Expert Review of Cardiovascular Therapy
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Organization of primary health care for diabetes and hypertension in high, low and middle income countries Dorothy Lall & Dorairaj Prabhakaran To cite this article: Dorothy Lall & Dorairaj Prabhakaran (2014) Organization of primary health care for diabetes and hypertension in high, low and middle income countries, Expert Review of Cardiovascular Therapy, 12:8, 987-995 To link to this article: http://dx.doi.org/10.1586/14779072.2014.928591
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Expert Rev. Cardiovasc. Ther. 12(8), 987–995 (2014)
Dorothy Lall* and Dorairaj Prabhakaran Centre for chronic Disease Control, Delhi, India *Author for correspondence: [email protected]
Chronic non-communicable diseases, predominantly diabetes and cardiovascular disease are a major public health problem globally. The chronicity of these diseases necessitates a restructuring of healthcare to address the multidisciplinary, sustained care including psychosocial support and development of self-management skills. Primary healthcare with elements of the chronic-care model provides the best opportunity for engagement with the health system. In this review, the authors discuss aspects of primary healthcare for management of diabetes and hypertension and innovations such as mobile-phone messaging, web-based registries, computer-based decision support systems and multifaceted health professionals in the care team among others that are being tested to improve the quality of care for these diseases in high, middle and low-income countries. The goal of quality care for diabetes and hypertension demands innovation within the realities of health systems both in high as well as low and middle-income countries. KEYWORDS: chronic disease care • diabetes • high income countries • hypertension • low and middle income countries • primary health care
Chronic noncommunicable diseases have emerged as a major public health threat globally. Most notable among these are diabetes and cardiovascular diseases. Worldwide, it is estimated that there were 382 million people with diabetes in 2013 and this is projected to increase to 592 million by 2035 [1]. The disability-adjusted life years for diabetes were estimated to be 680 in 2010, an increase of 30% from 1990 [2]. The global burden of disease, injuries and risk factors study also confirmed that cardiovascular diseases are the leading cause of mortality and hypertension is the leading risk factor globally [3]. Most people with these chronic diseases live in economically deprived countries. India had about 65 million persons with diabetes in 2013 with a projected increase to 110 million by 2035 [4]. The increasing burden of these diseases is challenging health systems worldwide. Diabetes and its complications such as cardiovascular disease have huge economic implications, not just for families but also for nations. The economic implications include informahealthcare.com
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the direct costs incurred not just by individuals and their families but also by governments in managing the disease and the indirect costs that result from a loss of wages and reduced productivity at work due to disability. Diabetes, particularly, imposes huge direct and indirect costs in both high-income countries such as the USA [5] as well as middle- and lowincome countries like India and Africa [6,7]. In these countries, it is the poorest families that are pushed to catastrophic spending due to the burden imposed by noncommunicable diseases [8]. A multicountry analysis of the Action in Diabetes and Vascular Disease study demonstrated that hospitalizations and complications of diabetes substantially increase the costs associated with the disease [9]. It is also fairly well established that good control of diabetes and risk factors of cardiovascular disease can delay the onset of complications and their associated morbidity [10,11]. It is therefore imperative that our health systems are geared towards managing every person with diabetes and other risk factors effectively in order to
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detect the disease early, delay complications and avoid hospital admissions. Primary health care provides tremendous opportunities for the care of chronic diseases and may also result in being cost-saving. It is often the first contact point for entry into the health system and continues as the focal point for most health needs of the patient. Primary health care has been described as health care that provides integrated and accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community [12]. Despite this universally applicable definition, the landscape of primary health care differs vastly in high-income countries compared with low- and middle-income countries. This has an impact on the delivery of health services in these countries and the consequent care of persons with diabetes or hypertension and other risk factors of cardiovascular disease. Why do diseases like diabetes & hypertension require primary care?
Persons with diabetes and hypertension require regular contact with the health system due to the chronic nature of these diseases. Patients with diabetes and hypertension need appropriate drug management to control blood glucose and blood pressure, regular screening for complications, control and management of other comorbidities, psychosocial support to deal with their disease condition and sustain healthy lifestyle choices such as quitting smoking, adopting healthy diets and increasing physical activity. Health systems that traditionally provide acute care need to be reoriented and reorganized. The usual practice of a single visit to the physician is unable to meet the more complex needs of multidisciplinary, continuous and sustained care required by persons with diabetes and hypertension. The role of a physician dealing with chronic diseases needs to extend beyond just acute care to prevention, counseling and engagement with patients for more long-term care. This spectrum of management for every person with diabetes or hypertension at a secondary or tertiary health care institution would be an enormous economic burden apart from the infrastructural incapacity of these health systems to respond. Therefore, continued care in the community through primary health care seems to be a way forward [13,14]. There are several innovations and measures at the primary health care level to improve care for chronic disease. These include opportunistic screening, use of technology, task sharing and task shifting. Early detection and evidence-based management provides a chance to start management early in the disease process. A primary care setting close to the patient’s community enhances and enables acceptance for this long-term sustained engagement with the health system. In this review, we discuss the chronic care model (CCM) as a standard of care for organization of health care services, the present delivery of health care for chronic diseases in high-, low- and middle-income countries and identify the gaps and barriers with reference to this standard of care. We also present 988
the literature available for innovations that are being tested in these scenarios and discuss the future of primary health care delivery for chronic diseases. Methodology of the review: We searched Medline, Cochrane database of reviews and Embase for relevant articles. The following broad search terms were used: primary health care, diabetes, hypertension and cardiovascular disease. The search was restricted to papers in English language and the last 5 years from January 2009 to March 2014. This yielded a total of 3523 articles from which 368 relevant articles were selected. For the purpose of this review, we have excluded studies that discussed primary prevention of diabetes or hypertension and those that focused on hypertension in persons with diabetes mellitus. These were then categorized as belonging to high-, middle- or low-income countries based on the World Bank classification for 2013 [15]. What is the standard for organization of health care for diabetes & hypertension?
