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Developing Systems for Cardiac and Stroke Care in Zambia

2023; Wiley; Volume: 13; Issue: 1 Linguagem: Inglês

10.1161/jaha.123.030151

2047-9980

Chabwela D. Shumba, Agnes Mtaja, Deanna Saylor,

Cardiac Arrest and Resuscitation

HomeJournal of the American Heart AssociationAhead of PrintDeveloping Systems for Cardiac and Stroke Care in Zambia Open AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessArticle CommentaryPDF/EPUBDeveloping Systems for Cardiac and Stroke Care in Zambia Chabwela Shumba, Agnes Mtaja and Deanna Saylor Chabwela ShumbaChabwela Shumba * Correspondence to: Chabwela Shumba, MBChB, MCS(ECSA), MMED, National Heart Hospital, Plot 101 sub C of Farm 4169, Off Airport Rd, Chongwe, Lusaka, N/A 00000 Zambia. Email: E-mail Address: [email protected] https://orcid.org/0000-0002-0813-9926 , National Heart Hospital, , Lusaka, , Zambia, , Agnes MtajaAgnes Mtaja https://orcid.org/0000-0002-2548-4422 , University Teaching Hospital, Children's Hospital, University of Zambia, , Lusaka, , Zambia, and Deanna SaylorDeanna Saylor https://orcid.org/0000-0002-9297-0244 , Johns Hopkins University School of Medicine, , Baltimore, , MD, Originally published29 Dec 2023https://doi.org/10.1161/JAHA.123.030151Journal of the American Heart Association. 2023;0:e030151In Zambia, a low middle‐income country of 20 million people in Southern Africa, the 2021 total life expectancy at birth is 62 years (life expectancy at birth for females is 68 years, while that for males is 58 years). The nation's maternal mortality rate is 135/100 000 live births (2020), while the neonatal mortality rate is 25/1000 live births. Zambia's gross domestic product in 2022 was USD 29.79 billion, and the gross domestic product on health was 5.6% in 2020.1In Zambia, the premature mortality rate from cardiovascular disease (CVD) (30–70 years of age) is 10%.The incidence of rheumatic heart disease (RHD) was 0.98%, while the total mortality rate due to RHD was 0.14% of all deaths.2Zambia was one of the low‐ and middle‐income countries to participate in the multicenter REMEDY (Rheumatic Heart Disease Registry) study that reported a hospital‐based registry for RHD and rheumatic fever. Mortality reported was 16.9%, and the median age was 28.7 years.3Globally, stroke is one of the leading causes of disability and mortality, accounting for 42% of disability‐adjusted life years following a neurological disorder. At the University Teaching Hospital in Lusaka, adults with stroke constituted 43% of all neurological admissions, had an average age of 60±18 years, and 62% of the cohort was female. Stroke subtypes were 58% ischemic, 28% hemorrhagic, and 14% unknown. Hypertension was present in 80% of all strokes.4Of men and women over the age of 25 years, 19.1% have raised blood pressure. Hypertension is the most common reason for clinic visits and hospital admissions.5Heart failure secondary to RHD tops the admissions at the newly opened National Heart Hospital in Lusaka, the country's capital. Furthermore, the burden of CVDs in Zambia is incomplete without the consideration of the estimated 6000 babies born with heart defects annually.CVDs are the leading cause of death from noncommunicable diseases (NCDs) in sub‐Saharan Africa, and the region accounts for ≈80% of deaths from CVDs globally (World Health Organization/World Heart Federation). The situation in Zambia is not different (Figure 1). Three‐quarters of deaths from heart attacks and strokes occur in low‐ and middle‐income countries such as Zambia and many other countries in sub‐Saharan Africa. A change in the demographics (eg, people surviving to older ages) and lifestyles (eg, higher rates of obesity, tobacco use, sedentary lifestyles, and processed food consumption) is thought to be fueling this surge of CVDs, which have been projected to overtake communicable diseases in prevalence by 2030. Unfortunately, access to quality health care services is not equally distributed globally, with many people lacking such access, especially those who reside in low‐ and middle‐income countries. The growing burden of NCDs in Zambia and other low‐ and middle‐income countries necessitates an urgent new approach to health care delivery and health system development in order to address this shift from a health care system dominated by communicable diseases to one in which NCDs predominate. Health system capacity in response to NCDs includes the following challenges: human resources for health and medical equipment.Download figureDownload PowerPointFigure 1. World Health Organization: noncommunicable diseases (NCDs) country profiles (Zambia), 2018.The experience of a 9‐year‐old girl from Lufwanyama, a rural district in Zambia, who we will call Farai, is 1 of many stories illustrating the challenges in accessing quality health care in Zambia as well as ongoing efforts to improve these challenges and develop a health care system ready to address the burden of NCDs in the country. Farai presented with a 2‐year history of abdominal swelling, yellowing of eyes, and weight loss. The abdominal distention had brought her a lot of ridicule and shame at school such that she stopped attending school. On many occasions, her mother had sought help from the nearest health center, but the interventions