Spring Newsletter 2023

Beginning this month, the Global Alliance for Health and Pollution (GAHP), with funding from SDC, will be implementing its Program for the Reduction of the Impact of Lead on Children's Health in Senegal through the “Jeunes Volontaires pour l’Environnement” (JVE), a local CSO advocating against environment and health issues associated with lead, pesticides, and POPs.
 
This project follows up on a 2021 study of Blood Lead Levels of children aged 1-6 years living in three at-risk neighborhoods throughout Dakar.  The 2021 study result confirmed the presence of lead in some children’s bloodstreams as well as in the soil in their environments.  The study confirmed the need for greater awareness of the dangers of lead and its impact on children’s health at multiple levels of society, especially for women and children who are the most vulnerable when it comes to exposure to lead contamination and its subsequent health impacts.  To achieve this, GAHP and JVE are developing and delivering education and awareness-raising activities for youth.  These campaigns will take place in two of the high-risk communities included in the BLL study and will engage youth through art, including a slam-poetry writing workshop and performance and a hackathon.  Also, they will organize and facilitate capacity-building workshops on the health impacts of lead for elected officials, women, and youth groups. These workshops will provide the communities with tools to sensibilize others and ensure there is a long-term impact.
The project will run until January 31, 2024, and is being implemented in partnership with the Senegalese Ministries of Health and Environment.

Madagascar

As part of its Health and Pollution Action Plan (HPAP) process, GAHP has been working with the government of Madagascar to help them develop a 10-year Roadmap for Pollution Management.  Madagascar was the first country to implement the HPAP in 2018 and since then GAHP continues to provide support to identify key pollution issues and find low-cost solutions to address them. This 10-year roadmap will include recommendations for actions to be implemented in the short, medium, and long term, with their impact expected to run beyond the duration of the project.  The development of this roadmap is a rigorous process that gives primacy to stakeholder engagement and collaboration.  The roadmap is expected to be completed by the end of this summer.

Zimbabwe, like many sub-Saharan African countries, is experiencing a surge in non-communicable diseases (NCD). Coupled with the high burden of infectious diseases, such as HIV, tuberculosis (TB) and malaria, Zimbabwe’s fragile and under-resourced health system is simply unable to cope. A range of NCDs, including hypertension, diabetes, rheumatic heart disease, cancer and chronic respiratory diseases account for approximately 33% of deaths in Zimbabwe (WHO 2018). This statistic is expected to increase rapidly, driven by the ageing and growing population as well as lifestyle factors such as diet, lack of exercise, tobacco and alcohol consumption and household air pollution.
Lack of resources including equipment, medicines and trained healthcare workers means often NCDs are not being adequately screened, diagnosed or treated in Zimbabwe. When chronic care services are available it is only in large urban cities like the capital Harare, making treatment both inaccessible and unaffordable for rural and poor populations. There is also a lack of public awareness and education about NCDs and therefore facilities are seeing late diagnoses with complications already well established (such as visual impairment caused by uncontrolled diabetes that leaves individuals stigmatised and severely affects their quality of life).
It is in this context that SolidarMed, a Swiss NGO active in Zimbabwe for over half a century, works to strengthen the Zimbabwean health system through a comprehensive NCD approach at the provincial, district, primary health care and community level. In 2018, SolidarMed launched a diabetes and hypertension project which today supports Masvingo Provincial Hospital (MPH), 5 district-level hospitals and 8 rural health centres (thanks to funding from the Swiss Development Cooperation (SDC) and the World Diabetes Foundation). Working in partnership with the Ministry of Health and Child Care (MoHCC) this project now reaches an active cohort of over 3,000 patients living with diabetes and/or hypertension.

