In reference to the 1991 Uganda Population and Housing Census , the population of older persons was 686,260 (4.1%) of the total population, which increased to 1,101,039 (4.6%) as per the Uganda Population and Housing Census results of 2002 and according Uganda National Household Survey report 2005/06 (4) it estimated the population of older persons at 1,200,000 of which 53% were female while 47% were male and the overall total at 6.5% of the total population And it projected to rise to 20% by 2020 and this is due to the increased technology, health and well being and nutrition which has increased the life expectancy(5).
In Uganda there is a continuing high burden of communicable diseases, with 2010 national estimates of HIV prevalence at 6.4% (6). Tuberculosis incidence at 330/100,000 per year, malaria, Acute Respiratory Infections, among the top 10 causes of illness, Dermot, M. & Sekajugo(7). Data from referral hospitals shows that Non communicable diseases (NCDs) particularly; cardiovascular diseases, diabetes, cancers, as well as chronic obstructive pulmonary diseases are also becoming increasingly as a major causes of morbidity and mortality. The Uganda Heart Institute records have demonstrated a 500% increase in outpatient attendance due to heart related conditions over the past 7 years (2002-2009) (8).
This is due to demographic transition characterized by an increasing aging population, urbanization, mechanization and sedentary living, changing lifestyles causing population's increased exposure to NCD risk factors. Older people's lives in Uganda are characterized by ill health and lack health due hypertension, cancer, cataracts and other visual problems, hearing impairments, arthritis, dementia, breathing problems, orthopedic problems, stroke and other age related diseases -as well as HIV/AIDS and malaria leading to multi-morbidity which is a common problem in the elderly and its occurrence rises with age.
Medicare data suggest that 32% of the population in the age group 65-69 suffer from three or more chronic conditions. In the age group 80-84 the prevalence of multi-morbidity increases to 52% and 76% of the patients in general practice have three or more chronic conditions hence higher mortality, increased disability, a decline of functional status and a lower quality of life. It also leads to a greater extent of health care utilization (costs, length of hospital stay, and number of physician visits), Schäfer I, etal. (9). Many older persons do not visit health centers due to long distances, poor mobility and negative attitudes towards older persons. There is limited availability of drugs and limited geriatric expertise. Traditional healers are often the alternative(5).
Formal and Informal Care for Elderly
Informal care
Traditionally the Ugandan social structure was organized around the family and community. The extended family network knitted together a network of blood relations, in-laws and close friends. This network acted as insurance against all disabilities of old age and other shortcomings. The young and energetic were insurance for their older folks and took care of their needs. Sadly, several factors have interfered with the treasured network leaving the elderly vulnerable. These factors include rural urban migration, debt crisis, unemployment, wars, poverty, disease especially AIDS, influence of foreign cultures, and lack of alternative social security system(10).
In addition grandparents contribute time, attention and care to their families either in their adult children homes or in families they head, as a result of unavoidable circumstances like HIV/AIDS and Wars have left them in isolation, depressed and can hardly provide advice and counsel about culture and family values that serve as legacy from generation to generation. In the Ugandan perspective, grandparents especially grandmothers are always looked at as good caregivers to children, their role became more evident in the era of HIV/AIDS(5).
Formal care
Uganda has a national policy for the elderly, there is a formal representation of old people at the local government, there is a national Department of Elderly and Disability under the Ministry of Gender, Labour and Social Development which supports the initiatives like empowerment of the elderly, strengthening the formal and informal community support institutions, enhancing access to social services like water and sanitation, food and nutrition, shelter, recreation, leisure and sports, education and training, Psycho-Social Support, Care and support of older persons with disabilities , research and information dissemination.
Associations of Older Persons have been established from village level to district level to mobilize older persons to participate in development activities, to promote interaction and intergenerational linkages to enable Government extend special services to them.
The Government of Uganda conducted a study to assess the health needs of older persons for purposes of designing evidenced based interventions.
Cash transfer scheme from the Ministry of Gender, Labour and Social Development targeting old people (5).
The initiatives above have had little impact on improving the daily lives of older persons in Uganda due to corruption, bureaucracy, lack of awareness about the available services and the distance to the service centers. The policy for the elderly does not also address the burden of non communicable diseases among the elderly hence little emphasis is put on health services provision.
Ageing Population and Functional ability taking into account physical and environmental factors.
In Uganda 85% of the older persons are in rural areas which are characterized with poorly developed and inadequate health facilities with limited geriatric expertise. The Older people's lives in Uganda are characterized by ill health due multiple diseases like hypertension, cancer, cataracts and other visual problems, hearing impairments, arthritis, dementia, breathing problems, orthopedic problems, stroke and other age related diseases -as well as HIV/AIDS and malaria which highly affects their functional ability(11). With this condition, they require constant medical checkups and treatment but unfortunately many older persons do not visit health centers due to long distances and because they are living in absolute chronic poverty they cannot afford private transport and this leaves them with no option but to use the public transport which does not favor them.
The seats of the buses and taxis are not adjustable to the comfort of the old person and there no special seats for the old personal. Since most old people are staying in the rural areas they have to find a way of getting to the main road as the taxis and buses do not go deep in the villages hence they have to use either a bicycle or a motor cycle of which some old people may not be in position to seat. The hustle of using the public means with all the associated difficulties forces old people to go traditional healers instead of health centers.
Ambulatory services at the village levels focusing on old peoples would solve the problem of transport on the other hand the government of Uganda should include an act regarding the preservation of seats for elder people in public transport in the national policy. Since the Ministry of Health has a group of Voluntary Health teams at the community levels focusing on health promotion, they could also be trained as care givers for the elderly so that they can provide primary health care and save the old people from the hustle of visiting health centers every now and then.
