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Abstract:

In sub-Saharan Africa (SSA), communicable diseases, particularly HIV/AIDS, tuberculosis (TB), and malaria, are still responsible for the greatest burden of morbidity and mortality [1]. However, non-communicable diseases (NCDs) are becoming a significant burden [1]. The Global Burden of Disease Study, conducted in 2001, showed that 20% of deaths in SSA were due to NCDs [2], and this burden is predicted to rise to 40% by 2020 [3]. Obesity, hypertension, diabetes mellitus, cardiovascular disease, asthma, chronic obstructive pulmonary disease, epilepsy, and mental illness are some of the important, chronic NCDs that pose significant challenges in terms of management and follow-up.

How are NCDs currently managed in the routine health care settings of African countries? In brief, badly. Anecdotal reviews point to poorly managed health care systems with frequent stock interruptions of essential drugs [4–6]. Untreated hypertension is blamed for high rates of stroke morbidity and mortality in urban and rural Tanzania [7] and rural South Africa [8,9]. Only a small proportion of patients with epilepsy receive drug treatment at any one time, mainly due to poor health care delivery systems and unavailability of drugs [10]. Even in specialist centres, asthma patients are given sub-standard care [11] and have poor access to essential medications [12]. There is a growing burden of diabetes mellitus and its associated complications, and many patients with type 1 diabetes mellitus have extremely short life expectancies [13].

Summary Points:

• In sub-Saharan Africa, management standards for NCDs in public health services are poor.
• With the growing burden of NCDs, now is the time to develop and implement standardised NCD management protocols and systems for diagnosis, treatment, monitoring, and reporting.
• DOTS has been the framework for tuberculosis control for over a decade, allowing structured and well-monitored services to be delivered to millions of tuberculosis patients in some of the poorest countries of the world.
• The DOTS model has been successfully adapted for the scale-up of ART in Malawi, allowing long-term, structured treatment to be given to thousands of patients.
• This paper discusses why the DOTS paradigm should be adapted for NCDs, and, with the “DOTS five-point policy package” as a template, shows how this could be implemented and rolled out in resource-poor countries, with special reference to sub-Saharan Africa.

Some of us know from personal experience of running routine diabetes and hypertension clinics in African hospitals that there are no formalized systems of recording how many patients have been diagnosed and started on therapy, how many are retained on therapy, or what proportion have died or developed complications. We treat patients with whatever drugs are available, and consider that our mission is accomplished. In summary, unstructured and unmonitored clinical care and little information about morbidity or mortality from NCDs are mostly the norm in sub-Saharan Africa [14]. How do we begin to rectify this unsatisfactory situation? A possible solution arises out of the existing “DOTS” framework for control of TB.

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