The CCM is a comprehensive model describing the organization of health services for chronic diseases that emerged in the 1990s. The concept has been refined over the years and is built on evidence that a multicomponent, structured care results in improved outcomes for chronic diseases [16]. In the standard of medical care for diabetes 2014, the American Diabetes Association also recommended CCM for organisation of care through primary health care networks [17]. CCM restructures care to create partnerships between health systems and communities. Chronic care takes place within three major areas: the entire community; the health care system; and the provider organization that may be an integrated delivery system or a small clinic or primary care practices. Within this universe, the CCM identifies the following six essential elements (FIGURE 1): • Health system – organization of health care (i.e., providing leadership for securing resources and removing barriers to care); • Self-management support (i.e., facilitating skill-based learning and patient empowerment); • Decision support (i.e., providing guidance for implementing evidence-based care); • Delivery system design (i.e., coordinating care processes); • Clinical information systems (i.e., tracking progress through reporting outcomes to patients and providers); • Community resources and policies (i.e., sustaining care by using community-based resources and public health policy). As its ultimate goal, the CCM envisions an informed, activated patient interacting with a prepared, proactive practice team, resulting in high-quality, satisfying encounters and improved clinical outcomes [18]. Given the increasing burden of chronic diseases, the fact that most chronic care is delivered in the primary care setting and because primary care physicians will continue to spend a considerable amount of their time treating chronic illness, primary care practices worldwide need to be reorganized to provide quality care. A recent review
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included 16 studies of which nine were randomized controlled trials that applied different elements of CCM in primary care in the USA. Six of these studies implemented all the elements in their services. The changes in health care team roles were associated with improved HbA1c levels, blood pressure, cholesterol and weight as were self-management supports such as telephone calls from nurse managers. Overall, it supports the idea that CCM-based interventions are generally effective for managing diabetes in US primary care settings [19]. Organization of primary care for diabetes & hypertension in high-income countries
Community Resources and policies Selfmanagement support
Informed, activated patient
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Health systems Organization of health care Delivery system design
Decision support
Productive interactions
Clinical information systems
Prepared, proactive practice team
Improved outcomes
The care of patients with diabetes and Figure 1. The chronic care model. hypertension in high-income countries is largely organized through a network of Despite these, continuing evaluation of health systems in primary care practices in the public sector. Although the extent of these primary health care networks and delivery is different high-income countries has shown the quality of care and outacross these high-income countries. A review assessing the con- comes of patients with diabetes and hypertension are still not tribution of primary care to health in 18 high-income Organi- optimal as envisioned in the standard for care. Drug adherence zation for Economic Development countries rated these in patients is still dismal despite the follow-up and continuity countries according to the delivery of primary health care. Den- of care, especially for hypertension. Several studies from differmark, UK, the Netherlands, Norway, Australia, Spain, Italy, ent high income countries report between 25 and 40% [26]. Finland, Sweden and Canada all scored above the mean of all Adherence to oral hypoglycemic agents across primary health countries and it is noteworthy that the USA, Germany, Swit- care units in the USA show a wide variability and is reported zerland and France were among the lowest scoring countries [20]. between 57 and 81% [27]. Several innovations within the health Most of these countries have had health reforms to improve system have tried to improve the quality of care and better health care delivery through primary health care in the last patient adherence to medication. The use of a polypill or fixed20 odd years. These general practices delivering primary health dose combinations, especially for secondary prevention, has care are understood or envisaged to provide a continuity of recently received much attention. The Use of a Multi Drug care as patients attend practices within their communities as an Pill in Reducing Cardiovascular Events Trial, a large randomessential component [21]. The continuity of care is also aided by ized controlled trial to assess the effects of fixed-dose combinaconsistency in the leadership of the practice. The primary care tions on drug adherence reported 86% adherence versus 65% physician provides counseling, lifestyle advice and follow-up in the control arm [28]. A Cochrane review that evaluated trials and maintains a relationship with the patient [22]. Most physi- of fixed-dose combinations in persons with cardiovascular discians are guided by protocols and are driven by targets that ease for mortality due to cardiovascular events found the eviresult in improved glycemic control of patients [23,24]. Staffed dence uncertain but reported a 33% improvement in by a physician trained in primary care, nurses and pharmacists, compliance to multiple drug regimens [29]. The following are the concept of a team for chronic disease care is widely preva- some other innovations to improve the quality of care for dialent. The patient records are maintained in the practice regis- betes and hypertension: Involving multifaceted professionals in the care team and ters or electronically, enabling easy retrieval and enhancing the continuity of care. The performance of these practices is also shift the primary responsibility of counseling and imparting regularly monitored using several quality improvement pro- education from the physician. There are many professionals grams that are embedded in the national health system such as involved in the care process and the nurse diabetes educator the quality and outcomes framework in the UK [25] and the has come to be widely accepted as a key person in the organiDiabetes Quality Improvement Program of the USA. The zation of care for diabetes in the primary care setting [30]. The patient too, owing to better education attainment, is perhaps implementation of the care team is variable across countries, better informed and prepared to participate in decisions regard- for example, in primary care networks in Canada, only half of ing their management and health compared with their counter- the practices use professionals other than doctors [31]. Recent studies suggest that pharmacist-led care for both diabetes and parts in developing countries. informahealthcare.com
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hypertension results in better quality of care and achievement of targets cost-effectively. Pharmacist-led care was reported from a trial in the USA to have better odds ratio (3.9) for reaching HbA1c goals compared with usual care. Similarly, for reaching blood pressure goals, they reported an odds ratio of 2.0 in the pharmacist-led arm of the study [32] . A similar cluster randomized trial from Iowa demonstrated an improvement in mean ambulatory blood pressure from 134.4 to 122.8 mmHg in the pharmacist-assisted care compared with usual care [33]. Economic analyses of Kaiser Permanente Northern California clinics using the Markov model provide evidence that it is also a costeffective strategy with the maximum gains after 4-5 years of implementation of pharmacist-led care [34]. Lay health workers or medical assistants and trained peers also form important linkages with the communities served through primary care [35–37]. The role taken on by these multifaceted professionals and lay workers is that of education, counseling and provision of psychosocial support. It encourages patients to maintain regular follow-up and achieve their disease management targets. Innovations that involve the delivery of care include improved management using computer-based decision support tools [38,39], web-based registries [40] and electronic health records, telemonitoring [41] and telephone-assisted management especially for hypertension [42]. These have been shown to improve the process of care, though not always translating to better adherence or improved glycemic and blood pressure control. More evidence is needed to utilize these in practice. Innovations involving organization of care include group counseling sessions [43,] and group visits [44] have