Readiness of the primary care system for non-communicable diseases in sub-Saharan Africa
Authors: Andre Pascal Kengne, Bongani M Mayosi
Journal: The Lancet Global Health (2014)

According to WHO global health estimates,1WHOHealth statistics and health information systems—Global Health Estimates (GHE), 2013.http://www.who.int/healthinfo/global_burden_disease/en/Google Scholar chronic non-communicable diseases (NCDs) are the second leading cause of death in Africa. In 2011, NCDs accounted for 30% of the 9·5 million deaths, and 25·8% of the 675·4 million disability-adjusted life years (DALYs) recorded in Africa. NCDs are emerging in both rural and urban areas, most prominently in people living in low-income urban settings, and are resulting in increasing pressure on acute and chronic health-care services.2Mayosi BM Flisher AJ Lalloo UG Sitas F Tollman SM Bradshaw D The burden of non-communicable diseases in South Africa.Lancet. 2009; 374: 934-947Summary Full Text Full Text PDF PubMed Scopus (701) Google Scholar Within the broad category of NCDs, stroke, hypertensive heart disease, diabetes, and chronic kidney disease have been identified as the leading disorders in the region.3Mayosi BM Lawn JE van Niekerk A et al.Health in South Africa: changes and challenges since 2009.Lancet. 2012; 380: 2029-2043Summary Full Text Full Text PDF PubMed Scopus (342) Google Scholar In Africa, between 2000 and 2011, the relative contribution of NCDs to death increased by 7·1% points and to DALYs increased by 6·4% points.1WHOHealth statistics and health information systems—Global Health Estimates (GHE), 2013.http://www.who.int/healthinfo/global_burden_disease/en/Google Scholar WHO has projected that by 2030 NCDs will exceed communicable diseases as the most common cause of death in Africa.1WHOHealth statistics and health information systems—Global Health Estimates (GHE), 2013.http://www.who.int/healthinfo/global_burden_disease/en/Google Scholar, 4WHOThe global burden of disease: 2004 update. World Health Organization, Geneva2008Google Scholar The increasing trend in the age-adjusted incidence of major NCDs in Africa and other developing countries contrasts with the decreasing patterns observed in high-income countries.5Feigin VL Lawes CM Bennett DA Barker-Collo SL Parag V Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review.Lancet Neurol. 2009; 8: 355-369Summary Full Text Full Text PDF PubMed Scopus (1968) Google Scholar This contrast partly results from differences in the capacity of countries to respond adequately to the emergence of NCDs. Health and demographic transitions leading to the surge of NCDs in Africa are occurring faster than those observed in developed countries, thereby compressing the timeline for effective adaptation.6Nikolic IA Stanciole AE Zaydman M HPN discussion paper. Chronic Emergency: Why NCDs Matter. The World Bank, Washington, DC2011Google Scholar The epidemic of NCDs is occurring in African countries that are still yet to develop economically, and still confronted with vital priorities in areas such as maternal and child health and major infectious diseases, and seem unprepared to cope with the growing challenge of providing preventive and curative care for NCDs.7Kengne AP June-Rose McHiza Z Amoah AG Mbanya JC Cardiovascular diseases and diabetes as economic and developmental challenges in Africa.Prog Cardiovasc Dis. 2013; 56: 302-313Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar According to WHO NCD country profiles for 2011,8WHONoncommunicable diseases country profiles 2011. World Health Organization, Geneva2011Google Scholar the capacity of countries to address NCDs varies substantially across Africa, with suggestions that NCDs are increasingly receiving attention across the continent. For instance, as of 2009–10, about 89% of African countries had dedicated departments in charge of NCDs within the national ministry of health. However, only about 26% of the countries had a functional programme or action plan for diabetes, for instance. Therefore, the good will of decision makers regarding NCDs has yet to be translated into concrete actions to better the health of populations at the interfaces of health-care delivery. In The Lancet Global Health, Robert Peck and colleagues9Peck R Mghamba J Vanobberghen F et al.Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: a cross-sectional survey.Lancet Glob Health. 2014; (published online April 14.)http://dx.doi.org/10.1016/S2214-109X(14)70033-6Google Scholar report the results of a cross-sectional evaluation of the preparedness of 24 public and not-for-profit Tanzanian health facilities to provide routine care for selected NCDs. Chronic diseases accounted for 58% of outpatients adult visits, of which about half were for HIV care and a quarter for three NCDs (hypertension, diabetes, and epilepsy). Chronic disease visits overwhelmingly occurred at hospitals as opposed to primary-care facilities. Compared with care for HIV, health facilities at all levels were ill-prepared to address the diagnosis, treatment, and ongoing monitoring needs of patients with NCDs. Low-level facilities were least prepared. Peck and colleagues make some recommendations to strengthen the health system to face the rising NCDs in the country. The findings of Peck and colleagues9Peck R Mghamba J Vanobberghen F et al.Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: a cross-sectional survey.Lancet Glob Health. 2014; (published online April 14.)http://dx.doi.org/10.1016/S2214-109X(14)70033-6Google Scholar are in major ways expected and apply to many developing countries. However, the quest for solutions must integrate many other important questions. To what extent is the report by Peck and colleagues specific for NCDs and not only a reflection of an overall non-optimum health system? Answering this question will help to segregate solutions into those targeting an overall improvement in the health system, and those specifically addressing NCDs. Tanzania has had Standard Treatment Guidelines10The United Republic of Tanzania Ministry of Health and Social WelfareStandard Treatment Guidelines (STG) and The National Essential Medicines List (NEMLIST) for Mainland Tanzania. 3rd edn, 2007.http://apps.who.int/medicinedocs/documents/s16199e/s16199e.pdfGoogle Scholar since 1991 in the form of a combined document that covers the disorders researched by Peck and colleagues. The guidelines are a national policy that health workers in the country are expected to implement. If the absence of guidelines referred to by Peck and colleagues also extends to the Tanzanian Standard Treatment Guidelines, then wide dissemination of this document as opposed to concentrating on NCD-specific guidelines will probably have a huge effect. The next question relates to the outcomes of care for NCDs under the existing scenario, and how these compare with the outcomes of care for conditions such as HIV that have received much attention. This question will help to determine which areas of care for NCDs need simple improvements and which areas must be completely redesigned. Another question refers to the determinants of the health-seeking behaviours of patients with NCDs. Efforts to prepare the primary health-care facilities to address NCDs must integrate those factors that in the study setting are currently motivating the preference of patients with chronic diseases to high-level facilities as opposed to primary-care facilities. A final question relates to whether actions at health facilities alone will be enough to achieve the expected effect for priority NCDs, many of which are silent killers, and also in settings where regular health checks are not a common practice. Perhaps it is time for developing countries to devise strategies to proactively deliver prevention and control interventions for NCDs beyond health facilities, including for high-risk individuals. We declare that we have no competing interests. Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: a cross-sectional surveyMost outpatient services for NCDs in Tanzania are provided at hospitals, despite present policies stating that health centres and dispensaries should provide such services. We identified crucial weaknesses (and strengths) in health systems that should be considered to improve primary care for NCDs in Africa and identified ways that HIV programmes could serve as a model and structural platform for these improvements. Full-Text PDF Open Access