Strengthening Healthcare Systems for the Prevention of Chronic Diseases in Rural Nigeria

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3 Strengthening Healthcare Systems for the Prevention of Chronic Diseases in Rural Nigeria Cardiovascular disease prevention in the Kwara State Health Insurance program Marleen E. Hendriks Amsterdam Institute for Global Health and Development The studies presented in this report are the result of a unique collaboration with: University of Ilorin Teaching Hospital Ogo Oluwa Hospital Amsterdam Institute for International Development Academic Medical Center, University of Amsterdam Lagos University Teaching Hospital Institute for Medical Technology Assessment, Erasmus University Their contributions were crucial for the success of the studies. The Kwara State Health Insurance program is a joint initiative of Kwara State, Hygeia Community Health Care, the Health Insurance Fund and PharmAccess - 1 -

4 Strengthening Healthcare Systems for the Prevention of Chronic Diseases in Rural Nigeria Correspondence to: Marleen Hendriks Amsterdam Institute for Global Health and Development Pietersbergweg DE Amsterdam +31 (20) Doctor performs blood pressure measurement on a household survey participant in rural Kwara State. Cover: Rogier Willems, info@rogierwillems.nl Lay-out: Abe Ontwerp, Printing: Ipskamp drukker, Enschede, The Netherlands Copyright: Amsterdam Institute for Global Health and Development, 2014 All rights reserved. No part of this publication may be reproduced, stored or transmitted in any forms or by any means, without written permission of the author

5 In remembrance of Prof. Dr. Joep Lange On 17 July 2014 Joep Lange passed away, together with his partner Jacqueline van Tongeren, on board Malaysian Airlines flight MH17, en route to the International AIDS Conference in Melbourne. Joep Lange was one of the architects of the Health Insurance Fund and founder of PharmAccess. He emphasized the need for rigorous scientific evaluations of health programs in Africa and initiated the operational research within the Health Insurance Fund programs. He was also among the first to recognize the upcoming epidemic of cardiovascular diseases in sub-saharan Africa and stressed the need for access to high quality cardiovascular disease prevention care. It is impossible to overestimate the contribution Joep Lange has made to the work that formed the basis of this report and the accompanying scientific articles, which are dedicated to his memory

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7 Table of contents 7 Citations of scientific articles presented in this report 8 Key messages 11 Introduction 12 Operational research within the Health Insurance Fund programs 15 Improvement of local research capacity 17 Health insurance to improve population health in sub-saharan Africa: the case of cardiovascular disease prevention 27 Recommendations for scale-up of cardiovascular disease prevention care in sub-saharan Africa 30 References - 5 -

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9 This research has been published in the following peer-reviewed, scientific journals Effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: a population-based study. Hendriks ME, Wit FW, Akande TM, Kramer B, Osagbemi GK, Tanovic Z, Gustafsson-Wright E, Brewster LM, Lange JM, Schultsz C. JAMA Intern Med Apr 1;174(4): Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria: an operational cohort study. Hendriks ME, Bolarinwa OA, Wit FW, Brewster LM, Odusola AO, Rosendaal NTA, Bindraban NR, Adenusi P, Agbede K, Lange JM, Akande TM, Schultsz C. J Hypertens, in press. Costs of cardiovascular disease prevention care and scenarios for cost saving: a microcosting study from rural Nigeria. Hendriks ME, Bolarinwa OA, Nelissen HE, Boers AC, Gomez GB, Tan SS, Redekop W, Adenusi P, Lange JM, Agbede K, Akande TM, Schultsz C. J Hypertens, in press. Target organ damage among hypertensive adults in rural Nigeria: a cross-sectional study. Nelissen HE, Hendriks ME, Wit FW, Bolarinwa OA, Osagbemi GK, Bindraban NR, Lange JM, Akande TM, Schultsz C, Brewster LM. J Hypertens Mar;32(3): Hypertension in sub-saharan Africa: cross-sectional surveys in four rural and urban communities. Hendriks ME, Wit FW, Roos MT, Brewster LM, Akande TM, de Beer IH, Mfinanga SG, Kahwa AM, Gatongi P, Van Rooy G, Janssens W, Lammers J, Kramer B, Bonfrer I, Gaeb E, van der Gaag J, Rinke de Wit TF, Lange JM, Schultsz C. PLoS One. 2012;7(3):e Step-by-step guideline for disease-specific costing studies in low- and middle-income countries: a mixed methodology. Hendriks ME, Kundu P, Boers AC, Bolarinwa OA, Te Pas MJ, Akande TM, Agbede K, Gomez GB, Redekop WK, Schultsz C, Tan SS. Glob Health Action. 2014;7: Cardiovascular disease prevention in rural Nigeria in the context of a community based health insurance scheme: QUality Improvement Cardiovascular care Kwara-I (QUICK-I). Hendriks M, Brewster L, Wit F, Bolarinwa OA, Odusola AO, Redekop W, Bindraban N, Vollaard A, Alli S, Adenusi P, Agbede K, Akande T, Lange J, Schultsz C. BMC Public Health Mar 25;11:186. Development and evaluation of a patient centered cardiovascular health education program for insured patients in rural Nigeria (QUICK - II). Odusola AO, Hendriks M, Schultsz C, Stronks K, Lange J, Osibogun A, Akande T, Alli S, Adenusi P, Agbede K, Haafkens J. BMC Public Health Mar 21;11:171. Perceptions of inhibitors and facilitators for adhering to hypertension treatment among insured patients in rural Nigeria: a qualitative study. Odusola AO, Hendriks ME, Schultsz C, Bolarinwa OA, Akande T, Osibogun A, Agyemang C, Ogedegbe G, Agbede K, Adenusi P, Lange J, Weert H, Stronks K, Haafkens J. Submitted

