Uganda: How Covid-19 Outbreak Has Worsened Non-Communicable Diseases Burden

30 September 2020

It is common knowledge that people living with non-communicable diseases (NCDs) such as hypertension, cancer, diabetes, and chronic respiratory disease, are more vulnerable to catching a severe form of Covid-19, and dying.

However, there appears to be a correlation between the disruption of treatment services for NCDs and the increasingly severe cases of Covid-19 in Uganda.

In mid-March, when the country went into a total lock-down, the delivery of many essential health services was disrupted. The NCD clinics at national and regional hospitals were closed to prevent the spread of the coronavirus. Over the months, this action has led to hundreds of people missing out on their drugs and routine medical check-ups.

In August, the Ministry of Health issued a circular to health service heads and providers at all levels, offering additional guidance on the continuity of essential health services, with a specific focus on addressing the critical needs for patients with NCDs. Among the guidelines offered was the need to ensure that NCDs screening is fully integrated into the triage.

This directive was a life-saver for 67-year-old Rosemary Nassolo, a retired civil servant, who is living with high blood pressure.

However, it is not all roses because the weekly NCD clinic Nassolo used to attend at Entebbe Regional Referral Hospital to measure her blood pressure and blood sugar free-of-charge is still closed. The hospital is now a Covid-19 treatment center.

"Last week, when I called the nurse, she told me not to come to the hospital. She advised me to continue going to a private clinic where I have to pay Shs1, 000 to measure blood pressure and Shs5, 000 to measure blood sugar. I no longer have access to free drugs," she says.

"In March and April, I was spending Shs51, 000 monthly on drugs. I eventually had to switch to cheaper medicine. Now, I spend Shs39, 400," the widow reveals.

Since her retirement 10 years ago, Nassolo's daughter has been paying for her medicine.

Now, with the labor force still reeling from the after-effects of the lockdown, her daughter's earnings have gone down. Luckily, Nassolo has not missed her medication because her daughter still priorities her medical condition.

Uganda's NCD burden

According to a 2014 national NCD risk factor survey, 33 percent of annual deaths in Uganda are attributed to the five leading NCDs - cardio-vascular disease, cancer, diabetes, chronic respiratory disease, mental health, and substance abuse.

For instance, 50,000 individuals were affected by diabetes in 2003, and a 10-fold increase is projected in the cases of diabetes by 2025 if no interventions are initiated.

The survey also found that 76.1 percent of the participants with raised blood pressure were not taking medications to lower it, while 89 percent of the patients living with diabetes were not on medication or aware of their raised blood glucose status.

In 2016, the World Health Organisation (WHO) reported that in the outpatient department in Uganda, high blood pressure (hypertension) cases increased from 60,000 between 2012 and 2015 to 85,000 cases between 2015 and 2016, an increase of 42 percent in just three years.

Diabetes cases registered in the out-patient department increased by seven percent from 30,000 to 32,000 over the same period.

Currently, there are no statistics on the impact of NCDs on the country. However, NCDs claim more than 50 percent of the resources required in the healthcare system.

In the 2020/2021 Shs1.2 trillion budget for the health sector, Uganda Cancer Institute (UCI) was allocated Shs105.8 billion, while Uganda Heart Institute took Shs24.7 billion.

Impact of closing NCD clinics

With the advent of Covid-19, UCI suspended cancer screening, outreach programs, and elective surgeries and procedures.

Kiruddu General Referral Hospital in Kampala has a large NCD clinic and before the lockdown, every month, it attends to more than 600 diabetic patients. The clinic also has a ward with a 40-patient capacity.

Dr Charles Kabugo, the hospital's executive director, says because of the Covid restrictions, many patients have lost control of their condition.

The hospital manages the Covid-19 treatment center at Mandela National Stadium Namboole.

"We are still screening patients, but at a very low scale. The diabetic clinic is running but the human resource is stretched because we have had to dedicate many people (medical personnel) to manage the new disease.

Besides, we now have space challenges, because we have to dedicate large areas to just a few people for isolation. This is impacting on the space where we would have operated to admit general patients with NCDs or other diseases," he says.

Dr Gerald Mutungi, the commissioner for NCD prevention and control at the Ministry of Health, says, the lack of attention to the NCD burden will have dire consequences.

"We are likely to see more severe cases of Covid-19 due to uncontrolled NCDs because some people have spent months without taking their medication.

The situation will be bad because until recently, we have been discouraging them from going to health facilities because they are likely to be exposed to the coronavirus," he says.

In the new guidelines, the Ministry of Health is now urging health service providers to ensure that patients are given drug supplies of two to three months so that they do not frequent the health centers.

Previously, patients were taking one-month refills.

"Because a number of health workers are contracting the Covid-19, NCD services are still being neglected. But, we have requested the National Medical Stores to increase their supplies to health centers. But when all resources are directed to Covid-19, in reality, you find nothing much on the ground," Dr Mutungi says.

While taking two or three-month drug refills is a laudable development, for the last few years, public health facilities have grappled with perennial stock-outs of insulin and diabetic and hypertension drugs.