she received there seemed to result in little improvement. Recently, Farai was eventually referred to the newly opened National Heart Hospital in Lusaka, the capital city of Zambia, ≈500 km and a 9‐hour bus ride from her home. Here, a diagnosis of constrictive pericarditis secondary to tuberculosis was made by a team of Zambia's newly trained cardiology specialists. She was taken in for surgery, and a pericardiectomy was performed with a good outcome. She is now back at school and thriving. Farai's story illustrates that access to quality health care means not only saving a life but also improving physical and mental well‐being as well as quality of life. It also demonstrates that at the primary health care level there is a need to deliberately have capacity to identify and make early appropriate referrals of NCDs. Farai was able to access specialized care as a result of the following: availability of specialized care at the National Heart Hospital, and the awareness of the existence of National Heart Hospital through the referral chain.Development of responsive health systems is driven by the aim of achieving access to the highest quality evidence‐based care for all people accessing that system. Development of a health service must take into consideration the 6 core components of the health system, as defined by the World Health Organization Monitoring and Evaluation framework, which are (1) service delivery, (2) human resources for health, (3) health information systems, (4) access to essential medicines, (5) health care financing, and (6) leadership and governance. In a resource‐limited setting such as Zambia with competing health needs such as malaria, HIV, and tuberculosis, the importance of political will cannot be overstated. To this effect, the Government of the Republic of Zambia has recognized the increasing burden of NCDs and has constituted a High Level Technical Working Group for NCDs.SETTING THE STAGEHigh‐income countries have robust primary health care programs for early detection and treatment of people with hypertension and other risk factors for CVDs. Functional referral and transfer systems have been set up for acute events such as stroke and heart attacks. Facilities are laden with modern equipment and specialized staff to cater to patients with these conditions by providing access to acute interventions such as thrombolysis and thrombectomy and are also prepared to manage complications arising from these conditions and their treatments. As a result, significant advances have been made. For example, global age‐standardized stroke incidence decreased by 8.1%, stroke mortality by 36.2%, and disability‐adjusted life years by 34.2% from 1990 to 2016 (Figure 2). However, these gains are unequal, with southern sub‐Saharan Africa 1 of only 2 world regions with increasing stroke incidence and less marked gains in stroke mortality during this period. In Zambia, stroke is the eighth leading cause of death, and stroke mortality increased 27% over the past decade. Like much of sub‐Saharan Africa, Zambia has not benefited from global gains in stroke outcomes. Stroke‐related mortality and disability‐adjusted life years have increased between 1990 and 2016, and reduction in stroke incidence has been markedly less than global and regional rates.Download figureDownload PowerPointFigure 2. Percent change in age‐standardized incidence, mortality, and disability‐adjusted life years (DALYs) by sociodemographic index (SDI).World region or country 1990 to 2016. SSA indicates sub‐Saharan Africa.The World Health Organization intersectoral global action plan on epilepsy and other neurological disorders sets out the required actions to improve access to care and treatment for people living with neurological disorders through a comprehensive, coordinated response across sectors. The strategic objectives of the intersectoral global Action plan on epilepsy and other neurological disorders include the following: to raise policy prioritization and strengthen governance; to provide effective, timely and responsive diagnosis, treatment and care; to implement strategies for promotion and prevention; to foster research and innovation and strengthen information systems; and to strengthen the public health approach to epilepsy. The intersectoral global action plan on epilepsy and other neurological disorders guides the advancement of neurological care, particularly in Africa and Asia.LOOKING TO SIMILAR EFFORTS WITHIN THE REGIONFrom a neurology and stroke perspective, several countries in sub‐Saharan Africa have shown the importance of capacity building and quality service provision over the past decade or more. For example, Ethiopia began its first postgraduate training program in neurology at the University of Addis Ababa in 2006 at a time when there were only 8 neurologists serving a country of 40 million people. Despite facing challenges, including limited teaching faculty, lack of diagnostic facilities, and inadequate services in other neurology specialties such as neuroradiology and neuropathology, there are now nearly 80 neurologists in the country with >10 neurology trainees each year. Another successful example of neurological capacity building in sub‐Saharan Africa is that of the Wessex‐Ghana Stroke Partnership, which began in 2009 with a