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Engaging the Entire Care Cascade in Western Kenya: A Model to Achieve the Cardiovascular Disease Secondary Prevention Roadmap Goals
Rajesh Vedanthan*, Jemima H. Kamano†,‡, Gerald S. Bloomfield§, Imran Manji‡, Sonak Pastakia†,‡,‖, and Sylvester N. Kimaiyo†,‡
*Icahn School of Medicine at Mount Sinai, New York, NY, USA
†Moi University College of Health Sciences, Eldoret, Kenya
‡Academic Model Providing Access to Healthcare, Eldoret, Kenya
§Duke Global Health Institute, Duke Clinical Research Institute, and Duke University School of Medicine, Durham, NC, USA
‖Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, IN, USA
Abstract
Cardiovascular disease (CVD) is the leading cause of death in the world, with a substantial health
and economic burden confronted by low- and middle-income countries. In low-income countries
such as Kenya, there exists a double burden of communicable and noncommunicable diseases, and
the CVD profile includes many nonatherosclerotic entities. Socio-politico-economic realities
present challenges to CVD prevention in Kenya, including poverty, low national spending on
health, significant out-of-pocket health expenditures, and limited outpatient health insurance. In
addition, the health infrastructure is characterized by insufficient human resources for health,
medication stock-outs, and lack of facilities and equipment. Within this socio-politico-economic
reality, contextually appropriate programs for CVD prevention need to be developed. We describe
our experience from western Kenya, where we have engaged the entire care cascade across all
levels of the health system, in order to improve access to high-quality, comprehensive,
coordinated, and sustainable care for CVD and CVD risk factors. We report on several initiatives:
1) population-wide screening for hypertension and diabetes; 2) engagement of community
resources and governance structures; 3) geographic decentralization of care services; 4) task
redistribution to more efficiently use of available human resources for health; 5) ensuring a
consistent supply of essential medicines; 6) improving physical infrastructure of rural health
facilities; 7) developing an integrated health record; and 8) mobile health (mHealth) initiatives to
provide clinical decision support and record-keeping functions. Although several challenges
remain, there currently exists a critical window of opportunity to establish systems of care and
prevention that can alter the trajectory of CVD in low-resource settings.
Correspondence: R. Vedanthan ([email protected]).
All other authors report no relationships that could be construed as a conflict of interest.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
HHS Public Access Author manuscript Glob Heart. Author manuscript; available in PMC 2016 December 01.
Published in final edited form as: Glob Heart. 2015 December ; 10(4): 313–317. doi:10.1016/j.gheart.2015.09.003.
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Cardiovascular disease (CVD) is the leading cause of mortality in the world, with 80% of
CVD deaths occurring in low- and middle-income countries [1,2]. In sub-Saharan Africa,
CVD is the leading cause of death among individuals over age 30 years [3]. In addition to
the epidemiologic burden, CVD threatens to impose a significant economic burden on low-
and middle-income countries [4-6]. Whereas atherosclerotic CVD (particularly stroke) [7]
and CVD risk factors (particularly hypertension) [8] are increasing in Kenya,
nonatherosclerotic CVD remains significant in Kenya, including rheumatic heart disease,
heart failure, and household air pollutionerelated CVD [9,10]. In addition, the country
continues to confront a “double burden” of disease, including a significant burden of human
immunodeficiency virus and other communicable diseases (Figure 1) [11], representing the
evolution of the epidemiologic transition in this country.
Socio-Politico-Economic Realities
Kenya is designated as a low-income country by the World Bank [12], and the average daily
income for a substantial proportion of its population is <U.S. $1 per day [13]. In addition,
total expenditure on health is <5% of gross domestic product, out-of-pocket expenditures are
more than 75% of private spending on health, and government expenditure on health is
<U.S. $40 per capita [14]. Although there is a national health insurance program, it has
traditionally covered only inpatient admissions and is only recently expanding to outpatient
coverage [15].
In Kenya, a Division of Non-Communicable Diseases was formed in the Directorate of
Preventive and Promotive Services within the Ministry of Health. This division is charged
with the responsibility of driving policy response to noncommunicable diseases for the
whole country. It is in the process of concluding the development of a strategic plan for
noncommunicable diseases, as well as ensuring that the national health policy includes
measures to prevent and control noncommunicable diseases. Clear targets have been
designated, and evidence-based interventions have been recommended, including those for
secondary CVD prevention. However, widespread implementation of programs for CVD
prevention is still lacking.
The infrastructure for CVD prevention is challenging. There are insufficient human
resources for health overall [16], and the double burden of disease exacerbates this human
resource shortfall. There are frequent and repeated medication stock-outs, of even the
essential medicines contained on the national formulary [17]. Even when medicines are
available, they often remain unaffordable, are subject to price gouging, and can sometimes
be of uncertain quality [18]. CVD medicines are even less reliably available, especially for
the rural population. In addition, there is a profound lack of facilities, supplies, and
equipment—spanning laboratory facilities, radiology equipment, even sphygmomanometers.
