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Study Tour: NCDs Crossing the Development Divide

By: Christine Sow, Global Health CouncilCross-posted from the Global Health Council Blog

GHC Executive Director Christine Sow accompanied US Senate staffers to Uganda and Rwanda on a study tour organized by the Livestrong Foundation and Management Sciences for Health. We will be featuring blogs and pictures from Christine on the tour – read on to hear about the trip, NCDs, and global health challenges.

The Uganda Cancer Institute. Photo credit: Sally Canfield.

The Uganda Cancer Institute. Photo credit: Sally Canfield.

One particularly striking thing I have noticed on this trip is that the challenges health officials face in tackling NCDs in low and middle income countries are not so different to the challenges the U.S. and other Western countries face in addressing these same diseases.  This is an area where our similarities are more significant than our differences; quite unlike most global health challenges today. “Tropical” diseases that ravage low and middle income countries were typically considered the unique purview of the “developing world.”  Not so, in the case of NCDs today.  In fact, top research and treatment institutions such as the Uganda Cancer Institute and the Joint Clinical Research Center are doing ground-breaking biomedical work on challenges such as Epstein-Barr Virus and antiretroviral therapy roll-out, and are returning findings and recommendations that have applications far beyond Uganda’s borders.

An interesting aspect of this research is their attention to the development of effective treatment regimens for low resource settings – the reality of their national context means that they will not have high-tech solutions on hand to treat their patients. This work is promising both for what the identification of low resource solutions means for patients in Uganda and elsewhere in the global South. But it is also promising because it can challenge high income countries – that have cost limitations and resource contraints of their own – to consider alternate approaches to how they address diseases that have traditionally “merited” high cost solutions. But while trying to continue their work, they also spend much of their time and energy on piecing together the funding to keep it going. This is not a new story, but one that deserves to be repeated – the efficiency and impact of cutting-edge programs, whether they be focused on research or implementation, need and deserve long-term funding commitments in order to be truly functional and achieve optimal impact. And this is true whether the funding is coming from external donors or from an institution’s own national government.

Christine Sow is the Executive Director of the Global Health Council.

Study Tour: Lessons Learned from the HIV/AIDS Epidemic

By: Christine Sow, Global Health Council
Cross-posted from the Global Health Council Blog

GHC Executive Director Christine Sow accompanied US Senate staffers to Uganda and Rwanda on a study tour organized by the Livestrong Foundation and Management Sciences for Health. We will be featuring blogs and pictures from Christine on the tour – read on to hear about the trip, NCDs, and global health challenges.

A group of children in Uganda. Photo credit: Sally Canfield.

A group of children in Uganda. Photo credit: Sally Canfield.

I come from a professional background focused squarely on reproductive and maternal health, child survival and HIV/AIDS. Most if not all of my career until now has been oriented towards saving young lives and the mothers who give birth and care for them.  Truth be told, I had never spent much time thinking about non-communicable disease control and management, except to acknowledge how far off we were from introducing anything resembling cancer screening or dialysis when there was no treatment available within the countries where I worked.

But today I am struck by the rapidly changing epidemiological profile of those same countries where I spent so much time on child survival. It’s true that the causes of child mortality continue to be a burden and still require high priority attention and resources. But at the same time, rapid urbanization and changing social norms and diet mean that NCDs are a growing threat to the economically-active segment of the population.

Here in Uganda, health authorities note that the rising prevalence of obesity, alcohol and tobacco use are contributing to a ballooning NCD problem, one that hits the most economically active segment of the population. Twenty-five percent of deaths in Uganda are currently attributed to NCDs and WHO estimated that deaths from NCDs in Africa will increase by 24% over the next decade. Worldwide, NCDs account for 29 million deaths annually, and of these, more than 9 million are “premature” deaths – meaning the deaths of people in the prime of their lives, who are wage-earners and caregivers. And of these, over 8 million deaths occur in low and middle income countries that have the least capacity to provide prevention, screening and management services to their rapidly growing populations.

When I reflect on where we are with regard to NCDs in 2014, I am reminded of the early years of the AIDS epidemic when we were just starting to address the economic impact of the disease, particularly in terms of what it meant as loss to GDP and corporate profits. While it’s still early, the same can be said of the growing burden of NCDs – premature mortality and morbidity due to these diseases also means the slowing of economic growth and the need for increased investment in the social safety net. Those lessons of the HIV epidemic present a rich reference point for consideration in tackling this next threat to global economic, social, and physical health and well-being.

Christine Sow is the Executive Director of the Global Health Council. This blog is part 3 of 4, stay tuned for the final post tomorrow.

