An Integrated Approach to Management of Diabetes and Hypertension in Western Kenya

Author(s) Simon Manyara1, Jemima Kamano2, Diama Menya3, Jeremiah Laktabai4, Benjamin Andama5, Evans Tenge6, FlorenceSituma7, SonakPastakia8
Affiliation(s) 1Pharmacy, Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya, 2Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya, 3Epidemiology and Nutrition, School of Public Health, Moi University, Eldoret, Kenya, 4Family Medicine, Moi University, Webuye,Kenya, 5Family Preservation Initiative, Academic Model Providing Access to Medicines, Eldoret, Kenya, 6Family Preservation Initiative, Academic Model Providing Access To Healthcare, Eldoret, Kenya, 7Home Glucose Monitoring, Webuye District Hospital, Webuye, Kenya, 8Purdue University College of Pharmacy, Purdue University, Eldoret, Kenya
Country - ies of focus Kenya
Relevant to the conference tracks Chronic Diseases
Summary This pilot project seeks to establish whether the provision of intensive, self and peer management trainings to patients combined with the integration of income generating incentives leads to enhanced diabetes and hypertension control for resource-constrained patients in rural western Kenya. Patients are placed into peer support groups where they receive group care and are trained on various aspects of diabetes and hypertension self-care. These groups also double as microfinance groups that offer capital to patients to start up income generating activities. The groups are further incentivised to compete against each other based on both clinical and non clinical parameters.
What challenges does your project address and why is it of importance? Developing countries are facing an increasing burden of non communicable diseases (NCDs). While there has been increased emphasis in addressing communicable diseases by the international community, the vast majority of NCDs have been neglected, leaving patients with very poor outcomes and limited prospects for a healthy life. Due to their chronic nature, NCDs strain the already scarce resources of healthcare systems and families in resource constrained settings. Furthermore, NCDs are no longer associated with the wealthy or elderly, for they also affect poorer rural dwellers and younger members of the society who are expected to be economically productive. This adversely affects economic development in these populations, further propagating the vicious cycle of poverty. The prevalence of diabetes in Kenya is 4.7%, while that of hypertension has been reported to be as high as 23.7% in some urban settings. Patients with chronic diseases in Kenya face several barriers to care, including lack of access to essential services and inadequate information. This project uses a holistic approach which directly addresses barriers related to the socioeconomic status of patients with diabetes and hypertension, while encouraging positive health seeking behaviors.
How have you addressed these challenges? Do you see a solution? Bridging Income Generation with Provision of Incentives for Care (BIGPIC) uses an integrated approach that capitalizes and builds on the AMPATH’s (Academic Model Providing Access To Healthcare) existing infrastructure and years of experience in managing patients with HIV/AIDS throughout western Kenya. We focus on the following points of intervention:
1) Peer Groups.
Following community-based screening, positively diagnosed patients are placed into peer groups where they receive intensive training on self-management strategies for diabetes and/ or hypertension. They are given targets for their management which will be evaluated upon completion of the pilot. Targets will comprise of both process metrics such as clinic attendance, medication refills, fulfillment of ordered tests and clinical outcome metrics including blood pressure and sugar control. Patients receive group care and are provided with essential services like clinical consultations, selected portable laboratory tests and medication at affordable prices. They are expected to pay for each service and all the money collected is used to restock supplies.
2) Incentivization.
Patients are instructed on the incentives that can be earned through participation in this program. Their care is evaluated after 6 months to document the progression of their glucose and/or blood pressure control using standardized laboratory assessments. They receive points based on the set targets and these points can be used to earn various predetermined rewards. Incentives are awarded at two levels of participation – the group level where the top three groups with the most improved outcomes will receive rewards, and at the individual level where each participant attaining pre-set goals receives a reward.
3) Economic empowerment
The economic component of the project is facilitated by the Family Preservation Initiative (FPI), which is AMPATH’S income generation program. This will be achieved by the incorporation of a micro finance component which provides interest-bearing loans to members while offering a limited form of financial insurance. Participants mobilize and manage their own savings. They can therefore access affordable loans and get advice from FPI agribusiness officers on sustainable income generating activities. BIGPIC combines the socioeconomic benefits of FPI activities with the care strategy utilized by our diabetes program to synergistically enhance the outcomes and retention in both programs.
