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 to 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 the 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. Competing Interest Statement The authors have declared no competing interest. Funding Statement GTB-M & FL (NIHR201708) and CLG (NIHR302394) are funded by the National Institute for Health and Care Research. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: In Malawi, the College of Medicine Research & Ethics committee (COMREC) REF P.11/21/3462 approved the study (under Multilink). In Zimbabwe, the Medical Research Council of Zimbabwe (MRCZ/A/2842), Joint Research Ethics Committee of the Parirenyatwa Group of Hospitals and University of Zimbabwe Faculty of Medicine and Health Sciences (386/2021), the City of Harare, and the London School of Hygiene and Tropical Medicine (26469) approved the study (under KnowM). All interviewees gave informed consent. Some signed a virtual form while others gave oral consent during a recorded video call. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability All data generated or analysed during this study are included in this published article [and its supplementary information files]. Anonymised copies of original transcripts can be shared upon reasonable request.