10 Key messages Context Chronic conditions such as hypertension and diabetes are the leading causes of death and disability worldwide, including low-income countries. In sub-saharan Africa, hypertension has overtaken childhood underweight as the leading risk factor for death. Treatment of hypertension and diabetes greatly reduces the risk of death and disability from cardiovascular disease. However, this treatment is often unavailable or inaccessible due to high costs of care combined with lack of health insurance. Treatment of hypertension and other cardiovascular risk factors is lifelong. High quality care for chronic conditions can only be implemented in a well-functioning health system. It requires consistent healthcare financing, high quality of care and long-term access to care for patients. This report evaluates the relevance of the Kwara State Health Insurance program in meeting these conditions and addressing the needs of people in rural areas. We found that high blood pressure (hypertension) is one of the most important health problems affecting the target populations of the Health Insurance Fund programs in Nigeria, Kenya and Tanzania. One third of the population with hypertension in rural Nigeria had hypertension-related organ damage, which underscores the need for adequate treatment of hypertension to prevent disability and deaths

11 Results Treatment of cardiovascular risk factors has been successfully financed and delivered within the Kwara State Health Insurance program: Implementation of guidelines for the treatment of cardiovascular risk factors has resulted in high quality of care. The measured quality of care is comparable to quality of care observed in high-income countries. The insurance program has improved the health of the hypertensive population in the program area. Blood pressure fell significantly more in the communities with health insurance compared to communities without health insurance. The systolic blood pressure reduction that could be attributed to the insurance program was 5 mmhg. This is an important reduction as each 10 mmhg reduction in systolic blood pressure is estimated to reduce the risk of stroke by 38% and the risk of ischemic heart disease by 26%. The successful delivery of care for chronic conditions within a health insurance program is an example of how an effective, accessible and resilient health system for low-income people can be developed. Policy implications The Kwara State Health Insurance program is an important model to provide access to affordable healthcare for low-income people in Nigeria. It offers a promising opportunity to finance and deliver high quality care for chronic diseases in sub-saharan Africa. Scale-up of health insurance programs for low-income people is needed to combat the rising trend of chronic, non-infectious diseases, including cardio- vascular diseases, in sub-saharan Africa. To rapidly scale-up and sustain high quality care for chronic conditions, including cardiovascular disease prevention, there is a need for: An increase in healthcare budgets of governments in sub-saharan Africa by allocating a larger percentage of their gross domestic product for health care; A shift in global health funding from infectious disease alone to a broader agenda that includes chronic, non-infectious, disease prevention; Simplified, low-cost treatment protocols for cardiovascular risk factors with task-shifting from doctors to non-physician health workers

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13 Introduction Kwara State Health Insurance program Like many African governments, Nigeria struggles to meet the growing healthcare demands of its people. Nigeria is one of the most populous nations and one of the fastest growing economies in the world. However, the country s health indicators have either stagnated or worsened during the past decade. The situation is much more alarming in rural areas where access to care is limited, impacting on morbidity and mortality. To address these challenges, the Kwara State Government, Hygeia Community Health Care, the Health Insurance Fund and PharmAccess joined forces in a public-private partnership, developing the Kwara State Health Insurance program in This program aims to improve access to affordable and quality healthcare for the people of rural Kwara (Figure 1), who live on less than USD 1.5 a day. It has been driven by committed support from the Nigerian Hygeia Ban Ki-moon, Secretary- Community Health Care, local politicians and General of the United Nations religious leaders, with the Kwara State Government covering 60% of the health insurance premium. The Health Insurance Fund, with the financial support of the Dutch Ministry of Foreign Affairs, has contracted Pharm Access to provide technical assistance to local partners. When United Nations Secretary General Ban Ki-moon visited the Kwara program in 2011, he described it as groundbreaking and innovative. Figure 1 Africa, Nigeria, Kwara State and the three main regions of Kwara State The groundbreaking Community Health Insurance of the Kwara State Government is exactly the kind of innovative partnership that we should replicate - here in Nigeria and beyond. North Central Baruten Kaiama South Moro Edu Ilorin East Ilorin West Ifelodun Ilorin South Asa Oyun Isin Oke Ero Offa Irepodun Ekiti Pategi

