Geneva Health Forum Archive

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The Zimbabwean Experience with Primary Healthcare in the Period 1981-2000: Which Factors Shaped this Success Story?

Author(s):

B. Criel*1, P. Bossyns2, T. Hoeree1, J. Macq3, B. Vander Plaetse4, A. Van Geldermalsen5, E. Mabiza6, G. Mhlanga6, C. Tshuma7, A. Chimusoro8

Affiliation(s):

1Department of Public Health, Institute of Tropical Medicine, Antwerp, 2Medical Department, Belgian Technical Cooperation, 3School of Public Health, Free University of Brussels, Brussels, Belgium, 4Health Section, Alafa project, Maseru, Lesotho, 5Health Services Support Programme, 6Department of Public Health, Ministry of Health & Child Welfare, Harare, 7Provincial Medical Office, Ministry of Health & Child Welfare, Bindura, 8Provincial Medical Office, Ministry of Health & Child Welfare, Gweru, Zimbabwe

Keywords: Primary healthcare, district health systems, strengthening health systems, Zimbabwe
Background:

Zimbabwe succeeded, after its independence in 1981, in dramatically transforming its health system. During the 80s and 90s, the Zimbabwean health services gradually evolved into one of the best performing systems of Sub-Saharan Africa.

Summary/Objectives:

We believe that the Zimbabwe experience constitutes a major learning opportunity for our understanding of how to organize Primary Health Care (PHC). We analyse the factors, both internal and external to the health system, which contributed to the success at the time. The current crisis in the health sector does not necessarily invalidate lessons from the past.

Results:

We distinguish between factors internal and external to the health system.

Internal factors:

1 – A clear operational model on how to organize PHC based on the development of integrated district health systems with networks of decentralized health centres staffed by small teams of versatile health workers, supported by district hospitals acting as back-up facilities for patients in need of more specialized nursing and medical care. Specific disease-control activities were largely integrated in the district health care delivery system.
2 – Multidisciplinary district health teams (doctors, nurses, health administrators, environmental workers, pharmacists) heading the district health services system and operating in a managerial environment with room for local decision-making and resource allocation.
3 – Significant support from provincial health teams for the district teams. The availability of true specialized care at the level of provincial hospitals and the existence of functional referral systems enhanced the health system’s overall credibility.
4 – Well-trained frontline health workers operating in a culture of rationalization of diagnostic and therapeutic behaviour and quality control.

External factors: 1 – Strong national political (and financial) commitment towards social sectors in general, and the health sector in particular. The rights-based approach of the Alma Ata philosophy found fertile soil in the postrevolution period.
2 – Support from the international donor community, including the provision of expatriate health workers integrated in the Zimbabwean public service system.
3 – Good basic transport and communication infrastructure inherited from the Rhodesia regime.
4 – Presence of economic development (commercial farming, tourism) in the 80s and early 90s.
5 – A bureaucratic but functional State apparatus: fulfilment of its normative role, payments of decent salaries to civil servants, punitive action in case of professional misconduct of health workers, etc.
Lessons learned:

In the case of Zimbabwe, in the period 1981-2000, a conjunction of elements, both internal and external to the health sector, led to an environment conducive to the development of equitable and effective PHC systems. With the increased attention for the strengthening of low-income countries’ health systems, the Zimbabwe experience provides a valuable source of inspiration.

Local Planning: An Experience of a Primary Care Centre in Florianópolis, Brazil

Author(s): C. M. S. Moutihno, Jr1
Affiliation(s): 1Public Health Department, Municipal Health, Florianópolis, Brazil
Keywords: Primary Care, health planning, Family Health Strategy
Background:

The project of health planning at the Primary Health Center Lagoa da Conceição, in Florianópolis (Brazil) emerged as a need to change a model of care assistance, based on the spontaneous demand and a limited scope in the practice of health (passive attitude) for a model of Family Health Strategy, with shares epidemiological data on a defined territory and organizes a supply of services, expanding the community’s access to health services (pro-active attitude). The planning tool enabled changes on the organization for the work process in the primary care of the Family Health Teams (FHT).

