Breaking down the silos of Universal Health Coverage: towards systems for the primary prevention of non-communicable diseases in Africa

Summary box African countries are not on track to achieve global targets for non-communicable disease (NCD) prevention, driven by an insufficient focus on ecological drivers of NCD risk factors, including poor urban development and the unbridled proliferation of the commercial determinants of health. As the risk factors for NCDs are largely shaped outside the healthcare sector, an emphasis on downstream healthcare service provision to the exclusion of upstream population-level prevention limits the goals of universal health coverage (UHC) and its potential for optimal improvements in (achieving) health and well-being outcomes in Africa. The political will for UHC in Africa will miss the opportunity to turn the tide of this emerging NCD epidemic in Africa, if not oriented to a systems for health rather than a solely healthcare-centric approach. A successful approach needs to proactively incorporate wider health determinants (sectors)—housing, planning, waste management, education, governance and finance, among others—in strategies to improve health. This includes aligning governance and accountability mechanisms and strategic objectives of all ‘health determinant’ sectors for health creation and long-term cost savings. Researchers have a vital role to play, collaborating with policy makers to provide evidence to support implementation and to facilitate knowledge sharing between African countries and globally

Ability of verbal autopsy data to detect deaths due to uncontrolled hyperglycaemia:testing existing methods and development and validation of a novel weighted score

Objectives: Verbal autopsy (VA) is a useful tool to ascertain cause of death where no other mechanisms exist. We aimed to assess the utility of VA data to ascertain deaths due to uncontrolled hyperglycaemia and to develop a weighted score (WS) to specifically identify cases. Cases were identified by a study or site physician with training in diabetes. These diagnoses were also compared with diagnoses produced by a standard computer algorithm (InterVA-4). Setting: This study was done using VA data from the Health and Demographic Survey sites in Agincourt in rural South Africa. Validation of the WS was done using VA data from Karonga in Malawi. Participants: All deaths from ages 1 to 49 years between 1992 and 2015 and between 2002 and 2016 from Agincourt and Karonga, respectively. There were 8699 relevant deaths in Agincourt and 1663 in Karonga. Results: Of the Agincourt deaths, there were 77 study physician classified cases and 58 computer algorithm classified cases. Agreement between study physician classified cases and computer algorithm classified cases was poor (Cohen’s kappa 0.14). Our WS produced a receiver operator curve with area under the curve of 0.952 (95% CI 0.920 to 0.985). However, positive predictive value (PPV) was below 50% when the WS was applied to the development set and the score was dominated by the necessity for a premortem diagnosis of diabetes. Independent validation showed the WS performed reasonably against site physician classified cases with sensitivity of 86%, specificity of 99%, PPV of 60% and negative predictive value of 99%. Conclusion: Our results suggest that widely used VA methodologies may be missing deaths due to uncontrolled hyperglycaemia. Our WS may offer improved ability to detect deaths due to uncontrolled hyperglycaemia in large populations studies where no other means exist

Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa : a mixed methods analysis of verbal autopsy data

Acknowledgments Thank you to the team at the Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), particularly Chodziwadziwa Kabudula for his assistance with assembling the Agincourt HDSS data set for our use. The MRC/Wits Rural Public Health and Health Transitions Research Unit and Agincourt Health and Socio-Demographic Surveillance System, a node of the South African Population Research Infrastructure Network (SAPRIN), is supported by the Department of Science and Innovation, the University of the Witwatersrand, and the Medical Research Council, South Africa, and previously the Wellcome Trust, UK (grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z).Peer reviewedPublisher PD

Hypertension screening, awareness, treatment, and control in India:A nationally representative cross-sectional study among individuals aged 15 to 49 years

