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Management of diabetes and associated costs in a complex humanitarian setting in the Democratic Republic of Congo: a retrospective cohort studyObjective We aimed to evaluate an Integrated Diabetic Clinic within a Hospital Outpatient Department (IDC-OPD) in a complex humanitarian setting in North Kivu, Democratic Republic of Congo. Specific objectives were to: (1) analyse diabetes intermediate clinical and programmatic outcomes (blood pressure (BP)/glycaemic control, visit volume and frequency); (2) explore the association of key insecurity and related programmatic events with these outcomes; and (3) describe incremental IDC-OPD programme costs. Design Retrospective cohort analysis of routine programmatic data collected from January 2014 to February 2017; analysis of programme costs for 2014/2015. Setting Outpatient diabetes programme in Mweso hospital, supported by Médecins sans Frontières, in North Kivu, Demographic Republic of Congo. Participants Diabetes patients attending IDC-OPD. Outcome measures Intermediate clinical and programmatic outcome trends (BP/ glycaemic control; visit volume/frequency); incremental programme costs. Results Of 243 diabetes patients, 44.6% were women, median age was 45 (IQR 32–56); 51.4% were classified type 2. On introduction of IDC-OPD, glucose control improved and patient volume and visit interval increased. During insecurity, control rates were initially maintained by a nurse-provided, scaled-back service, while patient volume and visit interval decreased. Following service suspension due to drug stock-outs, patients were less likely to achieve control, improving on service resumption. Total costs decreased 16% from 2014 (€36 573) to 2015 (€30 861). Annual cost per patient dropped from €475 in 2014 to €214 in 2015 due to reduced supply costs and increased patient numbers. Conclusions In a chronic conflict setting, we documented that control of diabetes intermediate outcomes was achievable during stable periods. During insecure periods, a simplified, nurse-led model maintained control rates until drug stock-outs occurred. Incremental per patient annual costs were lower than chronic HIV care costs in low-income settings. Future operational research should define a simplified diabetes care package including emergency preparedness.
The politics of exclusion: fighting for patients with Kidney failure in Yemen’s WarBackground To contribute toward the dialogue on addressing non-communicable and chronic disease in humanitarian emergencies, this article will explore the experiences of Médecins Sans Frontières in attempting to find support for the haemodialysis network in Yemen. With the changing profile of the global disease burden and a broadening concept of emergency health needs to include chronic illness and disability, the aid sector has committed through the World Humanitarian Summit and the Sustainable Development Goals to leave no one behind and thus to meet the health needs of these previously excluded and highly vulnerable people. The civil war in Yemen compromised the medical supply chain supporting the health facilities providing dialysis for patients with end-stage renal disease. The article will critique the aid sector’s slow response to this issue and expose the gap between principles, commitments, and practice related to noncommunicable disease in emergencies. Method Following direct experiences from the authors as leaders in the aid response in Yemen, reviews of grey literature from aid and health actors in Yemen were conducted along with a review of literature and policy documents related to noncommunicable disease in emergency. Key informant interviews and press statements supported analysis and events that took place in the time span of roughly 4 years that frames this period of analysis. Results Examination of the impacted patient population, interviews, literature and documented events indicates that there is discord between policy, commitments stated by aid donors and practice. Conclusion The aid sector must use a more contextualised approach when designing programmes to manage the burden of non-communicable diseases in health contexts where crises occur, particularly for lifesaving forms of therapy. Aid agencies and the global health community must increase pressure on donors and implementing agencies to live up to their commitments to include these patient populations.