Improving the health systems response to chronic diseases in Africa

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Epidemiology and Population Health

Abstract

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.

Technical Summary

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.

Publications

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Katende D (2015) Readiness of Ugandan health services for the management of outpatients with chronic diseases. in Tropical medicine & international health : TM & IH

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Lloyd-Sherlock P (2014) Is hypertension the new HIV epidemic? in International journal of epidemiology

 
Description Feedback to MoH Tz
Geographic Reach National 
Policy Influence Type Gave evidence to a government review
Impact The project comprised cross-sectional surveys to determine the burden of NCDs at the population and at the health services level, followed by a trial of a low-cost intervention to improve NCD services in Tanzania and Uganda. The study results influenced views of health authorities in these countries on the urgent need for health service improvements for NCDs. Health service delivery on NCDs have improved over the last few years in both countries. - It should be noted that these positive effects cannot be allocated to the research project only (and the evidence for this would be difficult to establish). Instead the research results addressed information needs and reinforced efforts that African (and other) countries have engaged in since heads of states committed themselves to strengthen NCD control when they convened at UN General Assembly meetings held in 2011, 2014 and 2018.
 
Description Feedback to MoHs
Geographic Reach National 
Policy Influence Type Gave evidence to a government review
 
Description Presentation of research results to policy makers and diabetes associations
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Gave evidence to a government review
Impact Improvement of access to primary care services for non-communicable diseases, in particular hypertension and diabetes in Uganda and Tanzania. The long term impact is not yet known as health services in both countries face a shortage of medicines for these diseases at primary care level.
 
Title survey tools 
Description (1) Modification of the WHO SARA questionnaire for the assessment of health service readiness; (2) A self-completed questionnaire to assess the knowledge of health workers on selected chronic diseases and to assess their experience and readiness regarding the diagnosis and treatment of these diseases; (3) Modification of the WHO STEP data collection tool on chronic diseases for use in general populations in Tanzania and Uganda. 
Type Of Material Biological samples 
Year Produced 2014 
Provided To Others? Yes  
Impact These materials are avaibale to be shared with other research groups on request. They are also accessible though a journal website, e.g. by looking up under 185. Peck R et al. Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: a cross-sectional survey. Lancet Glob Health. 2014 May;2(5):e285-e292. PMID: 24818084 In 2015 we shared tools with researchers from Ethiopia who plan to conduct a STEPS survey. In 2019 we shared tools with researchers of the Infectious Disease Research Collaboration (IDRC) and the MoH Uganda to assist in the design and the development of research tools for a randomised controlled trial on strategies to integrate hypertension care with HIV care. This trial is EDCTP funded; it commenced in 2020 and is being conducted in 20 districts of Uganda. 
 
Description Contribution to the design, implementation and governance of a randomised trial on the integration of NCD/HIV care in Uganda 
Organisation Infectious Diseases Research Collaboration (IDRC)
Country Uganda 
Sector Academic/University 
PI Contribution Following the results from and the reputation of our previous research on the response to the NCD epidemic in East Africa, HG has been invited to contribute to protocol development, research tool development, study implementation and governance (TSC) of a trial conducted by IDRC Uganda of an innovative strategy to integrate NCD care and HIC care. The study is being conducted in 52 health facilities from 20 districts of western Uganda. The study is being implemented by IDRC, MoH Uganda, Uganda Heart Institute and LSHTM.
Collaborator Contribution Securing funding, trial management, implementation and governance
Impact A trial has started in March 2020 to evaluate a strategy for the integration of NCD (hypertension) care and HIV care, conducted in 52 health facilities from 20 districts of western Uganda. The research is funded by the EDCTP. Following the outcomes of previous UKRI funded research (award on 'Improving the Health Systems Response to chronic diseases'), HG has been invited to contribute to the protocol and research design of this trial and to serve on the Project Implementation Group and the Trial Steering Committee.
Start Year 2020
 
Description MITU 
Organisation National Institute for Medical Research, Tanzania
Department Mwanza Intervention Trials Unit (MITU)
Country Tanzania, United Republic of 
Sector Public 
PI Contribution Collaboration on study steering committee; support of research design and planning; scientific advice during study implementation and preparation of publications; contribution to senior management team of the Unit.
Collaborator Contribution Collaboration on study steering committee; coordination of research with MoH Tanzania; planning and implementation of four cross-sectional studies in phase 1 of the award. Preparation of publications.
Impact Completion of a population based survey on NCDs and HIV infection, a health facility (HF) survey, qualitative studies at population and HF level; costing data collection - all within phase 1 of the work under this award. Four publications in preparation.
Start Year 2011
 
