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Introducing a Model of Cardiovascular Prevention in Slums of Nairobi

Author(s) Steven van de Vijver1, Samuel Oti2, Cate Hankins3, Catherine Kyobutungi 4, Gabriela Gomez 5, Lizzy Brewster6, Charles Agyemang7, Joep Lange8
Affiliation(s) 1Health Challenges and Systems, African Population and Health Research Center, Nairobi, Kenya, 2Health Challenges and Systems, African Population and Health Research Center, Nairobi, Kenya, 3Global Health, Amsterdam Institute for Global Health and Development & University of Amsterdam, Amsterdam, Netherlands, 4Health Challenges and Systems, African Population and Health Research Center, Nairobi, Kenya, 5Global Health, Amsterdam Institute for Global Health and Development & University of Amsterdam, Amsterdam, Netherlands, 6Vascular and Internal Medicine, University of Amsterdam, Amsterdam, Netherlands, 7Public Health, University of Amsterdam, Amsterdam, Netherlands, 8Global Health, Amsterdam Institute for Global Health and Development & University of Amsterdam, Amsterdam, Netherlands
Country - ies of focus Kenya
Relevant to the conference tracks Chronic Diseases
Summary As cardiovascular disease (CVD) has become a leading cause of death in sub-Saharan Africa (SSA), this study describes the development and introduction of a model of cardiovascular prevention in the slums of Nairobi by integrating a public health and private sector approach. The model includes community awareness, a home-based screening service, patient and provider incentives to seek and deliver treatment specifically for hypertension, and adherence support. Theoretical projections proved the model to be highly cost-effective and affordable (1USD/per person per year) and with these promising impressions on the ground, scale up of the service delivery package could be planned.
Background Cardiovascular disease (CVD) is the leading cause of mortality worldwide with up to 80% of global CVD deaths occurring in low- and middle-income countries (LMICs) such as Kenya. By 2030, two million annual CVD deaths are expected in sub-Saharan Africa (SSA).
The rise of CVDs in LMICs is mainly driven by globalization, industrialization, and urbanization, linked to an increased prevalence of CVD risk factors such as tobacco use, alcohol consumption, physical inactivity, and adoption of diets that are high in salt, sugar, and ‘unhealthy’ fat/oils.
The prevalence of behavioural and physiological risk factors for CVD is higher in urban than in rural areas. As the urban population in SSA is projected to increase from 395 million to 1.23 billion by 2050 the burden of CVD in this region is bound to increase.
In Kenya, almost 70% of the urban population lives in slums or slum-like conditions where access to formal health services is limited. With existing health care services suffering from the ‘double burden of disease’ of endemic infectious diseases and emerging chronic diseases, CVDs are treated predominantly at late stages after complications have occurred. This makes care unnecessarily costly and less effective.
Objectives Individual interventions for CVD prevention are both cost-effective and scalable, even in resource-constrained settings. However, evidence is limited on cost-effective and sustainable community-based CVD prevention programs in LMICs in general, and in severely resource-constrained settings such as slum settlements in particular. The aim of this article is to describe the development and introduction of a model that integrates public health and private sector approaches in a cost-effective and sustainable a service delivery package for CVD prevention among urban poor in SSA.
The integration of public health and private sector approaches to tackle CVD prevention could prove useful since, like CVD itself, prevention is closely linked to economic constraints. Such an approach could lead to the development of sustainable and scalable solutions that can be adapted locally to benefit public health in resource-poor settings in SSA.
Methodology Two public health research organisations, the Amsterdam Institute for Global Health and Development (AIGHD) and the African Population and Health Research Center (APHRC), collaborated with a private sector partner, Boston Consulting Group (BCG), to develop a service delivery package for primary prevention of CVD that is suitable for implementation in slum settings in Nairobi, Kenya. Previous studies in this setting and results of an intervention project to improve patient access to treatment for hypertension and diabetes in primary care settings, as well as a comprehensive literature review, informed the conceptual framework. This framework examines the flow of people from awareness of cardiovascular risk factors like hypertension and access to treatment, to adherence and successful blood pressure control. We show the main bottlenecks contributing to low service utilization and loss to follow-up, i.e. becoming aware of CVD risk, accessing screening, seeking treatment, and complying with medication.
