The project will seek to improve access to quality diabetes and NCD care at the primary care level, strengthen capacity of HCPs, improve patient referral pathways, empower patients and implement evidence-based policies in Kyrgyzstan and Uzbekistan.
The project will leverage the work that the World Health Organization and WDF have supported in the region in previous years by consolidating the efforts and creating strong partnerships. The WHO PEN model and the WHO HEARTS technical package will be applied. The project activities are channelled through three tracks:1. Health system strengthening Improving clinical practice and quality of care through clinical audits, training, and supportive supervision at the primary level:Capacity building of 12 ‘local care teams’ (incl. a nurse, a family doctor, a community pharmacist, a specialist, a technician and a patient representative) in clinical protocols for integrated management of NCDs with a focus on diabetes, CVDs and hypertension and team-based care. Piloting innovative tools for clinical supervision, measuring and monitoring the quality of care through a digital platform and decision support tools in selected regions. Prevention of complications through strengthened referral pathways, follow up and coordination at the national level for each country. Gaps to be mitigated through capacity building, procurement, and deployment of equipment with a particular focus on diabetic retinopathy.Enhancing the role of nurses in NCD care through a review of the role and practice of nurses and the development of a new set of guidelines to be rolled out in both countries.2. Patient empowerment and involvement:Capacity building of nurses and other HCPs to provide patient education, drawing on WHO materials and evidence-based approaches and leveraging ongoing cross-country exchanges. Strengthening patient associations to provide patient support and engage in policy, care design and patient schools, leveraging previous WDF-supported projects and partners in both countries.3. Advocacy and policy strengthening:Development of a road map for prevention of complications in people with diabetes, with focus on CVDs and diabetic retinopathy.Establishment of a Project Steering Committee led by the Ministry of Health to oversee the project and to ensure national level ownership and commitment. Corresponding steering groups to be formed in selected regions. Documentation of project achievements and learnings to inform policies and guidelines through baseline study, evaluation and implementation research. Patient experience and overall improvements in health outcomes to be included. Policy guidance and facilitation of knowledge and best-practices exchanged through policy dialogue with relevant stakeholders and authorities.
UZB - demonstration project in Syrdarya region (population 850,000). 32 health facilities, HCPs reached: 116 doctors and 350 nurses. KGZ – demonstration project in Chui region (population 936,000). HCPs reached: 654 doctors and 1286 nurses. 12 local care teams (KGZ: 72 specialists, 82 family doctors and 252 nurses and UZB: 26 specialists, 93 family doctors and 350 nurses) trained in clinical protocols for integrated management of NCDs. 12 local care teams (as above) plus 3 decision-makers and 3 health managers per country trained in conducting clinical audits and indicator measurement and providing feedback on quality of care in demonstration sites.Digital platform established and decision support tools co-created with local care teams to facilitate clinical supervision and performance monitoring.Two national-level situation analyses conducted on the prevention of complications. Two road maps for preventing diabetes, including national-level capacity building plans completed (based on the findings of the situation analyses).602 nurses trained in patient education. New guidelines developed on the role of nurses in NCD care.Two workshops held with patient associations, policymakers and 'local care teams' to discuss the role of patient associations and involve patients' voices in developing NCD policies and care models.10% increase in the enrolment of diabetes patients compared to baseline.