Understanding the Etiology of Heart Failure Among the Rural Poor in Sub-Saharan Africa: A 10-Year Experience From District Hospitals in Rwanda

Eberly, L. A., Rusingiza, E., Park, P. H., Ngoga, G., Dusabeyezu, S., Mutabazi, F., Harerimana, E., Mucumbitsi, J., Nyembo, P. F., Borg, R., Gahamanyi, C., Mutumbira, C., Ntaganda, E., Rusangwa, C., Kwan, G. F. & Bukhman, G.

Heart failure is a significant cause of morbidity and mortality in sub-Saharan Africa. Our understanding of the heart failure burden in this region has been limited mainly to registries from urban referral centers. Starting in 2006, a nurse-driven strategy was initiated to provide echocardiography and decentralized heart failure care within noncommunicable disease (NCD) clinics in rural district hospitals in Rwanda.

The results of the largest single-country heart failure cohort from rural sub-Saharan Africa demonstrate a persistent burden of rheumatic disease and nonischemic cardiomyopathies.

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Nurse-Driven Echocardiography and Management of Heart Failure at District Hospitals in Rural Rwanda

Lauren A. Eberly, MD, Emmanuel Rusingiza, MD, Paul H. Park, MD, MSc, Gedeon Ngoga, BS, RN, Symaque Dusabeyezu, RN, Francis Mutabazi, BCM, Emmanuel Harerimana, RN, Joseph Mucumbitsi, MD, Philippe F. Nyembo, MBChB, Ryan Borg, MPH, Cyprien Gahamanyi, RN, Cadet Mutumbira, BS, RN, Evariste Ntaganda, MD, MPH, Christian Rusangwa, MD, Gene F. Kwan, MD, and Gene Bukhman, MD, PhD

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To address gaps in care for the rural poor, the Rwandan Ministry of Health, supported by Inshuti Mu Buzima (Partners In Health—Rwanda), started to train nurses to provide care for a group of severe chronic noncommunicable diseases (NCDs), including heart failure, initially at 3 rural district hospitals, beginning in 2006.2 Nurses were trained in simplified diagnostic protocols incorporating basic echocar- diography to place patients into broad categories of heart failure most prevalent in the area.3 Treatment was administered based on category-specific pathways and delivered in the context of an integrated NCD clinic.

This represents the first reported strategy to successfully decentralize and integrate heart failure diagnosis and management at first-level hospitals in highly con- strained health systems.


The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

Gene Bukhman, Ana O Mocumbi, Rifat Atun, Anne E Becker, Zulfiqar Bhutta, Agnes Binagwaho, Chelsea Clinton, Matthew M Coates, Katie Dain, Majid Ezzati, Gary Gottlieb, Indrani Gupta, Neil Gupta, Adnan A Hyder, Yogesh Jain, Margaret E Kruk, Julie Makani, Andrew Marx, J Jaime Miranda, Ole F Norheim, Rachel Nugent, Nobhojit Roy, Cristina Stefan, Lee Wallis, Bongani Mayosi, for the Lancet NCDI Poverty Commission Study GroupLeading global health and development institutions continue to view non-communicable diseases (NCDs) predominantly through the lens of epidemiological transitions, wherein NCDs are best understood in terms of ageing, urbanisation, lifestyle choices, and affluence. This narrow framing is expressed through the so-called 5 x 5 model, favoured by WHO, of five diseases (cardiovascular disease, cancer, diabetes, chronic respiratory diseases, and mental ill-health) and five risk factors (tobacco use, unhealthy diets, physical inactivity, harmful use of alcohol, and air pollution), and is enshrined in Sustainable Development Goals target 3.4 on reducing NCD mortality.

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The Lancet Commission on NCDs and injuries (NCDIs) among the poorest billion argues that the current global NCD agenda does not address the needs, perspectives, and rights of the world’s poor. NCDIs account for more than a third of the disease burden among the poorest billion and are attributable to a far more diverse set of conditions and risk factors than contained in the 5 x 5 model. The evidence and recommendations in this Commission report must prompt the expansion of the NCD agenda as a matter of justice and equity for the world’s poorest.

Health system capacity to manage diabetic ketoacidosis in nine low-income and lower-middle income countries: A cross-sectional analysis of nationally representative survey data

Sarah Matthews, Matthew M. Coates, Alice Bukhman, Celina Trujillo, Gina Ferrari, Wubaye Walelgne Dagnaw, Darius Leopold Fénelon, Theodros Getachew, Biraj Karmacharya, Nancy Charles Larco, Aimée M. Lulebo, Mary Theodory Mayige, Maïmouna Ndour Mbaye, Getahun Tarekegn, Neil Gupta, Alma Adler, and Gene Bukhman

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There has been increasing awareness about the importance of type 1 diabetes (T1D) globally. Diabetic ketoacidosis (DKA) is a life-threatening complication of T1D in low-income settings. Little is known about health system capacity to manage DKA in low- and lower-middle income countries (LLMICs). As such, we describe health system capacity to diagnose and manage DKA across nine LLMICs using data from Service Provision Assessments.

We examined data from 2028 higher-level and 7534 lower-level facilities. Of these, 1874 higher-level and 6636 lower-level facilities’ data were eligible for analysis. Availability of all item sets were low at higher-level facilities, where less than 50% had the minimal set of supplies, less than 20% had the full minimal set, and less than 15% had the ideal set needed to diagnose and manage DKA. Across countries in lower-level facilities, less than 14% had the minimal set of supplies and less than 9% the full set of supplies for diagnosis and transfer of DKA patients. No country had more than 20% of facilities with the minimal set of items needed to assess or manage DKA.

