Support for Health Care of Chronic Diseases
On a study tour of Dutch physicians to Ghana in 2009, contact was made with the regional hospital Abura Dunkwa in the Central Region. Upon visiting the hospital, mutual interest for a partnership with respect to chronic illnesses arose.
Ghana has a growing problem where diabetes and high blood pressure are concerned. The Ghanaian medical care is not yet fully set up to treat this kind of chronic illness.
During a follow up journey in 2010, a stakeholders meeting was held where issues and goals were amassed, on the basis of which, the foundation “Ghaned for Health” was established and a project proposal for the development of medical care focused on chronic illnesses was prepared.
Dutch physicians and practice nurses have made themselves available to facilitate training, to use their expertise to develop protocols for treating chronic illness and to generate the means to offer proper medical care for chronic illnesses.
The required personnel and the means to treat people in Ghana, is being financed by the Abura Dunkwa Distict hospital.
Organisation in the Netherlands
Name : Ghaned for Health
Address : Dorpsstraat 15
Postal code : 1393 NE
Telephone number : +31 6 51497259
E-mail address : email@example.com;
Website : www.ghanedforhealth.org
Bank account : NL 44 TRIO 0254701264 Triodos Bank
Dutch Chamber of Commerce number : 54997577
Dutch charity number : 851522452
Name : Mw. F. Pingen
Telephone : +31 6 51497259
E-mail address : firstname.lastname@example.org
Chair: Dirk Achterbergh, General Practitioner
Secretary: Francien Pingen, General Practitioner
Treasurer: Mariska van Heerde, General Practitioner
Board member: Ekow Lamptey
Board member: Justus Laryea
Board member: Hannie Gevers
Organisation in Ghana
Name: Abura Dunkwa District Hospital
Address: P.O. Box 55
City/Town: Abura Dunkwa, Central Region, Ghana
Telephone number: +233 244981308
E-mail address : email@example.com
Name: Mr. Julius Waamsasiko
Telephone number: +233 244981308
Email address: firstname.lastname@example.org
3. Background / Problem Analysis
The World Health Organisation stated that in 2010, 8.8% of the Ghanaian population suffers from diabetes. The total population of Ghana consists of 24 million people, so approximately 2,112,000 Ghanaians suffer from diabetes. However, the total percentage of people having abnormal blood sugar levels in Ghana is 14% (International Diabetes Fund, http://www.idf.org/diabetesatlas/, august 2011).
During a large-scale study on non-transferable diseases in the region of Accra, it was determined that the total percentage of adults suffering from diabetes in the area was 6.3%. The percentage of adults having disrupted blood sugar levels was 10.7%. Almost 70% of the people that were part of the investigation and were diagnosed as diabetics were not aware they suffered from the condition (Amoah AGB, Owusu SK, Adjei S. Diabetes in Ghana: a community based prevalence study in Greater Accra. Diabetes Research and Clinical Practice).
Hypertension (High blood pressure), besides diabetes, is an important risk factor for developing cardiovascular complications. The total percentage of people in Ghana suffering from hypertension is around 28.7% (World Health Organization, http:/www.who.int/countries/gha/en/,august2011.).
Studies on hypertension in Ghanaian rural regions show percentages between 19 and 33% (Bosu WK.Epidemic of hypertension in Ghana: a systematic review.BMC Public Health 2010,10:418).
In 2010 2.4% of new patients at the Abura Dunkwa Hospital, were diagnosed with high blood pressure. Today the percentage has risen to 3.9%. The occurrence of hypertension and diabetes in patients from Abura Dunkwa Hospital is increasing.
On their first contact with the outpatients clinic many patients already present complications, such as diabetic cardiomyopathy (heart muscle disorder), angiopathy (damage to the blood vessels), nefropathy (kidney disorder), and retinopathy (damage to the retina), which can lead to heart and vascular disease, strokes, skin disorder of the feet, chronic eye disorder and blindness.
This high number of complications is primarily due to the fact that patients do not receive proper support. The health care system is mainly set up to treat transferable diseases. The indicated treatment for chronic diseases differs from that of transferable diseases.
The World Health Organisation and the International Diabetes Federation (IDF) see a worldwide increase in diabetes, the highest increases occur in low and middle income countries like Ghana. However in these countries, healthcare is primarily focused on treating contagious diseases and there is insufficientfocus on chronic disease.
