Clinical challenges in the co-management of diabetes mellitus and tuberculosis in southern Africa

Over the past 20 years, tuberculosis incidence in southern Africa has increased at an alarming rate, fuelled primarily by the human immunodeficiency virus epidemic. The emerging prevalence of diabetes mellitus in the region represents a new threat to tuberculosis control. The intersecting double burden is a cause for concern since diabetes mellitus increases the risk of tuberculosis and results in poor treatment outcomes. This review article discusses the evidence of a causal association between these two conditions, and examines the numerous clinical challenges that relate to tuberculosis and diabetes mellitus co-management. Diabetes is associated with a more advanced age and body weight in patients with tuberculosis, although not with a specific clinical presentation of tuberculosis. Rifampicin adversely alters glycaemic control by lowering the concentrations of most oral antidiabetic drugs. Poor glycaemic control, possibly exacerbated by tuberculosis and anti-tuberculous therapy, is an important contributing factor to tuberculosis case fatality and relapse. Clinicians need to be aware of these clinical and pharmacological challenges when co-managing these complex diseases.Keywords: diabetes, tuberculosis, rifampicin, co-management, southern Afric

Developing the Botswana Primary Care Guideline: an integrated, symptom-based primary care guideline for the adult patient in a resource-limited setting

Billy M Tsima,1 Vincent Setlhare,1 Oathokwa Nkomazana2 1Department of Family Medicine and Public Health, 2Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana Background: Botswana’s health care system is based on a primary care model. Various national guidelines exist for specific diseases. However, most of the guidelines address management at a tertiary level and often appear nonapplicable for the limited resources in primary care facilities. An integrated symptom-based guideline was developed so as to translate the Botswana national guidelines to those applicable in primary care. The Botswana Primary Care Guideline (BPCG) integrates the care of communicable diseases, including HIV/AIDS and noncommunicable diseases, by frontline primary health care workers.Methods: The Department of Family Medicine, Faculty of Medicine, University of Botswana, together with guideline developers from the Knowledge Translation Unit (University of Cape Town) collaborated with the Ministry of Health to develop the guideline. Stakeholder groups were set up to review specific content of the guideline to ensure compliance with Botswana government policy and the essential drug list.Results: Participants included clinicians, academics, patient advocacy groups, and policymakers from different disciplines, both private and public. Drug-related issues were identified as necessary for implementing recommendations of the guideline. There was consensus by working groups for updating the essential drug list for primary care and expansion of prescribing rights of trained nurse prescribers in primary care within their scope of practice. An integrated guideline incorporating common symptoms of diseases seen in the Botswana primary care setting was developed.Conclusion: The development of the BPCG took a broad consultative approach with buy in from relevant stakeholders. It is anticipated that implementation of the BPCG will translate into better patient outcomes as similar projects elsewhere have done. Keywords: Botswana, primary care, guidelines, developmen

Perceptions of physician leadership in Botswana

Background. Physician leadership is essential for the strengthening of health systems, especially in underserved settings such as sub-Saharan Africa. To be effective, leaders must be perceived as such by their community. It is unknown how perceptions of physician leadership in Botswana compare with those of the Canadian Medical Education Directives for Specialists (CanMEDS) Physician Competency Framework, which is used to shape the training of Botswana’s future physicians.Objective. To examine if the perceived competencies of physician leadership in Botswana are  specifically named in the CanMEDS Framework and thereby inform Botswana’s graduate medical education.Methods. We conducted focus groups discussions with nurses, interns, medical officers and specialists at Princess Marina Hospital and Nyangabgwe Referral Hospital. Key questions focused on describing the qualities of physician leadership. For data analysis we used inductive content coding and comparison with the CanMEDS frameworks.Results. Forty-eight clinicians participated and 111 unique codes were assigned to 503 comments.  Eighty-four per cent of comments corresponded to the CanMEDS 2005 competencies; many were  captured within the competencies of the medical expert (13.0%), communicator (17.8%), collaborator (15.6%), scholar (14.9%) and professional (31.3%) roles. About 5% of comments mapped to the draft CanMEDS 2015 update, and 11.5% were not specifically described in either version of CanMEDS, including charisma and decisiveness.Conclusion. The CanMEDS frameworks specifically address most of the competencies perceived as important for physician leadership in Botswana. Additional perceptions were identified that may require the attention of existing and aspiring physician leaders and their teachers to ensure they attain and maintain their effectiveness as leaders