Taking small strategic steps to move a mountain

While conducting potentially game-changing research on the prevention and management of non-communicable diseases (NCDs) at primary healthcare level in Limpopo, public health medicine specialist Dr Tumiso Malatji performs several daily high-wire acts.

One is balancing the care of her two sons with her career. Another is convincing overworked clinicians and nurses at district clinics to work closely together by appropriately matching tasks to competencies. Perhaps one of the most challenging yet rewarding acts is providing the right resources and NCD training to clinic staff. By helping healthcare staff in clinics develop the right skill set, providing vital resources and changing the environment in which they work, Dr Malatji believes change is possible. Her long-term vision is to relieve the overburdened hospital departments by strengthening primary healthcare.

Personal development

Dr Malatji grew up in Mankweng township 30 km from where she now works and lives. Her father is the vice rector at the nearby University of Limpopo and her mother is a high school teacher. The youngest of four siblings, she dared to dream about studying medicine at the University of Cape Town, and this was made possible through the Limpopo Department of Health’s bursary for medical students. “I always wanted to help people and still love to do so, but I didn’t know it could sometimes be so complicated,” she chuckles.

She counts herself fortunate to be doing public health medicine, having first been introduced to research while completing her specialisation in family medicine.

Finding solutions for Africa

Dr Malatji is driven by the University of Limpopo’s vision of finding solutions for Africa. Her aim is to develop and pilot context-specific interventions to strengthen the management of hypertension and diabetes. This will create a network of referring facilities where health professionals will be able to manage these two top diseases more effectively.

The gravitas of her task is illustrated by the recent South African National Health and Nutrition Examination Survey, which estimates that in Limpopo 32% of the population (1.8 million people) are affected by hypertension and 5% (300 000 people) have diabetes.

Using a 2016 grant from the Medical Research Council, Dr Malatji premised her baseline work on the findings from a prevalence study conducted in the Dikgale area. The study reported a startling 40% prevalence of hypertension and an over 10% prevalence of type 2 diabetes. However, little or no research exists on how clinics are responding to this disease profile.

Stark difference between the disease and treatment profile

Dr Malatji’s study found that at the four clinics in the district, patients are predominantly women older than 50, of whom 67% are hypertensive, with 25% of this group suffering from both hypertension and diabetes. Her audit of 427 treatment files at the clinics revealed only 11.2% had an overall audit score above 50%. More than 90% of the files she reviewed had no annual eye examination, no annual urine test for kidney function or a cardiac risk assessment. For patients with diabetes, the standard HbA1c test was recorded in 37% of the patient records, whereas annual foot exams were recorded in only 2% of the files. Only 23% of the records had an annual weight and waist circumference noted in the files.

Dr Malatji strongly emphasises that she worked from recorded notes and that the doctors and nurses surveyed did not have the basic equipment needed to carry out these tests.

She says the skewed HIV and TB treatment competence versus NCD treatment competence, while once highly appropriate, needs adjustment in the new era of antiretroviral therapy.

“The longer you live with HIV, the more you’re at risk of hypertension and diabetes, so having sub-optimal management of these conditions at primary healthcare level is a problem,” she explains. She backs this up by citing Statistics South Africa’s latest “Mortality and causes of death in South Africa” report, which reveals that deaths from NCDs as a group have exceeded deaths from HIV or TB since 2010.

Patient overload

“So, I’ve quantified the problem and now through this grant, I can begin addressing it with the NCD training and capacity development project,” she says.

Another reason why doctors and nurses can’t manage patients properly is because the patient load is so large. “Mankweng Hospital gets overloaded with stroke and ischaemic heart disease patients, because we are so ineffective at preventing complications at primary healthcare level. Once complications develop with ischaemic heart disease, we have to refer patients to Gauteng. Access to dialysis for chronic kidney diseases is severely constrained with one dialysis centre in Polokwane for 200 patients,” she says.

“Therefore, it’s absolutely critical that we prevent these complications. If you’re not treating these things at primary healthcare level, it’s virtually impossible and very expensive to treat at the Mankweng Hospital level, and people die unnecessarily,” she stresses.

Dr Malatji says reducing poverty and building good education systems are fundamental to mitigating the situation. “If we empower people and make sure they have access to healthy, affordable food and encourage them to exercise more, it would drastically reduce pressure on the health system. Yet, you’d need to be very smart to design interventions that are affordable, culturally sensitive and accessible for rural communities,” she concludes.