Response to the hypertension/diabetes challenge

Findings from interviews, focus groups and documents suggest a number of established and on-going activities in response to the management of hypertension and diabetes. The policy regime for managing hypertension and diabetes has been strengthened. There is an overarching NCD policy as well as NCD strategy (MOH, 2014) .Various stakeholders shared their knowledge and experiences on how Ghana is responding to the hypertension and diabetes challenge.

Policy-makers’ viewpoints

Policy-makers believe that the requisite policies are in place for managing diabetes and hypertension in Ghana. To policy-makers, these conditions are a priority as Ghana has ratified various conventions and protocols on NCDs and also, NCD management is an integral part of the medium term plans of the GHS. Apart from the NCD policy and strategy which provides the overall roadmap for diabetes and hypertension management, other policies have also been launched. These include the Tobacco Control Regulations (L.I. 2247) and Smoking Cessation Clinical Guidelines, the National Alcohol Policy, and the Nutrition Policy. The Standard Treatment Guidelines have also been established to guide clinicians in the management of hypertension and diabetes and other diseases.
Apart from major policies on these conditions, policy-makers have instituted the NCD Control Programme within the Disease Control Department of the Ghana Health Service. The programme is a unit responsible for planning, prevention and control of all NCDs in Ghana. Though policy makers (MOH/GHS) admit that there is no established screening program for diabetes and hypertension management in Ghana, what run through policy-makers’ responses is the ability to screen and treat at all levels of service delivery. At the basic level of service provision, the Community-Based Health Planning and Services (CHPS), Ghana’s primary health care service, is an innovative approach which provides basic diabetes and hypertension care to remote and hard-to-reach locations. Services are run through the referral system, that is, health posts, health centres, clinics, district hospitals, regional hospitals and teaching hospitals. Policy-makers, however, admit that more needs to be done on implementing preventive interventions. The findings suggest other activities being undertaken by policy-makers in response to the management of hypertension and diabetes as follows;
However, with the exception of community outreach programs, these activities do not happen on regular and sustained basis. While admitting that progress has been made in clinical interventions, policy-makers were unanimous on the need to scale-up preventive interventions especially when it comes to controlling risk factors of hypertension and diabetes. The establishment of the Regenerative Health and Nutrition Unit within the MOH to promote healthy lifestyle is considered a laudable idea though inadequate funding is obstructing its impact.

Health managers’ viewpoints

Health managers in health facilities act according to broad strategic paths provided by the GHS but have the mandate to initiate certain activities within their facilities in response to these conditions. In planning and allocating resources, health managers are guided by certain considerations. One health manager of a regional hospital explained what informs programs in response to hypertension and diabetes;
So as you can see from this table on my computer, this is 2016 and hypertension was 5th on the top 10 causes of admission in this hospital. Hypertension was also 5th for causes of death. So straightaway, this tells me that if we are budgeting, we need to get some resources for hypertension management
According to the findings, health managers respond by planning and ensuring that hypertensive and diabetes clinics are held to educate patients. Health managers also encourage counselling in their facilities on these conditions but most importantly, they liaise with their respective directorates to organize occasional sensitization campaigns in selected communities on these conditions when they have the resources.

Viewpoint of patient organization participant

Apart from championing the course of patients and lobbying for better concessions for patients with respect to accessing diabetes and hypertensive care, patient organizations have been aligning with other associations and groups in Africa and elsewhere to work towards reducing the incidence of these conditions. As part of the “Youth in Diabetes” project launched to reduce the incidence of diabetes by 15% between 2013 and 2020 across Africa, a screening program to ascertain the prevalence level in the youth is ongoing in Senior High Schools in Ghana. The findings suggest that so far schools in the Western, Eastern, Central and Greater Accra Regions have been screened and that screening the Volta region is about to commence. The organization partners with Associations of other countries for support and trains health personnel and trainers of trainers, a typical example being its collaboration with the Irish Diabetes Association to offer training to health care professionals on diabetes management. Though educational campaigns have been erratic due to inadequate resources, leaflets and easy-to-read fliers are designed and distributed in health facilities. Currently, the patient organization is liaising with government for the introduction of taxes on products with sugar levels in excess of approved limits with the intention of allocating some funds to advocacy groups for their activities.
Views from patient organization suggest several challenges in diabetes and hypertension management in Ghana. These include over-emphasis on malaria and HIV/AIDS to the neglect of diabetes and hypertension, inadequate resources to implement policies on diabetes and hypertension, high cost of treatment as certain services and medications are not covered by insurance, limited training on diabetes, inadequate health personnel (e.g. Ghana has only eight endocrinologists), and the absence of a specialist centre for diabetes complications management.

