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By Oluwasola Samuel, Freelance Writer, with editorial and medical review by The DLHA Team.
Solutions to the challemges of stroke care in Africa
Paul, a 51-year-old successful director of finance in an insurance company in Nigeria, lived a happy life with his wife and two lovely kids. He was a high-achieving and ambitious man, and he was always on the go. But one day, everything changed.
Paul was sitting in his office at work when he suddenly felt dizzy and lightheaded. He tried to stand up to get a glass of water, but his legs failed him. He fell on the floor, and his arm and leg went numb. He tried to scream, but no sound came out.
He felt his heart racing and pounding, and he was gasping for breath. He began to panic, and after what seemed like an eternity, Paul heard a noise. The office door opened, and his secretary, Sarah, walked in.
Paul, are you okay? She asked.
Paul tried to speak, but he couldn't. Immediately, she knew her boss was having stroke symptoms, so she alerted her colleagues, and they arranged to take him to the nearest hospital. On reaching the hospital, he was rejected because they didn't have the resources to handle his such case. They went to another hospital, and the same thing happened.
Luckily, someone pointed them in the direction of a specialised stroke centre close to the center of the city. On their way, they encountered several points of traffic hold ups, but they finally got to the stroke centre. Unfortunately, they had spent over 4 hours looking for a specialised stroke care centre around the city.
The neurologist examined Paul and noticed he had significant stroke problems associated with the delay in reaching the stroke care centre. Paul was admitted for three weeks, treated and eventually discharged with paralysis on one side of his body. He was advised to undergo rehabilitation to help him regain the use of his body and independence.
After many months, Paul remains to regain the full use of one side of his body. At his place of work, he was relieved of his duties, paid off and replaced by another executive.
There are some lessons to learn from this personal story. One of them is the importance of reaching a stroke care centre on time following a stroke. Since the opportunity for the reversal of stroke is critically time bound, delay could prove fatal and disability more permanent.
Stroke is a noncommunicable disease or brain disorder that poses a major health challenge in sub-Saharan Africa (SSA). It has ravaged the region for a long time. There are various stroke treatments, and there are challenges that limit the goal of ensuring that every stroke victim gets the best and recommended treatment according to global standards.
Some of these challenges include the following:
One of the biggest challenges to stroke treatment in Africa is the late arrival of stroke patients to the hospital. Arriving late to the hospital can have a significant impact on the outcome because stroke treatment and best outcome is time-sensitive. The sooner the patient receives treatment, the higher the chances of recovery and the lower the chances of having major physical or brain damage.
Arriving late at the hospital, is caused by different reasons like:
In addition, when private vehicles are used, traffic hold ups or slow go are also a factor that could delay the arrival of stroke victims at stroke care centres for treatment.
Policymakers should work to provide cheap and safe public transportation so people can afford to get to treatment centres more readily. Also, public health managers need to institute subsidised emergency ambulance transport services that patients and their families can call on in urban and rural centres to move them to a hospital or emergency centre. In addition, sensitisation amongst the public should be done more often to help educate the public on the signs and the next line of action when a stroke occurs to them or someone close to them. These proposals can help to ensure that people with stroke receive the best possible care promptly.
People in SSA hold their cultural values and beliefs dearly. Cultural beliefs play a significant role in stroke treatment in Africa. Some cultures believe strokes are caused by witchcraft or supernatural powers that no one can go against. Some also believe strokes are a punishment from God for the sins they have committed, thereby delaying treatment.
Lastly, some cultures believe stroke is incurable, so they seek out a traditional and spiritual healer, hoping to reduce the effects of the symptoms on victims.
Public health managers and health professionals should work together in raising awareness about stroke and its care among people generally, and also among traditional rulers and healers. This can help to discredit myths and misconceptions about stroke and also help bridge the gap between traditional or cultural beliefs and modern medicine.
3. Lack of specialised facilities for the performance of procedures
When stroke symptoms occur, victims are always advised to visit the nearest stroke care centre for swift and optimal treatment. In many parts of SSA, stroke care centres are few and when stroke victims eventually get to the nearest stroke care facility, many of these centres don't have appropriate and functioning equipment like MRI and CT machines for scanning the brain to ascertain what kind of stroke and to determine or guide treatment decisions.
Also, some stroke care centres lack facilities to perform specialised treatments like thrombolysis and others, which are time-sensitive. For these reasons, most stroke victims end up being transferred from one centre to the other before they eventually end up in a facility that is reasonably equipped for comprehensive stroke care. The delay in treatment of stroke victims that is caused by this low availability of well-equipped stroke centres generally results in damaging consequences.