Study Tour: Combating NCDs with Limited Resources

By: Christine Sow, Global Health Council
Cross-posted from the Global Health Council Blog

GHC Executive Director Christine Sow accompanied US Senate staffers to Uganda and Rwanda on a study tour organized by the Livestrong Foundation and Management Sciences for Health. We will be featuring blogs and pictures from Christine on the tour on the blog – read on to hear about the trip, NCDs, and global health challenges.

Hospital in Mulago. Photo credit: Sally Canfield.

Hospital in Mulago. Photo credit: Sally Canfield.

We visited a sub-district health referral center as well as Mulago hospital, the largest hospital in Uganda. The scale of services provided was vastly different across the two facilities – the referral center offered mostly primary care services along with some basic tertiary care while Mulago Hosptial offers a wide range of complex tertiary care to a patient population of more than 5,000. However the two have several important commonalities – both are under-staffed, over-used and lacking in the basic supplies and equipment necessary to allow staff to properly do their jobs. The referral center had little or no capacity at the current time to integrate NCD prevention, screening or treatment into its remit.

The question has to be asked: how will it be possible to add on yet another (and another and another) service to their mandate without providing additional resources in the form of staff, commodities and equipment to take on this additional burden?

A promising initiative, the Uganda Initiative for the Integrated Management of NCDs (UINCD) was launched to begin looking at how this might be accomplished. A partnership between Mulago Hospital and Yale University, the initiative will begin establishing a model this year for the integrated management of NCDs within existing health structures, starting with Mulago Hospital and rapidly extending out to lower-level health centers. Through the establishment of a center of excellence on NCD programming at Mulago Hospital, the initiative hopes to establish best practices and recommendations for the scale up of integrated NCD management within the Uganda health system.

Dr. Christine Sow is the Executive Director of the Global Health Council. This blog is part 2 of 4, stay tuned for the next two posts.

My Lessons from the Frontlines

By: Loyce Pace Bass
Cross-posted from the LIVESTRONG Foundation Blog

As those who followed the updates know, I traveled with a congressional delegation to Rwanda and Uganda last week, to learn from stakeholders on the ground what they are doing to address the growing burden of cancer and other non-communicable diseases (NCDs) in those countries. What was clear is that everyone is doing something. Government representatives, NGO leaders, and healthcare providers alike have identified NCDs as an immediate problem requiring action sooner rather than later. Of course, people are responding differently in various settings. Some such as health ministry or local CDC staff are still in the planning stages, looking at how to use available resources to further assess the problem and the best means for tackling it. Others such as those running health centers or community projects and leading dedicated hospital clinics are a bit farther along, given people are walking through their doors with comorbid conditions like HIV and cancer. These people basically on the frontlines have set protocols by which individuals can be screened and treated for certain NCDs, based on their capacity to do so. At least this way they address a patient’s overall health status, not just target discrete ailments.

Doctors talk with the group at the Uganda Cancer Institute. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation

Doctors talk with the group at the Uganda Cancer Institute. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation

No matter where stakeholders were on the spectrum of a response to NCDs, the key word was “leverage.” Repeatedly, they proposed the PEPFAR platform could be a means of expanding services for the prevention and control of NCDs. This is particularly relevant, given recent legislation reauthorizing the program has called for country reporting of comorbidities, including AIDS-related cancers, among the treatment population. Another area of potential integration was health-worker training, with new providers and support staff being versed in NCD risk factors and symptoms as well as educated about basic interventions and referral systems. Likewise, laboratory facilities and supply chains could be more dual-purposed to assist NCD-related healthcare. However, many of these solutions were presented as theories rather than practice; the challenge now is to implement more ideas and pilot ideal strategies.

Again, seeing the local response in living color can be important for informing policy solutions that complement country-based programs, and delegates highlighted some obvious takeaways. One was the fact that, while NCDs are becoming rampant in low- and middle-income countries, they aren’t necessarily a result of behavior or lifestyles, as is so often assumed. In fact, many cancers observed in Rwanda, Uganda, and elsewhere in sub-Saharan Africa are a result of infections. A delegate made the observation that the diseases can be the same but they’re of a different source and arguably require new solutions, other than those tailored for western, couch-potato cultures. Another distinction that resonated with delegates was the fact that many NCDs seen in these countries lead to premature death. So, it’s less a matter of trying to save people at the end of their life expectancy. Rather, interventions put in place today can help people in their prime, sustaining individuals, families, and communities as well as whole economies. As another delegate observed, countries will have little chance at being successful if their people are sick. How we interpret the NCD burden in low-resource settings is critical.

