Neil Gupta

Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI).

BackgroundMore than three decades after the 1978 Declaration of Alma-Ata enshrined the goal of ‘health for all’, high-quality primary care services remain undelivered to the great majority of the world’s poor. This failure to effectively reach the most vulnerable populations has been, in part, a failure to develop and implement appropriate and effective primary care delivery models. This paper examines a root cause of these failures, namely that the inability to achieve clear and practical consensus around the scope and aims of primary care may be contributing to ongoing operational inertia. The present work also examines integrated models of care as a strategy to move beyond conceptual dissonance in primary care and toward implementation. Finally, this paper examines the strengths and weaknesses of a particular model, the World Health Organization’s Integrated Management of Adolescent and Adult Illness (IMAI), and its potential as a guidepost toward improving the quality of primary care delivery in poor settings.DiscussionIntegration and integrated care may be an important approach in establishing a new paradigm of primary care delivery, though overall, current evidence is mixed. However, a number of successful specific examples illustrate the potential for clinical and service integration to positively impact patient care in primary care settings. One example deserving of further examination is the IMAI, developed by the World Health Organization as an operational model that integrates discrete vertical interventions into a comprehensive delivery system encompassing triage and screening, basic acute and chronic disease care, basic prevention and treatment services, and follow-up and referral guidelines. IMAI is an integrated model delivered at a single point-of-care using a standard approach to each patient based on the universal patient history and physical examination. The evidence base on IMAI is currently weak, but whether or not IMAI itself ultimately proves useful in advancing primary care delivery, it is these principles that should serve as the basis for developing a standard of integrated primary care delivery for adults and adolescents that can serve as the foundation for ongoing quality improvement.SummaryAs integrated primary care is the standard of care in the developed world, so too must we move toward implementing integrated models of primary care delivery in poorer settings. Models such as IMAI are an important first step in this evolution. A robust and sustained commitment to innovation, research and quality improvement will be required if integrated primary care delivery is to become a reality in developing world.

Leveraging the lessons learned from HIV/AIDS for coordinated chronic care delivery in resource-poor settings.

Though far from complete, the global fight against the HIV/ AIDS epidemic has made significant strides. Since 2001, global incidence of new HIV infections has declined by 38% annually, including a 58% decline in new infections in children. Fifteen million people are now receiving antiretroviral therapy, compared to less than one million ten years ago. Much of this progress has been accomplished in sub-Saharan Africa, which bears the burden of the epidemic with 71% of the global number of people living with HIV/AIDS. In this region, 87% of patients who know their status and are eligible for antiretroviral therapy (ART) are now receiving treatment, and 76% of those patients have achieved viral suppression. AIDS-related deaths have decreased by 35% since their peak in 2005, and 4.8 million deaths are reported to have been averted by the development and delivery of safe, effective antiretroviral therapy in sub-Saharan Africa alone. Many have taken to declaring the “End of an epidemic” and looking forward to an “AIDS-free generation”. However, despite the relative gains made in the health system response by sub-Saharan African countries for the chronic management of patients with HIV/AIDS, a diverse group of other chronic conditions comprise a major driver

Community-Based Accompaniment Mitigates Predictors of Negative Outcomes for Adults on Antiretroviral Therapy in Rural Rwanda

