Implementation of Non-communicable Diseases Interventions in Primary Health Care Facilities and at the Community Level in Nigeria: A call to Action and Partnership

Abstract

The burden of Non-communicable Diseases (NCDs) is on a steady rise in many developing countries, including Nigeria. There are proven population and individual-based cost-effective interventions adopted by the World Health Organization (WHO) for prevention and control of NCDs at the primary health care (PHC) facilities and the community level. Gaps exist in the country’s health system, hindering the implementation of essential NCDs interventions at the PHC and community levels. The Nigerian Federal Government has acknowledged the high prevalence of many NCDs and the risk factors, and taken steps to address this challenge, including the launch of eight national policy and guideline documents on NCDs. Document analysis was done to identify important areas for partnership and collaboration by the WHO, Federal Ministry of Health and Social Welfare (FMHSW), states’ Primary Health Care Development Agencies (states’ PHCDAs), and non-governmental organizations focused on NCDs in Nigeria. There is an urgent call for the implementation of the WHO package of essential NCD interventions in the PHC facilities and community level across Nigeria. Finally, a case example is made for an institutional support to Ekiti State, South-West Nigeria, a sub-national unit in the country, and an additional five other states, each from five remaining geopolitical zones, for an eighteen-month pilot implementation of essential interventions for prevention and control of NCDs based on three criteria. This could be scaled up across Nigeria following a review of the success and lessons learnt from the implementation of these NCDs interventions in the pilot states.

Introduction

The burden of non-communicable diseases (NCDs) such as cardiovascular diseases, diabetes mellitus, cancers, chronic respiratory diseases, mental health disorders, etc., is on a steady increase in the low- and middle-income countries, Nigeria inclusive. [1],[2] There are proven population and individual-based cost-effective interventions adopted by the World Health Organization (WHO) and its partners for prevention and control of NCDs at the primary health care (PHC) facilities and the community level. [3],[4]

On 22nd August, 2024, eight (8) national policy and guideline documents on NCDs [5] were launched by the Honorable Minister, Federal Ministry of Health and Social Welfare (FMHSW). This action demonstrated a new direction and national commitment by the Nigerian government to addressing NCDs among the Nigerian population. It was a welcome development. The documents that were launched include the National Policy for the Prevention and Control of NCDs; National NCD Task-shifting and Task-sharing (NTSTS) Policy for use at the Primary Healthcare level; National Guidelines for the Prevention and Management of Hypertension in Nigeria; the National Tobacco Control Strategic Plan of Action, 20242028; and a Newsletter for People Living with NCDs (PLWNCDs), among others. [5] In 2019, the Nigerian Government launched its first National Multisectoral Action Plan (NNMSAP) for the Prevention and Control of Non-communicable Diseases. [6] With the launch of these vital documents, there is a renewed vigour to involve the Primary Health Care (PHC) facilities to play key roles in the prevention and control of NCDs.

However, recent studies have reported gaps in the level of knowledge of prevention and control of NCDs among the non-physician healthcare workers (NPHWs) in the PHC facilities [7] and a low level of preparedness across other domains of basic equipment, diagnostics and essential medicines necessary for the implementation of essential NCDs interventions in the PHC facilities. [8],[9] These challenges pose a threat to the drive towards implementation of essential NCD interventions at the PHC facilities and at the community level.

Due recognition must be given to the pivotal roles of the WHO in curbing the menace of the NCDs and reducing their negative impact among the people at risk of developing NCDs and people living with NCDs (PLWNCDs) in Nigeria. In a similar vein, the latest efforts by the Nigerian government towards the prevention and control of NCDs are in line with the Strategic Priority three of the WHO African Region’s Country Cooperation Strategy 2023-2027 for Nigeria. [10] This policy commentary made an urgent call for implementation of essential NCDs interventions in the PHC and community levels across Nigeria in the face of the rising burden of NCDs and the risk factors among the population, and identified important areas for partnership and collaboration among the key stakeholders.

