By Srean Chhim
Research becomes more meaningful when its findings are used to take interventions or actions. Translating findings to interventions or actions is sometimes called "knowledge translation." The policy brief is one of the knowledge translation products which tells the readers the issues and solutions. The policy brief is usually a short communication tool targeting policymakers and people in the same field.
In this blog, we demonstrate the process of developing a policy brief to scale up Type 2 diabetes and hypertension intervention in primary healthcare in Cambodia. The original version of this policy brief can be accessed via this link.
Background of type-2 diabetes, hypertension, and our research in Cambodia
People with type-2 diabetes and hypertension have a higher chance of developing heart-related diseases. Heart disease, commonly occurring in the older population (40 years or older), kills millions of lives worldwide.
Cambodia is a low-income country with limited type-2 diabetes and hypertension services, while concerns about these two chronic diseases are increasing. Cambodia is trying to scale up services for people with these two diseases in primary healthcare for timely access to the services they need and to reduce unnecessary expenses related to travel.
However, knowledge of what is happening remains unclear. Therefore, to provide concrete evidence for policy decisions, our research team at the National Institute of Public Health (NIPH), in collaboration with the Department of Preventive Medicine (DPM) of the Ministry of Health, conducted a situation analysis through multiple research activities. These research activities were funded by the Belgian Government through the VLIR-UOS project, the Fourth Funding Agreement (FA4) Programme (2017–2021) between the Belgian Directorate of Development Cooperation and the Institute of Tropical Medicine, Antwerp, and the European Union’s Horizon 2020 research and innovation programme under grant agreement No 825432.
Process of collecting evidence
In collecting evidence, we asked two simple but hard-to-answer questions—what do we want to know and how to get it?
To answer "what we want to know," we used the framework “Integrated Care Package (ICP) for scaling up type-2 diabetes and hypertension”, as a part of the SCUBY project [Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study - PubMed (nih.gov)]. This framework focuses on six components: (1) early detection and diagnosis, (2) treatment in primary healthcare, (3) health education and counseling to patients by non-physician care providers, (4) self-management support to patients and caregivers, (5) collaboration between health care workers, community actors, and patients and caregivers, and (6) organization of care, delivery system design and clinical information systems.
We conducted three research activities to understand the situation of these six components (answering the ‘how to get it?’ question). First, we did a facility assessment using a standard checklist. Second, we surveyed 5072 households using a comprehensive questionnaire and blood specimen collection for type-2 diabetes and hypertension testing. Third, we interviewed people familiar with type-2 diabetes and hypertension for their opinion.
We then presented all the findings to stakeholders for their feedback and sought their opinions on addressing all identified issues.
Findings
More detail on findings can be found in the original policy brief [link]. Here, we provide brief findings as follows.
At the health facility, the performance score for type-2 diabetes and hypertension service at the selected health center is low at around 2 out of a possible 5.
In the community, only about 50% of people having type-2 diabetes know that they have the disease, and 64% of people having hypertension see that they have it. This leads them to get the treatment late and is not ideal for treatment.
The majority of people with type-2 diabetes and/or hypertension (75%) use health services in private facilities, which may lead to poor treatment outcomes and spending more money.
We also used the data from our research activities to identify health system issues that may impact the scaling-up.
Governance
New and older policies are sometimes inconsistent and hard for practitioners to follow.
No clear guidance (roadmap) at the national level to guide the intervention in the long-term
Lack of supervision from the district and provincial level to the facility level potentially impacts the performance of the practitioners.
Health workforce
The number of staff is not adequate to effectively implement the intervention we want. They need one more staff for small health centers and 3.5 staff for the medium or large health centers.
Medicine supply
The availability of medicine for people with type-2 diabetes or hypertension is limited. As a result, patients may not always get the medicine they need and seek private care instead.
The Ministry of health did not allocate enough funds for these two diseases. Therefore, health facilities have to charge fees from the users for screening services at about 5000 riels (1.25 USD). As a result, patients skip the screening service as it is felt that this is unnecessary.
Health information system
Several databases are used to track patient records. Still, none of these are ready for relevant and reliable tracking systems for these lifelong diseases.
Service delivery and support services
Through the facility assessment, the score on service delivery was low at about 2 points out of a possible 5 points.
People with uncontrolled/severe disease may need to be referred to a more advanced hospital and referred back when they feel better. However, the referral system does not work well, with a low score of 1.3 points out of a possible 5 points.
Recommendations
Identifying issues can be done through research activities, but formulating solutions to these identified issues is not straightforward. Therefore, to get the most from stakeholders, we had two consultative meetings or "policy dialogue" to draft and finalize the solutions.
We proposed three recommendations to address the identified issues that have been presented above.
We need to scale up services for people with type-2 diabetes and hypertension at health centers and support services at referral hospitals and in the community. It is also necessary to increase access to affordable screening for type-2 diabetes and hypertension to reduce the rate of unknown status.
The scaling up should be done in new health centers, and the scope and quality of services at existing health centers should also be done. The improvement can be made through better design and addressing all the identified issues related to the six components of ICP—identifying unknown patients, treatment, health education, patient self-support, collaboration (between community workers, health center, and referral hospital), and services organization; and health system cross-cutting issues.
Finally, to effectively foster the scaling up of quality and affordable care for the two diseases, a roadmap is required to present the key strategies and strategic interventions with a clear timeframe and roles and responsibilities of key stakeholders.
Authors’ note
In this blog, we present the process of developing the policy brief in a specific case. It may be different from other practices depending on the different target audience. However, the common things are that developing a policy brief is a long process. It requires skills, efforts, and support from stakeholders. A successful policy brief is one that is partially or fully adopted by stakeholders to implement. The impact of our policy brief has not yet been assessed. However, through our internal communications, we learned that this policy brief was adapted by Korea Foundation for International Healthcare (KOFIH) to implement in three provinces in Cambodia—Pursat, Battambang, and Pailin.
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