Due to changing diets and sedentary life styles, diabetes rates are growing
epidemically worldwide. Without major changes, WHO expects diabetes deaths to
increase by more than 50%. Because most patients with chronic diseases in low
and middle income countries are actually under 70 years (1), diabetes presents
a significant psychosocial and economic burden for the individuals, their families,
the health care system and country. Diabetes increases the overall risk of dying:
the risk of dying from heart disease, stroke, and kidney failure, as well as
the rate of visual impairment and blindness, foot amputations, and limb nerve
damage.
Premature deaths and long-term disability are to a large degree preventable,
however, medical treatment alone is insufficient. Diabetes requires significant
and persistent life style changes and continuous monitoring and control of blood
sugar levels. The behavioural changes and the patient’s reaction to them, as
well as some of side effects of the disease may affect the whole family. In
severe cases (blindness, foot amputations, dialysis, heart condition), adults
who would otherwise still be economically active can require significant home
care. To address the patient and the family’s multiple needs, a comprehensive
psycho-social and medical support system is needed by the patient and his/her
family.
Health care in one of the poorest countries
Bosnia and Herzegovina (B&H), one of the poorest European countries, has
a complex health care system, with 13 ministries of health and 13 health insurance
funds, and 264 health care institutions. Patients in need of treatment often
have to travel long distances for services that are covered by their geographic
entity health insurance fund, even though the services may be available at closer
proximity and cost, provided by another entity. This results in significant
additional costs to the patient and health care system.
In 2000, Bosnia and Herzegovina reported estimated 111’000 diabetes patients.
This number is expected to increase to 180’000 patients by 20302. Because of
the high costs of the disease and resulting complications, improved capability
of the health care system to prevent and manage diabetes as much as possible
at the primary health care level, is an important contribution to the ongoing
health reform efforts of the government.
Fondation Partnerships in Health (FPH), a Swiss NGO, has supported health reform
efforts of Bosnia and Herzegovina since 1998. Several projects in partnerships
with the Geneva University Hospitals and funded by the Swiss Agency for Development
and Cooperation have built local capacity to retrain doctors and nurses in family
medicine, rehabilitated ambulatory clinics, and procured essential equipment
in key regions across the country. In addition, from 2005 to 2007, FPH provided
basic HIV training to 1313 primary care doctors and nurses, using infectious
diseases specialists and primary care trainers. This has also contributed to
strengthening the working relationship between specialists and the primary care
level.
In 2005, patients diagnosed at the primary/ambulatory level of care with diabetes
in the Canton of Sarajevo were immediately referred to specialist care. Sarajevo
had one diabetes specialty clinic, serving a population of nearly half a million
people and more than 10’000 patients with diabetes. Before the introduction
of the new multi-disciplinary approach in 2006, specialists would share limited
information with the patient, in order not to create anxiety. Patients would
be requested to return to the specialist, if necessary daily, to check glucose
levels, and be referred immediately to the hospital when specialists were overloaded
with cases or on the weekend. Psychosocial counselling was not available to
the patient, and primary health care providers were lacking the basic information
about diabetes to provide routine care, follow-up, and counselling. Today, this
situation has changed substantially in the Canton of Sarajevo thanks to an innovative
pilot project.
Multi-disciplinary treatment and care
In 2006, Fondation Partnerships in Health and its partners (the Canton Sarajevo,
the Cantonal Ministry of Health and its primary and secondary health care system,
the professional chambers of doctors and nurses, and the Diabetic Patient Association,
with financing from the Canadian Agency for International Development, the Medtronic
Foundation, and the Vontobel Stiftung) developed a new approach to diabetes
that encompasses primordial, primary and secondary prevention, including improved
treatment and care for more than 2’000 diabetic patients. Under the guidance
of a locally established working group consisting of FPH staff, an eminent Sarajevo
diabetologist, Professor Dr. Heljic, and representatives of the other local
partners, multi-disciplinary diabetes teams were established at the primary
care level. These teams consist of family medicine doctors and nurses, social
workers and psychologists and are directly linked to the specialists and their
nursing staff at the secondary level.
To build the capacity of the cantonal health care system, a training-of-trainer
course was developed, based on internationally validated technical curricula,
team building approaches, and adult pedagogical methodologies. Twelve trainer
teams (consisting of a diabetologist, nurse, family medicine doctor and nurse,
psychologist and social worker) completed this course and then trained 151 family
medicine teams (doctor and nurse), six social workers, and five psychologists
in the Sarajevo health centres and ambulatory clinics. In addition, the 12 trainer
teams were trained to provide supervision and support to the trained staff at
the primary care level to assist them to implement the new government-approved
protocols and apply their new skills, particularly related to patient education.
International patient education materials were adapted for local use, and the
team developed an information booklet for children, with input from young patients
with diabetes.
Improving prevention
One of the local project partners is the Diabetic Patient Association which
has worked closely with Fondation Partnerships in Health and the Ministry of
Health staff on the organization of activities for the World Diabetes Day on
November 14, the development of information, education and communication (IEC)
materials, public education, and the promotion of the new services with their
members. For the World Diabetes Day in 2006, all 12 participating clinics offered
screening for diabetes, and 442 individuals were tested. Of these, 132 had glucose
levels exceeding 7 mmol/l, the cut-off level for diabetes. These individuals
were referred directly to the new medical and psychosocial support services
that are assisting them now in bringing their disease under control and prevent
serious and costly side effects.
