Non-communicable diseases like hypertension and diabetes have emerged as serious health crises in developing countries, as HIV was a decade ago. New models of primary health care that combine NCD and HIV care are catching on – and Tanzania is implementing this approach, with considerable success.
In the 1 500-bed Muhimbili National Hospital (MNH), the physical costs of diabetes are strikingly evident. Wards echo with the woes of chronic foot ulcers, even blindness – a reflection of the toll diabetes is taking on the population, writes Kizito Makoye for Health Policy Watch.
An estimated 12.8% of the population had diabetes by 2021 – up from around 2.8% in a decade.
However, cardiovascular disease – strokes and heart attacks, often driven by hypertension – is the biggest NCD killer in the country.
Many people are unaware they have either hypertension or diabetes until very late. The elderly bear a huge burden of NCDs, and around 90% of those aged 50 and above navigate the various health challenges without the safety net of health insurance, forcing them to trek from hospital to hospital, seeking elusive medical care.
HIV and NCD: under one roof
Many struggle with the both HIV/Aids and diabetes, the dual burden of disease presenting a complex challenge, forcing patients to juggle HIV and diabetes appointments at two different health centres.
Recognising these struggles, last year, the Temeke Regional Referral Hospital in Dar es Salaam (TRRH) integrated healthcare for NCDs within the ambit of HIV services.
Now people can manage co-existing conditions like diabetes and hypertension under one roof.
Oncologist Maria Bitwale told Health Policy Watch the integrated approach is helping to deter numerous health crises.
HIV an entry point for NCD care
In Tanzania, more than 1.4m people out of the 61m population have HIV: some 29% have hypertension and 13% have diabetes. These latter diseases are now the main causes of death in HIV+ Tanzanians.
Integrating NCDs care into HIV services, which are widely available at the primary healthcare level, means being able to diagnose, prevent and manage chronic diseases cost-effectively.
John Njingu, Tanzania’s Permanent Secretary at the Ministry of Health, said this integration, extending to HIV-targeted clinics where screening and management of NCDs can also be offered to people with or without HIV, is a logical move.
“We want to provide better services at a lower cost to service providers and the patients,” he said.
The country’s NCD response took a major leap forward in 2019, when a new national NCD Prevention and Control Programme was launched by Prime Minister Kassim Majaliwa.
The NCD strategy has been rolled out in 700 primary healthcare clinics in 26 regions, 245 of them in the first stage. These PHC centres have been provided with basic NCD diagnostic equipment, and more than 3 000 healthcare staff have been trained in basic NCD care.
The programme builds on several years of effort by the Health Ministry and national stakeholders to establish the necessary platform for NCD services to reach communities.
Various national and international partners, including the WHO, the Global Fund, the US President’s Emergency Fund for Aids Relief (Pepfar), and UNAids, are supporting the strategy.
But there is still some way to go, as the country has 8 549 primary, secondary and tertiary heath facilities, says the Health Ministry.
‘Unprecedented’ in sub-Saharan Africa
“What we see unfolding in Tanzania, with basic NCD services for conditions like diabetes and hypertension now reaching primary care at this scale, is unprecedented in a sub-Saharan African context,” says Bent Lautrup-Nielsen, head of global advocacy at the World Diabetes Foundation (WDF).
WDF began supporting NCD interventions in Tanzania two decades ago, and has played a key supporting role in the programme launch.
“With the strong results on NCDs achieved by the Health Ministry, the President’s Office for Regional Administration of Local Government, and partners like Tanzania Diabetes Association and Tanzania NCD Alliance, the plan of integrating primary care with NCDs to become part of routine services everywhere – with HIV, TB and maternal and newborn care – looks promising,” said Lautrup-Nielsen.
Research findings demonstrating the benefits of this have also helped pave the way for broader change. In the INTE-Africa study in Tanzania and Uganda in 2022, scientists documented the benefits of merging and decentralising services for HIV, diabetes, and hypertension in disease management and cost-savings.