This means even after having their condition checked, many people living with NCDs will still have to take their prescriptions to private pharmacies

"Drug stock-outs are not new to Kiruddu hospital. However, now, the unique needs of Covid-19 are eating into the other budget areas.

We now have to urgently procure a large number of personal protective equipment, masks, and hand sanitizers," Dr Kabugo says.

Dr Mutungi admits that the shortage of drugs is hampering their efforts. "In reality, we are not able to provide patients with three-month drug refills. We give them a maximum of a month's supply and tell them to buy the rest from pharmacies. But you know our people are poor. Unfortunately, many are getting off their medication. I tell you, NCDs are now out of control," he says.

Mr Christopher Kwizera, the head of the secretariat at Uganda NCD Alliance, says these are the effects of a health care system that has been orient-ed towards communicable diseases and lately, maternal health.

"People living with NCDs depend entirely on health care facilities for services, medicine and education. How can you scale down NCD services yet you have not scaled down on the number of patients?

A person living with NCDs cannot sustain visits to private clinics and pharmacies be-cause some of them have to be on medication for many years or for a lifetime," he says.

While most health centers have the basic equipment, such as blood pressure machines, weighing scales, stadiometers, and glucometers, Dr Mu-tungi acknowledges a general shortage of supplies.

"You may find that a health center has a glucometer to measure a patient's blood sugar, but there are no strips that must be used to measure the blood sugar. It's a chronic problem; the equipment is present but the supplies are out of stock," Dr Mutungi says.

A 2018 study of the capacity of health facilities to prevent and control NCDs found that none of all sampled facilities met the WHO-PEN stand-ards for essential tools and medicines to implement effective NCD interventions.

Five out of the 14 health center IVs had at least one automated blood pressure machine, while few facilities reported having blood pressure cuffs.

The study also found that there were few human resource persons specialized in NCDs at public health facilities such as cardiologists, radiologists, nutritionists, and diabetes educators.

Medical practitioners believe that due to the disruption of NCD services, in the next few months or years, there is likely to be a surge of people coming into hospitals with advanced stages of cancers, and complications of hypertension and diabetes.

Disruption in NCD services is global

Uganda is not the only country that has suffered a disruption of its health systems. A WHO survey released on June 1, revealed that the 155 countries that participated in the survey confirmed that prevention and treatment of services for NCDs have been severely disrupted since the outbreak of the Covid-19 pandemic.

More than half (53 percent) of the countries surveyed have partially or completely disrupted services for hypertension treatment, 49 percent for treatment of diabetes and diabetes-related complications, 42 percent for cancer treatment, and 31 percent for cardiovascular emergencies.

The survey adds that in 94 percent of the countries, the ministry of health staff working in the area of NCDs were partially or fully reassigned to support Covid-19.

The postponement of public screening programs for breast and cervical cancer was also widespread.

However, many countries are now establishing alternative strategies to support people living with NCDs.

Globally, 58 percent of countries are now using telemedicine to replace in-person consultations. At least 70 percent of countries reported collecting data on the number of Covid-19 patients who also have an NCD.

More funds needed

Dr Mutungi says the NCD department received only Shs400 million of the health sector budget and almost nothing from the supplementary budget to fight Covid-19.

"We only came in as a psychosocial pillar because mental health falls under the NCD department. So, through that, we got some funds to ensure people who are quarantined or in an isolation facility for treatment for Covid-19 are offered psychosocial support such as counseling.

However, I don't think we are funding even 10 percent of what should be funded to prevent and control NCDs in Uganda," Mutungi says.

Prof Charles Ibingira, the principal of Makerere University College of Health Sciences, says the importance of medical research into the prevention and control of NCDs cannot be overstated.

"Unfortunately, there is limited research on NCDs in Uganda. Most of the research funds go to communicable diseases. Last year, the government gave Makerere University Shs57 billion for research, but the money is not limited to NCDs. It is for any research into agriculture, environment, trade, and others.

The government should fund research into NCDs because, in a few years, we are going to see many more deaths from NCDs," he says.

Dr Ibingira adds that Uganda needs a minimum of Shs3 billion to carry out research in prevention, treatment modalities, rehabilitation, and palliative care for NCDs.

Most of the data used to access NCDs in Uganda is from the Western world.

In an earlier interview, Dr Ibingira indicated that Makerere University and St Augustine International University had held a fundraising drive in Kampala in December 2019 geared towards setting up a research fund on NCDs in which they collected Shs654 million.

What more needs to be done

The Ministry of Health is advising health providers to deliver drugs to patients' homes wherever possible, but Kwizera believes the lack of patient's data will hamper these efforts.

"We do not know where the patients live, their telephone contacts, and villages. How can you deliver drugs when you do not have the patient's contacts?

Let patients make sure they note down their contacts and directions to their homes whenever they visit hospitals. We are piloting electronic monitoring of patients with Kiruddu hospital so that at any point if the patient skips his or her appointment, the hospital can call them or send an ambulance," he says.

A study of the capacity of health facilities to prevent and control NCDs in Uganda found that all sampled facilities had limited use of NCD patient registries and NCD management guidelines to track patients yet this is the only way forward if people living with NCDs are to survive Covid-19.

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