In Mozambique the Department for NCDs (DNCD) within the Ministry of Health was created in 2002 to address both chronic NCDs and Trauma and Violence. The work of the DNCD focused on the following different areas: [48
1. Organisation of the Health System
2. Data Collection
4. Diagnostic tools and infrastructure
5. Drug procurement and supply
6. Accessibility and affordability of medicines and care
7. Healthcare workers
8. Adherence issues
9. Patient education and empowerment
10. Community involvement and diabetes associations
11. Positive policy environment
Three studies were initiated in 2003 to gain information on different aspects of NCDs. The WHO STEPwise approach on Surveillance of NCD Risk Factors (STEPS) was implemented to get population based data on the most common risk factors for NCDs [49
]. Another study focused on acute asthma at the Central Hospital in Maputo [45
] and the Rapid Assessment Protocol for Insulin Access (RAPIA) was carried out in three provinces of Mozambique to assess problems with providing care and access to medicines for diabetes [42
Besides these studies other registers and surveillance systems were developed. Questions related to injuries were introduced into the demographic study in 2003 to find incidence of injury and prevalence of disability due to injury in Mozambique [50
]. An epidemiological surveillance system for injuries was also established in Maputo Central Hospital to measure the number and causes of trauma. This was then extended to other health facilities in Maputo and throughout the country. A population based cancer registry in Beira in collaboration with the International Agency for Research on Cancer was also established.
Data provided a clear picture of the burden of disease (STEPS, registers, surveillance systems) as well the existing barriers to care (RAPIA). Based on this it was decided to use diabetes and hypertension as a model for the development of an NCD Plan.
The results from the RAPIA [42
] were prioritised and the main recommendations that it was decided to address were, improve and increase the role of Diabetes Association, implement Chronic Disease Law which stated that people with diabetes and other chronic conditions were entitled to 80% subsidy in their medicines, improve data collection, increase training in diabetes, improve communication between central medical store and periphery to address shortages and surpluses of insulin in some areas of the country, increase awareness of diabetes in general public, improve access to diagnostic tools, develop care guidelines adapted to the Mozambican situation and increase number of diabetes consultations.
As well as working with the Ministry of Health and clinicians to address the problems identified during the RAPIA and improve diabetes care, the DNCD actively involved the diabetes association (AMODIA) in improving care and education for people with diabetes and developing a model for a chronic consultation for both diabetes and hypertension. This collaboration also led to organising activities for World Diabetes Day from 2004 onwards. World Heart Day has also been celebrated since 2005. The aim of these events was to raise the profile and increase information on diabetes and cardiovascular disease to the general population. The organisation of these events led to increased activity in the existing diabetes association in the Capital City and the creation of new branches of this association in two other cities.
In organising these events different departments from the Ministry of Health were involved, as well as other members of civil society, the media and the community at large. This enabled the creation of an ad hoc coalition on diabetes and hypertension.
Training of health professionals was also cornerstone of developing these activities and this was done using IDF guidelines developed specifically for sub-Saharan Africa that were translated in to Portuguese and adapted to the Mozambican setting. Some training was carried out in Tanzania in collaboration with the IDF Africa Region and the Tanzanian Diabetes Association and also in Mozambique using local faculty and support from Diabetes UK and the World Diabetes Foundation (WDF) [51
]. Health care workers were trained in diabetes and hypertension (2007-present) with a view of those trained to then be trainers. At present a team of healthcare workers (doctors, medical technicians and nurses) have been trained in each province in Mozambique with the responsibility of training their colleagues and developing diabetes and hypertension care in their province. The result of this was the implementation of a chronic consultation to all Central Hospitals, 2 Provincial Hospitals and 12 health centres in Maputo city. These facilities were provided with the necessary tools for the management of both hypertension and diabetes, such as blood glucose monitors, sphygmomanometer, risk tables and education materials. To date a team of healthcare workers has received training in diabetes and hypertension in each Province of the country.
Initial education materials for people with diabetes and hypertension were pamphlets developed locally describing these conditions, giving dietary and lifestyle advice as well as detailing proper measures for foot care. More detailed education materials for people with diabetes have also been developed as well as training expert patients in how to use these. These visual materials are divided into different sections which form part of different modules for education on, what is diabetes, Type 1 diabetes, Type 2 diabetes, Low blood sugar (Hypoglycaemia), High blood sugar (Hyperglycaemia), Diet, Treatment and Monitoring and control.
In looking at the issue of affordability and accessibility of insulin and medicines following the RAPIA the Chronic Disease Law was fully implemented in 2006 and then a change in government policy with the putting in place of prescription fee of US$ 0.20 in 2007. Accessibility and issues surrounding distribution were addressed by closer collaboration between the Ministry of Health, Central Medical Stores and the Provinces.