PEN PLUS INITIATIVE

To build on this important work, at the end of 2022, SolidarMed joined a multi-country initiative to pilot the World Health Organisation’s (WHO) Package of Essential Noncommunicable Disease (PEN) PLUS strategy. Under the umbrella of the NCDI poverty network and in partnership with Partners in Health, the PEN Plus initiative is part of a regional effort to address severe NCDs at first-level referral health facilities by bridging the access gap in the treatment and care of patients with chronic and severe NCDs. The initiative urges countries to put in place standardised programmes to tackle chronic and serious non-communicable diseases by ensuring that essential medicines, technologies, and diagnostics are available and accessible in district hospitals. This should not only reduce the number of people who develop NCDs but also improve the quality of life for those already living with these conditions.
In 2022, SolidarMed conducted a baseline assessment at 12 health facilities which showed that both government and NGO support still targets mostly communicable diseases like HIV, TB and Malaria and only a few NCDs like cervical cancer and eye diseases. Heart failure was managed at the outpatient departments of only 4 (33%) hospitals. The survey confirmed that people in rural communities can often not afford NCDs medication and laboratory tests, and many remain undiagnosed or present late with advanced disease symptoms. NCD-related educational materials were only available at 58% (7/12) of the facilities, while NCD-related community education was only available at 25% (3/12) and social support for NCD patients was provided at 17% (2/12) facilities.
The NCD activities SolidarMed are implementing in partnership with the MoHCC fall into four categories:

1. Providing services at three PEN Plus clinics.
   In the last 6 months, SolidarMed established three PEN Plus clinics. One at Masvingo Provincial Hospital as well as one each at Mashoko and Ndanga district hospitals. SolidarMed renovated the clinic spaces and equipped them with modern furniture. Most importantly, specialised NCD diagnostic equipment was provided (including 6 echocardiogram machines, 3 patient monitors, 3 INR point of care machines, 3 ECG machines, 3 diagnostic sets, 3 heavy duty nebulisers and 3 doppler ultrasound scans). These clinics are now equipped for the early diagnosis and management of severe NCDs such as type 1 and insulin-dependent diabetes, rheumatic and congenital heart disease, asthma, epilepsy, and sickle cell diseases. Ndanga and Mashoko are the referral centres for 50 rural health centres in their respective districts and Masvingo Provincial Hospital is the referral hospital for all 14 district level hospitals in the 7 districts of Masvingo Province (population over 1.6 million).
   By May 2023, we had 105 patients enrolled in the programme. The main conditions seen are heart failure (53), type 1 diabetes (30), asthma (15) and there is a slowly increasing number of epilepsy patients (10). We have also collaborated with local sickle cell disease experts to increase sickle cell screening and diagnosis in Zimbabwe. So far, we have 1 sickle cell patient under our care, but we hope to have more patients once the sickle cell screening and diagnostic equipment and consumables are available in July 2023.
   SolidarMed team shared the story of 21-year-old Raviro who was diagnosed with rheumatic heart disease at 14 years old. She spent 6 years struggling to manage her condition due to a lack of access to the appropriate medicines. As a result, she dropped out of school and was very sick, often requiring hospitalisation. In March this year, Ravario finally accessed specialist care through the PEN Plus clinic and now has regular access to the medicines she needs. Her mother told the staff:

   “The life of my daughter is restored. I have started seeing signs of life in my daughter after years of struggle”.