shown modest but significant improvements to the tune of 0.46 (95% CI 0.80–0.12) difference in group visits reported in a meta-analysis that included 13 randomized control trials [45]. These hold promise for the efficient use of resources and may serve to improve patient awareness and self-management. Involving the patient in shared decision making and individualized treatment plans necessitates that the patient be informed and aware to assist in managing his disease. No longer is the onus just on the health care system. This shared decision making has also shown to have a positive impact on treatment outcomes [46]. Innovations to reach underserved populations and rural or difficult to access areas involve telemedicine [47,48] and online resources to improve self-management by patients [49]. Although none of these have shown improvements in glycemic control or adherence, they have been shown to contribute to awareness and quality of life and may require further evaluation. Integrating these innovations into practice will require implementation research and effectiveness studies. The role of monitoring and evaluation in understanding the mechanism of integration is important and Reynolds and Sutherland proposed the use of logic models that are necessary to outline the plausible causal pathways and define the inputs, roles and responsibilities, indicators and data sources across the health system. Finally, they also recommend improvements to the health information system and data use to ensure data-informed decision making [50]. 990
Organization of primary care in low- & middle-income countries
The care of patients with diabetes and hypertension in lowand middle-income countries among themselves is strikingly similar but is considerably different from high-income countries. Most low- and middle-income countries have multiple health care providers and the private sector is a prominent player. Therefore, organized care through a network in the public sector although existent does not cater to the majority and has not been well developed for chronic disease care [51]. The relative contributions of primary health care systems to health even among low- and middle-income countries are not the same. Some countries such as Latin America, Cuba, Iran and the state of Kerala in India have had primary health care at the core of expanding services, while in other countries such as Tanzania, it is embodied in national programs such as integrated management of childhood illnesses. Rwanda, Congo and Liberia implement basic packages of health services – an integrated set of essential services generally provided at primary care facilities as means to rapidly scale access [.52] The national priority for health care in most of these countries is still communicable diseases like malaria, tuberculosis and maternal and child health. This and other socioeconomic considerations compete with developing infrastructure systems for health care that meet the needs of chronic disease care [53]. There is a lack of continuity of care in the absence of a single major organized provider. Patients most often go from provider to provider in the private sector until they are satisfied with the care. The provider they choose may not even be close to the community they live in and this hinders them from regular follow-up. It is not uncommon for the provider to be a specialist at a tertiary care institution, leaving little time to take on the role of empowering, educating, counseling and providing psychosocial support as envisioned in the standard of care. Low- and middle-income countries also face several other barriers to provision of care through public sector such as inadequate manpower in terms of availability of physicians. For example, in India, the doctor patient ratio is 0.6 for every 1000 persons, which are woefully inadequate to meet the demands of a growing population. In rural and underserved areas, this may be even worse as most health care providers serve in urban locations. By contrast, the doctor-population ratio for the USA is 2.8 for every 1000 persons [54]. The team approach for care is a rarely existent concept and the physician is usually the decision maker for most of the management of patients. Adherence to guidelines and protocols is limited by poor availability of basic drugs and a lack of continued medical education [55–57]. The patients’ awareness and readiness to participate in the management of their disease is also poor. The challenge for low- and middle-income countries is to build health care that addresses the implications of chronicity, capturing the complexity of these conditions that are characterized by long duration and often slow progression [58]. The polypill or fixed-dose combinations for secondary prevention in persons with cardiovascular disease as discussed earlier in the Expert Rev. Cardiovasc. Ther. 12(8), (2014)
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context of high-income countries also holds additional promise for low- and middle-income countries in that it lowers costs, especially for patients on multiple drugs [59]. Despite these limitations and barriers of the health systems, there are innovations within low- and middle-income countries that are being tried to overcome these obstacles in order to deliver chronic disease care to patients. Innovations involving lay health or community volunteers and pharmacists as education and awareness providers are especially relevant in low- and middle-income countries due to the shortage of physicians. A Cochrane review evaluated 12 studies comparing pharmacist-provided services versus usual care. Of the 12 studies, 7 were from lower middle-income countries and 5 were from upper middle-income countries. The pharmacist-provided services targeting patients resulted in small improvements of blood pressure and also reported better quality of life [60]. Not just health care workers such as nurses or pharmacists but also lay health volunteers or traditional healers, as was explored in recent study in Cameroon, have been found successful [61]. This concept has been better utilized and explored in the care for persons with HIV/AIDS and there are many lessons that can be learned and translated to the organization of care of diabetes and hypertension. The contextual relevance of the key person providing information is important, patients identify with persons from their communities and that may be a reason why these persons seem to improve patient outcomes. Innovations involving mobile phone messaging and reminders using phones are important and have shown beneficial results. The usage and penetration of mobile phones in low- and middle-income countries are phenomenal and it is estimated that two-thirds of all mobile users live in these countries. This technology can be harnessed to deliver selfmanagement support and decision support, two essential elements of the CCM. The Cochrane review evaluating the use of mobile phones for care of long-term illnesses concluded that there is some benefit seen in achieving better self-management, mean difference of 6.10 (95% CI 0.45–11.75) and medication compliance for hypertension, mean difference of 8.90 (95% CI 0.18–17.62). [62]. However, the evidence is still limited and robust trials are needed to establish its effectiveness, especially in low- and middle-income countries [63]. Innovations involving computer-based decision support systems (DSSs) are being tried in urban clinics and this could be translated to primary care if found effective [64]. The findings of this study will enable a cost-effective tool to improve care for diabetes and hypertension. A clinical DSS based on 2007 Indian hypertension guidelines II for staging and risk stratification of hypertension has been developed for use in primary health care setting in India. This DSS suggests evidencebased recommendations of drug management and lifestyle advice to hypertensive patients to improve the management of hypertensive patients at a primary health care level. They report a good accuracy of the DSS with an area under the curve of 0.848 (95% CI 0.74–0.94) and a moderate to substantial informahealthcare.com
