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NEPAD health strategy - Initial programme of action
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3. SCALE UP DISEASE CONTROL
Proactively provide support for programmes against the major burdens of disease whose practice should coincide with the approach in the strategy and enable them to deliver at scale and to build the capacity required:
The intention is that these programmes do not operate simply as separate vertical programmes, but provide focussed emphasis on critical priorities within a comprehensive health systems development approach.
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Enhance prevention / promotion related HIV programmes in particular peer education programmes for vulnerable groups and those targeting youth
HIV/AIDS not only threatens health, social and economic development on the continent today, but also poses the greatest threat to the continent's future. A critical element of the fight against HIV/AIDS is to prevent new infections. Currently more than 3 million people are newly infected each year. Much has been learnt about the gap between knowledge and behaviour change and about the kind of programmes required to effectively impact on the rate of new infections.
The purpose of this programme is to specifically increase the capacity for effective prevention and promotion programmes for vulnerable groups and youth, and in particular to expand the capacity for peer education and the use of appropriate role models. There are a number of successes on the continent whose experience needs to be shared more widely and whose strategies need to be tested and adapted for use in a wiser range of countries.
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Advocate for and support the provision of affordable anti-retroviral therapy (ART) and treatment of opportunistic infections in persons living with HIV/AIDS
The NEPAD health strategy from its inception has advocated for the use of anti-retrovirals, based on the assessment that this is a critical component of what is required to offset the huge impact the disease is having on families, communities, societies and economies. Recent developments have made this even more possible, but there is still a gap between the emerging policy shift towards such provision and the effective operationalisation of this decision. Although there are many impediments to effective expansion in Africa that need to be addressed, the continent cannot develop if more than 2 million people a year continue to die of AIDS - and there is also a very human imperative to care.
This programme will advocate for affordability in the price of anti-retrovirals and drugs for the treatment of opportunistic infections, and for their wide provision across the continent. It will develop mechanisms to support their effective use within the health system, a challenge not to be underestimated. This must be tied to use of innovative methods for supervision and care of therapy and appropriate timing of its introduction. The aim is to facilitate the incorporation of ART into health systems in a manner that does not cause a burden that collapses other elements of the service.
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Support the expansion of services for voluntary counselling and testing
The introduction of anti-retroviral therapy can only be effective if people know their status. Yet, less than 5% of the 40 million Africans living with HIV are aware that they are infected. Lack of the possibility of receiving ARVs might be one factor for this low figure, but the determining reasons are around community recognition of the value of awareness, fear and stigma and the lack of accessible voluntary counselling and testing (VCT) services.
This programme seeks to support the expansion of services for voluntary counselling and testing of HIV status. This will start with community awareness and mobilisation and strong efforts to de-stigmatise HIV. VCT sites will be upgraded, to ensure that the service is effective, and their number increased in the periphery and in poor areas. Measures taken will include appropriate training of lay health workers and professional staff in counselling, and in providing an empathetic and supportive environment. It will also involve distribution and training in the use of rapid tests, together with backup to ensure accuracy of diagnosis.
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Support the scaling-up of interventions for the prevention and treatment of sexually transmitted infections (STIs)
It is well known that measures for the prevention of HIV/AIDS are also effective for the prevention of sexually transmitted infections (STIs). However, what is less well recognised is the much greater risk of transmission of HIV, in particular in women, in the presence of an STI and the gaps in providing accessible, effective care for STIs. It is therefore, not only the health risks of STIs but also the dramatically increased risk of HIV that makes this a service that is emphasised for scaling up.
The aim of this programme is to support the scaling up of interventions for the prevention and treatment of STIs. Both the public and private sector have been shown to be weak in modern clinical management and the use of appropriate drugs. The programme will broaden the use of evidence based practice and syndromic care, blended with a caring response from health workers. The learning here can be expanded to other services requiring enhanced clinical acumen and caring and thereby support health system strengthening.
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Support the implementation of initiatives that increase access to and improve the quality of TB DOTS services such as community based DOTS, collaborative TB/HIV/AIDS activities and public-private partnerships
Tuberculosis (TB) has long been a major burden of disease in Africa, but has worsened dramatically as a consequence of the HIV/AIDS epidemic. More than half a million people die of TB annually. Delayed diagnosis and incomplete treatment add not only to individual risk, but also to community risk and to the emergence of drug-resistant strains of tuberculosis. It is therefore imperative to ensure that TB patients are identified early and then are enabled to adhere to and complete their therapy. The directly observed treatment short course (DOTS) strategy has been proven as an effective way of achieving this, yet only 44% of people have access to such care and even less are successfully treated.