goal of improving stroke care in Ghana. Since that time, this partnership has seen the launch of a stroke unit at Korle Bu Teaching Hospital in the capital city of Accra, which has led to reduced mortality, improved clinical outcomes, and higher patient and caregiver satisfaction.NEUROLOGY JOURNEY AND IMPACTIn 2018, we launched the first postgraduate neurology training program in Zambia. In the first 5 years, we have graduated 9 neurologists (7 adult and 2 pediatric neurologists) and have an additional 10 neurologists currently in training and launched a neurology unit at the University Teaching Hospital. We launched Zambia's first teleneurology services to improve access to neurology care for people living outside of Lusaka. Our 3 most recent graduates have now been posted to other hospitals, and are leading the development of neurology training and specialist neurology units at these hospitals.6 Additionally, we have taken a research‐based approach to both our training and clinical care leading to a data‐driven approach to understanding the epidemiology and clinical outcomes of our patients, especially those admitted with stroke.7 Our first inpatient registry showed that stroke accounted for nearly half of all admissions; it also highlighted in particular that HIV infection is the second most common risk factor for stroke after hypertension.8 With an in‐hospital mortality rate of >20%, we also strove to identify predictors of poor outcome in our population and have subsequently focused on understanding and improving rates of aspiration pneumonia among patients with stroke at University Teaching Hospital, including through the use of locally contextualized and resource‐appropriate approaches such as caregiver interventions. This focus on high‐quality clinical research, often taking advantage of systematically collected routinely available data rather than high‐budget studies, has had an outsized impact in allowing us to contextualize our systems of care to maximize our patient's outcomes within the resource constraints in the local setting.CARDIAC CARE JOURNEY AND IMPACTThe journey of cardiac care in Zambia has been slow, long, and punctuated with bursts of activity. In the early 1980s patients with cardiac disease in clinics were seen by nonspecialists. Inadequate numbers of specialists still persist even currently, with no more than 20 cardiac care specialists (cardiac surgeons, pediatric and adult cardiologists combined) in the country for a population of 20 million citizens. The University Teaching Hospital, Lusaka had a dedicated cardiac operating room. The sporadic bursts of activity involved collaborative fly‐in missions done by partners from the West. The missions would perform surgeries on patients with limited emphasis of capacity building of the local teams and is unsustainable as a long‐term strategy for development of the service. The collaborative partners have also identified the strength of capacity building of the local team by offering training opportunities in their Centers of Excellence. In 2021, a government facility, the National Heart Hospital, was operationalized with a view to increase access to specialized care and reduce sending patients abroad for care. Since its inception, the facility has performed in excess of 200 surgeries and interventions. South‐to‐south collaborative partnerships with cardiac institutes in sub‐Saharan Africa are encouraged because these bring valuable lessons and experiences in development of a cardiac service in a similar setting. One such partner is the Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania, which will assist in training of nurses and perfusionists.CHALLENGESThe challenges to providing optimal care for CVDs and other NCDs within a resource‐constrained health system with multiple competing priorities are numerous and affect every level of the health care system. First, public awareness of CVDs, prevention, and timely recognition of disorders such as myocardial infarction and stroke is low, and provision of time‐dependent acute interventions for CVDs will require public education campaigns. Though being done by various players on the awareness and advocacy platform such as the Zambia Heart and Stroke Foundation, Beat RHD, and others, it needs to be strengthened. Second, prehospital emergency care systems in Zambia are in their infancy, and most populations outside of urban centers are far from any health care settings and out of reach of ambulances, further limiting provision of time‐dependent treatments for CVDs. Within the health care system itself, primary health care centers are often staffed by nonphysician health care workers with limited knowledge of diagnosis and guideline‐based management of CVDs; thus, robust referral systems that both prioritize patients in need of urgent assessment and facilitate early referral of all patients in need of specialist care need to be further developed. Additional specialists trained and practicing in‐country are urgently needed, and access to specialist care outside of major urban settings must be expanded. Finally, even once a patient reaches a specialist center, limited access to diagnostics, especially imaging and laboratory investigations, needed urgently to facilitate time‐limited acute interventions such as