The Aga Khan Development Network, the Community and NCDs in Tajikistan
Controlling NCDs calls for an integrated, multi-sector strategy
Von John Wyn Owen & Lailo Kurbonmamadova, Rudoba Rakhmatova, John B. Tomaro
Tajikistan, the poorest republic in post-Soviet Central Asia, faces a range of disease burdens. The health system, which has only modest means to improve maternal and child health, now faces the serious challenge posed by non-communicable diseases (NCDs). These conditions are linked to unhealthy behaviours that can be improved if individuals, families and communities adopt health promoting practices. The health programme of the Aga Khan Development Network is working closely with the Department of Health in Gorno-Badakhshan Autonomous Oblast (GBAO) to mobilise the community to take responsibility for its health and to reduce the prevalence of NCDs.
With the collapse of the Soviet Union, the health system of Tajikistan became one of the weakest sectors of the newly independent republic. While the first years of independence were difficult for all the new ministries, the Ministry of Health was especially hard hit. In large measure, government’s attention was mainly focused on sectors other than health. In this period, therefore, international donor agencies provided critical support to health programmes. To maintain some of the strengths of the old system, the government focused initially on supporting secondary level services and providing some pharmaceuticals.
Country Response and Challenges to Addressing NCDs in Tajikistan
In the recent past, however, priorities in health have changed and currently the Ministry of Health has actively outlined a range of policies and strategies to improve the health status of the population (see the table below)
Health and Nutrition Indicators -
Republic of Tajikistan
|Under 5 mortality rate (per 1,000 live births)||17.7|
|Maternal mortality rate (per 100,000 live births)||46.2|
|Percentage of home births||12.9|
|Anaemia among children||18.6%|
|Iodine deficiency among children||43.4%|
|Anaemia among women of reproductive age||24.2%|
|Iron-deficiency anaemia among women of reproductive age||4.8%|
|Low BMI (too thin) among women||6.7%|
Source: Health Status and Performance of health facilities 2010”, MOH, Dushanbe 2011
One document of singular importance is the Comprehensive Health Sector Strategy (2010-2020) that calls for strengthening primary health care and managing effectively non-communicable diseases (NCDs).
According to the latest data from the Statistical Department of the Ministry of Health and analysed by WHO (see pie chart below), NCDs account for around 20% of the diseases in the country.
Prevalence of NCDs, Republic of Tajikistan (2011)
The most prevalent NCDs are cardiovascular diseases and cancer. Breast cancer is the most common cancer among women and the most frequent cause of female cancer mortality. The Global Burden of Disease Study (2010) showed that in terms of the number of years of life lost due to premature death in Tajikistan, ischemic heart disease was ranked the second highest (after lower respiratory infections). Stroke was ranked number six. Extant data suggest that the percentage of both ischemic heart disease and stroke have increased by almost 30% since 1990. For both ischemic heart disease and stroke, Tajikistan performs very poorly compared to countries in the same socio-economic category when it comes to disability-adjusted life years.
To address these health problems, the government approved the National Strategy for Prevention and Control of Non-Communicable Diseases and Injuries in Tajikistan (2012) for the period 2013-2023. While the strategy is well defined, implementation has been slowed by several factors including lack of clear lines of responsibility, lack of clarity as to its ownership, absence of dedicated financing, and competing priorities. Implementation of the National Healthy Lifestyle Programme (2011-2020), created to raise awareness of NCDs and promote healthy lifestyles, has also been stalled.
Supported by WHO, the MoH established the Working Group on Monitoring and Prevention of NCDs (2012). In collaboration with the Ministry of Health, WHO also launched a project to survey non-communicable diseases (NCD) and to document the prevalence of risks in the country. According to the project plan, interventions will be implemented to strengthen Primary Health Care and promote healthy lifestyles. The project, financed by EU, is designed to contribute to reshaping the existing health system to give greater attention to PHC and to enhance palliative care.
Non-communicable diseases could be significantly reduced with lives saved and untold suffering avoided by reducing risk factors, promoting early detection and timely treatment and focusing on adopting interventions within and beyond the health sector that address NCDs. Evidence suggests that many if not most NCDs can be prevented and/or controlled by effective interventions with respect to tobacco use, poor diet, physical inactivity and the excessive use of alcohol.
NCDs in GBAO: AKDN’s Strategy and Programme Approach
Gorno-Badakhshan Autonomous Oblast (GBAO) represents 45% of the territory of Tajikistan but only 4% of the population. The Aga Khan Development Network (AKDN) has been present in GBAO since 1993 and for over 20 years has been implementing a Multi-Input Area Development (MIAD) Programme that works with and through government at both oblast (provincial) and national levels and with local communities to improve the wellbeing of the community. This programme has implemented a wide range of interventions in rural development, education, microfinance, civil society and health. During the last five years the AKDN approach has been expanded to serve the communities in Khatlon Oblast and the Rasht Valley (Region of the Republican Subordination).
