Impeding Uganda’s chronic burden In Uganda, people are rarely diagnosed with diabetes before they come to the hospital with complications. The dedicated work of trained health care staff at diabetes clinics around the country delays the onset of complications - to everyone’s advantage. Swahili sign outside a diabetes clinic. Chronic - as in “for the rest of your life” Today, there are no reliable figures on diabetes in Uganda. For the same reason, the World Diabetes Foundation has granted part funding for a national study using the WHO STEP-wise approach. Due to delay in finding the remaining resources the study is anticipated to take place only in 2010. In the meantime, the health care system receives people at the hospitals with diabetes at very late stages – when they have unknowingly had the disease for years. Therefore, the number of people with diabetes registered in the hospitals is not an indicator of the real disease burden in the community.  Despite the lack of data, it only takes simple calculations to understand the seriousness of chronic diseases for Ugandans. It may cost USD 10 to treat malaria and you may recover within five days. In comparison, diabetes or any chronic disease affects you throughout life, and lifelong treatment and medication is costly. ”When it comes to complications, they are even more costly and debilitating to the patient. The health facilities are not strong enough to support the increasing burden,” says Dr. James Sekajugo, Focal Person for Non-Communicable Disease, Prevention and Control in the Uganda Ministry of Health. Ms. Rajab Zainabu, aged 46, was diagnosed with type 2 diabetes two years ago - a diagnosis which turned out to affect her life in unimaginable ways. “I used to be a politician and a business woman, but I had to stop doing both. I can no longer do the fasting during the Muslim Ramadan and I cannot stand through the prayers, so I have to sit. Socially, diabetes limits me in going for parties and visiting my friends,” she explains. Rajab whose husband and daughter also have diabetes feels the economic burden of the disease in her family. But the burden also extends to the community which she used to serve and to the health facilities, and ultimately the burden extends to country level. “You may not see it immediately, but over time the economy will be affected and it will suffer. The burden on the health facilities, for medication and physiotherapy will be enormous. Any foresighted decision maker in the developing world needs to pay attention to prevention and early detection of diabetes now,” states Dr. James Sekajugo.   From temperature to blood pressure The prevention and control of non-communicable diseases is a priority for the Ministry of Health. Yet, it has not materialised all the way through the system and the normal procedure when patients report to any out patient health facility with illness is that they have their body temperature measured. “But diabetes risk factors are not assessed with a thermometer,” says Dr. James Sekajugo. “The reality is that most measurements indicating risk factors for chronic diseases are not taken, because health facilities were designed and are still predominantly geared towards detection and management of acute infectious diseases.” Just outside Arua, in Uganda’s West Nile Region, Ms. Agnes Joyo works as a Medical Clinical Officer at the Oli Health Centre 4. Every Wednesday, she and two nurses devote their services to diabetes patients in a room turned into a diabetes clinic for the day. The equipment in the diabetes clinic has been made available with support from the WHO and the World Diabetes Foundation. “Around 180 diabetes patients are registered at the clinic, and we see around 20 patients every Wednesday. Of these, half have an appointment – the rest come to have their blood sugar level and blood pressure measured. We talk with the patients about diet and physical activity and we monitor their BMI. If the patients have developed a complication, however, we refer them to another level of care,” Ms. Agnes Joyo explains.     Medical Clinical Officer, Ms. Agnes Joyo outside the Oli Health Centre in Arua.   At the clinic, patients can buy oral anti-diabetic drugs and insulin brought by the local diabetes association in collaboration with the Ministry of Health. On average, a patient’s insulin costs 30,000 UGX (15 USD) per month which corresponds to 25% of the average income per household, as most patients are peasant farmers depending on tobacco as cash crop.   Apart from the equipment needed to set up the diabetes clinic, the training of staff is essential. The three health workers in the Oli diabetes clinic have all undergone special training in diabetes and they are continuously trained every six months. They are trained to train others which they apply when conducting integrated health education to ante-natal clinics, out patient departments and HIV/AIDS clinics as well as to other staff at the health centre. Furthermore, they go into the districts and communities to raise awareness about diabetes. Nationwide coverage The Oli Diabetes Clinic is one among 71 of its kind established in Uganda since 2006 in a similar setup. The World Diabetes Foundation has supported four different projects to improve access to diabetes care. “We believe that it is essential to establish diabetes care at primary level in order to increase early diagnosis and delay and minimise the complications of the disease,” says Programme Manager at the World Diabetes Foundation, Ms Sanne Frost Helt. “I like to see the diabetes clinics at district level as shields protecting people from debilitating complications and allowing them to continue life in spite of a diabetes diagnosis.” Back in Arua, Ms. Agnes Joyo notices the improved quality of life for her patients. “Due to our diabetes awareness activities in the community, people show up for their routine checks every three to six months and some come by to be checked for diabetes. There is a higher degree of family involvement and awareness of physical activity. All in all, more knowledge and better control means delayed onset of complications. This has never been the case before,” she says. However, amidst all the positive changes, many diabetes patients still cannot afford the medicine required to control their blood sugar level – so they go unregulated. And where diabetes services are still poor, patients go undiagnosed and untreated – because they only had their temperature checked. But things are moving, and one of the protagonists in the process is grateful for the support: “Without the support from World Diabetes Foundation, the development within the field of diabetes would not have taken place in Uganda. Now, the government is much more aware and ready to contribute to the fight against the disease,” says Dr. James Sekajugo. “Both national contribution and commitment to non-communicable diseases is needed if the burden of chronic diseases is not to turn into a chronic burden for the country’s economy.” The latest project supported by the World Diabetes Foundation aims at extending diabetes care nationwide to all 80 districts of the country. Read more about the project in Uganda (scroll down)

  

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