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

50 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa
BOX 6: Palliative and End-of-Life Care for AIDS,
Cancer and Other Conditions
Uganda was the first country in Africa to include palliative
care for chronically and terminally ill people as a
priority within its National Health Policy in 1999 [337].
It later participated in a joint project with four other
countries – Botswana, Ethiopia, United Republic of Tanzania,
and Zimbabwe – and WHO to improve the quality
of life of AIDS and cancer patients by developing
comprehensive palliative care programs with a community-health
approach [339]. ART has not removed
the need for palliative care. Around one-quarter to
one-third of patients on ART can experience virological
failure [340], and despite treatment, HIV-related cancers
still develop, pain persists, and psychological and
spiritual need continues [341].
Palliative or end-of-life care for people, irrespective
of cause or condition, is scarce across the continent
[342]. One study mapping such initiatives during 2003-
05 found services in only 26 countries, and only in
Uganda, South Africa, Kenya, and Zimbabwe were they
integrated into the existing health system [343]. The
nature of palliative-care needs and services in SSA reflects
their development in the context of poverty and
AIDS, and include pain and symptom control, psychological
support, and financial support for food, shelter,
and funeral costs. Such a holistic approach is likely to
be relevant for any life-threatening condition. The African
Palliative Care Association advocates for palliative
care to be an integral part of health systems (with service
delivery models that span diseases), and promotes
south-south collaboration [344].
ger-term rehabilitation. Prompt emergency care can
save lives, reduce the incidence of short-term disability
and dramatically improve the long-term consequences
for victims and their families [63].
Setting up a single, nationwide telephone number
for emergencies could help simplify matters [202],
but one-third of SSA countries have no emergency
number, and in another third there are multiple
numbers which leads to inefficiency in dispatch
[61]. Five countries have no ambulance services, and
in only nine countries do a reasonable proportion
(50 percent or above) of injured patients reach hospital
by ambulance.
There is a lack of resources for emergency response
and care, especially in rural areas, and there is evidence
of inconsistent pre-hospital care with most
victims receiving minimal or no treatment in the
field, and with hospitals and their staff not equipped
to provide trauma care [345]. Even if admitted to a
more sophisticated unit, disabilities are often inadequately
assessed and rehabilitation services not in
place for the vast majority of cases [346]. This situation
results in a great loss of human potential. Ghana
is probably not the only country in which 95 percent
of disabled people have had no access to rehabilitative
services [347]. A study in Nigeria found that
RTIs resulted in disability for 29.1 percent of subjects,
of whom 67.6 percent were unable to perform
activities of daily living; 16.7 percent consequently
lost their jobs, and 88.6 percent had a reduction in
earnings [348].
5.5. Strengthening Health Systems
Countries’ ability to address chronic disease is
limited by challenges in many aspects of health systems;
notably, governance, financing, medicines and
technologies, service delivery, workforce, and information
[349]. The challenges are not related just
to the income or development level of the country.
The shortcomings are hampering progress to communicable
disease control and MDG targets, and
responding to NCD and RTI needs is likely to be
even more challenging. Box 7 illustrates the manner
in which countries as diverse as South Africa,
Mauritius, Ghana, and Kenya are working to assess
the health systems challenge posed by NCDs and to
address them comprehensively.
Governance
A well-governed health system should have clear
goals, participation of relevant stakeholders, transparent
policies, oversight, and accountability [356].
Weak governance impedes the work to improve
health-system effectiveness and health outcomes,
and, to some extent, may reflect the wider governance-environment
in a country [357]. As already
described in Section 6.1, in SSA relevant policies
frequently do not exist or are poorly implemented,
and regulatory frameworks are not in place or are
weakly or not enforced. Performance management
in African health systems is hindered by the absence
of robust indicators of quality of services as
experienced by citizens. Inadequate monitoring and