Results of programme interventions to date and anticipated by the end of 2013:
- Family Medicine programme covering 70 centres (pop. 89,647) in six of the seven districts
- Public awareness campaign -- prevention/promotion messages via mass media and CHPs
- Early detection, diagnosis and treatment by 46 trained FM physicians and 130 FM nurses
- Integrate NCD interventions into the community health /FM programme focusing on maternal, reproductive and child health care
- Promote FM specialists as ‘managers of care’ (focusing across the lifespan rather than on a disease)
- Health and Nutrition Survey (HNS) to document prevalence of NCD risk factors (2013)
In working to improve the functioning of the local health system and to enhance the quality of life of the communities, AKDN has rehabilitated health facilities, provided technical assistance to upgrade the competences of clinicians and managers of the health system and promoted appropriate health practices among the communities. Through projects like the Community-based Family Medicine (CBFM) Project, financed by the Swiss Development Corporation (SDC), AKDN is collaborating with the Department of Health in GBAO to deliver (i) family medicine training, (ii) exposure to clinical excellence, (iii) community health promotion, iv) community-based health financing and (v) generic pharmaceutical distribution and marketing. These components, like those of other projects implemented by AKDN, touch both the communities and the health system. Many of the activities promote increased awareness of NCDs and their associated risk factors by the communities and lead to the adoption of behaviours that reduce the risks.
While recognizing the policy-setting and health service delivery roles of the ministry, AKDN views the community as a powerful partner in creating awareness of the risks of NCDs and in adopting appropriate health behaviors that protect and promote good health. In creating community awareness of NCDs and others conditions, AKDN has trained and supports more than 900 Community Health Promoters (CHPs); these male and female volunteers inform and motivate their communities to practice health-promoting behaviors and serve as links between the communities and the health system.
Recognizing that lifestyle-related diseases are not linked only with operations in the health sector, AKDN is also implementing a range of interventions to increase income, improve educational attainment, create jobs and foster the creation of a vibrant civil society sector.
Although there are no assessments measuring the extent of NCDs in AKDN’s areas of operation, the Network assumes that the burden of NCDs in GBAO is similar to the pattern in place at the national level. Hospital data indicate that high blood pressure, obesity, high blood sugar and cholesterol are becoming increasingly common conditions in GBAO. These conditions are caused mainly by lifestyle-related, socially determined behaviours, namely, unhealthy diet, physical inactivity, tobacco use and the harmful use of alcohol. Breast cancer is also a frequent cause of female cancer mortality in GBAO and, as elsewhere in the country, the presentation of late-stage cancer leads to poor outcomes when combined with limited capacity for correct diagnosis and the provision of adequate therapy.
While data on the type and severity of NCDs in Tajikistan are incomplete, it is clear that targeting the main risk factors can have a significant impact on reducing the burden of NCDs. Thus, the specific objective of AKDN’s NCD community-based approach in GBAO is to promote healthy lifestyles, giving emphasis to programmes advocating smoking cessation, healthy diet, and a high level of physical activity. AKDN is also promoting screening using the services of the newly established Khorog Regional Diagnostic Unit and, in conjunction with the ministry, is supporting the provision of curative and/or palliative care
The Way forward to addressing NCDs in AKDN Programme Areas
AKDN has adopted the WHO package of Essential NCDs (PEN) to ensure that conditions related to NCDs are addressed in a comprehensive manner within the existing programs. As noted, the community plays a crucial role in raising awareness of the fact that many NCDs can be prevented and emphasising the importance of early detection. These measures are implemented by disseminating appropriate messages via mass media and IEC materials. In addition, where NCDs are suspected, AKDN promotes their early treatment at the PHC level where some of the newly trained Family Medicine specialists are based. Although tests and medications are often in short supply, the FM specialists can help patients manage their chronic diseases and they can treat illnesses that do not need higher level care. At the moment, there is no clear referral policy for patients with NCDs and the burden of accessing care falls on patients and their families. Establishing a referral system for the case management of NCDs and the provision of palliative care remain to be incorporated in the programme. Care guidelines and standard treatment protocols for the major NCDs are being developed and will soon be disseminated within the AKDN programme areas. These measures will rely on the presence of the KRDU for diagnosis and confirmatory testing and look to e-health connectivity to access specialist expertise based at higher level referral services within and beyond the borders of Tajikistan.
In addition AKDN will soon present the results of a household survey (HNS 2013) that will provide some baseline data on the NCDs risk factors in GBAO and in other areas where AKDN is operational
Another barrier to addressing NCDs in GBAO is the absence of appropriate data. Information on risk factors is not collected systematically and there is no information on complications, quality of health care, or health expenditures for NCDs. Nevertheless some surveys collecting data on alcohol, tobacco and other drugs associated with substance abuse have been collected. AKDN plans to add information on NCD risk factors to the next health and nutrition survey (HNS) to obtain additional data.
WHO surveys in Tajikistan report high levels of several NCDs and have identified the risk factors. The Ministry of Health has defined a National Strategy for the Prevention and Control of NCD, has established an NCD unit and launched information campaigns to raise awareness among the population. In GBAO and other areas of programme focus AKDN is in the process of working with partners – the community and the health ministry – to prevent and control NCDs.
The experience of AKDN to date indicates that controlling NCDs calls for an integrated, multi-sector strategy, a programme to promote healthy behaviours, and early diagnosis and effective treatment that includes palliative care. While the Government begins to take steps to put effective surveillance mechanisms in place, AKDN will continue to implement programme to create awareness of NCDs among the communities and encourage them to adopt behaviours that prevent the onset and modulate the severity of NCDs.
*Lailo Kubonmamadova, Health Programme Officer, Aga Khan Foundation, Dushanbe, Republic of Tajikistan. Kontakt: Lailo.Kurbonmamadova@akdn.org
Rudoba Rakhmatova, Senior Health Programme Officer, Aga Khan Foundation, Dushanbe, Republic of Tajikistan, Kontakt: email@example.com
John B. Tomaro, Director, Health Programme, Aga Khan Foundation, Geneva, Switzerland, Kontakt: firstname.lastname@example.org.