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SCale Up an integrated care package for diaBetes and hYpertension for vulnerable people in Cambodia, Slovenia and Belgium

Periodic Reporting for period 1 - SCUBY (SCale Up an integrated care package for diaBetes and hYpertension for vulnerable people in Cambodia, Slovenia and Belgium)

Reporting period: 2019-01-01 to 2020-06-30

While the burden of chronic disease is rising across the globe - especially in LMICs -, global commitments have been made towards an integrated care approach which offers non-episodic and patient-centered care. The SCUBY project aims to provide solutions from implementation science through the development, adoption and evaluation of roadmaps on scale-up of integrated care for type 2 diabetes (T2D) and hypertension (HT) in three distinct contexts, a health system in development (Cambodia), centralized health system (Slovenia), and decentralized health system (Belgium). The project prioritizes vulnerable population. In Cambodia, all people with T2D and HT are considered vulnerable, and therefore, the scale-up targets the whole population using the public health services. In Slovenia and Belgium, the scale-up focuses on vulnerable groups, being defined as elderly patients and/or patients with chronic comorbidities.
The SCUBY project is divided in three phases: a formative, intervention and evaluation phase. In the formative phase (year 1), the objective is to assess the current implementation in each country of the integrated care package (ICP) - consisting of primary care-based diagnosis, treatment, education and self-management support and collaboration, along with its facilitators and barriers and cost (WP2-4). In the implementation phase (year 2-3) the objectives entails the development and implementation of an improved scale-up strategy through a roadmap including activities related to stakeholder engagement and the definition of proximal and distant outcomes for implementation monitoring (WP5). Finally, the objective of the evaluation phase (year 4) will be to determine the impact and scale-up evaluation. For the impact, a Cascade of Care approach (CoC) to assess the number of patients with HT and/or T2D, those linked to care, treated and successfully managed clinical outcomes. For the scale-up evaluation, scale-up progress of the ICP will be tracked along the three axes of the scale-up framework. Aside from these types of evaluation, a process evaluation will be conducted in years 2 and 3, to monitor implementation (WP4-6). As the cornerstone of the SCUBY project is to provide a platform to share lessons learnt, throughout the three phases of the project, the objective of dissemination work package (WP7) will be to disseminate knowledge of scaling-up of the integrated care package will at regional and global level to countries with similar specificities
During M1-M18, which encompasses a one-year informative phase and the beginning of an implementation phase of the SCUBY project, an in-depth situation analysis for each country was conducted. Our preliminary quantitative and qualitative work underpin the design of the subsequent roadmap, identified barriers and facilitators at micro, meso and macro levels, as well as their interrelatedness in Cambodia, Slovenia, and Belgium. In addition, our preliminary research yielded insights into the positions and power of stakeholders within each setting. Alongside a situation analysis, an evaluation of economic costs of scaled-up interventions was performed in each implementation country, as well as of their respective strengths and weaknesses, with a view to identifying ways to design a scale-up in the most cost effective fashion.
During this time period, a minimal Cascade of Care consisting of indicators for a minimal dataset to allow for comparison across countries was developed. This was achieved by seeking a common ground among the country-specific guidelines and available data for the operationalization of the different steps of the Cascade of Care. A qualitative study was undertaken to assess the relevance and feasibility of monitoring of the indicators. In addition, an extended Cascade of Care was developed to enable the evaluation of the integrated care package within countries between the different care models. In conjunction with the development of these two cascades of care, a data management plan was elaborated with all partners to extract anonymised data.
Based upon this broad contextual understanding derived from qualitative data on the implementation, barriers and facilitators of integrated care, as well as insights into stakeholders’ positions and power in the country-specific challenges and policies, we have initiated the planning of activities to develop a roadmap to scale up integrated care in each implementation country. Thus, all three countries have launched formal and informal policy dialogues with stakeholders to improve and/or facilitate scale-up. Alongside these endeavours, an evaluation protocol is being developed for the process, implementation and impact of scale up, which will contain three dimensions of scale up: (a) the population coverage of the integrated care package (b) the expansion of the intervention package towards the integrated care package, and (c) the integration of the intervention into the larger health system.
With a view to facilitating an exchange of experiences, the project’s objectives, progress, methods, tools and results are being disseminated and communicated through the established mechanisms to link stakeholders among countries. Along with the development of dissemination materials, publications, and training programs for SCUBY researchers, a Community of practice (https://www.thecollectivity.org/en/communities/22) and a SCUBY website (https://www.scuby.eu) were created to display blog posts and all updates on scientific progress, published results or milestones reached are displayed.
To oversee the project, a steering Committee (SC) was created to ensure that all strategic decisions in the consortium are made in a transparent fashion. In addition, to the six meetings held with the SC, two major face-to-face consortium meetings were held: the Kick off in Ljubljana, Slovenia (M2) in collaboration with hosting partners, where the methodology of the first year was elaborated and a second consortium meeting in Siem Reap – Cambodia (M14).
The expected impacts of the project include 1) an increased coverage of the integrated care package for the target populations 2) an enhanced visibility of the concept of scale-up on the front burner of policy makers. 3) an increased responsiveness of health systems to the needs of vulnerable people with chronic conditions. 4) an opportunity to share lessons among countries, thereby increasing the body of knowledge regarding the art of scale-up for interventions of chronic conditions in health systems in low and middle income countries and high income countries. 5) an increase in efficiency in health care expenditure. By scaling-up effective interventions for T2D and HT control and reducing morbidity and mortality, through health services that will expand reach more people and provide more sustainable and accessible healthcare, our project aims to attain Sustainable Development Goal (SGD) 3 ‘Ensure health lives and well-being for all’ targets 4 and 8 from the 2030 SGD agenda, namely, reducing by one-third the premature mortality from NCDs through prevention and treatment and achieving universal health coverage, respectively. Furthermore, lessons on scale-up will contribute to the global movement that seeks to pursue the SDG agenda. Thus, the socio economic impact is anticipated, not only in Cambodia, Belgium, and Slovenia, but also at a global level.