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Tesema AG, Joshi R, Abimbola S, Mirkuzie AH, Berlina D, Collins T, Peiris D. Readiness for non-communicable disease service delivery in Ethiopia: an empirical analysis. BMC Health Serv Res 2024; 24:1021. [PMID: 39232694 PMCID: PMC11375874 DOI: 10.1186/s12913-024-11455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 08/19/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Ethiopia's health system is overwhelmed by the growing burden of non-communicable diseases (NCDs). In this study, we assessed the availability of and readiness for NCD services and the interaction of NCD services with other essential and non-NCD services. METHODS The analysis focused on four main NCD services: diabetes mellitus, cardiovascular diseases, chronic respiratory diseases, and cancer screening. We used data from the 2018 Ethiopian Service Availability and Readiness Assessment (SARA) survey. As defined by the World Health Organization, readiness, both general and service-specific, was measured based on the mean percentage availability of the tracer indicators, such as trained staff and guidelines, equipment, diagnostic capacity, and essential medicines and commodities needed for delivering essential health services and NCD-specific services, respectively. The survey comprised 632 nationally representative healthcare facilities, and we applied mixed-effects linear and ordered logit models to identify factors affecting NCD service availability and readiness. RESULTS Only 8% of facilities provided all four NCD services. Availability varied for specific services, with cervical cancer screening being the least available service in the country: less than 10% of facilities, primarily higher-level hospitals, provided cervical cancer screening. General service readiness was a strong predictor of NCD service availability. Differences in NCD service availability and readiness between regions and facility types were significant. Increased readiness for specific NCD services was significantly associated with increased readiness for communicable disease services and interacted with the readiness for other NCD services. CONCLUSION NCD service availability has considerable regional variation and is positively associated with general and communicable disease services readiness. Readiness for specific NCD services interacted with one another. The findings suggest an integrated approach to service delivery, focussing holistically on all disease services, is needed. There also needs to be increased attention to reducing resource allocation variation between facility types and locations.
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Affiliation(s)
- Azeb Gebresilassie Tesema
- School of Population Health, University of New South Wales, Sydney, Australia.
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Sydney, Australia.
| | - Rohina Joshi
- School of Population Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
| | - Seye Abimbola
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | | | - Daria Berlina
- Global Noncommunicable Diseases Platform, World Health Organization, Geneva, Switzerland
| | - Tea Collins
- Global Noncommunicable Diseases Platform, World Health Organization, Geneva, Switzerland
| | - David Peiris
- The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Sydney, Australia
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Chay J, Su RJ, Kamano JH, Andama B, Bloomfield GS, Delong AK, Horowitz CR, Menya D, Mugo R, Orango V, Pastakia SD, Wanyonyi C, Vedanthan R, Finkelstein EA. Cost-effectiveness of group medical visits and microfinance interventions versus usual care to manage hypertension in Kenya: a secondary modelling analysis of data from the Bridging Income Generation with Group Integrated Care (BIGPIC) trial. Lancet Glob Health 2024; 12:e1331-e1342. [PMID: 39030063 DOI: 10.1016/s2214-109x(24)00188-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/14/2024] [Accepted: 04/23/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND The Bridging Income Generation with Group Integrated Care (BIGPIC) trial in rural Kenya showed that integrating usual care with group medical visits or microfinance interventions reduced systolic blood pressure and cardiovascular risk in participants. We aimed to estimate the incremental cost-effectiveness of three BIGPIC interventions for a modelled cohort and by sex, as well as the cost of implementing these interventions. METHODS For this analysis, we used data collected during the BIGPIC trial, a four-group, cluster-randomised trial conducted in the western Kenyan catchment area of the Academic Model Providing Access to Healthcare. BIGPIC enrolled participants from 24 rural health facilities in rural western Kenya aged 35 years or older with either increased blood pressure or diabetes. Participants were assigned to receive either usual care, group medical visits, microfinance, or a combination of group medical visits and microfinance (GMV-MF). Our model estimated the incremental cost-effectiveness of the three BIGPIC interventions via seven health states (ie, a hypertensive state, five chronic cardiovascular-disease states, and a death state) by simulating transitions between health states for a hypothetical cohort of individuals with hypertension on the basis of QRISK3 scores. In every cycle, participants accrued costs and disability-adjusted life-years (DALYs) associated with their health state. Incremental cost-effectiveness ratios (ICERs) were calculated for the entire modelled cohort and by sex by dividing the incremental cost by the incremental effectiveness of the next most expensive intervention. The main outcome of this analysis was ICERs for each intervention evaluated. This analysis is registered at ClinicalTrials.gov (NCT02501746). FINDINGS Between Feb 6, 2017, and Dec 29, 2019, 2890 people were recruited to the BIGPIC trial. 