Primary care in the community: We come to you!

Andrew and I arrived back on Thursday and are right back into the swing of things – even after just 3 months, it feels like we came back home. On Saturday I went into the community to do CDCom, and I wanted to share more about it.

CDCom [“Chronic Disease in the Community”] is a program that DGH has been running for several years through which we bring a month of medicine to patients with known chronic diseases in their communities. Patients from two or three villages are mobilized by their village health workers (VHWs) to the meet-up point, usually a VHW’s home compound or local landmark like a grassy knoll or a water tank. We check “disease measures” like blood pressure, urine glucose, listening for wheeze, and gather basic history about symptoms, medication adherence, and possible side effects. If the patient’s complaints seem more complicated than just a refill and he or she would benefit from further work-up, we refer them to our chronic care clinic on Wednesdays or Thursdays. If they need medication titration, we work with the chronic care nurse and the attending on the wards to adjust the regimen.

We believe this service to be pretty unique and an valuable service – delivering anti-hypertensive, anti-diabetic, anti-epileptic, and anti-asthmatic medicines from a government hospital directly to patients who are miles and miles away over bumpy, rocky roads. This saves the patients or their caretakers a significant amount of time, as they don’t need to take the day off from working in the fields or taking care of work around the house.

The program was free for all participants for the first two years of its existence, but within the last two years, DGH has established a small transportation insurance program that has unfortunately introduced a fee for this service. “Tehaz”, as it is called, is modeled on various private community transportation funds that pool villagers’ money to be available to contributors to pay for transport to the hospital in emergencies. DGH figured that it could operate such a fund that heavily subsizes and discounts transport and allows proceeds to fund community health programs. 

We are in the midst of evaluating whether the added revenue is sufficient to warrant the time and money we invest in selling Tehaz (which is short for Tegurira Ejo Hazaza, which means “Planning for Tomorrow” in Rufumbira). It does make me uncomfortable as a healthcare provider in training that we are excluding people who don’t pay. We do have a stipulation that the poorest 10% of people in a village can join for free – but is difficult to determine. There are only a handful of people on our roster of ~300 patients who are “exempt” and I am sure there are many others who could benefit. My conscience is slightly eased when I remember that all patients are welcome to come to KDH for free chronic disease care any Wednesday or Thursday. But still, transportation for these patients, mostly on foot, takes hours and means lost wages or valuable time working in their “gardens”.

My colleagues over the years have integrated certain other programs into our mobile chronic disease clinic, most notably malnutrition services. VHWs screen for malnutrition in the community and invite newly identified cases to join us at CDCom. They actually can refer the mothers directly to the health centre, but many come to be enrolled in our community nutrition program either before or after visiting the health centre. We were once able to deliver RUTF (see: plumpy nut) straight to the communities, but a process of centralization took away that perk –something to do with USAID centralizing procurement of RUTF and not wanting us to be distributing it in the field. As I understand it, the USAID program is attempting to ensure that RUTF (called Rutafa here) is available at all or most government health centre IIs, a small health centre usually staffed by one or two nurses with only outpatient services.

To evaluate each child, we take their weight and measure their mid-upper arm circumference (MUAC). We compare this to measurements we recorded the previous month(s) and ensure they are growing. We refer patients with severe malnutrition to the hospital to ensure they are receiving RUTF and that they’ve received an HIV test and a medical evaluation. We also do very abbreviated counseling about what foods to eat more of. We follow kids for several months and make sure they are growing. If not, we refer them back to the hospital for a medical and nutrition work-up. 

In my first month of working on CDComs I met a grandmother with a severely malnourished 6-year-old granddaughter. The child had recently been sent from Kampala to Kisoro after one of her parents endured a long hospital stay and ultimately passed away. The child was so thin and had a full body rash. I suspected HIV and urged the grandmother to take her to the hospital on the same day. The grandmother said, “Maybe tomorrow.” I didn’t know what to do except to give her the money she would need to get there and back by motorcycle “boda” – about $4. I figured this could help her get to the hospital with less concern that she’d spend hours walking each way. We don’t have a good way to evaluate whether patients “need” this money for transport, but I think it’s a small price to pay to increase significantly the chances that these patients get to care ASAP. Plus, any money they do have could be better spent on school fees or food to feed the kids. We’ve been trying to establish a more regular “emergency referral fund” for patients like this one, but we also need criteria for who gets money, if it's not everyone.

We have recently started having VHWs measure vital signs for all of the children at these gatherings– especially respiratory rate and temperature. They take a history of any recent illnesses, like fever, cough, or diarrhea and feel for the fontanelle if the child is young enough. This is an important opportunity for continuing education with our VHWs and also a chance to identify sick kids. Children with malnutrition are much more likely to become sick and die from pneumonia, diarrhea, or even malaria, than children who are healthy.

In the coming months, we are looking to integrate mental health as well as family planning patients into our CDCom practice. We will keep you posted on how that goes! 

Please share your thoughts, questions, comments with us on this or other posts.