Diabetes care in refugee camps: ‘Keeping score is critical’

Hypertension and diabetes are two major health problems for Palestine refugees. United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has been providing diabetes and hypertension care in its primary health care centres since 1992, and is making significant strides in addressing the problems through a structured process of care delivery.

A new article in Diabetes Research and Clinical Practice, titled Diabetes care in refugee camps: The experience of UNRWA, presents key findings from a clinical audit of the programmes, and efforts to address the barriers and shortcomings it identified.

Gwendolyn Carleton spoke with Yousef Shahin and Anil Kapur, the authors of the report, to learn more about the ongoing effort – and what others can learn from it.

How did you become interested in diabetes care in UNRWA clinics?

Anil Kapur: It started when the UNRWA’s Commissioner General visited Denmark and I made a presentation about WDF and its projects in Palestine. These projects were mainly in collaboration with Augusta Victoria hospital and DanChurch Aid at that time. An outcome of the meeting was that WDF met with Dr. Akihiro Seita,  Director of UNRWA’s Health department and Yousef Shahin, head of the UNRWA NCD unit in Amman.

We discussed various opportunities, and one was how can the quality of diabetes care delivery be improved to prevent complications and how can the system be made more responsive to early detection and raise public awareness for diabetes.

UNRWA submitted two projects for WDF funding. I helped the UNRWA team to design the instruments of the audits, and during a visit to Palestine actually saw the services provided by UNRWA clinics and the difficult circumstances in which they operated.

Why did you write this article?

Yousef Shahin: We wanted to highlight and advocate for UNRWA work in the area of Diabetes care, which is considered a model in the region, despite limited resources.

There’s a significant focus on collecting and analyzing data – why?

Anil Kapur: The WDF and its partners have been advocating for improving record keeping and on the importance of analyzing and reporting the collected basic information periodically on lines similar to what has been done in TB and HIV control; using the quarterly and annual data to create cohorts and look at key process and outcome measures. This approach provides a unique opportunity to systematically map improvements - or otherwise - in service delivery and assess the impact of different programs.

So, for example: if a program is focused on raising community awareness about diabetes and its complications, yet year after year patients are coming for the first time to the clinics with late complications, then the awareness programs are making no impact. Or if patients continue to drop out of care, it might indicate that the services do not meet client expectations. Or if, despite training on the need to examine the feet of people with diabetes, a lot of people have foot complications, it may indicate that the training was not effective. Thus collecting information and analyzing it in a timely fashion is the only way to improve care.

The clinical audit of diabetes care within the UNRWA system revealed a wealth of information. It also showed that the simple model UNRWA had adapted to deliver diabetes and hypertension care at the primary care clinics, despite the many constraints, was working reasonably well.

Given that most developing countries face similar challenges and the WHO GAP (Global Action Plan)  is calling for improving systems for NCD care delivery, it was felt that the UNRWA model would be useful inspiration and hence the need to describe this approach in a scientific publication.

You write that these learnings ‘can serve as an inspiration to many developing countries’. How so?

Yousef Shahin: UNRWA Diabetes care was integrated into primary health in 1992, while many countries in the region and in other parts of the world are still dealing with diabetes as a standing-alone vertical program. In addition, WDF projects added more and more awareness to the disease and improved the quality of provided service, through the implementation of diabetes campaigns, the Clinical Audit on Diabetes Care, and the introduction of new services such as diabetic foot care in Gaza and Jordan.

From this article, I hope to disseminate information and advocate for more resources for UNRWA diabetes services. Despite all the challenges we are facing and the very unstable environment, we are doing our best to scale up diabetes care to Palestine refugees.

Anil Kapur: The UNRWA model shows that it is possible to implement simple structures, processes, and technical guidance to deliver fairly decent quality of care at the primary care setting. It also highlights that record keeping and data analysis are as important as setting up the service - and without timely analysis and corrective action any health care service, particularly for chronic diseases, will not achieve its objectives.

Implementing such approaches will help developing nations report on their achievements to prevent and control NCDs as envisaged in their commitment to the UN General Assembly. Keeping score is critical.

Related information:

Article in Diabetes Research and Clinical Practice: Diabetes care in refugee camps: The experience of UNRWA 

2012 Clinical Audit of Diabetes Care among Palestinian Refugees 

UNRWA Students encouraged to adopt a healthy lifestyle (film – 3 mins)

UNRWA website