2.  Strengthening the capacity of healthcare workers nationally
   In October 2022, SolidarMed established a national-level PEN Plus training hub at Masvingo Provincial Hospital (MPH), with a capacity for 45 trainees. Healthcare workers from various Provinces in Zimbabwe will come to this site to learn how to manage severe NCDs and will complete a clinical attachment here. MPH provided a room at the nursing school which SolidarMed subsequently renovated. This included the installation of proper lighting, training equipment such as a projector and projection screen, painting, internet installation, toilet upgrades, electrical wiring, and security screen doors and window repairs. The training hub was first used in October 2022, when 19 trainees (5 doctors, 13 nurses and the national NCD manager of which 13 females and 6 males) from the NCDs departments at three hospitals where the initial three PEN Plus clinics have been established, received the initial PEN plus training. The training was facilitated by national-level specialists including sickle cell specialists, endocrinologists, an asthma specialist, general internal medicine specialists, renal specialists and a cardiologist. The next PEN Plus training at this site will take place in June 2023 when previously trained healthcare workers from the 3 supported hospitals will learn to perform Echos, ECGs and Doppler ultrasound scans.
   In addition to the centralised national training in the Masvingo hub, SolidarMed established a 2-week clinical attachment programme. Out of the 19 trained healthcare workers (as described above) five nurses from MPH and one doctor had two weeks of attachment to the MPH specialist physician and paediatrician last November. Ten Health Care Workers (HCW) (4 doctors and 6 nurses) from Ndanga and Mashoko also had two weeks of clinical attachment at MPH in February and March 2023, respectively. These attachments included attending at least 2 ward rounds and 2 NCD clinics with both the physician and paediatrician, and other general outpatient consultations with the specialists. These sessions provided the nurses and the junior doctors with practical experience in managing severe NCDs under the guidance of the specialists. This included case finding, screening, diagnosis, and management of severe NCDs like those mentioned above. The groups had the opportunity to be mentored on PEN Plus (PP) disease management, oriented on the use of PP equipment like patient monitors, vascular dopplers and nebulisers. The groups also managed to attend to PP patients under the guidance of the specialists in preparation for running the PP clinics at their respective sites. Onsite mentoring will also start in July to boost the confidence of trained healthcare workers to provide the services.
   An important part of the training is equipping healthcare workers with the skills and understanding to use non-judgmental language in their interaction with patients and to promote patient empowerment. We believe it is this comprehensive approach to care that will result in a sustained impact with patients taking control of their conditions.
   When there is no PEN Plus training, the refurbished site will be of benefit to the nurses attending the training school at MPH. General Nurse, Sister Linda Sinyoro stationed at MPH commented:

   “It felt like stepping into the future of learning compared to our previous setup and other training rooms. For us to offer more up-to-date treatment, we should now step up on how we learn to provide those services. The renovated training hub provides great visual learning facilities and offers the perfect mood for learning.”

   
   Additionally, Sister C Chiumira, Ophthalmic nurse at MPH commented:

   “Having such a modern training hub is a huge milestone for the hospital and a major upgrade in the way we healthcare workers can be trained. We are appreciative of such developments, and I am proud to be one of the first cadres to be trained in such a remarkable environment.”

3. Collecting information
   In addition to the baseline survey, we will do an end-line survey in quarter 4 of 2024 to assess the general improvement in NCD care at the PEN-Plus facilities and the feasibility and acceptability of the PEN-plus initiative at first-level hospitals in Zimbabwe. We will also evaluate the general conditions of the patients to see if there was any improvement in their condition during the PEN-Plus implementation to identify how best to adapt the services to the rural Zimbabwe setting.
4. Engaging and contributing to NCD health policy development
   At an overarching level, SolidarMed is working closely with its partner Clinton Health Access Initiative (CHAI), to develop the PEN-Plus Policies and National Operational Plan. SolidarMed engage closely with MoHCC and other national stakeholders to describe, measure, and advocate for PEN-Plus, supporting the development of a national PEN-Plus operational plan for scale-up following this grant period (2022-2024). This work includes assessing gaps in relevant clinical guidelines, clinical forms, regulations around the scope of practice for mid-level providers such as nurses and clinical officers, and adaptation of training materials for national use in support of the MoHCC.  
   

OUTLOOK

Over the course of the project (2022 – 2024), the PEN-Plus clinics are expected to mature into PEN-Plus training sites, in preparation for national scale-up. This will consist of readiness to host mid-level provider trainees who will be working to establish PEN-Plus clinics in other parts of the country. Care provided through the three hospital clinics will also pave the way for more integrated case finding through the screening of clients within the various facility entry points such as the medical wards, opportunistic infections, family child health, outpatients, maternity, and casualty department. More support will also be provided to the laboratory, pharmacy, and radiology departments to improve their overall health service delivery. Finally, we plan on starting support groups for people with type 1 diabetes later in 2023. This will include linking the under 25-year-olds living with type 1 diabetes to a 3-day diabetes camp where they can participate in team-building activities, learn life skills and benefit from peer support.
In the long term, through the provision of resources and education, we believe the PEN Plus strategy will help people make healthier lifestyle choices, increase access to quality health care even at the periphery and create policies and environments that support healthy living. Ultimately, it is hoped that the prevalence of severe NCDs in Zimbabwe and the other implementing countries can be reduced and the quality of life for those living with these conditions can be improved.