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agreement of 0.66 (estimate for kappa) on drug management of hypertensive patients [65]. Health care in low- and middle-income countries has traditionally dealt with acute care and, in the context of chronic diseases, visits to the doctor are treated as a series of acute care episodes. Implementation research is needed to test the effect of such innovations to overcome barriers of an unorganized primary health sector in low- and middle-income countries. In response to the demands of chronic disease care, countries are looking to develop frameworks to restructure their primary health care for chronic disease care such as in Hong Kong [66]. The reforms suggested in Hong Kong envisage public–private partnerships in creating a primary health care network. It incorporates elements of the CCM and its main strategies include developing comprehensive care by multidisciplinary teams and intersectoral coordination, improving continuity of care for individuals, emphasizing person-centered care and patient empowerment and supporting professional development and quality improvement. The health reforms in China launched in 2009, which aimed at increasing equity through investment in primary health care also deserves mention. The government spending has been increased and utilization of the public health systems also increased [67]. Universal health coverage has gained international momentum and several countries consider it fundamental to attaining health [68]. This is especially important in the context of noncommunicable diseases where the cost of treatments and medication is high. In low- and middle-income countries, the challenge of reorienting systems to chronic care of diseases appears to be a difficult if not insurmountable task. Changes within the health system to prioritize chronic disease, effectively utilize available manpower and resources, provide universal health coverage and place greater emphasis on primary health care delivery require political will. Robinson and Hort proposed a four-phased approach in four areas: building political commitment and addressing health systems constraints, developing public policies in health promotion and disease prevention, creating new service delivery models and ensuring equity in access and payments for reform of health systems in low- and middle-income countries [69]. Expert commentary
Primary health care delivery in low- and middle-income countries is vastly different from the scenario in high-income countries. The essential of care for persons with diabetes and hypertension should include evidence-based quality care and management, regular screening for complications and encouragement of self-care. Primary care provides tremendous opportunities to manage and support patients and their families in this process. The CCM is a useful framework to structure the delivery of health care of diabetes and hypertension and is relevant to both high-income and low- or middle-income countries despite the differences (TABLE 1). Within this framework, the organization of health care delivery systems and coordination of care processes to involve other professionals such as nurses 991
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Table 1. Delivery of elements of the chronic care model through primary health care of high-, middle- and low-income countries. Elements of chronic care model
High-income countries
Low- and middle-income countries
Health system – organization of health care
Most have primary care delivered through public health systems but these may not comprehensively cover all population Rural, remote areas and minority populations are a challenge
Primary care is through a mix of public and private systems with varying levels of coverage Rural, remote and low SES populations are a challenge
Self-management support (i.e., facilitating skill-based learning and patient empowerment)
Polypill, group counseling sessions are some innovations
Mobile phone messages and reminders, polypill are some innovations
Decision support (i.e., providing guidance for implementing evidence-based care)
Computer-based decision support tools
Mobile phone and computer-based tools
Delivery system design (i.e., coordinating care processes)
Nurse diabetes educators, pharmacists, medical assistants, trained peers
Lay health or community volunteers, pharmacists
Clinical information systems (i.e., tracking progress through reporting outcomes to patients and providers and implementing evidence-based care)
Health information systems, online registries, electronic patient databases
Electronic data retrieval systems and registries not well developed
Community resources and policies (i.e., sustaining care by using communitybased resources and public health policy)
Focus on policies and finances to strengthen primary care
Focus on universal health coverage, increasing spending for health and policies for strengthening primary health care
and pharmacists in a team approach for care is again relevant to primary health care in both settings. As is the use of DSSs to enhance practice of evidence-based care. The challenge of implementing these in low- and middle-income countries is a very real one as care is not organized and the multiplicity of providers makes large-scale implementations difficult. There is a paucity of evidence from low- or middle-income countries regarding the usefulness and applicability of innovations compared with evidence from high-income countries. Implementation research and demonstration projects are needed before a prescription for reorientation of health care can be given. Five-year view
Given the rising burden of chronic disease, especially diabetes and hypertension, considerable thought and effort will continue to be devoted to enhancing systems to deliver health care based on their needs. Innovative approaches are needed, especially in low- and middle-income countries, to overcome the many barriers to delivering standard of care. Task sharing and use of mobile phones hold great promise. Also, mobile health projects under the larger ambit of electronic health approaches, such as a DSS using mobile and smart phones, have great potential. There are a few demonstration and implementation projects underway in India that will provide some evidence in the years to come. A large population-based study in Himachal Pradesh, India, with the government utilizing primary health care centers will provide substantiation of this approach. This project uses nurses to assist doctors in making evidence-based decisions in the care of patients. There is also an urgent need to build 992
capacity of primary care physicians and improve their adherence to protocols. To address this challenge, the Public Health Foundation of India has initiated a capacity building program for Primary Care Physicians and Gynecologists in diabetes and gestational diabetes management. The Certificate Course in Evidence-Based Diabetes Management is a uniquely designed once-a-month training program for primary health care physicians. The objectives of the course are to develop core skills and competencies in primary care physicians for the practice of evidence-based diabetes management and also to establish networks between primary care physicians and existing specialized diabetes care centers in India for improving patient outcomes in diabetes care. The Certificate Course in Evidence-Based Diabetes Management is a joint certification by Public Health Foundation of India and Dr. Mohan’s Diabetes Education Academy, Chennai, supported with an unrestricted educational grant provided by MSD Pharmaceutical Pvt. Ltd., India and is recognized by the International Diabetes Foundation [70]. Primary care for chronic disease, especially in low- and middle-income countries, in the coming years will also need to move away from only patient-centered care to a family approach and from only disease management to knowledge and prevention across the life course. This will enhance self-management and psychosocial support for patients with diabetes and hypertension. These need to be tested through well-designed implementation trials and research studies. The need is urgent and the scope of initiatives immense to improve the care delivered for diabetes, hypertension and other chronic diseases in both high-income and low- or middle-income countries. Expert Rev. Cardiovasc. Ther. 12(8), (2014)
Organization of primary health care for diabetes & hypertension in various countries
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This
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includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
Key issues • Diabetes and hypertension require multidisciplinary, continued and sustained, patient-centered care in a culturally and financially accessible setting such as primary care. • The challenge before health systems in high-, low- and middle-income countries is not in the lack of appropriate drugs but in the delivery of health care for chronic diseases. The chronic care model is a useful framework that describes the essential elements of health care delivery for chronic care. • The landscape of primary health care in high versus low- and middle-income countries is vastly different with differing challenges.
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• Team care approach that shifts the primary caregiving task from a physician-centered model to involving other health professionals is essential to improved care. • Innovations such as telephone messaging, telemonitoring, use of web-based registries, clinical decision support systems among others make health systems more patient centered, efficient and cost–effective, providing contextually relevant solutions for improved care in high-, low- and middle-income countries. • Implementation research is required to bridge the gap between evidence and the realities of health systems in low- and middle-income countries.