Part of the study tour group and Mpigi staff outside the Mpigi Health Centre. Photo credit: Brigid Boettler/MSH.

Part of the study tour group and Mpigi staff outside the Mpigi Health Centre. Photo credit: Brigid Boettler/MSH.

It remains to be seen how what we experienced will influence the US’ thinking in this space. The ongoing UN dialogue regarding global responses to NCDs is timely and provides a key opportunity. And surely US global health investments are affected by local realities in a way that warrants policymakers understand the new context. Ideally, we help other countries bridge persistent gaps between what they know and what they do, and further build their capacity to lead on improving public health for everyone’s benefit.

Loyce Pace Bass is the Director of Health Policy at the LIVESTRONG Foundation.

Study Tour: The Burden of NCDs in Low Resource Settings

By: Christine Sow, Global Health Council
Cross-posted from the Global Health Council Blog

Last week, GHC Executive Director Christine Sow accompanied US policymakers to Uganda and Rwanda on a study tour organized by the LIVESTRONG Foundation and Management Sciences for Health. We will be featuring blogs and pictures covering Christine’s experiences on the tour for the next four days – read on to hear about the trip, NCDs, and global health challenges.

Dr. Christine Sow (center) with other study tour delegates during a study tour meeting in Kampala, Uganda. Photo credit: Brigid Boettler/MSH.

Dr. Christine Sow (center) with other study tour delegates during a meeting in Kampala, Uganda. Photo credit: Brigid Boettler/MSH.

I’m excited to be spending the week with US policy makers and representatives from the LIVESTRONG Foundation and MSH in Uganda and Rwanda. We’re here to look at the burden of Non-Communicable Disease and how they are, or are not, taken into account in the national health systems of the two countries. So far, over a very short period of time we’ve been privileged to meet with many of the top decision-makers and senior management of Uganda’s health system and have heard first hand of the challenges and triumphs they’ve experienced in dealing with NCDs in low resource settings.

The great challenge of combating NCDs in a country like Uganda is that they are just one of many critical priorities within the health sector; not surprisingly most of Uganda’s health budget and donor aid for health are channeled into fighting communicable disease and funding child survival and maternal health programming.

There is strong clear message from donors and government alike that additional funds will not be forthcoming and that other ways will need to be identified to begin addressing the not-insignificant burden from NCDs. One key approach that is emerging is that of integrated health programming.  The lessons learned around the importance of integrating HIV and AIDS programming into existing health systems must now be extended to provide a platform for NCDs. The health systems platform is there, but the addition of prevention, screening and treatment for the “big four” – cardiovascular diseases, chronic-respiratory diseases, diabetes and cancer – pose a considerable challenge, especially when the already inadequate state of the Ugandan health system is taken into account. But the economic and social impact of the growing burden of NCDs in Uganda is undeniable so something must be done.

Dr. Christine Sow is the Executive Director of the Global Health Council. This blog is part 1 of 4, stay tuned for the next three posts.

Recap: February 21 – Rwanda

During the study tour’s last full day, the delegates visited Partner In Health’s (PIH) Rwandan headquarters and toured the Rwinkwavu District Hospital NCD Clinic and Health Center. At PIH headquarters, the group learned about PIH’s work in Rwanda and how they leverage leadership, skills, and experience of patients, local governments, and other partners to strengthen healthcare services in local communities. At Rwinkwavu District Hospital, delegates were able to witness firsthand the impact of public-private partnerships and how they improve health care training, strengthen referral and procurement systems, and build capacity at health care facilities. To conclude their tour in the Rwinkwavu district, the group went out on patient visits to meet with those receiving services, witness the local impact of trained community health workers, and understand the importance of strong community outreach programs. The day concluded with a dinner with Ministry of Health representatives.

A view of the Rwinkwavu District Hospital. Photo credit: Crystal Lander/MSH.

A view of the Rwinkwavu District Hospital. Photo credit: Crystal Lander/MSH.

