Strengthening healthcare systems in the face of comorbidities: 4 years of action in Mali, Burkina Faso and the Comoros

Since 2021, Santé Diabète has been running an ambitious project in Mali, in Burkina Faso and in the Comoros. The aim is to improve the quality of life of people living with diabetes, HIV and tuberculosis, by offering integrated management of these often interrelated diseases.

For four years, this project brought together healthcare professionals, associations, ministries and communities to build new ways of caring for and preventing disease.

Achievment:

• Enhancing the skills of healthcare professionals to provide better care for co-morbidities

To enhance the skills of care providers, curricula were developed and adapted to each country, thanks to collaboration between experts in endocrinology, pneumology and infectiology from the three countries. The first training sessions quickly revealed a specific need: to distinguish content based on professional profiles. For example, two distinct curricula have been developed: one for doctors, the other for nurses and paramedics. Each were adapted to the realities and needs of national healthcare systems.

As a result, nearly 400 professionals were trained through theoretical modules and clinical mentoring. This dynamic has improved the follow-up of more than 700 patients living with co-pathologies.

 

• An innovative community approach

The community approach was one of the pillars of the project, based on the active involvement of patients right from the design stage. Prevention and therapeutic education materials were developed with patients, taking into account their reality, needs and health practices.

A network of 48 patients peer educators (PPE) has been trained to carry out awareness-raising, guidance and support activities. Their mission: to inform, guide and support their peers living with diabetes, HIV or tuberculosis. Thanks to their interventions:

• 32 000 people living with HIV were made aware of the risks associated with diabetes, including 3 500 who were referred to the Diabetes Prevention Centers for individualized support;
• 13 500 people with diabetes were trained in HIV and tuberculosis prevention, including 1 500 who were referred to an HIV testing center.

The Diabetes Prevention Centers, who were created or reinforced in each country, have played an essential role in welcoming, informing and supporting patients.

« Thanks to the activities carried out by the peer educators at the Centre Médical de Pissy where I'm being treated for HIV, I recognized the signs of diabetes. The Maison de la Prévention referred me to a diabetologist, and I was quickly treated. Today, I'm better able to manage both illnesses and, in turn, I give talks to help other patients. » says a patient from Burkina Faso.

 

 

• Strengthening institutional and associative actorss for a common objective

At the start of the project, many institutional and community actors were unaware of the links between diabetes, HIV and tuberculosis, and the practical implications of these co-morbidities for healthcare systems. To fill this gap, a working paper has been drawn up in each country, outlining the current situation and identifying the specific challenges involved in integrating the three diseases.

This document served as the basis for for awareness-raising and capacity-building work involving ministries of health, national HIV, tuberculosis and diabetes programmes, the Country-Coordination Mechanism (CCM, the national structure coordinating funding requests to the Global Fund), hospitals, patient associations, local NGOs and HIV/AIDS, tuberculosis and hepatitis sector units.

This multi-stakeholder mobilization has laid the foundations for a more integrated governance, build common messages, and strengthen advocacy leading to the inclusion of diabetes/HIV and diabetes/tuberculosis co-morbidities in Global Fund grants, as well as in each country's national strategy documents.

Faced Challenges : a weakened dynamic and obstacles to overcome

For a year, the project progressed smoothly in all three countries. But at the end of 2022, a major turning point occurred: in Mali, the authorities announced the end of French public funding (Government announcement N°042). The project, supported by the Agence Française du Développement group, must therefore be suspended. While this decision has meant a complete halt to our actions in Mali, it has not broken the momentum: in Burkina Faso and the Comoros, the team has reorganized to consolidate achievements, adjust strategies and capitalize on progress.

On the ground, however, other structural obstacles have emerged. The integration of co-morbidities can only be effective if countries havea functional, high-quality healthcare offer for each of the pathologies concerned. While most countries benefit from a robust HIV system, diabetes care is often fragmented, underfunded and inequitable. This imbalance is particularly glaring for patients living with a dual pathology: while HIV treatment is free, diabetes treatment (insulin, oral antidiabetics, blood glucose meters, test strips) remains almost entirely the patient's financial responsibility , in contexts where Universal Health Coverage is virtually non-existent. This lack of access is a major obstacle to continuity of care and to the effectiveness of any integrated approach.

Although the project has made it possible to include co-morbidities in Global Fund grants, their consideration remains marginal, as these issues are still perceived as secondary by the lessor, despite the advocacy carried out in each country and the real scale of the need.

This observation reinforces more than ever the need for a targeted, coordinated, regional advocacy to make comorbidities a priority for public policies and funding agencies.

Next steps: amplifying impact and removing obstacles

The year 2025 will mark an important step forward: for the first time, Global Fund grants will include prevention and management of comorbidities diabetes/HIV and diabetes/tuberculosis in the three project countries.

Santé Diabète will support this implementation by contributing its technical expertise, training tools and support for the structuring of more integrated, community-based care systems. At the same time, several countries in West Africa and the Indian Ocean have expressed their desire to replicate the experience. Inspired by presentations made at AFRAVIH (Alliance Francophone des Acteurs de santé contre le VIH et les infections virales chroniques) and at regional symposia, they are now seeking Santé Diabète's support to initiate similar projects.

But this advance also raises a requirement: meeting systemic challenges highlighted by the project. In particular, the lack of access to essential diabetes drugs and equipment is a major obstacle to true integration. This is why Santé Diabète will continue its advocacy on two levels:

• With the Global Fund, to broaden its scope to include diabetes inputs in co-morbid situations.
• With governments, to ensure that diabetes care is a permanent part of Universal Health Coverage (UHC) schemes.

Our ambition for the future is therefore clear: extend the impact to the whole region, reinforce existing models, and make comorbidities a collective public health priority in Africa.

 

by Moïse Nguemeni, technical director of Santé Diabète