Bringing heart disease services closer to home in Eswatini
Cardiovascular disease is the world’s biggest killer, claiming 17.7 million lives every year. Eighty percent of all cardiovascular deaths are from heart attacks and strokes, and 75 percent of those occur in low- and middle-income countries. As we make progress in the fight against communicable diseases, the global burden is shifting to non-communicable diseases (NCDs), of which cardiovascular disease accounts for the most deaths. Governments must come up with ways to tackle this new public health threat.
In Eswatini, it is predicted that by 2030 NCDs, especially cardiovascular disease, will lead to more deaths than HIV, TB, malaria, and maternal complications combined, thus there is a need for the Ministry of Health and partners such as CHAI to urgently address this issue.
More than 90 percent of adults in Eswatini are at risk for an NCD.
One in three adults in the country has hypertension, or high blood pressure, which is the leading risk factor for cardiovascular disease. Prevention is simple and affordable. However less than 20 percent of people in Eswatini are treated for the condition.
The government of Eswatini is investing in better management of NCDs— that is, detecting, screening, and treating these diseases, as well as providing palliative care for people in need – because it is critical to address the growing crisis in the country.
NCD service delivery in Eswatini
NCD services in the country have always been centralized, available at a limited number of hospitals, mostly in large cities. This has posed a challenge to patients who need the services but cannot easily get to these large centers. Evidence shows that essential NCD interventions, such as management in primary care facilities, through screening, drug initiation and refill, are excellent economic investments because, if provided early enough, they can reduce the need for more expensive treatment.
To this end, the Ministry of Health ran a pilot to test whether decentralizing NCD services to primary level facilities was feasible. In 2019, the success of that pilot led the ministry to develop and roll out a package of cost-effective, point-of-care services which could be delivered within the country’s network of over 200 primary care facilities.
Decentralization of hypertension services to primary care
With funding from the European Commission, CHAI has been supporting the ministry to adopt the WHO Package of Essential Non-Communicable (PEN) diseases interventions, used in the pilot, to decentralize services across the rest of the country.
Since current guidelines did not allow primary care facilities to offer these services, the first step was to review the Standard Treatment Guidelines. This resulted in declassification of NCD drugs to be accessible at primary care level. To ensure hypertension and other NCD drugs are prioritized during procurement, the government reserved budget for these drugs to prevent shortages.
Decentralization will bring over 80 percent of the population within walking distance of simple, affordable services that can save their lives.
The Eswatini NCD Decentralization Operational Framework, a high level document for providing guidelines on implementation, was developed to act as a reference tool and operational manual for those implementing the decentralized services, including those in management or coordination functions, as well as those responsible for front-line service delivery such as doctors and nurses. This framework gives health workers guidance on how to manage treatment for hypertension, as well as other NCDs, such as type 2 diabetes, at primary care facilities instead of being referred to a hospital.
Decentralization guidelines for all levels of care were also developed and health workers were trained nationally on the new standardize services. Regional NCD coordinators were appointed to provide supportive supervision and monitoring to facilities in the four regions of the country.
The NCD Clinical Management Technical Working Group was also formed to improve coordination across stakeholders on the clinical management of NCDs at all levels and to advise on policies, guidelines, and standards to improve the clinical management of hypertension and type 2 diabetes.
This framework is helping to decentralize amenities to provide patients care closer to home and bring over 80 percent of the population within walking distance of simple, affordable services that can save their lives.
Although Eswatini has made strides in tackling cardiovascular disease by addressing hypertension, a lot remains to be done. The focus so far has been on treating hypertension, which is critical, but preventing the factors that put people at risk, such as physical inactivity, obesity, unhealthy diet, and harmful use of alcohol, must also be confronted – not just for cardiovascular disease but all NCDs. More than 90 percent of adults in Eswatini have at least one risk factor for an NCD but four out of five cases could be prevented or reversed if these factors were addressed. Furthermore, the government plans to decentralize services of other NCDs such as mental health and chronic lung diseases (including asthma). CHAI has been working with the government to come up with strategies to do this.
To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed requiring all sectors, including health, finance, transport, education, agriculture, planning and others, to collaborate to reduce the risks associated with NCDs, and promote interventions to prevent and control them.