Summary/Objectives:

The indicators available have been raised using SIAB (Information System in Primary Attention), SIM (Information System in Mortality), SINASC (Information System of Births), and HIPERDIA (Information System of hypertensive and diabetic people). There were used the following indicators:
1– Medical care / team resolution: consultations pop / year, the average time, total resolution, average visits / family.
2– Women/Children: exclusive breastfeeding, pregnant beginning the 1st quarter, pregnant medical/nursery care in the month, pregnant <20 years, low weight at birth, pregnant with more than 4 and 7 consultations in the prenatal, procedures Papanicolau / pop fem.
3– Hypertensive/ Diabetic people: lifting risk of disease DAC in 10 years, using of Framingham Score.
The objectives were:
1– Work with a common goal for the actors involved in the planning (FHT); stimulate work as a team
2– Develop the diagnosis of the current situation, with survey data; study of the data and dynamics of monitoring / update-dynamic planning
3– Improve health indicators of the population.

Results:
Lessons learned:

Strengthening Health Systems through Formal Links with Storekeepers, Volunteers and Community Health Committees in Urban Settings: Extending Services to Communities Project

Author(s):

B. M. Nhlema Simwaka*1, P. Nkhonjera1, A. Willetts2, F. M. L. Salaniponi3, R. Malmborg4, S. R. Theobald2, B. S. Squire2

Affiliation(s):

1Research for Equity And Community Health Trust, Lilongwe, Malawi, 2Liverpool School of Tropical Medicine, Liverpool, United Kingdom, 3National TB Control Programme, Ministry of Health, Lilongwe, Malawi, 4Norwegian Health and Lung Patient Association, Oslo, Norway

Keywords: Health system, informal health providers, referral, tuberculosis
Background:

This abstract highlights finding of an intervention research called Extending Services to Communities. The aim of the study was to document the impact of improving the advisory, referral and health promotion skills of storekeepers, volunteers, and community health committee in improving early care seeking for tuberculosis. The intervention package included a capacity building, referral system between the community and health facilities and health promotion on tuberculosis and chronic cough.

Summary/Objectives:

The objectives of the study were: (1) To develop and implement the Extending Services intervention package. (2) To analyse the acceptability of the intervention by the different stakeholders involved in implementation. (3) To explore, through gender and poverty analysis, the community perspectives of the impact of the intervention. (4) To quantify the extent of the impact of the intervention on TB control indicators. (5) To make recommendations for approaches for implementing and evaluating similar community based health interventions.
The research was conducted in Malawi by Research for Equity and Community Health Trust, in three resource-poor settings of urban Lilongwe in collaboration with the National TB Control Programme, Lilongwe District Health Office and City Assembly. The first intervention area was Ngwenya and second area was Kauma. Kauma was used to test replicability of the intervention. Chinsapo was used as a control area. The multi-method approach was used to develop and implement the intervention and to evaluate its impact and acceptability from social and biomedical perspectives.

Results:

A participatory process promoted ownership of the intervention and improved the referral and health promotion skills of storekeepers, volunteers and community health committees. Health workers used the referral letters as a screening tool for tuberculosis. The major limitations were coverage of health promotion activities and the participation of men in these activities. The community members explained that the intervention had greater impact on the poor men and women than the poorest because of the nature of their livelihood activities. In the intervention areas there was a significant increase between 2003 and 2006 in the proportion of chronic coughers seeking care within two weeks of symptom onset (Kauma from 23.4% to 68.8%, [p=0.001]; Ngwenya from 9.3% to 30.8 %, [p=0.042]) compared with the control area where the change did not reach statistical significance (Chinsapo from 36.9% to 15.4%, [p=0.0142]). In addition the proportion of Lilongwe city’s total annual notifications of smear positive TB arising from the intervention areas rose significantly (Kauma from 0.2% to 1.3%, [p=0.002], Ngwenya from 1.4% to 3.2%, [p=0.004]) while the proportion reported from the control area did not rise significantly (Chinsapo from 2.7% to 3.3%[p=0.44]).

