Ensuring access to NCD services: spotlight on the key role of primary care

People living with chronic diseases – otherwise known as Non-Communicable Diseases (NCDs) – are at greater risk of becoming severely ill or dying from COVID-19. The confluence of these two pandemics – the ‘slow-motion pandemic of NCDs’ – has created a dangerous double burden of disease.  In addition to poorer outcomes from COVID-19, people living with chronic diseases also face a lack of continuity of care for their existing conditions. We are now likely to see an increase in illness or death due to NCDs.

Whilst there are very high levels of NCDs in high-income countries, the burden of NCDs is rising disproportionately among low- and middle-income countries and populations, and the risk of dying prematurely from an NCD is almost double that in high-income countries, a result of late or absent diagnosis, poor access to treatment and health systems not oriented to long-term chronic disease care.

The need for continuity of services is widely recognised: the pandemic has shone a spotlight on pre-existing access challenges for people living with NCDs, now exacerbated by Covid-19 .  Health systems around the world are showing signs that they are not optimally organised or equipped to meet the challenge of caring for people living with NCDs.

A World Health Organization Rapid assessment of service delivery for NCDs during the COVID-19 pandemic in May this year heard from 163 counties. The assessment showed an alarming impact on NCD services due to COVID-19: 75% reported interruptions, and lower and middle-income countries are most affected. (graph credit: WHO):

Countries need to make difficult decisions to balance the demands of responding directly to COVID-19, while simultaneously maintaining essential health service delivery for NCDs and mitigating the risk of system collapse. Countries with the weakest health systems have the narrowest room to manoeuvre.

The key role of primary healthcare

This is where the unique, and critical, role of primary healthcare is clear. Primary care, in the community, is the place where NCDs are usually best addressed, in terms of early diagnosis and early intervention. And the best way to achieve continuous healthcare for all.

In Mozambique, a partnership between the Mozambique Institute for Health Education and Research (MIHER), the Instituto Nacional de Saude (INS) and Primary Care International has over the past few years been working with the Ministry of Health to develop a pilot model to decentralise NCD risk factor prevention, diagnosis and management by expanding the role of primary care. PCI developed a model of cascade training to support this transition. Ways to roll this model out across Mozambique had just begun when the impacts of the COVID-19 pandemic hit an already struggling healthcare system. The team there continue to offer services to people living with NCDs but are now seeing a number of new challenges.

Challenges and responses from healthcare workers in Mozambique

Fear of becoming infected with coronavirus means patients are attending clinics or hospitals later or not at all. The health centres and hospitals in Mozambique were – as in many countries – initially restricted to emergency patients at the start of the epidemic. But even now they have opened up, and can see patients about their diabetes or hypertension, people are still afraid to go. Clinicians are seeing far fewer patients.

“Initially, I and other colleagues had to stop making appointments, temporarily stopping seeing chronic patients. The patients just came to pick up the drugs. Patients were also afraid to go to the hospital, they were very afraid of contracting covid19, since everyone suffered from chronic illnesses and were vulnerable to developing serious illness.” (NCD clinic doctor, Mozambique)

Avoiding health services has created a lot of strain on people with chronic diseases.

“The number of patients whose chronic illnesses deteriorated (including congestive heart failure, hypertensive crisis, decompensated diabetes mellitus) increased because many remained at home without medication.” (Emergency services doctor, Mozambique)

Even in emergency departments in Maputo they are not seeing people come to hospitals – it is suspected there is an increase in deaths at home but the health information or statistics to confirm this don’t exist.

In response MIHER and INS are increasing their focus on seeing patients away from hospitals – in the community at primary care level, and have also embarked on projects that will teach us how to rely more on community-based care to respond to future health emergencies.  In direct response to COVID-19 – they have identified patient ‘champions’ in the health centres – who help other patients to get their medicines in nearby pharmacies.