Policymakers and health administrators should ensure that stroke care units are well-equipped for treatment and rehabilitation. This will ensure stroke patients are well attended to at their first point of call instead of transferring them from place to place.
In SSA, there are limited qualified and specialised trained personnel like neurosurgeons, neurologists, stroke care nurses, and other healthcare professionals who have the skills and knowledge required to treat stroke patients safely and effectively.
Some of the factors contributing to these challenges are:
Policymakers should look into investing heavily (a) in improving job satisfaction of healthcare personnel generally across the board to reduce the current level of brain drain and (b) in training certain categories of personnel (e.g. advanced nurse practitioners) in first line neurological care of stroke patients, as they are more likely to stay and work in rural district hospitals. Such workers should also be compensated with attractive remuneration to make them stay in the rural centres.
One of the reasons why stroke victims arrive late for treatment is due to the high cost of treatment and rehabilitation.2 Africa is a continent comprising mostly low- or middle-income countries. In many SSA countries, many people cannot afford the cost of treatment, which can lead to delays in treatment. Bear in mind that the cost of treating stroke patients is based on their type and severity. Stroke care is highly expensive, regardless of whether it is obtained from private or public stroke care hospitals.
Also, many people cannot afford the cost of rehabilitation because of their low income. Rehabilitation is essential for stroke victims during the post recovery period. Rehabilitation will help them recover their function and independence. When people cannot afford the cost of rehabilitation, this can lead to long-term disability.
Some of the factors contributing to this challenge are:
Policymakers need to put in place policies that will reduce the burden and help improve the standard of living of their citizens. Also, policymakers and insurance companies need to do a lot of sensitization to help educate people on the importance of health insurance and how it can protect them, their families and finances as well as improve their well-being.
A designated stroke unit is a unit in a hospital that specialises in providing comprehensive care for people with strokes. A stroke unit usually comprises trained and specialised healthcare professionals like neurologists, neurosurgeons, stroke care nurses, and other rehabilitation therapists. Only a few hospitals have these designated units available, making it difficult for stroke victims to locate any hospital that is nearest to them with a stroke unit available for treatment.
To tackle this issue, policymakers must ensure that more hospitals have specialised stroke care units in urban and rural areas. This will ensure that stroke victims can access stroke care easily without traveling long distances to get treatment.
Adequate data to inform policy intervention in stroke care is generally poor across most SSA countries. This imposes considerable limitations on political leaders and public health managers on their awareness of the need and what should be done to serve those needs. Research requires trained personnel, adequate infrastructure, funding, resources and a stable society. These are in short supply generally across most SSA countries and pose challenges to stroke care.
Policymakers must invest in and promote a more conducive environment for research to take place. Such would provide qualitative evidence-based data that can inform policy and decision making towards improvement in the delivery of services to stroke patients generally.
The challenges of stroke treatment in SSA are considerable, Stroke is one of the most deadly noncommunicable diseases that results in severe complications and significant death and disability worldwide and more so in Africa. Many of the factors responsible for this have been discussed at length here and some non-exclusive solutions have been proposed. With diligence, leadership, innovation and political will from Governments, Administrators, Health Systems, Healthcare and Community leaders in respective SSA countries, many of the challenges to stroke care in SSA could be effectively tackled and resolved. The ideas for solutions are available. What is needed is funding and action.
1. Brain drain in Africa’s health-care sector | D+C - Development + Cooperation [Internet]. 2023. Available from: https://www.dandc.eu/en/article/medical-professionals-are-emigrating-africa-because-catastrophic-conditions-health-care
2. Tawa N, Rhoda A, Brink Y, Urimubenshi G, Giljam-Enright M, Charumbira MY, et al. Stroke rehabilitation services in Africa – Challenges and opportunities: A scoping review of the literature. In: Louw Q, editor. Collaborative capacity development to complement stroke rehabilitation in Africa [Internet]. Cape Town (ZA): AOSIS; 2020. (Human Functioning, Technology and Health). Available from: http://www.ncbi.nlm.nih.gov/books/NBK574231/
3. Nicholas A, Deji O. Invisible illness: The consequences of limited health insurance in Africa. Health Sci Rep [Internet]. 2023 Jun 1 [cited 2023 p;6(6):e1313. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10234111/
Published: November 5, 2023
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