BACKGROUND: Evidence on where in the hypertension care process individuals are lost to care, and how this varies among states and population groups in a country as large as India, is essential for the design of targeted interventions and to monitor progress. Yet, to our knowledge, there has not yet been a nationally representative analysis of the proportion of adults who reach each step of the hypertension care process in India. This study aimed to determine (i) the proportion of adults with hypertension who have been screened, are aware of their diagnosis, take antihypertensive treatment, and have achieved control and (ii) the variation of these care indicators among states and sociodemographic groups. METHODS AND FINDINGS: We used data from a nationally representative household survey carried out from 20 January 2015 to 4 December 2016 among individuals aged 15-49 years in all states and union territories (hereafter "states") of the country. The stages of the care process-computed among those with hypertension at the time of the survey-were (i) having ever had one's blood pressure (BP) measured before the survey ("screened"), (ii) having been diagnosed ("aware"), (iii) currently taking BP-lowering medication ("treated"), and (iv) reporting being treated and not having a raised BP ("controlled"). We disaggregated these stages by state, rural-urban residence, sex, age group, body mass index, tobacco consumption, household wealth quintile, education, and marital status. In total, 731,864 participants were included in the analysis. Hypertension prevalence was 18.1% (95% CI 17.8%-18.4%). Among those with hypertension, 76.1% (95% CI 75.3%-76.8%) had ever received a BP measurement, 44.7% (95% CI 43.6%-45.8%) were aware of their diagnosis, 13.3% (95% CI 12.9%-13.8%) were treated, and 7.9% (95% CI 7.6%-8.3%) had achieved control. Male sex, rural location, lower household wealth, and not being married were associated with greater losses at each step of the care process. Between states, control among individuals with hypertension varied from 2.4% (95% CI 1.7%-3.3%) in Nagaland to 21.0% (95% CI 9.8%-39.6%) in Daman and Diu. At 38.0% (95% CI 36.3%-39.0%), 28.8% (95% CI 28.5%-29.2%), 28.4% (95% CI 27.7%-29.0%), and 28.4% (95% CI 27.8%-29.0%), respectively, Puducherry, Tamil Nadu, Sikkim, and Haryana had the highest proportion of all adults (irrespective of hypertension status) in the sampled age range who had hypertension but did not achieve control. The main limitation of this study is that its results cannot be generalized to adults aged 50 years and older-the population group in which hypertension is most common. CONCLUSIONS: Hypertension prevalence in India is high, but the proportion of adults with hypertension who are aware of their diagnosis, are treated, and achieve control is low. Even after adjusting for states' economic development, there is large variation among states in health system performance in the management of hypertension. Improvements in access to hypertension diagnosis and treatment are especially important among men, in rural areas, and in populations with lower household wealth

Variation in health system performance for managing diabetes among states in India:a cross-sectional study of individuals aged 15 to 49 years

Background: Understanding where adults with diabetes in India are lost in the diabetes care cascade is essential for the design of targeted health interventions and to monitor progress in health system performance for managing diabetes over time. This study aimed to determine (i) the proportion of adults with diabetes in India who have reached each step of the care cascade and (ii) the variation of these cascade indicators among states and socio-demographic groups. Methods: We used data from a population-based household survey carried out in 2015 and 2016 among women and men aged 15–49 years in all states of India. Diabetes was defined as a random blood glucose (RBG) ≥ 200 mg/dL or reporting to have diabetes. The care cascade—constructed among those with diabetes—consisted of the proportion who (i) reported having diabetes (“aware”), (ii) had sought treatment (“treated”), and (iii) had sought treatment and had a RBG < 200 mg/dL (“controlled”). The care cascade was disaggregated by state, rural-urban location, age, sex, household wealth quintile, education, and marital status. Results: This analysis included 729,829 participants. Among those with diabetes (19,453 participants), 52.5% (95% CI, 50.6–54.4%) were “aware”, 40.5% (95% CI, 38.6–42.3%) “treated”, and 24.8% (95% CI, 23.1–26.4%) “controlled”. Living in a rural area, male sex, less household wealth, and lower education were associated with worse care cascade indicators. Adults with untreated diabetes constituted the highest percentage of the adult population (irrespective of diabetes status) aged 15 to 49 years in Goa (4.2%; 95% CI, 3.2–5.2%) and Tamil Nadu (3.8%; 95% CI, 3.4–4.1%). The highest absolute number of adults with untreated diabetes lived in Tamil Nadu (1,670,035; 95% CI, 1,519,130–1,812,278) and Uttar Pradesh (1,506,638; 95% CI, 1,419,466–1,589,832). Conclusions: There are large losses to diabetes care at each step of the care cascade in India, with the greatest loss occurring at the awareness stage. While health system performance for managing diabetes varies greatly among India’s states, improvements are particularly needed for rural areas, those with less household wealth and education, and men. Although such improvements will likely have the greatest benefits for population health in Goa and Tamil Nadu, large states with a low diabetes prevalence but a high absolute number of adults with untreated diabetes, such as Uttar Pradesh, should not be neglected

Predicting the effects of introducing an emergency transport system in low-income and middle-income countries: a spatial-epidemiological modelling study

