Jeremy I. Schwartz

Looking at non-communicable diseases in Uganda through a local lens: an analysis using locally derived data

The demographic and nutritional transitions taking place in Uganda, just as in other low- and middle-income countries (LMIC), are leading to accelerating growth of chronic, non-communicable diseases (NCDs). Though still sparse, locally derived data on NCDs in Uganda has increased greatly over the past five years and will soon be bolstered by the first nationally representative data set on NCDs. Using these available local data, we describe the landscape of the globally recognized major NCDs- cardiovascular disease, diabetes, cancer, and chronic respiratory disease- and closely examine what is known about other locally important chronic conditions. For example, mental health disorders, spawned by an extended civil war, and highly prevalent NCD risk factors such as excessive alcohol intake and road traffic accidents, warrant special attention in Uganda. Additionally, we explore public sector capacity to tackle NCDs, including Ministry of Health NCD financing and health facility and healthcare worker preparedness. Finally, we describe a number of promising initiatives that are addressing the Ugandan NCD epidemic. These include multi-sector partnerships focused on capacity building and health systems strengthening; a model civil society collaboration leading a regional coalition; and a novel alliance of parliamentarians lobbying for NCD policy. Lessons learned from the ongoing Ugandan experience will inform other LMIC, especially in sub-Saharan Africa, as they restructure their health systems to address the growing NCD epidemic.

Towards reframing health service delivery in Uganda: the Uganda Initiative for Integrated Management of Non-Communicable Diseases

Background The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development. Methods Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs. Results In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs. Discussion Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda.Background The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development. Methods Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs. Results In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs. Discussion Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda.

Noncommunicable Diseases In East Africa: Assessing The Gaps In Care And Identifying Opportunities For Improvement

The prevalence of noncommunicable diseases in East Africa is rising rapidly. Although the epidemiologic, demographic, and nutritional transitions are well under way in low-income countries, investment and attention in these countries remain focused largely on communicable diseases. We discuss existing infrastructure in communicable disease management as well as linkages between noncommunicable and communicable diseases in East Africa. We describe gaps in noncommunicable disease management within the health systems in this region. We also discuss deficiencies in addressing noncommunicable diseases from basic science research and medical training to health services delivery, public health initiatives, and access to essential medications in East Africa. Finally, we highlight the role of collaboration among East African governments and civil society in addressing noncommunicable diseases, and we advocate for a robust primary health care system that focuses on the social determinants of health.

Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India.

Abstract Objective To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program. Methods We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models. Findings The programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered. Conclusion Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.

Discharge Rounds: Implementation of a Targeted Intervention for Improving Patient Throughput on an Inpatient Medical Teaching Service.

Objectives Patient throughput and early discharges are important for decreasing emergency department wait times and creating available beds for new hospital admissions. The educational schedule of internal medicine trainees can interfere with timely discharges, but targeted interventions can help residents meet the hospital’s patient flow needs. Our training program instituted daily morning discharge rounds on the inpatient service, requiring each team to prepare potential discharges 1 day ahead and prioritizing these discharges the next day. Methods We conducted a retrospective, pre–post analysis 1 month before and 3 months after implementation in August 2013 to assess discharge order entry times, the proportion of discharges before 11:00 am, and hospital departure times. Results One month post-implementation, discharge orders were entered 59 minutes earlier (from 1:07 pm to 12:08 pm; P = 0.001), the percentage of pre-11:00 am discharges increased from 21% to 39% (P < 0.01), and patients departed the hospital 50 minutes earlier (from 3:21 pm to 2:31 pm; P = 0.005). These effects, however, returned to pre-implementation times during the subsequent 2 months. Conclusions A targeted intervention can significantly improve early discharges and should be replicable at other academic medical centers. Reinforcement is needed for these gains to be sustainable, however.

Guidance on the diagnosis and management of asthma among adults in resource limited settings.

BACKGROUND Optimal management of asthma in resource limited settings is hindered by lack of resources, making it difficult for health providers to adhere to international guidelines. The purpose of this review is to identify steps for asthma diagnosis and management in resource limited settings. METHODS Review of international asthma guidelines and other published studies on diagnosis and management of asthma. RESULTS We establish that clinical diagnosis of asthma can be made if recurrent respiratory symptoms especially current wheeze or wheeze in the last 12 months are present. Presence of a trigger, other allergic diseases, personal or family history of asthma; clinical improvement and increase in the peak flow and forced expiratory volume in one second of ≥12% after salbutamol administration increases the likelihood of asthma. At diagnosis severity grading, patient education, removal or reduction of trigger should be done. Follow up 2-6 weeks and assessment of control during therapy is essential. Therapy should be adjusted up or down depending on control levels. Patients should be instructed to increase the frequency of their bronchodilators and/or steroids therapy when they start to experience worsening symptoms. CONCLUSION Good quality asthma care can be achieved in resource limited settings by use of clinical data and simple tests.