PIH and Rwinkwavu staff. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Rwinkwavu District Hospital staff. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

A Rwinkwavu District Hospital staff member shows the delegates the NCD Chronic Care Clinic. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

A Rwinkwavu District Hospital staff member shows the delegates the NCDs Chronic Care Clinic. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Delegates listen carefully during the Rwinkwavu District Hospital tour. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Delegates listen carefully during the Rwinkwavu District Hospital tour. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

A Ministry of Health representative speaks to the group during dinner. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

A Ministry of Health representative speaks to the group during dinner. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Recap: February 20 – Rwanda

The delegates kicked off their first day in Rwanda with a conversation with the Rwandan Minister of Health Agnes Binagwaho followed by a visit to the Busanza Health Center. At Busanza, they met with the staff, toured the facility, and learned how the center manages the community-based health insurance and health management information systems. The group then met with US government representatives for a lunch meeting at the US Embassy where they engaged in a discussion on USG-funded support and how it aligns with country-led health system strengthening efforts. After the US Embassy visit, the delegates visited the Centre Nationale de Transfusion de Sanguine (CNTS) and National Reference Lab (NRL). The day concluded with a reception at the US Embassy Deputy Chief of Mission’s residence. The reception, entitled Together for Health: Stronger Health Systems for Long-Term Impact, brought together the delegates, local NGO partners, government representatives, and their Excellencies Minister of Health Agnes Binagwaho and Minister of State for Health Anita Asiimwe to celebrate the importance of collaboration and partnership in health systems strengthening.

Rwandan Minister of Health Agnes Binagwaho (far right) talks with delegates and MSH Country Representative Apolline Uwayitu (second from left). Photo credit: Crystal Lander/MSH

Rwandan Minister of Health Agnes Binagwaho (far right) talks with delegates and MSH Country Representative Apolline Uwayitu (second from left). Photo credit: Crystal Lander/MSH

Community health workers greet the study tour delegates during their visit to the Busanza Health Center. Photo credit: Brigid Boettler/MSH.

Community health workers greet the study tour delegates during their visit to the Busanza Health Center. Photo credit: Brigid Boettler/MSH.

Delegates learn about the Rwanda health insurance system from the staff at the Busanza Health Center. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Delegates learn about the Rwanda health insurance system from the staff at the Busanza Health Center. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

A view of CNTS and NRL in Kigali. Photo credit: Brigid Boettler/MSH.

A view of CNTS and NRL in Kigali. Photo credit: Brigid Boettler/MSH.

The study tour delegates and CNTS and NRL staff. Photo credit: Brigid Boettler/MSH.

The study tour delegates and CNTS and NRL staff. Photo credit: Brigid Boettler/MSH.

A UN representative, Didi Farmer, and Loyce Pace Bass during the Together for Health: Stronger Health Systems for Long-Term Impact reception. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

From left to right, UN representative, Didi Farmer, and Loyce Pace Bass during the Together for Health: Stronger Health Systems for Long-Term Impact reception. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Minister of Health Agnes Binagwaho, Minister of State for Health Anita Asiimwe, and Deputy Chief of Mission Jessye Lapenn (left to right) at the Together for Health: Stronger Health Systems for Long-Term Impact reception. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Minister of Health Agnes Binagwaho, Minister of State for Health Anita Asiimwe, and Deputy Chief of Mission Jessye Lapenn (left to right) at the Together for Health: Stronger Health Systems for Long-Term Impact reception. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Didi Farmer (left) and a study tour delegate at the Together for Health: Stronger Health Systems for Long-Term Impact reception. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Didi Farmer (left) and a study tour delegate at the Together for Health: Stronger Health Systems for Long-Term Impact reception. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Some of the reception guests and study tour delegates pose for a group photo at the Together for Health: Stronger Health Systems for Long-Term Impact reception. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Some of the reception guests and study tour delegates pose for a group photo at the Together for Health: Stronger Health Systems for Long-Term Impact reception. Photo credit: Brigid Boettler/MSH.

100 Hours in Uganda

By: Loyce Pace Bass, LIVESTRONG Foundation

We’ve had a great start to what’s shaping up to be a successful study tour so far!

Delegates came ready with energy for a number of site visits and plenty of questions for stakeholders on the ground. Health systems definitely have emerged as a major theme here in Uganda, with human resources topping the list of concerns. The country retains only fifty percent of trained health personnel, which has officials constantly playing catch-up when it comes to bringing new doctors, nurses, and other clinical staff online. Another problem is supplies, from drugs and technologies to basics such as antiseptic and rubber gloves. Providers are hard-pressed to meet the country’s vast health priorities with increasingly limited resources, and this is only becoming more strained with a growing population (expected to triple within the next 15 years) and as the disease burden shifts to include NCDs. For example, there is currently only one cardiologist in the country to deal with the vast number of patients that come through the main hospital’s clinics with complications stemming from hypertension and heart disease.

Uganda Cancer Institute Director Jackson Orem (right) and a study tour delegate during the group's visit.

