10-Year Heart Failure Outcomes From Nurse-Driven Clinics in Rural Sub-Saharan Africa

Eberly, Lauren A.; Rusingiza, Emmanuel; Park, Paul H.; Ngoga, Gedeon; Dusabeyezu, Symaque; Mutabazi, Francis; Gahamanyi, Cyprien; Ntaganda, Evariste; Kwan, Gene F.; Bukhman, Gene

doi:10.1016/j.jacc.2018.12.028

Cited by 19 publications

(16 citation statements)

References 4 publications

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“…Quality was reinforced through supportive supervision by local generalist physicians and visiting cardiologists and endocrinologists. We previously have demonstrated the feasibility and validity of nurse-performed diagnosis and management of such complex conditions as type 1 DM and HF 11–13 23. These results now support the affordability of this approach and will be useful considerations in the advocacy for implementation of such models in similar settings.…”

Section: Discussionsupporting

confidence: 54%

Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda

Eberly

Rusangwa²,

Ng’ang'a³

et al. 2019

BMJ Glob Health

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BackgroundIntegrated clinical strategies to address non-communicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention and treatment of common conditions at primary health centres. This study examines the cost of organising integrated nurse-driven, physician-supervised chronic care for more severe NCDs at an outpatient specialty clinic associated with a district hospital in rural Rwanda. Conditions addressed included type 1 and type 2 diabetes, chronic respiratory disease, heart failure and rheumatic heart disease.MethodsA retrospective costing analysis was conducted from the facility perspective using data from administrative sources and the electronic medical record systems of Butaro District Hospital in rural Rwanda. We determined initial start-up and annual operating financial cost of the Butaro district advanced NCD clinic for the fiscal year 2013–2014. Per-patient annual cost by disease category was determined.ResultsA total of US$47 976 in fixed start-up costs was necessary to establish a new advanced NCD clinic serving a population of approximately 300 000 people (US$0.16 per capita). The additional annual operating cost for this clinic was US$68 975 (US$0.23 per capita) to manage a 632-patient cohort and provide training, supervision and mentorship to primary health centres. Labour comprised 54% of total cost, followed by medications at 17%. Diabetes mellitus had the highest annual cost per patient (US$151), followed by heart failure (US$104), driven primarily by medication therapy and laboratory testing.ConclusionsThis is the first study to evaluate the costs of integrated, decentralised chronic care for some severe NCDs in rural sub-Saharan Africa. The findings show that these services may be affordable to governments even in the most constrained health systems.

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Section: Discussionsupporting

confidence: 54%

Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda

Eberly

Rusangwa²,

Ng’ang'a³

et al. 2019

BMJ Glob Health

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“…In Tibet and India, a mobile technology-supported non-physician health worker program improved hypertension control [38]. In Rwanda, a decentralized and nurse-led heart failure care program had good survival rates [39]. The emergence of mobile technologies and text message reminders may improve communication between patients and health providers [40].…”

Section: Discussionmentioning

confidence: 99%

High Poverty and Hardship Financing Among Patients with Noncommunicable Diseases in Rural Haiti

