Perspectives of Healthcare Workers, National and Regional Policy Stakeholders on the Management of Chronic Lung Disease in Five Sub-Saharan African Countries: Tale of a Vicious Cycle of Neglect

Background:  Chronic lung diseases are among the top four non communicable diseases (NCDs), associated with 80% of premature mortality worldwide, debilitating health, and poor quality of life for survivors. Common risk factors for lung diseases include exposure to biomass fuels, environmental pollution, tobacco smoke, hereditary factors, and lower respiratory tract infections. Low-and-middle-income countries bear the biggest burden of chronic lung diseases, due to increasing exposures to risk factors, and weak health systems.To manage this rising threat, countries need to orient their systems towards chronic disease management, strengthen their primary healthcare systems even as they pursue universal health coverage reforms. This paper draws on the views and experiences of health systems actors to explore the current challenges to improving high quality, accessible care for chronic lung diseases. Methods: We explored the perspectives of policy stakeholders on management of chronic lung diseases in five Sub-Saharan African countries, Kenya, Malawi, Sudan, Tanzania, and Uganda. Data were collected between May 2018 and March 2019 through key informant interviews and in-depth interviews with government officials, representatives of non-governmental organizations supporting various health system functions, and healthcare workers of 36 healthcare facilities. Data were analysed using the framework approach. Findings: We identified intersecting vicious cycles of neglect of chronic lung health at both the strategic policy level and the healthcare facility level. At strategic policy level, low diagnostic capacity, weak recording and reporting systems limit the availability of reliable data on the burden of disease, which negatively affects inclusion in policy, and in turn budgetary allocations for diagnostic equipment, training, and medicines. At the service level, lack of budgetary allocations for equipment and training of staff, constrains diagnostic capacity, which, along with limited availability of appropriate medicines reduces service delivery quality and collection of appropriate data within healthcare facilities. These vicious cycles leave health systems ill equipped to respond to the rising burden of chronic lung disease, an issue that has been brought into sharp focus as countries plan for dealing with post COVID lung disease.   Interpretation: 1. There is increasing recognition among policymakers that NCDs, including CLD are rising in LMICs. 2. CLDs are under-diagnosed, under-reported and underfunded leading to a vicious cycle of invisibility and neglect at all levels of the health system. 3. Appropriate diagnosis and CLD management require strengthening of the health systems, particularly at the primary healthcare level. Funding Statement: This research was funded by the National Institute for Health Research (NIHR (IMPALA, grant reference 16/136/35) using UK aid from the UK Government to support global health research. Declaration of Interests: None declared. Ethics Approval Statement: The Liverpool School of Tropical Medicine Ethics Committee approved these studies separately (Kenya: protocol 18-054; Uganda: protocol 18-037; Malawi: protocol M1803; Tanzania and Sudan; protocol 18-043). Additionally, each approved was by in-country committees.