Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district

Abstract

Background: With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring longterm care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. Methods: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo.Results: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems.

Integrated chronic disease care delivery at a primary care level in sub-Saharan Africa: A systematic review, ‘best fit’ framework synthesis, and new conceptual model

“…‘Equipped healthcare teams to deliver evidence-based patient-centred care’ was a dominant theme, found within 9 of the 12 primary studies, and supporting the ICCCF modification of the original CCM ‘decision support’ model element to include equipping of healthcare teams 30 . Common findings from the primary studies were that healthcare facilities lacked basic screening equipment 37 38 40 45 , access to laboratory diagnostic tests 38 45 , and a reliable supply of diabetes drugs 37 38 45 . The development and implementation of local and national evidence-based guidelines and diagnostic and treatment algorithms was found to be important for improving patient care 38 41 42 45 .…”

“…Common findings from the primary studies were that healthcare facilities lacked basic screening equipment 37 38 40 45 , access to laboratory diagnostic tests 38 45 , and a reliable supply of diabetes drugs 37 38 45 . The development and implementation of local and national evidence-based guidelines and diagnostic and treatment algorithms was found to be important for improving patient care 38 41 42 45 . Several studies highlighted clinical mentorship as a method of providing continuing professional education 38 42 45 48 .…”

“…The development and implementation of local and national evidence-based guidelines and diagnostic and treatment algorithms was found to be important for improving patient care 38 41 42 45 . Several studies highlighted clinical mentorship as a method of providing continuing professional education 38 42 45 48 .…”

“…‘Empowerment and support of patients for self-management and prevention’ was a theme identified in 7 of the primary research studies. Self-management was mainly supported through the delivery of health education to patients 37 38 40 45 47 , such as a programme to empower patients with diabetes to take responsibility for their health through education about glycaemic control 42 . From a patient perspective, participants in a South African study emphasised the importance of trusting relationships between patients and healthcare workers to facilitate effective clinic-based support for self-management 44 .…”

“…‘Use of data collection systems to facilitate effective care and follow-up’ was identified as a theme present in 5 studies. Integration of HIV and NCD patient data into a single, easily accessible patient file was found to facilitate patient data collection for clinical decision-making and monitoring and evaluation activities to improve team performance 38 42 45 48 . Specific, detailed patient records were identified as enabling nursing staff to improve longitudinal follow-up, quantification of patient demand and accurate medication ordering 42 43 .…”