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ISSN: 1477-9072 (Print) 1744-8344 (Online) Journal homepage: http://www.tandfonline.com/loi/ierk20
Organization of primary health care for diabetes and hypertension in high, low and middle income countries Dorothy Lall & Dorairaj Prabhakaran To cite this article: Dorothy Lall & Dorairaj Prabhakaran (2014) Organization of primary health care for diabetes and hypertension in high, low and middle income countries, Expert Review of Cardiovascular Therapy, 12:8, 987-995 To link to this article: http://dx.doi.org/10.1586/14779072.2014.928591
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Expert Rev. Cardiovasc. Ther. 12(8), 987–995 (2014)
Dorothy Lall* and Dorairaj Prabhakaran Centre for chronic Disease Control, Delhi, India *Author for correspondence: [email protected]
Chronic non-communicable diseases, predominantly diabetes and cardiovascular disease are a major public health problem globally. The chronicity of these diseases necessitates a restructuring of healthcare to address the multidisciplinary, sustained care including psychosocial support and development of self-management skills. Primary healthcare with elements of the chronic-care model provides the best opportunity for engagement with the health system. In this review, the authors discuss aspects of primary healthcare for management of diabetes and hypertension and innovations such as mobile-phone messaging, web-based registries, computer-based decision support systems and multifaceted health professionals in the care team among others that are being tested to improve the quality of care for these diseases in high, middle and low-income countries. The goal of quality care for diabetes and hypertension demands innovation within the realities of health systems both in high as well as low and middle-income countries. KEYWORDS: chronic disease care • diabetes • high income countries • hypertension • low and middle income countries • primary health care
Chronic noncommunicable diseases have emerged as a major public health threat globally. Most notable among these are diabetes and cardiovascular diseases. Worldwide, it is estimated that there were 382 million people with diabetes in 2013 and this is projected to increase to 592 million by 2035 [1]. The disability-adjusted life years for diabetes were estimated to be 680 in 2010, an increase of 30% from 1990 [2]. The global burden of disease, injuries and risk factors study also confirmed that cardiovascular diseases are the leading cause of mortality and hypertension is the leading risk factor globally [3]. Most people with these chronic diseases live in economically deprived countries. India had about 65 million persons with diabetes in 2013 with a projected increase to 110 million by 2035 [4]. The increasing burden of these diseases is challenging health systems worldwide. Diabetes and its complications such as cardiovascular disease have huge economic implications, not just for families but also for nations. The economic implications include informahealthcare.com
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the direct costs incurred not just by individuals and their families but also by governments in managing the disease and the indirect costs that result from a loss of wages and reduced productivity at work due to disability. Diabetes, particularly, imposes huge direct and indirect costs in both high-income countries such as the USA [5] as well as middle- and lowincome countries like India and Africa [6,7]. In these countries, it is the poorest families that are pushed to catastrophic spending due to the burden imposed by noncommunicable diseases [8]. A multicountry analysis of the Action in Diabetes and Vascular Disease study demonstrated that hospitalizations and complications of diabetes substantially increase the costs associated with the disease [9]. It is also fairly well established that good control of diabetes and risk factors of cardiovascular disease can delay the onset of complications and their associated morbidity [10,11]. It is therefore imperative that our health systems are geared towards managing every person with diabetes and other risk factors effectively in order to
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detect the disease early, delay complications and avoid hospital admissions. Primary health care provides tremendous opportunities for the care of chronic diseases and may also result in being cost-saving. It is often the first contact point for entry into the health system and continues as the focal point for most health needs of the patient. Primary health care has been described as health care that provides integrated and accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community [12]. Despite this universally applicable definition, the landscape of primary health care differs vastly in high-income countries compared with low- and middle-income countries. This has an impact on the delivery of health services in these countries and the consequent care of persons with diabetes or hypertension and other risk factors of cardiovascular disease. Why do diseases like diabetes & hypertension require primary care?
Persons with diabetes and hypertension require regular contact with the health system due to the chronic nature of these diseases. Patients with diabetes and hypertension need appropriate drug management to control blood glucose and blood pressure, regular screening for complications, control and management of other comorbidities, psychosocial support to deal with their disease condition and sustain healthy lifestyle choices such as quitting smoking, adopting healthy diets and increasing physical activity. Health systems that traditionally provide acute care need to be reoriented and reorganized. The usual practice of a single visit to the physician is unable to meet the more complex needs of multidisciplinary, continuous and sustained care required by persons with diabetes and hypertension. The role of a physician dealing with chronic diseases needs to extend beyond just acute care to prevention, counseling and engagement with patients for more long-term care. This spectrum of management for every person with diabetes or hypertension at a secondary or tertiary health care institution would be an enormous economic burden apart from the infrastructural incapacity of these health systems to respond. Therefore, continued care in the community through primary health care seems to be a way forward [13,14]. There are several innovations and measures at the primary health care level to improve care for chronic disease. These include opportunistic screening, use of technology, task sharing and task shifting. Early detection and evidence-based management provides a chance to start management early in the disease process. A primary care setting close to the patient’s community enhances and enables acceptance for this long-term sustained engagement with the health system. In this review, we discuss the chronic care model (CCM) as a standard of care for organization of health care services, the present delivery of health care for chronic diseases in high-, low- and middle-income countries and identify the gaps and barriers with reference to this standard of care. We also present 988
the literature available for innovations that are being tested in these scenarios and discuss the future of primary health care delivery for chronic diseases. Methodology of the review: We searched Medline, Cochrane database of reviews and Embase for relevant articles. The following broad search terms were used: primary health care, diabetes, hypertension and cardiovascular disease. The search was restricted to papers in English language and the last 5 years from January 2009 to March 2014. This yielded a total of 3523 articles from which 368 relevant articles were selected. For the purpose of this review, we have excluded studies that discussed primary prevention of diabetes or hypertension and those that focused on hypertension in persons with diabetes mellitus. These were then categorized as belonging to high-, middle- or low-income countries based on the World Bank classification for 2013 [15]. What is the standard for organization of health care for diabetes & hypertension?