14 Operational research within the Health Insurance Fund programs The Amsterdam Institute for Global Health and Development (AIGHD) and the Amsterdam Institute for International Development (AIID) were contracted by the Health Insurance Fund (HIF) to conduct operational research within all HIF-supported programs, including the Kwara State Health Insurance program in Nigeria. The research in Kwara was conducted in collaboration with the University of Ilorin Teaching Hospital (UITH). The operational research includes impact evaluations that assess the effect of the HIF programs on socio-economic and health outcomes of the target populations. In addition, demand and supply side studies provide more insight into specific aspects of the programs, such as determinants of enrolment and quality of care, and led to recommendations for the program management. Several topics for operational research within the Kwara State Health Insurance program were identified. These topics were chosen based on the burden of disease in the target populations, healthcare utilization in the clinics participating in the insurance program during the first year of the program, public health relevance, questions from program management and based on hypotheses which aspects of population health could be influenced by a health insurance program in the short term. This led to operational research on cardiovascular disease prevention, maternal and child health, access to care and financial protection for patients, and studies on household expenditures for health care. This brief report summarizes the main findings of all studies on cardiovascular disease prevention within the Kwara State Health Insurance program (see page 7 for references to all full-text scientific articles)

15 The Kwara State Health Insurance program addresses both the demand and the supply side of health care. The participating public and private clinics in the Kwara program are enrolled in the quality improvement program called SafeCare. SafeCare (ISQua approved) is an initiative of PharmAccess, the US-based Joint Commission International and the Council for Health Service Accreditation of Southern Africa (COHSASA) for improving quality standards of primary health and clinics in resource-restricted settings. SafeCare offers clinics positive incentives to move steadily upwards in quality as well as provides patients with insights into quality levels. Important aspects of the healthcare improvement standards include implementation of treatment guidelines, training of staff in guideline-based care, upgrading of laboratory equipment, continuous essential drug supplies and hospital infection control protocols. In parallel, clinics within the program have access to capital through the Medical Credit Fund, allowing them Some of the key findings in to obtain loans to invest in capacity and quality previous research: improvement even further. Once quality is in place, people are more willing to (pre)pay for healthcare through the health insurance program. The total cost of the annual health insurance premium is USD 28. The subsidized health insurance allows low-income groups to gain access to comprehensive health care, including primary care, treatment for malaria, tuberculosis and HIV/AIDS opportunistic infections, maternal and child care and care for chronic diseases and surgeries. So far, more than 80,000 low-income people have enrolled. 90% 52% 70% increase in healthcare utilization reduction in out-ofpocket spending on healthcare of women were insured during delivery A unique element of the Kwara program is the operational research component (see page 12). Independent bio-medical and socio-economic impact research is conducted to continuously measure the impact of program and stimulate effective implementation. Some of the key findings from previous research are that people with health insurance have been able to reduce out-of-pocket spending on healthcare (including premium) by 52%. The overall healthcare utilization has increased by 90% and 70% of women in the treatment group in Kwara Central were insured during delivery. The strengthening of the health system has contributed to the improved prevention of cardiovascular diseases, which is the focus of this report. Working towards universal health coverage, one state at a time The Kwara State Government has committed to scaling up the program to cover 60% of the rural segment of the population by Over the next few years, 600,000 low-income people in the rural areas of Kwara State will be covered by the health insurance program. In addition, the State Government has committed to taking over the funding of the program, which was originally set up by the Health Insurance fund, using development aid from the Dutch Ministry of Foreign Affairs

16 Universal health coverage has been on the Nigerian federal agenda since 2005, but the challenges have been daunting. During the Presidential Summit on universal health coverage that took place between 7-10 March 2014, the Kwara program was repeatedly mentioned as a best practice for achieving universal health coverage. Several Nigerian States have shown interest to replicate the Kwara model of state-supported health insurance. Ogun State launched a similar program in April 2014, also with the technical support of PharmAccess. The public-private partnership is vital to assist interested states through technical support, bringing one Nigerian state closer to universal health coverage, and providing an effective model for others

17 Improvement of local research capacity The research partnership between AIGHD, AIID and the University of Ilorin Teaching Hospital (UITH) in Kwara State has resulted in significant research capacity building over the years. Teams of local research staff, including interviewers, data entrants, data managers, study monitors, project managers and other research support staff, were trained as part of several large research projects. AIGHD, AIID and UITH launched their own research office in Ilorin two years ago. In addition, several joint academic articles have been published in peer-reviewed international scientific journals and AIGHD-AIID- UITH wrote grant applications for future projects together. Two Nigerian researchers are currently registered as PhD students at the University of Amsterdam whilst performing their research on the project locally. This improved local research capacity is extremely valuable and will allow UITH to initiate and conduct independent research in the future