thrombolysis, thrombectomy, and angioplasty, hinders provision of these life‐saving and outcome‐changing interventions. Supply chain for essential medications needed both for acute interventions and long‐term primary and secondary prevention must also be improved to facilitate optimal patient outcomes. A health information gap for NCDs is also a challenge, and there is a need to establish National Registries for Strokes and CVDs.NEXT STEPSUltimately, to achieve optimal stroke and cardiac outcomes on a national scale, we will need to develop systems of care for stroke and cardiac diseases that include provision of acute care such as thrombolysis, management of acute myocardial infarction, and thrombectomy.The neurointerventional service and training program recently established in Ethiopia provides a model for what could ultimately be accomplished in Zambia for stroke care. For cardiac care, development of local specialization training programs will lead to having cardiac care specialists such as cardiologists, cardiac nurses, and sonographers in second‐level facilities.Apart from training, it is essential to develop effective and locally contextualized stroke units and that these units, defined as specialized wards for caring for patients with acute stroke by multidisciplinary teams of stroke specialists, reach every hospitalized patient with stroke, which can reduce odds of dependence and death by >20% compared with patients not cared for in a stroke unit.7 In sub‐Saharan Africa, where thrombolysis is often unavailable,9 stroke units are also uncommon. Overall, stroke care is variable and substandard, with low uptake of evidence‐based clinical practice guidelines likely accounting for substantial proportions of high mortality and poor outcomes in this region.10, 11 We hope to develop an evidence‐based approach to stroke center development that is applicable to all levels of the Zambian health care setting in the near term, thus improving access to standardized and evidence‐based stroke care for all patients with stroke in Zambia.The strengthening of diagnostic capabilities will be done through tailor‐made echocardiography training for the sonographers at all levels. This upskilling will also be useful in the implementation of the Rheumatic Heart Disease Screening Program, which will be part of the National Cardiac Service.The inclusion of cardiac services in the benefit package of the National Health Insurance Scheme, as part of efforts to achieve Universal Health Coverage, will reduce catastrophic out‐of‐pocket expenditure by patients. With all these facets of the National Cardiac Service in place, the impact will be increased access to cardiac care with resultant better outcomes and improved life.Sources of FundingNone.DisclosuresNone.Footnotes* Correspondence to: Chabwela Shumba, MBChB, MCS(ECSA), MMED, National Heart Hospital, Plot 101 sub C of Farm 4169, Off Airport Rd, Chongwe, Lusaka, N/A 00000 Zambia. Email: dcshumba@gmail.comThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.This manuscript was sent to Tazeen H. Jafar, MD, MPH, Associate Editor, for review by expert referees, editorial decision, and final disposition.For Sources of Funding and Disclosures, see page 5.References1 Indicators. The World Bank. Accessed September 15, 2023. https://data.worldbank.org/indicatorGoogle Scholar2 Goma F, Fourie JM, Scholtz W, Scarlatescu O, Nel G, Ghannem H. Zambia country report: PASCAR and WHF cardiovascular diseases scorecard project. Cardiovasc J Afr. 2020; 31:S49–S55. doi: 10.5830/CVJA-2020-043CrossrefGoogle Scholar3 Zühlke L, Karthikeyan G, Engel ME, Rangarajan S, Mackie P, Mauff BCK, Islam S, Daniels R, Francis V, Ogendo S, et al. Clinical outcomes in 3343 children and adults with rheumatic heart disease from 14 low‐and middle‐income countries: two‐year follow‐up of the global rheumatic heart disease registry (the REMEDY study). Circulation. 2016; 134:1456–1466. doi: 10.1161/CIRCULATIONAHA.116.024769LinkGoogle Scholar4 Nutakki A, Chomba M, Chishimba L, Zimba S, Saylor D. 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Risk factors and outcomes of HIV‐associated stroke in Zambia. AIDS. 2021; 35:2149–2155. doi: 10.1097/QAD.0000000000002999CrossrefMedlineGoogle Scholar9 Baatiema L, Chan CKY, Sav A, Somerset S. Interventions for acute stroke management in Africa: a systematic review of the evidence. Syst Rev. 2017; 6:213. doi: 10.1186/s13643-017-0594-4CrossrefMedlineGoogle Scholar10 Urimubenshi G, Cadilhac DA, Kagwiza JN, Wu O, Langhorne P. Stroke care in Africa: a systematic review of the literature. Int J Stroke. 2018; 13:797–805. doi: 10.1177/1747493018772747CrossrefMedlineGoogle Scholar11 Akinyemi R, Adeniji O. Stroke care services in Africa: a systematic review. J Stroke Med. 2018; 1:55–64. doi: 10.1177/2516608518775233CrossrefGoogle Scholar eLetters(0) eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. 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Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/JAHA.123.030151PMID: 38156470 Manuscript receivedMay 31, 2023Manuscript acceptedNovember 8, 2023Originally publishedDecember 29, 2023 Keywordscardiac care facilitiesGlobal HealthheartstrokeZambiaPDF download Subjects Cardiovascular Disease Epidemiology Health Services Hypertension Transient Ischemic Attack (TIA)