Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease.

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.

ACHIEVE conference proceedings: implementing action plans to reduce and control hypertension burden in Africa.

The prevalence of hypertension, the commonest risk factor for preventable disability and premature deaths, is rapidly increasing in Africa. The African Control of Hypertension through Innovative Epidemiology, and a Vibrant Ecosystem [ACHIEVE] conference was convened to discuss and initiate the co-implementation of the strategic solutions to tame this burden toward achieving a target of 80% for awareness, treatment, and control by the year 2030. Experts, including the academia, policymakers, patients, the WHO, and representatives of various hypertension and cardiology societies generated a 12-item communique for implementation by the stakeholders of the ACHIEVE ecosystem at the continental, national, sub-national, and local (primary) healthcare levels.

African Control of Hypertension through Innovative Epidemiology and a Vibrant Ecosystem (ACHIEVE): novel strategies for accelerating hypertension control in Africa.

Hypertension is a leading preventable and controllable risk factor for cardiovascular and cerebrovascular diseases and the leading preventable risk for death globally. With a prevalence of nearly 50% and 93% of cases uncontrolled, very little progress has been made in detecting, treating, and controlling hypertension in Africa over the past thirty years. We propose the African Control of Hypertension through Innovative Epidemiology and a Vibrant Ecosystem (ACHIEVE) to implement the HEARTS package for improved surveillance, prevention, treatment/acute care of hypertension, and rehabilitation of those with hypertension complications across the life course. The ecosystem will apply the principles of an iterative implementation cycle by developing and deploying pragmatic solutions through the contextualization of interventions tailored to navigate barriers and enhance facilitators to deliver maximum impact through effective communication and active participation of all stakeholders in the implementation environment. Ten key strategic actions are proposed for implementation to reduce the burden of hypertension in Africa.

Targeting elimination of cervical cancer by 2030: a baseline assessment in six African countries-part II.

Background: Africa is home to many countries with the highest incidence of cervical cancer in the world. It is encouraging to see that the efforts to prevent and manage this disease are intensifying across the continent. The World Health Organization (WHO) has, in the last years, led a world-wide initiative to eliminate cervical cancer as a public health problem, starting by setting clear targets for 2030. Aim: To assist those African countries with the largest burden of cervical cancer, to reach the set targets, as a first step, WHO initiated a baseline capacity assessment in African high burden countries. We present and discuss the results thereof in this paper. Method: The countries selected for the baseline evaluation were Eswatini, Guinea, Malawi, Rwanda, Uganda and Zambia. The data were collected by a mailed questionnaire in English, with 129 questions, most of them with preset answer options. It was answered by national coordinators of non-communicable diseases, cancer control or reproductive health programmes in the ministries of health and by the WHO country representatives. Based on the answers, suggestions were made towards optimising the efforts for cancer control. Results: Except for Eswatini and Guinea, vaccination against the human papilloma virus (HPV) has reached between 74% and 98% of girls in the age bracket. The main method for cervical screening is still inspection with acid acetic. HPV testing, recommended by WHO, is being introduced slowly. The numbers of women screened are not yet nearing the required levels. Between 30% and 70% of the cervical cancers diagnosed are being treated with palliative intent. A deficit of personnel was reported for all professions involved in cervical cancer care. Conclusions: Guinea will need assistance to implement HPV immunisations and expand screening. In all six countries surveyed, steps should be taken to introduce or scale up the more precise HPV screening instead of acid acetic inspection of the cervix, to replace the current cryoablation of the preinvasive lesions of the cervix with thermal ablation and to increase the capacity for screening. Solutions need to be found for covering the dearth in gynaecological oncologists and radiotherapy installations and personnel.

The World Health Organization targets for cervical cancer control by 2030: a baseline assessment in six African countries-part I.

Aim: We present and analyse the findings of a survey of the readiness of the healthcare systems in Eswatini, Guinea, Malawi, Rwanda, Uganda and Zambia, to implement the necessary measures for attaining the targets for cervical cancer control, set by The World Health Organization (WHO), by the year 2030. Methods: A questionnaire with 129 questions with preset answer options was completed in 2020, by ministries of health programme coordinators for non-communicable diseases, cancer control and/or reproductive health, and by WHO country offices, in the six countries selected. Results: The findings on demographics, burden of disease, governance and management, laboratory services, equipment, supplies and medicines, as well as on personnel and training are presented here. The burden of cervical cancer in the countries studied is considerable, according to The International Agency for Research on Cancer estimations. The incidence of the disease is augmented by the high prevalence of HIV infection, in most of the countries surveyed. Most of the population live in rural areas, where access to the health services is far from ideal. Facilities for screening with human papilloma virus tests and for histopathology are limited. One pathologist covers the diagnostic needs of between 0.5 and 4 million inhabitants. Most other categories of health professionals are under-represented, and the capacity to train them is inadequate. Conclusions: Strong country commitment and leadership, innovative solutions and extensive international cooperation would be needed to attain the targets of cervical cancer control set by WHO, in these countries.

