Comoros pilot offers lessons in building diabetes care from the ground up

In 2014, there was only one place where the roughly 40,000 residents of Comoros, an archipelago of volcanic islands situated off the southeastern coast of Africa, could receive diabetes care - the National Hospital, El-Maarouf on the island of Mohéli. 

An international partnership set out to change this. Improving the fight against diabetes in the Union of Comoros, WDF14-928, a project designed by the French NGO Santé Diabète and the Comoros Ministry of Health and funded by WDF and The Agence Française de Développement (AFD), began in 2015. 

By the project’s end this spring, 190 health professionals and 25 community health workers had received diabetes training. This made it possible to open 15 diabetes clinics at the secondary level, and to extend diabetes services to the tertiary level as well. The new clinics had access to diabetes medications and were equipped with diabetes management equipment including Hba1c readers.

Also as of this spring, the first preventive actions in the community and in schools had begun and the first patient associations established on each of the three islands. Nearly 50 large diabetes screening events had been held, 888 new diabetes cases detected, and treatment had been improved for the 3,795 residents with diabetes.

Now a new project, Strengthen diabetes care and prevention in the Comoros, WDF19-1735, is building on this foundation.

How was diabetes care established in one of the world’s poorest nations? WDF spoke with Stéphane Besançon, Directeur Général of Santé Diabète, to find out.

•    What was the situation in Comoros in 2014? 

The situation was very, very bad. There were no Health Care Practitioners (HCPs) trained in diabetes, almost no drugs in the health system, and the consequence was that many patients received diabetes care outside of Comoros. They travelled to Mayotte, Tanzania, Réunion Island, Madagascar... the challenge was to try to start providing diabetes care inside the country.

•    How did Santé Diabète become involved?

French cooperation has supported the health system in Comoros for years. So the Vice President of Comoros, who was also the Minister of Health, asked the French Development Agency for an assessment regarding what was possible. 

The Vice President also asked for our support. We recommended strengthening the health system starting with training people and adding HbA1c measurements, and also introducing prevention, working step by step.
 
We designed the project, and the Vice President asked the French Development Agency for support, and we asked for co-funding from WDF. 

•    How did you organise the task?

We used a methodology for decentralisation of care that was developed in other countries: Mali, Burkina Faso etc, but took care to adapt it to the local context. We worked with the ministry of health (MOH), the local medical specialist, the patient associations to adapt the curriculum and the prevention and education tools so it reflected real life in Comoros. For example, in our prevention curriculum we needed to adapt the drawings and text to reflect local foods – we could not use dishes from Mali.

•    What challenges did you face at the outset?

The main challenge was to start something from nothing – this is complicated. We needed to develop a collaboration with the Ministry of Health and start training HCPs at the tertiary and secondary level. It wasn’t a good time to start on primary healthcare because there was nothing above at that point …

In West Africa there is always a professor of diabetology or endocrinology to support you in the training. In Comoros there was no such expert, so in the first phase of training, we needed strong support from international experts - a team from Réunion Island, a French overseas department, was especially supportive.

When we begin building diabetes services in a country, we always start with type 2 diabetes because it affects the most people, and treatment does not necessarily require insulin – and type 1 often remains a big problem. This happened in Comoros. The situation with type 1 diabetes in Comoros is very bad because there is almost no access to insulin. 

But we have been able to strengthen the health system to the point that we now can address this. We recently signed a new agreement with Life for a Child that, beginning in late 2021 or early 2022, will provide free insulin and type 1 diabetes training for HCPs. Identifying young children with type 1 in Comoros who are still alive is a challenge right now – but the awareness and training provided by the first project is helping. 

•    What are you most proud of?

We’re very proud to enter a country with no diabetes care, and to work step by step within the system to give patients access to care. We still have a long way to go, but we have started to give care to patients, including the poorest patients, and that is very good.

For example: in the main hospital on each island, at the secondary level, we have new diabetes clinics running. They are not perfect and there are still a lot of problems, but this was the first opportunity for diabetes management and care in Comoros. Unless they have advanced complications, many patients now stay in Comoros for diabetes care. 

In Santé Diabète we work step by step – identify the challenge, fix the challenge, find new challenges – it’s like this every time. The first project is very important because it creates the basis for addressing new challenges.

We like to say we are not here to do a project, we’re here to support a country in building a public policy. It can take 10-15 years, and you will see different challenges along the way. Ministries of Health often view Santé Diabète as a global technical assistant, and we are very proud of that.
 
•    What advice do you have for others hoping to establish diabetes services where little or no infrastructure exists?

First, do a real assessment, a real mapping of the situation. Don’t start with action, start with assessment. Next, address the reality of the problem and not your wishes. The focus is not on what Stéphane, Santé Diabète or WDF wants, but what is needed for the health of the patient. 

The next step is to build diabetes services to help the Ministry of Health fix the problems you have identified. If the problem is training, do training – if the problem is HbA1c equipment or something else, find out what can help. 

It’s very important to have a strong partnership with the MOH. Partnership for me is not just signing a Memorandum of Understanding (MOU) – everybody can do this. Strong partnership is the capacity for dialogue around real problems – openly discussing what the MOH can and can’t do - and means collaborating day after day, fixing problems together, seeing who can do what. 

•    The project was successfully completed in April. What now?

We built the foundation with the first project, and now we must train more people, provide more care for patients, introduce new types of activities and open more consultations. We must start to register patients, and also expand our focus to include type 1, gestational care, diabetic foot and more. It also will integrate care of diabetes and HIV and TB, using a model from Mali and Burkina Faso. 

To increase diabetes expertise on the islands, three Comoros doctors will receive scholarships to go to Mali next year for 80 hours of intensive training over 2 weeks. The focus of the new project will not just be on quantity of care, but also quality.

•    Has this project catalysed additional attention/focus on diabetes and Non-communicable Diseases (NCDs) in Comoros?

Yes – totally. This project has focused real attention on NCDs in Comoros – there’s now a focal point for NCDs in the government, which is a big change at the ministerial level.
We helped the Comoros government develop a new policy on NCDs and diabetes, a national framework. Recently, when the French government offered financial support for health in Comoros, the government asked for diabetes management to be included. 

It’s a strong outcome of this project that the Comoros government is using this funding opportunity to address NCDs and diabetes. 

Read more about Comoros:

Diabetes project launched in Comoros | World diabetes foundation