Global health assistance for chronic illness: a look at the practical

Epidemiological transition in morbidity: 10-year data from emergency consultations in Dakar, Senegal

Background

It is thought that low-income countries are undergoing an epidemiological transition from infectious to non-communicable diseases; however, this phenomenon is yet to be examined with long-term data on morbidity.

Methods

We performed a prospective evaluation of all emergency medical consultations at a major emergency service provider in Dakar, Senegal from 2005 to 2014. Using standardised definitions, the primary diagnosis for each consultation was classified using the International Classification of Diseases-10 and then broadly categorised as ‘infectious’, ‘non-communicable’ and ‘other’ diseases. Morbidity rates for each year in the 10-year observation period were plotted to depict the epidemiological transition over time. To quantify the yearly rate ratios of non-communicable over infectious diagnosis, we used a generalised Poisson mixed model.

Results

Complete data were obtained from 49 702 visits by African patients. The mean age was 36.5±23.2 and 34.8±24.3 years for women and men, respectively. Overall, infections accounted for 46.3% and 42.9% and non-communicable conditions 32.2% and 40.1% of consultations in women and men, respectively. Consultation for non-communicable compared with infectious conditions increased by 7% every year (95% CI: 5% to 9%; p<0.0001) over the 10 years. Consultations for non-communicable condition were more likely in women compared with men (RR=1.29, 95% CI: 1.18, 1.40) and at older ages (RR=1.27; 95% CI 1.25, 1.29 for 10-year increase in age).

Conclusion

Using high-quality disease morbidity data over a decade, we provide novel data showing the epidemiological transition of diseases as manifested in emergency service consultations in a large Sub-Saharan African city. These results can help reorientation of healthcare policy in Sub-Saharan Africa.

Implementing elements of a context-adapted chronic care model to improve first-line diabetes care: effects on assessment of chronic illness care and glycaemic control among people with diabetes enrolled to the First-Line Diabetes Care (FiLDCare) Project in the Northern Philippines

Aim

The purpose of this study was to investigate the effects of implementing elements of a context-adapted chronic disease-care model (CACCM) in two local government primary healthcare units of a non-highly urbanized city and a rural municipality in the Philippines on Patients’ Assessment of Chronic Illness Care (PACIC) and glycaemic control (HbA1c) of people with diabetes.

Background

Low-to-middle income countries like the Philippines are beset with rising prevalence of chronic conditions but their healthcare systems are still acute disease oriented. Attention towards improving care for chronic conditions particularly in primary healthcare is imperative and ways by which this can be done amidst resource constraints need to be explored.

Methods

A chronic care model was adapted based on the context of the Philippines. Selected elements (community sensitization, decision support, minor re-organization of health services, health service delivery-system re-design, and self-management education and support) were implemented. PACIC and HbA1c were measured before and one year after the start of implementation.

Findings

The improvements in the PACIC (median, from 3.2 to 3.5) as well as in four of the five subsets of the PACIC were statistically significant (P-values: PACIC=0.009; ‘patient activation’=0.026; ‘goal setting’=0.017; ‘problem solving’&lt;0.001; ‘follow-up’&lt;0.001). The decrease in HbA1c (median, from 7.7% to 6.9%) and the level of diabetes control of the project participants (increase of optimally controlled diabetes from 37.2% to 50.6%) were likewise significant (P&lt;0.000 andP=0.014). A significantly higher rating of the post-implementation PACIC subsets ‘problem solving’ (P=0.027) and ‘follow-up’ (P=0.025) was noted among those participants whose HbA1c improved. The quality of chronic care in general and primary diabetes care in particular may be improved, as measured through the PACIC and glycaemic control, in resource-constrained settings applying selected elements of a CACCM and without causing much strain on an already-burdened healthcare system.

The growing caseload of chronic life-long conditions calls for a move towards full self-management in low-income countries

Background

The growing caseload caused by patients with chronic life-long conditions leads to increased needs for health care providers and rising costs of health services, resulting in a heavy burden on health systems, populations and individuals. The professionalised health care for chronic patients common in high income countries is very labour-intensive and expensive. Moreover, the outcomes are often poor. In low-income countries, the scarce resources and the lack of quality and continuity of health care result in high health care expenditure and very poor health outcomes. The current proposals to improve care for chronic patients in low-income countries are still very much provider-centred.

The aim of this paper is to show that present provider-centred models of chronic care are not adequate and to propose 'full self-management' as an alternative for low-income countries, facilitated by expert patient networks and smart phone technology.

Discussion

People with chronic life-long conditions need to 'rebalance' their life in order to combine the needs related to their chronic condition with other elements of their life. They have a crucial role in the management of their condition and the opportunity to gain knowledge and expertise in their condition and its management. Therefore, people with chronic life-long conditions should be empowered so that they become the centre of management of their condition. In full self-management, patients become the hub of management of their own care and take full responsibility for their condition, supported by peers, professionals and information and communication tools.

We will elaborate on two current trends that can enhance the capacity for self-management and coping: the emergence of peer support and expert-patient networks and the development and distribution of smart phone technology both drastically expand the possibilities for full self-management.

Conclusion

Present provider-centred models of care for people with chronic life-long conditions are not adequate and we propose 'full self-management' as an alternative for low-income countries, supported by expert networks and smart phone technology.