Evolution of the joint International Atomic Energy Agency (IAEA), International Agency for Research on Cancer (IARC), and WHO cancer control assessments (imPACT Reviews).

Before 2005, cancer and other non-communicable diseases were not yet health and development agenda priorities. Since the 2005 World Health Assembly Resolution, which encouraged WHO, the International Agency for Research on Cancer (IARC), and the International Atomic Energy Agency (IAEA) to jointly work on cancer control, progress was achieved in low-income and middle-income countries on a small scale. Recently, rapid acceleration in UN collaboration and global cancer activities has focused attention in global cancer control. This Policy Review presents the evolution of the IAEA, IARC, and WHO joint advisory service to help countries assess needs and capacities throughout the comprehensive cancer control continuum. We also highlight examples per country, showcasing a snapshot of global good practices to foster an exchange of experiences for continuous improvement in the integrated mission of Programme of Action for Cancer Therapy (imPACT) reviews and follow-up support. The future success of progress in cancer control lies in the high-level political and financial commitments. Linking the improvement of cancer services to the strengthening of health systems after the COVID-19 pandemic will also ensure ongoing advances in the delivery of care across the cancer control continuum.

Cancer in sub-Saharan Africa: a Lancet Oncology Commission.

In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.

Evaluation of effectiveness, acceptability and safety of thermal ablation in the treatment of cervical neoplasia in Burundi.

This longitudinal study aimed at evaluating the effectiveness, acceptability and safety of the thermal ablation procedure (TA) in the treatment of cervical neoplasia. Women referred to the Gynaecology ward for symptoms or for opportunistic screening were assessed by visual inspection with acetic acid (VIA) and colposcopy. Those with lesions eligible to ablation were counselled and treated by TA. They were inquired about the level of pain during the procedure, and their level of satisfaction. Patients were followed up at 6 weeks for any complication and reassessed by VIA and colposcopy at 12 months for any persistent or recurrent lesion and for any adverse event. A total of 86 women with a positive VIA test were included in the study. The mean age was 46 years (28-61 years). Most of the women did not complain about any adverse event during treatment; one-third presented mild pain or cramp. At the 6-week visit, watery discharge was the main adverse event reported. All women were highly satisfied with TA and most of them would recommend it. At the 12-month visit, 82 women were examined (95% follow-up rate), and the overall cure rate was 96% (low-grade lesions: 98%; high-grade lesions: 94%). Three women presented low- and high-grade lesions that were treated by TA. No major adverse event or hospitalisation after the treatment was reported. In conclusion, TA was an effective procedure with a high cure rate at the 1-year follow-up visit. It was acceptable and safe, with only minor short-term side-effects reported and with a high satisfaction rate among the patients.

Addressing severe chronic NCDs across Africa: measuring demand for the Package of Essential Non-communicable Disease Interventions-Plus (PEN-Plus).

Severe chronic non-communicable diseases (NCDs) pose important challenges for health systems across Africa. This study explores the current availability of and demand for decentralization of services for four high-priority conditions: insulin-dependent diabetes, heart failure, sickle cell disease, and chronic pain. Ministry of Health NCD Programme Managers from across Africa (N = 47) were invited to participate in an online survey. Respondents were asked to report the status of clinical care across the health system. A care package including diagnostics and treatment was described for each condition. Respondents were asked whether the described services are currently available at primary, secondary and tertiary levels, and whether making the service generally available at that level is expected to be a priority in the coming 5 years. Thirty-seven (79%) countries responded. Countries reported widespread gaps in service availability at all levels. We found that just under half (49%) of respondents report that services for insulin-dependent diabetes are generally available at the secondary level (district hospital); 32% report the same for heart failure, 27% for chronic pain and 14% for sickle cell disease. Reported gaps are smaller at tertiary level (referral hospital) and larger at primary care level (health centres). Respondents report ambitious plans to introduce and decentralize these services in the coming 5 years. Respondents from 32 countries (86%) hope to make all services available at tertiary hospitals, and 21 countries (57%) expect to make all services available at secondary facilities. These priorities align with the Package of Essential NCD Interventions-Plus. Efforts will require strengthened infrastructure and supply chains, capacity building for staff and new monitoring and evaluation systems for efficient implementation. Many countries will need targeted financial assistance in order to realize these goals. Nearly all (36/37) respondents request technical assistance to organize services for severe chronic NCDs.

Risk factors associated with albuminuria in Rwanda: results from a STEPS survey.

