Kisoro District Hospital, Kisoro, Uganda.
Doctors for Global Health, Kisoro, Uganda.
PLoS One. 2020 Jun 5;15(6):e0234049. doi: 10.1371/journal.pone.0234049. eCollection 2020.
The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tri-partite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD risk-based treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of "stockouts" and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a granular description of the solutions we devised will be of benefit to others managing chronic disease in similar rural African communities.
全球非传染性疾病（NCDs）负担的文献对比了低收入国家中以低水平意识、风险因素控制、基础设施、人员和资金为中心的螺旋式上升的流行情况。在这些国家中，几乎没有关于广泛和相互关联的策略的基于数据的报告，以应对这些最严重的挑战。乌干达西南部的基索罗区是一个农村、偏远、人口过多和贫穷的地区，其大多数人口以自给农民为生。本文描述了基索罗区医院、一家纽约教学医院和一家美国非政府组织之间为期 10 年的三方合作的经验，该非政府组织向该地区提供高血压服务。我们使用来自患者和药房登记处以及手动审查的随机样本图表的数据，描述了质量护理的常见和经常被忽视的障碍（诊所拥挤、药品缺货、提供者短缺、就诊不遵守、和无信息的医疗记录）以及为解决这些障碍而采取的策略（当地适应性治疗指南、患者-诊所-药房费用分担、预约系统、劳动力发展、患者-提供者连续性举措和持续的数据监测）。我们发现：1）尽管按照心血管疾病风险为基础的治疗指南，可以安全地首先将稀缺药物分配给风险最高的患者，但强调在血压超过 140/90mmHg 时进行治疗的国家指南忽略了“缺货”的现实，与这一目标相冲突；2）经常被忽视的质量护理障碍，如医疗记录质量差、诊所混乱和当地就业做法是可以克服的；3）在政府供应药物缺货期间，费用分担举措部分填补了缺口，但对于最贫困的患者来说，可能仍然不足；4）对于大多数农村 SSA 的已知高血压患者来说，频繁的长期护理中断可能是常态；5）持续的数据监测可以识别质量护理的本地障碍，并提供改善这些障碍的动力。我们预计，我们在适应高血压管理复杂挑战方面的 10 年经验以及我们设计的解决方案的详细描述将对其他在类似农村非洲社区管理慢性疾病的人有所帮助。