The study, published in The Lancet in 2023, found it resulted in a 75% higher rate of retention in care for people with HIV and one or more NCD conditions; did not adversely affect viral suppression rates among HIV patients; and saved costs in the health services provided.
The researchers randomly allocated 32 facilities (17 in Uganda and 15 in Tanzania) serving 7 028 eligible patients, to integrated care or standard care groups.
In the integrated care group, those with HIV, diabetes or hypertension were managed by the same staff, used the same pharmacy and had uniform medical records, registration and laboratory services. In the standard care group, patients attended separate standalone clinics for each condition, following the standard practice in sub-Saharan Africa.
Data collection was conducted at baseline, and at months six and 12. Retention was assessed through routine clinic attendance and track-and-trace procedures.
Roadmap for policymakers
The study’s findings provide a roadmap for policymakers, not just in Tanzania and Uganda, but more widely, for scaling up integrated care for conditions like HIV, diabetes, and hypertension: saving money while providing effective care.
Anchoring such care in HIV clinics and providing HIV patients with steady care has seen dramatic suppression of viral load. The death toll for this group has plunged from 2m in the early 2000s to fewer than 500 000 in 2022.
Inspired by the INTE-Africa trial, Tanzania, which, for many years, embraced infectious diseases as its priority in policy and resource allocations, is undergoing a seismic shift in its primary healthcare services to address the new NCD crisis.
This has earned global recognition, and also aligns with the evolving strategy of the Global Fund Prioritisation Framework Supporting Health Longevity Among People Living with HIV, which articulates the priorities for integrated investments to prevent, identify and manage advanced HIV disease and NCDs, among other diseases, from 2023-2025.
Global Fund specialist Dan Koros said the Fund’s support for NCD Integration into HIV programmes in Tanzania began in January 2024 with a grant of $115 075 – primarily for baseline assessment, developing protocols, and training healthcare workers from 2024-2026.
The Global Fund investments support integrated diagnosis and treatment of HIV+ adults over 40 and on antiretroviral treatment who are also receiving treatment for one or more NCD, including cardiovascular disease, hypertension, diabetes, obesity, and mental health conditions.
Highest premature mortality
Globally, NCDs are the leading cause of death, killing 41m people annually, or 71% of all deaths worldwide. And the highest rates of premature mortality – deaths before 70 – are in low- and middle-income countries, particularly Africa.
Across the WHO’s African region, patients with diabetes and hypertension are neglected, with fewer than half remaining in care one year after diagnosis, leading to 2m deaths annually.
When their disease condition is addressed later in life, it makes treatment more complex. Many do not get access to specialised care.
Diabetes affects younger people too.
While traditionally Tanzanians perceived diabetes as a disease primarily haunting the elderly, Dar es Salaam, one of Africa’s fastest growing urban areas, shows a different reality.
From Tandale, a labyrinthine slum, to the upscale Masaki favoured by Western diplomats, and further to Kariakoo, a business hub replete with fast-food joints, youth obesity is on the rise, accompanied by an alarming surge in diabetes cases.
Out of the 613 210 patients screened for diabetes at MHN in the past six months, 165 566 were diagnosed with diabetes. Along with the consequences of co-infections, this crisis is attributed to poor dietary choices and lack of physical activity.
Irene Masanja, an infectious diseases specialist at Bagamoyo District Hospital, says the rising incidence of diabetes and hypertension among HIV patients as well as in the general population is alarming.
“Early detection and intervention are key. We must empower healthcare providers and equip them with appropriate skills and knowledge to address interconnected health problems effectively,” she says.
See more from MedicalBrief archives:
Cardiologists call for help, local research, for Africa’s CVD burden
NCDs cause 7 out of 10 deaths worldwide — 186 country analysis
An ‘important contribution’ to understanding global health interventions in Africa
Tanzanian president: COVID vaccines ‘a plot to steal Africa’s wealth’
Health tourism by Africa's leaders costs their countries dearly