Because of the great success of this one-day event, a special one-month campaign
to reach high-risk individuals for screening was organized for December 2006
to January 2007. Pharmaceutical companies (Novo Nordisk, Oktal Pharma, Roche
Diagnostics, and Bauerfiend) assisted with some of the testing materials, reagents,
and equipment, further increasing the public-private cooperation around diabetes
prevention and care.
Expanding access to individualized counselling
Until this project had started, all patients were served by the main Diabetes
Clinic at the University Hospital campus. The local working group members agreed
that counselling and specialty care is needed to be more accessible to many
of the patients in the Canton. A Diabetes Counselling Centre was established
at one of the largest ambulatory care facilities, Ilidza, outside of the city
centre of Sarajevo.
The new counselling site opened in May 2007 and is staffed by a family medicine
doctor and nurse who received additional training in counselling, adult and
child education, and diabetes technical skills. The Centre was equipped with
educational materials, glucometers, testing strips and books donated by Roche
and Oktal Pharma. Using a patient appointment system, individualized attention
is given to assisting patients and their families with insulin injection techniques
and use of the blood glucose meter, individualized diabetes meal planning, and
other special needs. The centre is also organizing patient support group sessions.
Approximately 110 patients per month benefit now from these special services
that help individuals to take an active role in controlling their disease and
preventing some of the serious consequences. Because of critical needs in other
geographic locations, the Canton of Sarajevo has requested FPH’s assistance
in helping to set up two more counselling centres.
Radio, television, and newspapers have covered many of the key events of the
project, including the celebration of the World Diabetes Day, the training workshops
for the multi-disciplinary teams, the opening of the Ilidza Diabetes Counselling
Centre, and the one-month screening campaign. Each of these events has provided
a special opportunity to talk about diabetes and educate the public about its
causes, possibilities for prevention, as well as the symptoms that should alert
individuals to get tested.
The future
Fondation Partnerships in Health and its local partners are implementing methodologies
to track patient satisfaction with this new approach and monitor the skills
of the participating providers. In addition, they are working on scaling up
this approach with current and new donors to more underserved and remote rural
areas, given the success of the pilot project and continuing needs of patients
and the health care system.
*Bettina Schwethelm, PhD, MPH, is the Executive Director of Fondation Partnerships
in Health, a Swiss NGO working in chronic and infectious diseases advocacy,
prevention and care in the Western Balkans and Central Asia. Francisca Merino,
MD, a family physician from Chile, is the Medical Advisor of Partnerships in
Health. Dr. Suzana Hadzialjevic is a family physician and the Medical Director
of Partnerships in Health, B&H. She co-manages the diabetes project with
Damir Lalicic. Damir Lalicic serves as Nursing Expert and Project Manager of
Partnerships in Health, B&H and is Co-manager of the diabetes project. Aida
Muslic develops and manages the programs of Partnerships in Health in Bosnien
and Herzegovina. Contact: bsch@partnershipsinhealth.ch.
References
- Preventing Chronic Diseases: A vital investment WHO, 2005
- WHO, Diabetes in the European Region: www.who.int/diabetes/facts/world
figures/en/index4.html
Story from an involved doctor
“Hey, this one is on insulin.”
The patient, 65 years, walked into my office confused, scared... accompanied
by his worried wife. With sunken eyes, red face and dry lips looked like
a person lost in desert for many days. He was confused and told me that
he was very healthy until yesterday, but suddenly felt very thirsty, hungry
and often needed to go to the toilet.
He was diagnosed with severe diabetes, with a blood sugar level of 29.5,
and urine showing the presence of ketones. He did not understand how it
could happen at his age, as he had eaten well, felt fine and was not obese.
It was obvious that he was trying to hide his despair with the diagnosis
of this newly discovered disease. Very proudly he mentioned that his wife
is a great cook and the he loves pies, baklavas, meet...
When I told him that he would need insulin injections, he jumped out
of his chair and asked me to give any other medication, promising that
he will listen to all advice and obey any other solution. I had the feeling
he would be a difficult patient.
I told him about the new project to prevent diabetes and related complications
and referred him to our family medicine team that had just been trained
to deal with diabetic patients. I also convinced him to take insulin for
few days and maybe later on he would be able to continue with tablets,
but I was almost sure that he would need to stay on insulin injections.
Within a few days time his blood sugar level became more normal and his
appearance improved, but at every visit he asked me when he will be able
to drop the insulin injections. I contacted the psychologist of our team
and his family doctor and explained that the patient needs to stay on
insulin for another 3 weeks. After consultation with my colleagues I thought
that with appropriate psychological support and nutrition advice, he should
be able to get used to being insulin dependent.
Meanwhile, the trained nurse from the counselling section educated the
patient about proper insulin intake, and his wife was counselled about
the type of food to prepare, and the family medicine team provide other
routine care.
At the 3-week check up, there was significant improvement. When I asked
the patient how he is dealing with insulin therapy, he became very embarrassed,
and admitted that he does not use the therapy at all. After all the efforts
I had made, I was surprised and a bit angry. To make me happy, the patient
suggested measuring his blood sugar level. I was shocked when the nurse
told me that his level was only 7.8mmol, just two hours after the meal.
He smiled and told me about his talks with psychologist and family medicine
doctor who tried to help him overcome his fear of insulin therapy. He
promised them that he would take care of what he eats and get sufficient
exercise, just so he would not to inject himself and have people talk
„hey, this one is on insulin“. His strong will and support from my trained
colleagues helped him to achieve some control over his disease.
By Dr. Azra Avdagić, Dom Zdralja Sarajevo
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