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NIROGI Lanka - Phase 1

National Initiative to Reinforce and Organize General diabetes care In Sri Lanka

COMPONENT 2 - Health Care Model of Primary-tertiary Care Partnership

Objectives:
To establish a health care model of primary-tertiary care partnership to improve the quality of diabetes care for residents living in the Colombo Municipal Council (CMC) area by
  • Developing the infrastructure of PHC services of the CMC
  • Training of the PHC medical practitioners
  • Strengthening the laboratory services for diagnosis and management of diabetes and CVD risk factors at primary care
Justification:
In the tertiary care settings, diabetes care is provided in overcrowded clinics by the medical staff under direct supervision of consultant physicians or endocrinologists. In the CMC clinics that cater to about 3000 diabetic patients on a regular basis, there are no medical staff trained on diabetes care. In addition, the CMC clinics lack even the basic facilities necessary for provision of diabetes care. It was envisaged that by initiating a partnership between the specialized tertiary care services and the PHC services in the Colombo City limits, the CMC medical staff both in terms of expertise and material resources necessary for provision of standard diabetes care in the community could be empowered. If proven to be successful, this model can be used as state of the art PHC service for families with DM and CVD risk, and thereby diminish the patients overcrowding the draining tertiary care centres and to optimize the true tertiary care services for diabetes.


Project area:
Five selected Colombo Municipal Council (CMC) clinics in the CMC area


Beneficiaries:
  • Laboratory and clinic staff in state PHC settings in highly urban CMC areas
  • All patients seeking follow-up care for diabetes at such clinics
  • Patients and immediate family members residing in CMC areas for health education and screening for diabetes
Expected outcomes:
To build effective bridges between preventive and curative health services towards improved quality of diabetes care
  • To improve the competency of medical officers of the CMC to ensure their ability for providing quality diabetes care
  • To uplift the infrastructure of outpatient clinics of the CMC to provide quality diabetes care and prevention
  • To improve metabolic control to achieve the target of HbA1C, lipids and blood pressure in at least 50% of those not controlled at present)
Methods adopted:
Under this programme, the existing PHC services of the CMC sector were planned to be strengthened to provide quality follow-up care for diabetics and those with CVD risks, using a health care model developed through tertiary-primary care partnership. Both human and infra-structure development was focussed upon.

The basic framework was to re-model six (three central dispensaries and three peripheral units) out of the 30 CMC outpatient clinics that provided standard diabetes care in overcrowded Metropolitan areas. Two tertiary care hospitals with focussed care for diabetes were linked with these six clinics.

The local Western provincial directorate signed an MoU with NIROGI Lanka to undertake the overall function and provide consumables in a sustained manner. Re-modelling of these clinics involved conducting stakeholder meetings, developing training modules and training of human resource, upgrading laboratory facilities, and applying mechanisms for monitoring and evaluation.

The following activities were undertaken:
  • The clinics were refurbished with dedicated sitting areas, screening areas, pharmacy and record rooms, which were stylised and put into action.
  • The clinics were furnished with appropriate health education material.
  • Patient record books and recording systems were introduced for the clinic personnel and laboratory.



  • The laboratory was established under the supervision of consultant chemical pathologist and biochemists who played a crucial role in processing the tender documents and purchasing a state of the art automated analyser. This is the first such instance that the state sector primary care curative division was enhanced.
  • HBA1C, urinary microalbuminuria, lipid profile, renal function tests and hepatic trans-aminase tests which are not routinely done in the CMC clinics were introduced to provide better services in diagnosis of diabetes, screening for diabetic complications and assessment of metabolic control.
  • The laboratory usage, collection and transport of samples from each clinic and issuance of results were streamlined.
  • A training programme was developed by the experts in tertiary care in line with the WHO Package of Essential Non-Communicable Disease Interventions (WHO PEN) in collaboration with the PDHS western province, Health Education Bureau and Sri Lanka College of General Practitioners. This training programme was conducted annually for 2 days for the medical staff of the CMC in batches of 15-20 to ensure their ability to provide quality diabetes care. Additionally, DENOs were trained to help run the clinics in a consistent manner.
  • Primary care practitioners in the Western province who were registered in the College of General Practitioners were also provided the same training.
  • Protocol based algorithmic approach was developed for shared care with clear guidelines (in accordance with the Ministry of Health policies) for referral and back-referral loop.
  • A team of diabetes specialists and trained non-specialists provided periodic services (twice a year follow up of patients) on an out-reach basis.
  • Regular review of the clinic coverage was ensured by site visits of the tertiary care trained doctors for a period of 20 months, whereupon the need for such regular visits was deemed not essential due to self-sustenance of the clinic systems.
  • The Western Province Minister of Health conceived the concept of recruiting retired health care workers and providing screening and health promotion activities at workplaces. NIROGI Lanka found this to be an able partner and joined the process to achieve the targeted number of opportunistic community screening.
  • Displayed educational bill boards at 10 Health Care Institutions.


