The cornerstone of NCD care in Zimbabwe
When it comes to long-term care of chronic conditions, human resources make up the indispensable core of any intervention. In low-income countries, training and support can be a challenge.
A 2015 study pointed out that, in many cases, Community Health Workers (CHW) are the only medical staff accessible to local populations. They should therefore have training, supervision and logistical support to help with the detection and treatment of hypertension, diabetes, and other priority chronic diseases. Furthermore, the greater their capacity to provide advice about diet, physical activity, and other healthy lifestyle habits (such as avoidance of smoking and excessive alcohol intake) the more impact they can have on non-communicable disease (NCD) management.
The newest generation of CHWs who tend to be on the frontlines of disease control in rural Zimbabwe are seeing an increase in NCDs. Though the health sector is in the process of recovering from its past, doctors and nurses are still few and far between. The majority go to countries where the conditions of service are better.
However, CHWs come from within the rural communities – typically young people with around eight to twelve years of schooling. Yet when properly trained and supported as part of the local primary health system, CHWs save lives on par with doctors and nurses.
CHWs understand, and bring cultural knowledge and sensitivity to their positions, so they know better then others how to bring up personal medical questions. And they are able to reach vulnerable individuals – the very poor, remote, elderly and disabled – that would not be able to go to clinics for help. CHWs have been a key part of the primary health system for almost a decade in Zimbabwe.
Zimbabwe, a country that has historically experienced a particularly high burden of HIV, has seen recent declines in its HIV incidence. One result of this is that older adults compromise an increasingly large proportion of people living with HIV (PLHIV) in Zimbabwe.
As reported in the AIDS Society Journal: “A recent study from Zimbabwe has reported that the NCD burden amongst PLHIV is substantial, with 19.6% diagnosed with at least one NCD and 4.6% with multiple NCDs.”
That article notes the need to adapt the roles of CHWs in Zimbabwe. In recent decades, their activities have been heavily focused on controlling the spread of HIV, as well as child and maternal health initiatives. Their training and presence in communities should now be leveraged to address NCDs, both among the general public and PLHIV (who are now twice as likely to suffer from one or more NCDs as the average).
“Some important changes are already underway that may facilitate these efforts. HIV programs are shifting from vertical programs, focused on HIV diagnosis and treatment, to integrated care management, incorporating testing and treatment for other conditions and exploring community-based delivery. Recent World Health Organization (WHO) guidelines have promoted integrated and differentiated care, which increasingly seeks to minimise the requirement of PLHIV that are stably virally suppressed to attend clinics. As the PLHIV population ages, new protocols should carefully consider the extent to which patients with NCDs should have differential care, and balance the benefits of reduced treatment monitoring intensity against the benefits of risk group identification, screening and management of NCDs among PLHIV.” (AIDS Society Journal)
However, due to the lack of detailed data on lifestyle factors, such as smoking, alcohol consumption, diet and exercise and lack of robust projections on how these factors may change in the coming 20 years, community health workers have to give the same advice to everyone. This in turn makes their job harder and creates significant challenges around the fact that the profile of PLHIV in Zimbabwe and throughout Africa is changing. Failing to adapt the care that they receive could lead to deteriorating outcomes for PLHIV and further strain fragile health systems.
NCD care is complicated. Add HIV to the mix and horizontal treatment programmes become ineffective and inefficient. But research still needs to be done into how the many competing priorities can be managed effectively with the limited resources that are available to them.
The promotion of healthy diets is another area where CHWs could have an enormously positive effect. The increase in NCDs in countries like Zimbabwe has accompanied the on-going move towards urbanisation, and the switch to more calorific but nutrient-poor diets that has been made by many urban residents. Dr Bernard Madzima, the Zimbabwe Health and Child Care Ministry’s family health director, has called it a “slow-motion disaster” overtaking his country.
In June, a team from the Defeat-NCD Partnership went to Zimbabwe to explore and initiate the potential country activities of the Partnership while strengthening capacity and scaling up universal access and coverage to NCD services in Zimbabwe. The mission was very fruitful and productive, engaging with different levels of actors in the area: international, national, county and community levels. Field visits were a real eye-opener on the actual problems and the reality of sick people in their communities. Along with these communities and their support systems, it is hoped that the Partnership will be able to make a difference to the vertical process of NCD care in this country. By understanding NCD coordination, performance and governance along with the situation of disease burden and access, coverage and quality of services, potential partners will be able to move forward strategically in the coming years.