The need for sustained support in Bosnia
Integrating diabetes prevention and care into the routine services at the primary care level
Von Bettina Schwethelm, Suzana Hadzialjevic, Aida Muslic & Damir Lalicic / Fondation PH Suisse
As in many health systems in Eastern Europe and the CIS, the diagnosis and treatment of patients with chronic diseases in Bosnia and Herzegovina was until recently managed at the secondary level. Using the interest of the government to strengthen the role of family medicine in routine patient care and health promotion, Partnerships in Health worked with the primary and secondary level of the Ministry of Health and the Diabetes Patient Association to integrate routine diabetes care into the existing primary health care structures. The project is an example of a successful public-private partnership.
As elsewhere in the region, until recently, the diagnosis and management of patients with chronic diseases in Bosnia and Herzegovina (BiH) was the responsibility of specialists at the secondary health care level. This meant that patients in the cantons of Sarajevo and Goražde had to travel to the University of Sarajevo Endocrinology Clinic, even for routine care. To increase access and quality of care at the primary care level, the government initiated a health care reform that, supported by donors such as the Swiss Agency for Development and Cooperation, World Bank, Canadian International Development Agency, and others, invested heavily in the retraining and training of medical and nursing personnel in family medicine. With support from the SDC, Partnerships in Health and the Geneva University Hospitals, assisted the ministries of health for about ten years in the rehabilitation of primary health care facilities and the retraining of doctors and nurses as family medicine providers across different regions of BiH. Chronic diseases were included in the retraining courses and in the purchase of some essential equipment for primary health care facilities. However, it became clear that additional efforts were needed to build the capacities of the primary care level in diabetes prevention and care.
At the request of the Canton Sarajevo and in the context of rapidly increasing rates of diabetes, Partnerships in Health and the cantonal health authorities of Sarajevo developed a multi-disciplinary approach to diabetes in 2006. The emphasis was placed on an approach that would be replicable and locally sustainable.
Bosnia and Herzegovina has a complex health care system
Since the Dayton Agreement in 1995, BiH is formally divided into three political entities, each with its own health care structures and health insurance funds. The Federation is subdivided further into ten cantons, each with its own ministry of health and health insurance fund. Services at the primary care level are provided through a system of Dom Zdravlas (DZs), health care clinics with general and family medicine providers and basic specialties (pediatrics, OB/GYN. Dentistry, internists). Implementing new approaches into the existing health care structures in the Federation thus requires approval and support from the Federation and from each of the participating cantonal health authorities.
Diabetes management inconsistent at the Primary Care Level
Even though the routine management of diabetic patients had been included in the retraining of doctors and nurses in family medicine, a study in a different geographic region of BiH and involving 18 family medicine teams found serious deficiencies in service delivery in 2007. The researchers noted that diabetes management within and across DZs was inconsistent, the monitoring of complications (foot and eye care) low, and that providers lacked national standards, guidelines and training. (Novo/Jokic 2008)
Diabetes: An explosive epidemic
Between 1985 and 2000, the prevalence of diabetes increased from 30 to 171 million worldwide and is expected to more than double to 366 million in 2030. (Wild et al. 2004) Rapid increases have also been observed in BiH: life-style factors (i.e., poor diet, lack of physical activity, smoking) are exacerbated by post-war stress factors and environmental contamination, resulting in rates of diabetes about twice that of Switzerland (6.4% compared to 3.2% for individuals 45-54, and 12.2% compared to 6.1% for individuals 55-64, respectively; www.who.int/infobase/report.aspx)
Diabetes is one of the most costly diseases globally – consuming 5-10% of countries’ health care budgets. It is also a significant economic and emotional burden to families of affected individuals. Low income levels, limited geographic access to specialist care, combined with cultural variables and mobility factors (diabetes-related complications resulting in cardiovascular disease, leg and foot infections and amputations, blindness, and kidney disease), make it even more difficult for patients (particularly women) to seek care on their own. In addition, many individuals live with the disease unknowingly for many years, and are diagnosed when complications have started to set in. Therefore, increasing access to primary and secondary prevention within the patient’s home community is critical. The purpose of this partnership project with the cantonal health authorities was to increase population awareness of the disease (i.e., how to prevent diabetes through healthy life styles) and improve routine patient care for diabetes at the primary care level.
Sustainability planning from the onset
Aware that many projects unravel when donor support ends, Partnerships in Health and its local partners planned this project from the inception with sustainability as a key concern. A multi-disciplinary Ministry of Health expert group, consisting of diabetes specialists from the University Endocrinology Clinic and representatives from the primary health care level (family medicine doctors and nurses, psychologists and social workers) guided and monitored the project from the planning to completion. The activities were piloted first in the Canton of Sarajevo, before extending to the more rural and distant Canton Goražde. A curriculum for family medicine providers, derived from internationally available and evidence-based curricula, as well as patient and public education materials was developed and formally adopted by the Ministry of Health for use at the primary care level in 2007.
Multi-disciplinary teams (diabetes specialists and PHC providers) were trained to train primary care doctors and nurses, social workers and psychologists in the local settings. The same trainer teams also provided onsite supervision to help the local teams adapt new practices, conduct self-assessments of their care of diabetic patients, and to improve the referral and counter-referral mechanisms with the University of Sarajevo Endocrinology Clinic. In addition, the project established two diabetes counselling centers, with a doctor-nurse team of each Center trained intensively over a one-month period at the University Endocrinology Clinic.
Annual campaigns on World Diabetes Day contributed to raising population awareness about diabetes and to screening individuals at-risk. The media covered all project activities extensively, including the training of providers, local conferences and workshops to exchange experiences, the opening of the two counselling centers, and the World Diabetes activities and maximized this opportunity to inform the public about diabetes and the newly available services.