2020 (69·9%) of 2890 participants were female and 870 (30·1%) were male. At baseline, mean QRISK3 score was 11·5 (95% CI 11·1-11·9) for the trial population, 11·9 (11·5-12·2) for male participants, and 11·3 (11·0-11·6) for female participants. For the population of Kenya, group medical visits were estimated to cost US$7 more per individual than usual care and result in 0·005 more DALYs averted (ICER $1455 per DALY averted). Microfinance was estimated to cost $19 more than group medical visits but was only estimated to avert 0·001 more DALYs. Relative to group medical visits, GMV-MF was estimated to cost $29 more and avert 0·009 more DALYs ($3235 per DALY averted). Relative to usual care, GMV-MF was estimated to cost $37 more and avert 0·014 more DALYs ($2601 per DALY averted). In the first year of the intervention, usual care was estimated to be the least expensive intervention to implement ($87 per participant; $10 238 per health-facility catchment area [HFCA]), then group medical visits ($99 per participant; $12 268 per HFCA), then microfinance ($120 per participant; $14 172 per HFCA), with GMV-MF estimated to be the most expensive intervention to implement ($139 per participant; $16 913 per HFCA). INTERPRETATION Group medical visits and GMV-MF were estimated to be cost-effective strategies to improve blood-pressure control in rural Kenya. However, which intervention to pursue depends on resource availability. Policy makers should consider these factors, in addition to sex differences in programme effectiveness, when selecting optimal implementation strategies. FUNDING US National Institutes of Health.
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Affiliation(s)
- Junxing Chay
- Health Services and Systems Research, Duke-NUS Medical School, Singapore.
| | - Rebecca J Su
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Jemima H Kamano
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Benjamin Andama
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Allison K Delong
- Center for Statistical Sciences, Brown University, Providence, RI, USA
| | - Carol R Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Diana Menya
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Richard Mugo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Vitalis Orango
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Sonak D Pastakia
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | | | - Rajesh Vedanthan
- Department of Population Health, Grossman School of Medicine, New York University, New York, NY, USA
| | - Eric A Finkelstein
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Duke Global Health Institute, Duke University, Durham, NC, USA
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Alie MS, Girma D, Adugna A, Negesse Y. Diabetes mellitus service preparedness and availability: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1427175. [PMID: 39099669 PMCID: PMC11294177 DOI: 10.3389/fendo.2024.1427175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/28/2024] [Indexed: 08/06/2024] Open
Abstract
Background In areas with limited resources, the lack of preparedness and limited availability of diabetes mellitus services in healthcare facilities contribute to high rates of illness and death related to diabetes mellitus. As a result, this study focused on analyzing the combined prevalence of preparedness and availability of diabetic services in countries with limited resources. Methods A comprehensive search was conducted across various databases, such as PubMed/MEDLINE, Web of Science, Google Scholar, and African Journal Online. The search aimed to identify primary research articles that assessed the availability and preparedness of services for individuals with type 2 diabetes mellitus specifically. The articles included in the search spanned from January 2000 to 23 February 2024. To analyze the data, a meta-analysis of proportions was performed using the random-effects model. Additionally, the researchers assessed publication bias by examining a funnel plot and conducting Egger's test. Heterogeneity and sensitivity analyses were also conducted to evaluate the data. The findings of the study regarding the pooled prevalence of diabetes service preparedness and availability, along with their corresponding 95% confidence intervals, were presented using a forest plot. Results A comprehensive analysis was conducted on 16 research articles that focused on service preparedness and 11 articles that examined service availability. The sample sizes for these studies were 3,422 for service preparedness and 1,062 for service availability. The findings showed that the pooled prevalence of diabetes service preparedness was 53.0% (95% CI: 47.0-60.0). Furthermore, in this systematic synthesis, the overall pooled prevalence of service availability for diabetes mellitus was 48% (95% CI: 36.0-67.0), with the highest pooled prevalence observed in Asia, with a pooled prevalence of 58% (95% CI: 38.0-89.0). Conclusion Our study reveals a significant disparity in the preparedness and availability of services for diabetes mellitus, which falls below the minimum threshold set by the WHO. These findings should capture the attention of policymakers and potentially serve as a foundation for reevaluating the current approach to diabetes service preparedness and availability. To enhance the availability and preparedness of diabetes services, a tailored, multifaceted, and action-oriented approach to strengthening the health system is required. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42024554911.