Impact assessment and evaluation:
  • Provision of diabetes care - Knowledge, skills and attitudes of the medical officers were evaluated at baseline and on annual basis using questionnaires
  • Achievement of targets for metabolic control – the achievement of HBA1C, lipid, blood pressure control according to the American Diabetes Association recommendations were evaluated at baseline and on an annual basis using the database that would be maintained. The frequency of retinopathy screening and foot examination too was evaluated.
  • Satisfaction of the patients and their families on the care provided was evaluated using a qualitative questionnaire.
  • Number of health education sessions for patients and their families, number of people screened for diabetes and new cases identified were assessed.
Key Achievements:
  • An in-house case-based novel training module was developed for PHC doctors in collaboration with the College of General Practitioners.
  • A total of 119 medical officers, 69 general practitioners from the Western Province (in 7 consecutive weekend courses) and 14 DENOs were trained to help run the clinics in a consistent manner.
  • 12 laboratory technicians were trained.
  • 6 PHC clinics dedicated for diabetes care were strengthened in collaboration with the Western Provincial Director of Health Services. The clinics were functioning full time under the supervision of trained medical officers and supported by the DENOs.
  • Laboratory services were established in the six upgraded clinics under the supervision of a consultant chemical pathologist.
  • The empowered staff worked in collaboration with the main tertiary referral centre, with the back referral rate to tertiary centres being only 3%.
  • Community opportunistic screening for diabetes was initiated.
    - No. of awareness camps held = 526
    - No. of people detected with diabetes = 3,130 (12.11% of all screened)


Lessons Learnt:
  • The project provides evidence that strengthening of PHC clinics into state of the art centres would enable the delivery of quality diabetes care for the urban dwellers in Colombo and suburbs in terms of better control of the disease, patient satisfaction and compliance through the enhancement of primary care in urban areas.
  • PHC can co-exist with a busy tertiary referral centre, provided partnerships are established. The project proves this approach is feasible for the Sri Lankan health care model.
  • Referral and back-referral system works efficiently with the empowered staff working in collaboration with the main tertiary referral centre.
  • Upgrading existing PHC settings to deliver quality care through doctor-nurse pairs is achievable in the state health sector in urban areas. Further, capacity building enabled a team approach to the care giving.
  • Protocol based management is applicable in primary settings in the state and private sectors through the incorporation of training modules.
  • Private sector primary care/ family medicine is a useful resource for managing diabetes and CVD. Private GPs received official status in management and feedback aspects and brought in new collaborations in screening of persons at risk in the work settings and in standardizing quality care in the follow up of Diabetes and CVD.
  • Furnishing returns / audits at primary care (curative) is feasible in Sri Lanka.
  • Opportunistic screening of Colombo work places provides valuable data for national planning.
  • The health administrators pledge to sustain the delivery of medication through internal fund diversions. In parallel, the Ministry of Health has commenced a programme of Healthy Life Style centres throughout the country.
Technical group:
  • Dr Noel Somasunderam (Consultant Endocrinologist, National Hospital of Sri Lanka) - Coordinator
  • Prof Kusum de Abrew (Professor in Pharmacology, University of Colombo)
  • Dr K Chandrasekher (Consultant Family Physician)
  • Dr R Haniffa (Secretary, Sri Lanka Medical Association)
  • Dr Prasad Katulanda (Senior Lecturer in Clinical Medicine, University of Colombo)
  • Dr Chamari Weeraratne (Senior Lecturer in Pharmacology, University of Colombo)
  • Dr Nimmi Wickramasinghe (Chief Dispensary Medical Officer, Colombo Municipal Council)
  • Dr Preethi Aluthge (Medical Officer, Colombo Municipal Council)