Integrating NCD diagnosis into remote primary care in the Maldives

Faafu Atoll, Maldives: At the age of 46, Saira Ibrahim was diagnosed with diabetes in one of her NCD health checkups. Her father, in contrast, rarely had a checkup. Only his upcoming pilgrimage which mandated a complete health checkup revealed his diabetes at 76 years old. Her granddaughter on the other hand, at just 23 years, already has had multiple NCD focused checkups, with no symptoms and no diagnosis.

The difference in awareness and accessibility of health checks across all three generations is a result of their home, Faafu Atoll in the Maldives, being chosen as a demonstration site for the integration of noncommunicable diseases (NCDs) into primary health care (PHC), which means accessing health care services became easier for residents. It encouraged and enabled people like Saira and her daughter to be checked regularly for multiple NCDs and use the primary health care facilities as needed. 

Reorientating the health care system

The project is a collaboration between World Health Organization and the Ministry of Health Maldives, emphasizing a people centred care throughout their lifetime.

The reorientation of the primary health care system in Maldives includes a comprehensive set of services, including testing for selected NCDs such as cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, lifestyle counselling services, identification and referral for common cancers, and selected mental health conditions.

In the beginning, the scheme revealed over 90% of the eligible population had been tested for diabetes, hypertension, high cholesterol and NCD risk factors such as raised blood pressure, increased blood glucose, elevated blood lipids and obesity. The result shows that 9% of the people are living with diabetes and 88% of whom were put on treatment.

Over 14% of those people examined have hypertension and 95% of them are on treatment. Over 22% are living with high cholesterol and 73% of these are on treatment.

Saira Ibrahim says: “Under the changes through PHC, if there are any identified changes to the patients’ health, the health centre brings the patients in for advice and gives them information on doing further investigations… They bring us into the health centre to give information too”.

^{Launch of the Faafu Atoll PHC demonstration site on 18 December 2022 by the Ministry of Health and WHO. Credit: WHO}

Noncommunicable diseases in Maldives

In recent decades, health outcomes have improved substantially in the Maldives. However, the country’s health sector faced challenges due to changing demographics, and lifestyles, including the emergence of NCDs. NCDs are estimated to account for 84% of all deaths in Maldives; diabetes is one of the leading four causes of death, alongside cardiovascular disease, chronic kidney diseases, and respiratory conditions.

In common with other Small Island Developing States (SIDS), Maldives face pressure from commercial determinants such as tobacco marketing and a reliance on food imports, making it vulnerable to global price changes and the increasing use of ultra processed foods.

In response, World Health Organization is supporting the Ministry of Health Maldives in reorientating health systems to ensure access to high quality, affordable, comprehensive primary health care, a step towards achieving universal health coverage.

The impact can be seen in the Saira’s life. Since her diagnosis she needs insulin twice a day. Insulin is free of charge and usually available in the island pharmacy, each inhabited island in Faafu Atoll has both a pharmacy and a health facility. When out of stock, the insulin can be ordered from the capital, covered by health insurance.

^{Areal view of Maldives islands. Credit: WHO/Vismita Gupta-Smith}

The use of technology

A major component of the project depends on information. After any NCD diagnosis, advice is given on how to manage one’s lifestyle and take medications for that disease if needed. Health workers also do house visits, call, and encourage people to go to the health centres.

Saira works as an attendant in a health centre. She cannot remember how she first heard about diabetes, but now, a Facebook group is one of her main sources of information. The group she is on has dozens of members, but the administrator is the island council. This gives an extra layer of reassurance that the information is up to date. There is a similar Viber group aimed at her daughter’s generation.

Technology is also being used to support the development of an online, real time, primary health care register, which was used for early testing and monitoring of patients at the demonstration site and to build an island health profile database. The system has already been developed and implemented at the Faafu Atoll PHC demonstration site and uses the District Health Information System. Basic information such as patient history, demographic data, risk factors for NCDs, treatment given, follow up, and referral can be used to determine the health status of each island. This information along with risk of NCDs is calculated based on the WHO Package of Essential Noncommunicable Disease Interventions (PEN) package. The system has monitoring dashboards for island, atoll, and national levels.

Expansion

Plans are underway to expand the pilot scheme to other atolls. This expansion aims to significantly reduce the need for patients to travel to the capital city for treatment and specialized care. This system can be easily adopted by other small island developing states.

“Strengthening the integration of diagnosis and treatment of noncommunicable diseases into primary health care systems in the Faafu Atoll can provide a working model, not only for other islands in Maldives but for other small island developing states around the world.” Dr Bente Mikkelsen, Director. Department of Noncommunicable. Diseases, Rehabilitation and Disability.