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Affiliation(s)
- Melsew Setegn Alie
- Department of Public Health, School of Public Health, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Desalegn Girma
- Department of Midwifery, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Amauel Adugna
- Department of Midwifery, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Yilkal Negesse
- Department of Public Health, College of Medicine and Health Science, Debre Markos University, Debre Markos, Ethiopia
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Mwenda V, Murage D, Kilonzo C, Bor JP, Njiri P, Osiro L, Nyangasi M, Arbyn M, Tummers P, Temmerman M. Baseline assessment of cervical cancer screening and treatment capacity in 25 counties in Kenya, 2022. Front Oncol 2024; 14:1371529. [PMID: 39015502 PMCID: PMC11249718 DOI: 10.3389/fonc.2024.1371529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/18/2024] [Indexed: 07/18/2024] Open
Abstract
Background Cervical cancer is the leading cause of cancer deaths among women in Kenya. In the context of the Global strategy to accelerate the elimination of cervical cancer as a public health problem, Kenya is currently implementing screening and treatment scale-up. For effectively tracking the scale-up, a baseline assessment of cervical cancer screening and treatment service availability and readiness was conducted in 25 priority counties. We describe the findings of this assessment in the context of elimination efforts in Kenya. Methods The survey was conducted from February 2021 to January 2022. All public hospitals in the target counties were included. We utilized healthcare workers trained in preparation for the scale-up as data collectors in each sub-county. Two electronic survey questionnaires (screening and treatment; and laboratory components) were used for data collection. All the health system building blocks were assessed. We used descriptive statistics to summarize the main service readiness indicators. Results Of 3,150 hospitals surveyed, 47.6% (1,499) offered cervical cancer screening only, while 5.3% (166) offered both screening and treatment for precancer lesions. Visual inspection with acetic acid (VIA) was used in 96.0% (1,599/1,665) of the hospitals as primary screening modality and HPV testing was available in 31 (1.0%) hospitals. Among the 166 hospitals offering treatment for precancerous lesions, 79.5% (132/166) used cryotherapy, 18.7% (31/166) performed thermal ablation and 25.3% (42/166) performed large loop excision of the transformation zone (LLETZ). Pathology services were offered in only 7.1% (17/238) of the hospitals expected to have the service (level 4 and above). Only 10.8% (2,955/27,363) of healthcare workers were trained in cervical cancer screening and treatment; of these, 71.0% (2,097/2,955) were offering the services. Less than half of the hospitals had cervical cancer screening and treatment commodities at time of survey. The main health system strength was presence of multiple screening points at hospitals, but frequent commodity stock-outs was a key weakness. Conclusion Training, commodities, and diagnostic services are major gaps in the cervical cancer program in Kenya. To meet the 2030 elimination targets, the national and county governments should ensure adequate financing, training, and service integration, especially at primary care level.
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Affiliation(s)
- Valerian Mwenda
- National Cancer Control Program, Ministry of Health, Nairobi, Kenya
| | - David Murage
- National Cancer Control Program, Ministry of Health, Nairobi, Kenya
- Field Epidemiology and Laboratory Program, Ministry of Health, Nairobi, Kenya
| | - Catherine Kilonzo
- Field Epidemiology and Laboratory Program, Ministry of Health, Nairobi, Kenya
| | - Joan-Paula Bor
- National Cancer Control Program, Ministry of Health, Nairobi, Kenya
| | - Patricia Njiri
- Noncommunicable Disease Program, Clinton Health Access Initiative, Nairobi, Kenya
| | - Lance Osiro
- Noncommunicable Disease Program, Clinton Health Access Initiative, Nairobi, Kenya
| | - Mary Nyangasi
- National Cancer Control Program, Ministry of Health, Nairobi, Kenya
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Philippe Tummers
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium
| | - Marleen Temmerman
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
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Kassa RN, Shifti DM, Alemu K, Omigbodun AO. Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003183. [PMID: 38743652 DOI: 10.1371/journal.pgph.0003183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 04/11/2024] [Indexed: 05/16/2024]
Abstract
Cervical cancer is a prevalent disease among women, especially in low- and middle-income countries (LMICs), where most deaths occur. Integrating cervical cancer screening services into healthcare facilities is essential in combating the disease. Thus, this review aims to map evidence related to integrating cervical cancer screening into existing primary care services and identify associated barriers and facilitators in LMICs. The scoping review employed a five-step framework as proposed by Arksey and O'Malley. Five databases (MEDLINE, Maternity Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science) were systematically searched. Data were extracted, charted, synthesized, and summarised. A total of 28 original articles conducted in LMICs from 2000 to 2023 were included. Thirty-nine percent of the reviewed studies showed that cervical cancer screening (CCS) was integrated into HIV clinics. The rest of the papers revealed that CCS was integrated into existing reproductive and sexual health clinics, maternal and child health, family planning, well-baby clinics, maternal health clinics, gynecology outpatient departments, and sexually transmitted infections clinics. The cost-effectiveness of integrated services, promotion, and international initiatives were identified as facilitators while resource scarcity, lack of skilled staff, high client loads, lack of preventive oncology policy, territorial disputes, and lack of national guidelines were identified as barriers to the services. The evidence suggests that CCS can be integrated into healthcare facilities in LMICs, in various primary care services, including HIV clinics, reproductive and sexual health clinics, well-baby clinics, maternal health clinics, and gynecology OPDs. However, barriers include limited health system capacity, workload, waiting times, and lack of coordination. Addressing these gaps could strengthen the successful integration of CCS into primary care services and improve cervical cancer prevention and treatment outcomes.