Lessons learned:

The multi-method approach helped to understand the impact of the intervention on access to services from different perspectives and in framing different research outputs for different audiences. It was also clear that integration of the informal health providers to the formal health system depended on building on their existing roles as early entry points into the health system for poor men and women and was not intended as a way of replacing the role of the health workers. The Extending Services to Communities Model is one way of strengthening the health system to increase access to elements of the Essential Health Package. Meaningful integration calls for embracing of both biomedical and social models of health.

Policy Analysis of Community-Based Organisations as Providers of Community Health Services: The Case of Four Districts in Malawi

Author(s): L. J. Nyirenda*1, P. Nkhonjera1, B. N. Simwaka1
Affiliation(s): 1Research for Equity and Community Health Trust, Lilongwe, Malawi
Keywords: CBOs, CHBC, CHBC Policy, sustainability, health system
Background:

Malawi is currently experiencing an acute healthcare worker crisis taking place in a context of severe HIV/AIDS epidemic with 14% of the 12 million total population infected by HIV. While the formal health system structures are not easily accessible by most Malawians, there are several close-to-communities providers known as community based organizations (CBOs) linked to HIV/AIDS. Although CBOs provide a clear framework for reaching the poor rural masses there is little evidence on mechanisms of sustainability, integration and linkage with the health system. The weakening and eventual collapse of CBOs might worsen the health worker crisis. This might mostly affect the poor and those residing in rural areas as they are the major beneficiaries of services provided by CBOs. This study set out to investigate factors within CBOs that are necessary for the sustainability of the organizations mainly in the delivery of Community Home Based Care (CHBC). Methods used for the study were focus group discussions, in-depth interviews and desk review of relevant documents and publications. A framework of analysis was used to summarise the findings into different themes and sub-themes.

Summary/Objectives:

1–To find out the knowledge of existence of the CHBC policy amongst different stakeholders.
2– To investigate coordination mechanism for CHBC activities in Malawi.
3– To determine the extent to which funding towards CHBC activities is sustainable.
4– To find out the nature and existence of linkage between CBOs providing CHBC and the formal health system as well as the strength or weaknesses of such links.

Results:

There was poor knowledge and lack of dissemination of CHBC policy amongst stakeholders. Although each district claimed existence of CHBC coordinator, there was poor coordination for CHBCs activities and stakeholders at all levels (national and district), despite existence of policy. This is exacerbated by lack of clarity as to which Ministry or department is appropriate to host the CHBC coordinator and reporting line. Most officials admitted that they were not sure as to who was the overall in-charge of CBO activities including CHBC. It appeared, however, that stakeholders with resources at a particular time were the ones wielding power and reports covering different activities were being sent to such stake-holders. Most CBOs depend on grant facility funding from National AIDS Commission (NAC) grants and other NGOs.  There are weak links between the CBOs and the formal health systems; no formal referral mechanism and reporting exist. Most Health Surveillance Assistants (HSA) who are supposed to link the HBC work at community level with hospitals and health centres are not trained in CHBC work and are ignored in most of the activities carried out by CBOs. Communication is a huge challenge amongst stakeholders. For instance, some health centres turn away CHBC volunteers when the latter go there to replenish their drug and material stocks.

Lessons learned:

CBOs remain an indispensable part of the health system in the context of an acute shortage of trained/professional health workers. But without proper coordination and predictable funding, they are bound to provide the worst services to their beneficiaries. Such services would perpetuate inequities as the people accessing such services would be the poor and those who mostly reside in villages. Expecting organizations like CBOs to report to different stakeholders on different issues can bring about confusion; CBOs are mostly run by lowly qualified people who work on voluntary basis.

