Boost of cardiovascular diseases at Lugala Hospital in rural Tanzania

Non-communicable diseases (NCDs) - an increasing threat for poor people in rural Africa

Von Peter Hellmold & Frank Jacob

The World Health Organisation estimates that deaths from NCDs in the African region will increase by 27% by the year 2030, that is 28 million additional deaths. In Tanzania, at least 31% of all deaths have been associated to NCDs. The main killers are Cardiovascular Diseases (9%) and Cancers (5%). These numbers are of great concern, and this article serves as a reality check against these global and national numbers and trends. It reports experiences and data from Lugala Hospital, situated in the Malinyi District, Tanzania, where SolidarMed supports the availability and quality of health services since 2005 and where NCDs are now a major cause of morbidity and mortality of adult inpatients.

Non-communicable diseases (NCDs) - an increasing threat for poor people in rural Africa

One of the classical NCD is the cataract (‘grey star’) in elder people.Here: a woman at Lugala Hospital’s Primary Eye Care Clinic being examined with the slit lamp. Photo © SolidarMed

 

SolidarMed is the Swiss Organisation for Health in Africa. Its overarching goal is to improve the health of 1.5 million people living in 5 countries in sub-Saharan Africa (Lesotho, Mozambique, Zambia, Zimbabwe and Tanzania). SolidarMed’s vision is that all people have equal and financially secured access to good health care. In its current strategy, infectious diseases and maternal, neonatal, child and adolescent health are focus themes of the programme. Nevertheless, recognizing that non-communicable diseases (NCDs) have also become an important burden and will gain in importance in the near future in the programme areas, SolidarMed has taken up the task to investigate, explore and develop NCD strategies, that can address the rising burden in its target populations.

SolidarMed addresses such multifaceted challenges through focused – geographically and thematically – and cost-effective, sustainable health system strengthening measures. Through the transversal benefits of good health, it therefore strives to directly contribute to the Sustainable Development Goals 1, 3, 5, 8, 10 and 17 (Transforming our world: the 2030 Agenda for Sustainable Development).

Local Context

The Malinyi Districtis located in the lowlands of the Kilombero river, in southern Morogoro Region in Tanzania. Literacy rate is below 60% and the average daily per caput income is less than 1 CHF. The population (164 000 inhabitants) pyramid shows the characteristic shape of a poor socio-economic area with 48% of people being below fifteen years of age. Life expectancy in this remote region is 61 years and fertility, morbidity and mortality are high. Teenage pregnancies make up for 25% of all deliveries at the Lugala Hospital. Malaria is holoendemic, intestinal worm load is high, and a quarter of all children admitted to the hospital has significant anaemia. Forty-eight percent of the population is stunted due to chronic malnutrition.

With more than 50 deaths per 1000 live births, child mortality remains too high and can mainly be attributed to malaria, respiratory infections and acute intestinal tract infections. For adults, HIV/AIDS and tuberculosis are additional important contributors to morbidity and mortality.

While the above burden still reigns the scale, today, the spectrum of NCDs in the same population has widened and are more frequently recorded. This, despite the fact that the world-wide hazards of environmental pollution of air, soil and water as well as neuropsychiatric disorders, substance use and the burden of excessive obesity have not yet critically reached the Malinyi District.

Directly from the health records

Until recently, communicable diseases have represented the major burden of disease for adults and children in the remote Malinyi District.  While this is still true for children, the burden has changed for adults. Cardio-vascular diseases – and in particular strokes– are a major cause of morbidity and mortality of adult inpatients. Chronic respiratory diseases, cancers and Diabetes mellitus type II are increasingly diagnosed and represent a spectrum of diseases that was hardly diagnosed a decade ago.

Figure 1: In-patient data, Lugala Hospital. 1400 diagnoses from 1 Jan – 30 June 2017. All ages, both genders. “Communicable diseases” also include maternal, perinatal and nutritional conditions. 

 

The new spectrum of diseases (Cardio-vascular diseases, diabetes, chronic respiratory disease and diabetes mellitus) represent 12% of all diagnoses and half of all NCD diagnoses, excluding injuries. The inclusion of children into the data set is reflected by the dominance of 66 % of communicable diseases, maternal, perinatal and nutritional conditions (Figure 1). Looking at only the adult population, communicable, maternal, perinatal and nutritional conditions are just above half of all diagnoses, whereas the new spectrum of diseases – excluding injuries – account for 52% of all the diagnosed NCDs in this population, predominantly, cardio-vascular diseases (Figure 2).

Figure 2: In-patient data, Lugala Hospital. Adults only (>16y of age). 769 diagnoses from 1 Jan – 30 June 2017, both genders.

 

Experiences, Observations and Challenges

While the data are clearly calling for action, the service delivery side still struggles to deal with the new situation. Eighty percent of the patients admitted with hypertensive complications know that they have arterial hypertension; and, 80% of those who know about their diagnosis, are aware that their condition requires continuous treatment. Most of these patients had already taken medication in the past, however, often only for one or two weeks! Discontinuation of treatment and/or irregular intake is frequent in this patient population. More so, these patients only re-engage in treatment once the situation becomes acute.

