Cohort monitoring – As a tool to improve diabetes care services

Abstract

The need to stem the rising tide of non-communicable diseases (NCDs) including diabetes has been recognised at the highest levels through the UN political declaration. Diabetes care services are largely unavailable in the primary care setting in most developing countries and where available the services are unstructured, with poor record keeping, stock outs and frequent disruption in supplies. With no systematic monitoring of care and programme implementation, treatment outcomes are poor and are consequently associated with a high economic burden. Systematic evaluation of programmes through cohort monitoring has been shown to be effective in large-scale interventions for two chronic infectious diseases-tuberculosis and HIV/AIDS. Can the same simple tool of cohort monitoring be applied to improve diabetes care delivery in the developing world? Pilot projects show it is possible, but scale up and expansion would require investment in information technology. In a scenario where systems for NCD are just beginning to be set up, it makes sense to learn from and build further on the initial pilot programmes.

Introduction

Chronic non-communicable diseases (NCDs) are now the leading cause of death – annually accounting for over 36 million deaths globally [1]. In the developing world, the majority of these deaths occur prematurely. Unfortunately, very little has been done to address this problem for patients with NCDs through effective, equitable and affordable health sector interventions, or to implement policies to reduce the population-level risks for NCDs [2]. The need for urgent action to address NCDs has been recognised and is now acknowledged at the highest level through the UN political declaration [3].

Given its rapid growth in low-, low middle- and middle-income countries, diabetes in particular poses a significant challenge to the already stretched resource constrained health systems in these countries. Some of the challenges posed by diabetes relate to the nature of the disease and others to patient and health system related factors as shown in Table 1. Because of its chronic unrelenting nature, and need for follow up requiring repeated contact with health care professionals, diabetes care delivery must be available at the primary care level, which is ‘the route to greater efficiency and fairness in healthcare and greater security in the health sector and beyond’ [4]. Despite the rhetoric, diabetes care services are largely unavailable in the primary care setting in most developing countries. Where available the services are by and large unstructured, with poor record keeping, stock outs and frequent disruption in supplies. There is no systematic follow up and monitoring of care and treatment outcome is poor. The rule of halves is well known in the world of diabetes and hypertension – only half of the people with diabetes are diagnosed, half of those diagnosed get a recognised process of care, half of those who get care achieve desired targets and only half of these achieve desired outcomes. In many least developed countries there may be a rule of thirds or even quarters.