Payers’ viewpoints

Findings suggest that the National Health Insurance Scheme was set up to pay for curative care for patients who have received care from health facilities. To payers, preventive care is the responsibility of the Public Health Directorate of the GHS who are given budgetary allocation to undertake preventive activities on all conditions of public health importance including hypertension and diabetes. Thus, the main contribution of payers is to reimburse providers for diabetes and hypertension treatment services and medications covered under the scheme. Discussions on the benefit package for hypertensive and diabetic care is on-going as findings from a patient organization indicated that its effort to convince payers to cover at least the first prick of the finger for all patients who go to health facilities is yet to be considered. The NHIA has a budget line for MOH with a strategic purpose of helping them to support and improve health care infrastructure. Payers also play important role as key stakeholders in engaging with MOH/GHS on financial implications of policies and action plans.

Providers’ viewpoints

Findings suggest that the NDA, the MOH/GHS and Novo Nordisk, a Danish Organization, have established a diabetes centre in the Ga South Municipality which provides holistic diabetes and hypertension services to communities in the municipality. The centre is well equipped with a pharmacy, consulting room, and education and counselling centre. The centre provides preventive and clinical services for patients suffering from diabetes and hypertension. Services in response to these conditions include;
Providers in the Effutu Municipality provide clinical care for patients suffering from hypertension and diabetes in the out-patient department. Providers believe that given the resources at their disposal, they are providing good clinical services even in acute situations for patients with high creatinine levels and bad urea secondary to hypertension. Participants stated that increasing cases of diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycaemic State (HHS) have been manged well. General education in the outpatient department occurs as patients wait to see health providers but this is not necessarily about hypertension and diabetes. However, health managers have recognised the need and are now planning to organize periodic diabetes and hypertension clinics as the incidence of these conditions rise in communities. The findings suggest that there is limited action in terms of education and screening programs in the community but patients who come to health facilities with suspected cases of hypertension and diabetes are screened. Education is mainly physician-based as doctors attend to patients but this is quite limited due to the number of patients doctors have to attend to.

Viewpoints from advocacy group

Participants stated that their response to the diabetes and hypertension challenge has been two-fold; education and advocacy. One way of encouraging advocacy on hypertension and diabetes is through the promotion of research on these conditions.
A discussant stated;
We advocate for strong research currently. For example, from the RODAM study we see that although we usually believe that staying in the rural area should be protective of these conditions, preliminary findings suggested otherwise so what is it that we are doing differently?
The findings suggest that the GMA encourages members to undertake effective research on these conditions through its journal, the Ghana Medical Journal. On education, participants stated that this is being done on several platforms and include going on radio and TV stations, churches and other organized groups to educate stakeholders on these conditions. The Association uses its AGMs to educate stakeholders on NCDs in general and more specifically on hypertension and diabetes. A participant explained:
Last two years our AGM program and theme was on NCDs and about two weeks from now we are holding a program with all players in the health sector at the Ghana College of Physicians and Surgeons on NCDs with the theme ‘Non-communicable diseases burden in Ghana: the eye of the crocodile’. So because we see it as a major challenge we seize every opportunity to do some education on these conditions

Patients’ viewpoints

Focus group discussions with patients revealed findings which confirms viewpoints from other stakeholders about more attention being placed on treatment than prevention. Some patients believed the way forward for health authorities is to undertake the same education as they do on malaria and HIV/AIDS. Most patients did not know about the risk factors of hypertension and diabetes before they became hypertensive or diabetic and findings suggest that some patients still have limited knowledge of their condition. Patients stated that it appears Ghana’s response is “a get-sick-and-come” response and that you hear more of these conditions only when you come to the health facilities. Patients’ views on treatment were however mixed. Whereas some believed that once diagnosed, treatment was very good especially if appointments are kept, others concentrated on challenges associated with treatment. Patients were not happy about being made to see different doctors on different occasions as they feel this does not ensure consistency in treatment. However, a crosscheck with health providers suggested this sometimes become necessary due to doctors and nurses having different schedules in theatres or being made to attend to emergency situations. A major issue that came out of discussions was compliance. Some male patients admitted that they use herbal medications because they have sexual issues whenever they take some of the hypertension medications.