The Challenge of Non-Communicable Diseases and Road Traffic ...

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62 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa TABLE 12: Illustrative HIV/AIDS Program Innovations Stewardship Financing and payments Human resources Infrastructure Commodities /supply chain Information /data Clinical services Transparent target-setting; ‘Three Ones’ principles * ; support for decentralization Performance-based financing, elimination of user fees, and innovative insurance schemes Training, mentoring, task-shifting, task-sharing, and engaging PLWH in care and support Renovations and repairs of clinical, counseling, laboratory, and pharmacy space Development and strengthening of procurement systems On-site medical records, electronic medical records, and ‘Three Ones’ approach Family-focused care, adherence support, and comprehensive primary care for PLWH Behaviors of providers and patients Multi-disciplinary teams, prominent use of counselors and peer educators, increased focus on adherence and psychosocial support, and enhanced demand/uptake of services Source: [211] * In 2004, donors, developing countries, and UN agencies agreed to three core principles – known as the “Three Ones” – to better coordinate the scale-up of national AIDS responses; namely, one agreed HIV/AIDS action framework that provides the basis for co¬ordinating the work of all partners; one national AIDS coordinating authority, with a broad based multi-sector mandate; and one agreed country-level monitoring and evaluation system [425, 426]. An integrated approach to the management of chronic diseases in LMIC, irrespective of cause, is being called for increasingly [427]. Suggestions include integrating the management of chronic NCDs such as diabetes and hypertension with those of chronic communicable diseases such as AIDS [428]. A focus on broad care needs rather than disease categories could be more beneficial in planning services [177]; and the establishment of multidisciplinary chronic disease clinics with standardized approaches could improve continuity of care [429], adherence to therapy [430], and in turn efficiency gains. It may also help to decrease the stigma often associated with some communicable diseases. Examples of ‘cross-fertilization’ of care between communicable and NCDs are given in Box 12. BOX 12: Cross-Fertilization of Care for Chronic Conditions Care models from HIV/AIDS, TB, and other communicable diseases are being extended or adapted to address other chronic conditions and co-morbidities. The DOTS framework (directly observed therapy, short-course) has been a cornerstone of TB control for over a decade. The model has also been developed to deliver ART successfully in Malawi, with simplified management protocols, uninterrupted drug supplies, and monitoring of standardized treatment outcomes and key contributory factors [431]. It was proposed that a similar paradigm could be adapted for NCDs [407] and aspects of the DOTS model have since been applied to the management of people with diabetes mellitus in Malawi [432]. Care for people with HIV/AIDS was resourced and expanding in Cambodia, but care for diabetes, hypertension and other chronic diseases was limited. During a three-year project, multi-disciplinary chronic disease clinics were established to offer integrated care for patients with HIV/AIDS, diabetes, and hypertension within the same clinic [428]. Services were well accepted by patients and continuity of care and adherence to treatment were achieved with good outcomes. Providing care for sero-positive patients and those with other conditions within the same facility also reduced HIV-related stigma. Chronic care models, more frequently used for the care of chronic NCDs, are also being applied to cover chronic diseases whatever their cause. Projects using such models to improve quality of care for chronic conditions such as HIV, hypertension, and diabetes are underway in Uganda, Tanzania, and South Africa [5, 422-423, 433]. There have also been moves to apply self-management programs from chronic NCDs to HIV care [434].