The current situation in Abura Dunkwa Hospital
Diabetes and hypertension are characterized by patients not noticing symptoms in the early stages of the disease. The first signs patients notice are caused by the effects of hypertension or diabetes mellitus when left untreated. For the group of patients who already suffer from serious forms of diabetes or high blood pressure it is important they receive a long-term treatment programme and are checked regularly by a nurse.
In the current situation patients at the Abura Dunkwa Hospital receive medicine monthly. The patient has to travel to the hospital every month to pick up the medicine. In reality however, patients only come to the hospital when they have serious complications. At that time, they receive medicine for a month and the patient does not show up at the hospital again until new complications arise.
Analysis of the situation
To form an overview of how (potential) patients are treated, exploratory research on healthcare for patients who suffer from chronic disease has been conducted in the district of the Abura Dunkwa Hospital. The research was conducted by:
· Interviewing employees on different levels in the healthcare sector: Hospitals, Health centres and fieldworkers working in several different compounds (Community based Health Planning and Service, CHPS);
· Interviewing the District Manager of Ghana Health Services, responsible for healthcare in several communities within the district.
· Workshop with delegates from Abura Dunkwa Hospital management and the doctors and nurses working in the hospital and health centres in the district.
The research has shown several problems, which can be attributed to community bound factors and institutionally bound factors.
Community bound factors
· For many patients the distance to the hospital is too large, resulting in high travel cost and thus preventing patients from travelling to the hospital.
· Superstition concerning diabetes and high blood pressure are in the way of proper treatment of the diseases.
· A high level of illiteracy and an attitude of not using official bodies of healthcare.
Institutionally bound factors
· In some cases medication for treatment of the diseases is not in stock at the health care centres.The CHPS within different compounds are not permitted to provide medicine.
· Treatment and check-ups on diabetes and high blood pressure are not part of the regular tasks of nurses working within the communities.
· There is a lack of protocol for consultation of people with chronic disease at the different institutions in the district.
· Communication between the hospital and the nurses in the community is insufficient where treating chronic disease is concerned.
· The level of knowledge of treating people for chronic disease is insufficient for nurses working in the communities as well as for nurses in general.
Based on this research, Ghaned for Health identifies possible solutions in two areas. The areas are the location where care is provided and the manner in which it is provided. By offering care for diabetes and hypertension decentralized and in the vicinity of patients situated in rural areas, the accessibility of healthcare is improved. Furthermore, by offering healthcare in a more structured way, the possibilities for providing higher quality and more frequent care are improved.
Such an approach comes with the following benefits:
· The transfer of part of the health care for diabetics and people with high blood pressure to centres for basic health care and ambulatory nurses, will decrease the number of patients who visit the hospital. As a result, the decreased workload will enable hospitals to focus their efforts on treating patients with complications.
· Diabetics and people who suffer from hypertension, will be more inclined to visit a local health care centre as opposed to the hospital. The check-up frequency on patients and the treatment of these chronic diseases will improve as a result.
· By educating patients, regular check-ups and better use of medication, complications resulting from diabetes and hypertension will decrease.
· By employing a structured medical protocol, patients will receive better care within their own community by trained ambulatory nurses. Where complications do occur, patients will be referred to the hospital.
4. Goals and objectives
The primary goal of Ghaned for Healths activities in the district surrounding Abura Dunkwa Hospital is to improve the ability of local health workers to diagnose when people need care and improve the quality of care provided too people with diabetes or hypertension.
The project has the following sub-objectives:
· Realizing a outpatients clinic from where specialized nurses coordinate the care.
· Developing decentralized facilities in rural areas, from where local health care can be provided to people suffering from diabetes and high blood pressure in the community.
· Developing a protocol to counsel diabetes mellitus and hypertension patients, which Ghanaians can work with.
· Improving on the level of knowledge and the skills of nurses in treating chronic disease.
· Increasing awareness of the local population with respect to chronic and non-contagious diseases.
· Motivating the local population to be forward in seeking out help for the diagnosis and treatment of diabetes and high blood pressure in an early stage and on a regular basis.
5. Target audience
The target audience with respect to developing medical care for diabetes and high blood pressure is twofold:
1. Patients with diabetes and/or high blood pressure situated in the Abura Dunkwa district in the Ghanaian Central Region.
2. Nurses and community health care service employees working in the Abura Dunkwa Hospital, the centres for health care and the ambulatory nurses working within the Abura Dunkwa district in de Ghanaian Central Region.
