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Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district

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Background: With the increasing double burden of communicable and non-communicable diseases (NCDs) in subSaharan Africa, health systems require new approaches to organise and deliver services for patients requiring longterm care. There is increasing recognition of the need to integrate health services, with evidence supporting
integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This
study investigates current practices of delivering and implementing integrated care for chronically-ill patients in
rural Malawi, focusing on the primary level.
Methods: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017,
with a sub-analysis performed on the data following a document analysis to understand the policy context and
how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities,
selected purposively to represent different levels of care (primary and secondary), and ownership (private and
public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities.
Meetings with five non-governmental organisations to study their projects and support towards chronic care in
Phalombe. Data were analysed using a thematic approach and managed in NVivo.
Results: Our study found that, while policies supported integration of various disease-specific programmes at point
of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g.
inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There
were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined
NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. Conclusion: In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the
frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of
integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering
multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among
care teams supported with proper training and incentive mechanisms; and collaborative partnership between
public and private sector actors to expand the resource-base and promoting cross-programme initiatives.

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Articles publicats en revistes (ISGlobal)

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Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district