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Affiliation(s)
- Rahel Nega Kassa
- Pan African University Life and Earth Sciences Institute (including Health and Agriculture), University of Ibadan, Ibadan, Oyo State, Nigeria
- School of Nursing, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Akinyinka O Omigbodun
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Oyo State, Nigeria
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R S, R A, P P. Root Cause Analysis of Gaps in Non-communicable Disease Monitoring in a Sub-district Hospital, Tamil Nadu: A Quality Improvement Initiative. Cureus 2024; 16:e57095. [PMID: 38681427 PMCID: PMC11053342 DOI: 10.7759/cureus.57095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Introduction Non-communicable diseases (NCDs) present a significant public health challenge globally, and India is deeply affected. With the largest population in the world, India struggles with a high burden of NCDs, encompassing cardiovascular diseases, diabetes, cancer, and chronic respiratory conditions. These ailments contribute substantially to morbidity and mortality, placing a strain on healthcare systems. Despite efforts through public health initiatives, NCD monitoring and management remain deficient, especially at grassroots levels. Methods At a sub-district hospital in Tamil Nadu, India, a quality improvement initiative targeted diabetes and hypertension, prevalent NCDs. Utilizing Fishbone analysis and process flow diagrams, we identified gaps in NCD monitoring. Employing the Plan-Do-Study-Act model and reorienting the patient flow, we enhanced NCD monitoring by optimizing patient health record maintenance within the hospital. Results Root cause analysis identified a lack of patient record protocols and patient loss of records as key hindrances in NCD monitoring. We revamped patient flow and implemented a robust record-keeping system, boosting access to patient health records. This initiative was embraced by healthcare providers, enhancing NCD management. Leveraging these records, we assessed control rates of diabetes and hypertension patients effectively. Conclusion The research underscores the importance of maintaining comprehensive patient health records in healthcare centers for enhancing NCD monitoring. These records serve as valuable tools for healthcare providers, aiding in the monitoring and treatment of patients with diabetes and hypertension. By leveraging these records, healthcare providers can achieve better disease control outcomes, thereby improving the overall management of NCDs.
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Affiliation(s)
- Stalin R
- Community Medicine, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Chennai, IND
| | - Angusubalakshmi R
- Community Medicine, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Chennai, IND
| | - Priya P
- Community Medicine, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Chennai, IND
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Ahmed S, Cao Y, Wang Z, Coates MM, Twea P, Ma M, Chiwanda Banda J, Wroe E, Bai L, Watkins DA, Su Y. Service readiness for the management of non-communicable diseases in publicly financed facilities in Malawi: findings from the 2019 Harmonised Health Facility Assessment census survey. BMJ Open 2024; 14:e072511. [PMID: 38176873 PMCID: PMC10773330 DOI: 10.1136/bmjopen-2023-072511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 11/08/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION Non-communicable diseases (NCDs) are rising in low-income and middle-income countries, including Malawi. To inform policy-makers and planners on the preparedness of the Malawian healthcare system to respond to NCDs, we estimated NCD service readiness in publicly financed healthcare facilities in Malawi. METHODS We analysed data from 564 facilities surveyed in the 2019 Harmonised Health Facility Assessment, including 512 primary healthcare (PHC) and 52 secondary and tertiary care (STC) facilities. To characterise service readiness, applying the law of minimum, we estimated the percentage of facilities with functional equipment and unexpired medicines required to provide NCD services. Further, we estimated permanently unavailable items to identify service readiness bottlenecks. RESULTS Fewer than 40% of PHC facilities were ready to deliver services for each of the 14 NCDs analysed. Insulin and beclomethasone inhalers had the lowest stock levels at PHC facilities (6% and 8%, respectively). Only 17% of rural and community hospitals (RCHs) have liver and kidney diagnostics. STC facilities had varying service readiness, ranging from 27% for managing acute diabetes complications to 94% for chronic type 2 diabetes management. Only 38% of STC facilities were ready to manage chronic heart failure. Oral pain medicines were widely available at all levels of health facilities; however, only 22% of RCHs and 29% of STCs had injectable morphine or pethidine. Beclomethasone was never available at 74% of PHC and 29% of STC facilities. CONCLUSION Publicly financed facilities in Malawi are generally unprepared to provide NCD services, especially at the PHC level. Targeted investments in PHC can substantially improve service readiness for chronic NCD conditions in local communities and enable STC to respond to acute NCD complications and more complex NCD cases.