Question 2
The existing Non Communicable Diseases' program in Uganda from a life course perspective:
Burden
Over 60% of all deaths in the world are caused by NCDs. 80%, or 38 million, of these deaths are in people from low- and middle-income countries. Two-thirds of the 177 million people with type-2 diabetes are estimated to live in the developing world, and old people are at a higher risk of dying from Non Communicable Diseases. The largest age group currently affected by diabetes is between 40-59 years and by 2030 this "record" is expected to move to the 60-79 age groups (12).
The Uganda Cancer Institute has also reported an upward trend in cancer incidence over the past four years. Regional referral hospitals have reported an increasing number of diabetes (8).
The Non communicable disease program in Uganda was established during the 2006/07 Financial Year under the Ministry of Health to plan, coordinate and implement actions aimed at prevention and control of NCDs in Uganda. The mandate of Non Communicable Disease prevention and control program is to reduce the morbidity and mortality attributable to non-communicable diseases through appropriate health interventions targeting the entire population of Uganda.
The Ministry of Health is currently implementing national Diabetes/Non Communicable Disease program from 2008 -2016 in partnership with World Diabetic Foundation (WDF) in a life course perspective which is clearly reflected in the four major components of the program which are policy, guidelines and standards, capacity building for improved diagnosis, care, awareness and nomadic and internally displaced population groups. The National Program seeks to improve prevention, detection and control of diabetes and other related non-communicable diseases (NCDs) (8).
A Life Course Approach in prevention of Non Communicable Diseases in Uganda.
The national program acknowledges the fact Life Course and Health Perspective considers chronic disease in terms of the social and physical hazards, and the consequent biological, behavioural and psychosocial processes, that operate across all stages of the life span to cause or modify risk of disease. This perspective carries a substantial potential for identifying the most appropriate and effective policies for NCD prevention and health promotion. The program addresses the fact that the risk of non communicable diseases accumulates with age and is influenced by factors acting at all stages of the life span. The influencing factors at different stages of life include the following;
Fetal Life: The program has designed activities on promotion fetal growth, maternal nutritional status, and socioeconomic position at birth to address the four relevant factors in fetal life which are intrauterine growth retardation (IUGR), premature delivery of a normal growth for gestational age fetus, over-nutrition in utero and intergenerational factors that are considered to be associated with increased risk of coronary heart disease, stroke, diabetes and raised blood pressure.
Infancy and Childhood: At infancy the program is implementing activities in promotion of growth rate, breast feeding, healthy diets and nutrition, physical activities and infectious disease control geared towards prevention of retarded growth in infancy which can be a reflected in a failure to gain weight and a failure to gain height. Both retarded growth and excessive weight or height gain can be factors in later incidence of chronic disease. An association between low growth in early infancy (low weight at 1 year) and an increased risk of coronary heart disease (CHD) has been described, irrespective of size at birth. Blood pressure has been found to be highest in those with retarded fetal growth and greater weight gain in infancy. Conversely, a high calorie intake in childhood may be related to an increased risk of cancer in later life.
Adolescents: In this age group the program promotes healthy diet, physical activities and creates awareness about the dangers of obesity, tobacco and alcohol use through awareness programs in schools and community level. The program also aims to address the three critical aspects of adolescence that have an impact on chronic diseases; the development of risk factors during in this period, the tracking of risk factors throughout life in terms of prevention, the development of healthy or unhealthy habits that tend to stay throughout life. The presence and tracking of high blood pressure in children and adolescents occurs against a background of unhealthy lifestyles, including excessive intakes of total and saturated fats, cholesterol and salt, inadequate intakes of potassium, and reduced physical activity, often accompanied by high levels of television viewing. In adolescents, habitual alcohol and tobacco use contributes to raising blood pressure in adulthood.
Adult life: Among the adults the program is addressing behavioural and biological risk factors. This program acknowledges the fact that adult phase of life is the period during which most chronic diseases are expressed, as well as a critical time for the preventive reduction of risk factors, early diagnosis and increasing effective treatment. The most firmly established associations between cardiovascular disease or diabetes and factors in the lifespan are the ones between those diseases and the major known ''adult'' risk factors, such as tobacco use, obesity, physical inactivity, cholesterol, high blood pressure and alcohol consumption. The Program also contains activities for supervision and monitoring of implementation, strengthening the NCD Division in the Ministry of Health for advocacy action and complication surveillance for measuring outcome levels.
Existing gaps:
Inappropriate Surveillance tools. Not sufficiently sensitive to capture required data on NCDs and their risk factors.
Inappropriately designed Health Systems. Designed for management of communicable diseases , not Non Communicable Diseases
Insufficient quality national data on Non Communicable Diseases, particularly community based data
Annex 1
Table 5.11: Distribution of population aged 10 years and above with Non-Communicable Diseases by Respondent Characteristics (%)
Non-Communicable Diseases
Respondent
Characteristics
Diabetes
High blood
pressure
Heart
disease
None
Residence
Urban
1.0
4.1
2.3
92.7
Rural
0.7
3.9
4.3
91.1
Sex
Male
0.8
2.4
2.6
94.3
Female
0.8
5.3
5.3
88.7
Age category
10-14
0.0
0.1
0.5
99.4
15-19
0.1
0.5
1.4
98.0
20-24
0.1
0.8
3.8
95.3
25-29
0.5
2.6
4.8
92.1
30-34
0.7
4.2
5.3
89.8
35-39
1.1
5.2
6.1
87.6
40-44
1.6
8.9
7.5
81.9
45+
2.7
13.8
8.4
75.2
Uganda
0.8
3.9
4.0
91.4
The older people get the higher the incidence of NCDs. (Uganda National Household Survey Findings 2009/2010)
Annex 2
