-titration of insulin in primary care has been identified as a major challenge in diabetes care and achieving optimal insulin control. This is related to scarcity of resources, lack of healthcare practitioners trained in insulin use as well as patient-related factors, such as psychological insulin resistance

TIP is a much-needed project aimed at integrating diabetes care and especially initiation and up-titration of insulin by both primary care nurses and clinic physicians. Integrating prevention and effective treatment of diabetes and optimal glucose control is a crucial component of strengthening health systems and vulnerable communities where the impact of non-communicable diseases, like diabetes are often hardest felt.

UP has been involved in diabetes research in primary care for several years and through its research and training workshops, it has become clear that many patients in primary care are very poorly controlled.

One of the challenges with initiation and up-titration of insulin stems from the fact that insulin may legally only be prescribed by a doctor and not a nurse. Depending on the province and the district, many primary healthcare clinics do not have primary care physicians available full-time or even one day a week.

Many primary care physicians are also not confident in initiating and up-titrating insulin which leaves diabetes patients incredibly vulnerable and unable to access quality care close to their home.

Pathways to be taken

This programme is designed to explore the feasibility of using telemedicine or phone apps to assist the nurse or even the primary care physician to better serve the needs of people living with diabetes in underserved areas. It’s well-recognised that the major achievement of getting millions of people onto anti-retroviral treatment in SA was due to successful task-shifting using primary care nurses.

Inclusion of home visits by community healthcare workers will also be evaluated as they potentially could enhance compliance and patient education. TB care was also decentralised in a similar way and care and treatment was made available to patients as close to their homes as possible. We believe that the same can be achieved with diabetes care and we can avoid the current tragedy of people presenting at hospitals with advanced stages of diabetic co-morbidities and complications due to poor glucose control.

Comments from Eli Lilly

Evan Lee, Senior Director Global Health Programs and Strategy of Eli Lilly Global Health says diabetes is a major contributor to poverty and a barrier to social and economic development in developing countries like SA.

Diabetes is a growing problem worldwide, and its costs to society are high and escalating. It’s alarming when one considers that of the 10 leading causes of death in SA in 2016, five were non-communicable diseases and all had increased in 2016 compared with 2014. In fact, diabetes, which ranked third in 2014, moved to being the second most common natural cause of death in 2016, responsible for 5,5% of all deaths by natural causes. That’s 25 255 lives lost in 2016 alone, 69 deaths each day. Diabetes is ranked second only to tuberculosis and ahead of HIV, and in women, diabetes is the leading cause of death¹.

The importance of getting quality diabetes care embedded at a primary care level can’t be emphasised enough. Evidence shows that good diabetic control reduces the risk of diabetes complications and co-morbidities. This is a crucial aspect of the quality of life that a patient living with diabetes can expect to enjoy.

Therefore, finding new approaches to the detection and management diabetes, and bringing access to quality care to the community is so important. SA has been a pioneer in enabling care and management of complex diseases, like HIV and MDR-TB. So, it should be feasible to do so for diabetes.

By working closely with the UP and local municipal clinics, we aim to transfer the learnings from this research project to other regions in SA. By rigorously documenting, monitoring and evaluating the intervention, we hope this project will be shared nationally and the massive impact of diabetes, especially on vulnerable communities, can be halted.

References:, Appendix M


Professor Paul Rheeder is a trained specialist physician with a PhD in clinical epidemiology obtained from Utrecht University, the Netherlands. He occupied the Medihelp Chair in clinical epidemiology at UP for 10 years. He is past acting head of the School of Health Systems and Public Health, UP. Currently he is employed as senior specialist physician at the Steve Biko Academic Hospital, Department of Internal Medicine. His main research interest is in improving management and outcomes of patients with diabetes mellitus.