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Affiliation(s)
- Sali Ahmed
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Yanjia Cao
- Department of Geography, The University of Hong Kong, Hong Kong, China
| | - Zicheng Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Matthew M Coates
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pakwanja Twea
- Bergen Centre for Ethics and Priority Setting, University of Bergen, Bergen, Norway
- Department of Planning and Policy Development, Ministry of Health, Lilongwe, Malawi
| | - Mingyang Ma
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jonathan Chiwanda Banda
- Curative and Medical Rehabilitation Services, Ministry of Health, lilongwe, Malawi
- Department of Community and Environmental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Emily Wroe
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lan Bai
- Department of Public Administration, Nanjing University of Traditional Chinese Medicine, Nanjing, China
| | - David A Watkins
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, Washington, USA
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Njuguna C, Tola HH, Maina BN, Magambo KN, Phoebe N, Tibananuka E, Turyashemererwa FM, Rubangakene M, Richard K, Opong G, Richard S, Opesen C, Mateeba T, Muyingo E, George U, Namukose S, Woldemariam YT. Essential health services delivery and quality improvement actions under drought and food insecurity emergency in north-east Uganda. BMC Health Serv Res 2023; 23:1387. [PMID: 38082433 PMCID: PMC10714455 DOI: 10.1186/s12913-023-10377-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Essential health services can be disrupted due to several naturally occurring public health emergencies such as drought, flood, earthquake and outbreak of infectious diseases. However, little evidence exists on the status of essential health services delivery under the effect of drought and food insecurity. North-east Uganda is severely affected by prolonged drought that significantly affected the livelihood of the residents. Therefore, we aimed to determine the current status of essential health services and quality improvement (QI) actions in health facilities in north-east Uganda. METHODS We used a descriptive cross-sectional study design to assess the availability of essential health service and quality improvement activities in drought and food insecurity affected districts of north-east Uganda. We included a total of 150 health facilities from 15 districts with proportionated multistage sampling method. We interviewed health facilities' managers and services focal persons using structured questionnaire and observation checklist. We used a descriptive statistic to analyze the data with SPSS version 22. RESULTS A few health facilities (8.7%) had mental health specialist. There was also lack of capacity building training on essential health services. Considerable proportion of health facilities had no non-communicable diseases (38.3%), mental health (47.0%), and basic emergency obstetric care (40.3%) services. Stock out of essential medicines were observed in 20% of health facilities. There was lack of supportive supervision, and poor documentation of QI activities. CONCLUSION Essential health service and QI were suboptimal in drought and food insecure emergency affected districts. Human resource deployment (especially mental health specialist), provision of capacity building training, improving non-communicable diseases, mental health and basic emergency obstetric care services are required to improve availability of essential health services. Supporting supply chain management to minimize stock out of medicines, and promoting QI activities are also vital to assure quality of health service in drought and food insecurity affected districts in north-Eastern Uganda.
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Affiliation(s)
- Charles Njuguna
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda.
