Primary-Health Integrated Care for Four Chronic Diseases (PIC4C) Changes Lives
Non-communicable diseases (NCDs), such as diabetes and hypertension, are a growing global public health concern, accounting for 39 percent of deaths and close to a 30 percent loss of household incomes in Kenya according to the national strategic plan from the Ministry of Health (MoH).
Many stakeholders attended the dissemination meeting.
The MoH, through Moi Teaching and Referral Hospital (MTRH) and AMPATH, tested the Primary-Health Integrated Care for Four Chronic Diseases (PIC4C) model. This model integrates early diagnosis and treatment of hypertension, diabetes, breast and cervical cancer into the primary care level supported by a robust and seamless referral system. The PIC4C project was piloted from 2019-2022 in Trans Nzoia and Busia Counties and generously supported by Access Accelerated through the World Bank.
Chronic diseases are insidious, often developing over a long time and very slow from the onset and sometimes with no symptoms until it is too late. The PIC4C pilot established that the treatment of chronic diseases needs an integrated, wholistic approach that’s based on strengthened health systems across the entire care system.
Instead of the reactive approach for acute illness management, the project adopted community education and screening, health worker training and equipping of lower-level facilities with necessary tools and supplies. The project also focused on strengthening the supply chain, health information systems, and leadership and governance strengthening. The findings, challenges and best practices resulting from PIC4C will hopefully inform follow-up implementation strategies to scale up the integration of NCD management into Primary Health Care to the rest of the country to ensure that no one is left behind.
Dr. Wilson K. Aruasa, MBS, EBS, CEO of MTRH, emphasized the magnitude of the NCD problem at the PIC4C dissemination meeting last year. He said, “The growing burden of NCDs poses a major public health concern and a threat to economic productivity at both household and national levels. This economic burden is driven by failed primary preventive measures, late diagnosis compounded by multiple complications, inaccessible care for most of the population and a disjointed care system. Currently, there is overreliance on secondary and tertiary health facilities for NCDs control disregarding the more accessible primary care level.”
The pilot project generated many lessons on integrating diabetes, hypertension, breast and cervical cancer into primary care, optimizing access to care, challenges facing this process, and innovations addressing these challenges.
To fully understand and document the lessons learned from PIC4C to inform scale-up, the London School of Hygiene and Tropical Medicine (LSHTM), AMPATH, and KEMRI Welcome Trust, set up the PIC4C Scale-Up study through funding by UK Medical Research Council (MRC), in collaboration with the Global Alliance for Chronic Diseases (GACD).
Dr. Jemimah Kamano
Dr. Jemimah Kamano, principal investigator of the pilot study reflected on the journey to better health outcomes for people with chronic illnesses. “At the onset of the PIC4C model, during one of my first interviews with a patient, I realized that this would not just be another research project. The client, Rose*, broke my heart, yet gave me all the fire and passion.”
Rose had lived with Type 1 diabetes for five years at the time of the entry interview. Despite being frail, she worked a hard manual job of crushing bolder rocks to ballast to make ends meet. The struggle to get insulin for her, like many other clients living with type 1 diabetes, was not just the cost of the insulin, but its unavailability too. Rose would spend a whole day, (which was a labour day lost) to get to Busia town to get the insulin. She would be lucky if it was available at the county hospital where it is slightly cheaper than in the private pharmacies.
In order to have the insulin stretch for two months, Rose used half the prescribed dosage. Further, she would use one needle and syringe for two weeks instead of discarding it after every use as recommended. Re-use of the syringes exposed her to lipohypertrophy (a lump of fatty tissue under the skin caused by repeated injections in the same place. It's common in people with diabetes).
“I walked out of the interview midway and cried my heart out!” recalled Dr. Kamano. “As I wound up the interview with Rose, I gave all the money I had on me and wished she had a phone that I would keep giving her. However, I realized even if I did, this would not change the situation for many more like her in this country. With these premises, I put all my heart into the PIC4C project and with a great team and a supportive system the results of the PIC4C model are a tale of victory and challenges, offering lessons that the country should follow moving forward,” she continued.
“The project is a testament that indeed screening, identification, and basic management of NCDs can be done at the primary healthcare level. Further, it lays down clear evidence of what the power of partnerships can do. The Ministry of Health commits to scale-up and scale-out the recommendations to reverse and halt the rising burden of NCDs in the country,” affirmed Sen. Mutahi Kagwe, EGH, former cabinet secretary in the Ministry of Health, during the dissemination event.
Stakeholders present during the dissemination of the findings were drawn from Ministry of Health, county governments, MTRH, Moi University, Indiana University, AMPATH partners, Access Accelerated, London School of Hygiene and Tropical Medicine, KEMRI-Wellcome Trust Research Programme, Research Triangle Institute, National Health Insurance Fund, Members of NCD Alliance, Medtronics Lab, PATH Cancer City Challenge, Council of Governors, and Kenya Medical Practitioners and Dentists Council.
Mercy’s Success Story
Mercy receives recognition at the dissemination meeting.
Busia County has more than 3.7 per cent of its population with diabetes out of which only 20 percent are on treatment. Further, a screening conducted by the PIC4C project, with the help of Community Health Volunteers (CHVs) established that over 25 percent of the adult population in Busia County is affected by hypertension (high blood pressure).
Mercy is one of those residents with hypertension. However, the screening outreaches and care by the PIC4C program changed her story of living with a chronic illness that she narrates with an infectious smile.
“For a long time, I suffered endless headaches and body malaise. I treated the symptoms for years before I was finally diagnosed with hypertension at the Teso North Sub-County Hospital. Despite the relief of knowing the source of my frequent discomfort, I now faced the challenge of accessing care from the Sub-County Hospital which was hours away from where I lived. I was struggling to get enough money to purchase the hypertension drugs and to frequent clinic appointments.
Mercy talks about how the pilot project changed her life.
“The PIC4C project was a lifesaver for me. The program supported Amukura Health Center which is a short walk from where I live to provide care for me and 30 other residents who had either hypertension, diabetes or both conditions. The program mobilized us to have a support group and taught us all we needed to know about the management of the diseases we had to bear for the rest of our lives.
“The groups became a source of hope for all of us, as we encouraged each other not just on medication but also to choose healthier lifestyles. We used the same groups as savings groups and we would contribute as little as 100 Kenyan Shillings per month which would help us to pay for our National Health Insurance Fund (NHIF) premiums. Having the NHIF cover would ensure that we get health care services without having to go deeper into our pockets.
“The program also trained and facilitated CHVs with a blood pressure testing kit to help monitor our blood pressure easily. The CHVs use the equipment to assess other residents and refer them to the hospital when necessary.
“Earlier, people would die suddenly from hypertension complications, and we thought that it was a curse or witchcraft. However, with the knowledge we have now, we are ambassadors in the community advocating for healthy lifestyles and regular screening.”
Months after the program closed out, the support group based at the Amukura Health Centre continued. The group chaired by Mercy is registered as a Community-Based Organization (CBO) and they can lend out seed capital to members and other groups to invest with.