In one of the most under-resourced places in Uganda, where there is just one doctor for every 25,000 people, success does not go unnoticed.
Most Ugandan government health facilities focus on infectious diseases, but in Nakaseke district, about 65km from the capital Kampala, three clinics treat people with non-communicable diseases (NCDs) such as diabetes, kidney disease and chronic lung conditions.
As in other low- and middle-income countries, the burden of illnesses in Uganda is transitioning from tropical and infectious diseases to these common NCDs, which kill 41 million people every year worldwide, roughly 71% of annual global deaths.
Uganda “has been overwhelmed by the growing burden of NCDs across all socioeconomic strata”, according to a 2021 assessment.
But the clinics, run by the Balamu project, have proven so successful that the Ugandan government has now committed to replicating them nationally.
The weekly clinic at Nakaseke general hospital has seven nurses and a doctor, who works across the three clinics. When it opens every Friday, staff see about 100 to 200 patients, in a region more than 60% of people live on less than £10 a month.
“In Uganda, about 80% of the health worker force lives in big towns, which constitute about 20% of the population,” says Dr Robert Kalyesubula, founder of the African Community Centre for Social Sustainability (Access Uganda), the organisation behind Balamu. “This creates a great imbalance in the number of health workers available to provide services to the majority of Ugandans.” Kalyesubula says NCDs are “often left untreated in Uganda”.
Born in Nakaseke, Kalyesubula was seven when war broke out in the 1980s and, after becoming separated from his parents as they fled the fighting, grew up in an orphanage. His father was killed, and he didn’t see his mother again for nearly nine years. But Kalyesubula made it to medical school, then to the Yale School of Medicine in the US, before returning to Nakaseke and establishing Access.
Balamu (“being healthy” in the Luganda language), is community-based, educating nurses, pioneering electronic medical records and providing public education booklets. Following World Health Organization (WHO) guidelines, it integrates care under one roof.
The human toll of non-communicable diseases (NCDs) is huge and rising. These illnesses end the lives of approximately 41 million of the 56 million people who die every year – and three quarters of them are in the developing world.
NCDs are simply that; unlike, say, a virus, you can’t catch them. Instead, they are caused by a combination of genetic, physiological, environmental and behavioural factors. The main types are cancers, chronic respiratory illnesses, diabetes and cardiovascular disease – heart attacks and stroke. Approximately 80% are preventable, and all are on the rise, spreading inexorably around the world as ageing populations and lifestyles pushed by economic growth and urbanisation make being unhealthy a global phenomenon.
NCDs, once seen as illnesses of the wealthy, now have a grip on the poor. Disease, disability and death are perfectly designed to create and widen inequality – and being poor makes it less likely you will be diagnosed accurately or treated.
Investment in tackling these common and chronic conditions that kill 71% of us is incredibly low, while the cost to families, economies and communities is staggeringly high.
In low-income countries NCDs – typically slow and debilitating illnesses – are seeing a fraction of the money needed being invested or donated. Attention remains focused on the threats from communicable diseases, yet cancer death rates have long sped past the death toll from malaria, TB and HIV/Aids combined.
'A common condition' is a Guardian series reporting on NCDs in the developing world: their prevalence, the solutions, the causes and consequences, telling the stories of people living with these illnesses.
Tracy McVeigh, editor
A key achievement has been training health workers to screen patients, make referrals and follow up on medication. They have screened 16,000 people so far.
“The major challenge to NCDs in Uganda is that most of the care, even in government hospitals, is met by patients using out-of-pocket payments,” Kalyesubula says.
“Many hospitals lack equipment and medicines to fight NCDs. This compares poorly with communicable diseases like HIV/Aids, tuberculosis and malaria, which have received a tremendous amount of funding for the last 30 years.
“In fact, as a nephrologist, when I tell my patients that they have chronic kidney disease and may need hemodialysis, they tell me they wish they had HIV instead, because those people receive free medical care.”
NCDs are projected to become the leading cause of death across Africa by 2030. In eastern Uganda, that milestone has already been reached.
Hypertension is a particular issue, with the prevalence estimated to be between 26% and 31%, with only 7% aware of their condition, according to surveys.
Immaculate Nakabiri, 73, has been attending Balamu’s Semuto clinic since her dizziness and joint pains were diagnosed as high blood pressure. “I’m the head of the family,” she says. “The disease doesn’t allow me to work to support my family, which has created a big gap to meet my family needs. We no longer had enough to eat at home because I cannot dig in the garden.”
She now takes medication but says most people over 50 in her community have undiagnosed illnesses that badly affect their lives.
Dr Richard Munana rotates his time between the three Balamu clinics. He says the biggest challenge is out-of-stock medicines: “By government policy, more attention is paid to communicable diseases than NCDs. This means that the majority of our patients go without the required medication.”