| | - Habteyes Hailu Tola
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Benson Ngugi Maina
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Kwikiriza Nicholas Magambo
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Nabunya Phoebe
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Evelyne Tibananuka
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Florence M Turyashemererwa
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Moses Rubangakene
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Kisubika Richard
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - George Opong
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Ssekitoleko Richard
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Chris Opesen
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
| | - Tim Mateeba
- Ministry of Health of Uganda, Kampala, Uganda
| | | | | | | | - Yonas Tegegn Woldemariam
- World Health Organization Uganda Country Office, Plot 60 Prince Charles Drive, Kololo, P.O. Box 24578, Kampala, Uganda
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Aber-Odonga H, Nuwaha F, Kisaakye E, Engebretsen IMS, Babirye JN. Health facility readiness to screen, diagnose and manage substance use disorders in Mbale district, Uganda. Subst Abuse Treat Prev Policy 2023; 18:63. [PMID: 37925411 PMCID: PMC10625191 DOI: 10.1186/s13011-023-00570-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/19/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Substance use disorders (SUD) pose a significant public health problem in Uganda. Studies indicate that integrating mental health services into Primary Health Care can play a crucial role in alleviating the impact of SUD. However, despite ongoing efforts to integrate these services in Uganda, there is a lack of evidence regarding the preparedness of health facilities to effectively screen and manage SUD. Therefore, this study aimed to assess the readiness of health facilities at all levels of the health system in Mbale, Uganda, to carry out screening, diagnosis, and management of SUD. METHODS A health facility-based cross-sectional study was carried out among all the 54 facilities in Mbale district. A composite variable adapted from the WHO Service Availability and Readiness Assessment manual (2015) with 14 tracer indicators were used to measure readiness. A cut-off threshold of having at least half the criteria fulfilled (higher than the cutoff of 7) was classified as having met the readiness criteria. Descriptive analyses were performed to describe readiness scores across various facility characteristics and a linear regression model was used to identify the predictors of readiness. RESULTS Among all health facilities assessed, only 35% met the readiness criteria for managing Substance Use Disorders (SUD). Out of the 54 facilities, 42 (77.8%) had guidelines in place for managing SUD, but less than half, 26 (48%), reported following these guidelines. Only 8 out of 54 (14.5%) facilities had staff who had received training in the diagnosis and management of SUD within the past two years. Diagnostic tests for SUD, specifically the Uri stick, were available in the majority of facilities, (46/54, 83.6%). A higher number of clinical officers working at the health centres was associated with higher readiness scores (score coefficient 4.0,95% CI 1.5-6.5). CONCLUSIONS In this setting, a low level of health facility readiness to provide screening, diagnosis, and management for substance use disorders was found. To improve health facility readiness for delivery of care for substance use disorders, a frequent inventory of human resources in terms of numbers, skills, and other resources are required in this resource-limited setting.
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Affiliation(s)
- Harriet Aber-Odonga
- School of Public Health, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.
| | - Fred Nuwaha
- School of Public Health, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda
| | - Esther Kisaakye
- School of Public Health, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda
| | - Ingunn Marie S Engebretsen
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, 7804, Norway
| | - Juliet Ndimwibo Babirye
- School of Public Health, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda
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Onteri SN, Kariuki J, Mathu D, Wangui AM, Magige L, Mutai J, Chuchu V, Karanja S, Ahmed I, Mokua S, Otambo P, Bukania Z. Diabetes health care specific services readiness and availability in Kenya: Implications for Universal Health Coverage. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002292. [PMID: 37756286 PMCID: PMC10529624 DOI: 10.1371/journal.pgph.0002292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023]
Abstract
Diabetes is a major cause of morbidity and mortality worldwide yet preventable. Complications of undetected and untreated diabetes result in serious human suffering and disability. It negatively impacts on individual's social economic status threatening economic prosperity. There is a scarcity of data on health system diabetes service readiness and availability in Kenya which necessitated an investigation into the specific availability and readiness of diabetes services. A cross sectional descriptive study was carried out using the Kenya service availability and readiness mapping tool in 598 randomly selected public health facilities in 12 purposively selected counties. Ethical standards outlined in the 1964 Declaration of Helsinki and its later amendments were upheld throughout the study. Health facilities were classified into primary and secondary level facilities prior to statistical analysis using IBM SPSS version 25. Exploratory data analysis techniques were employed to uncover the distribution structure of continuous study variables. For categorical variables, descriptive statistics in terms of proportions, frequency distributions and percentages were used. Of the 598 facilities visited, 83.3% were classified as primary while 16.6% as secondary. A variation in specific diabetes service availability and readiness was depicted in the 12 counties and between primary and secondary level facilities. Human resource for health reported a low mean availability (46%; 95% CI 44%-48%) with any NCDs specialist and nutritionist the least carder available. Basic equipment and diagnostic capacity reported a fairly high mean readiness (73%; 95% CI 71%-75%) and (64%; 95%CI 60%-68%) respectively. Generally, primary health facilities had low diabetic specific service availability and readiness compared to secondary facilities: capacity to cope with diabetes increased as the level of care ascended to higher levels. Significant gaps were identified in overall availability and readiness in both primary and secondary levels facilities particularly in terms of human resource for health specifically nutrition and laboratory profession.
