The island nation Republic of Maldives is most commonly known for its bounty islands surrounded by turquoise water. Being the lowest country on the planet with an average ground level of 1.5 metres above sea level, the nation has also been active in recent climate change debates. Apart from worrying about being submerged, the country is now faced with a new challenge - non-communicable diseases with rapid growth in prevalence of heart diseases, hypertension, cancer and - diabetes.
27 April 2012 Brit Larsen
March 2011. The current diabetes prevalence is not known for the entire country, but a STEPS 3 survey carried out for Male capital island in 2005 showed an estimated diabetes prevalence of 7%. There are no updated data available but it is conceivable that many people go undiagnosed.
In an island nation with well over 1,000 islands of which 200 are inhabited, the logistical challenges are obvious; access to quality health care is no exception. It was in this context that the World Diabetes Foundation acceded to an application from the Diabetes Society of Maldives (DSM) to promote quality diabetes education throughout the 200 inhabited islands.
"Project 200 islands" was initiated in September 2009 and it will train one diabetes educator for every inhabited island of the country. Once the participants have been trained and passed the exam, they will be given a three year contract to work in their respective island.
DSM has institutionalised a "contract" between DSM and the trained educator. The contract is signed by both parties on the day of course completion and it obliges the diabetes educator to report every three months to DSM on the work carried out in terms of diabetes care, including numbers of patients, examinations, results etc. Furthermore, the contract specifies that in case the educator decides to relocate to another duty station or is transferred, this person is obliged to train the successor in basic diabetes care prior to departure from duty station.
The contract has so far been an efficient tool for DSM to monitor the performance of the trained educators and the extent to which they are applying the skills acquired right upon return to duty station. WDF Programme Coordinator, Mr.Bent Lautrup-Nielsen, who visited the Maldives in January, found the contract system of great inspiration to other projects supported by the Foundation:
"The occasional low permanence of trained health personnel within diabetes care and continuity of services due to attrition of acquired skills are issues that pose constant challenges to project partners worldwide. - Not because the training is inappropriate, but rather because of widespread migration of those trained to other areas of work without the benefit of transferring the knowledge to others. The contract system between DSM and the trained health worker addresses the almost inevitable risk of migration away from the Maldives for better career or income options," he says.
On the small island of Huraa, one hour's sail from Male, there is one primary level health centre which provides service to the total island population of around 900 people. The health centre is manned by a nurse and occasionally by a general practitioner. The nurse, Ms. Aishath Shaany, is one of the 70 health workers who have been trained in diabetes under the project to date. Upon return from training she has carried out screenings which has led to the identification of 20 new diabetes cases. These newly identified people now attend the clinic on a regular basis and Ms. Shaany expects more patients to be identified in the time to come.
According to the Mr. Lautrup-Nielsen, the diabetes service established at Huraa's only health centre is likely to provide relief to many patients from the demanding travels to Male capital for basic care.
"However, the absence of pharmacy service on the island does at times demand patients to travel to Male to acquire their medication," he says.
During his visit to the Huraa Health Centre, Mr. Lautrup-Nielsen met two of the people with diabetes who attend the recently opened diabetes clinic at a regular basis. Ms. Rasheeda Mohamed, aged 57, was diagnosed with diabetes in 2002. She applauded the opening of the diabetes service at the health centre on the island. During the first eight years after she was diagnosed she had travelled to Male capital island every two months for controls and examinations.
"After I found out that the care services and advice they provide at the local health centre are of standards comparable to what I got in Male, I am positive that my diabetes condition can be managed here at Huraa island. This has been a great relief in my life and to my family," she expressed.
Mr. Abdul Hassan, aged 66, was diagnosed with diabetes in 2004 and has since spent substantial resources on travels to Male island for care and advice. He was particularly pleased with the perspective of eye services becoming available at the DSM premises in the future as he has experienced vision problem in recent times.
"This will save me a trip to India or Sri Lanka which is currently the nearest place I can get proper eye examination," he said.
After the successful launch of the first World Diabetes Foundation and DSM collaboration in the "Project 200 islands", DSM sought the opportunity to further improve the level of diabetes services in the Maldives. Under the second project which will commence in June 2011, an eye care clinic will be established at the DSM premises in Male.
During the three year project period, 86 eye screening camps will be held on six main atolls. Diabetes patients identified in need of advanced eye care will be referred to the new clinic in Male. In addition, since the eye clinic will be the first of its kind in Maldives, it will also be the referral centre for diabetes-related advanced eye care from all islands. A local ophthalmologist will be the key person in charge of the project roll out of the screening camps and of the care provision at the new eye clinic. In addition, awareness activities will be carried out with targeted population covered to reach more than 100,000.
When asked about the difference this project does, Ms. Aishath Shiruhana, CEO of DSM immediately drew attention to the end users, namely people with diabetes: "As awareness is being created people increasingly understand the need for early action with regard to health issues and complications. We see people with diabetes taking the initiative to do health checks on their own. As a result, people are leading healthier lives due to the knowledge gained about preventive and curative measures. Through the trained educators who are working on their own islands in the existing health settings we are now able to continue screening and awareness program to the disadvantaged and remote islands," she concludes.