To improve on the health care, with respect to diabetes and high blood pressure by delegated care and protocol, Ghaned for Health in collaboration with Ghana Health Services has prepared a plan. The following activities are included in the plan:
· Construct and equip a outpatients clinic for the treatment of chronic diseases.
· Organizing meetings with counterparts for the development of guidelines and protocol with regards to providing health care to people with high blood pressure and diabetes.
· Train nurses and community health workers to provide health care to diabetics and high blood pressure patients and to educate patients on community level.
· Train two nurses in the Netherlands. Among other subjects, attention will be paid to implementing, coordinating and improving protocol based health care in Ghana.
· Implement delegated health care based on protocol for diabetics and high blood pressure patients
6.1 Construct and equip an outpatients clinic for the treatment of chronic diseases..
In the current situation, there is no separate area for treating and informing chronic patients within the hospital. All available space is already exploited beyond optimal. To enable staff to treat and educate patients who suffer from complications due to chronic disease, a separate area will built and equipped.
In the outpatients clinic, the following facilities will be included:
· Treatment/consultation room
· Storage for medical equipment, medication, etc.
· Sanitary facilities
· Office space
Furthermore, the location will be equipped with a PC, an ECG glucose test strips, glucose meter, consultation/educational material, etc.
Research shows, it is problematic for patients situated in rural areas to come to the hospital. The distance and the cost of travel are often too high. Even people that have been diagnosed with diabetes or hypertension do not make frequent use of the health care facilities available. In reality, only patients having serious complications come to the hospital. By realizing de-centralized facilities, near to (potential) patients, health care will be more accessible. Making it possible to provide frequent care for patients and enabling health care staff to better treat the chronic disease. In doing so, preventing possible complications or timely intervening when complications occur.
As such, the majority of the care will be provided peripherally in the existing community health care centres. The outpatients clinic for chronic disease, will handle management and supply.
6.2 Organizing meetings with health care institutions in Ghana
Ghaned for Health aims to tune and consolidate its plans, on a Ghanaian national level, with all stakeholders involved in developing health care with respect to diabetes and hypertension. It is of importance and mutual interest to explore the possibilities to improve health care for chronic non-transferrable diseases. In doing so, a start is made to develop guidelines and tuning these to existing plans in Ghana.
Plans will be prepared and developed in close collaboration with the head of the Ghana Health Service and physicians, with a specialty in diabetes mellitus and hypertension, will be involved.
6.3 Development of a protocol for medical care concerning diabetes and hypertension
We are developing a protocol for offering health care to diabetics and people suffering from hypertension. Within the protocol, the guidelines for all involved layers off medical care are included and attention is paid to implementing the protocol. The infrastructure, making the de-centralisation of health care possible, is organised on the following levels:
. Het Abura Dunkwa Hospital : district level
. Centres for basic health care
. Community Health Planning and Services (CHPS) workers within compounds
. Volunteers working within various villages
6.4 Training nurses in providing medical care to diabetics and high blood pressure patients.
After the development of the protocol for the treatment of diabetes and hypertension, we will train the various involved parties in the district surrounding Abura Dunkwa Hospital in providing the care. The training is provided with the collaboration of Dutch physicians. The training is based on the tasks that fall under the responsibility of the Abura Dunkwa Hospital and tasks that are performed de-centrally. The following starting points have been identified, when caring for diabetics and hypertension patients is concerned:
Care from the Abura Dunkwa Hospital
· Yearly lab research, eye tests and physical examination by specifically trained nurses.
· Two to three specially trained nurses with regards to diabetes and high blood pressure.
· Regular supplementary training and supervision of ambulatory nurses.
· Monitor that yearly check-ups/physicals are performed.
· Monitor all patients
· Treatment of complications, such as diabetics foot.
· Obtain feedback from ambulatory nurses, regarding possible problems with patients.
First line care from health care centres / Community Health Planning and Services compounds
· Referral cards, issued to patients by the hospital, are used.
· Informing and instructing patients on diabetes.
· Three monthly check-ups and issue of medication.
· Motivating patients to go to the hospital for their yearly physical (laboratory research and eye test)
· Consulting or referring patients to the specially trained nurses for the treatment of diabetes and high blood pressure at the hospital.
The initial training will take two days. Around 20 nurses (participants) will receive training to start working with the protocol. The first year, a 3 monthly training will follow. In the following years a 2 yearly supplementary training will follow. Community health workers will also receive training for informing patients in the communities on diabetes and hypertension. Information materials too support this are being developed.
