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.

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910

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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