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

58 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa
ier to introduce practices that benefit patients with
chronic conditions [405].
In many African countries primary care for NCDs
is very poorly developed and expectations of what
can be delivered need to take account of the realities
and challenges faced. Practical policy proposals
for improving primary and NCD care include:
improving data on disease burden; implementing
a structured approach to care delivery, with the
part played by primary care in the broader system
of care better defined; and highlighting quality of
care, aligned with broader health system strengthening
[406]. A number of existing programs in
low-resource countries such as TB control and maternal
and child health include strengthening primary
care as one aim. This creates an opportunity
for improvements for NCD care to ‘piggy-back’
onto existing efforts [406].
Innovations to cope with staff shortages in primary
care include developing a cadre of clinical associates
to perform a limited clinical role, and on-site training
of nurses and mid-level health workers for integrated
care of chronic diseases, whether infectious
or NCD in origin [399]. The role of appropriately-trained
community health workers for NCD care
should also be explored for SSA settings.
Frameworks and simple, standardized protocols
for case finding, diagnosis, and treatment of several
risk factors and diseases can effectively be used by
nurses and mid-level health workers [399]. These
may be adaptations of protocols for individual diseases,
such as TB [407], and designed for the management
of symptoms and signs of chronic disease,
irrespective of cause (see Box 10) [408], potentially
increasing cost-effectiveness by improving the care
of several conditions [409].
BOX 10: Integrated Care for Communicable
Diseases and NCDs in Primary Care
In South Africa, cough is the commonest complaint in
primary care and eight of the top 10 diagnoses are respiratory
conditions of both an infectious and chronic
nature, including upper respiratory tract infection, acute
bronchitis, asthma, TB, and HIV-associated pneumonias
[399].
Programs such as PALSA PLUS (Practical Approach to
Lung Health in South Africa) have been training health
workers in state-funded primary care clinics to take a
more people-centered rather than disease-centered approach,
using a syndromic, integrated guideline for diagnosis
and care of patients with respiratory symptoms
[408]. An educational outreach program has enabled the
guideline to be used successfully by nurse practitioners
with favorable outcomes, including increased TB-detection
rates, proportion of patients with asthma appropriately
managed, and cost-effectiveness [409].
The PALSA PLUS program has been extended to include
the most frequently occurring NCDs in the primary care
setting. This program is called ‘PRIMARY CARE 101’ [410].
Widespread use of traditional medicine providers
for primary care may reflect cultural and/or
health beliefs, taboos, or inaccessibility of other
forms of health care and drug costs, but one reason
for its popularity may be a desire for continuity of
care [401]. There have been moves to acknowledge
its role within primary health care and national
health systems, as well as to ensure its safety and
quality [411]. Better understanding of why people
go to traditional healers could help inform the design
of the health care delivery system for it to be
more accessible and desirable to people, especially
in rural areas.
Chronic-Care Models
Primary health care should not be seen in isolation
– it is but one cog in a wheel of care that also
involves secondary and tertiary care as well as the
community and patient, in both public and private
health systems. And while for SSA the challenge
of strengthening primary health care remains, and
there is limited integration of NCD prevention and
promotion in primary health care, hospitals are also
not ready in most countries to address even the existing
burden of NCDs and RTIs.
A further challenge is ensuring that various aspects
of care are linked and coordinated across care levels
and boundaries. Care of chronic conditions requires
a complex response over an extended time period,
involving coordinated inputs from a wide range of
health professionals, continuous access to essential
medicines, health information and monitoring systems,
and a system that promotes patient empowerment
[412]. Several organizational models exist