Clinical, socioeconomic, and access barriers remain a critical problem to antiretroviral (ART) programs in sub-Saharan Africa. Community-based accompaniment (CBA), including daily home visits and psychosocial and socioeconomic support, has been associated with improved patient outcomes at 1xa0year. We conducted a prospective observational cohort study of 578 HIV-infected adults initiating ART in 2007–2008 with or without CBA in rural Rwanda. Among patients without CBA, those with advanced HIV disease, low CD4 cell counts, lower social support, and transport costs had significantly higher odds of negative outcomes at 1xa0year; amongst patients who received CBA, only those with low CD4 cell counts had significantly higher odds of negative outcomes at 1xa0year. CBA also significantly mitigated the effect of transport costs and inaccessibility of services on the likelihood of negative outcome. CBA may be one approach to mitigating known risk factors for negative outcomes for patients on ART in resource-poor settings.ResumenBarreras clínicas, socioeconómicas, y del acceso siguen siendo un problema crítico para los programas de antiretrovirales (ART) en el Africa subsahariana. Acompañamiento basado en la comunidad (ABC), incluyendo visitas domiciliarias diarias y apoyo psicosocial y socioeconómico, se ha asociado con mejores resultados de los pacientes en un año. Realizamos un estudio de cohorte prospectivo observacional de 578 adultos infectados por el VIH que iniciaron ART entre 2007 y 2008, con o sin ABC en Ruanda rural. Entre los pacientes sin ABC, aquellos con enfermedad avanzada, recuentos bajos de células CD4, apoyo social más bajo, y costos de transporte tuvieron significativamente mayor probabilidad de resultados negativos en un año; entre los pacientes que recibieron ABC, solo aquellos con recuentos bajos de células CD4 tuvieron significativamente mayores probabilidades de resultados negativos en un año. ABC también mitigó significativamente el efecto de los costos de transporte y la inaccesibilidad a los servicios en la probabilidad de un resultado negativo. ABC puede ser un método para mitigar los factores de riesgo conocidos para los resultados negativos para los pacientes de ART en entornos con pocos recursos.

Non-Obstetric Surgical Care at Three Rural District Hospitals in Rwanda: More Human Capacity and Surgical Equipment May Increase Operative Care

BackgroundMost mortality attributable to surgical emergencies occurs in low- and middle-income countries. District hospitals, which serve as the first-level surgical facility in rural sub-Saharan Africa, are often challenged with limited surgical capacity. This study describes the presentation, management, and outcomes of non-obstetric surgical patients at district hospitals in Rwanda.MethodsThis study included patients seeking non-obstetric surgical care at three district hospitals in rural Rwanda in 2013. Demographics, surgical conditions, patient care, and outcomes are described; operative and non-operative management were stratified by hospitals and differences assessed using Fisher’s exact test.ResultsOf the 2660 patients who sought surgical care at the three hospitals, most were males (60.7xa0%). Many (42.6xa0%) were injured and 34.7xa0% of injuries were through road traffic crashes. Of presenting patients, 25.3xa0% had an operation, with patients presenting to Butaro District Hospital significantly more likely to receive surgery (57.0xa0%, pxa0<xa00.001). General practitioners performed nearly all operations at Kirehe and Rwinkwavu District Hospitals (98.0 and 100.0xa0%, respectively), but surgeons performed 90.6xa0% of the operations at Butaro District Hospital. For outcomes, 39.5xa0% of all patients were discharged without an operation, 21.1xa0% received surgery and were discharged, and 21.1xa0% were referred to tertiary facilities for surgical care.ConclusionSignificantly more patients in Butaro, the only site with a surgeon on staff and stronger surgical infrastructure, received surgery. Availing more surgeons who can address the most common surgical needs and improving supplies and equipment may improve outcomes at other districts. Surgical task sharing is recommended as a temporary solution.

Estimation of the size of the female sex worker population in Rwanda using three different methods

HIV prevalence is disproportionately high among female sex workers compared to the general population. Many African countries lack useful data on the size of female sex worker populations to inform national HIV programmes. A female sex worker size estimation exercise using three different venue-based methodologies was conducted among female sex workers in all provinces of Rwanda in August 2010. The female sex worker national population size was estimated using capture–recapture and enumeration methods, and the multiplier method was used to estimate the size of the female sex worker population in Kigali. A structured questionnaire was also used to supplement the data. The estimated number of female sex workers by the capture–recapture method was 3205 (95% confidence interval: 2998–3412). The female sex worker size was estimated at 3348 using the enumeration method. In Kigali, the female sex worker size was estimated at 2253 (95% confidence interval: 1916–2524) using the multiplier method. Nearly 80% of all female sex workers in Rwanda were found to be based in the capital, Kigali. This study provided a first-time estimate of the female sex worker population size in Rwanda using capture–recapture, enumeration, and multiplier methods. The capture–recapture and enumeration methods provided similar estimates of female sex worker in Rwanda. Combination of such size estimation methods is feasible and productive in low-resource settings and should be considered vital to inform national HIV programmes.

