Understanding integrated service delivery: a scoping review of models for noncommunicable disease and mental health interventions in low-and-middle income countries

Alma J. Adler, Laura Drown, Chantelle Boudreaux, Matthew M. Coates, Andrew Marx, Oyetayo Akala, Temo Waqanivalu, Hongyi Xu and Gene Bukhman

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Noncommunicable diseases (NCDs) and mental health conditions represent a growing proportion of disease burden in low- and middle-income countries (LMICs). While past efforts have identified interventions to be delivered across health system levels to address this burden, the challenge remains of how to deliver heterogenous interventions in resource-constrained settings. One possible solution is the Integration of interventions within exist- ing care delivery models. This study reviews and summarizes published literature on models of integrated NCD and mental health care in LMICs.


Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda

Emmanuel K Rusingiza, Ziad El-Khatib, Bethany Hedt-Gauthier, Gedeon Ngoga, Symaque Dusabeyezu, Neo Tapela, Cadet Mutumbira, Francis Mutabazi,2 Emmanuel Harelimana, Joseph Mucumbitsi, Gene F Kwan, Gene Bukhman

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In sub-Saharan Africa, continued clinical follow-up, after cardiac surgery, is only available at urban referral centres. We implemented a decentralised, integrated care model to provide longitudinal care for patients with advanced rheumatic heart disease (RHD) at district hospitals in rural Rwanda before and after heart surgery.

Patients were followed for a median of 3 years (range 0.2–7.9) during which 7.4% of them died; all deaths were patients who had undergone bioprosthetic valve replacement. For patients with mechanical valves, anticoagulation was checked at 96% of visits. There were no known bleeding or thrombotic events requiring hospitalisation.

Outcomes of postoperative patients with RHD tracked in rural Rwanda health facilities were generally good. With appropriate training and supervision, it is feasible to safely decentralise follow-up of patients with RHD to nurse-led specialised NCD clinics after cardiac surgery.

Integration of Chronic Oncology Services in Noncommunicable Disease Clinic in Rural Rwanda

Robert Rutayisire, Francis Mutabazi, Alice Bayingana, Ann C. Miller, Neil Gupta, Gedeon Ngoga, Eric Ngabireyimana, Ryan Borg, Emmanuel Rusingiza, Charlotte Bavuma, Bosco Bigirimana, Fulgence Nkikabahiz, Marie Aimee Muhimpundu, Gene Bukhman, and Paul H. Park

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In 2006, the Rwandan Ministry of Health at Rwinkwavu District Hospital (RDH) and Partners In Health established an integrated NCD clinic focused on nurse-led care of severe NCDs, within a single delivery platform. Implementation modifications were made in 2011 to include cancer services. For this descriptive study, we abstracted medical record data for 15 months after first clinic visit for all patients who enrolled in the NCD clinic between 1 July 2012 and 30 June 2014.

Three hundred forty-seven patients enrolled during the study period: oncology – 71.8%, hyper- tension – 10.4%, heart failure – 11.0%, diabetes – 5.5%, and chronic respiratory disease (CRD) – 1.4%. Twelve-month retention rates were: oncology – 81.6%, CRD – 60.0%, hypertension – 75.0%, diabetes – 73.7%, and heart failure – 47.4%.

The integrated NCD clinic filled a gap in accessible care for severe NCDs, including cancer, at rural district hospitals. This novel approach has illustrated good retention rates.

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

Ruderman, T., Chibwe, E., Boudreaux, C., Ndarama, E., Wroe, E. B., Connolly, E. & Bukhman, G.

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.

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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.

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.

Crohn’s disease in low and lower-middle income countries: A scoping review

Ruma Rajbhandari, Samantha Blakemore, Neil Gupta, Alma J Adler, Christopher Allen Noble, Sara Mannan, Klejda Nikolli, Alison Yih, Sameer Joshi, Gene Bukhman

While Crohn’s disease has been studied extensively in high-income countries, its epidemiology and care in low and lower-middle income countries (LLMICs) is not well established due to a lack of disease registries and diagnostic capacity.

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The database search yielded 4486 publications, 216 of which were determined tobe relevant to the research questions. Of all 79 LLMICs, only 21 (26.6%) have publications describing individuals with Crohn’s. Overall, the highest number of studies came from India, followed by Tunisia, and Egypt. The mean number of Crohn’s patients reported per study is 57.84 and the median is 22, with a wide range from one to 980.

This scoping review has shown that, although there is a severe lack of population- based data about Crohn’s in LLMICs, there is a signal of Crohn’s in these settings around the world.

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

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

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Effective coverage of non-communicable disease (NCD) care in sub-Saharan Africa remains low, with the majority of services still largely restricted to central referral centres. Between 2015 and 2017, the Rwandan Ministry of Health implemented a strategy to decentralise outpatient care for severe chronic NCDs, including type 1 diabetes, heart failure and severe hypertension, to rural first-level hospitals.

By 2017, all NCD clinics were staffed by at least one NCD-trained nurse. With the exception of warfarin and beta-blockers, national essential medicines were available at more than 70% of facilities. Clinicians adhered to clinical protocols at approximately 70% agreement with evaluators.

The government of Rwanda was able to scale a nurse-led outpatient NCD programme to all first-level hospitals with good fidelity, feasibility and penetration as to expand access to care for severe NCDs.

Implementation of blood glucose self- monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda

Loise Ng’ang’a, Gedeon Ngoga, Symaque Dusabeyezu, Bethany L Hedt-Gauthier, Patient Ngamije, Michel Habiyaremye, Emmanuel Harerimana, Gilles Ndayisaba, Christian Rusangwa, Simon Pierre Niyonsenga, Charlotte M Bavuma, Gene Bukhman, Alma J Adler, Fredrick Kateera, Paul H. Park

 This study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group— participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group—participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG.

Cost of Providing Quality Cancer Care at the Butaro Cancer Center of Excellence in Rwanda

Claire Neal, Christian Rusangwa, Ryan Borg, Neo Tapela, Jean Claude Mugunga, Natalie Pritchett, Cyprien Shyirambere, Elisephan Ntakirutimana, Paul H. Park, Lawrence N. Shulman, Tharcisse Mpunga

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This study is one of the first to examine operating costs for implementing a cancer center in a low-income country. Having a strong commitment to cancer care, adapting clinical protocols to the local setting, shifting tasks, and creating collaborative partnerships make it possible for BCCOE to provide quality cancer care at a fraction of the cost seen in middle- and high-income countries, which has saved many lives and improved survival. Not all therapies, though, were available because of limited financial resources.

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

Gene F. Kwan, Lily D. Yan, Benito D. Isaac, Kayleigh Bhangdia, Waking Jean-Baptiste, Densa Belony, Anirudh Gururaj, Louine Martineau, Serge Vertilus, Dufens Pierre-Louis, Darius L. Fenelon, Lisa R. Hirschhorn, Emelia J. Benjamin, and Gene Bukhman

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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. 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.

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.

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

Neil Gupta, Matthew M Coates, Abebe Bekele, Roodney Dupuy, Darius Leopold Fénelon, Anna D Gage, Theodros Getachew, Biraj Man Karmacharya, Gene F Kwan, Aimée M Lulebo, Jones K Masiye, Mary Theodory Mayige, Maïmouna Ndour Mbaye, Malay Kanti Mridha, Paul H Park, Wubaye Walelgne Dagnaw, Emily B Wroe, Gene Bukhman

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Non-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.

We 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.

Our 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.