by Evelyn Kamgang, Project Coordinator, MNCH/FP, and Kathleen Hill, Senior Quality Improvement Advisor
May 25, 2012
URC commemorates the International Day of Action for Women’s Health on May 28th, a day that calls for greater focus on women’s health. A recent report, by URC’s Health Care Improvement Project (HCI), sheds light on the health needs of women of reproductive age in Albania, Armenia, Georgia, and Russia. Funded by the USAID Europe and Eurasia Bureau, the report describes an assessment of non-communicable diseases (NCDs) and related health care services for women of reproductive age. The assessment evaluated recommended prevention, screening, and treatment services for NCDs – including cardiovascular disease, chronic respiratory disease, cervical and breast cancer, diabetes, and mental health conditions – in these women.
The report highlights the burden these preventable and treatable diseases impose on countries while revealing critical gaps in coverage and quality of high-impact interventions for the leading causes of death and disability in the region. Report recommendations outline immediate- and short-term actions countries can take to scale-up delivery of NCD prevention, screening and care services.
NCDs Have a Serious Impact for Individuals, Families, and Society
According to the World Health Organization (WHO), NCDs now represent the leading cause of death and disability worldwide, causing 63% of deaths, 80% of which occur in low- and middle-income regions. A third of such deaths in low- and middle-income countries are premature, occurring before age 60. The age-adjusted chance of a woman’s dying from an NCD in a low- or middle-income country is 65% higher than in a high-income country (WHO, 2010). The onset of modifiable NCD risk factors for women often occurs during the reproductive years, making prevention and screening services vitally important for women in this age range. “There is a huge burden of premature morbidity and mortality imposed by NCDs which affects people at the height of their productivity,” said the study’s lead researcher, Dr. Kathleen Hill, Senior Quality Improvement Advisor at URC. “This has a substantial economic and human impact on families and communities due to increased health care costs and lost productivity. Although NCDs exert a high toll for people in all countries, their impact in middle- and low-income countries is particularly devastating.”
Increasing Global Attention on NCDs
In September 2011, the UN convened a High Level Meeting on NCDs, the second-ever UN High Level Meeting on a health issue (the first was on HIV/AIDS), reflecting the growing international commitment to tackle the enormous and neglected problem of NCDs worldwide. “Non-communicable diseases are a threat to development. NCDs hit the poor and vulnerable particularly hard, and drive them deeper into poverty,” said UN Secretary General N. Ban Ki-Moon at the meeting’s opening session. Subsequently, there has been increasing focus on country-led implementation and global policy frameworks to accelerate prevention and control of NCDs. In March 2012, the WHO released the first draft of a set of global NCD targets and a voluntary, country-level NCD monitoring framework. These and other WHO documents highlight the importance of country-level implementation of a combination of population-level interventions (e.g., smoking bans) and individual-level interventions (e.g., giving up cigarettes) to control of NCDs. However, most countries have yet to begin implementing effective NCD control strategies.
Assessment Methods: Focus on High-impact NCD Interventions
The assessment evaluated health care services for delivery of high-impact NCD prevention and control interventions that WHO characterizes as best buy interventions due to their feasibility, cost-effectiveness, and overall effectiveness in controlling high-burden NCDs in low- and middle-resource settings. The assessment also examined the cross-cutting essential health system functions that are required to deliver best practices, as well as provider and client knowledge, attitudes, and self-described NCD practices. Conducted in 47 representative ambulatory health centers across the four countries, assessment data sources included a structured review of medical charts; an inventory of essential supplies, medications, laboratory, and service delivery organization; structured surveys of managers, clients, and physicians; and semi-structured individual interviews with key informants.
