Chronic patient care at North West Province clinics

Introduction: Chronic illnesses are a signifi cant burden to the health services in South Africa. There is a specifi c national health plan whereby chronically ill patients who are acceptably controlled should be managed at clinic level. The perception has emerged that the management of primary care has not been optimal in the Southern District of the North West Province. This provided the motivation to initiate this research, namely consideration of chronic patient care at clinics in the North West Province of South Africa. Method: A cross-sectional descriptive study was carried out at four randomly selected clinics covering four sub-districts in the Southern District (North West Province). This was done using charts and registers at the clinics. Inclusion criteria were patients older than 18, and presenting with the following chronic illnesses: asthma/chronic obstructive airways disease (COAD), hypertension, diabetes and epilepsy. The major focus areas were the regular assessment of the patients, the level of control of the illness and the use of the Essential Drugs List and Standard Treatment Guidelines (EDL/STG). Results: In the cases of all the chronic illnesses it was found that regular assessments were poorly done, with asthma (peak fl ow measurements) being the most poorly done. Control was generally less than 50% for all the illnesses, although the EDL was followed fairly well by the personnel at the clinics. Conclusion: In the light of the burden of chronic illness the results give cause for great concern about the quality of care for chronically ill patients, and reasons were sought for some of the poor results. A subsequent decision was taken to carry out comprehensive quality improvement projects on each of the illnesses over the following fi ve years. intRoduCtion After 1994 the Department of Health reconfi gured the country’s health services to include free clinic services and free access to health for pregnant women and children under six years.1 The government integrated primary care in the so-called supermarket approach to patient care.2 The down referral from the district hospitals to the community resources was also mapped out in the National Health Plan, and chronically ill patients who were not experiencing complications or needing specialised treatment were to be down-referred to their nearest clinics and health centres, where the visiting doctor would reassess them six monthly and the clinic sister would supply monthly medication as well as carry out basic screening tests.1 In this area there is a very large number of patients who are chronically ill. This was confi rmed in a report to the National Directorate of Chronic Illness and Rehabilitation in July 2006. Annual statistics for 2005/2006 from the Southern District confi rmed this.3 It has been suggested that the care of chronically ill people is often not optimal at clinics and that they then incorrectly access hospitals after-hours, in particular, in efforts to access what they perceive to be better care. Diabetes (NIDDM) In South Africa, an estimated two to three million people are affected with diabetes mellitus (DM), more than one million of whom are undiagnosed. During the period 1990-2000 an increase of 30% in the prevalence of diabetes was reported in Africa, mostly due to a change of lifestyle and an increase in obesity.4 Hypertension (H/t) is a common co-morbidity to DM in South Africa and contributes signifi cantly to morbidity in diabetes.5 – 9 It is therefore very important to optimise the care of diabetic and hypertensive patients and to persist in the maintenance of care of the highest standard. The bulk of this care rests on the primary care system and in particular the care provided by clinics. Hypertension Hypertension has been targeted as a priority disease by the Reconstruction and Development Programme10 as well as by the National Department of Health.11 Recently, in Limpopo Province, a high prevalence of hypertension with poor levels of control was found amongst adults, as reported by the Demographic and Health Survey (2003).12 In Sub-Saharan Africa, in 2006, the prevalence was estimated at 10–20 million, out of 650 million people.13 Asthma A world map showing the prevalence of asthma, taken from the GINA Burden of Asthma report (2007)14 is shown in Figure 1. In this map, South Africa lies within the orange area (7.5–10% prevalence) and, according to the GINA report, has a proportion of 8.1% asthmatics in the population. Vol.1 No. 1 Page 1 of 5 Original Research Van Deventer, Couper & Sondzaba PHCFM http://www.phcfm.org A fri ca n Jo ur na l o f P rim ar y H ea lth C ar e & F am ily M ed ic in e