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19 Health insurance to improve population health in sub-saharan Africa: the case of cardiovascular disease prevention Why research on cardiovascular diseases? Cardiovascular diseases (CVDs) are the leading cause of death and disability worldwide.1,2 CVDs are a group of disorders of the heart and blood vessels such as heart disease, stroke, vascular diseases of the kidney, and peripheral arterial disease. Globally, 15.6 million people died from CVD in 2010, a 31% increase compared to 1990 when 11.9 million people died from CVD.1 A common misconception is that CVDs are diseases of the wealthy because the main risk factors for CVD, such as high blood pressure (hypertension), diabetes, obesity, smoking, high cholesterol and physical inactivity, are associated with a Western lifestyle. Over 80% of CVD-related mortality occurs in low- and middle-income countries3 and the poorest people in low- and middle-income countries are affected most.4 1. The growing epidemic of cardiovascular diseases in sub-saharan Africa While cardiovascular disease mortality in high-income countries is decreasing due to improved treatment of CVD and CVD risk factors, mortality in low- and middle-income countries is increasing.1,5-7 The burden of CVD risk factors in low- and middle-income countries is growing due to a change from traditional lifestyles to a Western lifestyle with changing diets, more sedentary lifestyles and increasing tobacco and alcohol intake.1,8-14 In addition, specific ethnic groups in low- and middle-income countries have a genetic predisposition for CVD. For example, people of African descent have a higher risk of hypertension and of CVD compared to Caucasians. The growing burden of CVD in sub-saharan Africa has a large economic impact. At the household level, CVD contributes to poverty due to catastrophic health spending with high out-ofpocket expenditures for health care if a household member suffers from CVD. At macroeconomic level, CVDs place a heavy burden on the economies of low- and middle-income countries. CVDs and other non-infectious diseases such as cancers are estimated to reduce GDP by up to 7% in low- and middle-income countries, as many people die prematurely.4 Hypertension is the leading risk factor for death in sub-saharan Africa according to the Global Burden of Disease study from Sub-Saharan Africa faces a double disease burden with a rising burden of CVD, while at the same time the burden of infectious diseases such as HIV, tuberculosis and malaria is still very high.1 This double burden puts an enormous constraint on already overburdened health systems in sub-saharan Africa. The focus of health programs in sub-saharan Africa has traditionally been on infectious diseases. Governments, international health organizations and global health funders have only recently recognized the need for prevention of CVDs

20 and other non-infectious diseases in low- and middle-income countries. A high-level meeting of the United Nations in September 2011 resulted in a political declaration to prevent and combat CVDs and other non-infectious diseases in low- and middle-income countries Hypertension among top five reasons to visit a doctor in the insurance program Hypertension and diabetes were among the most frequently reported reasons for enrolees of the Kwara State Health Insurance program to see a doctor in the first year of the program.16 In addition, a pilot household survey in the target groups of the insurance program in Kwara North in 2008, showed that hypertension was one of the most important health problems of the population.17,18 Finally, the insurer and several healthcare providers of the Kwara State Health Insurance program perceived cardiovascular disease prevention as an important topic for operational research. They emphasized the need for high quality CVD prevention care and the need for capacity building for treatment of CVD risk factors in the clinics participating in the insurance program, as most doctors were mainly trained in the management of infectious diseases and clinics were not organized to provide care for chronic conditions. 3. A litmus test for health systems in sub-saharan Africa Drug treatment for cardiovascular disease risk factors greatly reduces morbidity and mortality due to cardiovascular diseases For example, treatment of hypertension can reduce the risk of stroke by 40%.22 However, as hypertension is usually asymptomatic, most people with hypertension in sub-saharan Africa do not know they have high blood pressure. Of those who know they have hypertension, only a minority is treated with anti-hypertensive drugs and an even smaller proportion of patients is treated successfully.23 The discrepancy between CVD burden and treatment coverage for CVD risk factors can be explained by dysfunctional health systems. Chronic conditions such as hypertension and other CVD risk factors require lifelong treatment and successful treatment can only be delivered in a functional health system.24 On the demand side of the healthcare system, patients need to be aware of their condition and continuous access to care for patients needs to be guaranteed. On the supply side, quality of care needs to be sufficient. Evidence-based interventions for CVD prevention should be delivered by skilled health professionals that have access to essential equipment and medicines.24 Consistent healthcare financing is needed to set up and sustain CVD prevention programs. These conditions are usually not met in sub-saharan Africa. CVD prevention care is often not available due to poor infrastructure and a lack of qualified staff, equipment and supplies,24 or not accessible for patients because of high costs.25,26 Total healthcare expenditures per capita were USD 158 per year (purchasing power parity adjusted) in sub-saharan Africa in 2012 compared to USD 4,512 purchasing power parity in high income countries, and around one third of the healthcare expenditures in sub-saharan Africa are paid out-of-pocket by patients.27 These figures would even be worse if outlier South Africa were excluded. Because chronic disease programs can only be effective in a well-functioning health system, CVD prevention programs serve as a litmus test for health system strengthening interventions such as the Kwara State Health Insurance program