In all, 450 family doctors, nurses, social workers, and psychologists were trained to provide improved care for patients with diabetes. The training and celebration of World Diabetes Day in 2006 increased the interest of providers in diabetes and resulted in additional active case finding. Building on the strong interest of the medical providers, the Canton Sarajevo in late 2006 authorized free screening to at-risk individuals during a one-month period at the ambulantas (doctors’ offices) of the newly trained providers. This contributed to the fact that during the first six months of the project, Family Medicine providers increased their number of registered patients by 9.1%, but the number of patients with diabetes by 41.3%.
Family medicine staff also began to refer patients which needed special counseling in nutrition or injection techniques or required psycho-social advice or foot care to the Diabetes Counselling Centers. These Centers were also publicized widely in the magazines of the local Diabetes Patient Association. As a result, the Counseling Center at the DZ Ilidza (ocated in the outskirts of Sarajevo), staffed part-time by a doctor and nurse served as many as 200-300 patients per month with individualized services and group counseling, reducing the need for patients to travel downtown to the often heavily booked University Clinic. Furthermore, the trained family medicine staff in the DZs appreciated the improved collaboration through referral and counter-referral and consultations with colleagues from the secondary level, and patients were satisfied with the continuity of care available through their own family doctor and nurse.
Support for the project activities
The project was supported by several donors (CIDA, Medtronic Foundation, FEDEVACO, Vontobel Stiftung), and during the final year also through a contract with the Federal Ministry of Health via a World Bank loan. Fundraising was a labour-intensive activity, covered by the limited human and financial resources of Partnerships in Health. It took nearly three years to obtain the first two grants, and the total amounts obtained for the project were limited, totalling less than CHF300’000 for a three year period. In addition, the application processes, reporting, and financial requirements differed for each donor. The low predictability of resource flow and the lack of longer-term security created challenges for the project and for Partnerships in Health in Switzerland and BiH.
The NGO contribution
One donor agency rejected the proposal for our project proposal with the following comments “The Board’s main focus was on the resource aspect – that Bosnia & Herzegovina does not belong among the poorest of the poor. In addition, during their discussions, the issue of the role of Partnerships in Health did come up, questioning whether a country like BiH would not itself have the capacity to drive such a process rather than having external parties come in…” This led to some discussion among the staff whether this and similar projects should be pursued for this region. What is the role of Partnerships in Health Switzerland and BiH in this context? Was it important, even critical? Helpful? Introducing innovation and new directions? Based on the feedback from the project’s local technical expert, the answer is affirmative.
Partnerships in Health did not directly implement the activities of this project, but facilitated the work of its local partners. The varied roles and activities of Partnerships in Health in this project include:
- Contract the local experts
- Determine the existing local needs and resources, including stakeholder and stakeholder organizations
- Identify potential donors for cash and in-kind (e.g., education materials, equipment and testing materials) support
- Manage the budget and finance the activities
- Introduce innovative approaches (i.e., multi-sectoral work)
- Organize and participate in curricula and materials review sessions, trainings events, conferences, meetings, supervision visions, etc.
- Facilitate and coordinate the collaboration and contributions of public-private and for-profit and not-for profit agencies around diabetes
- Keep activities on a tight time-line
- Provide all project-related logistics support
- Mobilize the media
- Act as the overall “cheerleader” to local activities and achievements
This role was well understood by the local partners and contributors and highly appreciated. Because FPH had little to gain for itself, it could bring partners with very different agendas together, assure that contributions were recognized publicly, and even facilitate the participation of competitors for the common good of patients with and at-risk of diabetes.
The external financial support for the project ended in 2008 and many activities were still ongoing in 2009. However, despite all efforts of project planning and implementation with and through our local partners, only partial sustainability was achieved. Based on a quick assessment with the local stakeholders, it was determined that the project has contributed to improved collaboration between the primary and secondary level of health care. Additional cases have been identified and are under treatment, hopefully with fewer or more delayed complications. The numerous contacts with the media and coverage of diabetes have also contributed to increased population awareness.
However, due to the fragility and resource constraints of the BiH health system, important weak areas have been identified. These need to be addressed before true sustainability can be assured.
- Human resources remain extremely limited. Some providers trained at a substantial cost to the project BiH have been transferred and assigned to others positions. Anticipatory prevention strategies might have included training several doctor-nurse teams to staff the Diabetes Counselling Centers. In addition, cost-effectiveness studies could have been conducted to compare the health care costs of poorly managed diabetes vs. the costs associated with maintaining the necessary trained personnel to assist diabetic patients in better managing their disease.
- Consumables for testing and monitoring glucose levels and equipment, even if not of high cost, have already created constraints in the project area.
- Providers have also mentioned the need for additional training for professionals and patient education materials
- Motivational factors are also important. With the end of the externally-funded project, some of the energies and motivational factors that had been channeled carefully by the project staff and key stakeholders have been overtaken by the need to deal with the existing structures and constraints.
*Bettina Schwethelm (Partnerships in Health Switzerland), Aida Muslic (Partnerstvo za zdravlje), Dr. Suzana Hadzialjevic (Partnerstvo za zdravlje), and Damir Lalicic (Partnerstvo za zdravlje). Contact: firstname.lastname@example.org
Partnerships in Health acknowledges the technical contributions of its local partners, foremost Professor dr Bećir Heljić, Head of Department Of Endocrinology, Diabetes And Metabolic Diseases , University Clinic Center Sarajevo.
- Novo, A., & Jokic, I. Medical Audit of DM in Primary Care Setting in Bosnia and Herzegovina. Croat. Med. J., 2008, 49(6), 757-762.
- Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. Global Prevalence of Diabetes – Estimates for the Year 2000 and projections for 2030. Diabetes Care 27:1047–1053, 2004