Evaluation of Different Types of Community Health Centres in China: Is There Any Disparity in Delivering Their Services?

Author(s): H. H. Dib*1, P. Sun2, Q. Liu3, J. Chen4
Affiliation(s):

1Health Care Management, Dalian Medical University, 2Graduate M.Sc Research nursing department, Second hospital affiliated with Dalian Medical University, 3Statistics department, School of Public Health, 4Vice Dean, School of Graduate Studies, Dalian Medical University, Dalian, China

Keywords:

Community health centres (CHC), yearly revenues, medical drug revenues, Private-owned and State-owned CHCs

Background:

Investigate the performance of two types of Community Health Centres (CHCs): Private (individual-owned and operated or Factory-sublet CHC to private and operated) and State-owned community health centres (Factory owned and operated; Hospital owned and operated) within the city of Dalian, Liaoning province.

Summary/Objectives:

Total 58 community health centres were surveyed studying patients’ turnover, cost of medical drugs and total drug’s revenue, number and types of staff’s specialty (orthopaedics, preventive medicine, dermatologists, cardiologists, Endocrinologists, Gastro-enterologists, Respiratory medicine OB/GYN, GP), number of community nurses and their years of experience, yearly revenue, medical IT filing system and/or recorded paper filing, ownership of high tech equipments, and two tier referral system, physicians and nurses level of education.

Results:

1– Higher revenues among private-owned community centres than state-owned centres (P<0.001).
2– Higher medical drugs costs and drug revenues in the State-owned then in the private CHCs (P<0.05).
3– Higher patients’ turnover among state-owned then the private-owned CHCs (P<0.001).
4– Higher percentage of old-aged people then middle age and young attending State-owned than in the private CHCs (P< 0.05).
5– Less specialized professional staff and more GP role within the State than the private-owned CHCs (P<0.0001).
6– Number of community nurses is higher in the State-owned than the private CHCs (P<0.0001), while the level of education of nurses was higher in the private than in the State-owned (P<0.0001), but training as GP nurses found more in the state owned than the private owned CHCs (P<0.0001).
7– Gender distribution was higher in females than males among the two types of CHCs (P>0.05).
8– Presence of hi-tech equipments were higher in the state owned than in the private CHCs (P<0.05).
9– Nearly absence of IT filing system in the state-owned than in the private CHCs (P<0.05).
10– Sate-owned centres witnessed more referrals to and from the hospitals than the private centres
11– There was no significant difference between the State and private in delivering the six functions services (P>0.05).
12– Under CHCs charges there was no significant differences in physicians’ consultation, opening patient’s file and physical examination-free of charge (P>0.05); while there was significant difference in service charges concerning blood tests, x-ray and ultrasound fees, dentistry treatment (tooth extraction and filling), surgical treatment-cast fixation (P<0.0001).
13– There was total absence of IT connecting system of CHCs with each other in each district (P>0.05)

Lessons learned:

There are great potentials for improvement in delivering the CHCs’ services through increasing community nurses training, opening more training for GP and family medicine physicians to serve better the community, introduce more hi-tech medical equipments, widening the scope of population coverage, and enhance the referral system between hospitals and CHCs.

Making It Better: NZ GPs Improving Access to Elective Services and Bridging the Primary/Secondary Gap

Author(s): R. S. J. Gellatly*1, R. Naden1, c. Perry1, J. Palmer1
Affiliation(s): 1Elective Service team, Ministry of Health, Wellington, New Zealand
Keywords: GPs (general practitioners), primary/secondary interface, GP Liaisons, elective services
Background:

Ministry of Health committed to improving elective services waiting times from 1999.The idea of using GP Liaisons (GPs who liaise) to assist this work came from an article in the BMJ. Since the inception of the role, changes in the NZ health system such as District Health Boards being responsible for regional health needs (rather than a focus on hospital services only) and the implementation of the primary healthcare strategy require better communication across that interface.GPLs now have a broad range of activities in improving the patient journey across the primary/secondary interface.