21 How can health insurance be used for cardiovascular disease prevention in sub-saharan Africa? Insurance programs offer opportunities to improve access to care for patients with cardiovascular disease risk factors in sub-saharan Africa. Insurance programs rely on the concept of risk pooling: healthcare expenditures will be high for some enrolees while others rarely utilize care and will therefore have low healthcare expenditures.28 In other words, healthy people partly pay for the healthcare services for sick people. Because of this risk sharing, patients with chronic conditions such as CVD risk factors will have access to care that would have been unaffordable for these patients if they had to pay out-of-pocket. In addition, insurance programs can be used to improve the quality of care, for example through performancebased contracts between insurers and healthcare providers. We postulated that the Kwara State Health Insurance program, which addresses both the demand and supply side of the health system through insurance and quality improvements, could be used to finance and deliver high quality CVD prevention care. Several studies were conducted from both the demand and the supply side perspective of the healthcare system. The burden of CVD risk factors in the communities eligible for the Kwara State Health Insurance program (and other health insurance programs) was studied. In addition, we evaluated access to care for hypertension patients, as well as factors that facilitate adherence to antihypertensive treatment. The effect of the insurance program on blood pressure in individuals with hypertension was measured. Finally, the operational and financial feasibility of implementation of international CVD prevention guidelines from a healthcare provider perspective was studied. The main results of the studies are summarized in the next sections. Results from operational research Hypertension was one of the most important health problems in four populations from Nigeria, Kenya, Tanzania and Namibia. The populations were (partly) eligible for health insurance programs. In total, 7,569 adults were interviewed and underwent medical tests such as blood pressure measurements. The surveys took place before the roll-out of the insurance programs in Nigeria, Kenya and Tanzania. The population in Namibia had access to a comparatively well developed market of affordable health insurance. 1. High burden of hypertension but low coverage of anti-hypertensive drugs before insurance roll-out Hypertension can cause (sub-) clinical target organ damage if not appropriately treated. In the survey in Kwara State, Nigeria, 32% of the population with hypertension had hypertension-related organ damage. The burden of hypertension ranged from 19% of the adult population in rural Nigeria (Kwara State) to 38% in urban Namibia. Awareness of hypertension, i.e. the proportion of respondents with hypertension who are aware of their condition, was low, ranging from 8% in rural Nigeria to 38% in urban Namibia (Figure 2A). The

22 proportion of respondents with hypertension reporting to use anti-hypertensive treatment ranged from 7% in those with mild hypertension to 17.5% in those with severe hypertension. The percentage of patients who were successfully treated, defined as a blood pressure at the target goal for treatment, was poor, ranging from 2.6% in Kenya to 17.8% in Namibia (Figure 2A). In Namibia, treatment coverage and the proportion of patients treated successfully was higher for people enrolled in a health insurance program (Figure 2B). However, no conclusion about whether this was caused by insurance can be drawn based on these data as people who know they have hypertension might be more likely to enrol in insurance programs. In Nigeria, Kenya and Tanzania, baseline surveys on the awareness of hypertension were conducted before introduction of the insurance program. Figure 2 Proportion of hypertension patients aware of their condition, treated with anti-hypertensive drugs and treated successfully with a blood pressure on target in Nigeria, Kenya, Tanzania and Namibia. The data from Nigeria, Kenya and Tanzania were collected before the roll-out of the insurance programs. A Nigeria Kenya 3% 2% 3% 3% 9% 6% 92% 83% Not aware Tanzania Namibia Aware Treated 5% 9% 5% 18% Blood pressure on target 17% 82% 62% 3%

