The Problem

Approximately, 39% of all deaths in the country are caused by non-communicable diseases (NCDs) up from 27% in 2014 and projected to rise to 47% by 2030 without any intervention. Cardiovascular diseases (CVDs) and Diabetes are the top killers and contribute to 42% of NCD deaths. This is expected to double by 2030 if not interventions are put in place.

Goals

·      Reduce mortality and morbidity caused by the diabetes and hypertension.

Categories of intervention

1.    Patients unaware and undiagnosed.

2.    Patients aware and not on treatment.

3.    Patients on treatment and not achieving control

Root causes of the problem

Service delivery: (Screening and Diagnosis)

·      Availability of services

o  Over 90% of facilities offer DM & HTN services, however less than 50% of health centres and dispensaries manage children with diabetes.

o  Majority of the patients are receiving services at outpatient departments without a longitudinal approach ~12% NCD & DM clinics available

o  Screening is done for hypertension than diabetes unless one symptomatic or with a history. Blood pressure is checked in 91% of the service points while blood sugar is checked in 40%.

o  Screening of complications

o  Limited access points for Type 1 DM children-43 CDiC clinics available nationally

·      Health care worker capacity

o  45% reported having post service training on DM & HTN management

·      Lack of specialized providers i.e. endocrinologists (6), paed endos, cardiologists

·      Late initiation to treatment

·      Low index of suspicion for children-96% not screened and unaware

·      Multi-disciplinary Teams not constituted in the management of NCDs in facilities-fragmented services

·      Need for decentralization of DM & HTN management to PHC and establish clear linkages to care (referral pathway)

·      Lack of standardized and simplified guidelines

2023-Outcomes

·      Policy

o  Coordinated revision of harmonized national diabetes & CVD guidelines

o  First ever T1DM guidelines in Children & Adolescents developed

o  Development of simplified NCDs protocols & algorithms

o  Training package for the children and adolescents developed by Paediatric Endocrinologists Society of Kenya- CHAI has trained 2 of these specialists

·      Disseminated baselines assessment findings to all 47 counties reaching 1564 HCWs

·      Engaged and secured buy-in from 5 focus counties based on high disease burden, presence of trained specialists, active CDiC clinics and existing CHAI work (Kajiado, Machakos, Nakuru, Nyeri and Tharaka Nithi)

·      Secured commitment from Novo to expand to an additional 76 hubs from the current 43

·      Trained 81 HCWs from Machakos and Kajiado counties (CRH & SCH) mentored in Dec 2023 – 12 Hubs

2024-Focus

·      Train health care workers in T1, T2 & HTN from the additional 3 counties (CRH & SCH) from A&E, OPD, HIV clinics, ANC, IPDs- 25 Hubs and cascade it to 127 PHC facilities

·      Initiate routine screening & diagnosis for diabetes and HTN in multiple entry points in facilities and community

·      Reorganization of patient flow from episodic care to chronic care at the NCD clinics- start with DM & HTN 7 establish patient follow up/appointment systems & defaulter tracing in facilities

·      Innovative approach to cascading insulin to PHC- ordering at HUB then supply to PHC

Supply chain: (Treatment & monitoring)

·      Poor control levels leading to complications from:

o  Inadequate self-monitoring

o  Inadequate diagnostic testing-72% of facilities reported having the tests

o  High cost of optimal commodities, drugs, and testing commodities

·      Low volumes procured by counties leading to shortage of drugs at the facility level

2023-Outcomes

·      Secured commodity commitment from Novo-nordisk for any new T1DM children diagnosed

2024-Focus

·       Engagement of a local manufacturer on potential for an affordable locally manufactured glucose test and HBA1C

Data systems

·      75% of the facilities lacking relevant data tools

·      Incomplete reporting to KHIS

·      Lack of visibility of key data indicators such as mortality and complications

·      Lack of robust F&Q focusing on ideal commodities

·      Lack of data affects the volumes procured by KEMSA

2023-Outcome

·      Roll out of 1500 clinical tools to 39 counties- ongoing virtual training by M.O.H

2024-Focus

·      Accurate forecasting and quantification of commodity need in counties to inform procurement

Finance

·      Lack of visibility into county allocation budget set for health

·      Not enough financing allocated leading to high OOP costs for patients and commodities

·      Currently under NHIF: Screening is not covered. Management is covered but this differs across the various schemes and also the sector i.e., private vs public depending on the contract with the facilities

·      Under the Social Health Insurance (SHI): It is envisioned that screening for DM &HTN will be covered under the PHC fund and management will be covered under the emergency and chronic illness fund. NOTE: The modalities on the provider payment mechanism and the tariffs is still under discussion (this will determine the extent of what will be covered)

·       

2024-Focus

·      Continued advocacy for increased allocation of $$ for glucometers/strips, HBA1c equipment & reagents, drugs in counties

·      Working with the facilities in our focus counties to ensure availability of basic HPTs in the facilities to ensure service availability

·      Integrating the work that we are doing with the county to ensure sustainability of the activities