Prioritizing Health-Sector Interventions for Noncommunicable Diseases and Injuries in Low- and Lower-Middle Income Countries: National NCDI Poverty Commissions

Neil Gupta, Ana Mocumbi, Said H. Arwal, Yogesh Jain, Abraham M. Haileamlak,
Solomon T. Memirie, Nancy C. Larco, Gene F. Kwan, Mary Amuyunzu-Nyamongo, Gladwell Gathecha, Fred Amegashie, Vincent Rakotoarison, Jones Masiye, Emily Wroe, Bhagawan Koirala, Biraj Karmacharya, Jeanine Condo, Jean Pierre Nyemazi, Santigie Sesay, Sarah Maogenzi, Mary Mayige, Gerald Mutungi, Isaac Ssinabuly Ann R. Akiteng, Justice Mudavanhu, Sharon Kapambwe, David Watkins, Ole Norheim, Julie Makani, Gene Bukhman;
NCDI Poverty National Commissions Authorship Group; NCDI Poverty Network Secretariat

Health sector priorities and interventions to prevent and manage noncommunicable diseases and injuries (NCDIs) in low- and lower-middle-income countries (LLMICs) have primarily adopted elements of the World Health Organization Global Action Plan for NCDs 2013–2020. However, there have been limited efforts in LLMICs to prioritize among conditions and health-sector inter- ventions for NCDIs based on local epidemiology and contextually relevant risk factors or that incorporate the equitable distribution of health outcomes. The Lancet Commission on Reframing Noncommunicable Diseases and Injuries for the Poorest Billion supported national NCDI Poverty Commissions to define local NCDI epidemiology, determine an expanded set of priority NCDI conditions, and recommend cost-effective, equitable health-sector interventions.

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD–HIV model

Emily B Wroe, Noel Kalanga, Elizabeth L Dunbar, Lawrence Nazimera, Natalie F Price, Adarsh Shah, Luckson Dullie, Bright Mailosi, Grant Gonani, Enoch P L Ndarama, George C Talama, Gene Bukhman, Lila Kerr,
Emilia Connolly, Chiyembekezo Kachimanga

BMJOpen_Malawi_ICCC_Oct-2020Non-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3).

The study includes an HIV–NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.

The IC3 model, built on an HIV platform, Health Office, Ministry of Health, facilitated rapid decentralisation and access to NCD Neno, Malawi services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.

Burden of non-communicable diseases from infectious causes in 2017: a modelling study

Matthew M Coates, Alexander Kintu, Neil Gupta, Emily B Wroe, Alma J Adler, Gene F Kwan, Paul H Park, Ruma Rajbhandari, Anthony L Byrne, Daniel C Casey, Gene Bukhman

Non-communicable diseases (NCDs) cause a large burden of disease globally. Some infectious diseases cause an increased risk of developing specific NCDs. Although the NCD burden from some infectious causes has been quantified, in this study, we aimed to more comprehensively quantify the global burden of NCDs from infectious causes.

Globally, we quantified 130 million DALYs from NCDs attributable to infection, comprising 8·4% of all NCD DALYs.

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

Lauren Anne Eberly, Christian Rusangwa, Loise Ng’ang’a, Claire C Neal, Jean Paul Mukundiyukuri, Egide Mpanusingo, Jean Claude Mungunga, Hamissy Habineza, Todd Anderson, Gedeon Ngoga, Symaque Dusabeyezu, Gene Kwan, Charlotte Bavuma, Emmanual Rusingiza, Francis Mutabazi, Joseph Mucumbitsi, Cyprien Gahamanyi, Cadet Mutumbira, Paul H Park, Tharcisse Mpunga, Gene Bukhman

Integrated 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.

The COVID-19 Pandemic: A Massive Threat for Those Living With Cardiovascular Disease Among the Poorest Billion

Sheila L. Klassen, Gene F. Kwan, Gene Bukhman

The coronavirus disease 2019 (COVID-19) pandemic has significantly affected the poorest billion people worldwide. This is not only because of the chal- lenges specific to COVID-19 infection (establishing this complex diagnosis and managing severe cases of infection), but also because of the interruptions in routine medical care, disruptions in local and global supply chains, and increase in health care costs, all leading to further poverty and food insecurity. In this article, we discuss the unique vulnerabilities of the poorest billion population with cardio- vascular disease (CVD) to the COVID-19 pandemic and explore possible contribu- tions of the global CVD community to mitigate these disastrous effects.

Evaluating implementation of Diabetes Self-Management Education in Maryland County, Liberia: protocol for a pilot prospective cohort study

Trujillo, C., Ferrari, G., Ngoga, G., Mclaughlin, A., Davies, J., Tucker, A., Randolph, C., Cook, R., Park, P. H., Bukhman, G., Adler, A. J. & Pierre, J

Achieving glycaemic targets for people living with diabetes (PLWD) is challenging, especially in settings with limited resources. Programmes need to addressgaps in knowledge, skills and self-management. Diabetes Self-Management Education (DSME) is an evidence-based intervention to educate and empower PLWD to improve self-management activities. This protocol describes a pilot study assessing the feasibility, acceptability and effect on clinical outcomes of implementing DSME in clinics caring for people living with insulin-dependent diabetes in Liberia.