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. 2021 Aug;26(8):953-961.
doi: 10.1111/tmi.13593. Epub 2021 May 16.

Implementation outcomes of national decentralization of integrated outpatient services for severe non-communicable diseases to district hospitals in Rwanda

Simon Pierre Niyonsenga  1 , Paul H Park  2   3   4 , Gedeon Ngoga  2   5 , Evariste Ntaganda  1 , Fredrick Kateera  5 , Neil Gupta  2   3   4 , Edson Rwagasore  1 , Samuel Rwunganira  1 , Antoine Munyarugo  1 , Cadet Mutumbira  1 , Symaque Dusabayezu  5 , Arielle Eagan  4 , Chantelle Boudreaux  4 , Christopher Noble  4 , Marie Aimee Muhimpundu  1 , F Gilles Ndayisaba  1 , Sabin Nsanzimana  1 , Gene Bukhman  2   3   4   6 , Francois Uwinkindi  1
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Implementation outcomes of national decentralization of integrated outpatient services for severe non-communicable diseases to district hospitals in Rwanda

Simon Pierre Niyonsenga et al. Trop Med Int Health. 2021 Aug.

Abstract

Objectives: Effective coverage of non-communicable disease (NCD) care in sub-Saharan Africa remains low, with the majority of services still largely restricted to central referral centres. Between 2015 and 2017, the Rwandan Ministry of Health implemented a strategy to decentralise outpatient care for severe chronic NCDs, including type 1 diabetes, heart failure and severe hypertension, to rural first-level hospitals. This study describes the facility-level implementation outcomes of this strategy.

Methods: In 2014, the Ministry of Health trained two nurses in each of the country's 42 first-level hospitals to implement and deliver nurse-led, integrated, outpatient NCD clinics, which focused on severe NCDs. Post-intervention evaluation occurred via repeated cross-sectional surveys, informal interviews and routinely collected clinical data over two rounds of visits in 2015 and 2017. Implementation outcomes included fidelity, feasibility and penetration.

Results: By 2017, all NCD clinics were staffed by at least one NCD-trained nurse. Among the approximately 27 000 nationally enrolled patients, hypertension was the most common diagnosis (70%), followed by type 2 diabetes (19%), chronic respiratory disease (5%), type 1 diabetes (4%) and heart failure (2%). With the exception of warfarin and beta-blockers, national essential medicines were available at more than 70% of facilities. Clinicians adhered to clinical protocols at approximately 70% agreement with evaluators.

Conclusion: The government of Rwanda was able to scale a nurse-led outpatient NCD programme to all first-level hospitals with good fidelity, feasibility and penetration as to expand access to care for severe NCDs.

Keywords: Africa; Rwanda; first-level hospital; national scale-up; non-communicable disease; rheumatic heart disease; rural; type 1 diabetes.

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Figures

Figure 1
Figure 1
Feasibility of NCD medication availability from 2015 (out of 29 DH sampled) to 2017 (out of 42 DH).
Figure 2
Figure 2
Quality of NCD care at all DHs in 2017.
Figure 3
Figure 3
NCD distribution across all DH NCD clinics in Rwanda, HMIS, 2019.
Figure 4
Figure 4
National enrolment of Type 1 Diabetes patients at DHs, HMIS, 2015–2019.
See this image and copyright information in PMC

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