A patient receives an intial vital signs check before seeing the doctor
Over the past five years, the World Bank has embarked on a major new initiative to strengthen Ukraine’s capacity to address non-communicable diseases (NCDs), with a focus on cardiovascular diseases, or CVDs. During the same period, the World Bank launched a pilot NCD project in Kenya to expand access to care, including hypertension management.
As we pause to observe World Heart Day, it’s valuable to examine how these countries, which are at different points in the epidemiologic transition, are grappling with similar challenges when it comes to responding to CVDs
Heart diseases are in the rise around the world
CVDs in Ukraine cast a shadow too large to ignore. In 2017, ischemic heart disease (reduced flow of blood to the heart) and stroke (constricted flow to or bleeding on the brain) represented the first and second leading causes of death. Hypertension contributed to 42 percent of total deaths in 2016, the highest in the world (compared to 15 percent in France, and 23 percent in China).
The biggest risk factors driving premature death and disability from CVDs are poor diet, high blood pressure, tobacco use, excessive alcohol consumption, and obesity.
In Kenya nearly 75 percent of the poorest have never been measured for blood pressure. Only 3 percent of Kenyans have none of the main risk factors for CVDs (i.e. daily smoking, obesity, raised blood pressure, low levels of physical activity).
CVDs and other NCDs are rising rapidly with projected deaths expected to increase by 55 percent while deaths due to communicable diseases are expected to drop by 48 percent by 2030. Kenya has the unique opportunity to intervene early, savings lives and containing health care costs.
Cardiovascular disease has biggest impact on people living in extreme poverty
Ukraine and Kenya are far from the only countries grappling with the threat of CVDs, a group of disorders that affect heart health, the brain and the circulatory systems. Close to 18 million people died from CVDs in 2016, representing 31 percent of all global deaths. About 75 percent of CVD deaths take place in low- and middle-income countries ill prepared to address the rising disease burden.
Within these countries, CVDs have the biggest impact on people living in extreme poverty, and many of these conditions occur at younger ages (i.e. congenital heart disease), as documented in the recently released Lancet NCDI Poverty Commission Report.
The World Bank supports analytic work to better understand what contributes to CVDs, including the rising incidence of obesity; how best to reduce risk factors; and how to mobilize greater domestic financing through, for example, tobacco taxation and other sin taxes.
The Bank also helps countries make CVD services more accessible and affordable, as well as to raise awareness, change behavior and enhance management of the conditions. By bringing care closer to people, primary health facilities offer the easiest ways to learn about cardiovascular health, detect disorders early, and manage them well and relatively inexpensively .
Prevention is key
The health systems in Ukraine and Kenya, as in many other countries, have long been hospital centered and curative, rather than preventative. In Ukraine, the government has made an effort to allow more doctors to become a point of care for patients at the primary level. The program has resulted in a reduction of hospital admissions for hypertension – from about 6 per 1,000 (2015) to 4.5 per 1,000 (2019) due to the shift towards primary care and better at home management.
Primary health centers, especially in rural areas, have been strengthened with critical equipment for better and more accurate diagnoses; growing numbers of doctors and other health care workers have received cardiac care training; schools of health in primary health settings were revamped to conduct public education campaigns about heart health; and selective improvements of hospital CVD treatment infrastructure were undertaken to deal with severe cases.
In Kenya, the Bank-supported chronic care model, funded by Access Accelerated, a private sector initiative aimed at addressing NCDs, is raising awareness about heart health and improving hypertension management. It is also studying the impact of integrating several NCDs into primary care settings.
The pilot project in Kenya has involved task shifting, with greater use of nurses; community health volunteers who raise awareness in communities; revolving drug pharmacies to ensure timely access to medicines to control blood pressure; and support for patients to enroll in the National Health Insurance Fund to shield patients from costly CVD care.
Preliminary results suggest the program has already expanded the reach of care to people who previously had little, and many more are now managing their hypertension better than before. The proportion of patients with controlled hypertension rose from 30% to 51%.
Using COVID-19 to make health systems stronger
The arrival of COVID-19 has made it more difficult to address CVDs in nearly all countries, but it also offers the opportunity to build more resilient, inclusive health systems. We now know that people with poor cardiovascular health and other NCDs, are especially vulnerable to serious COVID-19 complications. As global health leaders have stressed, taking strong action on NCDs must be an integral part of the COVID-19 response.
Worried about leaving their homes or about getting infected with the coronavirus on public transportation, people with CVDs are less likely to seek care and to collect vital medicines. As cases of COVID-19 rise, health providers often have less time to devote to CVD care.
Many countries are finding creative ways to address these issues. In Kenya, the health care staff reach out to patients to check how well they are coping and adhering to treatment. They’re also reorganizing clinic visits by pre-screening for COVID-19, employing strict booking to avoid overcrowding, triaging patients, and providing medications for longer duration to minimize visits.
This World Heart Day, we salute frontline workers whose dedication is remarkable. As the global community continues to fight the pandemic, the commitment to mitigating CVDs must match theirs.
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