Cost analysis of the WHO-HEARTS program for hypertension control and CVD prevention in primary health facilities in Ethiopia.

Background: In 2020, Ethiopia launched the Ethiopia Hypertension Control Initiative (EHCI) program to improve hypertension care using the approach described in the WHO HEARTS technical package. Objective: To estimate the costs of implementing the HEARTS program for hypertension control and cardiovascular disease (CVD) prevention in the primary care setting in Ethiopia for adult primary care users in the catchment area of five examined facilities. Study design: This study entails a program cost analysis using cross-sectional primary and secondary data. Methods: Micro-costing facility surveys were used to assess activity costs related to training, counselling, screening, lab diagnosis, medications, monitoring, and start-up costs at five selected health facilities. Cost data were obtained from primary and secondary sources, and expert opinion. Annual costs from the health system perspective were estimated using the Excel-based HEARTS costing tool under two intervention scenarios - hypertension-only control and a CVD risk management program, which addresses diabetes and hypercholesterolemia in addition to hypertension. Results: The estimated cost per adult primary care user was USD 5.3 for hypertension control and USD 19.3 for integrated CVD risk management. The estimated medication cost per person treated for hypertension was USD 9.0, whereas treating diabetes and high cholesterol would cost USD 15.4 and USD 15.3 per person treated, respectively. Medications were the major cost driver, accounting for 37% of the total cost in the hypertension control program. In the CVD risk management scenario, the proportions of medication and lab diagnostics of total costs were 18% and 64%, respectively. Conclusions: The results from this study can inform planning and budgeting for HEARTS scale-up to prevent CVD across Ethiopia.

Landscape of team-based care to manage hypertension: results from two surveys in low/middle-income countries.

OBJECTIVES: Team-based care is essential for improving hypertension outcomes in low-resource settings. We assessed perceptions of country representatives and healthcare workers (HCWs) on team-based hypertension care in low/middle-income countries. DESIGN: Two cross-sectional surveys. SETTING: The first survey (Country Profile Survey) was conducted in 17 countries and eight in-country regions: Algeria, Bangladesh, Burundi, Chile, China (Beijing, Henan, Shandong), Cuba, Ethiopia, India (Kerala, Madhya Pradesh, Maharashtra, Punjab, Telangana), Nepal, Nigeria, Philippines, Saint Lucia, Sri Lanka, Thailand, Turkey, Uganda and Vietnam. The second survey (HCW Survey) was conducted in four countries: Bangladesh, China, Ethiopia and Nigeria. PARTICIPANTS: Using convenience sampling, participants for the Country Profile Survey were representatives from 17 countries and eight in-country regions, and the HCW Survey was administered to HCWs in Bangladesh, China, Ethiopia and Nigeria. OUTCOME MEASURES: Country-level use of team-based hypertension care framework, comprising administrative, basic and advanced clinical tasks. Current practices of different HCW cadres, perspectives on team-based management of hypertension, barriers and facilitators. RESULTS: In the Country Profile Survey, all (23/23, 100%) countries/regions surveyed integrated team-based care for basic clinical hypertension management tasks, less for advanced tasks (7/23, 30%). In the HCW Survey, 854 HCWs participated, 47% of whom worked in rural settings. Most HCWs in the sample acknowledged the value of team-based hypertension care. Although there were slight variations by country in the study sample, overall, barriers to team-based hypertension care were identified as inadequate training (83%); regulatory issues (76%); resistance by patients (56%), physicians (42%) and nurses (40%). Facilitators identified were use of treatment algorithms (94%), telehealth/m-health technology (92%) and adequate compensation for HCWs (80%). CONCLUSIONS: Our findings revealed key lessons for health systems and governments regarding team-based care implementation. Specifically, policies to facilitate additional training, optimise HCWs' roles within care teams, use of hypertension treatment protocols and telehealth/m-health technology will be essential to promote team-based care.

Limitations in cataract surgical services for children in Ethiopia: a nationwide survey of pediatric cataract surgeons.

BACKGROUND: Bilateral cataract is a significant cause of blindness in children in Ethiopia. This study aimed to identify the resources available for cataract surgery in children, and to assess current surgical practices, surgical output and factors affecting the outcome of surgery in Ethiopia. METHODS: A Google Forms mobile phone questionnaire was emailed to nine ophthalmologists known to perform cataract surgery in young children (0-5 years). RESULTS: All nine responded. All but one had received either 12- or 3-5-month's training in pediatric ophthalmology with hands-on surgical training. The other surgeon had received informal training from an experienced colleague and visiting ophthalmologists. The surgeons were based in seven health facilities: five in the capital (Addis Ababa) and eight in six public referral hospitals and one private center. Over 12 months (2017-2018) 508 children (592 eyes) aged 0-18 years (most < 15 years) were operated by these surgeons. 84 (17%) had bilateral cataract, and 424 (83%) had unilateral cataract mainly following trauma. A mean of 66 (range 18-145) eyes were operated per surgeon. Seventy-one additional children aged > 5 years were operated by other surgeons. There were substantially fewer surgeons per million population (nine for 115 million population) than recommended by the World Health Organization and they were unevenly distributed across the country. Methylcellulose and rigid intraocular lenses were generally available but less than 50% of facilities had a sharp vitrectomy cutter and cohesive viscoelastic. Mean travel time outside Addis Ababa to a facility offering pediatric cataract surgery was 10 h. CONCLUSION: Despite the high number of cases per surgeon, the output for bilateral cataracts was far lower than required. More well-equipped pediatric ophthalmology teams are urgently required, with deployment to under-served areas.