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Affiliation(s)
- Stephen N. Onteri
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - James Kariuki
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - David Mathu
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Antony M. Wangui
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Lucy Magige
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Joseph Mutai
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Vyolah Chuchu
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Sarah Karanja
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Ismail Ahmed
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Sharon Mokua
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Priscah Otambo
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
| | - Zipporah Bukania
- Centre for Public Health Research, Kenya Medical Research Institute Kenya, Nairobi, Kenya
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11
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Otieno P, Agyemang C, Wainaina C, Igonya EK, Ouedraogo R, Wambiya EOA, Osindo J, Asiki G. Perceived health system facilitators and barriers to integrated management of hypertension and type 2 diabetes in Kenya: a qualitative study. BMJ Open 2023; 13:e074274. [PMID: 37567749 PMCID: PMC10423776 DOI: 10.1136/bmjopen-2023-074274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVE Understanding the facilitators and barriers to managing hypertension and type 2 diabetes (T2D) will inform the design of a contextually appropriate integrated chronic care model in Kenya. We explored the perceived facilitators and barriers to the integrated management of hypertension and T2D in Kenya using the Rainbow Model of Integrated Care. DESIGN This was a qualitative study using data from a larger mixed-methods study on the health system response to chronic disease management in Kenya, conducted between July 2019 and February 2020. Data were collected through 44 key informant interviews (KIIs) and eight focus group discussions (FGDs). SETTING Multistage sampling procedures were used to select a random sample of 12 study counties in Kenya. PARTICIPANTS The participants for the KIIs comprised purposively selected healthcare providers, county health managers, policy experts and representatives from non-state organisations. The participants for the FGDs included patients with hypertension and T2D. OUTCOME MEASURES Patients' and providers' perspectives of the health system facilitators and barriers to the integrated management of hypertension and T2D in Kenya. RESULTS The clinical integration facilitators included patient peer support groups for hypertension and T2D. The major professional integration facilitators included task shifting, continuous medical education and integration of community resource persons. The national referral system, hospital insurance fund and health management information system emerged as the major facilitators for organisational and functional integration. The system integration facilitators included decentralisation of services and multisectoral partnerships. The major barriers comprised vertical healthcare services characterised by service unavailability, unresponsiveness and unaffordability. Others included a shortage of skilled personnel, a lack of interoperable e-health platforms and care integration policy implementation gaps. CONCLUSIONS Our study identified barriers and facilitators that may be harnessed to improve the integrated management of hypertension and T2D. The facilitators should be strengthened, and barriers to care integration redressed.
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Affiliation(s)
- Peter Otieno
- Chronic Disease Management Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
- Department of Public & Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development (AIGHD), AHTC, Amsterdam, The Netherlands
| | - Charles Agyemang
- Department of Public & Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Caroline Wainaina
- Department of Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Emmy Kageha Igonya
- Department of Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Ramatou Ouedraogo
- Department of Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | | | - Jane Osindo
- Department of Emerging and Re-emerging Infectious Diseases, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Gershim Asiki
- Chronic Disease Management Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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12
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Adhikari B, Pandey AR, Lamichhane B, Kc SP, Joshi D, Regmi S, Giri S, Baral SC. Readiness of health facilities to provide services related to non-communicable diseases in Nepal: evidence from nationally representative Nepal Health Facility Survey 2021. BMJ Open 2023; 13:e072673. [PMID: 37423630 DOI: 10.1136/bmjopen-2023-072673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE To assess the readiness of public and private health facilities (HFs) in delivering services related to non-communicable diseases (NCDs) in Nepal. METHODS We analysed data from nationally representative Nepal Health Facility Survey 2021 to determine the readiness of HFs for cardiovascular diseases (CVDs), diabetes mellitus (DM), chronic respiratory diseases (CRDs) and mental health (MH)-related services using Service Availability and Readiness Assessment Manual of the WHO. Readiness score was measured as the average availability of tracer items in per cent, and HFs were considered 'ready' for NCDs management if they scored ≥70 (out of 100). We performed weighted univariate and multivariable logistic regression to determine the association of HFs readiness with province, type of HFs, ecological region, quality assurance activities, external supervision, client's opinion review and frequency of meetings in HFs. RESULTS The overall mean readiness score of HFs offering CRDs, CVDs, DM and MH-related services was 32.6, 38.0, 38.4 and 24.0, respectively. Guidelines and staff training domain had the lowest readiness score, whereas essential equipment and supplies domain had the highest readiness score for each of the NCD-related services. A total of 2.3%, 3.8%, 3.6% and 3.3% HFs were ready to deliver CRDs, CVDs, DM and MH-related services, respectively. HFs managed by local level were less likely to be ready to provide all NCD-related services compared with federal/provincial hospitals. HFs with external supervision were more likely to be ready to provide CRDs and DM-related services and HFs reviewing client's opinions were more likely to be ready to provide CRDs, CVDs and DM-related services. CONCLUSION Readiness of the HFs managed by local level to provide CVDs, DM, CRDs and MH-related services was relatively poor compared with federal/provincial hospitals. Prioritisation of policies to reduce the gaps in readiness and capacity strengthening of the local HFs is essential for improving their overall readiness to provide NCD-related services.
