The Challenge of Non-Communicable Diseases and Road Traffic ...

An Overview 63
Guidelines and Quality of Care
Support for decision making by health care professionals
in the form of evidence-based guidelines
and other educational materials, educational meetings,
audit, and feedback, improve their adherence
to disease management guidelines and standardized
case management, and improve patient outcomes
[421]. High-quality drugs need to be procured and
supplied at low prices and equipment upgraded and
available. Successful implementation of guidelines
requires wide distribution, training, and supervision
of health workers, and evaluation in practice with
appropriate quality or care and outcome measures
[118]; this is not straightforward, given the shortages
of health workers and funding and the organization
needed. Nevertheless, the use of clinical
guidelines as tools for linking allocative efficiency
with the practice of care has already been discussed
in Section 5.5 on ‘Health Financing’.
Using models familiar from communicable disease
care has been proposed for strengthening performance
management [435]; and lessons learnt
from efforts to improve quality of HIV/AIDS care
may be applicable to promoting quality of care of
those with NCDs. Elements include the number and
mix of health staff, clinician performance, a safe and
well-equipped health care environment, diagnostic
support, and reliable drug supply [436].
Diagnosis and management of disease can be frustrated
by the paucity or quality of equipment. Measurement
of lung function or hypertension using
simple and inexpensive methods can be a major issue
for diagnosis and management of disease, given
the limited access to spirometry and sphygmomanometers
[51] for example. Adaptation of guidelines
for use in low-resource settings to avoid dependence
on laboratory measurement has been referred to already
in relation to CVD risk assessment [308].
Efforts to scale up interventions for chronic diseases
still tend to focus on individual diseases [349]
or use a single disease guideline as a starting point
[147]. This approach is likely to be unaffordable and
unsustainable as populations age [215]. It risks confronting
front-line health workers and patients with
multiple disease management frameworks, which
may be unworkable in practice for patients with
multiple co-morbidities [437], and runs contrary to
patient-centered care.
Self-Management and Patient-Centered Care
For developing countries, team-work and patient
partnership may be as important as adequate funding
[438]. Apart from the organization and quality of
care, it can be a significant challenge in some settings
to enable patients to understand the choices they
have, and to make informed decisions, as well as to
support patient compliance and active participation
in treatment.
Supporting patient self-management is worthwhile,
central to good outcomes of NCD treatment,
and has the potential to alleviate pressure on health
and social services [439], especially given that people
with long-term conditions manage these most
of the time by themselves or with family members.
Self-management support, particularly patient education
about their condition and care and motivational
counseling, improves patient adherence to
treatments and outcomes, service use and satisfaction,
and knowledge of their disease [421]. Patientcentered,
self-management support is already provided
to PLWH in Africa although its quality may
vary [422]. An example of how patient self-management
for HIV has been implemented and extended
to cover other risk factors is given in Box 13.
Supporting self-management is likely to work best
as part of a wider initiative to improve care which
also includes education of practitioners, effective use
of evidence and technology , decision aids, and community
partnerships [439]. Information provision
alone is unlikely to be enough, and different clinical
conditions may need varying approaches according
to the self-care activities required. There is emerging
evidence that strategies co-created by professionals
and service users have positive outcomes [440].
Given the limited health service resources in
low-income countries, ‘full self-management’, with
the patient as the hub of disease management, supported
by smart phone technology, peer support,
and other resources such as primary care providers
and informal care givers, has been proposed as an
alternative to models of chronic care that are more
provider-centered [441].