It is the intention of this programme to strengthen access to and quality of DOTS services. The programme will address each of the steps in the process to ensure that the system functions well. DOTS requires a partnership between the patient, the health service and a supervisor / treatment supporter in the community, at school or at work, which ties to the broad goal of enhancing community involvement in health. The bond that develops between these supporters and the patient and the sharing of a mutual responsibility is what strengthens adherence.
As more than half the new cases of tuberculosis in many countries are in HIV-positive people, the programme will address the urgent need to pool resources, experience and services of the two programmes and integrate them into the close-to-client health system.
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Develop regional strategies to mobilise human and financial resources for tuberculosis (TB) control activities, and to ensure uninterrupted supply of affordable quality anti-TB drugs in all countries
The responsibility for ongoing care of tuberculosis patients will and should lie with multi-purpose clinic workers. However, for them to fulfil this task effectively they require skilled support from a designated and trained local expert at the district level, and an uninterrupted supply of good quality anti-tuberculosis drugs. Problems in both these areas have impeded tuberculosis control activities.
Ensuring drug availability at the periphery and capacity building amongst close-to-client staff, together with strengthening preventive and early treatment seeking behaviour are the focus of this programme. New models of achieving these and adapting them to local circumstances need to developed, which in turn will inform the strengthening of other chronic care and communicable disease control programmes in districts.
Facilitate mechanisms for financing, procurement and distribution of effective malaria control interventions, such as use of artemisinin derivatives, insecticide treated nets and insecticides, so that they reach vulnerable populations
Amongst the key reasons for the resurgence of malaria across Africa is the lack of effective personal protection in the face of increased vector prevalence and the use of drugs which are no longer effective, as resistance to them has developed widely. Insecticide treated nets and prudent insecticide use (which also benefit the prevention of lymphatic filariasis) and adding artemisinin derivatives to essential drugs lists are proven effective interventions. Yet, less than 2% of those at risk receive prevention and less than 27% effective care.
This programme aims at mobilising the health system, communities and the local private sector to work collaboratively to ensure that these services reach vulnerable populations. It will support innovative approaches to overcoming a number of factors that have impeded the potential of nets, including their high cost, effective distribution and in particular, their re-treatment. Social mobilisation is an essential part of this, which systems can simultaneously be applied to other important diseases. The programme will also seek to establish artemisinin on essential drugs lists, increase the volume of their use and aim to bring the price down. Its distribution needs to be tied to the broad programme to improve the drug supply chain.
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Include Integrated Management of Childhood Illness (IMCI) implementation in all district health plans.
There is much to be done if the Millennium Development Goal of a 2/3 reduction in under-five mortality by 2015 is to be achieved. 161 out of every 1000 children born in Africa die before their fifth birthday. Although IMCI has proven its worth as a key intervention and significant progress has been made in its implementation, there remains an urgent need for its strengthening and scaling up. Countries need to move purposefully beyond pilot sites into the expansion and then to the acceleration phases and reach into all districts of the country.
This programme will focus on addressing the constraints hindering implementation, particularly at the district level. It will involve strengthening district IMCI planning and community and family involvement. This in turn will act as an entry point and a catalyst to strengthen both of these features in the health system, as well as the clinical capability of staff and their understanding of community based practice and effective health promotion measures. The IMCI component strengthening quality of care at the referral level will also support the goal of strengthening district hospitals. To support the programme further, the IMCI guidelines will be simplified and tools and guides adapted to be country-specific. National capacity to support the programme will be strengthened.
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Advocate and support inclusion of IMCI into pre-service training of health workers towards achieving sustainability in capacity.
A concern has been raised about the ability of educational programmes in medical, para-medical and nursing schools on the continent to ensure that their training is in line with the latest developments in the prevention and treatment of the major burdens of disease. The limited number of staff, who often have multiple subject responsibilities, makes it difficult for them to keep abreast of the various fields. But, it is only if our educators are constantly going forward, that graduates will continually improve.
As it is imperative for newly qualified health workers to emerge with practical up-to-date skills, this programme will expand the initiative to provide skills to educators and support to training institutions across the continent on IMCI. The programme will act as a lever for creating mechanisms for ensuring the current relevance and accuracy of education across the spectrum of Africa's burden of disease, and encourage teachers to recognise the need for their own academic continuing development. It will show them ways in which this can be achieved, including through the use of information technology.
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Advocate and support trypanosomiasis elimination through revival of case detection and treatment, improved surveillance and targeted vector control.
There has been a resurgence of human African Trypanosomiasis (sleeping sickness) in sub-Saharan Africa and of the Tsetse fly that transmits it. There are 250 foci in 36 sub-Saharan countries affected by the disease, which Ѕ million people are carrying and which is 100% fatal if untreated. There is no reason why the burden of Trypanosomiasis cannot be removed from Africa by a scaled up, committed effort.