Finally, patients often engage the health care system at advanced and complicated stages of
disease, at which point, prevention efforts are too late and curative efforts are expensive and
sometimes futile.
It is within this socio-politico-economic reality that contextually appropriate programs for
CVD prevention need to be developed. Here, we describe our experience from western
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Kenya, where we have engaged the entire care cascade across all levels of the health system,
in order to improve access to high-quality, comprehensive, coordinated, and sustainable care
for CVD and CVD risk factors.
Engaging the Entire Care Cascade
Academic Model Providing Access to Healthcare (AMPATH) is a collaboration among the
Moi University College of Health Sciences, the Moi Teaching and Referral Hospital, and a
consortium of North American universities led by Indiana University. This partnership
“leads with care” while addressing the full academic mission that includes education and
research. AMPATH has established a human immunodeficiency virus care system in
western Kenya that has served over 160,000 patients [19,20]. Recently, AMPATH has
leveraged this infrastructure to expand its clinical scope of work to develop a comprehensive
chronic disease management program, focusing initially on CVD, hypertension, and diabetes
[21]. In so doing, the program was guided by the following principles across the entire care
cascade: find, link, treat, and retain. These four principles were embodied in several
initiatives (Table 1): 1) population-wide screening for hypertension and diabetes; 2)
engagement of community resources and governance structures; 3) decentralization of care
services in order to improve geographic access; 4) task redistribution to allow for more
efficient use of available human resources for health; 5) ensuring a consistent supply of
essential medicines; 6) improving physical infrastructure of rural health facilities; 7)
developing an integrated health record across all levels of the Kenyan health system; and 8)
targeted, strategic use of mobile health (mHealth) initiatives to provide clinical decision
support and record-keeping functions for rural clinicians.
By bringing together all of these components, AMPATH has been able to create an
integrated system of chronic disease treatment and prevention services throughout its
catchment area. Community health workers at the village level have received structured
training to provide health education and assist with linkage and retention to chronic disease
care. Nurses in rural dispensaries have been provided specialized training and support in
order to independently manage hypertension and diabetes. Referral networks have been
established that connect dispensaries, health centers, district hospitals, and the Moi Teaching
and Referral Hospital. At the referral hospital, AMPATH has established outpatient
cardiology and diabetes clinics that provide comprehensive, multidisciplinary, and
longitudinal care for patients, many of whom have advanced or complex cardiovascular and
metabolic diseases. Finally, by leveraging the academic partnership and philanthropic
support, the program has built the first inpatient cardiac care unit in western Kenya, which
allows for management, resuscitation, and rehabilitation of critically ill cardiovascular
patients [22]. This integrated and comprehensive system of care provides the foundation for
education, capacity building, and research, in line with the mission of AMPATH. The
program has also launched a community-based outpatient health insurance program to
facilitate greater access by resource-limited rural populations to the integrated care system.
AMPATH has also implemented creative and novel programs to increase access to CVD
medicines. The program has partnered with key stakeholders in the Kenya Ministry of
Health and local communities to establish a network of revolving fund pharmacies [17]. At
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the rural health center level, each revolving fund pharmacy is located within the government
health center and serves as a backup to the government pharmacy, in order to prevent stock-
outs of essential medicines. The revolving fund pharmacy dispenses medications only when
the medication is out of stock at the government pharmacy, and the generated revenues are
used to restock the pharmacy. At the dispensary level, supply of CVD medications was
previously not available due to the commonly held view and policy that CVD was a health
issue that required more expertise than could be provided at the dispensary level. In this
setting, the revolving fund pharmacy serves as the primary supply for these medications.
Thus, the availability of essential CVD medicines has improved dramatically across all
levels of the health care system [17]. Local communities help to govern and monitor the
operations of each revolving fund pharmacy in order to ensure accountability to the local
population and patients. Demand for these services has increased, leading to the launch of
revolving fund pharmacies throughout the AMPATH catchment area.
The role of primary care clinicians, including nurses, clinical officers, and generalist
physicians, in this entire cascade cannot be understated. They will continue to provide care
to the vast majority of patients attending allopathic care facilities in low-resource, rural
settings. They also are often embedded in communities and have long-standing relationships
with community leaders and governance structures. Therefore, they have a great potential to
raise awareness both among individual patients as well as throughout entire communities.
Because they ultimately care for the bulk of patients in Kenya, these rural primary care
clinicians require appropriate training, mentorship, and support. In addition, they need to be
made aware of the relevant clinical guidelines, and be incentivized and motivated to use and
adhere to them. As has already been described, AMPATH has actively engaged primary care
clinicians with training, mentorship, and support, and those efforts need to continue and be
expanded.