Low screening and treatment for high-burden NCDs and risk factors
A cervical cancer screening intervention (e.g., pap smear, or VIA) was documented in only 12% of 658 charts reviewed in the four countries, and a screening mammogram for breast cancer was documented in only 10% of charts of eligible women. The low frequency of such screenings was corroborated by interviews with 397 clients, 269 providers, and 47 managers and is particularly worrisome in light of the known high rates of cervical and breast cancer mortality for women in the region. “There is no reason why any woman anywhere in the world should die of cervical cancer, which is very easy to treat if caught early,” Dr. Hill stated.
Systematic screening for modifiable cardiovascular disease (CVD) risk factors was likewise low, with only 30% of 658 charts recording a cholesterol level (at any time) and only 26% and 12% of charts, respectively, recording dietary or exercise counseling, all considered best buy CVD prevention interventions. Despite the high prevalence of smokers in this region and the importance of smoking as a highly modifiable risk factor for chronic lung disease (e.g., asthma), only 25% of charts recorded the smoking status of patients, and no facility had nicotine replacement treatment available, another best buy. Assessment results for the detection and treatment of hypertension, an important CVD risk factor, were more encouraging: nearly 90% of charts of women with documented high blood pressure were prescribed evidence-based medicines for hypertension.
Although diabetes is a major CVD risk factor and a high-burden NCD in its own right, only 50% of providers could correctly identify international diagnostic criteria for diabetes, and less than half of charts documented diabetes Type 2 treatment with an oral medication, also a best buy.
Inadequate Mental Health Screening and Treatment
The assessment also addressed mental health, another important high-burden NCD for women of reproductive age. “Mental health has a huge impact on the control and management of NCDs as well as on quality of life and economic stability for individuals and families, but we observed many missed opportunities for detection and treatment of depression and other mental health disorders,” pointed out Dr. Hill. While 37% of 397 patients surveyed reported symptoms of current or past depression, less than 6% of their medical charts documented any mental health intervention, such as referral to a mental health provider or treatment with an antidepressant. By contrast, many charts recorded non-evidence-based treatments for depression, such as sedatives.
Weak Health Systems
Assessment findings demonstrate variable but generally weak performance of essential health system functions for delivery of high-impact NCD services, including weak health information systems, low provider access to up-to-date evidence (e.g., journals and national guidelines), weak chart and service delivery organization for best practices and continuity of care, and inadequate financing for screening services. The availability of essential NCD medications and lab services was generally stronger, with some important exceptions. Overall, three of the four countries fared poorly with regard to a standardized patient medical record organized to support efficient delivery and monitoring of high-impact NCD prevention, screening, and treatment interventions. According to Dr. Tamar Chitashvili, the second lead researcher in this study and Chief of Party of the HCI Quality of Care project in Georgia, “many gains in NCD care could be achieved through improved standardization of medical charts to support better use of relevant clinical data by providers for patient care.”
Report Recommendations and Next Steps
Most high-burden NCDs are preventable through low-cost prevention and screening and interventions to identify and reduce modifiable risk factors. For non-preventable or established NCDs, early treatment usually significantly delays disease progression and complications. The report recommends immediate- and mid-term actions to scale up best NCD prevention and control practices. Recommendations are likely to be relevant for most low- and middle income countries struggling to avert millions of preventable premature deaths and illnesses and promote stable development. The HCI Georgia Quality of Care Project is actively implementing many of the report’s recommendations in that country.
URC’s work in NCDs
URC has been working to strengthen high-impact services and health system functions for NCDs and other chronic diseases such as HIV, diabetes, and hypertension in Eastern Africa and cervical cancer prevention and diabetes treatment in Mongolia. We recently partnered with the Republic of Georgia to launch a USAID-funded program to improve the quality, continuity, and consistency of medical service delivery for high-burden adult and pediatric conditions, including NCDs. The Georgia project provides an important opportunity for URC, working in close collaboration with in-country counterparts, to improve coverage and quality of high-impact NCDs for Georgians by tackling many of the challenges highlighted in the assessment at national, regional, district, and facility levels.
In parallel with this assessment, the researchers conducted a four-country assessment of maternal and newborn best care practices in the Europe and Eurasia region. The report will be available soon.