Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic

Abstract

The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tripartite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD riskbased treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of "stockouts" and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a

Chronic Disease in the Community (CDCom) Program: Hypertension and non-communicable disease care by village health workers in rural Uganda

“…Chronic Care Clinic (CCC): In 2006, the collaboration established the CCC at KDH. The CCC is the facility-based “parent” of CDCom and the first and only publicly-financed clinic in the district delivering continuous care to patients with hypertension, diabetes, heart disease, asthma, epilepsy and other NCDs [ 28 ]. Patients are referred to the CCC from the KDH wards after hospital discharge or from private and lower-level public clinics, which do not consistently treat NCDs.…”

“…While these costs seem relatively low, scaling this kind of (intensive) program nationally for 42 million people would require a substantial increase in consistent government or third-party investment. Moreover, a major caveat in the cost of the CDCom program is our use of an SBP cut-off of 170 for PLOS ONE uncomplicated hypertension, intentionally set to provide treatment only for those that reap the most benefit [28]. Treating lower risk patients would substantially increase overall costs.…”

Integrated multi-month dispensing of antihypertensive and antiretroviral therapy to sustain hypertension and HIV control

“…To prevent frequent stock out of medicines for NCDs given the weak supply chains, health systems opt for monthly patient visits and dispensing for hypertension and other NCDs. Monthly drug dispensing comes at a cost of increased transport needs to patients, poor adherence to medications, high level of loss to follow-up, and poor hypertension control [ 31 ].…”

Hypertension screening, prevalence, treatment, and control at a large private hospital in Kampala, Uganda: A retrospective analysis

“…Although medication nonadherence for chronic disease is under extensive study in the United States, data are more sparse in Uganda [7,9,34,35]. Previous work on hypertension control barriers in Uganda details frequent and unpredictable medication stockouts, and limited evidence suggests that inconsistent access to medications may drive loss to follow-up [12,36]. Nonetheless, it remains unclear whether inconsistent medication access impairs medication adherence relative to an uninterrupted medication supply, as most prior work on medication adherence in Uganda has occurred only in the setting of inconsistent medication access.…”