Disparities in availability of essential medicines to treat non-communicable diseases in Uganda: A Poisson analysis using the Service Availability and Readiness Assessment

Objective Although the WHO-developed Service Availability and Readiness Assessment (SARA) tool is a comprehensive and widely applied survey of health facility preparedness, SARA data have not previously been used to model predictors of readiness. We sought to demonstrate that SARA data can be used to model availability of essential medicines for treating non-communicable diseases (EM-NCD). Methods We fit a Poisson regression model using 2013 SARA data from 196 Ugandan health facilities. The outcome was total number of different EM-NCD available. Basic amenities, equipment, region, health facility type, managing authority, NCD diagnostic capacity, and range of HIV services were tested as predictor variables. Findings In multivariate models, we found significant associations between EM-NCD availability and region, managing authority, facility type, and range of HIV services. For-profit facilities’ EM-NCD counts were 98% higher than public facilities (p < .001). General hospitals and referral health centers had 98% (p = .004) and 105% (p = .002) higher counts compared to primary health centers. Facilities in the North and East had significantly lower counts than those in the capital region (p = 0.015; p = 0.003). Offering HIV care was associated with 35% lower EM-NCD counts (p = 0.006). Offering HIV counseling and testing was associated with 57% higher counts (p = 0.048). Conclusion We identified multiple within-country disparities in availability of EM-NCD in Uganda. Our findings can be used to identify gaps and guide distribution of limited resources. While the primary purpose of SARA is to assess and monitor health services readiness, we show that it can also be an important resource for answering complex research and policy questions requiring multivariate analysis.

The global health chief resident: modifying an established role, strengthening a collaboration

What problems were addressed? The growing desire among medical trainees for structured exposure to global health issues has increased the demand for short-term field experiences in health care centres abroad. Establishing collaborations to provide these opportunities involves maintaining a balance between sponsoring and host institution interests. Trainees encounter a number of challenges in the course of these experiences, including personal and medical cultural differences, and ethical concerns relating to professionalism and patient care. The job of chief resident encompasses a host of administrative, educational and clinical activities that are well suited to addressing the needs that emerge as a result of these experiences. What was tried? In the 2010–2011 academic year, the Yale Primary Care Residency Programme created two new leadership positions: global health chief residents. These chiefs split their time between Yale and the established Makerere University–Yale University (MUYU) medical education collaboration based at Mulago National Referral Hospital, in Kampala, Uganda, the country’s national referral and teaching hospital. These two individuals are committed to careers in global health and had previously spent a total of 15 months working at Mulago Hospital in various capacities; thus they were familiar with the institution, faculty staff and leadership. Although they fulfilled typical clinical and educational responsibilities when in the USA, their goals during the time they spent in Uganda included providing educational supervision to visiting and local trainees, participating in direct patient care as members of the local faculty, and providing administrative support to the Kampalaand New Haven-based staff of the collaboration. Clinically, the chief residents served as attending physicians and held both bedside and classroom teaching sessions for Ugandan trainees. Administratively, they facilitated cross-cultural communications regarding finances, procedures and educational content, assisted the local staff and visiting trainees in understanding one another’s needs, standardised the on-site orientation process, and involved staff and faculty members from both universities in completing a summary report of the first 5 years of the collaboration. Importantly, their cumulative experiences with both institutions enabled them to provide emotional support and gave them the insight they needed to assist visiting trainees in processing their clinical and personal experiences. What lessons were learned? A tense political situation, arising from the presidential election that occurred during their stay, intermittent public demonstrations and a terrorist attack in Kampala a few months prior to their arrival, reduced the number of trainees who visited Uganda as part of the MUYU collaboration during the chief residents’ tenure. The chiefs took appropriate safety precautions and followed US State Department recommendations. Instead of negatively impacting the experience, this provided a greater opportunity for involvement in Ugandan medical education and in the administrative structure of the collaboration than had been anticipated. Recently proposed guidelines for global health training experiences emphasise the responsibilities of sponsoring institutions regarding the mentorship of visiting trainees, with a view towards meeting local needs and the priorities of host institutions. We successfully modified a well-established educational role, that of the chief resident, to improve the experience of our trainees while on rotation abroad and also demonstrated a commitment between international collaborators. We believe this role is reproducible and would strongly encourage all international collaborations that involve undergraduate or postgraduate medical education to consider placing a chief resident on site.

