Partners in Health

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• Partners in Health
• Rwanda

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• There are a total of 27 rural health districts
• They include more than 80 of the population
• Current annual per capita health care spending
  by public sector is around 4 (40 million total)
• Additional 15 per capita donated by PEPFAR (150
  million total)
• Target for annual per capita health care spending
  is 27

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Burera
Southern Kayonza
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HaitiRwanda
S. Africa
France
China
BP
BMI
CHOL
Ezzati et al. PLoS Medicine. 2005
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• 90 patients with heart failure identified from
  October 2006 to October 2007
• All have structural heart disease confirmed by
  echocardiography
• Median age 36 years

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Based on estimates of disease prevalence and
intensity of case finding
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Physicians Nurses
Nurses Physicians
Community health workers Nurses and physicians
Echocardiography Point of care laboratory
testing Clinical protocols
Echocardiography Point of care laboratory
testing Clinical protocols
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• I-STAT machine for monitoring of
• Renal function
• Electrolytes
• INR in case of anticoagulation

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Clinical Protocols
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Clinical Protocols
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www.imres.nl
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Faris et al. Cochrane Collaboration.
2006 McMurray and Pfeffer. Lancet. 2005
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Stage IV hypertension almost eradicated
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Prophylaxis
55 patients with Rheumatic MR treated with
monthly IM benzathine PCN
Tompkins et al. Circulation. 1972
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Prophylaxis
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• Walter Sisulu Heart Center, Johannesburg, South
  Africa
• Emergency, Salam Heart Center, Khartoum
• Operation Open Heart at King Faisal Hospital in
  Kigali
• Brigham and Womens Hospital at King Faisal
  Hospital

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• How to scale-up a heart failure program at a
  national level?
• Procurement of echocardiography equipment at
  district hospital level
• Procurement of point of care laboratory testing
  at district hospitals and health center level
• Formulary changes at district hospital and health
  center level
• Development and implementation of
  country-specific clinical protocols for district
  hospitals and rural health centers
• Development of training material and a training
  curriculum for physicians, nurses, and community
  health workers
• Development of a training model requiring 1 to 1
  clinical mentorship and leading to official
  certification
• Partnership with Ministry of Health, National
  Medical School, and other stakeholders (i.e.
  Rwandan Heart Association)

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• Why only heart failure?
• There is the need for a program targeting all
  chronic diseases of poverty
• Edematous conditions
• Heart failure
• Cirrhosis/portal hypertension
• Chronic renal disease
• Insulin-dependent diabetes
• Severe hypertension
• Asthma and other chronic lung diseases
• Epilepsy
• Malarial hyper-reactive splenomegaly
• We are currently working on the development of a
  chronic care team (2 physicians and 3 nurses)

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