6.5 Educating/training of Ghanaian nurses in the Netherlands
Apart from training nurses in Ghana, we are considering to have two Ghanaian nurses take a two-month training course in the Netherlands. On return, based on their broad knowledge, they will take an important part in treating diabetics and hypertension patients.
They will perform their work from the outpatients clinic for chronic disease and will visit the peripheral locations from there. Furthermore, they will be representing the project locally and as such will monitor the peripheral locations.
6.6 Implementing a process with regard to de-centralised working based on the developed medical protocol.
When the nurses have been trained, the de-centralized care for diabetics and hypertension patients will commence. An extensive evaluation will follow in six months.
The community health workers will organise a briefing on diabetes and hypertension twice a year. The number of patients per community health centre, familiar with diabetes or hypertension, will be inventoried and it will be ascertained if a nurse has checked in these patients at least once.
In the years after, trained nurses will do a biannual control of the patient charts to evaluate if the patients are showing up for their check-ups and are receiving their medication. We want to setup this research in cooperation with the “Amsterdam Medisch Centrum”. Physicians in training can also be utilized for this. The possible problems identified will be corrected. Educational programs that have been given will also be registered. Follow-up and beginners training for nurses will be provided biannually.
The goal is to fully implement this manner of care, within the Abura Dunkwa district, in 5 years. After which, the local healthcare personnel will function independently.
6.7 Planning of activities in 2012/2013
September 2013 to May 2013
· Build the outpatients clinic
· Consultation with involved authorities and physicians in Ghana with regard to the treatment of diabetes and hypertension.
· Document a protocol for de-centralized care for diabetes and high blood pressure.
· Set up a training programme for nurses and healthcare workers.
· Document a plan, with the stakeholders in the Central Region, for implementing the programme.
· Take inventory of participating patients on the programme.
· Develop a website
· Develop training materials concerning public health care and keeping patient records.
· Train nurses and ambulatory health workers.
· Possibly, train two Ghanaian nurses in the Nether
· Start the treatment of patients and provide lifestyle training to patients.
· Check up on patients who are taking part in the programme.
· Take care of any problems that may occur during the first year.
· Evaluation of the programme
· Biannual follow-up and beginners training for nurses and ambulatory health workers.
· Training of nurses and ambulatory health workers.
· Continue de-centralised health care in the region and yearly check-ups of patients in the hospital.
· Evaluation of the programme
· Set up a plan for continuing the programme
6.8 Expected results
By implementing a procedure for healthcare for diabetics and people with high blood pressure, Ghaned for Health expects to achieve the following results:
· Within 3 years, 50% of possible patients is diagnosed and are coming in to the local health care centre for check-ups on a regular basis.
· Within 3 years, two nurses specialized in the field of diabetes and high blood pressure are working in the hospital in the Abura Dunkwa district.
· The infrastructure for health care is adapted to the treatment of non-transferable disease.
· The knowledge of the local population regarding diabetes and high blood pressure has increased significantly.
· Dutch general practitioners and nurses have the opportunity to increase their knowledge concerning care for diabetics and people with high blood pressure in Ghana.
· In 5 years, the procedure for diabetes and high blood pressure is fully implemented in the local health care system in the Abura Dunkwa district.
In the coming months potential partners for cooperation are consulted.
· Physicians and practice nurse take part on personal title. Currently, four general practitioners and one practice nurse are involved in the project.
· The department for general practitioner medical science of the AMC is being consulted to investigate the possibilities for involving medical students by giving them the opportunity to do part of their internship in Ghana.
· Dutch society for practice nurses. They are involved in setting up the training.
· Mr . Ekow Lamptey: AFAPAC foundation.
· Mr. Agyemang: epidemiologist AMC.
· Mr. Justus Larey: pharmacist.
Ghanaian partners :
· Het Abura Dunkwa Hospital, district hospital.
· Ghana Health Services non communicable diseases
8. PR & awareness
To create awareness for the project, the following activities are undertaken:
· Publications in magazines, (local) newspapers, television and radio. We are in contact with the local broadcaster “Amsterdam Zuid Oost”, the magazine of the “Amsterdams Medisch Centrum” and the magazine “Medisch Contact”.
· Fundraisers; crowding trough personal networks.
· Recruiting donors; Pharmaceutical industry
· Sponsoring; Several companies in Ghana, associated with the Ghana Netherlands Chamber of Commerce and Culture (Ghanecc), will be approached.
· Information on the websites of organisations like the “WHIG”, the workgroup general practitioners international health care.
9. Budget and coverage plan
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