Strengthening of primary-care delivery in the developing world: IMAI and the need for integrated models of care

Vasan, A; Ellner, A; Lawn, SD; Gupta, N; Anatole, M; Drobac, P; Nicholson, T; Gove, S; Seung, K; Mabey, D; +1 more... Farmer, P; (2013) Strengthening of primary-care delivery in the developing world: IMAI and the need for integrated models of care. The Lancet Global health, 1 (6). e321-3. ISSN 2214-109X DOI: https://doi.org/10.1016/S2214-109X(13)70102-5 Downloaded from: http://researchonline.lshtm.ac.uk/1878113/ DOI: https://doi.org/10.1016/S2214-109X(13)70102-5

Clinical outcomes of a comprehensive integrated program for HIV-exposed infants: a 3-year experience promoting HIV-free survival in rural Rwanda.

Background:Prevention of mother-to-child transmission of HIV services are often inadequate in promoting HIV-free child survival in rural areas with limited resources. An integrated comprehensive child survival program in rural Rwanda with special emphasis on HIV-exposed infants was established in 2005 and scaled-up. The objective of this study was to report program outcomes and identify predictors of program retention. Methods:We conducted a retrospective study of infants born to HIV-infected women enrolled in the program at or before birth from March 1, 2007, to February 28, 2010, in Eastern Rwanda. Key program elements included improved access to health care, antiretroviral prophylaxis for prevention of mother-to-child transmission of HIV, clean water sources and replacement feeding, home visits by community health workers, prevention and treatment of childhood illness, nutritional support, family planning, and socioeconomic support for the extremely vulnerable. Results:Overall,1038 infants enrolled in the program in the study period during which time there was a 4-fold increase in the number of current participants. Uptake of contraception and treatment for diarrheal disease were high. The 18-month survival probability and retention probability were 0.93 (95% confidence interval: 0.91 to 0.94) and 0.88 (95% confidence interval: 0.86 to 0.90), respectively. Twenty-seven (2.6%) children tested positive for HIV, of which 1 died and none were lost-to-follow-up at 18 months. No statistically significant predictors of retention were identified. Conclusions:Our findings demonstrate that a comprehensive integrated program to promote HIV-free survival can achieve high rates of retention and survival in a highly vulnerable population, even during a period of rapid growth.

Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda

BACKGROUNDnIn developing countries, 9 out of 10 patients lack access to timely operative care. Most patients seek care at district hospitals that often lack operative capacity, creating a need for referral. Delays in referrals contribute to substantial disability and death. This study assessed the predictors of delayed referrals for injured patients.nnnMETHODSnThis retrospective cohort study included injured patients, recommended for referral between January 1, 2013, and December 31, 2013, from 3 rural district hospitals in Rwanda. We defined delay as nonexecution of referral 2xa0days after referral recommendation. We performed a multivariate logistic regression using stepwise backward selection to identify the predictors of delayed referral.nnnRESULTSnOf the 1,227 injured patients, 23.0% (nxa0=xa0282) were recommended for referral. Of these, 36.5% (nxa0=xa0103) had road traffic injuries and 53.6% (nxa0=xa0151) were diagnosed with closed fractures/dislocation. Among 231 patients, 108 (46.8%) had a delay in referral execution. The predictors of delay included age >35xa0years (odds ratioxa0=xa02.45, 95% confidence interval: 1.09-5.50), closed fractures/dislocation (odds ratioxa0=xa016.37, 95% confidence interval: 3.13-85.78), admission to surgical wards (odds ratioxa0=xa010.25, 95% confidence interval: 2.70-38.82), and a duration ≥7xa0days from admission to referral recommendation (odds ratioxa0=xa04.80, 95% confidence interval: 1.38-16.63).nnnCONCLUSIONnOver 50% of referrals were completed in a timely fashion due to a strong referral system and a patient support program. Empowering district hospitals with trained staff and appropriate equipment could reduce the need for referral, and increasing surgeons at referral hospitals could reduce referral delays.