The CCM is a comprehensive model describing the organization of health services for chronic diseases that emerged in the 1990s. The concept has been refined over the years and is built on evidence that a multicomponent, structured care results in improved outcomes for chronic diseases [16]. In the standard of medical care for diabetes 2014, the American Diabetes Association also recommended CCM for organisation of care through primary health care networks [17]. CCM restructures care to create partnerships between health systems and communities. Chronic care takes place within three major areas: the entire community; the health care system; and the provider organization that may be an integrated delivery system or a small clinic or primary care practices. Within this universe, the CCM identifies the following six essential elements (FIGURE 1): • Health system – organization of health care (i.e., providing leadership for securing resources and removing barriers to care); • Self-management support (i.e., facilitating skill-based learning and patient empowerment); • Decision support (i.e., providing guidance for implementing evidence-based care); • Delivery system design (i.e., coordinating care processes); • Clinical information systems (i.e., tracking progress through reporting outcomes to patients and providers); • Community resources and policies (i.e., sustaining care by using community-based resources and public health policy). As its ultimate goal, the CCM envisions an informed, activated patient interacting with a prepared, proactive practice team, resulting in high-quality, satisfying encounters and improved clinical outcomes [18]. Given the increasing burden of chronic diseases, the fact that most chronic care is delivered in the primary care setting and because primary care physicians will continue to spend a considerable amount of their time treating chronic illness, primary care practices worldwide need to be reorganized to provide quality care. A recent review
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included 16 studies of which nine were randomized controlled trials that applied different elements of CCM in primary care in the USA. Six of these studies implemented all the elements in their services. The changes in health care team roles were associated with improved HbA1c levels, blood pressure, cholesterol and weight as were self-management supports such as telephone calls from nurse managers. Overall, it supports the idea that CCM-based interventions are generally effective for managing diabetes in US primary care settings [19]. Organization of primary care for diabetes & hypertension in high-income countries
Community Resources and policies Selfmanagement support
Informed, activated patient
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Health systems Organization of health care Delivery system design
Decision support
Productive interactions
Clinical information systems
Prepared, proactive practice team
Improved outcomes
The care of patients with diabetes and Figure 1. The chronic care model. hypertension in high-income countries is largely organized through a network of Despite these, continuing evaluation of health systems in primary care practices in the public sector. Although the extent of these primary health care networks and delivery is different high-income countries has shown the quality of care and outacross these high-income countries. A review assessing the con- comes of patients with diabetes and hypertension are still not tribution of primary care to health in 18 high-income Organi- optimal as envisioned in the standard for care. Drug adherence zation for Economic Development countries rated these in patients is still dismal despite the follow-up and continuity countries according to the delivery of primary health care. Den- of care, especially for hypertension. Several studies from differmark, UK, the Netherlands, Norway, Australia, Spain, Italy, ent high income countries report between 25 and 40% [26]. Finland, Sweden and Canada all scored above the mean of all Adherence to oral hypoglycemic agents across primary health countries and it is noteworthy that the USA, Germany, Swit- care units in the USA show a wide variability and is reported zerland and France were among the lowest scoring countries [20]. between 57 and 81% [27]. Several innovations within the health Most of these countries have had health reforms to improve system have tried to improve the quality of care and better health care delivery through primary health care in the last patient adherence to medication. The use of a polypill or fixed20 odd years. These general practices delivering primary health dose combinations, especially for secondary prevention, has care are understood or envisaged to provide a continuity of recently received much attention. The Use of a Multi Drug care as patients attend practices within their communities as an Pill in Reducing Cardiovascular Events Trial, a large randomessential component [21]. The continuity of care is also aided by ized controlled trial to assess the effects of fixed-dose combinaconsistency in the leadership of the practice. The primary care tions on drug adherence reported 86% adherence versus 65% physician provides counseling, lifestyle advice and follow-up in the control arm [28]. A Cochrane review that evaluated trials and maintains a relationship with the patient [22]. Most physi- of fixed-dose combinations in persons with cardiovascular discians are guided by protocols and are driven by targets that ease for mortality due to cardiovascular events found the eviresult in improved glycemic control of patients [23,24]. Staffed dence uncertain but reported a 33% improvement in by a physician trained in primary care, nurses and pharmacists, compliance to multiple drug regimens [29]. The following are the concept of a team for chronic disease care is widely preva- some other innovations to improve the quality of care for dialent. The patient records are maintained in the practice regis- betes and hypertension: Involving multifaceted professionals in the care team and ters or electronically, enabling easy retrieval and enhancing the continuity of care. The performance of these practices is also shift the primary responsibility of counseling and imparting regularly monitored using several quality improvement pro- education from the physician. There are many professionals grams that are embedded in the national health system such as involved in the care process and the nurse diabetes educator the quality and outcomes framework in the UK [25] and the has come to be widely accepted as a key person in the organiDiabetes Quality Improvement Program of the USA. The zation of care for diabetes in the primary care setting [30]. The patient too, owing to better education attainment, is perhaps implementation of the care team is variable across countries, better informed and prepared to participate in decisions regard- for example, in primary care networks in Canada, only half of ing their management and health compared with their counter- the practices use professionals other than doctors [31]. Recent studies suggest that pharmacist-led care for both diabetes and parts in developing countries. informahealthcare.com
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hypertension results in better quality of care and achievement of targets cost-effectively. Pharmacist-led care was reported from a trial in the USA to have better odds ratio (3.9) for reaching HbA1c goals compared with usual care. Similarly, for reaching blood pressure goals, they reported an odds ratio of 2.0 in the pharmacist-led arm of the study [32] . A similar cluster randomized trial from Iowa demonstrated an improvement in mean ambulatory blood pressure from 134.4 to 122.8 mmHg in the pharmacist-assisted care compared with usual care [33]. Economic analyses of Kaiser Permanente Northern California clinics using the Markov model provide evidence that it is also a costeffective strategy with the maximum gains after 4-5 years of implementation of pharmacist-led care [34]. Lay health workers or medical assistants and trained peers also form important linkages with the communities served through primary care [35–37]. The role taken on by these multifaceted professionals and lay workers is that of education, counseling and provision of psychosocial support. It encourages patients to maintain regular follow-up and achieve their disease management targets. Innovations that involve the delivery of care include improved management using computer-based decision support tools [38,39], web-based registries [40] and electronic health records, telemonitoring [41] and telephone-assisted management especially for hypertension [42]. These have been shown to improve the process of care, though not always translating to better adherence or improved glycemic and blood pressure control. More evidence is needed to utilize these in practice. Innovations involving organization of care include group counseling sessions [43,] and group visits [44] have shown modest but significant improvements to the tune