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ObjectivesNon-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3).DesignThis is a retrospective cohort study.SettingThe study includes an HIV–NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.ParticipantsAll new patients, including 6233 HIV–NCD diagnoses, enrolled between January 2015 and December 2017 were included. This included 3334 patients with HIV (59.7% women) and 2990 patients with NCD (67.3% women), 10% overall under age 15 years.InterventionsPatients were seen at their nearest health centre, with a hospital team visiting routinely to reinforce staffing. Data were collected on paper forms and entered into an electronic medical record.Primary and secondary outcome measuresRoutine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis.ResultsNCD diagnoses were 1693 hypertension, 668 asthma, 486 epilepsy, 149 diabetes and 109 severe mental illness. By December 2018, 8.3% of patients with NCD over 15 years were also on HIV treatment. One-year retention was 85% for HIV and 72% for NCDs, with default in 8.4% and 25.5% and deaths in 4.0% and 1.4%, respectively. Clinical outcomes showed statistically significant improvement for hypertension, diabetes, asthma and epilepsy. Of the 1807 (80%) of patients with HIV with viral load results, 85% had undetectable viral load.ConclusionsThe IC3 model, built on an HIV platform, facilitated rapid decentralisation and access to NCD services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.

BackgroundUser fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare. We examined the effects of the introduction and removal of user fees on outpatient attendances and new diagnoses of HIV, malaria, and tuberculosis in Neno District, Malawi where user fees were re-instated at three of 13 health centres in 2013 and subsequently removed at one of these in 2015.MethodsWe conducted two analyses. Firstly, an unadjusted comparison of outpatient visits and new diagnoses over three periods between July 2012 and October 2015: during the period with no user fees, at the re-introduction of user fees at four centres, and after the removal of user fees at one centre. Secondly, we estimated a linear model of the effect of user fees on the outcome of interest that controlled for unobserved health centre effects, monthly effects, and a linear time trend.ResultsThe introduction of user fees was associated with a change in total attendances of −68 % [95 % CI: −89 %, −12 %], similar reductions were observed for new malaria and HIV diagnoses. The removal of user fees was associated with an increase in total attendances of 352 % [213 %, 554 %] with similar increases for malaria diagnoses. The results were not sensitive to control group or model specification.ConclusionsUser fees for outpatient healthcare services present a barrier to patients accessing healthcare and reduce detection of serious infectious diseases.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1856-x) contains supplementary material, which is available to authorized users.

IntroductionCountries with strong primary healthcare (PHC) report better health outcomes, fewer hospital admissions and lower expenditure. People-centred care that delivers essential elements of primary care (PC) leads to improved health outcomes and reduced costs and disparities. Such outcomes underscore the need for validated instruments that measure the extent to which essential, evidence-based features of PC are available and applied to users; and to ensure quality care and provider accountability.MethodsA systematic scoping review method was used to identify peer-reviewed African studies and grey literature on PC performance measurement. The service delivery dimension in the Primary Healthcare Performance Initiative conceptual framework was used to identify key measurable components of PC.ResultsThe review identified 19 African studies and reports that address measuring elements of PC performance. 13 studies included eight nationally validated performance measuring instruments. Of the eight, the South African and Malawian versions of Primary Care Assessment Tool measured service delivery comprehensively and involved PC user, provider and manager stakeholders.Conclusion40 years after Alma Ata and despite strong evidence for people-centred care, significant gaps remain regarding use of validated instruments to measure PC performance in Africa; few validated instruments have been used. Agreement on indicators, fit-for-purpose validated instruments and harmonising existing instruments is needed. Rigorous performance-based research is necessary to inform policy, resource allocation, practice and health worker training; and to ensure access to high quality care in a universal health coverage (UHC) system—research with potential to promote socially responsive, accountable PHC in the true spirit of the Alma Ata and Astana Declarations.