Race to the Top: evaluation of a novel performance-based financing initiative to promote healthcare delivery in rural Rwanda

Background Performance-based financing (PBF) has demonstrated a range of successes and failures in improving health outcomes across low- and middle-income countries. Evidence indicates that the success of PBF depends, in large part, on the model selected, in relation to a variety of contextual factors. Objective Partners In Health∣Inshuti Mu Buzima aimed to evaluate health outcomes associated with a novel capacity-building model of PBF at health centers throughout Kirehe district, Rwanda. Design Thirteen health centers in Kirehe district, which provide healthcare to a population of over 300,000 people, agreed to participate in a PBF initiative scheme that integrated data feedback, quality improvement coaching, peer-to-peer learning, and district-level priority setting. Health centers progress toward collectively agreed upon site-specific health targets was assessed every 6 months for 18 months. Incentives were awarded only when health centers met goals on all three priorities health centers had collectively agreed upon: 90% coverage of community-based health insurance, 70% contraceptive prevalence rate, and zero acute severe malnutrition cases. Improvement across all four time points and facilities was measured using mixed-effects linear regression. Findings At 6-month follow-up, 4 of 13 health centers had met 1 target. At 12-month follow-up, 7 centers had met 1 target, and by 18-month follow-up, 6 centers had met 2 targets and 2 centers had met all 3. Average health center performance had improved significantly across the district for all three targets: mean insurance coverage increased from 68% at baseline to 93% (p<0.001); mean number of acute malnutrition cases in the previous 6 months declined from 24 to 5 per facility (p<0.001); and contraceptive prevalence increased from 42 to 59% (p<0.001). A number of innovative improvement initiatives were identified. Conclusion The combining of PBF, district engagement/support, and peer-to-peer learning resulted in significant improvements despite resource constraints and is now being considered as a model for scale-up in other districts of Rwanda.Background Performance-based financing (PBF) has demonstrated a range of successes and failures in improving health outcomes across low- and middle-income countries. Evidence indicates that the success of PBF depends, in large part, on the model selected, in relation to a variety of contextual factors. Objective Partners In Health∣Inshuti Mu Buzima aimed to evaluate health outcomes associated with a novel capacity-building model of PBF at health centers throughout Kirehe district, Rwanda. Design Thirteen health centers in Kirehe district, which provide healthcare to a population of over 300,000 people, agreed to participate in a PBF initiative scheme that integrated data feedback, quality improvement coaching, peer-to-peer learning, and district-level priority setting. Health centers’ progress toward collectively agreed upon site-specific health targets was assessed every 6 months for 18 months. Incentives were awarded only when health centers met goals on all three priorities health centers had collectively agreed upon: 90% coverage of community-based health insurance, 70% contraceptive prevalence rate, and zero acute severe malnutrition cases. Improvement across all four time points and facilities was measured using mixed-effects linear regression. Findings At 6-month follow-up, 4 of 13 health centers had met 1 target. At 12-month follow-up, 7 centers had met 1 target, and by 18-month follow-up, 6 centers had met 2 targets and 2 centers had met all 3. Average health center performance had improved significantly across the district for all three targets: mean insurance coverage increased from 68% at baseline to 93% (p<0.001); mean number of acute malnutrition cases in the previous 6 months declined from 24 to 5 per facility (p<0.001); and contraceptive prevalence increased from 42 to 59% (p<0.001). A number of innovative improvement initiatives were identified. Conclusion The combining of PBF, district engagement/support, and peer-to-peer learning resulted in significant improvements despite resource constraints and is now being considered as a model for scale-up in other districts of Rwanda.

Baseline assessment of adult and adolescent primary care delivery in Rwanda: an opportunity for quality improvement

BackgroundAs resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda.MethodsPatients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard.ResultsFour hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (pu2009=u20090.03 and pu2009=u20090.04, respectively).ConclusionFundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.