23 B Awareness, treatment and successful treatment in insured versus uninsured respondents with hypertension in Namibia Namibia Not insured Insured 15% 24% Not aware 12% 70% 3% 45% Aware Treated 27% Blood pressure on target 3% These findings show that hypertension is a major health problem in the Health Insurance Fund target populations, also reported in the international scientific literature. Access to good quality treatment is poor in the absence of health insurance. The Health Insurance Fund programs in sub-saharan Africa should include treatment for hypertension and other cardiovascular risk factors. In addition, they should include patient education to raise awareness of cardiovascular risk factors. 2. Quality of care in insurance program comparable to high income countries The QUality Improvement Cardiovascular care Kwara (QUICK) study followed a cohort of 349 patients who were treated for cardiovascular disease risk factors in one of the Kwara State Health Insurance clinics during one year. All patients were insured. As part of the quality improvement program, guidelines for CVD prevention based on World Health Organization29,30 and other international CVD prevention guidelines,31-33 were implemented in the clinic. This included training of healthcare professionals, implementation of treatment protocols, upgrading of facilities for diagnostic testing and management and administrative support to provide chronic care. Quality of care was measured 1.5 years after guideline implementation using quality indicators. An example of a quality indicator is the number of patients who are treated for hypertension who have their blood pressure on target (Figure 3). Scores on quality indicators were high, comparable to scores reported from primary care settings in high income countries (Figure 3). Over 90% of the patients were still in care after one year. This percentage is very high compared to other CVD prevention programs in sub-saharan African countries

24 Figure 3 Quality of care for hypertension in one of the Kwara State Health Insurance clinics in Kwara State, Nigeria, and in high income countries (HIC) Percentage of hypertension patients with blood pressure on target KWARA STATE HEALTH INSURANCE PROGRAM CLINIC 64% Lower bound high income countries (HIC)* (42%) Lower bound populations from African descent HIC** (14%) (81% ) Upper bound HIC* (59%) Upper bound populations from African descent HIC** *Summary of studies conducted in high income countries based on literature review of international scientific journals. **Studies conducted in populations of African descent in high income countries in whom blood pressure targets are more difficult to achieve. The results of the QUICK study are encouraging as they demonstrate that high quality care can be delivered in sub-saharan Africa under certain conditions. The context of the insurance program has most likely contributed to the success of the program. First, insured hypertension patients reported that the Kwara State Health Insurance program facilitated treatment compliance because they did not incur out-of-pocket expenditures for treatment. A pilot study in a health facility nearby the QUICK study clinic with a similar patient population but without access to insurance showed that many patients did not return after initial diagnosis. Costs of care is also frequently reported as a reason to drop-out of care by patients in other studies.25,26 Second, the insurance program provided resources for quality improvement in participating clinics, such as upgrading of facilities and training of staff. For example, implementation of protocols for drug treatment, combined with training and feedback sessions have likely contributed to the high quality of care. The results of the QUICK study showed that insurance programs can be used to deliver high quality CVD prevention care in sub-saharan Africa. Scaling up insurance programs can offer a unique opportunity to improve urgently needed treatment of CVD risk factors in sub-saharan Africa. 3. Implementation of cardiovascular prevention care improved the general clinic management Quality improvement programs need to address typical operational issues in order to be successful. The QUality Improvement Cardiovascular care Kwara (QUICK) study showed that implementation of CVD prevention guidelines improved the general clinic management and service administration. For example, in order to better follow patient treatments, single patient files were introduced with standardized forms instead of family folders in which disease courses were difficult to track. In addition, forms were developed for the pharmacy to track drug dispensary and stock outs. Organizational support was provided to reduce the waiting time in the clinic and laboratory staff was trained in standard operational procedures, quality

25 control and administration procedures. Equipment such as laboratory machines for biochemical testing was purchased. These investments will also benefit non-cvd patients and therefore strengthen the local health system. 4. Barriers to care remain The QUICK study also demonstrated that it was not feasible to implement specific recommendations of international guidelines, despite the availability of the insurance program. Guidelines recommend target organ damage screening in all patients at risk of cardiovascular disease. For example, a patient with hypertension should have yearly screening for kidney disease with laboratory tests and a yearly electrocardiogram to screen for heart disease. The results of these tests are used to make decisions on treatment intensity. However, target organ damage screening was perceived as too time consuming, too complicated and too expensive by the healthcare provider. If target organ damage screening is not available, around a quarter of the population with hypertension would be undertreated because organ damage would not be diagnosed. Alternative, simplified tools are needed to select patients who need more intensive treatment. Combination pills and high dose formulas were not available for patients in the Kwara State Health Insurance program, leading to a large numbers of pills prescribed per day in case of high dose multidrug regimes. For example, a patient that needed 60 mg three times a day for one drug and 50 mg twice a day for another had to take 13 pills a day as only 20 mg and 25 mg pills were available. Patients perceived this as a barrier to treatment adherence. In addition, the lack of combination pills led to high costs of drugs for the healthcare provider as combination pills or higher dose pills are usually cheaper than the sum of separate low dose pills. Therefore, cheap combination pills are an essential component of CVD prevention programs in sub-saharan Africa. The World Health Organization and other international guidelines recommend frequent follow-up visits when drug treatment is started (every two to four weeks). However, if a patient s condition is stable visit frequency can be reduced to every two to six months.31,32,34 Nevertheless, monthly doctor appointments were perceived as necessary for all patients by doctors in the QUICK study clinic. Providing a drug supply for longer periods to patients posed logistical barriers due to the high number of pills per day for multidrug regimes and because doctors feared that large amounts of drugs would get lost. In addition, they emphasized that regular appointments were needed to keep patients in care. Yet, for patients the frequent visits posed a barrier to treatment adherence because of inflexible clinic hours, long waiting times in the clinic, resulting income loss and associated travel costs. These barriers demonstrate the need for simplification of CVD prevention guidelines. The next chapter provides recommendations for innovative delivery models of CVD prevention care to enable rapid scale-up of services in sub-saharan Africa. 5. Cardiovascular disease prevention, a vital investment The costs to deliver CVD prevention care in the QUICK study were USD 144 (range ) per patient per year. We used a healthcare provider perspective which means that the costs

