The management of diabetes at primary level in South Africa: the results of a facility-based assessment

Pathways to diabetic care at hospitals in rural Eastern Uganda: a cross sectional study

Background

Prompt access to appropriate treatment reduces early onset of complications to chronic illnesses. Our objective was to document the health providers that patients with diabetes in rural areas seek treatment from before reaching hospitals.

Methods

Patients attending diabetic clinics in two hospitals of Iganga and Bugiri in rural Eastern Uganda were asked the health providers they went to for treatment before they started attending the diabetic clinics at these hospitals. An exploratory sequential data analysis was used to evaluate the sequential pattern of the types of providers whom patients went to and how they transitioned from one type of provider to another.

Results

Out of 496 patients assessed, 248 (50.0%) went first to hospitals, 104 (21.0%) to private clinics, 73 (14.7%) to health centres, 44 (8.9%) to drug shops and 27 (5.4%) to other types of providers like community health workers, neighbours and traditional healers. However, a total of 295 (59.5%) went to a second provider, 99 (20.0%) to a third, 32 (6.5%) to a fourth and 15 (3.0%) to a fifth before being enrolled in the hospitals’ diabetic clinics. Although community health workers, drug shops and household neighbours were utilized by 65 (13.1%) patients for treatment first, nobody went to these as a second provider. Instead patients went to hospitals, private clinics and health centres with very few patients going to herbalists. There is no clear pathway from one type of provider to another.

Conclusions

Patients consult many types of providers before appropriate medical care is received. Communities need to be sensitized on seeking care early from hospitals. Health centres and private clinics need to be equipped to manage diabetes or at least diagnose it and refer patients to hospitals early enough since some patients go to these health centres first for treatment.

Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town

BACKGROUND

The majority of patients with type 2 diabetes mellitus in Cape Town who attend primary care community health centres (CHCs) have unsatisfactory glycaemic control. Insulin is rarely prescribed despite its being indicated for type 2 diabetic patients with inadequate metabolic control on maximum oral glucose-lowering agent (OGLA) therapy.

OBJECTIVE

The study examined barriers to initiating insulin therapy in poorly controlled type 2 diabetes patients on maximum OGLAs in CHCs in the Cape Town metropolis.

METHODS

Five focus group discussions and 10 in-depth semistructured individual interviews were conducted with 46 medical officers working at the CHCs. The discussions and interviews were transcribed and common themes were identified and categorised.

RESULTS

Doctor, patient, and system barriers to initiating insulin therapy were identified. Doctors' barriers include lack of knowledge, lack of experience with and use of guidelines related to insulin therapy, language barriers between doctor and patients, and fear of hypoglycaemia. Patient barriers were mistaken beliefs about insulin, non-compliance, lack of understanding of diabetes, use of traditional herbs, fear of injections, and poor socioeconomic conditions. System barriers were inadequate time, lack of continuity of care and financial constraints.

CONCLUSION

Suggestions for overcoming barriers include further education of doctors on insulin initiation and the use of standardised guidelines. In addition, a patient-centred approach with better communication between doctors and patients, which may be achieved by reorganising aspects of the health system, may improve patient knowledge, address mistaken beliefs, improve compliance and help overcome barriers. Further research is needed to investigate these recommendations and assess patients' and nurses' perceptions on initiating insulin therapy.

Integrated approaches to prevention and control of chronic conditions

Integrated approaches to prevention and control of chronic conditions. Chronic conditions currently account for more than 50% of the global disease burden, and this figure is projected to continue to rise. Yet, around the world, health care systems are not organized to provide effective and efficient care for chronic health problems. Health care systems have evolved around the concept of acute, infectious disease, and they perform best when addressing patients' acute and urgent symptoms. Without change, health care systems will grow increasingly inefficient and ineffective. Effective prevention, management, and rehabilitation of chronic conditions require an evolution of health care, away from a model that is focused on acute symptoms toward a coordinated, comprehensive system of care. The results of this shift include less waste and improved efficiency. Integrated health care models that transcend specific illnesses provide a feasible solution. The World Health Organization's Innovative Care for Chronic Conditions Framework provides a flexible but comprehensive model to build or redesign health systems in accord with local resources and demands.

Improving the quality of health care for chronic conditions

Chronic conditions are increasingly the primary concern of health care systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (health care organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.

Improving the quality of health care for chronic conditions

Chronic conditions are increasingly the primary concern of health care systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (health care organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.