of 0.46 (95% CI 0.80–0.12) difference in group visits reported in a meta-analysis that included 13 randomized control trials [45]. These hold promise for the efficient use of resources and may serve to improve patient awareness and self-management. Involving the patient in shared decision making and individualized treatment plans necessitates that the patient be informed and aware to assist in managing his disease. No longer is the onus just on the health care system. This shared decision making has also shown to have a positive impact on treatment outcomes [46]. Innovations to reach underserved populations and rural or difficult to access areas involve telemedicine [47,48] and online resources to improve self-management by patients [49]. Although none of these have shown improvements in glycemic control or adherence, they have been shown to contribute to awareness and quality of life and may require further evaluation. Integrating these innovations into practice will require implementation research and effectiveness studies. The role of monitoring and evaluation in understanding the mechanism of integration is important and Reynolds and Sutherland proposed the use of logic models that are necessary to outline the plausible causal pathways and define the inputs, roles and responsibilities, indicators and data sources across the health system. Finally, they also recommend improvements to the health information system and data use to ensure data-informed decision making [50]. 990
Organization of primary care in low- & middle-income countries
The care of patients with diabetes and hypertension in lowand middle-income countries among themselves is strikingly similar but is considerably different from high-income countries. Most low- and middle-income countries have multiple health care providers and the private sector is a prominent player. Therefore, organized care through a network in the public sector although existent does not cater to the majority and has not been well developed for chronic disease care [51]. The relative contributions of primary health care systems to health even among low- and middle-income countries are not the same. Some countries such as Latin America, Cuba, Iran and the state of Kerala in India have had primary health care at the core of expanding services, while in other countries such as Tanzania, it is embodied in national programs such as integrated management of childhood illnesses. Rwanda, Congo and Liberia implement basic packages of health services – an integrated set of essential services generally provided at primary care facilities as means to rapidly scale access [.52] The national priority for health care in most of these countries is still communicable diseases like malaria, tuberculosis and maternal and child health. This and other socioeconomic considerations compete with developing infrastructure systems for health care that meet the needs of chronic disease care [53]. There is a lack of continuity of care in the absence of a single major organized provider. Patients most often go from provider to provider in the private sector until they are satisfied with the care. The provider they choose may not even be close to the community they live in and this hinders them from regular follow-up. It is not uncommon for the provider to be a specialist at a tertiary care institution, leaving little time to take on the role of empowering, educating, counseling and providing psychosocial support as envisioned in the standard of care. Low- and middle-income countries also face several other barriers to provision of care through public sector such as inadequate manpower in terms of availability of physicians. For example, in India, the doctor patient ratio is 0.6 for every 1000 persons, which are woefully inadequate to meet the demands of a growing population. In rural and underserved areas, this may be even worse as most health care providers serve in urban locations. By contrast, the doctor-population ratio for the USA is 2.8 for every 1000 persons [54]. The team approach for care is a rarely existent concept and the physician is usually the decision maker for most of the management of patients. Adherence to guidelines and protocols is limited by poor availability of basic drugs and a lack of continued medical education [55–57]. The patients’ awareness and readiness to participate in the management of their disease is also poor. The challenge for low- and middle-income countries is to build health care that addresses the implications of chronicity, capturing the complexity of these conditions that are characterized by long duration and often slow progression [58]. The polypill or fixed-dose combinations for secondary prevention in persons with cardiovascular disease as discussed earlier in the Expert Rev. Cardiovasc. Ther. 12(8), (2014)
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context of high-income countries also holds additional promise for low- and middle-income countries in that it lowers costs, especially for patients on multiple drugs [59]. Despite these limitations and barriers of the health systems, there are innovations within low- and middle-income countries that are being tried to overcome these obstacles in order to deliver chronic disease care to patients. Innovations involving lay health or community volunteers and pharmacists as education and awareness providers are especially relevant in low- and middle-income countries due to the shortage of physicians. A Cochrane review evaluated 12 studies comparing pharmacist-provided services versus usual care. Of the 12 studies, 7 were from lower middle-income countries and 5 were from upper middle-income countries. The pharmacist-provided services targeting patients resulted in small improvements of blood pressure and also reported better quality of life [60]. Not just health care workers such as nurses or pharmacists but also lay health volunteers or traditional healers, as was explored in recent study in Cameroon, have been found successful [61]. This concept has been better utilized and explored in the care for persons with HIV/AIDS and there are many lessons that can be learned and translated to the organization of care of diabetes and hypertension. The contextual relevance of the key person providing information is important, patients identify with persons from their communities and that may be a reason why these persons seem to improve patient outcomes. Innovations involving mobile phone messaging and reminders using phones are important and have shown beneficial results. The usage and penetration of mobile phones in low- and middle-income countries are phenomenal and it is estimated that two-thirds of all mobile users live in these countries. This technology can be harnessed to deliver selfmanagement support and decision support, two essential elements of the CCM. The Cochrane review evaluating the use of mobile phones for care of long-term illnesses concluded that there is some benefit seen in achieving better self-management, mean difference of 6.10 (95% CI 0.45–11.75) and medication compliance for hypertension, mean difference of 8.90 (95% CI 0.18–17.62). [62]. However, the evidence is still limited and robust trials are needed to establish its effectiveness, especially in low- and middle-income countries [63]. Innovations involving computer-based decision support systems (DSSs) are being tried in urban clinics and this could be translated to primary care if found effective [64]. The findings of this study will enable a cost-effective tool to improve care for diabetes and hypertension. A clinical DSS based on 2007 Indian hypertension guidelines II for staging and risk stratification of hypertension has been developed for use in primary health care setting in India. This DSS suggests evidencebased recommendations of drug management and lifestyle advice to hypertensive patients to improve the management of hypertensive patients at a primary health care level. They report a good accuracy of the DSS with an area under the curve of 0.848 (95% CI 0.74–0.94) and a moderate to substantial informahealthcare.com