26 for the hospital were USD 144 per patient. Profits were not included. The healthcare provider perspective includes all direct and indirect costs for the hospital, such as costs for drugs, consumables, staff and overheads. Additional costs for patients or for society, such as travel costs or productivity losses due to illness, were excluded. The two main cost drivers were drugs (USD 39) and diagnostic tests (USD 36). Without health insurance, costs of care of USD 144 per year would be unaffordable for many patients. Our survey in Kwara Central showed that CVD prevention care would represent 23% of their yearly expenditures if uninsured individuals were to pay out-of-pocket for care. Health insurance programs such as the Kwara State Health Insurance program offer opportunities to improve access to CVD prevention care for patients in sub-saharan Africa. A rough estimate of the costs of scale-up of CVD prevention care showed that the costs of CVD prevention were estimated at USD 8 (7-9) per head of the population in rural Kwara. Total healthcare expenditure per capita in Nigeria was USD 94 in 2012 of which only USD 29 (31%) was funded by public means.27 Within this healthcare budget, CVD prevention care is most likely not affordable. However, healthcare budgets in most countries in sub-saharan Africa are disproportionately low compared to the Gross Domestic Product (GDP). Total healthcare expenditure in Nigeria was only 6.1% of GDP in 2012 and 66% of total healthcare expenditures came from out-of-pocket payments by patients.27 In addition, economies in sub-saharan African countries, including Nigeria, are among the fastest growing economies in the world. Finally, treatment of CVD risk factors will prevent CVD in the long term and is thus expected to reduce direct healthcare costs of CVD and indirect economic costs to society such as loss of human capital and productivity losses due to CVD.35 With hypertension being the leading risk factor for death in sub-saharan Africa,36 CVD prevention should be a top priority for local and global policymakers. In addition, global funding for health should shift from a focus on infectious diseases alone to a broader agenda that also covers non-infectious diseases such as CVD.37 If there is a political will to allocate sufficient resources to CVD prevention and health care in general, it should be possible to implement large scale CVD prevention programs in sub-saharan Africa. 6. Health insurance reduces blood pressure in hypertension patients The QUality Improvement Cardiovascular care Kwara (QUICK) study demonstrated that the Kwara State Health Insurance program facilitated the delivery of high quality CVD prevention care, as described above. We hypothesized that increased access to improved quality health care could lead to blood pressure reduction in 413 hypertension patients living in the insurance program area. Indeed, the insurance program was associated with a significant decrease in blood pressure in the hypertensive population. More specifically, hypertensive respondents living in the area where the insurance program was operational had a twofold greater reduction in blood pressure compared to subjects living in a control area. Systolic blood pressure (pressure when the heart contracts) decreased by 10 mmhg in the program area, compared to 5 mmhg in the control area (Figure 4). Diastolic blood pressure (pressure when the heart relaxes) decreased by 4 mmhg in the program area compared to 2 mmhg in the control

27 area (Figure 4). This is an important reduction as each 10 mmhg reduction in systolic blood pressure at the population level is associated with a 38% reduction in the risk of stroke and a 26% reduction in the risk of ischemic heart disease.38 Therefore, the observed blood pressure reductions will lead to a substantial reduction of CVD in the population if sustained over time. Figure 4 Effect of the Kwara State Health Insurance program on blood pressure in people with hypertension Change systolic blood pressure (mmhg) * ,1 155,8 151, , start insurance in program area 2011 Control area Program area Change diasystolic blood pressure (mmhg) * ,8 96,0 95,7 91, start insurance in program area 2011 Control area Program area *Change in mean blood pressure between the baseline survey in 2009, before the Kwara State Health Insurance program was rolled out in the program area, and the follow up survey in 2011, two years after program implementation. The difference in change between the program area and the control area is considered as the effect of the insurance program. These results highlight the potential of health insurance programs which include quality improvements for long-term disease management. Scale-up of health insurance programs is needed to combat the growing epidemic of cardiovascular disease in sub-saharan Africa and other low- and middle-income countries

