Decentralising diabetes care from hospitals to primary health care centres in Malawi

Colin Pfaff¹, Gift Malamula¹, Gabriel Kamowatimwa¹, Jo Theu¹, Theresa J Allain², Alemayehu
Amberbir^1,3, Sunganani Kwilasi¹, Saulos Nyirenda⁴, Martias Joshua⁴, Jane Mallewa², Clement
Mandala⁵, Joep J van Oosterhout^1,2, Monique van Lettow^1,3

1. Dignitas International, Zomba, Malawi
2. Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi/Kamuzu University of Health Sciences
3. Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
4. Ministry of Health, Zomba, Malawi
5. Diabetes Association of Malawi, Blantyre, Malawi.
   Correspondence: Colin Pfaff; (colinpfaff@yahoo.co.uk)

Abstract
Background
Non-communicable diseases (NCDs) such as diabetes and hypertension have become a prominent public health concern in Malawi, where health care services for NCDs are generally restricted to urban centres and district hospitals, while the vast majority of Malawians live in rural settings. Whether similar quality of diabetes care can be delivered at health centres compared to hospitals is not known.
Methods
We implemented a pilot project of decentralized diabetes care at eight health centres in four districts in Malawi. We described differences between district hospitals and rural health centres in terms of patient characteristics, diabetes complications, cardiovascular risk factors, and aspects of the quality of care and used multivariate logistic regression to explore factors associated with adequate diabetes and blood pressure control.
Results
By March 2019, 1339 patients with diabetes were registered of whom 286 (21%) received care at peripheral health centres. The median duration of care of patients in the diabetes clinics during the study period was 8.8 months. Overall, HIV testing coverage was 93.6%, blood pressure was recorded in 92.4%; 68.5% underwent foot examination of whom 35.0% had diabetic complications; 30.1% underwent fundoscopy of whom 15.6% had signs of diabetic retinopathy. No significant differences in coverage of testing for diabetes complications were observed between health facility types. Neither did we find significant differences in retention in care (72.1 vs. 77.6%; p=0.06), adequate diabetes control (35.0% vs. 37.8%; p=0.41) and adequate blood pressure control (51.3% vs. 49.8%;p=0.66) between hospitals and health centres. In multivariate analysis, male sex was associated with adequate diabetes control, while lower age and normal body mass index were associated with adequate blood pressure control; health facility type was not associated
with either.
Conclusion
Quality of care did not appear to differ between hospitals and health centres, but was insufficient at both levels.
Keywords: Diabetes care, decentralization, non-communicable diseases, Malawi, health centres.