Abstract
Background
In the light of the increasing burden of non-communicable diseases on health systems in low- and middle-income countries, particularly in Sub-Saharan Africa, context-adapted, cost-effective service delivery models are required urgently. Multiple models have been trialled across Africa with varying degrees of success. Zimbabwe is a low-income country with unique socio-economic challenges and a dual disease burden of infectious chronic diseases such as HIV and non-communicable diseases. We describe the experience of setting up and organising a nurse-led Diabetes Mellitus (DM) and Hypertension (HTN) model of care in rural Zimbabwe from July 2016 to June 2019.
Programme design and implementation
We used a conceptual framework successfully applied in the roll-out of antiretroviral therapy in Zimbabwe. Mirroring the HIV experience, we describe key enablers in the design and implementation of the model: decentralization of services, integration of care, simplification of guidelines, mentoring and task-sharing, provision of affordable medicines, quality assured laboratory support, patient empowerment, a dedicated monitoring and evaluation system, and a robust referral system. DM and HTN services were set up in 9 primary health care (PHC) facilities and two hospitals in Chipinge district, and integrated into the general out-patient department or pre-existing HIV clinics. In one hospital, an integrated chronic care clinic (ICCC) emerged. We provided mentoring for staff using simplified protocols, and patient education. Free medication and monitoring with point of care (POC) glycosylated haemoglobin (HbA1c) were provided. Nurses in 7 PHC facilities and one hospital developed sufficient knowledge and skills to diagnose and manage DM and HTN patients, and 3094 patients were registered. Major lessons learned include: the value of POC devices in the management of diabetes; the pressure on services due to added caseload, exacerbated by the availability of free medications; and the importance of leadership in successful programme implementation.
Conclusion
Our experience demonstrates a model for nurse-led decentralized integrated DM and HTN care in a high HIV prevalence rural, low-income context. Developing a context-adapted model of care is a dynamic process. We present our lessons learned with the intention of sharing experience which may be of value to other public health programme managers.
On-site mentorship and quality improvement to strengthen Non-Communicable
Diseases care in resource-limited settings: Lessons learned from rural
Rwanda
