Applying the Care Delivery Value Chain: HIV/AIDS Care in Resource Poor Settings

Joseph Rhatigan, Sachin Jain, Joia S. Mukherjee, Michael E. Porter

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The care delivery value chain (CDVC) is a framework that allows a systemic analysis of value creation across the myriad of activities that occur during the care of a patient for a specific medical condition. The CDVC looks at care as an overall system, not as a series of discrete interventions. It describes the discrete activities that are required to deliver care and illustrates their sequence and organization. As clinical care requires many interdependent activities, value is measured as a product of the entire care cycle. The CDVC is a tool that allows one to outline and analyze the process of care delivery for a medical condition in order to use this information to configure this process to maximize value for patients. Individual activities within the care delivery cycle contribute value but do so in relation to other activities in the cycle. Thus the value of any discrete activity can only be understood by considering its relation to other activities within the care delivery value chain. The CDVC also highlights activities such as patient access, external factors, patient information, and patient engagement that are crucial in resource poor settings.

What women want: A mixed-methods study of women’s health priorities, preferences, and experiences in care in three Rwandan rural districts

A.J. Adler, T. Randall, L.N. Schwartz, L. Drown, S. Matthews, L.E. Pace, C. Mugabo, F. Kateera, G. Bukhman, E. Baganizi, L.M. Ng’ang’a

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Objective: To explore Rwandan women’s experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda.

Results: Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transpor- tation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care.

Conclusion: The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.

Realigning noncommunicable disease monitoring with health systems priorities in the Africa region

Chantelle Boudreaux, Devashri Salvi, Alma J. Adler, Emily B. Wroe, Matthew M. Coates, Maia Olsen, Yogesh Jain, Ana O. Mocumbi and Gene Bukhman

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The African region of the World Health Organization (WHO) recently adopted a strategy aimed at more comprehensive care for noncommunicable diseases (NCDs) in the region. The WHO’s World Health Assembly has also newly approved several ambitious disease-specific targets that raise the expectations of chronic care and plans to revise and update the NCD-Global Action Plan. These actions provide a critically needed opportunity for reflection and course correction in the global health response to NCDs. In this paper, we highlight the status of the indicators that are currently used to monitor progress towards global goals for chronic care. We argue that weak health systems and lack of access to basic NCD medicines and technologies have prevented many countries from achieving the level of progress required by the NCD epidemic, and current targets do little to address this reality. We identify gaps in existing metrics and explore opportunities to realign the targets with the pressing priorities facing today’s health systems.

Non-communicable disease burden among inpatients at a rural district hospital in Malawi

Peter Olds, Chiyembekezo Kachimanga, George Talama, Bright Mailosi, Enoch Ndarama, Jodie Totten, Nicholas Musinguzi, Dickson Hangiwa, Gene Bukhman and Emily B. Wroe

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The goal of this study was to understand the burden of NCDs among inpatients in a rural district hospital in Malawi. We broadened our definition of NCDs beyond the tradi- tional 4 × 4 set of NCDs, and included neurological disease, psychiatric illness, sickle cell disease, and trauma. We conducted a retrospective chart review of all inpatients who were admitted to the Neno District Hos- pital between January 2017 and October 2018. We broke patients down by age, date of admission, type, and number of NCD diagnoses, and HIV status, and constructed multivariate regression models for length of stay and in-hospital mortality.

We found two distinct populations of NCD patients. The first were patients 40 years and older with primary diagnoses of hypertension, heart failure, cancer, and stroke. The second were patients under 40 years old with primary diagnoses of mental health conditions, burns, epilepsy, and asthma. We also found significant trauma burden, accounting for 40% of all NCD visits.

There is a significant burden of NCDs in a rural hospital in Malawi, including those outside of the tradi- tional 4 × 4 set. We also found high rates of NCDs in the younger population (under 40 years of age). Hospitals must be equipped with adequate resources and training to meet this burden of disease.

Implementation of self-monitoring of blood glucose for patients with insulin-dependent diabetes at a rural non-communicable disease clinic in Neno, Malawi

T Ruderman, G Ferrari, F Valeta, M Boti, K Kumwenda, P H Park, G Ngoga, E Ndarama, E Connolly, G Bukhman, A Adler

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Self-monitoring of blood glucose (SMBG) is a widely accepted standard of practice for management of insulin-dependent diabetes, yet is largely unavailable in rural sub-Saharan Africa (SSA). This prospective cohort study is the first known report of implementation of SMBG in a rural, low-income country setting.

Forty-eight patients with type 1 and insulin-dependent type 2 diabetes were trained to use glucometers and logbooks. Participants monitored preprandial glucose daily at rotating times and overnight glucose once a week. Healthcare providers were trained to evaluate glucose trends, and adjusted insulin regimens based on results. Adherence was measured as the frequency with which patients checked and documented blood glucose at prescribed times, while clinical changes were measured by change in glycated haemoglobin (HbA1c) over a 6-month period.

