Forty Years since Alma-Ata: Do we need a new model for NCD? Implications for Botswana

23 Sep 2019

The year 2018, marked the 40th Anniversary of the Alma – Ata Declaration which stated that Primary Health Care (PHC) was essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally acceptable to individuals and families in the community. The Declaration mentioned the need for PHC to evolve with changing disease and socio-economic conditions, focus on  the main health problems by providing health promotion, prevention, care and rehabilitation, involving the community resources at large for health, empowering communities and adequate human resources, David Beran and Pablo Perel  (2019), wrote.

Forty years ago, the main causes of morbidity and mortality were communicable diseases impacting children under the age of 5 and maternal mortality. Responses focused on providing, growth monitoring, promotion of breastfeeding, immunizing children, family planning and providing female literacy. However, in 2018, the leading cause of morbidity and mortality are Noncommunicable Diseases (NCD). NCD targets are included in the Sustainable Development Goals (SDG) and the importance of PHC in achieving the SDGs has been noted. In addition the recent Declaration of Astana, marking the 40th Anniversary of Alma-Ata, stated that PHC is a cornerstone for Universal Health Coverage (UHC) and the health related SDGs.  Included in the Declaration of Astana is mention of NCDs with the importance of the 4 common risk factors (tobacco use, unhealthy diets, control and management of these conditions.  David Beran and Pablo Perel argued that the Declaration of Astana lacks concrete measures.

For NCDs, PHC needs to provide a wide range of preventative and curative services. This cuts across all ages and also need a gender specific approach. NCDs require a variety of factors from the health systems, access to medicines, diagnostics, education, continuity of care, in addition to a wide range of societal factors across the life course.

A model to address NCDs at PHC would therefore need to include Prevention focused on the community at large as well as targeted to those with specific risk factors. For those without an NCD their risk profile needs to be assessed. For those with NCDs there is the need to look beyond their individual disease to focus on the individual and their wide range of needs, such as social, psychological and health. All these need to be adapted to the local context.

WHO’s Package of Essential Noncommunicable provides framework for PHC in the different elements needed for services to be delivered and tools that are needed, including diagnostic and medicines. From an Organizational perspective the management of people with an NCD has to consider that once the individual is diagnosed their NCD needs to be considered in each interaction with the health system. Clinical needs around continuity of care and multi-morbidity and wider elements of responsive services needs also need to be addressed.

For NCDs there is need to address a wide range of societal factors in communities and adapts responses to this local context. This community will fall within a spectrum of risk from those at no risk, those with certain factors, those with undiagnosed NCD, those already with an NCD and those with an NCD related complication. All these sub-populations will require a tailored response for their current needs and risks.  PHC needs to be embedded within communities and seen as the link between populations and their health system.

Many African countries, together with other LMICs are currently undergoing an epidemiological transition from predominantly infectious to non-communicable diseases. This change according to (WHO, 2011) can be attributed to changes in life style like diet, physical activity, smoking and drinking habits. It could also be due to demographic profile of the population. Despite the many gains towards the prevention and control of communicable diseases in Africa, their prevalence in African countries still remain un acceptably high.

Although morbidity and mortality of NCDs in Botswana is not well documented, they are estimated to account for 31% of deaths in the country. The most common ones are cardio vascular disease, hypertension, cancer, chronic obstructive pulmonary disease and diabetes (WHO, 2018). Before the 1980s, the common diseases in Botswana were infectious diseases and those associated with un- sanitary conditions, poverty and inadequate hygiene. The interaction between communicable and non-communicable diseases increasingly placed a burden on health care systems and individual health.

Although Botswana is considered a celebrity in the Public Health World for its management and response to HIV/AIDS epidemic,  it is currently going through an epidemiological transition of having to deal with the double disease burden of infectious and non-infectious diseases that calls for an immediate policy attention and intervention. The double disease burden that Botswana has to deal with threatens to overwhelm an already over taxed health system. Health services in Botswana have been fatigued and are financially overstretched as the available resources are dedicated primarily to communicable disease and most importantly HIV/AIDS.

The number of patients, especially those who are taking ARVs has put strain on the health system and caused concerns about the GoB apparent neglect of other system programmes. Botswana has had an unprecedented positive response to the HIV/AIDS epidemic and has been able to reverse the situation that initially seemed would wipe out the gains that had been achieved after independence. The Government’s efforts have been complemented by a number of nongovernmental organizations and community-based organizations and community network that have provided support and advocacy for the rights of people infected or affected by HIV/AIDS.

As an effort to respond to the NCDs, Botswana recently launched the multisectoral strategy for the prevention and control of NCD, 2018-2023. Historically the PHC system developed response to acute communicable disease, with governments prioritising and allocating funds and training opportunities towards these conditions. In Botswana, approximately 96% of health budgets have been directed towards HIV/AIDS, despite this being the case,  the country  does not have health facilities for effective diagnosis and treatment of NCDs with many of the patient’s referred to South African hospitals taking a knock on its  national health accounts.   Compounding this situation is many people who do not report for health services with NCDs, thus leading to an under estimation of the actual prevalence of these conditions. In turn this affects the allocation of funds to NCDs by the government. There is therefore, an urgent need to integrate NCDs and HIV/AIDS services as opposed to re-inventing the wheel. There is also an urgent need for Botswana to strengthen its health system to deal with palliative health care and not depend on faith based organizations that provide such facilities.

Whilst the opposition in Botswana, UDC to be precise in its election campaign manifesto for the 2019 general elections has used the provision of sanitary pads to the girl child and women as its election campaign trump card, it is important that they are alive to the overall health systems challenges the country is faced with and must not turn a blind eye to the great achievements the country has made. Many have asked the question, why now?  And why is it that they are being selective instead of packaging and include gender based violence. Credit needs to be given where it is due, instead of cheap political electioneering, the opposition must appreciate that despite the challenges the country is faced with it  has continued  to make positive strides in health care as well its attempt to address NCDs , the silent epidemic.

All too often, politicians push short term solutions to various health crises without reference to the knowledge base that exists for sound programs. The general public is confused. The result is a hodgepodge of fractioned interests and programs without coherent direction by well qualified professionals. The dilemma faced by public health is how to take on new challenges while continuing its work to contain long existing problems. 

Reform and renewal are fundamental features of every health system though the ambition and scale varies over time. After 53 years of independence, Botswana continues to strive for an improved health system, a health system that better meets the needs and preferences for treatment, care and dignity of all its population. The Botswana health system remain hospi-centric and specialized, with decision making driven more by service than population needs. People who are on medical Aid mostly use the private health care system. There are two types of medical aid schemes; one for people who are employed in the private sector and another that is for public civil servants. Unemployed people have an option to join the medical Aid schemes. However, the majority of Batswana mostly use the public sector of health care as patients and clients pay nominal fees and no one is ever turned away for lack of fees. The Primary Health Care Strategy is to attain health for all, in pursuit of the national objectives as in the context of vision 2036. Hence the National Health Care Policy stipulates as priority activities geared towards health for all.

Thabo Lucas Seleke is a Researcher & Scholar of Health Policy Analysis