It’s a double burden of disease.
As Kenya, along with many countries in Sub-Saharan Africa, continues to wrestle with communicable diseases—HIV, malaria and tuberculosis are among the leading causes of death in the country—it also faces another emerging public health threat in the form of noncommunicable diseases (NCDs). NCDs caused 39% of deaths in Kenya in 2020, up from 27% in 2014.
“Many developing countries like Kenya have an unfinished communicable disease and maternal and reproductive health agenda, and a rapidly growing NCD burden,” says Miriam Schneidman, former Lead Health Specialist of the World Bank. “With governments facing competing demands in an increasingly tight fiscal space, finding innovative ways to tackle this double burden is critical.”
But rather than buckle under the weight of these dual challenges, Kenya’s leaders have demonstrated perseverance and creativity to address the rising NCD challenge. Takanori Sato, Director, Global Public Affairs, Takeda and Vice-chair of Access Accelerated sees this as the basis for a strong partnership, where governments create a strong enabling environment that includes commitment from a wide range of stakeholders and funders to support countries to effectively address these emerging public health issues.
“Kenya has a solid track record of creating a strong enabling environment, with high-level commitment and leadership, a national NCD strategic plan, and disease-specific strategies and guidelines,” he explains. “There is a strong foundation to build on.”
Pilot project builds evidence for chronic care model
This enabling environment has helped strengthen cooperation between the government of Kenya, the World Bank and Access Accelerated, and it has underpinned a range of projects designed to tackle NCDs. Those projects include a pilot to support the AMPATH Primary Integrated Care For 4 Chronic Diseases (PIC4C) initiative, aimed at strengthening services at the primary care levels by working with communities to improve access to NCD services and to strengthen financial protection for patients and their families.
The pilot focused on prevention and management of some of the leading NCDs in Kenya— hypertension, diabetes, breast cancer and cervical cancer—targeting two counties in Western Kenya (Busia and Trans Nzoia). Together, these four diseases represent the kind of devastation NCDs can cause for families, health systems and society alike, given the pervasive low levels of awareness, late health seeking behavior, and late-stage diagnoses. Addressing them means building a body of evidence that can enable policymakers and practitioners to replicate good practices.
“It’s important to generate strong evidence for the government to expand the model,” says Toni Lee Kuguru, the project’s Task Team Leader and Senior Health Specialist at the World Bank. “It requires rigorous evaluation, which needs to be embedded in the design of the project or program, so that in the end you have a body of reliable evidence that can contribute to future program design and planning.”
To that end, the pilot was designed to generate lessons that would inform and support its national scale-up in Kenya by inspiring county officials to replicate the chronic care model of integrated NCD care in their own communities.
“From the inception, we aimed to design a pilot project that would generate lessons about what works, how much it costs, and how it can be scaled,” says Miriam. “Using a science of implementation approach was critical to the success of the project, with clear research questions, systematic monitoring of results, and identification of lessons learned. The knowledge generated was shared widely at the national, regional, and global levels.”
Ultimately, the project led to several key insights which can be used to guide future initiatives.
1) Foster partner engagement and shared goals
Kenya’s devolved health system means that much of health service delivery is in the hands of county governments so engaging and empowering these officials was key to ensuring continuity and sustainability.
“At the end of the day, despite all of the evidence, strong buy-in by decision makers is needed as well as the supporting budget to scale up and sustain the interventions,” says Toni. “You need close engagement at every stage of the program, from design to implementation, so that everyone recognizes the importance and value of what is being piloted.”
“For NCDs like cancer, you don’t see the benefit right away, so it’s important for everyone to have a common understanding and a shared vision and goal,” says Kenneth Munge Kabubei, Health Economist at the World Bank. “You need to engage and align with other stakeholders, including institutions, donors and partners who are working in the same space, so that everyone is working towards the same goal.”
2) Work with the right partners
The pilot project was led by a group of Kenyan experts in Western Kenya, who worked in close collaboration with officials from the Ministry of Health in Nairobi.
“AMPATH brought decades of experience on a chronic care model for AIDS that was gradually adapted to deal with NCDs,” explains Miriam. “This provided a unique opportunity to leverage this expertise for further replicating and testing the model for NCDs.”
The AMPATH and Moi Teaching and Referral Hospital teams successfully mobilized community leaders and county officials to bolster commitment for the pilot.
“It was important to work with organizations which are a critical part of the local community,” says Munge. “By building up this trust and giving them room to implement the program, the pilot was embedded at the community level, and solutions could reflect the local needs and realities.”
3) Innovative solutions
The project introduced several new practices to address the major barriers to accessing NCD care, including task sharing from doctors to nurses, as well as using community health promoters and community health volunteers to improve awareness and link patients to facilities.
“There was a certain degree of pragmatism that was key to the success of this pilot,” says Miriam. “Interim solutions were identified to move things ahead. Policymakers need to adapt their strategies and its approaches to what’s feasible and what’s doable in their particular health system context.”
4) Create patient-driven initiatives
One of the major innovations of the pilot project was the establishment of patient support groups which proved critical to empowering patients to better manage their own health, a feature of the initiative that became especially important when the COVID-19 pandemic disrupted the normal delivery of health services. The support also assisted patients to enroll in the National Health Insurance Fund and provided support during treatment to bolster adherence.
“The patient’s voice and perspective are absolutely critical,” says Takanori. “This initiative is an example of patients being placed at the forefront of care and becoming advocates of the NCD agenda themselves.”
Looking beyond Kenya
In total, hypertension screening reached roughly 185,000 individuals; diabetes screening was done among close to 94,000 individuals; and breast and cervical cancer screening was performed among 20,000 and 24,000 women, respectively.
“It’s been a phenomenal learning experience, a very rich and important one for Kenya, and for other countries on the continent,” says Miriam. “As the global community looks to reimagine primary health care so that people can be identified early, diagnosed accurately, and placed on treatment promptly, the lessons from this project will help inform this vision.”