Improving the health systems response to chronic diseases in Africa

In recent years it has been observed that primary health care services in Africa, most of which are working under severe resource limitations, are confronted with the additional problem of a growing burden of treatable chronic diseases (CDs). Common CDs include HIV infection, hypertension, heart failure, diabetes, asthma and epilepsy. Unfortunately current health policies and practices are often inappropriate to address this burden, and accurate data about the burden of CDs, required for health planning, are often not available. A research programme is proposed in Uganda and Tanzania that will document current policies, assess the burden of CDs in the population and document the quality of existing health services for CDs. Based on the findings and in collaboration with health policy makers and programme managers in both countries, we will design and implement an intervention package that aims to improve the health system through training and the introduction of standardized cost-effective diagnostic and treatment procedures, complemented by health education of patients and communities. We will evaluate the effectiveness of the intervention in improving the services provided by health facilities. Finally, we will work with policy makers and service managers to change policies in the light of the research results obtained.

Primary health care services in Africa are facing a growing burden of chronic diseases (CDs), due to the rapidly increasing incidence of chronic non-communicable diseases (NCDs) and because HIV infection has become a manageable chronic condition. In many countries, health services are ill equipped to respond to this situation: accurate data required for planning are scarce, policies on CDs inadequate and standardised protocols for diagnosis and management often not available. Health workers have little training in providing CD care including the provision of anti-retroviral therapy. The choice of drugs for NCDs is rarely rational, and drug supplies are erratic. In consequence a large proportion of patients with CDs are inadequately managed.
We propose a research programme in southern Uganda and northern Tanzania that will address this complex problem through a multi-faceted approach. The programme will be planned and implemented in close collaboration with health policy makers and programme managers. During the first phase of the research we will (i) document existing policies and epidemiological data, (ii) assess the burden of HIV infection and other important CDs (including hypertension, cardiac failure, diabetes, asthma and epilepsy) through a cross-sectional population survey of 800 participants in each of the countries, recruited from urban, peri-urban and rural areas using a stratified multi-stage sampling approach, and (iii) conduct a survey of the quality of current CD services in about 24 health facilities in both countries. The results will be used to plan and implement an intervention that aims to improve the health system so that it will cope more effectively with CDs.
The intervention will reflect the fact that the requirements for the management of chronic HIV infection and non-communicable CDs are similar. It will comprise standardized diagnostic, treatment and referral procedures, opportunistic screening for CD risk factors and symptoms, training and supervision of health workers, and health education for patients and communities. The intervention will be introduced stepwise. Facilities will be randomised to receiving the intervention earlier or later, stratified by type of facility.
After 12 months of implementation, we will evaluate effectiveness using a controlled design. Through substudies we will investigate cost-effectiveness, possible adverse effects on other essential services, and changes of perceptions of CDs at community level. Working with policy makers and service managers, the results will be used to facilitate changes in health policy aiming to improve CD services in general.