A great change with few resources       (Es: Un gran cambio) Martha del Carmen has given up taking long walks in her neighbourhood, Monseñor Lezcano, because she is afraid of thieves and wild dogs  (photo: Christian Korsgaard).   Nicaragua is the second least developed country in the Americas (after Haiti). The neighbouring Central American countries Honduras, El Salvador and Guatemala follow suite with minimally better rankings at the Human Development Index (1).  Besides geography, the four countries often referred to as Central America share a limited capacity to provide care for people with diabetes and other chronic diseases. This led the Pan American Health Organization (PAHO) to initiate a low cost project model to improve the lives of people with diabetes in the four countries. The recipe was simple: train 50 health care professionals in each country in 3-4 test clinics and recruit around 200 patients in each country. The integrated intervention programme should last for one year, and the evidence found and experience gained during this period of time should form the basis of national guidelines and a clinical information system (QUALIDIAB) to measure quality before and after the intervention. In line with the World Diabetes Foundations’s ambition to support capacity building, the Foundation granted support to this project. Out of the morgue At one of the test clinics in Nicaragua’s capital, Managua we asked Martha del Carmen Pavón, a person living with diabetes at one of Managua’s public health centres about her experience with the project. Martha was diagnosed with type 2 diabetes three years ago, at the age of 46. “It totally changed my life,” she says. “At first, I was very sad because I had caught the same disease as my mother. She only lived four years after she was diagnosed – she passed away very quickly. So I thought that the same thing would happen to me – that the diabetes diagnosis was a death sentence. I went into a severe depression. I remember that every time I went to the health centre, I felt like I was entering a morgue and I was TERRIFIED.”   Today, she is more cheerful and she is very aware of the depression she was suffering earlier. The patient education she received during the project at the local health centre has taught her how to deal with diabetes and that discipline is very important; otherwise you destroy yourself. Coherence creates results One of the four clinics in Managua where the project “Integrated Disease Management Model” was implemented was the Sócrates Flores Health Centre in the Monseñor Lezcano neighbourhood. Led by the dedicated diabetologist Dr. Maria Eugenia Largaespada, a group of health workers (including a dentist, two nurses, a dietician, a psychologist, a physiotherapist, an educator and a lab worker) started to coordinate their work - all with the objective of improving the life of people with diabetes. “The obvious result is that we work in a much more coherent manner than before,” says Dr. Largaespada. “Before, the patients got lost among all the different health workers, but now that everyone knows what the other is doing it is much easier and better for all.” Dr. Maria Eugenia Largaespada and dietician Linda Solórzano attend a diabetes patient at the health centre (photo: Christian Korsgaard).   For a period of one year, 108 diabetes patients were followed strictly and their data recorded. This data allowed for simple comparisons in development of HbA1c-levels and BMI, and the result was overwhelming. In general, the patients managed to loose weight, and the share of patients with normal weight doubled from 10 to 20 % during the project period. At the heavier end of the scale, a gradual decrease from severe obesity towards obesity and overweight was also seen (figure 1). According to Dr. Largaespada, the dietician played a huge role in this: she made most of the patients eliminate sugar from their diet and she succeeded in convincing some of them to do physical activity. Neighbourhood unfit for exercise In the beginning, Martha del Carmen Pavón followed the dietician’s instructions and went for long walks, but later she gave it up because she was afraid of thieves and wild dogs in her neighbourhood. Yet, in spite of the limited physical activity, her BMI decreased from 35 to 32 and she also improved her HbA1c-levels from 9 to 6.1 %. The overall improvement of HbA1c among the 108 patients was another positive tendency in the project. At onset, almost half of the patients (44 %) had HbA1c above 10; after one year this was nearly halved to 26 % of the patients. The share of the well-regulated patients with HbA1c below 7 % rose from 17 to 27 % of the patients in the project period (figure 2).    The patients at the Sócrates Flores Health Centre have very few economic resources and as a result, they have difficulties in following the instructions of the nutritionist or doctor. Due to economic difficulties it is hard for them to eat healthily, but at least the health workers have made many of them reduce sugar in their diet. “Despite the low income levels among our patients, I would say that we have complied 80% with the project objective of improving patients’ lives,” says Dr. Largaespada. “For me this is a great success because we managed to make significant improvements for the patients in terms of blood sugar level and weight loss.” Recognition and expansion Under the regional project, a total of 260 health workers from 14 clinics have been trained in the four countries (Nicaragua, Honduras, Guatemala and El Salvador). More than 800 patients have been registered in the clinical information system (QUALIDIAB) implemented to measure quality of care before and after the intervention. The data now exists and as seen at the health centre in Managua, it does not require a lot of funds to make considerable improvements in the lives of people with diabetes. Data is currently being analysed from the four project countries, and the expansion of this intervention to broader areas is planned. Furthermore, evidence on the impact on the health care system for diabetes and other chronic diseases is being compiled and will be used to advocate for the inclusion of this model in the package of care offered to the population. In Guatemala, norms and protocols for diabetes care are currently being implemented nationwide. In El Salvador, the diabetes norms are being validated and the final activity of the demonstration project is planned for the coming months. At regional level, COMISCA (Council of Health Ministers of Central America) has developed an operative plan where countries are requested to evaluate the chronic care model and apply its principles to their national health systems. “This will have a strong impact on the national policies for care for diabetes and other chronic diseases, in particular those related to the availability of services and medication,” says Dr. Alberto Barceló, PAHO project responsible. “This project has fomented the collaboration of government, government agencies, and academic and diabetes associations across the region. Specifically, diabetes associations have contributed greatly by providing volunteers to be trained as diabetes educators as well as providing the perspective of people with diabetes which is the essential human side of this intervention,” Dr. Barceló states.     Facts: Diabetes prevalence in Central America The average reported diabetes prevalence in Nicaragua, Guatemala, Honduras and El Salvador show a slightly lower level of burden than in Spain. However, the average level of investment for diabetes care in the four countries is less than one tenth that of Spain. While it is difficult to compare levels of burden and health investment given different structures, these figures still provide more than adequate evidence to the low level of preparedness and capacity to deal with the burden of conditions which affect more than every tenth citizen in Central America.      Read more about the project Integrated chronic disease management model WDF06-171, in El Salvador, Guatemala, Honduras and Nicaragua --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   References   [1] Nicaragua is ranked 124; Guatemala 122; Honduras 112 and El Salvador 106. Human Development Index 2009: http://hdr.undp.org/en/statistics/

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