Decentralizing Diagnosis: Controlling Non-Communicable Diseases (NCDs) in Africa

Jacob sat by the fire in his thatched round kitchen hut, dabbing himself with a wet towel. The air around him was heavy and still. As I sat next to Jacob, the weight of the oppressive humidity made every breath feel thicker, and every movement slower. Jacob told me, with conviction, that the wet towel would lower his blood pressure, while also relieving the pressure from the headache and relentless ringing in his ears. Although Jacob had been put on treatment for his recently diagnosed Stage 1 hypertension, he did not take the medication consistently, as he believed it made his feet swell. During his consultation at the health centre, the health practitioners did not take the time to share information and help him understand how the medication worked and the possible side-effects. This lack of information led him to assume that the swollen feet were a result of the medication.  

Since his diagnosis, Jacob had not monitored his blood pressure, nor had he visited the clinic. I asked him whether he had a blood pressure monitoring device so that he could closely track his blood pressure. Jacob seemed to contemplate this for a second. He did not know that this was something he could do. The swell of anticipation that had initially swept across his face when he heard me speak about monitoring at home gave in to despair as Jacob reasoned that he would very likely not be able to afford such a device.  

“How much does it cost?” He asked. I promised to send him more information about the device, but I recommended that he goes back to the clinic in the meantime. He smiled and reached for a shirt. He still owed his neighbour USD$53 from his last visit, he told me.  

As Jacob and I stepped outside, he began to tell me of the many instances when he spent hours waiting in line at the clinic, 5km from his home. When he was finally seen by a nurse, she was not able to assess his blood pressure as the clinic did not have the appropriate equipment in functioning order. His blood pressure was only measured on his second visit, 3 months later.  

Telling Jacob that he is not alone in his struggle to access care and better manage life-threatening hypertension would not provide him comfort. His experience is a common one in many low-income countries - a result of lifestyle factors, compounded by inadequate healthcare systems that are not well equipped to deal with the rapidly increasing prevalence of noncommunicable diseases.  

The lack of access to quality, timely diagnosis is a fundamental challenge in the effort to detect and manage hypertensive patients like Jacob. Globally, up to 47% of the population have little or no access to diagnostics. In Africa, these access gaps are further amplified, particularly at the lowest levels of the healthcare system where most patients seek care.  

Hypertension and other non-communicable diseases (NCDs) are a growing contributor to the health burden in Africa. According to the World Health Organization (WHO), NCDs are fast becoming the main cause of mortality; in 2019, they were responsible for 37% of all deaths. Cardiovascular diseases are the most frequent causes of NCDs deaths, accounting for nearly 13% of all deaths and 37% of all NCDs deaths in Africa. Added to this, the diagnosis of NCDs has traditionally involved centralized or specialist healthcare facilities, which has resulted in patients failing to get comprehensive diagnosis and treatment at their first contact point with the health system. They are either: referred to higher level facilities like hospitals and specialist NCD clinics; referred to private-owned health facilities for diagnosis, treatment, and care; given pain killers and dismissed in the same way that Jacob was. Only a fraction of patients eventually makes it to the referral center. Many are lost trying to navigate the myriads of referral pathways that exist in many health systems.  

Task shifting and decentralizing of diagnosis and treatment service is therefore critical in improving patient outcomes. Access to point-of-care diagnostic technologies (POCT) brings testing closer to the patient, allowing treatment and clinical decisions to be made more rapidly and as part of the same clinical visit.

Our work at Market Access Africa is catalyzing the introduction of a range of affordable legacy and novel POCT in Africa, including rapid diagnostic tests (RDTs), wearable devices, portable diagnostic analyzers, and mobile health (mHealth) solutions. We are supporting ministries of health, global health agencies, and the private sector to design and implement effective deployment strategies for these technologies, with a keen focus on addressing the supply and demand-side bottlenecks that prevent these technologies from being introduced in the first place. These efforts are contributing to the broader global initiatives aimed at supporting countries to decentralize integrated management of NCDs in primary health care settings so that health systems can detect and manage NCDs sooner.

Our work with health technology innovators, as well as public and private sector health providers has highlighted some critical priorities if we are to see widespread and more streamlined adoption of decentralized POCT into Africa’s health care systems.  

For POCT’s to be effectively and sustainably adopted by national governments, they need to be integrated into existing NCDs diagnostic and laboratory networks. They cannot and should not be seen as a standalone system. Addressing the regulatory and quality assurance concerns associated with diagnostic testing done outside of laboratory settings would also need to be addressed. Healthcare providers and other lay workers will also need to be trained appropriately to test, interpret and relay the results to the patients.  

The POCT solution must also use a specimen type that can easily be collected at the lowest levels of care, and it must be easy to use. If a platform-based device is being considered, an all-inclusive cartridge-based model with short wait time for results should be prioritized, to reduce the risk of errors in the sample preparation and analysis. This model does not require precision pipetting or strict environmental control and can use alternative power sources, like solar or battery packs. They require minimum training, calibration, and quality control.  

Across the continent, we are seeing encouraging efforts to expand access to NCD testing and treatment services at the lowest levels of care. Several countries are now piloting and/or scaling up the World Health Organization’s PEN/PEN Plus Programme, an integrated package of essential chronic care interventions for primary healthcare settings. The package includes building capacity of healthcare workers to screen, treat, refer patients, and avail diagnostic solutions at the point clients make their first contact with the health system. This approach also involves the deployment of portable, easy-to-use, and cost-effective diagnostic devices and technologies that can be used outside traditional healthcare or laboratory settings. Rwanda and Uganda are just two of several countries scaling up PEN-Plus.

We have evidence of countries (e.g. Côte d’Ivoire and Kenya) proactively including diagnostic and treatments solutions for key cardiovascular diseases into the benefits package of their national health insurance schemes. Although only the most basic diagnostic and therapeutic options are reimbursed at this point, we see this changing with time as better pricing is negotiated for POCTs and health technology assessments become entrenched in the decision-making process.

There is also support for inclusion of relevant funding requests for activities under existing multilateral funding mechanisms like The Global Fund in Malawi, Kenya, and Zimbabwe  

Lastly, we are encouraged by the increased collaboration between the public and private sectors in the delivery of NCD services. In many countries, pharmaceutical companies are partnering with diagnostic providers and non-governmental organizations in rolling out expansive multi-disease screening programmes using POCTs in community and primary healthcare settings.  

Beyond enabling faster diagnosis, making point-of-care diagnosis available at lower levels of care also empowers individuals to actively engage in their healthcare, promoting self-monitoring and self- management of chronic conditions. By deploying robust, easy-to-use POCT solutions that require minimal environmental requirements and can be utilized by all health workers, we ensure equitable access to essential diagnostic tools.  

These solutions can be strategically placed in communities and primary healthcare settings, addressing the most significant gaps in access, coverage, capacity, capability, competencies, and resource allocation. Expanding this holistic approach is necessary if we are to improve African health outcomes and strengthen healthcare systems to foster healthier communities less susceptible to NCDs.

This means patients like Jacob can better manage their hypertension and live a longer, fulfilling life, without incurring prohibitive transport and health care bills in their efforts to manage their conditions.

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