In case of arterial hypertension – however – many years can go by before the first symptoms manifest. Obviously, this often leads to late presentation at the hospital as the condition receives less priority from the patient and his/her family members compared to the daily challenges of poverty.

The patient’s treatment is also hindered by external factors, such as costs. While treatment for Aids and tuberculosis are free in Tanzania, drugs for cardio-vascular diseases and diabetes must be paid by the patient. Notably, this often incurs on-going, sometimes life-long costs for medication. As of today, no global basket has been established to alleviate the financial pressure on the patient.

The main challenge from a service provider’s point of view, is therefore to convince the patient with arterial hypertension – who makes a living on less than one dollar a day – to invest in a condition without – yet – suffering from symptoms, and which he/she does not perceive as a health hazard.

Arterial hypertension can therefore be considered a silent killer in such context. Patients admitted to the hospital demonstrate clearly the consequences of the delay in treatment: development of an irreversible state resulting from e.g. cerebral insult.

Successful adherence counselling needs profound professional skills. Here: a counselling session at Lugala Hospital’s OPD. Photo: © SolidarMed

 

Based on our experience, adherence counselling of patients with arterial hypertension or Diabetes mellitus type II is also more challenging than counselling of persons living with HIV/Aids or tuberculosis patients. Changes in lifestyle and diet are challenging for any patient but even more so for patients living in absolute poverty with limited alternatives. In addition, most of the diagnosed arterial hypertension must be classified as essential hypertension, given obesity and other lifestyle risk factors are not a striking feature in Malinyi District yet. Repeated counselling in form of triangulation would be needed, however, will put additional strain on an already overburdened health system.

The health system itself demonstrates classical gaps, such as insufficient or out-of-order equipment, lack of maintenance and replacement and unreliable supplies, as well as the inability to manage patient files over the entire life of the patient.

Finally, poverty and illiteracy lead to reduced health seeking and late presentation of disease, which in turn increases the risk of complications. Gender inequalities influence health seeking behaviour, access to health facilities and acceptance of treatment. Traditional beliefs and disease models result in non-acceptance of scientific concepts, most clearly witnessed when men decide about the treatment for their women and children.

One of the newly emerged and further emerging NCD is Diabetes mellitus. Here: Pregnant women at Lugala Hospital’s Reproductive Health Clinic undergoing an Oral Glucose Tolerance Test (OGTT). Photo: SolidarMed

 

Approaches and next steps

As complex and multifaceted the growing NCD burden is, as complex and multi-level the response must be. At the Lugala Hospital, we can address some of these responses directly (population and service delivery level) but rely on other actors to push agenda items forward on other levels. The Lugala Hospital is – however – committed to provide these actors and national authorities with all necessary information to get the health system prepared to face this double burden of disease and actively seeks partnerships and collaborations to overcome the situation.  

System level

  • Across all levels, the continuum of care for the person/patient needs to be guaranteed. This starts with prevention of NCDs in the communities and schools, to early recognition and diagnosis, counselling and adequate treatment, patient-friendly chronic disease management (e.g. bringing services closer to the patient); and, it includes alleviating the financial burden on the patient, by introducing pro-poor payment schemes
  • A close cooperation and coordination between hospitals, district, regional and national Health Authorities as well as cooperation partners is a pre-requisite
  • Such initiatives are then likely to lead to a revision of current national guidelines

Service delivery level

  • Adequate infrastructure, equipment and personnel are at the core of quality services
  • Continuous training and supervision of health staff is required to ensure patients are well counselled and cared for
  • Decongestion at the outpatient clinics (differentiated care models for chronically ill – and adherent – patients), may create room for repeated counselling and the care of unstable patients
  • Task sharing and task shifting among health staff has proven effective and requires the involvement of community health workers to achieve coverage

Patient (population level)

  • Enabling equitable access to health services is the overall vision for this poverty stroke region
  • Health empowerment through health education, awareness building, and health seeking is therefore of utmost importance
  • Strengthening community committees can further support the promotion of addressing gender issues, right to health care and organizing referral /financing systems
  • Health promotion on NCDs in this setting appears more challenging though: The common messages of lifestyle changes, reduction of soda-drink and junk-food consumption, as well as abandoning the sedative lifestyle do not seem appropriate for the majority of this poor population. This calls for the development of new, adapted messaging.

SolidarMed included NCDs as a focus area for the current strategy and is committed to develop adequate strategies to alleviate the problem jointly with its partners and beneficiaries. It is drawing from its vast experience in the roll out of antiretroviral treatment in three countries and is currently in the process of translating the lessons learnt into a comprehensive NCD response in its programme areas.

References

Peter Hellmold & Frank Jacob

Peter Hellmold is the medical officer in charge of the rural Lugala Hospital in Tanzania. He is employed by SolidarMed and coordinates the SolidarMed support to Lugala Hospital.

 
Frank Jacob
is a regional medical officer for the Morogoro region in Tanzania.