Integrated Non-Communicable Disease Management at Primary Health Care Level (Health Centre III & IV and District Hospital) in Western Uganda

Objectives

To strengthen non-communicable disease (NCD) capacity in Western Uganda through establishment of clinics, training of health care professionals (HCPs) and the development of a manual of Integrated Chronic Disease Management
To engage key opinion leaders and enhance public knowledge on NCDs
To establish and operationalise a digital data management tool for Electronic Health Records

Approach

The project seeks to pilot a model for the management of NCDs in 40 primary level heath facilities using a team-based approach to chronic care management and involving communities through village health teams (VHTs).

Project activities include the refinement of training curriculum for HCPs and VHTs and elaboration of an integrated chronic disease management manual, based on WHO-PEN model, with SOPs for use in NCD outpatient clinics.

The project will build capacity of NCD clinics at each targeted facility through the provision of an initial 3-day training of HCPs in NCD care, hereafter combined with on-the-job training/mentorship and daily continuing medical education.

A model for integrated NCD care will be rolled out. This will include management of diabetes complications at targeted facilities through facility re-organisation to improve service efficiency and referral pathways, incl. provision of equipment. Fundus cameras will be procured for three district hospitals and diagnostic tools will be procured at the primary level.

The project will also include the refinement of a locally-owned Electronic Health Record (EHR)-NCD system, based on the successful model and roll out for Type 1 Diabetes Mellitus (T1DM) (WDF09-457) and CDiC, using algorithms based on WHO PEN protocols and the introduction of chronic care passports for patients of the NCD clinics.

Village Health Teams will be trained to identify high-risk persons for NCDs, deliver health education, refer patients and conduct follow-up visits, including usage of digital tools for management and record keeping.

Finally, the project will engage with district health officials, policy makers and key opinion leaders to advocate for the inclusion of NCD prevention and care in district health financing.

Expected results

40 integrated NCD outpatient clinics established in three districts in Western Uganda (catchment population of 1,325,800)
635 HCPs trained in the management of integrated NCDs (20 doctors, 75 clinical officers, 300 nurses, 40 pharmacists, 40 health information officers, 80 medical alboratory technicians and 80 village health teams).
One electronic patient registry established; 80 data managers trained
2,000 patients (1,200 Type 2 diabetes patients, 100 Type 1 diabetes patients, and 1,500 hypertensive patients) enrolled and treated in the established NCD clinics
1,250 patients screened for retinopathy and diabetes foot complications
180 local policy makers and key opinion leaders mobilised to support advocacy related to NCD management in their respective districts
Estimated 50% of diabetes patients within agreed target for glucose control at the end of the project