Several challenges remain in terms of developing a roadmap for secondary CVD prevention
in a low-income country such as Kenya. Screening and detection of individuals with risk
factors and subclinical CVD requires the development and dissemination of novel diagnostic
equipment, including low-cost point-of-care technology that is portable and durable.
Simplification of CVD medication regimens, such as a cardiovascular polypill, could
potentially have benefit with respect to affordability and adherence [23]. For individuals
with known CVD, novel strategies to use mHealth to strengthen the link between patients
and providers may improve retention and adherence to care; however, the literature lacks
strong evidence in this regard [24]. New approaches to behavior modification and careful
attention to promoting healthy lifestyles, within the context of socio-politico-economic
constraints and life circumstances, will be required. Poor knowledge of secondary
prevention measures among clinicians needs to be addressed with training, capacity
building, and strong referral networks across the health system. Finally, ensuring high-
quality clinical care with a motivated health workforce can also promote a favorable clinical
experience for patients, thereby improving retention in care and adherence to treatment
regimens.
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Conclusions
CVD is a global problem, and increasingly so, even for low-income countries. While the
global CVD burden is still on the rise in low-income countries such as Kenya, there exists a
critical window of opportunity to establish systems of care and prevention that can alter the
trajectory of CVD in these settings. Engaging the entire care cascade, in the context of
epidemiologic and socio-politico-economic realities, is a promising way forward to achieve
the roadmap goals for secondary prevention of CVD in low-resource settings.
Acknowledgments
R. Vedanthan is supported by the Fogarty International Center of the National Institutes of Health under Award Number K01 TW 009218e05.
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Figure 1. Percentage of total deaths by cause, all ages, both sexes NCD, noncommunicable disease(s). Reproduced, with permission, from World Health
Organization [11].
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Table 1 The care cascade (find, link, treat, retain), with associated challenges, responses, and future directions
Challenges AMPATH Responses Future Directions
FIND Identifying individuals at risk and individuals with disease
Home-based, door-to-door screening Community-based screening
Evaluation of different screening and detection strategies
Laboratory facilities and diagnostic equipment not accessible to entire population
Providing diagnostic equipment to rural health facilities
Development and evaluation of low- cost, point-of-care diagnostic technology
Mistrust of public sector services Improve relationship with community leaders and tribal elders
Continue to engage community and elicit feedback as to future services and quality care
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Challenges AMPATH Responses Future Directions
LINK Excessive distance to health facilities Geographic decentralization of care services
Further geographic decentralization and portabilization of care delivery
Low awareness of risks Community health workers with specialized training
Evaluation of different strategies to improve linkage to care
Asymptomatic disease at early stages Smartphone-based tailored behavioral communication
Evaluate mHealth initiatives
Emotional factors (fears) Community health workers with motivational interviewing
Engage individuals emotionally as well as cognitively
Poverty Microfinance initiatives Iteration and improvement of microfinance
Lack of health insurance Community-based outpatient health insurance
Iteration and improvement of program
Scale-up of insurance coverage
Poor reputation of public sector facilities
Community health workers with motivational interviewing
Raise awareness of quality improvement initiatives and improve desirability of public sector services
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Challenges AMPATH Responses Future Directions
TREAT Insufficient human resources Task redistribution Evaluation of task redistribution strategy
Development of optimal health care provider composition
Inadequate training and knowledge of management approaches
Targeted training; mHealth with clinical decision support
Evaluate mHealth initiatives
Poor knowledge of secondary prevention measures
Training of physicians in guideline-based practices at the referral hospital
Capacity building of clinicians at district hospitals in catchment area
Medication stock-outs Revolving fund pharmacy with community governance and oversight
Novel community-based supply chain solution development
Lack of facilities and equipment Improving physical infrastructure of rural health facilities
Continued improvement of rural health facility infrastructure and equipment
Development of cardiac care unit
Strengthening referral pathways
Lack of integration of medical records across levels of care
Integrated electronic health record with real-time access for rural clinicians
Improvement and optimization of health record functionality and clinical applicability
Lack of health insurance Community-based outpatient health insurance
Iteration and improvement of program
Scale-up of insurance coverage
Poor provider-patient relationship Incorporate patient-centric approaches into care model
Iteration and optimization of program
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Challenges AMPATH Responses Future Directions
RETAIN Low awareness of risks Community health workers with specialized training
Evaluation of different strategies to improve retention in care
Asymptomatic disease at early stages Smartphone-based tailored behavioral communication
Evaluate mHealth initiatives
Emotional factors (fears) Community health workers with motivational interviewing
Engage individuals emotionally as well as cognitively
Poverty Microfinance initiatives Iteration and improvement of microfinance
Lack of health insurance Community-based outpatient health insurance
Iteration and improvement of program Scale-up of insurance coverage
mHealth, mobile health.
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