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MSF INTERNAL REPORT Evaluation of NCD Service Integrated Into A Evaluation of NCD service integrated into a general OPD and HIV service in Matsapha, Eswatini, 2017 Authors Ansbro, Eimhin; Meyer, Inga; Okello, Velephi; Verdecchia, Maria; Keus, Kees; Piening, Turid; Sadique, Zia; Roberts, Bayard; Perel, Pablo; Jobanputra, Kiran Download date 02/10/2021 17:01:29 Link to Item http://hdl.handle.net/10144/619308 Kingdom of Eswatini MSF INTERNAL REPORT Evaluation of NCD service integrated into a general OPD and HIV service in Matsapha, Eswatini, 2017 Author: Éimhín Ansbro1 Contributors: Inga Meyer2, Velephi Okello3, Maria Verdecchia2, Kees Keus2, Turid Piening4, Zia Sadique1, Bayard Roberts1, Pablo Perel1, Kiran Jobanputra5 1London School of Hygiene and Tropical Medicine, London, UK; 2Médecins Sans Frontières (MSF), Mbabane, Eswatini; 3Ministry of Health, Eswatini; 4MSF, Amsterdam, The Netherlands; 5MSF, London, UK This report is available in several versions, linked below: • Executive Summary (1 page) • Report – Short Version (5 pages) • Report – Extended Version (42 pages) MSF OCA and Eswatini MOH Matsapha NCD Evaluation Page 1 of 132 LIST OF ACRONYMS AHF AIDS Healthcare Foundation ART Antiretroviral Therapy BP Blood Pressure DRTB Drug-resistant Tuberculosis DSTB Drug-sensitive Tuberculosis FBG Fasting Blood Glucose HIV Human Immunodeficiency Virus LSHTM London School of Hygiene and Tropical Medicine MOH Ministry of Health MSF Médecins sans Frontières NCDs Noncommunicable diseases OPD Out-patient department PPPY Per person per year SOPs Standard Operating Procedures TB Tuberculosis WHO World Health Organization MSF OCA and Eswatini MOH Matsapha NCD Evaluation Page 2 of 132 TABLE OF CONTENTS EXECUTIVE SUMMARY ............................................................................................................................................ 4 REPORT – SHORT VERSION ..................................................................................................................................... 5 REPORT – EXTENDED VERSION ............................................................................................................................. 11 Background ........................................................................................................................................................... 11 Evaluation aim and objectives .............................................................................................................................. 15 Methodology ........................................................................................................................................................ 16 Study design ................................................................................................................................................. 16 Study Setting ................................................................................................................................................ 16 Data sources and collection ......................................................................................................................... 17 Data analysis ................................................................................................................................................ 19 Ethical considerations .................................................................................................................................. 23 Study implementation ................................................................................................................................. 23 Key Results ............................................................................................................................................................ 24 Model of integrated NCD care ......................................................................................................................... 24 Effectiveness of NCD care delivery ................................................................................................................... 32 Predictors of NCD treatment outcomes ........................................................................................................... 37 Costing results .................................................................................................................................................. 38 Discussion and Lessons Learned ........................................................................................................................... 42 Limitations ............................................................................................................................................................ 50 Recommendations for application in MSF settings .............................................................................................. 51 Recommendations for broader changes to policy and practice ........................................................................... 52 Future Research .................................................................................................................................................... 53 Acknowledgements .............................................................................................................................................. 53 References ............................................................................................................................................................ 54 Annexes ................................................................................................................................................................ 59 12.1 Matsapha Comprehensive Clinic Site Plan ........................................................................................... 59 12.2 Logistic regression to determine risk factors for uncontrolled fasting blood sugar among diabetic patients enrolled in Matsapha NCD programme ......................................................................................... 60 12.3 Patient flow, staffing and NCD/HIV screening In Matsapha NCD Programme .................................... 61 12.4 Input quantities and unit prices for MSF Eswatini MOH NCD programme cost analysis ..................... 62 12.5 Drugs prescribed by NCD diagnosis ..................................................................................................... 72 12.6 SOP for MSF Eswatini MOH Matsapha NCD Programme ..................................................................... 73 MSF OCA and Eswatini MOH Matsapha NCD Evaluation Page 3 of 132 EXECUTIVE SUMMARY Background: Swaziland faces a growing noncommunicable disease (NCD) burden alongside HIV and TB epidemics. MSF provided primary care services, HIV and TB programmes at Matsapha MOH comprehensive clinic from 2011 to 2018. With MOH collaboration, MSF integrated NCD care into general outpatient (OPD), HIV and TB services in April 2016. A retrospective analysis of routine clinical and programmatic data was undertaken to examine programme processes, effectiveness and costs in order to strengthen the service, facilitate handover and inform MSF and MOH policy and scale-up. The specific objectives were to: 1) describe the care model; 2) examine its effectiveness; 3) examine predictors of NCD treatment outcomes, including HIV status; and 4) determine incremental total and unit service costs. Methods: We undertook a retrospective evaluation of routine data from Matsapha Comprehensive Care Clinic, located outside Manzini, Eswatini’s largest city. This comprised: care model description; routine cohort data analysis to investigate effectiveness of care and predictors of reaching clinical targets; and incremental costing analysis. Enrolment criteria included: a diagnosis of established cardiovascular disease (CVD), hypertension, diabetes mellitus (DM) types 1 or 2, chronic respiratory disease; and committing to regular attendance. Routine clinical data of adults aged 18 or over, enrolled from July 2016 to July 2017, were analysed using descriptive statistics and logistic regression modelling. A costing analysis from the providers’ perspective utilised routine accounting, service and consumption data. Results: Model of care description: We implemented: staff training; locally adapted protocols; chronic care files; a revised appointment system and patient flow; and a new database. Doctors reviewed patients at first visit, and saw complex or unstable patients monthly, resulting in significant workload. Nurses reviewed stable patients three-monthly; patients requiring treatment initiation/adjustment, ad hoc blood testing or external referral were referred back to doctors. Thus, task sharing to nurses did not occur as intended. Specific health literacy, adherence support groups or lay counsellor involvement were lacking. Integrating NCD care resulted in longer consultation times. Repeated medication stock outs occurred despite MSF’s efforts to support the MOH supply chain. Routine cohort data analysis: Of 895 enrolled patients, mean age was 55 years (IQR 5.3 to 10.6); 66% were women, of whom 54.6% were obese. Mean follow-up was 8 months; 16.3% defaulted during the study period. The most common diagnoses at enrolment were: hypertension (85.7%) and DM type 2 (37.4%), asthma (3.8%) and DM type 1 (1.2%). 3 patients had known CVD; none had known chronic obstructive pulmonary disease. At last visit, 60.4% (n=608) of hypertensive patients and 63.3% (n=289) of diabetics were at target. Obesity and HIV positivity were weakly associated with an increased risk
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