Impact of COVID-19 on access to medicines

Another huge challenge for continuity of NCD services due to COVID-19 is the lack of medicines for chronic illnesses. Medicines for infectious diseases tend to have more structured support programmes from international multilateral organisations. But such support does not usually exist for NCD medicines. As in Mozambique’s case, these medicines are often not produced locally, and therefore for the majority have to be imported.  Closure of international borders led to a severe shortage there, which is still ongoing.

“There is embarrassment with the lack of some medicines to be dispensed at the level of the Health Units, which hinders adequate disease control since not everyone is able to purchase the medicines in private pharmacies” (primary health centre doctor, Mozambique)

Even when the medicines can be found, many people can no longer afford them as the COVID-19 related restrictions on movement has meant many people, especially those in the informal economy, not being able to earn an income.

In response to such widespread health service disruption on a global scale , WHO has issued a joint statement with the International Narcotics Control Board (INCB) and the United Nations Office on Drugs and Crime (UNODC), calling on governments to sufficiently procure and supply controlled medicines to meet the needs of patients. This call applies to both people being treated for COVID-19, and for patients experiencing pain, palliative care and ongoing NCDs. The WHO have also recently outlined five key lessons and five overarching developments that will be critical to expanding access to medicines and health products for NCDs and mental health conditions.

Strengthening primary healthcare is key

NCDs remain the largest, most underfunded public health issue globally where most lives could be saved. We must keep repeating the message that people living with NCDs are at greater risk from COVID-19 – and this is even more so if their illness is not managed well. They are also more vulnerable to other co-morbidities and to future pandemics.  More broadly we need to ensure we reinforce and amplify patient and healthcare workers messages about the importance of continuity of care. As outlined as one of the eight recommendations for building back better in Bente Mikkelsen’s recent ‘one’ blog, we need to continue to focus on strengthening primary healthcare (and primary healthcare workforce) as the best place to manage NCDs . The pandemic has served to put a spotlight on the need to strengthen health infrastructures with primary health care at their core  and we must include NCDs as a priority in post-COVID-19 support for health systems.

 

Authors

  • Dr. Bente Mikkelsen. Bente is the Director of the World Health Organisation’s Department for NCDs. Previously she was Head of the Secretariat for the Global Coordination mechanism on the Prevention and Control of NCDs at WHO. Bente is trained as a Gynaecologist and Obstetrician.
  • Prof Ana Mocumbi. Ana is Associate Professor of Cardiology at Universidade Eduardo Mondlane, Mozambique and Head of NCD Research at National Institute of Health, Mozambique. She is also currently Co-Chair of the Lancet NCDI Poverty Commission .
  • Dr.Edna Juga. Edna is General Practitioner, working at the National Health Institute, Mozambique – coordinator of the HyRisk Program, trainer of training of trainers course.
  • Dr. Chamila Adam. Chamila is a general medicine doctor and has been working in the Medical Ward of Hospital Geral de Mavalane for 10 years. She follows patients daily for infectious diseases, decompensated chronic disease and complications of chronic disease. She makes a weekly consultation of chronic disease for DM / HTN. Before that, she worked for 2 years at the Mavalane Health Center giving consultations on chronic disease DM / HTA / HIV and Focal point of MDR TB.
  • Dr. Philippa Harris, Clinical Associate, PCI. Philippa initially trained as a physician with an interest in infectious diseases, tropical medicine and HIV and has worked with rural communities in Kenya, Tanzania and South Africa.  She is now combining primary care clinical practice in the UK with an MSc in Epidemiology at the London School of Hygiene and Tropical Medicine, focusing on NCD care. She is part of the PCI team collaborating with MIHER and INS in Mozambique.

 

EDITOR’S NOTE: This article was written as part of Primary Care International’s new Op-Ed series exploring resilient systems and healthy populations in the context of COVID-19 and beyond, which will be published in multiple venues. The perspectives of the authors are not necessarily the views of any of their institutions or affiliations.