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Affiliation(s)
- Bikram Adhikari
- Research, Evaluation and Innovation Department, HERD International, Kathmandu, Nepal
| | - Achyut Raj Pandey
- Research, Evaluation and Innovation Department, HERD International, Kathmandu, Nepal
| | - Bipul Lamichhane
- Research, Evaluation and Innovation Department, HERD International, Kathmandu, Nepal
| | - Saugat Pratap Kc
- Research, Evaluation and Innovation Department, HERD International, Kathmandu, Nepal
| | - Deepak Joshi
- Research, Evaluation and Innovation Department, HERD International, Kathmandu, Nepal
| | - Shophika Regmi
- Research, Evaluation and Innovation Department, HERD International, Kathmandu, Nepal
| | - Santosh Giri
- Research, Evaluation and Innovation Department, HERD International, Kathmandu, Nepal
| | - Sushil Chandra Baral
- Research, Evaluation and Innovation Department, HERD International, Kathmandu, Nepal
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13
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Sureshkumar S, Mwangi KJ, Gathecha G, Marcus K, Kohlbrenner B, Issom D, Benissa MR, Aebischer-Perone S, Braha N, Candela E, Chhabra KG, Desikachari BR, Dondi A, Etchebehere M, Kengne AP, Missoni E, Mustapha F, Palafox B, Pati S, Madhu PP, Peer N, Quint J, Tabrizi R, Yusoff H, Oris M, Beran DH, Balabanova D, Etter JF. Exploring key-stakeholder perceptions on non-communicable disease care during the COVID-19 pandemic in Kenya. Pan Afr Med J 2023; 44:153. [PMID: 37455892 PMCID: PMC10349631 DOI: 10.11604/pamj.2023.44.153.38616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/14/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction over one third of total Disability-Adjusted-Life-Years lost in Kenya are due to non-communicable diseases (NCD). In response, the Government declared significant commitment towards improving NCD care. The COVID-19 pandemic increased the burden on the already overstretched health systems in Kenya. The aims of this study are to assess whether health care providers perceived NCD care to be optimal during the pandemic and explore how to improve responses to future emergencies. Methods this cross-sectional online survey included healthcare personnel with non-clinical roles (public health workers and policy-makers) and those delivering health care (doctors and nurses). Respondents were recruited between May and September 2021 by random sampling, completed by snowball sampling. Results among 236 participants (42% in clinical, 58% in non-clinical roles) there was an overall consensus between respondents on NCD care being disrupted and compromised during the pandemic in Kenya. Detracted supplies, funding, and technical resources affected the continuity of NCDs' response, despite government efforts. Respondents agreed that the enhanced personnel capacity and competencies to manage COVID-19 patients were positive, but noted a lack of guidance for redirecting care for chronic diseases, and advocated for digital innovation as a solution. Conclusion this paper explores the perceptions of key stakeholders involved in the management of NCDs in Kenya to improve planning for future emergency responses. Gaps were identified in health system response and preparedness capacity during the pandemic including the perceived need to strengthen NCD services, with solutions offered to guide resilience efforts to protect the health system from disruption.
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Affiliation(s)
- Sugitha Sureshkumar
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Kibachio Joseph Mwangi
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
| | - Gladwell Gathecha
- Department of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
| | - Kailing Marcus
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bogomil Kohlbrenner
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - David Issom
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | | | - Nirit Braha
- Royal Free Hospitals, National Health Service, London, United Kingdom
| | - Egidio Candela
- RCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Kumar Gaurav Chhabra
- Department of Public Health Dentistry, Nims Dental College and Hospital, Nims University, Rajasthan, India
| | | | - Arianna Dondi
- RCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marina Etchebehere
- Faculdade Israelita de Ciencias da Saude Albert Einstein, Sao Paulo, Brazil
| | - Andre Pascal Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Eduardo Missoni
- Center for Research on Health and Social Care Management - CERGAS, SDA Bocconi Management School, Milan, Italy
| | - Feisul Mustapha
- Disease Control Division, Ministry of Health, Putrajaya, Malaysia
| | - Benjamin Palafox
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Priyanka Paul Madhu
- Department of Public Health Dentistry, Sharad Pawar Dental College and Hospital, Wardha, India
| | - Nasheeta Peer
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Reza Tabrizi
- Non-Communicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Haironi Yusoff
- Department of Public Health, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Sarawak, Malaysia
| | - Michel Oris
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - David Henry Beran
- Division of Tropical and Humanitarian Medicine, Faculty of Medicine, University of Geneva, Geneva University Hospitals, Geneva, Switzerland
| | - Dina Balabanova
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jean-François Etter
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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