Uganda Cancer Institute Director Jackson Orem (right) and a study tour delegate during the group’s visit. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

One bright spot amidst the myriad challenges is Uganda Cancer Institute. During the 40-plus years of its existence, this facility has emerged a leader in cancer research for Uganda, Africa, and the world at-large. Their cases were the first to help identify and address linkages between cancers and infectious diseases like malaria and HIV. They’ve implemented groundbreaking treatment protocols now adopted by oncologists worldwide. But there’s still a ways to go. The director speaks to a persistent missing link with the PEPFAR program, although 60 percent of the Institute’s cases are related to HIV. An ideal scenario, he noted, is one in which patients and providers aren’t battling two diseases simultaneously – cancer and HIV – but able to control one and focus on the other. “Cure, not co-morbidity.” He also hopes for a time when children with cancer in Uganda can enjoy the same survival rates as their peers in western countries. Still Uganda Cancer Institute is doing everything it can to address the needs of people affected by cancer in Uganda today. And, by many accounts, having a significant impact on the burden.

One of the dedicated staff at the Mpigi Health Centre outside of Kampala discusses antenatal and postnatal care during the group's visit. Photo credit: Crystal Lander/MSH.

One of the dedicated staff at the Mpigi Health Centre outside of Kampala discusses antenatal and postnatal care during the group’s visit. Photo credit: Crystal Lander/MSH.

That’s another recurring theme from our brief, whirlwind visit: people who feel responsible for the health of this country are doing what they can, earnestly so. The alternative clearly isn’t an option for them. It’s dedicated individuals like the head of a health center in a district outside the capital city of Kampala who hold promise for many women that visit him for antenatal and postnatal care. And efforts such as that of the Yale Global Health Leadership Institute whose members have developed a strategic plan for integrating NCDs into existing healthcare programs, with a focus on training and research. These champions are critical to bridging the gap between what’s needed and what’s possible, at least for now.

 

 

Loyce Pace Bass is the Director of Health Policy at the LIVESTRONG Foundation. Stay tuned for updates throughout the week on Loyce’s travels and dialogue with our Africa partners.

Recap: February 19 – Uganda

During the study tour’s last day in Kampala, the delegates visited the US Embassy. The group met with US Ambassador to Uganda Scott DeLisi in the morning before attending an interagency lunch meeting in the afternoon. During the interagency meeting, delegates met with representatives from the US Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), National Institutes for Health (NIH), and Walter Reed. The delegates and agency representatives discussed how each agency’s work in Uganda supports US policy objectives in peace and security, democracy and governance, health, education, and economic growth. The meetings with US government officials provided a great way to wrap up the Uganda half of the tour!

Recap: February 18 – Uganda

On Tuesday, February 18, study tour delegates visited a health center in the Mpigi district, Mulago hospital in Kampala, and attended a partnership dinner. At the Mpigi Health Centre located outside of the capital city of Kampala, delegates observed the impact of the USAID -funded, MSH-led STRIDES for Family Health project which improves health services and builds capacity. After visiting the Mpigi district, the group traveled back to Kampala to visit Mulago Hospital where they met staff, toured the hospital’s NCD ward, and learned about the progress made and the challenges faced by the public healthcare system. To conclude the day’s events, the group attended a dinner and discussion, entitled Partnerships for Global Health, where they met with private partners and the Chairman of the Parliament’s Committee on Health to discuss the role that diverse global health partners play in sustaining strong health systems.

A study tour participant talks with Mpigi Health Centre staff during a tour of the facility. Photo credit: Crystal Lander/MSH.

A study tour delegate talks with Mpigi Health Centre staff during a tour of the facility. Photo credit: Crystal Lander/MSH.

The study tour group outside the Mpigi Health Centre in Uganda, a STRIDES for Family Health project facility. Photo credit: Crystal Lander/MSH.

The study tour group at the Mpigi Health Centre in Uganda, a STRIDES for Family Health project facility. Photo credit: Brigid Boettler/MSH.

A study tour participant thanks the Mulago Hospital staff. Photo credit: Crystal Lander/MSH.

A study tour delegate thanks the Mulago Hospital staff. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

Two of the panelists participate in the discussion during the Partnerships for Global Health dinner. Photo credit: Crystal Lander/MSH.

MSHer Celia Kakande, project director for STRIDES for Family Health, moderates a dynamic panel on the importance of partnerships for results. Seated here with Raymond Bayarugaba from the AIDS Information Center. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.

An attendee asks the panelists a question during the Partnerships for Global Health dinner. Photo credit: Crystal Lander/MSH.

An attendee asks the panelists a question during the Partnerships for Global Health dinner. Photo credit: Loyce Pace Bass/LIVESTRONG Foundation.