Addressing NCD needs in rural resource-constrained settings: A comprehensive integrated nurse-led care
model at public facilities in Rwanda
Dual Burden
• 80% of NCD-related deaths occur in LMICs (WHO)
• In sub-Saharan Africa, NCDs are projected to cause more deaths than communicable, maternal, perinatal, and nutritional diseases combined by 2030 (WHO)
Anderson and Chu, NEJM 2007; 356:209-211
• Yet, LMICs have limited capacity to address health needs
Task-shifted NCD service deliery described in SSA
• Mental health
– Zimbabwe (Chibanda)
– South Africa (Peterson)
• Diabetes, hypertension, epilepsy, CVD, asthma
– Cameroon (Kengne, Labhardt)
– South Africa (Coleman, Gill)
– Rwanda (Kwan, Bukhman)
– Ethiopia (Berhanu)
Gaps in Evidence
• Many of the LMICs NCD services delivery programs described are in urban or private settings, middle-income countries, or focused on single disease
• Lifestyle risk factors emphasized: unhealthy diet, lack of physical activity, tobacco use, and harmful alcohol use
Alwan A et al, WHO global status report 2011
Aims
• Describe comprehensive public sector-based NCD program in rural low-income country setting
• Describe baseline clinical and sociodemographic characteristics of patients presenting
Background: Rwanda
Population1
11 million (84% rural)
GNI per capita2 $ 395 ($142 in 1994)
Human Development Index3
0.434 (167th)
Doctors : 1,000 citizens2
0.05 (1/50th of USA)
1. DHS 2010
2. World
Bank
3. UNDP
Farmer P et al. (2013). “Reduced Premature Mortality in Rwanda: Lessons from Success.” British Medical Journal 346(f65): 20-22.
7
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200
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1000
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1990 1995 2000 2005 2010 2015 MDG Target
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tern
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ath
s p
er
10
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irth
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Rwanda
Sub-Saharan Africa
World
Rwanda
Sub-Saharan Africa
World
910
840
340
850
740
500
400
320
210 100
213 228
Maternal Mortality in Rwanda
1990 – 2015
Farmer P et al. (2013). “Reduced Premature Mortality in Rwanda: Lessons from Success.” British Medical Journal 346(f65): 20-22.
PIH-supported NCDs in Rwanda
• 2005: PIH invited by Rwanda MOH
• 2006: Rwinkwavu DH NCD clinic established
• To date: 3 district hospitals and 7 health centers have implemented PIH-supported NCD programs
Services • Comprehensive: Prevention,
diagnosis, treatment and long term follow up for major NCDs
• Integration within MOH
• Task-shifting: nurse-led, protocol based, structured mentorship and outreach
Decision support
• Protocols
• Mentorship – On-site
– Remote (Kigali, Boston)
Services II • Patient-centered: Point-
of-care testing, outreach, subsidized medication, socioeconomic supports – Nutrition – Transport – Patient education – Home visits – CHW accompaniment – Mental Health, Social Work
Structured Clinical Forms
Methods
• Retrospective review of routine electronic medical records of patients enrolled at PIH-supported MOH NCD programs between January 1, 2007 and September 30, 2014
• Did not include cancer and epilepsy patients (EMR limitations)
• Analysis with stata v12
Results: Sociodemographic characteristics
• Total 3,367 patients have been enrolled
• 67% are female
• Median age 48.4 years (range: weeks-101 years)
Age N % < 18 years 275 8.2 18 - 39 years 780 23.2
40 - 64 years 1,561 46.4
65 years or older 751 22.3
Occupation (N=904) N % Subsistence farmer 683 75.6
Non-professional work 24 2.7
Professional or retired 92 10.2
Unemployed 105 11.6 Mode of travel (N=930) N % By foot 160 17.2 By bicycle 120 12.9 By public taxi 595 64.0
Other 55 5.9
No. children (median, range) 6 0-20
Where are patients coming from?
Kigali
Results: Types of Diagnoses
• Few co-morbidities
Types of diagnoses N %
Hypertension 1,075 30.5
Asthma 901 25.6
Heart failure 900 25.6
Diabetes 550 15.6
HIV 96 2.7
NCD co-morbidities N %
Single NCD 3,211 98.2
Two NCDs 57 1.7
Three or more NCDs 1 0.0
Results: Risk Factors
• Low prevalence of typical risk factors
Smoking (N=2,611) N %
Never 1,780 68.2
Yes (currently or in past) 831 31.8
Alcohol* (N=2,573) N %
Never 1,176 45.7
Yes (currently or in past) 1,397 54.3
BMI (N=1,698) N %
Underweight 187 11.0
Normal 1,137 67.0
Overweight 264 15.5
Obese 110 6.5
Limitations
• Study – Missing data (retrospective review, EMR-based)
– Did not describe outcomes (yet)
• Program – Staff turn-over at health center level
– Public supply chain stock outs
– Socioeconomic supports are only available in the hospital catchment districts (while many patients reside outside)
Future Directions
• Evaluation of quality of care and outcomes: – Death, LTFU – Disease control (diabetes,
hypertension) – Clinical skills (ECHO concordance)
• Further expansion of services to health center level
• Nationally:
– Scale up of NCD programs at DH – Integration of chronic care CHWs
Summary
• Our experience indicates that it is possible to deliver comprehensive NCD care embedded within the public health system in a rural resource-constrained setting
• Care is accessible to rural poor
• Low prevalence of lifestyle risk factors, reflecting need to characterize
context-specific risk factors and identify tailored interventions
• Protocol-based, task-shifting approach and partnerships designed to transfer knowledge, skills, technology and drug availability are critical
• The experience from these facilities has contributed to ongoing
nationwide scale-up of district level NCD services
Acknowledgements
• Gene Bukhman
• Emmanuel Rusingiza
• Charlotte Bavuma
• Gedeon Ngoga
• Gene Kwan
• Pio Uwiragiye
• Emmanuel Harerimana
• Francis Mutabazi
• Cadet Mutumbira
• Symaque Dusabayezu
• Rwinkwavu, Butaro and Kirehe clinicians and hospital leadership
• Rwanda MOH, Hon Minister Agnes Binagwaho, Dr Jean De Dieu Ngirabega, Marie Aimee Muhimpundu, Evariste Ntaganda
• Medtronic Foundation, Helmsley Foundation, LIVESTRONG, GIPAP
Murakoze!!
Authors: Neo Tapela1,3,4, Gene Bukhman1,3,4,5, Gedeon Ngoga1, Gene Kwan1,4,6, Francis Mutabazi2, Symaque Dusabeyezu2, Cadet Mutumbira2, Charlotte Bavuma2,5, Emmanuel Rusingiza2,5
Affiliations: 1Inshuti M Buzima/Partners in Health, Rwanda 2Ministry of Health, Rwanda 3Harvard Medical School 4Brigham and Women’s Hospital 5University of Rwanda, Rwanda 6Boston University School of Medicine