We constructed various alternatives of service delivery packages aimed at minimizing the bottlenecks identified in the theoretical framework. As evidence of community-based CVD prevention programs in LMICs is relatively limited, we borrowed important lessons from HIV prevention and control programmes to address CVD. Overall, the cost and potential impact of the various alternative service delivery packages we considered were based on existing literature as well as our knowledge of the study area. The various alternative service delivery packages were then discussed with various CVD prevention stakeholders including policy makers, academic experts, program implementers, researchers, and field staff from previous projects, as well as local community representatives. Health care provision in Kenya is shared equally by the public and private sectors. Therefore, we aimed to include the feedback of representatives from both types of service providers. The objective was to ensure that each component of the service delivery package would address critical bottlenecks in the patient care continuum in a manner that is practical and acceptable within Nairobi slums. Finally, the service delivery packages were ranked based on their theoretical cost-effectiveness to determine the package most likely to succeed.
Results The outcome of the above mentioned process was the final selection of a service delivery package for primary prevention of CVD that comprised four elements: 1) increasing community awareness through announcements at community gatherings and religious services, and a local community radio jingle, 2) improving access to screening for CVD risk factors such as hypertension through household visits, 3) increasing treatment-seeking through vouchers for free treatment and Community Health Worker (CHW) incentives to follow up patients and persuade them to visit the clinic, and 4) improving long-term compliance by setting up patient support groups, subsidizing medication through these groups, providing incentives for CHWs, and sending text messages (SMS) to remind patients of clinic appointments, medication use, and healthy lifestyles.
Overall, we estimated that the final selected service delivery package could avert 248-391 DALYs and cost less than 1 USD per person in the community resulting in a cost-effectiveness between 760-1200 USD/DALY averted. This makes the service delivery package, in theory, a highly cost-effective intervention for CVD risk prevention, with the potential to be sustainable in the resource-constrained settings.
The selected service delivery package began being implemented in August 2012 as the SCALE UP Study in Korogocho, a Nairobi slum with a total population of 35,000. More than one hundred CHWs and field interviewers have been trained during an intense one-week training, after a pilot was completed. The CHWs are incentivized by receiving a fixed amount of money (approximately U$3) for every person they screen and refer to the local clinic, and who demonstrates long term compliance. The estimated total amount of payments and workload is in line with the guidelines for respectively compensation and duties of CHWs from the Ministry of Health. Therefore introduction of the model in the existing public health care structure is feasible. Enrollment of participants is ongoing, with close to 5,000 people 35 years and above already screened. This has led to approximately 900 referrals and 500 patients visiting the clinic. These numbers are close to the projected estimates. The population has reacted positively to the household screening with overall gratitude towards CHWs and low rates of refusals (3%). However, the field work remains challenging due to the dynamic circumstances of the slum setting with high insecurity and mobility.
Conclusion Through the collaboration of public health and private sector a theoretically cost-effective model was developed for prevention of CVD, which is currently being implemented in a Nairobi slum. Collaboration between public health researchers and management consultants introduced innovative aspects to the design and selection of interventions. Based on early HIV screening approaches, public health researchers initially did not consider household screening as a realistic option. However after discussions with the management consultants and a systematic comparison of different combinations of service delivery packages, door-to-door screening seemed likely to be more cost-effective and sustainable within a comprehensive group of interventions than traditional stand-alone screening sites. The underpinning hypothesis is that active engagement of people is needed when products and projects, such as hypertension screening, are relatively unknown. Additionally the household approach significantly reduces costs by combining awareness-raising and screening, two activities that would otherwise be considered separately.
Performance-based payments and incentives as part of prevention and control strategies for CVD are relatively new in the public health sector in SSA. In low-resource settings they may play an important role in making effective use of limited resources. The downside is that rigorous follow up is required to prevent beneficiaries and program staff from manipulating the incentive system, especially in settings of extreme poverty such as slums. Furthermore, we experienced some resistance from key stakeholders such as CHWs to the idea of an incentive-based payment, preferring the old system of fixed remuneration.
From the study onset, we have maintained regular contact with key stakeholders, including the Ministry of Health, City Council of Nairobi, WHO, and leading NGOs such as Médecins sans Frontières. In order to facilitate potential scale-up to other settings, a manual is being developed to show how a similar package of interventions can be designed, implemented, and adapted to different contexts.
If results are in line with the theoretical projections and first impressions on the ground, scale up of the service delivery package could be extended to other poor urban areas in Kenya by relevant policymakers and NGOs. In time, this approach may also prove to be sustainable and scalable elsewhere in Africa

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