Methods

The key areas of partnership and collaboration among various stakeholders involved in the prevention and control of NCDs at the PHC and community levels were identified through document analysis, where relevant scholarly articles, government agencies’ reports, policy briefs, expert views, among others, were reviewed. Themes and patterns were identified; the key areas of partnership and collaboration were then summarized. Relevant stakeholders involved in the prevention and control of NCDs at the PHC and community levels in Nigeria were identified through stakeholder analysis. Ekiti State, South-West, Nigeria, was purposefully selected for an eighteen-month implementation of essential NCDs interventions based on the high burden of NCDs and the risk factors among the population, [11],[12] favourable health system framework and the strong political will for health sector reforms and development in the state. Additional states, one in each geopolitical zone that meets similar criteria highlighted above, could be selected for the pilot implementation of the essential NCDs interventions to ensure wider geographical spread and varying implementation experiences and lessons, which may become relevant during scale-up.

A call to Action and Partnership

There is an urgent call for implementation of essential NCDs interventions in the PHC facilities and community level across Nigeria in the face of the rising burden of NCDs and the risk factors among the population. The WHO framework for implementing a package of essential non-communicable disease (WHO PEN) interventions using a step-wise approach can be adapted to guide the implementation. [3] Existing gaps in the Nigerian health system should be addressed through concerted efforts among the three tiers of government and relevant stakeholders. Strengthening Nigerian health system using the WHO health system framework [3],[13] through its various building blocks (service delivery; health workforce; health information; medical products, essential medicines, vaccines and technologies; financing; and leadership and governance) will be invaluable in making PHC facilities ready to respond to the challenges posed by the increasing burden of NCDs in communities, where people live and work. Monitoring and evaluation process using relevant indicators such as three or six-monthly control of blood pressure and glycemic control among people treated for hypertension and diabetes, availability of essential cardiovascular disease and diabetes medicines, number of patients and number of new patients diagnosed and being treated for diabetes and other major NCDs, etc., is advocated. [3] To ensure the successful implementation of essential NCDs interventions in the PHC and community levels, there is a need for strong partnership and collaboration among the critical stakeholders involved in the prevention and control of NCDs in the country.

Identified Key Areas of Partnership and Collaboration by the WHO, FMHSW, States’ PHCDAs and Non-governmental Organizations Focused on NCDs in Nigeria

1. Training and Re-training of Health Care Workers in the PHC Facilities and the Health Volunteers in the Community

   Task-shifting in NCDs prevention, control and care in the PHC facilities and at the community level would require training and re-training of non-physician healthcare workers (NPHWs). [7], [14] They will be involved in the new drive to implement the multi-sectoral strategies for addressing the risk factors for NCDs, and prevention and control of major NCDs such as hypertension, other cardiovascular diseases, diabetes, chronic respiratory diseases, early identification of cancers, and mental health disorders, among others, in the PHC facilities in Nigeria. For an instance, the NCD Alliance Nigeria, a recognised non-governmental organization focused on NCD prevention and control activities in Nigeria, has a pool of experts and specialists that are willing and able to offer support to the WHO, NCD division of the FMHSW, the National Primary Health Care Development Agency (NPHCDA) and various states’ Primary Health Care Development Agencies (states’ PHCDAs) in the training and re-training of these major human resources for health under the PHC.

2. Supportive Supervision during Implementation of NCD Interventions at the PHC Facilities

   Implementation of essential NCDs interventions at the PHC facilities and at the community level would require supportive supervision to ensure the NPHWs stay the course and operate optimally in the overall interest of the patients who access NCDs preventive and care services at that level. [7], [15] Supportive supervision programmes, tailored towards providing guidance and effective support for NCDs service provision in the PHC facilities and the volunteer health workers to be involved in health promotion, NCDs service linkage and counseling across communities in Nigeria, should be developed. This effort should be led and coordinated by the NCD Division of the FMHSW in collaboration with NPHCDA, WHO and relevant NGOs, including NCD Alliance Nigeria, Nigerian Heart Foundation, Diabetes Association of Nigeria (DAN), Resolve to Save Lives Nigeria, Association of Public Health Physicians of Nigeria (APHPN), among others.

