The government of Samoa is tackling non-communicable diseases (NCDs) through a primary health care approach, bringing interventions such as awareness campaigns and health screenings to the community.
NCDs in Samoa are reaching epidemic proportions. About half the population aged 18-64 is at high risk of developing diabetes, cancer, chronic respiratory disease or cardiovascular disease. Action is needed at individual and community levels.
A drastic reduction in the population’s risk of developing major NCDs through revitalizing primary health care services in the community.
The Ministry of Health and the National Health Service worked with WHO to map the way forward for a primary health care model, which was adapted to the Samoan context. National guidelines were developed and a pilot project began.
PEN Fa’a Samoa has been important not only for addressing Samoa’s NCD crisis, but also because it has stimulated the search for a model of health care which can better address needs in preventive and promotive services. From that perspective, PEN Fa’a Samoa could be considered as an agent of change leading to reforms of Samoa’s health care system away from a hospitalcentric model to one based on primary health care.
Facing up to NCDs
The problem of NCDs marks a shift in the public health landscape of Samoa. Historically the largest public health concerns were infectious and parasitic diseases. Today, however, half the population has at least three of the five risk factors that can contribute to developing NCDs: smoking, elevated blood pressure, high body mass index, poor diet and low levels of physical activity.
Many people at risk for or living with an NCD remain undiagnosed because rates of detection and referrals to care remain low.
Over the last 30 years, the government of Samoa focused on modernizing clinical services. This led to a centralization of services and a hospital-based model of care. Dealing with the rapid rise in NCDs, however, requires a different approach - one which combines population-level screening, community engagement and long-term chronic disease management.
The government recognizes that the current model of care is not well equipped to respond to this public health crisis. It cannot meet the demands placed on the health system from increasing numbers of people requiring long-term care and support for chronic disease management. Addressing the NCD epidemic requires action at individual and community levels to strengthen promotive, preventive and curative services.
As a first step, the government has decided to integrate the two existing health structures: the Ministry of Health (MoH), responsible for policies, surveillance and monitoring, and the National Health Service (NHS) which oversees service delivery. These reforms have been passed into law, but given a shortage of available resources, their reintegration will be a gradual process.
PEN Fa’a Samoa
The Samoan government enlisted the assistance of the WHO Country Office for Samoa in mapping the way forward for the implementation of a primary health care model. Putting a focus on NCDs was seen as a way to catalyze health system transformation, revitalize primary health care services in the community, and support existing human resources.
PEN (package of essential noncommunicable disease interventions) is a prioritized set of cost-effective strategies for the prevention, early detection and management of key NCDs. These interventions are designed to be easily delivered in resource-constrained settings.
Through a series of meetings and workshops, the NHS, the Ministry of Health and WHO adapted the interventions to the Samoan context, and PEN Fa’a Samoa was born.
In traditional Samoan culture, each village or community has its own governance structure and hierarchy. This includes the Komiti Tumana, or women’s committees, and by working through them to deliver prevention, detection, and referral services, the PEN Fa’a Samoa initiative seeks to incorporate the PEN interventions into Samoan culture and traditions.
Piloting community approaches
The first phase of work was to develop specific national guidelines for the initiative, which would include individual, peer, family and community mobilization components. WHO worked with the health authorities to develop the criteria and the tools that women volunteers of the Komiti Tumana and health care workers would use for assessment, monitoring and referral.
Then the MoH launched a pilot programme involving seven villages. Members of the Komiti Tumana were approached to assist in carrying out village-wide screening campaigns.
These women’s committees have existed since the 1920s and are therefore especially well positioned to help raise awareness and facilitate the testing part of the campaign. Working with and through the Komiti Tumana was the best way to ensure that the NCD initiative would be well received by villagers.
The women’s committee volunteers, who showed a great deal of support for the initiative, were paired with health care workers to create crossdisciplinary outreach teams.
WHO provided training to the volunteers and paired each volunteer with a health care worker. Outreach teams invited the entire adult population of each village to participate in the screenings. The women’s committee members collected demographic information and basic health data while the health care workers measured blood pressure, blood glucose and cholesterol levels.
At the end of the campaign, villagewide public meetings were held and the overall, anonymized assessment of results was presented to the whole village. The teams also followed up with individuals deemed to be at high risk.
Going forward
Since the initial pilot phase, the PEN Fa’a Samoa has expanded to include 15 villages. There are plans to scale up the programme throughout the country. However, a number of challenges exist, not least of which is the issue of funding. The pilot was carried out with funding received from WHO. While the government is funding the overall programme, it is seeking supplemental funding from a donor or development partner.
Anecdotal evidence suggests that participating in this initiative has been a positive experience for the women of the committees and that villagers responded well to the women’s role as community facilitators.
To date, the women’s participation has been on a voluntary basis, but it is widely acknowledged that this approach is not sustainable, and there is a high level of turnover among the volunteers. The MoH will develop more detailed terms of reference for the role of facilitator and will consider the option of adding other components to the role of the facilitator, such as nutrition and infant monitoring.
By working with the Komiti Tumana, the government has been able to integrate these interventions into traditional Samoan culture. This can be seen in the success of the screening campaigns - 92% of the population across the seven pilot villages were screened, and 45% of those identified as being “high risk” were referred to a clinic for further care.
Nonetheless, the fact remains that Samoa has one of the highest rates of excess weight in the world, with more than half of the population considered overweight or obese. Testing and treating alone will not be enough. Much more needs to be done to address some of the root causes of the epidemic such as poor nutrition, lack of knowledge, and sedentary lifestyles.
The increasing numbers of people – and communities – affected by non-communicable diseases, with the concomitant economic and social repercussions, will require strong action and considerable resources, both human and financial. The success of the PEN Fa’a Samoa initiative makes it clear any solutions to these issues must come from the Samoan people themselves and be rooted within Samoa’s strong cultural traditions.
92% of the population across the seven pilot villages were screened, and 45% of those identified as being “high risk” were referred to a clinic for further care.