Kwan

Yan

Isaac³

et al. 2020

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Background: Poverty is a major barrier to healthcare access in low-income countries. The degree of equitable access for noncommunicable disease (NCD) patients is not known in rural Haiti. Objectives: We evaluated the poverty distribution among patients receiving care in an NCD clinic in rural Haiti compared with the community and assessed associations of poverty with sex and distance from the health facility. Methods: We performed a cross-sectional study of patients with NCDs attending a public-sector health center in rural Haiti 2013-2016, and compared poverty among patients with poverty among a weighted community sample from the Haiti 2012 Demographic and Health Survey. We adapted the multidimensional poverty index: people deprived ≥44% of indicators are among the poorest billion people worldwide. We assessed hardship financing: borrowing money or selling belongings to pay for healthcare. We examined the association between facility distance and poverty adjusted for age and sex using linear regression. Results: Of 379 adults, 72% were women and the mean age was 52.5 years. 17.7% had hypertension, 19.3% had diabetes, 3.1% had heart failure, and 33.8% had multiple conditions. Among patients with available data, 197/296 (66.6%) experienced hardship financing. The proportions of people who are among the poorest billion people for women and men were similar (23.3% vs. 20.3%, p > 0.05). Fewer of the clinic patients were among the poorest billion people compared with the community (22.4% vs. 63.1%, p < 0.001). Patients who were most poor were more likely to live closer to the clinic (p = 0.002). Conclusion: Among patients with NCD conditions in rural Haiti, poverty and hardship financing are highly prevalent. However, clinic patients were less poor compared with the community population. These data suggest barriers to care access particularly affect the poorest. Socioeconomic data must be collected at health facilities and during community-level surveillance studies to monitor equitable healthcare access. Highlights:• Poverty and hardship financing are highly prevalent among NCD patients in rural Haiti.• Patients attending clinic are less poor than expected from the community. • People travelling farther to clinic are less poor. • Socioeconomic data should be collected to monitor healthcare access equity.

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“…39 Several studies have reported promising outcomes for task-shifting and task sharing of essential NCD services to support decentralisation and increase availability of such services. [40][41][42] Integration of NCD services with existing HIV and MCH services has been suggested as a cost-effective and important step towards increasing the availability of services in a universal health coverage (UHC) package, particularly at the primary care level. 43 Coordination of governance and policy making for NCDI health sector interventions would also provide opportunities for integration of staff, training, guidelines, and supply chains required for adequate service delivery.…”

Section: Open Accessmentioning

confidence: 99%

Availability of equipment and medications for non-communicable diseases and injuries at public first-referral level hospitals: a cross-sectional analysis of service provision assessments in eight low-income countries

Gupta¹,

Coates²,

Bekele³

et al. 2020

BMJ Open

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Context and objectivesNon-communicable diseases and injuries (NCDIs) comprise a large share of mortality and morbidity in low-income countries (LICs), many of which occur earlier in life and with greater severity than in higher income settings. Our objective was to assess availability of essential equipment and medications required for a broad range of acute and chronic NCDI conditions.DesignSecondary analysis of existing cross-sectional survey data.SettingWe used data from Service Provision Assessment surveys in Bangladesh, the Democratic Republic of the Congo, Ethiopia, Haiti, Malawi, Nepal, Senegal and Tanzania, focusing on public first-referral level hospitals in each country.Outcome measuresWe defined sets of equipment and medications required for diagnosis and management of four acute and nine chronic NCDI conditions and determined availability of these items at the health facilities.ResultsOverall, 797 hospitals were included. Medication and equipment availability was highest for acute epilepsy (country estimates ranging from 40% to 95%) and stage 1–2 hypertension (28%–83%). Availability was low for type 1 diabetes (1%–70%), type 2 diabetes (3%–57%), asthma (0%–7%) and acute presentations of diabetes (0%–26%) and asthma (0%–4%). Few hospitals had equipment or medications for heart failure (0%–32%), rheumatic heart disease (0%–23%), hypertensive emergencies (0%–64%) or acute minor surgical conditions (0%–5%). Data for chronic pain were limited to only two countries. Availability of essential medications and equipment was lower than previous facility-reported service availability.ConclusionsOur findings demonstrate low availability of essential equipment and medications for diverse NCDIs at first-referral level hospitals in eight LICs. There is a need for decentralisation and integration of NCDI services in existing care platforms and improved assessment and monitoring to fully achieve universal health coverage.

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10-Year Heart Failure Outcomes From Nurse-Driven Clinics in Rural Sub-Saharan Africa

Cited by 19 publications

References 4 publications

Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda

Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda

High Poverty and Hardship Financing Among Patients with Noncommunicable Diseases in Rural Haiti

Availability of equipment and medications for non-communicable diseases and injuries at public first-referral level hospitals: a cross-sectional analysis of service provision assessments in eight low-income countries

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