The aim of this programme is to implement the Pan-African Tsetse and Trypanosomiasis eradication campaign (PATTEC), which has been launched, but has yet to be implemented for lack of committed resources. The programme aims to intensify social mobilisation and awareness raising, develop targeted vector control, scale up case detection and treatment and implement a strengthened surveillance system. The measures used in the programme, including social mobilisation, community health workers and programme monitoring and evaluation will be used as an entry point for strengthening the health systems that serve the 60-million at-risk people. They are amongst the poorest on our continent.
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Promote and support the control of schistosomiasis and soil-transmitted helminths, to improve school performance and adult productivity.
Schistosomiasis and soil-transmitted helminths are an underestimated public health problem on the continent affecting economic development and particularly school learning. Africa carries 85% of the global burden of schistosomiasis and soil transmitted helminths. Efforts to control these diseases have been sporadic and yielded limited success, while the high cost of drugs has led to the abandonment of many programmes.
The purpose of this programme is to convert isolated activities into effective national control activities in the approximately 20 highly endemic countries in need of urgent support. Features of the programme are the administration of anti-helminthic drugs six-monthly to school age children and community health education and advocacy around the disease. This programme will in particular work to integrate with other school health services and become a nidus for their strengthening and development. It will also grow the sense of community responsibility for their health and community based measures to enhance it.
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Advocate for and support lymphatic filariasis elimination as a tool for poverty reduction
More than 43 million people in sub-Saharan African suffer from Lymphatic Filarisasis (Elephantiasis). Countries are committed to addressing this debilitating and resurging problem, but have lacked the dedicated resources to do so.
This programme will support social mobilisation around the disease and especially tackle the stigma around it. It will include the targeted use of a drug prophylaxis regime, provide effective treatment and encourage and enable early attendance for care. The programme will provide a basis for strengthening community structures in the fight against disease, through the approach of social mobilisation and mass treatment and in particular through addressing the stigma associated with the disease. It will advance the development of "caring communities" and link to the programme to make drugs affordable and provide maximal coverage.
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Enable countries to develop comprehensive responses to the increasing incidence of lifestyle-related chronic diseases e.g cardio-vascular disease (CVDs), lung cancer and diabetes, through promotion of proper diet, physical activity and the reduction of consumption of tobacco, alcohol and other substances.
Chronic diseases of lifestyle are increasing alarmingly on the continent and emerging as a major burden of disease. Strokes, kidney failure, heart failure and blindness are amongst the many costly complications that arise from negative changes lifestyle, while undetected carcinoma of the cervix and inadequately treated diabetes are further examples that contribute substantially to mortality. In the face of major burdens from communicable diseases, this rapidly growing threat has not always received the considered attention required, nor the focussed strengthening of the health system that needs to underpin the response.
The core response to the non-communicable disease burden is to build a health system that is effective in both health promotion and care, and within this to develop a comprehensive integrated non-communicable disease prevention and control programme. The programme will focus on strengthening capacity to prevent unnecessary deaths from tobacco, alcohol, physical inactivity, poor diet, high blood pressure and cholesterol. It will facilitate governments' to be well equipped technically and institutionally to reduce exposure to the major risk factors for non-communicable diseases and to promote standards of care. In particular, this programme will build teams capable of supporting programmes in countries and develop areas that will become demonstration sites for effective prevention and care, which can then be expanded. Development and use of innovative and effective lifestyle promotion methods and techniques to enable adherence to treatment will be focus areas.
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Improve the management of epilepsy at primary health care level and contribute to the reduction of the Treatment Gap of people living with epilepsy.
Most of the 10 million people living with epilepsy in Africa could have had this prevented, and 8 million of them are without treatment with modern anti-epileptic drugs, even though this costs as little as US$5 per person per year, as improved management needs more than just the money for drugs. The global campaign against epilepsy has aimed to bring this stigmatised disease out of the shadows and has been supported by the African Declaration on Epilepsy. Important steps have been taken by countries to implement the recommendations of these programmes, but there is still a great deal to be done.
The main focus of this programme is to improve the management of epilepsy at a primary health care level and to reduce the treatment gap of people living with epilepsy. This will require multi-purpose primary health care workers to gain case management skills for epilepsy and to ensure provision of suitable drugs. It also provides an entry point for dealing with the challenges of mental health problems on the continent including the stigma associated with mental ill health, and for increasing community awareness about this and similar conditions.
The programme will also support the development of national organisations for epilepsy, potentially as local chapters of the international organisation. This will provide an example for the effective development of other national organisations against other diseases which would benefit from bringing together those affected by and involved in the care of these conditions, e.g. diabetes, stroke, depression. This will give government experience in how to create an enabling environment and support the emergence of such organisations.
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