Response to the hypertension/diabetes
challenge
Findings from interviews, focus groups and documents suggest a number of
established and on-going activities in response to the management of
hypertension and diabetes. The policy regime for managing hypertension
and diabetes has been strengthened. There is an overarching NCD policy
as well as NCD strategy (MOH, 2014) .Various stakeholders shared their
knowledge and experiences on how Ghana is responding to the hypertension
and diabetes challenge.
Policy-makers’ viewpoints
Policy-makers believe that the requisite policies are in place for
managing diabetes and hypertension in Ghana. To policy-makers, these
conditions are a priority as Ghana has ratified various conventions and
protocols on NCDs and also, NCD management is an integral part of the
medium term plans of the GHS. Apart from the NCD policy and strategy
which provides the overall roadmap for diabetes and hypertension
management, other policies have also been launched. These include the
Tobacco Control Regulations (L.I. 2247) and Smoking Cessation Clinical
Guidelines, the National Alcohol Policy, and the Nutrition Policy. The
Standard Treatment Guidelines have also been established to guide
clinicians in the management of hypertension and diabetes and other
diseases.
Apart from major policies on these conditions, policy-makers have
instituted the NCD Control Programme within the Disease Control
Department of the Ghana Health Service. The programme is a unit
responsible for planning, prevention and control of all NCDs in Ghana.
Though policy makers (MOH/GHS) admit that there is no established
screening program for diabetes and hypertension management in Ghana,
what run through policy-makers’ responses is the ability to screen and
treat at all levels of service delivery. At the basic level of service
provision, the Community-Based Health Planning and Services (CHPS),
Ghana’s primary health care service, is an innovative approach which
provides basic diabetes and hypertension care to remote and
hard-to-reach locations. Services are run through the referral system,
that is, health posts, health centres, clinics, district hospitals,
regional hospitals and teaching hospitals. Policy-makers, however, admit
that more needs to be done on implementing preventive interventions. The
findings suggest other activities being undertaken by policy-makers in
response to the management of hypertension and diabetes as follows;
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Encouraging health facilities to organize education programs (e.g.
periodic diabetes/hypertension clinics)
-
Organizing seminars, workshops and training programs on
hypertension/diabetes management
-
Leading health workers talking to identifiable groups on these
conditions (e.g. Youth groups, churches, civil society groups).
-
Organising regular community outreach programs using community health
nurses and volunteers
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Encouraging research on these conditions
-
Liaising with other bodies to provide support and infrastructure (e.g.
Liaising with Novo Nordisk for the establishment of diabetes centres
in Ghana)
However, with the exception of community outreach programs, these
activities do not happen on regular and sustained basis. While admitting
that progress has been made in clinical interventions, policy-makers
were unanimous on the need to scale-up preventive interventions
especially when it comes to controlling risk factors of hypertension and
diabetes. The establishment of the Regenerative Health and Nutrition
Unit within the MOH to promote healthy lifestyle is considered a
laudable idea though inadequate funding is obstructing its impact.
Health managers’
viewpoints
Health managers in health facilities act according to broad strategic
paths provided by the GHS but have the mandate to initiate certain
activities within their facilities in response to these conditions. In
planning and allocating resources, health managers are guided by certain
considerations. One health manager of a regional hospital explained what
informs programs in response to hypertension and diabetes;
So as you can see from this table on my computer, this is 2016 and
hypertension was 5th on the top 10 causes of admission in this hospital.
Hypertension was also 5th for causes of death. So straightaway, this
tells me that if we are budgeting, we need to get some resources for
hypertension management
According to the findings, health managers respond by planning and
ensuring that hypertensive and diabetes clinics are held to educate
patients. Health managers also encourage counselling in their facilities
on these conditions but most importantly, they liaise with their
respective directorates to organize occasional sensitization campaigns
in selected communities on these conditions when they have the
resources.
Viewpoint of patient organization
participant
Apart from championing the course of patients and lobbying for better
concessions for patients with respect to accessing diabetes and
hypertensive care, patient organizations have been aligning with other
associations and groups in Africa and elsewhere to work towards reducing
the incidence of these conditions. As part of the “Youth in Diabetes”
project launched to reduce the incidence of diabetes by 15% between
2013 and 2020 across Africa, a screening program to ascertain the
prevalence level in the youth is ongoing in Senior High Schools in
Ghana. The findings suggest that so far schools in the Western, Eastern,
Central and Greater Accra Regions have been screened and that screening
the Volta region is about to commence. The organization partners with
Associations of other countries for support and trains health personnel
and trainers of trainers, a typical example being its collaboration with
the Irish Diabetes Association to offer training to health care
professionals on diabetes management. Though educational campaigns have
been erratic due to inadequate resources, leaflets and easy-to-read
fliers are designed and distributed in health facilities. Currently, the
patient organization is liaising with government for the introduction of
taxes on products with sugar levels in excess of approved limits with
the intention of allocating some funds to advocacy groups for their
activities.
Views from patient organization suggest several challenges in diabetes
and hypertension management in Ghana. These include over-emphasis on
malaria and HIV/AIDS to the neglect of diabetes and hypertension,
inadequate resources to implement policies on diabetes and hypertension,
high cost of treatment as certain services and medications are not
covered by insurance, limited training on diabetes, inadequate health
personnel (e.g. Ghana has only eight endocrinologists), and the absence
of a specialist centre for diabetes complications management.
