Evidence brief: Pathways of health care for people living with multimorbidity in two Southern African countries

Abstract

Multimorbidity, the presence of multiple chronic conditions in one person, is a growing global health concern. Integration of chronic care services is urgently needed, especially in low-resource settings including in Southern Africa, where care has been fragmented by vertical and siloed disease approaches. Many countries share similar challenges of integration, presenting rich opportunities for shared learning. Yet, rarely are these opportunities capitalised upon, in part because of a lack of systematic knowledge about the similarities and differences in health system contexts, challenges and current progress towards integration. As part of an inter-country collaboration, we sought to answer the questions: What are the common and distinct characteristics of the care pathways for people living with multimorbidity in Malawi and Zimbabwe, and the opportunities and challenges that emerge through such a country-level comparison? We used an iterative, qualitative research design that involved a desk review of relevant indicators, policies and strategies; key informant interviews, collaborative workshops, and the development of case studies of service integration in practice. Thematic analysis and comparison of challenges of integration across different levels of care revealed uneven funding for different diseases, a lack of both ‘vertical’ and ‘horizontal’ integration, frequent stockouts of drugs and diagnostic equipment, especially for noncommunicable diseases (NCDs), and inadequate training and support for clinicians. In both countries, progress towards decentralising and integrating chronic disease care at national level, has occurred through inclusion of specific NCDs into HIV programmes. This is prone to leave out comprehensive chronic care for people that are not living with HIV and reproduces verticalised programming. We suggest that a promising avenue for wider scale-up of decentralised, non-HIV-dependent integrated care lies in the expansion of an Integrated Chronic Care Clinic (IC3) model that provides comprehensive health system integration for all chronic diseases. Further cross-country learning and feasibility assessment is needed to advance this model.

Introduction

Multimorbidity, when two or more chronic conditions coexist in one person, is a global health concern [1]. Increasingly recognised as a challenge in low- and middle-income countries (LMICs), its prevalence is highly variable, ranging from 3.2% to 90.5% depending on age group and conditions examined, [2] but tends to be higher in older populations, among females, and those engaged in substance abuse [3]. In the African region, multimorbidity is characterised by the increasing co-existence of the human immunodeficiency virus (HIV) with noncommunicable diseases (NCDs) such as diabetes, hypertension and mental health conditions [4]. In a multi-country study in Eastern Africa, multimorbidity accounted for 47% of admissions to the medical wards, with “HIV and hypertension”, and “hypertension and diabetes” the most common disease combinations and multimorbidity present in 63.5% of admitted patients living with HIV [5] Multimorbidity predisposes to loss of function, a lower health-related quality of life (HRQoL), polypharmacy (the use of many medications), and high socioeconomic costs [5–7]. People with multimorbidity are more likely to be hospitalized, remain longer in hospital, and die early than those with a single chronic disease [8,9]. These associated factors raise healthcare utilisation costs, particularly in already financially constrained public health systems in LMICs [10].