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29 Recommendations for scale-up of cardiovascular disease prevention care in sub-saharan Africa Our studies showed that it was feasible to deliver high quality cardiovascular disease (CVD) prevention care within the Kwara State Health Insurance program. However, our studies also demonstrated that delivery of this care was complex, resource intensive and time consuming for healthcare providers that already face a high workload. In addition, it was not feasible to implement several aspects of the guidelines, such as target organ damage screening and high-dose multidrug regimes. These findings have led to several recommendations to scaleup CVD prevention care in sub-saharan Africa. 1. Simplified guidelines: one pill for all To enable rapid scale-up of CVD prevention care in sub-saharan Africa, simplified, low-cost guidelines for CVD prevention are needed. Scenario analyses in the QUality Improvement Cardiovascular care Kwara (QUICK) study demonstrated that task-shifting from doctors to nurses, reduction of frequency of clinic appointments for patients, and limited target organ damage screening would result in a direct cost reduction of 42%. In this light, the so-called poly pill may be an interesting opportunity for CVD prevention in sub-saharan Africa.39 The polypill is a fixed-dose combination formula that includes different types of CVD prevention drugs in one pill. Different formulas are available; most pills contain two or three antihypertensive drugs and a pill for cholesterol reduction The polypill could be prescribed to anyone with a high CVD risk based on simple risk prediction tools that use for example age, gender, blood pressure and body mass index. Extensive diagnostic testing to decide on drug intensity will not be needed as all patients will receive the same multidrug combination. Because of the simple treatment protocol, the pill could be prescribed by non-physician health workers, such as nurses, that provide care in the communities. Only patients with complications could be referred to a health center. This approach has the potential to reduce costs for diagnostic tests and staff and to reduce travel time and travel costs for patients. In addition, such a strategy could reduce the workload of overburdened doctors. Finally, the polypill strategy has shown to improve treatment compliance by patients by 33-49% compared to usual care. 2. Explore additional models to finance and deliver care Besides health insurance programs, other models to finance CVD prevention care should be explored. Alternative models for CVD prevention care financing and delivery include workplace programs similar to the Heineken Workplace program.42 This initiative finances and provides HIV treatment and general primary care for all Heineken s employees and their family members in sub-saharan Africa. CVD prevention could also be integrated into

30 existing vertical (i.e. disease specific) health programs, such as HIV, malaria and tuberculosis programs, thereby benefitting from the infrastructure and tools that are already in place In collaboration with the African Population and Health Research Center (APHRC), the Amsterdam Institute for Global Health and Development (AIGHD) is currently conducting a study in the slums of Nairobi, Kenya, to develop and test a model to scale-up affordable CVD prevention care using community-health workers to screen for CVD risk factors and low-cost drugs for patients at high CVD risk.46 Mobile phone technology can be used for treatment support to patients, for example by text messages and applications to support a healthy lifestyle and drug treatment adherence.47,48 Mobile phone financial services, such as M-PESA in Kenya (a service that allows money transfers between mobile phones),49 can be used as a tool to facilitate financing of chronic care for patients, for example by offering credits for healthcare expenditures, or vouchers for health care on mobile phones that patients use to pay in health facilities. Future research In addition to (operational) research on new CVD prevention approaches, such as the polypill and different models of service delivery, the findings of our studies yield several other subjects for future research. Cost-effectiveness analyses will provide more insight in the costs of prevention of CVD-related death and disability. In the context of insurance programs, cost-effectiveness analyses can be used to compare the value for money of different healthcare interventions. This can be used to decide what services should be included in insurance benefit packages. However, although interventions may be costeffective, they may still be unaffordable within existing budgets. Budget impact analyses, for example by insurance providers or governments, will provide more insight into the need for additional resources for CVD prevention care. Studies evaluating willingness and ability to pay for different insurance packages from the patient perspective can inform package pricing for insurance providers. Finally, because insurance companies can decide how healthcare providers are reimbursed, health insurance programs provide an opportunity to test the effect of different financial incentives on healthcare utilization, quality of care and patient outcomes in sub-saharan Africa. For example, pay for performance systems, in which providers are rewarded for quality of healthcare services, are an interesting area for future research. Conclusions Chronic care, including treatment of cardiovascular risk factors is resource-intensive and costly. It requires effective health financing and delivery mechanisms to provide high quality of care on a long-term basis. Health insurance programs with quality improvements are a promising opportunity to scale-up CVD prevention care services in sub-saharan Africa. Improvement of access to care and quality of care through the Kwara State Health Insurance program resulted in high quality CVD prevention care and led to a reduction in blood pressure in the hypertensive population

31 However, rapid scale-up of CVD prevention services in sub-saharan Africa does not seem feasible when using current guidelines, even when health insurance programs are expanded. Simplified, low-cost treatment protocols with limited diagnostic testing, limited monitoring, and task-shifting to non-physician health workers are needed in order to combat the growing CVD burden in sub-saharan Africa

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