An Overview 63 Guidelines and Quality of Care Support for decision making by health care professionals in the form of evidence-based guidelines and other educational materials, educational meetings, audit, and feedback, improve their adherence to disease management guidelines and standardized case management, and improve patient outcomes [421]. High-quality drugs need to be procured and supplied at low prices and equipment upgraded and available. Successful implementation of guidelines requires wide distribution, training, and supervision of health workers, and evaluation in practice with appropriate quality or care and outcome measures [118]; this is not straightforward, given the shortages of health workers and funding and the organization needed. Nevertheless, the use of clinical guidelines as tools for linking allocative efficiency with the practice of care has already been discussed in Section 5.5 on ‘Health Financing’. Using models familiar from communicable disease care has been proposed for strengthening performance management [435]; and lessons learnt from efforts to improve quality of HIV/AIDS care may be applicable to promoting quality of care of those with NCDs. Elements include the number and mix of health staff, clinician performance, a safe and well-equipped health care environment, diagnostic support, and reliable drug supply [436]. Diagnosis and management of disease can be frustrated by the paucity or quality of equipment. Measurement of lung function or hypertension using simple and inexpensive methods can be a major issue for diagnosis and management of disease, given the limited access to spirometry and sphygmomanometers [51] for example. Adaptation of guidelines for use in low-resource settings to avoid dependence on laboratory measurement has been referred to already in relation to CVD risk assessment [308]. Efforts to scale up interventions for chronic diseases still tend to focus on individual diseases [349] or use a single disease guideline as a starting point [147]. This approach is likely to be unaffordable and unsustainable as populations age [215]. It risks confronting front-line health workers and patients with multiple disease management frameworks, which may be unworkable in practice for patients with multiple co-morbidities [437], and runs contrary to patient-centered care. Self-Management and Patient-Centered Care For developing countries, team-work and patient partnership may be as important as adequate funding [438]. Apart from the organization and quality of care, it can be a significant challenge in some settings to enable patients to understand the choices they have, and to make informed decisions, as well as to support patient compliance and active participation in treatment. Supporting patient self-management is worthwhile, central to good outcomes of NCD treatment, and has the potential to alleviate pressure on health and social services [439], especially given that people with long-term conditions manage these most of the time by themselves or with family members. Self-management support, particularly patient education about their condition and care and motivational counseling, improves patient adherence to treatments and outcomes, service use and satisfaction, and knowledge of their disease [421]. Patientcentered, self-management support is already provided to PLWH in Africa although its quality may vary [422]. An example of how patient self-management for HIV has been implemented and extended to cover other risk factors is given in Box 13. Supporting self-management is likely to work best as part of a wider initiative to improve care which also includes education of practitioners, effective use of evidence and technology , decision aids, and community partnerships [439]. Information provision alone is unlikely to be enough, and different clinical conditions may need varying approaches according to the self-care activities required. There is emerging evidence that strategies co-created by professionals and service users have positive outcomes [440]. Given the limited health service resources in low-income countries, ‘full self-management’, with the patient as the hub of disease management, supported by smart phone technology, peer support, and other resources such as primary care providers and informal care givers, has been proposed as an alternative to models of chronic care that are more provider-centered [441].
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The Challenge of Non-Communicable D
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THE CHALLENGE OF NON-COMMUNICABLE D
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TABLE OF CONTENTS Abstract.........
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List of Tables Table 1: Top 15 Lead
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LIST OF ACRONYMS AIDS Acquired Immu
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2 The Challenge of Non-communicable
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Page 20 and 21:
Page 22 and 23:
Page 25 and 26: 2. BURDEN OF NCDs AND RTIs This sec
Page 27 and 28: An Overview 13 A Rising Epidemic of
Page 29 and 30: An Overview 15 Types of Disease Ref
Page 31 and 32: An Overview 17 FIGURE 7: ASMR by NC
Page 33 and 34: An Overview 19 For young men, RTI a
Page 35 and 36: 3. THE DRIVERS AND DETERMINANTS OF
Page 37 and 38: An Overview 23 FIGURE 10: The Doubl
Page 39 and 40: An Overview 25 TABLE 5: Prevalence
Page 41 and 42: An Overview 27 Life expectancy has
Page 43 and 44: An Overview 29 employ business prac
Page 45 and 46: 4. THE RATIONALE FOR PUBLIC INTERVE
Page 47 and 48: An Overview 33 factors (given that
Page 49 and 50: 5. A COMPREHENSIVE, INTEGRATED APPR
Page 51 and 52: An Overview 37 clarity of vision an
Page 53 and 54: An Overview 39 Tobacco There is str
Page 55 and 56: An Overview 41 into account [255].
Page 57 and 58: An Overview 43 • Secure sustainab
Page 59 and 60: An Overview 45 financing and extern
Page 61 and 62: An Overview 47 percent) - or those
Page 63 and 64: An Overview 49 Several intervention
Page 65 and 66: An Overview 51 BOX 7: Country Respo
Page 67 and 68: An Overview 53 some NCD prevention
Page 69 and 70: An Overview 55 to fragmentation and
Page 71 and 72: An Overview 57 experienced shortfal
Page 73 and 74: An Overview 59 for managing chronic
Page 75: An Overview 61 In this example, a s
Page 79 and 80: An Overview 65 a balance needs to b
Page 81 and 82: An Overview 67 death statistics to
Page 83 and 84: An Overview 69 nations of intervent
Page 85 and 86: “As we start the journey of the n
Page 87 and 88: REFERENCES 1. The Economist, Africa
Page 89 and 90: An Overview 75 56. Bukhman, G. and
Page 91 and 92: An Overview 77 114. BeLue, R., et a
Page 93 and 94: An Overview 79 168. Stuckler, D., S
Page 95 and 96: An Overview 81 222. Narayan, K.M.V.
Page 97 and 98: An Overview 83 278. Catford, J., Im
Page 99 and 100: An Overview 85 336. O’Brien, M.,
Page 101 and 102: An Overview 87 390. Beran, D., A. M
Page 103 and 104: An Overview 89 444. The World Bank,
Page 105: MAP IBRD 39854: SUB-SAHARAN AFRICA
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