Implementation outcomes of national decentralization of integrated outpatient services for severe non‐communicable diseases to district hospitals in Rwanda

Niyonsenga, Simon Pierre; Park, Paul H.; Ngoga, Gedeon; Ntaganda, Evariste; Kateera, Fredrick; Gupta, Neil; Rwagasore, Edson; Rwunganira, Samuel; Munyarugo, Antoine; Mutumbira, Cadet; Dusabayezu, Symaque; Eagan, Arielle Wilder; Boudreaux, Chantelle; Noble, Christopher A.; Muhimpundu, Marie Aimée; Ndayisaba, F Gilles; Nsanzimana, Sabin; Bukhman, Gene; Uwinkindi, François

doi:10.1111/tmi.13593

Cited by 18 publications

(28 citation statements)

References 14 publications

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“…Particularly in the two thirds of NAMPROPA sites without an on-site physician, PWH with a new diagnosis of HTN faced significant delays in treatment initiation, with many receiving referrals to other facilities. Policy changes to enable nurse-led HTN treatment in SSA have been considered [ 51 ], and several pilot studies have explored the feasibility of nurse-led delivery models with encouraging results [ 52 – 55 ]. Should nurse-led models find broad acceptance, steady attention to quality of care remains paramount [ 51 , 56 ].…”

Section: Discussionmentioning

confidence: 99%

Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach

et al. 2022

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Background Hypertension (HTN) is highly prevalent among people with HIV (PWH) in Namibia, but screening and treatment for HTN are not routinely offered as part of HIV care delivery. We report the implementation of a quality improvement collaborative (QIC) to accelerate integration of HTN and HIV care within public-sector health facilities in Namibia. Methods Twenty-four facilities participated in the QIC with the aim of increasing HTN screening and treatment among adult PWH (>15 years). HTN was defined according to national treatment guidelines (i.e., systolic blood pressure >140 and/or diastolic blood pressure >90 across three measurements and at least two occasions), and decisions regarding initiation of treatment were made by physicians only. Teams from participating hospitals used quality improvement methods, monthly measurement of performance indicators, and small-scale tests of change to implement contextually tailored interventions. Coaching of sites was performed on a monthly basis by clinical officers with expertise in QI and HIV, and sites were convened as part of learning sessions to facilitate diffusion of effective interventions. Results Between March 2017 and March 2018, hypertension screening occurred as part of 183,043 (86%) clinical encounters at participating facilities. Among 1,759 PWH newly diagnosed with HTN, 992 (56%) were initiated on first-line treatment. Rates of treatment initiation were higher in facilities with an on-site physician (61%) compared to those without one (51%). During the QIC, facility teams identified fourteen interventions to improve HTN screening and treatment. Among barriers to implementation, teams pointed to malfunctions of blood pressure machines and stock outs of antihypertensive medications as common challenges. Conclusions Implementation of a QIC provided a structured approach for integrating HTN and HIV services across 24 high-volume facilities in Namibia. As rates of HTN treatment remained low despite ongoing facility-level changes, policy-level interventions—such as task sharing and supply chain strengthening—should be pursued to further improve delivery of HTN care among PWH beyond initial screening.

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Section: Discussionmentioning

confidence: 99%

Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach

et al. 2022

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“…While this work is extremely important, a gap remains in management and treatment of more severe NCDs at first level hospitals. Task shifting care to mid-level providers for complex NCDs is a feasible [11] and cost effective [29] way to provide care at first level hospitals. However, there is little literature on providing care for complex NCDs in rural, remote, and poverty-stricken regions of LICs and LMICs.…”

Section: Discussionmentioning

confidence: 99%

“…Countries, such as Rwanda have shown how to decentralize integrated care for less common, but more severe, chronic NCDs such as type 1 diabetes and rheumatic heart disease [10,11]. In 2019, the WHO Regional Office for Africa hosted a regional consultation to discuss Package of Essential NCD Interventions -Plus (PEN-Plus), a strategy to accelerate WHO PEN implementation, and to promote integrated care for severe chronic NCDs at intermediate-care facilities (such as district hospitals) throughout the African region [12].…”

Section: Introductionmentioning

confidence: 99%

Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies

Ruderman

Chibwe

Boudreaux

et al. 2022

Annals of Global Health

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Background: Non-communicable diseases (NCDs) are a leading cause of worldwide morbidity and mortality, yet access to care in lower-income countries is limited. Rural communities, where poverty levels are high, feel the greatest burden. In Malawi, as elsewhere in the African region, it is particularly challenging for patients in rural districts to obtain care for locally endemic and severe NCDs such as type 1 diabetes, rheumatic heart disease, and sickle cell disease. The Package of Essential NCD Interventions -Plus (PEN-Plus) is a strategy to decentralize care for these severe conditions by enabling local clinicians at intermediate-care facilities to provide services otherwise available only through specialty clinics at central hospitals. Objectives:The primary objective of this study was to evaluate the impact of training mid-level providers to treat severe and chronic NCDs in newly established PEN-Plus clinics in Neno, Malawi. Methods:Our team developed a logic model to describe the anticipated impacts of the intervention on provider knowledge, patient recruitment, and care provision. We applied a retrospective review of routinely collected clinical and administrative data to assess changes along these hypothesized pathways.Findings: Didactic trainings improved provider test scores immediately following training (25-point improvement; p < 0.01), with demonstrated retention of knowledge after 6 months (21-point improvement, p < 0.01). Over 350 patients were enrolled in the first 18 months of program initiation. The PEN-Plus clinic led to significant improvement in the provision of medications and testing across a range of services. Conclusion:Mid-level providers can be successfully trained to treat severe NCDs with physician-guided education, mentorship, and supervision. The PEN-Plus clinic improved patient enrollment, the quality of clinical care and access to essential medications and laboratory supplies. These lessons learned can guide decentralization of NCD care to district hospitals in Malawi and expansion of PEN-Plus services in the African region.

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“…The findings of this study reflect a larger historical context in Rwanda, with a shortage of trained physicians trained, especially after the 1996 genocide. 19 Accordingly, recently there has been a national movement for nurse-led task sharing of HTN care. 19 20 …”

Section: Discussionmentioning

confidence: 99%

“… 19 Accordingly, recently there has been a national movement for nurse-led task sharing of HTN care. 19 20 …”

Section: Discussionmentioning

confidence: 99%

Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda: a cross-sectional study using the COACH questionnaire

et al. 2021

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ImportanceHypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary.ObjectiveTo study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool.DesignA cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training.SettingThree tertiary care hospitals in Rwanda.ParticipantsHealthcare professionals (n=223).Primary outcome(s) and measure(s)The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0–1 scale). Four questions surveyed training on hypertension.ResultsResponders (n=223, 75% women; 56% aged 20–35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had <3-year experience working with hypertension care delivery. The majority (99%) indicated a need for additional training in hypertension care.ConclusionsThere is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

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Implementation outcomes of national decentralization of integrated outpatient services for severe non‐communicable diseases to district hospitals in Rwanda

Cited by 18 publications

References 14 publications

Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach

Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach

Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies

Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda: a cross-sectional study using the COACH questionnaire

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