3. Media Campaign, Community Engagement and Advocacy on Prevention and Control of NCDs

   Many non-governmental organizations focused on NCDs, such as NCD Alliance Nigeria, Nigerian Heart Foundation, Nigerian Cancer Society, Resolve to Save Lives Nigeria, etc., have many seasoned communication experts and health educators as members. They have been involved in sensitization and awareness campaigns to different population groups and the general public on behavioural change communication about the prevailing risk factors for NCDs and the need for making healthy lifestyle choices and promotion of regular screening for early identification and prompt treatment of NCDs among the Nigerian populace. Of particular interest is the NCD Alliance Nigeria, which publishes a quarterly national PLWNCDs Newsletter to educate the general public on NCDs and the risk factors, and serves as an advocacy tool to reach out to key stakeholders on the challenges facing the PLWNCDs in Nigeria.

4. Research, Innovation and Development on Prevention and Control of NCDs

   Astute researchers with an interest in NCDs in academia, among medical consultants, public health experts, reputable scholars and research fellows across Nigeria could help to design and conduct cutting-edge and transformational research on best modalities and solutions to address the risk factors and management of major NCDs in the country. They should be identified to form an NCDs Researchers’ Network in Nigeria. There is a need to identify more cost-effective NCDs interventions that work and are better suited for Nigeria’s socio-cultural peculiarities.

A case example for Institutional Support to Ekiti State and Five other States for Pilot Implementation of Essential Interventions for Prevention and Control of NCDs by the FMHSW, WHO and relevant NGOs

Ekiti State, South-West Nigeria, is one of the thirty-six states in Nigeria. The state has committed leadership at the various organs of government, willing to support every effort towards the prevention and control of NCDs among its people. The state has several policies aimed at reducing the burden of NCDs, such as the Ekiti State Cancer Control Policy and the Ekiti State Mental Health Policy, among others. The PHC facilities (more than 103 PHC facilities) in the State are being upgraded to support NCD prevention and control efforts, and provide other essential healthcare services. [16]

The Ekiti State Cancer Registry, established about twelve years ago, is one of the widely recognised state cancer registries in the West Africa Sub-Region. It is a population-based cancer registry. This registry is hosted by the Ekiti State University Teaching Hospital (EKSUTH), Ado Ekiti. Also, in EKSUTH, there is a purpose-built, one-stop health unit, the Funmi Adunni Olayinka Diagnostic and Wellness Centre (named after a female former Deputy Governor of the state who died following a battle with cancer), for coordinating screening efforts for major NCDs among the people of the state and its environs. This prevailing conducive health system framework in Ekiti State and the strong political will for health sector development are enablers for the implementation of essential NCDs interventions.

Therefore, a case example is made for institutional support by earlier identified stakeholders to Ekiti State, especially on training of NPHWs and other domains where gaps exist, sustainable financing, among others, for an eighteen-month pilot implementation of essential interventions for prevention and control of NCDs. An additional five states, one selected from each of the remaining five geopolitical zones, that shared similar highlighted criteria as Ekiti State, could be included in the pilot phase. This could be scaled up across Nigeria following a review of the success and lessons learnt from the implementation of these essential NCDs interventions in Ekiti State and other pilot states.

Conclusion

The renewed commitment of the Federal Government of Nigeria towards the prevention and control of NCDs, particularly the launching of several national policy and guideline documents on NCDs, is a welcome development. Due recognition is given to the pivotal roles and important contributions of the WHO in addressing the challenges posed by the rising burden of NCDs in Nigeria. There is a call for an urgent action and an enduring partnership among the FMHSW, WHO, states’ PHCDAs and other relevant stakeholders towards a multi-sectoral approach for prevention and control of NCDs in the country, particularly at the PHC and community levels.