Introduction: Many low-income and middle-income countries lack an organised emergency transportation system, leaving people to arrange informal transport to hospital in the case of a medical emergency. Estimating the effect of implementing an emergency transport system is impractical and expensive, so there is a lack of evidence to support policy and investment decisions. Alternative modelling strategies may be able to fill this gap. Methods: We have developed a spatial-epidemiological model of emergency transport for life-threatening conditions. The model incorporates components to both predict travel times across an area of interest under different scenarios and predict survival for emergency conditions as a function of time to receive care. We review potentially relevant data sources for different model parameters. We apply the model to the illustrative case study of providing emergency transport for postpartum haemorrhage in Northern Ghana. Results: The model predicts that the effects of an ambulance service are likely to be ephemeral, varying according to local circumstances such as population density and road networks. In our applied example, the introduction of the ambulance service may save 40 lives (95% credible interval 5 to 111), or up to 107 lives (95% credible interval −293 to –13) may be lost across the region in a year, dependent on various model assumptions and parameter specifications. Maps showing the probability of reduced transfer time with the ambulance service may be particularly useful and allow for resource allocation planning. Conclusions: Although there is scope for improvement in our model and in the data available to populate the model and inform parameter choices, we believe this work provides a foundation for pioneering methodology to predict the effect of introducing an ambulance system. Our spatial-epidemiological model includes much oppurtunity for flexibility and can be updated as required to best represent a chosen case study

Diabetes in sub-Saharan Africa: from clinical care to health policy.

Rapid demographic, sociocultural, and economic transitions are driving increases in the risk and prevalence of diabetes and other non-communicable diseases (NCDs) in sub-Saharan Africa. The impacts of these transitions and their health and economic consequences are evident. Whereas, in 1990, the leading causes of death in sub-Saharan Africa were HIV/AIDS, lower respiratory infections, diarrhoeal diseases, malaria, and vaccine-preventable diseases in children, in more recent years, cardiovascular diseases and their risk factors are replacing infectious diseases as the leading causes of death in this region, and rates of increase of cardiovascular risk factors are predicted to be greater in sub-Saharan Africa than in other parts of the world. Thus, sub-Saharan Africa—which contains a high proportion of the world\u27s least developed countries—will face the multifaceted challenge of dealing with a high burden of infectious diseases and diseases of poverty, while also addressing the increasing burden of cardiovascular disease and its risk factors. At present, many of the health systems in sub-Saharan Africa struggle to cope with infectious diseases. Meeting the goals of the UN high-level meeting on NCDs (to reduce premature mortality from NCDs by 25% by 2025) and Sustainable Development Goals (SDGs; to reduce premature mortality from NCDs by a third by 2030) requires a coordinated approach within countries, which starts with a firm consideration of disease burden, needs, and priorities

Cardiovascular disease risk profile and management among people 40 years of age and above in Bo, Sierra Leone : a cross-sectional study

Introduction: Access to care for cardiovascular disease risk factors (CVDRFs) in low- and middle-income countries is limited. We aimed to describe the need and access to care for people with CVDRF and the preparedness of the health system to treat these in Bo, Sierra Leone. Methods: Data from a 2018 household survey conducted in Bo, Sierra Leone, was analysed. Demographic, anthropometric and clinical data on CVDRF (hypertension, diabetes mellitus or dyslipidaemia) from randomly sampled individuals 40 years of age and above were collected. Future risk of CVD was calculated using the World Health Organisation–International Society of Hypertension (WHO-ISH) calculator with high risk defined as >20% risk over 10 years. Requirement for treatment was based on WHO package of essential non-communicable (PEN) disease guidelines (which use a risk-based approach) or requiring treatment for individual CVDRF; whether participants were on treatment was used to determine whether care needs were met. Multivariable regression was used to test associations between individual characteristics and outcomes. Data from the most recent WHO Service Availability and Readiness Assessment (SARA) were used to create a score reflecting health system preparedness to treat CVDRF, and compared to that for HIV. Results: 2071 individual participants were included. Most participants (n = 1715 [94.0%]) had low CVD risk; 423 (20.6%) and 431 (52.3%) required treatment based upon WHO PEN guidelines or individual CVDRF, respectively. Sixty-eight (15.8%) had met-need for treatment determined by WHO guidelines, whilst 84 (19.3%) for individual CVDRF. Living in urban areas, having education, being older, single/widowed/divorced, or wealthy were independently associated with met need. Overall facility readiness scores for CVD/CVDRF care for all facilities in Bo district was 16.8%, compared to 41% for HIV. Conclusion: The number of people who require treatment for CVDRF in Sierra Leone is substantially lower based on WHO guidelines compared to CVDRF. CVDRF care needs are not met equitably, and facility readiness to provide care is low