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Diabetes Care in Uganda

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Jessica Skinner

on 5 May 2013

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Transcript of Diabetes Care in Uganda

32 year old male
Learned he was at risk for diabetes via screening survey
Referred to clinic for blood sugar test although asymptomatic
Advised to fast before going to clinic Current State Path to Diagnosis Maintenance &
Monitoring Local Healthcare Options Diagnosis Clinic Day Lack refrigerator to keep insulin cool
Cannot check blood sugar between visits
Few alternative food options available
Each time Rx must be renewed, requires travel cost (time and money) Local Pharmacy Traditional Healer Malaria Diabetes Care in Uganda Agenda I. The Path to Diagnosis: Current state delivery of diabetes care in Uganda

II. Future State: Recommendations and Action Plan for Improvement Meet Our Patient: Josephine Village resident near Kumi, Uganda
Age 45
Farms and sells cassava at market
Mother to six children Suffering from frequent urination, excessive thirst, and fatigue Health Information in the Community Information exchange is predominately oral Objectives:
Mobilize village for education and immunizations
Assist community in accessing healthcare
Nature: Groups meetings and person to person assistance
Make weekly visits Village Health Teams (VHTs) VHTs: Current Barriers to Delivery VHTs may not have transportation to attend training or take patients to hospitals VHTs do not receive training about diabetes Health Worker Village Visits Objectives:
Test for HIV and provide immunizations
Educate population
Nature: Group meetings
Weekly visits Outreach Teams: Barriers to Delivery Opportunity Cost: Same resources staff the clinics at the hospital Rarely educate about diabetes; HIV, Malaria, and communicable diseases take priority Do not test blood sugar, even when glucometers sit idle at hospital on non-clinic days How much does she already know about what her symptoms indicate?
Where did she learn what she knows? While the current infrastructure has made great strides fighting AIDS and Malaria, most citizens have a low level of awareness about diabetes Wanting to relieve her symptoms, Josephine first visits easily accessible local healthcare providers... Non-clinical diagnosis:
No blood sugar testing or glucometers
Low awareness of diabetes

Incentive to sell drugs that are stocked Witchcraft is possible cause of mysterious symptoms Financial incentive to assure patient that symptoms can be treated with natural remedies ` Despite interacting with the local health system, Josephine's symptoms continue to worsen. Throughout, she has continued to eat a diet of staple foods: cassava, potatoes, and other high starch, low protein offerings.

She makes dinner for her family each night using a large amount of cooking oil. The fatigue is beginning to interfere with her work. Desperate for relief, Josephine decides to attend the hospital. ` Patients like Josephine often travel 1-3 hours each way to reach a hospital with a diabetes clinic The journey is expensive
Opportunity cost from day's wages lost
Boda Boda (motorbike), bus or taxi hire Patients may further delay diagnosis/ treatment Diabetes clinics only occur 1-2 days per week Disease has progressed markedly since symptoms first appeared
Blood sugar test is inaccurate since she was not fasting
Chronic worker shortages mean long waits and that it is unlikely to see a doctor below level one health center
At private hospitals, cost of test may be prohibitively expensive Step 3...you get the idea Long wait to see a clinician
A blood sugar test is performed
Josephine is diagnosed with diabetes
Given Rx and told to attend diabetes clinic the next week for follow-up Demand for clinics varies by location Clinics occur only on designated days Pull system: Rx amounts are determined based on severity of symptoms so that patients will return to clinic Meet Thomas Arrives at HC on diabetes clinic day
Fasting blood sugar taken first
Encouraged to snack after test
Education on diabetes care during wait time Fasting patients may faint during waits
Overload results in spending "as little time as possible" with patients
Attending clinic requires half day minimum for most patients
No follow-up with patients until they appear at clinic (incurring costs of transport) Josephine keeps her records with her in a log book or on sheets of paper In a separate book, the clinic records her name and blood sugar level, filed by date of visit How can we better deliver care to patients like Josephine? Ideal Future State Meets with clinician, gets diabetes diagnosis
Receives Rx, pamphlets, and schedule with blood glucose test plan and check-up dates
Joins National Diabetes Registry
Stays for more education about living with diabetes Visits Diabetes Treatment Center for blood sugar checks on recommended schedule
Information updated in his log book and national registry Makes diet changes at home
Joins walking program
Talks openly about disease with friends and community
Turns to Church community for support Returns for follow up Dr. visit
Medication adjusted due to improvements in blood sugar levels
Dr. sets new schedule for follow ups based on improvements Project Goal Recommend a structured, implementable approach to type 2 diabetes care in Uganda, informed by ethnographic research and best practices from other communities Future State Enablers Short Term Long
Term Short Term Customize diabetes risk survey Clinic Improvements:
Draw blood of patients upon their arrival at clinic
Provide education to patients while in waiting area Patient Self-Care:
Develop pamphlets on how to live with diabetes
Pilot non-refrigeration of insulin
Identify other diabetics in community to support each other Thank you! Medium Term Increase Awareness at Lower Levels:
Coordinate mobile diabetes clinic for screening
Train lower level clinicians to diagnose/treat diabetes Develop Partnerships:
Glucometer Manufacturers
World Diabetes Foundation Final Thoughts Increase Awareness with National Campaign Medium Term Long Term Implement Policy Changes:
Introduce healthcare policies to target diabetes and tax policies to dis-incentivize unhealthy lifestyle choices
Provide subsidies for transportation
Develop "National Standards of Care" Improve Patient Experience:
Create Diabetes Treatment Centers concept
Implement electronic patient tracking system ...real challenges
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