Summary/Objectives:

The range of roles and activities of GPLs around the country will be described, in relation to various sized district health boards in urban and rural New Zealand. Examples of improvements in which GPLs have been involved will be detailed, such as triaging referrals, changing pathways to improve patient access, providing a primary care perspective in hospital settings. Opportunities for further collaboration and innovation will be highlighted.

Results:

Elective service access has been improved. One of the factors in this has been GP Liaisons. As hospital-based consultants and administration staff gain confidence working with GPLs, other areas for improvement are identified. These vary with the local areas needs. Primary care benefits from having a voice in the hospital and a recognised conduit for issues and ideas to be raised.

Lessons learned:

Building relationships based on improved outcomes has opened up communication across the primary/secondary interface. GPs have a combination of practical can-do attitude, experience of working in both primary and secondary care, and the ability to see the big picture in the complex system that is healthcare delivery. Supporting the GPL network is important for its success. GPLs use many tools gleaned from leaders in health. Having paid time in the day is also a success factor.

New Ways to Achieve Primary Healthcare in India: A Critical Review of National Rural Health Mission

Author(s): K. R. Nayar*1
Affiliation(s): 1Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
Keywords: Primary healthcare, health services system, India
Background:

The idea of a health ‘worker’ from the community is not a new one; from a public health point of view, it may be an ideal vehicle for another development in the field. But it failed miserably in the case of the Community Health Guide/Volunteer (CHV) scheme due to several reasons. The most serious problem with the CHV scheme was the selection process; it was misused to distribute political patronage and even close relatives of panchayat leaders were selected. The training was extremely limited but in the course of time, most of the CHVs became quacks. A programme meant to give ‘people’s health in people’s hands’ ended up as mere quackery. It is against this background that the government introduced the National Rural Health Mission (NRHM) which includes a women’s community health volunteer called Accredited Social Health Activist (ASHA).

Summary/Objectives:

This paper critically reviews the National Rural Health Mission from a public health perspective as well as based on the ideals of Primary Health Care (PHC).

Results:

The key strategies of the Rural Health Mission include: ensuring intra- and inter-sectoral convergence, strengthening public health infrastructure, increasing community ownership, creating a village level cadre of health workers, fostering public-private partnerships, emphasizing quality services and enhanced programme management inputs.. Community participation will be enhanced by giving functional responsibilities and powers to the panchayati raj (local self-government) institutions, apart from creating a cadre of voluntary accredited social health activists, and a drug and contraceptive depot at the village. The mission will also use management experts, Chartered Accountants, Business management specialists and GIS specialists for its management units.
We find that the utter neglect of primary care and primary healthcare institutions has influenced the utilization of health services and contributed to the worsening epidemiological profile in the country in recent years. In the present form, the proposed mission adds to the confusion about the approach to healthcare in the country. Cost-effective interventions such as the rational distribution of financial and medical resources, including drugs, effective manpower distribution and primary healthcare approaches, should be part of the vision.

Lessons learned:

This paper recommends that a vision that gives primacy or rather credibility to the vast network of health institutions that the country has built over years is needed. Strengthening the sub-centres and equipping the government’s own health workers (instead of adding posts) would be epidemiologically and economically more effective. States should be allowed to define their own priorities and plan programmes. At present the public health scenario is extremely nebulous and the differential pattern across states is so glaring that it does not allow the imposition of pan-Indian solutions.  Apart from this, there is also a need to equip and enable elected representatives at the village and block level for handling health issues. Presently, health programmes are beyond the reach of people who are supposed to govern under the decentralised form of government as these are often considered technical subjects. There is a need to remove the confusion among representatives and officials at the panchayat (local self-government) level about the roles and responsibilities around health services. This paper concludes that initiatives such as the rural health mission would greatly benefit if it follows the vision of those that scripted India’s health service system based on an integrated and unified approach as against the selective interventions being proposed in recent years.