How do you know whether you have made a difference? While AMPATH has enjoyed immense success in the management of patients with both communicable and non communicable diseases, a lot of effort still needs to be put into retention of new patients to care. Data from the chronic disease management team shows that only 30% of patients who screened positive for diabetes and hypertension ever returned to a health facility for care. Preliminary data from this project shows that out of the 902 patients that were screened, 157 patients screened positive for either diabetes or hypertension. Of those that screened positive, 67.5% (n=106) came back to the health centre for confirmatory screening. Currently, 70.3% (n=71) of all those who confirmed positive for diabetes or hypertension are enrolled into the peer groups and are receiving care. The pilot will be completed in December and the final results will be presented at the conference
Have you or the project mobilized others and if so, who, why and how? This project draws expertise from a multidisciplinary team and intricately incorporates several aspects of patient care. The chronic disease management team provides the necessary platform for the management of diabetes and hypertension, from facilitation of screening activities to capacity building through staff training at health facilities. The Primary Healthcare team at AMPATH provides valuable insights into community strategies and engagement both at the macro and micro levels. One of the key approaches has been the use of community health workers (CHWs) for the purposes of finding patients, linking them to health facilities and raising awareness on chronic diseases within the community. The peer groups are also led by the CHWs who we train intensively on diabetes and hypertension self-care and on the operations of the GISE groups. The project taps into AMPATH’s Family Preservation Initiative’s GISE project. Through the microfinance groups, we strive to empower our patients economically through access to capital and giving them advice on viable business ventures. These microfinance groups have been shown to have high retention rates of its members, an outcome that we hope to achieve by incorporating the microfinance element into healthcare. This project is further strengthened by AMPATH’s pharmacy team which has a revolving fund pharmacy project that provides quality medicines to its patients at affordable prices. The revolving fund pharmacy works by procuring quality controlled medication in bulk and availing it to patients at a price that is almost at cost. Through this project, we have been able to provide quality, low cost essential antidiabetic and antihypertensive medicines to our patients. The biggest piece of the puzzle is the government health management team which is responsible for the implementation of all health initiatives within a district. This team facilitates all our activities on the ground. Part of the activities that we engage in include capacity building of the existing infrastructure by carrying out refresher courses on good practices in the management of diabetes and hypertension and mentoring the staff in the lower level facilities like dispensaries and health centres.
When your donor funding runs out how will your idea continue to live? BIGPIC offers a sustainable means of ensuring access to healthcare while at the same time promoting economic empowerment, leading to a healthier, more productive labor force. The project is modeled around the existing healthcare system and infrastructure in Kenya. Care for diabetes and hypertension at the facility level is enhanced through capacity building by training of the existing government healthcare workers. This is followed by close mentorship by the chronic disease management team at AMPATH, ensuring that patients can access quality care even in our absence. The microfinance groups have been shown to have a high retention rate of its members, and we believe that this model will maintain the members of the peer groups long after completion of the initial six months of our involvement. This will promote self-care within the members hence leading to improved patient outcomes. Patients are also empowered economically through these groups where they can access capital from their own savings. The groups create their own constitutions that guide their operations, and we only facilitate income generation through our agribusiness advisors. This ensures that they own the project and that the groups can continue independent of our support. Provision of drugs through the revolving fund pharmacy ensures continuity of drug supply since patients pay for the drugs and the money collected is solely used to purchase more drugs. Furthermore, antihypertensive and antidiabetic medicines are not supplied to dispensaries and health centres and the provision of these drugs at this level ensures accessibility while promoting the use of lower level facilities, with only complicated cases being referred to higher level facilities. Patients are expected to pay for every service that is provided through group care. The money collected from this model of care makes its continuity sustainable. The information provided to the community through the CHWs and the patients participating in the project will also go a long way in preventing NCDs by averting common risk factors such as poor diets, physical inactivity, unhealthy use of alcohol and cigarette smoking. This project therefore draws its strengths from a multidisciplinary team and integrates proven, sustainable interventions to achieve a holistic care model for diabetes and hypertension within a resource-constrained setting.

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