Payers’ viewpoints
Findings suggest that the National Health Insurance Scheme was set up to
pay for curative care for patients who have received care from health
facilities. To payers, preventive care is the responsibility of the
Public Health Directorate of the GHS who are given budgetary allocation
to undertake preventive activities on all conditions of public health
importance including hypertension and diabetes. Thus, the main
contribution of payers is to reimburse providers for diabetes and
hypertension treatment services and medications covered under the
scheme. Discussions on the benefit package for hypertensive and diabetic
care is on-going as findings from a patient organization indicated that
its effort to convince payers to cover at least the first prick of the
finger for all patients who go to health facilities is yet to be
considered. The NHIA has a budget line for MOH with a strategic purpose
of helping them to support and improve health care infrastructure.
Payers also play important role as key stakeholders in engaging with
MOH/GHS on financial implications of policies and action plans.
Providers’ viewpoints
Findings suggest that the NDA, the MOH/GHS and Novo Nordisk, a Danish
Organization, have established a diabetes centre in the Ga South
Municipality which provides holistic diabetes and hypertension services
to communities in the municipality. The centre is well equipped with a
pharmacy, consulting room, and education and counselling centre. The
centre provides preventive and clinical services for patients suffering
from diabetes and hypertension. Services in response to these conditions
include;
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Educating patients on diabetes and hypertension
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Counselling services
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Foot care
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Neuropathy and retinopathy assessments
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General laboratory services
-
Using dummies to train patients and immediate relatives on
self-insulin injections
-
Undertaking occasional screening programs for selected communities
(some communities screened include Weija, Aplaku, Oblogo, Mallam, and
Dome market)
-
Minor surgeries
-
Liaising with Municipal Health Directorate to provide education and
screening support for churches and youth groups, and
-
Occasionally liaising with celebrities to run campaigns on
hypertension and diabetes.
Providers in the Effutu Municipality provide clinical care for patients
suffering from hypertension and diabetes in the out-patient department.
Providers believe that given the resources at their disposal, they are
providing good clinical services even in acute situations for patients
with high creatinine levels and bad urea secondary to hypertension.
Participants stated that increasing cases of diabetic ketoacidosis (DKA)
or Hyperosmolar Hyperglycaemic State (HHS) have been manged well.
General education in the outpatient department occurs as patients wait
to see health providers but this is not necessarily about hypertension
and diabetes. However, health managers have recognised the need and are
now planning to organize periodic diabetes and hypertension clinics as
the incidence of these conditions rise in communities. The findings
suggest that there is limited action in terms of education and screening
programs in the community but patients who come to health facilities
with suspected cases of hypertension and diabetes are screened.
Education is mainly physician-based as doctors attend to patients but
this is quite limited due to the number of patients doctors have to
attend to.
Viewpoints from advocacy
group
Participants stated that their response to the diabetes and hypertension
challenge has been two-fold; education and advocacy. One way of
encouraging advocacy on hypertension and diabetes is through the
promotion of research on these conditions.
A discussant stated;
We advocate for strong research currently. For example, from the RODAM
study we see that although we usually believe that staying in the rural
area should be protective of these conditions, preliminary findings
suggested otherwise so what is it that we are doing differently?
The findings suggest that the GMA encourages members to undertake
effective research on these conditions through its journal, the Ghana
Medical Journal. On education, participants stated that this is being
done on several platforms and include going on radio and TV stations,
churches and other organized groups to educate stakeholders on these
conditions. The Association uses its AGMs to educate stakeholders on
NCDs in general and more specifically on hypertension and diabetes. A
participant explained:
Last two years our AGM program and theme was on NCDs and about two weeks
from now we are holding a program with all players in the health sector
at the Ghana College of Physicians and Surgeons on NCDs with the theme
‘Non-communicable diseases burden in Ghana: the eye of the crocodile’.
So because we see it as a major challenge we seize every opportunity to
do some education on these conditions
Patients’ viewpoints
Focus group discussions with patients revealed findings which confirms
viewpoints from other stakeholders about more attention being placed on
treatment than prevention. Some patients believed the way forward for
health authorities is to undertake the same education as they do on
malaria and HIV/AIDS. Most patients did not know about the risk factors
of hypertension and diabetes before they became hypertensive or diabetic
and findings suggest that some patients still have limited knowledge of
their condition. Patients stated that it appears Ghana’s response is “a
get-sick-and-come” response and that you hear more of these conditions
only when you come to the health facilities. Patients’ views on
treatment were however mixed. Whereas some believed that once diagnosed,
treatment was very good especially if appointments are kept, others
concentrated on challenges associated with treatment. Patients were not
happy about being made to see different doctors on different occasions
as they feel this does not ensure consistency in treatment. However, a
crosscheck with health providers suggested this sometimes become
necessary due to doctors and nurses having different schedules in
theatres or being made to attend to emergency situations. A major issue
that came out of discussions was compliance. Some male patients admitted
that they use herbal medications because they have sexual issues
whenever they take some of the hypertension medications.