Adapting consultation practices
While no country in Eastern Africa has established a strict nationwide lockdown, Uganda, Kenya and Ethiopia have put in place movement restrictions that have forced hospitals and clinics to limit face-to-face appointments with their patients suffering from chronic diseases. “We initially had to establish a triage system” Dr Nancy Kunyiha, Physician and Assistant Professor at the Aga Khan University Hospital in Nairobi, explained. “Thinking about who is coming to the hospital, and when they need to come in.” was one of the first tasks for healthcare professionals.
Similar measures were taken to reduce the flow of outpatients at St Paul’s Hospital Millenium Medical College in Addis Ababa, Ethiopia, which was partially repurposed to welcome COVID-19 patients. “We have maintained but redesigned our non-communicable disease clinic” Dr Sisay S. Betizazu, endocrinologist at St Paul’s, described. The new set up leaves more time between face-to-face clinical appointments, but the medicine prescribed are renewed at shorter intervals, to avoid hoarding and shortages.
With a few adaptations, consultations have resumed. When possible, physicians now conduct their routine diabetes consultations over the phone, instead of face-to-face. Patients are generally able to make phone calls, but video calls remain the exception in the region. Paper prescriptions are the norm and thus require a physical appointment, but some places, such as the Aga Khan Hospital, have put in place email prescriptions, which are password-protected to ensure patient confidentiality.
Information and prevention by SMS
SMS are widely used in Eastern Africa, particularly in a health context. In Uganda, patients can receive information about the availability of insulin by text messages. The service tells them the status and distance of the nearest facility and when they can access insulin. Prevention can be also done by SMS. In Kenya, Safaricom, the largest telecommunications provider, deployed an information service two years ago. Created in partnership with the Ministry of Health and local associations, Fafanuka helps share advice on diabetes and non-communicable diseases, using unstructure supplementary service data (USSD). This system sends messages to users without the need to store them on their smart or feature phones.
Controlling blood sugar levels
Diabetes specialists have seen the behaviour of their patients evolve during the pandemic. Even with an appointment, patients were initially reluctant to visit the hospital, for fear of contracting the disease. But patients have since realised the importance of consulting healthcare professionals when blood glucose and other conditions such as asthma are not well controlled. “Fear has had an impact on health-seeking behaviours, but this trend has changed as patients realised that they are at higher risk of COVID-19 complications with poor glucose control”, Dr Kunyiha remarked.
One of the consequences of the communications campaigns around COVID-19 has been an improvement in glycaemic control behaviours among patients, something that physicians have observed in their practice: “Patients are taking a little more care than they used to do before [the pandemic]” Prof. Bahendera noted. “The families are also more careful”. “But this is the nature of human behaviour in time of natural disaster.”
But the effects of the pandemic are not all positive. The uncertainty and pressure caused by the new environment may also negative consequences for patients: “Because patients know that they are at higher risk, it also puts them under a lot of stress, which may also affect their blood sugar levels” Dr. Sisay pointed out.
Accompanying type-1 diabetes patients
A particularly fragile group of patients are those suffering from type-1 diabetes, as they require regular access to insulin to survive.
Prof. Silver Bahendeka, who also coordinates the management of type-1 diabetes at the national level in Uganda, explained the challenges he faced in the country. “Most of our population is in the rural areas, which makes it difficult to access [central] facilities” he said. Ahead of the first partial closure, the authorities dispatched supplies to the rural clinics, using local motorcycle taxis to access the most remote areas.
Uganda is unique in the region, as the country operates a central web-based health registry that allows physicians to access medical records both on-line and off-line and confirm the identity of type-1 patients if they are not visiting their regular centres. The system, which has been running for nine years, also helps monitor insulin stocks in and stocks out.
In Kenya, the devolved administration system has given counties a key role in tracking type-1 diabetes patients. “We also have centres of excellence, established through public-private sector partnerships, which focus on the supply of medicine and routine care for the persons with type-1 diabetes.” Dr Kunyiha explained.
Diabetes care going forward
Looking at the future, experts are concerned about the direct and indirect costs of COVID-19, and the increased human toll as the pandemic and restrictions go on.
Medical professionals point out that the pandemic should not obstruct normal care for patients with chronic diseases, who are at the most at risk of complications if untreated. “Our initial reaction was to refocus most of our activities to COVID-19, but after two weeks we realised that we were at risk of neglecting a significant number of patients” Dr Sisay said.
The pandemic could also disrupt access to medicine more widely. Dr. Sisay admitted being “seriously worried” about possible disruptions in the medicine supply chain, both internationally and inside the country. This concern is shared by others. A group of organisations working with diabetes in low-and middle-income countries recently created the COVID-19 Diabetes Supplies Coalition, to help identify shortages of insulin and diabetes supply and mobilise support on the issue.
Physicians also fear the economic consequences of the pandemic, as restrictions impede activity and result in a loss of income. “In sub-Saharan Africa, the problem has been paying out of the pocket, which is a barrier to accessing care”, Prof. Bahendeka highlighted. “People need to be helped out.” “There is a need for more funding for medicines and other supplies for patients with chronic diseases.”
As for the changes of behaviours observed in patients, it is hard to predict whether they will continue beyond the pandemic. For Prof. Bahendeka, health workers have a role to play in cementing the positive changes they have observed. For him, “we should hammer on that these can be done: if they are done [during a pandemic], why don’t we do it under normal conditions?”