A Model for the Integration of Primary Healthcare Services in KwaZulu-Natal, South Africa

Author(s): M. N. Sibiya*1
Affiliation(s): 1Nursing, Child and Youth and Environmental Health, Durban University of Technology, Durban, South Africa
Keywords: Primary healthcare, integration, district health system, South Africa, grounded theory approach
Background:

The redirection of the healthcare system towards Primary Health Care (PHC) along with the concomitant establishment of the District Health System (DHS)as a framework for PHC delivery and management has been the transformation event in the public health sphere in South Africa since 1994. On the other side, this move towards transforming the healthcare system has been met with numerous impediments, flaws and failures, many of which have not yet been mastered, solved or ironed out. As equity and access to healthcare have since 1994 been considered the key principle to steer the transformation of health services in South Africa, a mechanism was required to define parameters for service delivery, as well as to ensure comparability in the rendering of services. This mechanism realized in the form comprehensive PHC service package that was introduced by the National Department of Health in 2001. Whereas in the past in the South Africa, the model of PHC delivery was strongly based on a vertical approach, the PHC package envisages an organization of services that allows for a one-stop approach. The comprehensive PHC service package is aimed at defining services per level of facility as a way to maximize the integration of services. Nevertheless, integration of PHC services continues to be seen as a pivotal strategy towards the achievement of the national goals of transformation of health services, and the attainment of a comprehensive and seamless public health system. The problem, however, arises in the implementation of integrated PHC as there is no agreed upon understanding of what this phenomenon mean in the South African context. To date no re- search studies have been reported on the meaning of the integration of PHC services. Hence, there is a need for shared views on this phenomenon in order to facilitate an effective implementation of this approach.

Summary/Objectives:

The purpose of the study was to analyse the integrated PHC (IPHC) within a DHS in South Africa and thus the shared meaning of the phenomenon. Ultimately the aim is to develop a model for the integration of PHC programmes in KwaZulu-Natal.

Results:

Grounded theory approach was used to guide the research process. Theoretical selection of clinics located within four health districts in KwaZulu-Natal was done. Data were collected by means of observation, interviews and document analysis. The results indicated that the majority of the clinics offered most of the services that are listed on the comprehensive PHC core package although the process of implementing the integration of PHC services was done differently in all the clinics where observations were done. All participants interviewed understood the IPHC services as provision of all services in the clinic as stated in the comprehensive PHC core package. However, they expressed different views regarding the process of provision of these services. From the data sources, it emerged that the need for the integration of PHC services in South Africa arose as a response to health needs of the community, the shortage of staff and limited infrastructure and the fragmentation of PHC services. The results also indicated that IPHC resulted in improved accessibility of services. However, on the contrary the unintended consequences of integration were reported to be overcrowding in the clinics thus resulting in deteriorating quality of patient care.

Lessons learned:

These are the preliminary results of the study. The researcher is still in the process of identifying the emerging categories that she will use in developing a model. Supermarket approach, one stop shop and comprehensive services emerged as conceptual categories for understanding integration of PHC services from the data analysis process. The researcher noted that the interviewees used the terms ‘supermarket approach and one stop shop’ interchangeably.

Primafamed: An Institutional Network for the Development of Family Medicine in Africa

Author(s): M. M. Flinkenflögel*1, J. De Maeseneer1
Affiliation(s): 1Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium
Keywords: Family medicine; African universities; primary healthcare; institutional network
Background:

Facing the challenges of high rates of infant and maternal mortality, HIV/AIDS, TB infection, endemic malaria and pervasive poverty, countries in Africa, need to develop an accessible, high quality comprehensive primary healthcare system. Nowadays, specific community based training of future family physicians is lacking in most of the African countries. WHO - World Health Report 2006 ‘Working together for health’ emphasises the need for primary healthcare-training in the local community in order to tackle actual ‘brain-drain’.