SMBG is feasible for patients with insulin-dependent diabetes in a rural SSA population, and may be associated with improved HbA1c levels. Despite common misconceptions, all patients, regardless of education level, can benefit from SMBG. Further research on long-term retention of SMBG activities and the benefits of increasing frequency of monitoring is warranted.

Why there is new hope for the care of chronic diseases in Africa

Matshidiso Moeti, Ana Mocumbi, Gene Bukhman

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Over the past decade, with support from global non-governmental organisations, the ministries of health in Haiti, Liberia, Malawi, and Rwanda have refined an integrated healthcare delivery model called PEN-Plus that aims to alleviate the burden of non-communicable diseases on low income, rural communities by improving the accessibility and quality of care services.

In August 2022, the 47 countries that comprise WHO’s African region unanimously adopted PEN-Plus as the strategy to expand care for severe non-communicable diseases because it offers an efficient method for integrating services while ensuring ownership lies with each country’s health leaders. WHO is now mobilising ministries of health to support the implementation of PEN-Plus in 20 countries over the next three years. WHO is now mobilising ministries of health to support the implementation of PEN-Plus in 20 countries over the next three years. But to save lives, the strategy requires continued support and commitment.

The PEN-Plus Partnership: addressing severe chronic non-communicable diseases among the poorest billion

Gene Bukhman, Ana Mocumbi, Emily Wroe, Neil Gupta, Luwei Pearson, Raoul Bermejo, Jean Marie Dangou, Matshidiso Moeti

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PEN-Plus was designed to strengthen outpatient care for severe chronic NCDs at intermediate-level facilities such as district hospitals.PEN-Plus takes an equity-driven approach by first addressing severe conditions among the rural and urban poor. At the same time, PEN-Plus builds capacity to train, mentor, and supervise health workers at lower-level facilities, strengthening WHO PEN and chronic care decentralisation and integration for common NCDs.

In August, 2022, the 47 countries of WHO’s African Region approved a resolution and strategy to achieve high-levels of PEN-Plus coverage by 2030. 3 weeks later, a global PEN-Plus Partnership was launched as an initiative of the NCDI Poverty Network. This global partnership includes leading organisations focused on childhood heart disease, diabetes, and sickle cell disease working together with WHO and UNICEF to dramatically increase the number of the poorest children and young adults on high-quality treatment for these three conditions and other severe chronic NCDs by the end of the decade.

Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries

Alma J Adler, Emily B Wroe, Andrea Atzori, Neusa Bay, Wondu Bekele, Victoria M Bhambhani, Remy Bitwayiki Nkwiro, Chantelle Boudreaux, Dawson Calixte, Jonathan Chiwanda Banda, Matthew M Coates, Wubaye Walelgne Dagnaw, Katia Domingues, Laura Drown, Symaque Dusabeyezu, Darius Fenelon, Neil Gupta, Isaac Ssinabulya, Yogesh Jain, Yogeshwar Kalkonde, Innocent Kamali, Catherine Karekezi, Biraj Man Karmacharya, Bhagawan Koirala, Julie Makani, Fabio Manenti, Alexio Mangwiro, Beatriz Manuel, Jones K Masiye, Fastone Mathew Goma, Mary Theodory Mayige, Amy McLaughlin, Emmanuel Mensah, Nicole Mocumbi Salipa, Reuben Mutagaywa, Alvern Mutengerere, Gedeon Ngoga, Marta Patiño, Giovanni Putoto, Todd Ruderman, Devashri Salvi, Santigie Sesay, Fameti Taero, Emílio Tostão, Sterman Toussaint, Gene Bukhman, Ana Olga Mocumbi, for the PEN-Plus Partnership study group.

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The Package of Essential Noncommunicable Disease Interventions—Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. Inthe PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up.

Models of care for sickle cell disease in low-income and lower-middle-income countries: a scoping review

Laura Drown, Miriam Osei, Ada Thapa, Chantelle Boudreaux, Natasha Archer, Gene Bukhman, Alma J Adler

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As part of the Centre for Integration Science’s ongoing efforts to define, systematise, and implement integrated care delivery models for non-communicable diseases (NCDs), this Review explores models of care for sickle cell disease in LICs and LMICs. We identified 99 models from 136 studies, primarily done in tertiary, urban facilities in LMICs. Except for two models of integrated care for concurrent treatment of other conditions, sickle cell disease care was mostly provided in specialised clinics, which are low in number and accessibility. The scarcity of published evidence of models of care for sickle cell disease and integrated care in rural settings of LICs and LMICs shows a need to implement more integrated models to improve access, particularly in rural areas. PEN-Plus, a model of decentralised, integrated care for severe chronic non-communicable diseases, provides an approach to service integration that could fill gaps in access to comprehensive sickle cell disease care in LICs and LMICs.

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.