Kyrgyzstan: Implementing the PEN protocol to enhance diabetes diagnosis
In 2014, the health system in Kyrgyzstan reported 47 000 registered diabetes patients, equaling approximately 1.2% of the population. However, results from the STEP wise approach to surveillance (STEPS) indicated that diabetes prevalence in the country was likely closer to 6.2%. The disparity between official figures and the true diabetes prevalence meant that a large number of diabetes cases were going undiagnosed and, consequently, untreated. The government of Kyrgyzstan aims to ensure full coverage for diabetes patients, but it is costly, particularly for a lower middle-income country like Kyrgyzstan, to diagnose and begin treating diabetes once patients have already developed one or more complications. This led health authorities to look for ways to enhance the health system's ability to diagnose earlier, thereby preventing complications.
To improve early detection of diabetes, health officials chose to implement the WHO PEN protocols – the Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-resource Settings. These protocols provide a prioritized set of cost-effective interventions for noncommunicable diseases (NCDs) to strengthen national capacity to integrate and scale up care of heart disease, stroke, cardiovascular risk, diabetes, cancer, asthma and chronic obstructive pulmonary disease. These interventions enable health care workers to collect the data needed to more effectively identify people at risk of diabetes, among other diseases, diagnose those with the disease and then recommend early treatment options to prevent complications.
The PEN protocols were first implemented in the capital of Bishkek and in two regions of Kyrgyzstan, within 10 health facilities, all of which were family medicine centres. The implementation began with the education of doctors and nurses, training them to conduct the measurements included in the PEN protocol. Once trained, these health care workers began administering the protocol measurements to patients visiting their facilities. After a six-month pilot, results from PEN indicated that detected diabetes had increased by an average of 25% in the two regions. In one of the facilities that had implemented PEN, diabetes was diagnosed twice as much during the six-month pilot than it had been previously. The increased diagnosis of diabetes was a result of nurses and doctors having the knowledge and skills necessary to identify diabetes in patients. The resulting data from implementation of the protocols validated the approach taken by the health system and made a strong case for scaling up PEN in other parts of the country.
A questionnaire distributed to doctors and nurses in the pilot regions showed that, prior to the PEN implementation, approximately 60-70% had knowledge about diabetes risk factors and could make medical recommendations to patients about treatment and care. Following the implementation of PEN, the questionnaire indicated that 80-90% can now give proper recommendations to diabetes patients. Moreover, the medical information collected through the PEN protocol is now shared in an electronic database. This powerful monitoring tool not only offers a way for the health system to track diabetes cases and trends, it also provides an overview of, for example, the coverage of patients and the completeness of clinical data collection. It also allows the health system to compare the performance of health centres.
Kyrgyzstan plans to move forward with expanding use of the PEN protocol in other parts of the country, beginning with implementation in three other districts in 2016. The 3rd PEN protocol on chronic obstructive pulmonary disease (COPD) will be introduced to the country's most mountainous region during the summer of 2016.