Summary/Objectives:

Primafamed is a 2 year project, coordinated from Ghent University, funded by Edulink, a programme from the European Union. 10 African Universities in 8 different Sub-Saharan countries are participating in this project. Primafamed is establishing an institutional network between departments and units of family medicine and primary healthcare in African universities, focussing on South-South cooperation, in order to:
1 – strengthen development of departments of family medicine/primary healthcare in African countries;
2 – create a forum for international cooperation to enhance the quality of programme content, educational methods and training in family medicine;
3 – encourage research collaboration in family medicine and primary healthcare education;
4 – insert motivated and locally well-trained generalists or ‘African family doctors’ into the primary healthcare systems;
5 – contribute to improvement of access to quality primary healthcare, especially for the most vulnerable communities in Africa.

Results:

The Primafamed-network, Ghent University and the 10 African partner institutions, has started and is working on the implementation of its mission to set up family medicine education in Africa to create a sustainable quality primary healthcare system in Africa, accessible and affordable for all.

Lessons learned:

Primafamed embraces the principle of South-South cooperation, encouraging the sharing of unique knowledge and wisdom between African institutions. By motivating, stimulating and supporting these institutions in the set up of family medicine training, primary healthcare systems in Africa can improve.

Comprehensive Assessment and Management of Hypertensive Patients in Primary Healthcare Facilities of Guatemala

Author(s): C. Mendoza Montano*1, P. Orellana2, A. de Arroyo3, M. Ramirez Zea4
Affiliation(s): 1Health Promotion, 2Medicine, 3Epidemiology, Guatemalan Association for the Prevention of Heart Diseases-APRECOR, 4Chronic Diseases, Institute of Nutrition of Central America and Panama CAP, Guatemala, Guatemala
Keywords: Chronic diseases, cardiovascular diseases, risk factors, hypertension, health system interventions.
Background:

In Guatemala, cardiovascular diseases (CVD) are becoming the leading cause of mortality and disability. The rising burden of these diseases makes it imperative to formulate effective community and health system-based interventions. Currently, the primary healthcare (PHC) system in Guatemala is mostly oriented to communicable diseases and maternal/child health so public PHC centres lack adequate programmes to cope with the increasing demand of CVD.

Summary/Objectives:

The objective of the study was to assess the feasibility and effectiveness of a comprehensive CVD risk reduction programme targeting patients with hypertension that could be integrated into the PHC facilities of Guatemala. The programme was designed for assessment, CVD risk stratification and management of adult individuals detected to have hypertension through opportunistic screening. Patients were stratified at low, medium and high risk based on the level of blood pressure and the presence or absence of other simple, non-invasive variables such as age, personal and family history of CVD, waist circumference (WC) and tobacco use. All patients received lifestyle counselling including smoking cessation, promotion of healthy diet and physical activity. Drug therapy with an antihypertensive medication was restricted to patients at high cardiovascular risk.

Results:

A total of 114 patients (54 ± 13 years old, 74% women and 26% men) were enrolled during a 6 months period at the public PHC clinic of the community of Villa Nueva. Seventy patients were followed up with a second visit to the clinic, and 43 with a third visit. Significant reductions were observed during the first follow up (36 ± 18 days later) in the group mean systolic blood pressure (from 164.9 ± 27.7 to 150.0 ± 21.0, p < 0.01 mmHg) and was even higher during the second follow up (168.0 ± 27.0 to 138.1 ± 17.3, p < 0.01). WC did not change during the first follow up (97.1 ± 8.4 to 95.2 ± 8.8cm, p = 0.14); however, a significant reductions were achieved (from 97.1 ± 8.4 to 93.2 ± 6.9, p=0.04) in patients (N=40) who had 3 visits to the clinic (71±20 days later). Of the 13 tobacco users, 7 discontinued use (53%).

Lessons learned:

This pilot study provides preliminary evidence of the effectiveness and feasibility of incorporating a CVD risk reduction programme into the limited healthcare infrastructure of Guatemala and probably applies to other developing countries.