Description MRC Uganda 
Organisation MRC/UVRI Uganda Research Unit on AIDS
Country Uganda 
Sector Public 
PI Contribution Collaboration on study steering committee; support of research design and planning; scientific advice during study implementation and preparation of publications; contribution to senior management team of the Unit.
Collaborator Contribution Collaboration on study steering committee; coordination of research with MoH Uganda; planning and implementation of cross-sectional studies in phase 1 of the award. Preparation of publications.
Impact Outputs: Completion of a population based survey on NCDs and HIV infection, a health facility (HF) survey, qualitative studies at population and HF level; costing data collection - all within phase 1 of the work under this award. Four publications in preparation.
Start Year 2011
 
Description MRC Uganda 
Organisation MRC/UVRI Uganda Research Unit on AIDS
Country Uganda 
Sector Public 
PI Contribution Collaboration on study steering committee; support of research design and planning; scientific advice during study implementation and preparation of publications; contribution to senior management team of the Unit.
Collaborator Contribution Collaboration on study steering committee; coordination of research with MoH Uganda; planning and implementation of cross-sectional studies in phase 1 of the award. Preparation of publications.
Impact Outputs: Completion of a population based survey on NCDs and HIV infection, a health facility (HF) survey, qualitative studies at population and HF level; costing data collection - all within phase 1 of the work under this award. Four publications in preparation.
Start Year 2011
 
Description MoH Tanzania at national and regional level 
Organisation Ministry of Health, Uganda
Country Uganda 
Sector Public 
PI Contribution Collaboration on study steering committee; provision of new data on NCDs and on the health services for NCDs in NW Tanzania. Collaboration on publications still expected from this award.
Collaborator Contribution Collaboration on study steering committee; approval of research plans; support to study implementation; recognition of research results on current health services; suggestions for intervention design for activities to be conducted in phase 2 of the award. Collaboration on publications still expected from this award.
Impact Outputs: Completion of a health facility (HF) survey. Publications.
Start Year 2011
 
Description MoH Uganda 
Organisation Ministry of Health, Uganda
Department Non Communicable Diseases
Country Uganda 
Sector Public 
PI Contribution Collaboration on study steering committee; provision of new data on NCDs and on the health services for NCDs in SW Uganda.
Collaborator Contribution Collaboration on study steering committee; approval of research plans; support to study implementation; recognition of research results on current health services; suggestions for intervention design for activities to be conducted in phase 2 of the award.
Impact Outputs: Completion of a health facility (HF) survey. Publications in preparation.
Start Year 2011
 
Description Dissemination meeting with senior colleagues from Moh, International Diabetes Foundation NCD advisers 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Final dissemination workshop at end of trial
Year(s) Of Engagement Activity 2017
 
Description Feedback MoH 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Presentation of research results from phase 1 and 2 of the award to policy makers and district health services managers in Uganda and Tanzania. Discussion of potential policy implications, and of activities for final phases of the award.

Repeated contact with MoH officials and District Medical Officers in Uganda and Tanzania

National NCD programme leaders and district health services managers in Uganda and Tanzania confirmed earlier committments made to collaborate closely on activities of the award. Subsequently we observed a tangible increase in the support of efforts with respect to the control of non-communicable diseases in their areas of jurisdiction.
Year(s) Of Engagement Activity 2013,2014,2015
 
Description Teaching on DTMH course run by the Institute for Tropical Medicine Hamburg, Germany - Lectures on NCD epidemiology and control in LMICs. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact About 50 medical doctors and public health experts attended a set of 5 lectures (including discussions and small planning exercises) on the epidemiology of and the public health response to the NCD epidemic in LMICs. This is part of the Diploma Course in Tropical Medicine and Hygiene at the Bernard-Nocht-Institute for Tropical Medicine, Hamburg, Germany.
Year(s) Of Engagement Activity 2018,2019
 
Description Teaching on DTMH course run in Tanzania and Uganda by the London School of Hygiene and Tropical Medicine (LSHTM) - Lectures on NCD epidemiology and control in LMICs. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact About 50 medical doctors and public health experts attended a set of 3 lectures and discussions on the epidemiology of and the public health response to the NCD epidemic in LMICs. This is part of the Diploma Course in Tropical Medicine and Hygiene conducted by LSHTM, conducted at Makerer University, Kampala, Uganda.
Year(s) Of Engagement Activity 2014,2015,2016
 
Description Teaching on a study module attended by MSc students at LSHTM. Lecture and practical - NCD epidemiology and control in LMICs. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact About 70 medical doctors and public health experts attended a lecture and practical on the epidemiology of and the public health response to the NCD epidemic in LMICs. This is part of a study module on 'Applying Public Health Principles in Developing Countries' affiliated with an MSc course at LSHTM.
Year(s) Of Engagement Activity 2018,2019,2020