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Cardiovascular Journal of Africa • Volume 31, No 4 August 2020
S5
AFRICA
No recent clinical guidelines for CVD prevention are
available. Although clinical guidelines for the detection and
management of AF along with those for the management
of pharyngitis and acute rheumatic fever have not been
developed, those for RHD management are being addressed
(AOM, pers commun). As part of the REMEDY study,
a prospective, international, multi-centre, hospital-based
registry, and ongoing INVICTUS GTRial (INVestIgation
of rheumatiC AF Treatment Using vitamin K antagonists,
rivaroxaban or aspirin Studies), Mozambique has clinical
registers of people with a history of rheumatic fever and
RHD.
17,18
No system is available to measure the quality of
care provided to people who have suffered acute cardiac
events, or national guidelines for the treatment of tobacco
dependence. In collaboration with the World Diabetes
Foundation and International Diabetes Federation (IDF)
African Region, treatment guidelines for diabetes were
developed to suit sub-Saharan African trends and specifically
Mozambique conditions.
19,20
Essential medicines and interventions
In 2019, angiotensin converting enzyme (ACE) inhibitors,
aspirin, metformin and insulin were available in the public
sector but not statins, as indicated by the WHO’s GHO.
10
However, insulin was reported not always being available
and not everywhere.
b
-blockers, such as propranolol and
atenolol are widely available, whereas clopidogrel was not
available.
21,22
Provision for secondary prevention of rheumatic fever and
RHD is not part of Mozambique’s national prevention and
control programme in the public health sector, and CVD risk
stratification is not in place. However, according to the GHO,
TC measurement has been available at the primary healthcare
level since 2015, although discontinuity in the supply of
laboratory reagents is frequent, even in urban areas.
10
Secondary prevention and management
Assessing the measures in place for secondary prevention and
management of CVD, no information is available regarding
the percentage of patients with AF on treatment, and less
than 5% of those with a history of CVD are taking aspirin,
statin and at least one antihypertensive (AD pers commun).
In 2015, only 14.5% of the adults with hypertension were
aware and 7.3 and 3.2% of all hypertensive people had their
blood pressure controlled.
11
Part D: Cardiovascular disease governance
Mozambique developed a national strategic plan for the
prevention and control of NCD including CVD and their
risk factors, such as diabetes, within a small unit in the
Ministry of Health (MoH).
23
However, there is no dedicated
budget for its implementation. A national programme is
being implemented to address RHD prevention and control
as a priority.
24
Mozambique also has a national surveillance
system that includes CVD and their risk factors every
10 years.
7
According to the WHO framework convention on
tobacco control (FCTC), there is no national tobacco control
plan or a national multi-sectoral co-ordination mechanism
for tobacco control.
25
However, some control policies had
already been implemented by the time the country had
approved the FCTC in 2017.
26
Collaborative projects for NCD interventions, which
include CVD, have been implemented between theMoH, non-
health ministries and civil societies.
27
The government’s total
annual expenditure on cardiovascular healthcare is difficult
to assess (AD, pers commun). Although Mozambique was
included in the WHO-CHOICE (CHOosing Interventions
that are Cost Effective) project that assists countries with
health policy and planning, no modelling tool incorporating
cost-effectiveness benefits of CVD prevention and control
has been implemented.
28
Assessment of policy response
Legislation mandating health financing for CVD is not
available. Although legislation mandating essential CVD
medicines at affordable prices is lacking, Mozambique
subsidises drug prices in the public sector at 20–100% of
their value.
29
However, most of the time, these drugs are
not available or in insufficient quantities. According to
Russo and McPake,
30
possible reasons were depicted as to
why medicines are unaffordable in low-income countries
such as Mozambique. These researchers mentioned that
two para-statal enterprises, Medimoc and FARMAC
pharmacies, used to be the only importer and distributor,
respectively. The more sophisticated and expensive drugs,
such as CVD medicines, were only available through the
private sector and the high prices could be ascribed to world
manufacturing and trade policies. They concluded that
controlling prices is not the best way to legalise access to
medicines in low-income countries, and suggested demand
and supply for cheaper drugs would be a more appropriate
policy option.
30
Legislation is employed in areas where smoking is
banned, clear and visible warnings have been introduced
on at least half the principal display areas of tobacco packs,
and advertising, promotion and sponsorship of tobacco have
been banned.
25
There are no measures to protect tobacco
control policies from tobacco industry interference.
25
In 2013, the excise tax of the final consumer price of
tobacco products was 65% for imported and domestically
produced cigarettes.
31
However, in 2016, excise tax for
tobacco products was reported to be 75%,
32
with the most
popular 20-pack cigarettes rendering about 17% excise
tax,
26
while that for alcohol is variable (AD, pers commun).
No information is available on policies ensuring equitable
nationwide access to healthcare professionals and facilities,
neither have policies been implemented that ensure
screening of individuals at high risk of CVD.
There is no sustainable funding for CVD from taxation
or any taxes on unhealthy foods or sugar-sweetened
beverages.
33
No legislation banning the marketing of
unhealthy foods to minors exists nor that mandating clear
and visible warnings on foods that are high in calories,
sugar or saturated fats. Policy interventions that promote
a diet to reduce CVD risk and those that facilitate PA have
also not been developed.