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agreement of 0.66 (estimate for kappa) on drug management of hypertensive patients [65]. Health care in low- and middle-income countries has traditionally dealt with acute care and, in the context of chronic diseases, visits to the doctor are treated as a series of acute care episodes. Implementation research is needed to test the effect of such innovations to overcome barriers of an unorganized primary health sector in low- and middle-income countries. In response to the demands of chronic disease care, countries are looking to develop frameworks to restructure their primary health care for chronic disease care such as in Hong Kong [66]. The reforms suggested in Hong Kong envisage public–private partnerships in creating a primary health care network. It incorporates elements of the CCM and its main strategies include developing comprehensive care by multidisciplinary teams and intersectoral coordination, improving continuity of care for individuals, emphasizing person-centered care and patient empowerment and supporting professional development and quality improvement. The health reforms in China launched in 2009, which aimed at increasing equity through investment in primary health care also deserves mention. The government spending has been increased and utilization of the public health systems also increased [67]. Universal health coverage has gained international momentum and several countries consider it fundamental to attaining health [68]. This is especially important in the context of noncommunicable diseases where the cost of treatments and medication is high. In low- and middle-income countries, the challenge of reorienting systems to chronic care of diseases appears to be a difficult if not insurmountable task. Changes within the health system to prioritize chronic disease, effectively utilize available manpower and resources, provide universal health coverage and place greater emphasis on primary health care delivery require political will. Robinson and Hort proposed a four-phased approach in four areas: building political commitment and addressing health systems constraints, developing public policies in health promotion and disease prevention, creating new service delivery models and ensuring equity in access and payments for reform of health systems in low- and middle-income countries [69]. Expert commentary
Primary health care delivery in low- and middle-income countries is vastly different from the scenario in high-income countries. The essential of care for persons with diabetes and hypertension should include evidence-based quality care and management, regular screening for complications and encouragement of self-care. Primary care provides tremendous opportunities to manage and support patients and their families in this process. The CCM is a useful framework to structure the delivery of health care of diabetes and hypertension and is relevant to both high-income and low- or middle-income countries despite the differences (TABLE 1). Within this framework, the organization of health care delivery systems and coordination of care processes to involve other professionals such as nurses 991
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Table 1. Delivery of elements of the chronic care model through primary health care of high-, middle- and low-income countries. Elements of chronic care model
High-income countries
Low- and middle-income countries
Health system – organization of health care
Most have primary care delivered through public health systems but these may not comprehensively cover all population Rural, remote areas and minority populations are a challenge
Primary care is through a mix of public and private systems with varying levels of coverage Rural, remote and low SES populations are a challenge
Self-management support (i.e., facilitating skill-based learning and patient empowerment)
Polypill, group counseling sessions are some innovations
Mobile phone messages and reminders, polypill are some innovations
Decision support (i.e., providing guidance for implementing evidence-based care)
Computer-based decision support tools
Mobile phone and computer-based tools
Delivery system design (i.e., coordinating care processes)
Nurse diabetes educators, pharmacists, medical assistants, trained peers
Lay health or community volunteers, pharmacists
Clinical information systems (i.e., tracking progress through reporting outcomes to patients and providers and implementing evidence-based care)
Health information systems, online registries, electronic patient databases
Electronic data retrieval systems and registries not well developed
Community resources and policies (i.e., sustaining care by using communitybased resources and public health policy)
Focus on policies and finances to strengthen primary care
Focus on universal health coverage, increasing spending for health and policies for strengthening primary health care
and pharmacists in a team approach for care is again relevant to primary health care in both settings. As is the use of DSSs to enhance practice of evidence-based care. The challenge of implementing these in low- and middle-income countries is a very real one as care is not organized and the multiplicity of providers makes large-scale implementations difficult. There is a paucity of evidence from low- or middle-income countries regarding the usefulness and applicability of innovations compared with evidence from high-income countries. Implementation research and demonstration projects are needed before a prescription for reorientation of health care can be given. Five-year view
Given the rising burden of chronic disease, especially diabetes and hypertension, considerable thought and effort will continue to be devoted to enhancing systems to deliver health care based on their needs. Innovative approaches are needed, especially in low- and middle-income countries, to overcome the many barriers to delivering standard of care. Task sharing and use of mobile phones hold great promise. Also, mobile health projects under the larger ambit of electronic health approaches, such as a DSS using mobile and smart phones, have great potential. There are a few demonstration and implementation projects underway in India that will provide some evidence in the years to come. A large population-based study in Himachal Pradesh, India, with the government utilizing primary health care centers will provide substantiation of this approach. This project uses nurses to assist doctors in making evidence-based decisions in the care of patients. There is also an urgent need to build 992
capacity of primary care physicians and improve their adherence to protocols. To address this challenge, the Public Health Foundation of India has initiated a capacity building program for Primary Care Physicians and Gynecologists in diabetes and gestational diabetes management. The Certificate Course in Evidence-Based Diabetes Management is a uniquely designed once-a-month training program for primary health care physicians. The objectives of the course are to develop core skills and competencies in primary care physicians for the practice of evidence-based diabetes management and also to establish networks between primary care physicians and existing specialized diabetes care centers in India for improving patient outcomes in diabetes care. The Certificate Course in Evidence-Based Diabetes Management is a joint certification by Public Health Foundation of India and Dr. Mohan’s Diabetes Education Academy, Chennai, supported with an unrestricted educational grant provided by MSD Pharmaceutical Pvt. Ltd., India and is recognized by the International Diabetes Foundation [70]. Primary care for chronic disease, especially in low- and middle-income countries, in the coming years will also need to move away from only patient-centered care to a family approach and from only disease management to knowledge and prevention across the life course. This will enhance self-management and psychosocial support for patients with diabetes and hypertension. These need to be tested through well-designed implementation trials and research studies. The need is urgent and the scope of initiatives immense to improve the care delivered for diabetes, hypertension and other chronic diseases in both high-income and low- or middle-income countries. Expert Rev. Cardiovasc. Ther. 12(8), (2014)
Organization of primary health care for diabetes & hypertension in various countries
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This
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includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
Key issues • Diabetes and hypertension require multidisciplinary, continued and sustained, patient-centered care in a culturally and financially accessible setting such as primary care. • The challenge before health systems in high-, low- and middle-income countries is not in the lack of appropriate drugs but in the delivery of health care for chronic diseases. The chronic care model is a useful framework that describes the essential elements of health care delivery for chronic care. • The landscape of primary health care in high versus low- and middle-income countries is vastly different with differing challenges.
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• Team care approach that shifts the primary caregiving task from a physician-centered model to involving other health professionals is essential to improved care. • Innovations such as telephone messaging, telemonitoring, use of web-based registries, clinical decision support systems among others make health systems more patient centered, efficient and cost–effective, providing contextually relevant solutions for improved care in high-, low- and middle-income countries. • Implementation research is required to bridge the gap between evidence and the realities of health systems in low- and middle-income countries.
diseases and diabetes as economic and developmental challenges in Africa. Prog Cardiovasc Dis 2013;56(3):302-13
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