Integrated Care of Refugees in a Primary Care Residency Clinic

Providing quality health care for refugees requires cross-cultural competence and unique medical knowledge.1,2 While the Society of General Internal Medicine called for the development of longitudinal training for residents in refugee care in 2004,3 most residents do not feel prepared to care for new immigrants.4 We describe the experience of the Yale Combined Internal Medicine-Pediatrics Residency Program in providing integrated care for a population of Burmese refugees. This model presented numerous challenges but we believe it represents a viable, rewarding alternative to one in which refugees are cared for in a distinct clinic. In 2007, our patient-centered medical home practice serving a multiethnic, largely poor and underserved community began caring for 66 newly resettled Burmese refugees, most of whom were members of the Karen ethnic minority. We developed 3 distinct interventions that helped us provide quality care to this group. We first organized an introductory community meeting that brought together faculty, residents, and office staff with representatives of the community. We held home visits during which we led health education discussions, reviewed common health concerns, and held pediatric acute care and catch-up immunization clinics. Connecticut, like many states, lacked comprehensive guidelines for refugee health care. Since our Karen patients were randomly distributed between physicians, we devised a standardized instrument to provide guidance during the initial visit. It prompted the clinician to gather information relevant to refugees and provide recommendations regarding infectious disease screening. The provision of efficient, quality care was limited by a vast cultural divide and by unreliable telephone interpretation. Taking medical histories, eliciting symptoms, and comprehending and following through on management plans were challenging. The extended time taken by visits with our Burmese patients affected patient flow and clinic efficiency. An integrated care model offers several advantages. Serving as a medical home to this population created a sense of trust between patients and providers. We focused on refugee-specific matters and general health issues concurrently and could effectively coordinate care with the resettlement agency and community. However, this model of care also presented distinct challenges. Varying degrees of cultural competence meant different levels of comfort in caring for this population. Our screening protocol was developed in parallel with home visits and ongoing primary care, limiting its effective, widespread implementation. We were faced with the question of when and how to shift the focus from fulfilling the needs of the newly arrived refugee to those of the primary care patient. Finally, though this vulnerable population merited special attention, we struggled with how to balance their needs with those of our other patients. With tens of thousands of refugees being resettled annually in the United States,5 exposure to their medical care needs is a vital component of residency training and one that fosters cultural competency. Our interventions provided structure and built trust as we cared for this population. Though rife with challenges, we believe a residency clinic can provide effective, comprehensive care to refugees.

Prescribing and dispensing practices for medicines used to treat non-communicable diseases in Uganda: a cross-sectional study

Abstract Background Non-communicable diseases (NCDs) are increasingly prevalent in low-income and middle-income countries (LMIC) and accessibility of medicines is essential for the management of these conditions. In Uganda, although many NCD medicines are now included in the national essential medicines list, sporadic evidence suggests that these medicines are widely unavailable to patients. The prescribing patterns of NCD medicines by providers and the dispensing patterns by dispensers represent important knowledge gaps in efforts to understand the care cascade for NCDs in Uganda. We aimed to describe the prescribing and dispensing practices for medicines used to treat NCDs, particularly hypertension, diabetes, and heart failure in Ugandan health-care facilities. Methods Based on WHO methodology, we did a cross-sectional study in which systematic sampling was used to collect data from patients attending outpatient NCD clinics at 15 higher-level public health-care facilities throughout Uganda. Demographic, prescribing, and dispensing information were collected using pre-tested structured questionnaires. Prescribing information was recorded from prescriptions, and dispensing information was obtained from medicine packets. Medicine tablets were counted by data collectors. Patients who reported not receiving all of their prescribed doses were contacted by phone to determine if they obtained the non-dispensed doses elsewhere. The primary outcome, which we term the Prescribing-Dispensing (P-D) Gap, was the percentage of prescribed doses that were not dispensed. Associations were tested using a linear mixed model. Findings We analysed data from 477 participants, of whom 454 (71%) were women. The average age was 51·4 years (SD 13·5). The mean number of drugs prescribed per encounter was 2·5 (SD 1·1), of which only 1·4 (0·9) drugs were dispensed. Overall, 82 591 total doses were prescribed, and 35 290·5 doses were dispensed, resulting in a P-D Gap of 57·3%. The P-D Gap was smaller for diabetes medicines than for medicines for cardiovascular diseases (46·2% vs 67·5%; p Interpretation A large P-D Gap exists for medicines used to treat NCDs in Ugandan public health-care facilities. The P-D Gap differs by medicine class and appears to be driven by medicine availability at public sector pharmacies. Most patients do not close this gap by purchasing medicines at private pharmacies, suggesting that under-treatment of these chronic conditions is widespread in patients who are already linked to care. Future work should explore feasible approaches to decrease this P-D Gap. Funding Doris Duke Clinical Research Fellowship.