Zambia Non-Communicable Diseases Programme: call for proposals

Strategic Context

The Review recognised Health as one of the thematic areas prioritised by all three of the SG’s African PCs. Health therefore remains a key area for co-operation within the IDF. The review also recognised the need to move from small grants funding with a focus on multiple different areas and types of interventions to a more strategic approach to funding.

A SG commissioned evidence review identified NCDs (including, but not limited to, mental health, cancer, road traffic accidents, and haemoglobinopathies) as a specific area of health requiring increased global attention. Despite being the leading cause of death and disability globally, investment in the prevention and management of NCDs is extremely low at under 2% of Development Assistance of Health at a global level. ^[8]This level of investment has been static for at least the last decade. In 2019 cost Sub-Saharan Africa (SSA) over 225 million disability adjusted life years.^[9] This has increased from 90.6 million in 1990. WHO estimates that NCDs will be the leading cause of death in SSA by 2030 and will be responsible for 3.8 million premature deaths per annum.^[10] In the SG’s partner countries, it is estimated that 30-50% of all deaths are due to NCDs.^[11]

In 2015 the United Nations Sustainable Development Goals (SDGs) recognised the importance of tackling NCDs, including a specific target to reduce the probability of premature death from the four main NCDs in adults aged 30-70 years by 30% by 2030. A Global Action Plan to tackle NCDs was adapted and extended to 2030, setting out a roadmap to guide Member States in how best to achieve targets. A list of cost effective interventions or ‘WHO Best Buys’ sets out ways of tackling the major risk factors associated with the four most common causes of death from NCDs (cardiovascular disease, diabetes, cancer and chronic respiratory disease). In 2020 WHO Member States (MS) launched a Global NCD compact 2020-2030 to encourage adoption of best practice policies on prevention and control to galvanise momentum towards the SDGs. A range of technical packages have been developed to provide MS with support towards achieving this. These include PEN (Package of NCD interventions) which supports the decentralisation of services for common NCDs (hypertension, type 2 diabetes and chronic respiratory disease) to primary care level and PEN-Plus which supports decentralisation of outpatient services for more complex or severe NCDs to district hospitals. Together these form part of the regional strategy for WHO’s Africa Region (adopted in 2022) for expanding access to NCD care. SG and partners hope that initial focus on district hospital capacity will lead to strengthened primary care capacity through formalised links between the two service delivery levels.

PEN-Plus is an integrated care delivery strategy that focuses on improving access of the poorest to quality chronic care services in rural areas of LMICs. PEN Plus was adopted by MSs of the WHO African Region as the regional strategy for improving access to decentralised care for NCDs in particular Type 1 Diabetes Mellitus, Sickle Cell Disease and Rheumatic Heart Disease^{[12] [13]}. Treatment for these conditions is traditionally only available in tertiary level hospitals with well documented barriers to care experienced by the poorest.¹³

PEN-Plus bridges the gap between training, mentoring, treatment, and referral for NCDs. Investment in the scaling up access to diagnosis and treatment of these relatively complex diseases that could, if untreated, lead to premature death and disability, could support increases in life expectancy for some of the poorest people will inevitably increase ^[14].

Given Scotland’s longstanding expertise in delivering NCD Health Programmes domestically NCDs were identified as an area where Scotland would be well placed to share learning beyond its borders ^{[15] [16]}.

Zambia programme investment case

The case for investing in NCDs is compelling given the increasing burden that will be seen over the coming years and the paucity of investment in NCDs both domestically and internationally. Given this divergence between need and prioritisation, Scotland has an opportunity to work with partners at a political level to shift the global dialogue on NCDs.

NCDs are inextricably linked to poverty with the poorest disproportionately affected by NCDs throughout their life course. Hunger, exposure to toxic environments, infectious disease hazards and lack of access to health care compound this risk. Across the poorest billion more deaths under 40 years of age are a consequence of NCDs compared with HIV, TB and maternal deaths combined. The vast majority of those living with or at risk of NCDs are undiagnosed or unaware of their risk and are often diagnosed at a late stage of the disease making management more complex.

Lack of access to diagnostics and long-term supply of medications, including blood pressure monitors and glucose strips is a barrier to management. Out of pocket (OOP) payments are common, limiting access of the poorest to access care ^[17]. Lack of training and poor patient data collection and follow up have challenged scale up of PEN and PEN-Plus in Zambia ^[18]. Human resources for health are sparce, requiring task shifting and cross specialism^[19].

The NCD Health Programme in Zambia proposes funding the set-up of two additional PEN-Plus training centres and supporting an increase in NCD capacity at the MoH. At present the Centre for Infection Disease Research in Zambia (CIDRZ) are working with the MoH to set-up two training centres, one in Lusaka and one in the rural outskirts of the city. This would be in addition to that activity. As of 2024, the MoH is also currently drafting a National Operational Plan for PEN-Plus in Zambia to further detail ambitions of PEN-Plus scale up in the country.

The activities involved in setting up the training centres are subject to scoping by the successful grant holder. Hospitals differ in the levels of service delivery, training and overall systems in place. Based on these contexts, we expect a range of approaches for different components of the implementation. However, there are several resources to guide the addition of 2 PEN-Plus training centres in Zambia:

1. the forthcoming National Operational Plan led by the MoH that details the PEN-Plus interventions, training content, indicators, and scale up plans;

2. the successes and experience from the existing initial 2 PEN-Plus sites supported by CIDRZ;

3. the network of countries in the AFRO region, totaling 11 countries, also working on PEN-Plus. Much of that experience is summarized in the PEN-Plus Programmatic Standards and Resource Library available from the NCDI Poverty Network. It is not expected that this will involve a significant investment in infrastructure or capital equipment.

Two additional training centres would allow a substantial scale up in the number of HCWs trained in delivering PEN-Plus, thus improving access for the poorest to services. It would accelerate ambitions in terms of dissemination of capacities to rural and harder to reach areas. In addition, support for a secondment to the Zambian MoH NCD department would build capacity of the MoH to prioritise NCD care and PEN-Plus, helping to accelerate progress as per the Zambian National Health Strategic Plan 2017 ^[20].

Alignment with SG strategic commitments and ID principles

The proposed grant of up to £275,000 per annum for up to 3 years subject to review from the SG and Government of Zambia and the annual enactment of the Budget (Scotland) Bill for each of those financial years and will support:

• our ongoing commitment to SG’s Vision (2016 Strategy) for its international development investment, that “through embedding the UN Global Goals, Scotland will contribute to sustainable development and the fight against poverty, injustice and inequality internationally”;
• our commitment to equality in our ID Principles, that “We recognise the enduring and intersectional inequalities that exist and we ensure reducing inequalities is central to how we work. We oppose racism in all its forms and aspire to be anti-racist in our work.”;
• our commitment to inclusion and diversity in our ID Principles, that “We question whose expertise we value, who we listen to and who holds the levers of power. We support new and innovative ways to break down barriers, to harness a diverse range of new voices and new ideas to drive change”;
• our overarching commitment to equalising power in our programme through alignment with our ID Principles, to equalise power with the Global South, by ensuring that the programme design included participants from the Global South.