BACKGROUND: Non-communicable diseases (NCDs) are a growing burden which affects every part of the world, including developing countries. Chronic kidney disease (CKD) has varied etiology which can result from or complicate other NCDs such as diabetes and cardiovascular diseases. The growing prevalence of NCDs coupled with the increasing age in most developing countries, has seen a marked increase of CKD in these settings. CKD has been described as "the most neglected NCD" and greatly affects the quality of life of patients. It also places a huge economic burden on societies. However, few epidemiological data exist, particularly in sub-Saharan Africa. Assessment of the prevalence of albuminuria as a marker of kidney damage and CKD progression and its main risk factors was thus needed in Rwanda. METHODS: This study analyzed data collected during the first STEPwise approach to NCD risk factor Surveillance (STEPS) survey in Rwanda, conducted from 2012 to 2013, to assess the prevalence of albuminuria. A multistage cluster sampling allowed to select a representative sample of the general population. Furthermore, descriptive, as well as univariable analyses and multiple logistic regression were performed to respond to the research question. RESULTS: This survey brought a representative sample of 6,998 participants, among which 4,384 (62.65%) were female. Median age was 33 years (interquartile range, IQR 26-44), and over three quarters (78.45%) lived in rural areas. The albuminuria prevalence was 105.9 per 1,000 population. Overall, semi-urban and urban residency were associated with lower odds of CKD (odds ratio, OR 0.36, CI 0.23-0.56, p<0.001 and OR 0.34, CI 0.23-0.50, p<0.001, respectively) than rural status. Being married or living with a partner had higher odds (OR 1.44 (CI 1.03-2.02, p=0.031) and OR 1.62 (CI 1.06-2.48, p=0.026), respectively) of CKD than being single. Odds of positive albuminuria were also greater among participants living with human immunodeficiency virus (HIV) (OR 1.64, CI 1.09- 2.47, p=0.018). Gender, age group, smoking status and vegetable consumption, body mass index (BMI) and hypertension were not associated with albuminuria. CONCLUSION: The albuminuria prevalence was estimated at 105.9 per 1,000 in Rwanda. Rural residence, partnered status and HIV positivity were identified as main risk factors for albuminuria. Increased early screening of albuminuria to prevent CKD among high-risk groups, especially HIV patients, is therefore recommended.

Challenges and opportunities in the creation and implementation of cancer-control plans in Africa.

Cancer on the African continent is quickly becoming an overt public health crisis due to an aging population and changes in lifestyle. The World Health Organization (WHO) states that a national cancer-control programme should aim to reduce cancer incidence and mortality and improve quality of life of cancer patients, through a national cancer-control plan (NCCP) that is systematic, equitable and evidence-based. Despite this, only 11 countries in Africa have a current NCCP. Participants in a US National Cancer Institute-supported, multi-year, technical assistance programme for cancer-control planning noted three main opportunities to improve how plans are created and implemented: 1) mobilisation of resources and partners for plan implementation; 2) accurate surveillance data to promote better resourcing of NCCPs; and, 3) sustainable and innovative partnership models to strengthen capacity to implement NCCPs. Most countries in the region face similar challenges in the development and implementation of an NCCP, including inadequate human, technical, and financial resources. Collaborative partnerships increase access to evidence-based cancer-control planning tools, mentoring and technical assistance, and have the potential to bridge the capacity gap and catalyse better implementation of NCCPs. Challenges can be overcome by better leveraging these opportunities to address the gaps that inhibit cancer control in Africa.

Conclusions of the digital health hub of the Transform Africa Summit (2018): strong government leadership and public-private-partnerships are key prerequisites for sustainable scale up of digital health in Africa.

BACKGROUND: The use of digital technologies to improve access to health is gaining momentum in Africa. This is more pertinent with the increasing penetration of mobile phone technology and internet use, and calls for innovative strategies to support implementation of the health-related Sustainable Development Goals and Universal Health Coverage on the continent. However, the huge potential benefits of digital health to advance health services delivery in Africa is yet to be fully harnessed due to critical challenges such as proliferation of pilot projects, poor coordination, inadequate preparedness of the African health workforce for digital health, lack of interoperability and inadequate sustainable financing, among others. To discuss these challenges and propose the way forward for rapid, cost-effective and sustainable deployment of digital health in Africa, a Digital Health Hub was held in Kigali from 8th to 9th May 2018 under the umbrella of the Transform Africa Summit 2018. METHODS: The hub was organized around five thematic areas which explored the status, leadership, innovations, sustainable financing of digital health and its deployment for prevention and control of Non-Communicable Diseases in Africa. It was attended by over 200 participants from Ministries of Health and Information and Communication Technology, Private Sector, Operators, International Organizations, Civil Society and Academia. CONCLUSIONS: The hub concluded that while digital health offers major opportunities for strengthening health systems towards the attainment of the Sustainable Development Goals including Universal Health Coverage in Africa, there is need to move from Donor-driven pilot projects to more sustainable and longer term nationally owned programmes to reap its benefits. This would require the use of people-centred approaches which are demand, rather than supply-driven in order to avoid fragmentation and wastage of health resources. Government leadership is also critical in ensuring the availability of an enabling environment including national digital health strategies, regulatory, coordination, sustainable financing mechanisms and building of the necessary partnerships for digital health. RECOMMENDATIONS: We call on the Smart Africa Secretariat, African Ministries in charge of health, information and communication technology and relevant stakeholders to ensure that the key recommendations of the hub are implemented.