Assessing healthcare system support for diabetes in Malawi

Chimwemwe Kwanjo Banda is a CARTA+ Fellow at the University of Malawi, College of Medicine in Malawi. CARTA+ (Consortium for Advanced Research Training in Africa+) is one of the eleven Developing Excellence, Leadership, and Training in Science in Africa (DELTAS Africa) programmes. DELTAS Africa funds Africa-based scientists to amplify the development of world-class research and scientific leadership on the continent while strengthening African institutions. DELTAS Africa is implemented through the AESA Platform. AESA (The Alliance for Accelerating Excellence in Science in Africa) is a funding, agenda-setting, programme management initiative of the African Academy of Sciences (AAS), the African Union Development Agency (AUDA-NEPAD), founding and funding global partners, and through a resolution of the summit of African Union Heads of Governments. DELTAS Africa is supported by Wellcome and the United Kingdom Foreign, Commonwealth and Development Office (FCDO formerly DFID).

Summary

People living with diabetes require support from healthcare providers for them to effectively manage their illness. Understanding strengths and weaknesses of the healthcare system in diabetes services is important for improvement of care. Opinions of people with diabetes, their family members and healthcare providers at a central hospital in Blantyre Malawi were sought to help identify and address gaps in diabetes care.

Background

Diabetes mellitus is a non-communicable disease (NCD) in which there is abnormal insulin production and/or impaired use of insulin in the body. Insulin is a hormone that helps the body to breakdown sugars. Failure of this breakdown results in abnormally high sugar levels (hyperglycemia) in the blood stream. Uncontrolled diabetes is one of the leading causes of premature death and disability. Globally, over 422 million adults live with diabetes and about 1.5 million deaths occur annually from the disease. In Malawi, prevalence in adults aged 25 and over is 6%; many suffer from poorly controlled sugar levels and diabetes-related complications including nerve, kidney and eye damage. There is also a high mortality rate among those with diabetes-related complications and disabilities admitted to hospitals.

The health care system can make a critical contribution to supporting and empowering people living with diabetes (PLWD) by providing resources, knowledge and skills to enable them to control their diabetes and care for themselves. In 2010, the World Health Organization (WHO) developed a conceptual framework for a Package of Essential NCD (PEN) interventions to improve the equity and efficiency of primary healthcare in low-resource settings like Malawi. In 2013, the NCD and Mental Health Unit of the Malawi Ministry of Health implemented the WHO PEN and a national action plan for NCD prevention and management. However, the availability of diabetes and other NCD services in Malawian primary care facilities continue to be inconsistent, in part because healthcare systems in Malawi and other low- and middle-income countries are generally built on an acute care model, and are ill-equipped to promote self-management for chronic disease.

Description of Study

This study was initially inspired by my own clinical observations as a nurse educator of frequent admission of patients with severe complications of diabetes to medical and surgical wards at teaching hospitals. This was confirmed by a literature review which showed that diabetes complications were common among PLWD seeking care at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. Literature also showed that   many people admitted at QECH due to diabetes complication, do not survive.

A qualitative study collected the views of PLWD, their family members and healthcare providers on diabetes self-management support and how it influences diabetes self-management at QECH. This site was chosen because it is the main referral hospital in the southern region of Malawi and serves people from urban and rural areas from all districts in the region. Individual in-depth interviews were conducted with 20 PLWD, 20 PLWD family members and eight diabetes clinic healthcare providers. Four focus group discussions (FGDs) were conducted with 35 PLWD. Unlike previous local studies, this study incorporated the views of family members to account for the social support system for PLWD in Malawi. I conducted all the interviews personally to ensure consistency in technique, depth and interpretation. The interviews stopped after sufficient data was collected. A framework analysis was applied to the data.

Outcome of the study

One main theme that emerged is that the organisation of the healthcare system contributes to poor outcomes for PLWD. Among the interrelated service provision challenges are accessibility, shortage of staff, long diabetes clinic waiting times, lack of primary healthcare services and the unsustainability of programs. Due to the lack of primary care services for diabetes, PLWD from Blantyre and surrounding districts go to QECH for care, causing over-crowding of clinic patients and waiting periods that usually last a whole day or more. Clinic staff shortages compromise the ability to thoroughly assess patients for actual or real risks of complications. PLWD felt generally that the organisation of the healthcare system was in some ways an impediment to effective self-management, leading to poor blood sugar control.  Persistently high blood sugar levels contribute to diabetes complications. This lack of primary care services for diabetes is a major contributor to inadequate diabetes self-management; its improvement must be a priority for health care service managers and policy makers.

Lessons

In order for the healthcare system to adequately support PLWD, services must be provided closer to the people. Future studies should explore strategies to engage communities and community workers in diabetes self-management.

Impact

This study has demonstrated the need to strengthen the capacity of primary care facilities to provide diabetes care services and implement the WHO PEN. This would also ensure that services meet the needs and expectations of the intended recipients. As an FGD participant observed:“…the number of people living with diabetes is continuously increasing. I would have loved if health centers were empowered, so that diabetes clinics are conducted at the health centers.”

Providing diabetes care services at the primary care level will also free up the capacity of referral hospitals to treat complicated cases.

This study introduced opportunities for collaboration and networking with other local and international NCD researchers which will enhance my research skills. For example, I was offered a mentored fellowship in the NCD BRITE (Building Research Implementation Translation and Expertise) Consortium, a collaboration in Lilongwe, Malawi, between the College of Medicine of the University of Malawi and the University of North Carolina. I also received funding for a second phase of this study to evaluate the preparedness of the Blantyre District Health Office to provide primary diabetes care services. The WHO recommends a needs assessment of resources and service utilization to determine the capabilities of health infrastructure to integrate diabetes care services. Coordinated efforts at all levels of the healthcare system (community, primary, secondary and tertiary) are needed to improve outcomes of self-management for PLWD.