1. Partners in Health Rwanda

2.  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

3. Southern Kayonza Kigali Kirehe ● ● ● ● ● Health center District hospital + health center 1 hour good road + 30 minutes slow track Burera

4. Ezzati et al. PLoS Medicine. 2005 S. Africa Haiti Rwanda FranceChina BMI BP CHOL

5. IndicatorRuralUrban Farmer92 %44 % % in lowest wealth quintile24 %6.1% Dirt-floor housing93 %52 % % of women with BMI > 25 kg/m210 %19 % % of women with BMI < 18.5 kg/m220 % Cannot read at all32 %15 % No education25 %14 % No trained assistance during delivery65 %34 % Access to health care limited by facility distance (women’s self-report) 42 %28 % Infant mortality (per 1000 live births)10869

6. AuthorsCountry City or Region N % of Heart Failure Admissions D’Arbela et al. 1966UgandaKampala15,1763.5% Turner 1962TanzaniaMombasa3,0526% Baldachin 1962ZimbabweBulawayo12,1053% Beet 1956NigeriaJos and Katsina2,7007%

9.  90 patients with heart failure identified from October 2006 to October 2007  All have structural heart disease confirmed by echocardiography  Median age: 36 years

13. DiseaseMedication Costs Annual Per Patient Operative Costs Per Patient Marginal Per Capita Program Cost Cardiomyopathy (0.2% prevalence) $55$0.19 Advanced RHD (0.1% prevalence) $5,000 – 10,000$0.76 Malignant HTN (0.3 % prevalence) $25$0.53 Total$1.48* *Based on estimates of disease prevalence and intensity of case finding

14. Physicians Nurses Physicians Community health workers Nurses and physicians Echocardiography Point of care laboratory testing Clinical protocols Echocardiography Point of care laboratory testing Clinical protocols

16.  I-STAT machine for monitoring of  Renal function  Electrolytes  INR in case of anticoagulation

19. MedicationInitial EstimateFinal Estimate Captopril 37.5 mg tid$22$16 Lisinopril 20 mg qd$241$12 Atenolol 50 mg qd$2 Carvedilol 25 mg bid$1261$26 HCTZ 12.5 mg$1 Amlodipine 10 mg qd$805$4 www.imres.nl

20. Faris et al. Cochrane Collaboration. 2006 McMurray and Pfeffer. Lancet. 2005

21. Stage IV hypertension almost eradicated

24. 55 patients with Rheumatic MR treated with monthly IM benzathine PCN Tompkins et al. Circulation. 1972

26.  Walter Sisulu Heart Center, Johannesburg, South Africa  Emergency, Salam Heart Center, Khartoum  Operation Open Heart at King Faisal Hospital in Kigali  Brigham and Women’s Hospital at King Faisal Hospital

28.  How to scale-up a heart failure program at a national level? 1. Procurement of echocardiography equipment at district hospital level 2. Procurement of point of care laboratory testing at district hospitals and health center level 3. Formulary changes at district hospital and health center level 4. Development and implementation of country-specific clinical protocols for district hospitals and rural health centers 5. Development of training material and a training curriculum for physicians, nurses, and community health workers 6. Development of a training model requiring 1 to 1 clinical mentorship and leading to official certification 7. Partnership with Ministry of Health, National Medical School, and other stakeholders (i.e. Rwandan Heart Association)

29.  Why only heart failure?  There is the need for a program targeting all chronic diseases of poverty 1.Edematous conditions a)Heart failure b)Cirrhosis/portal hypertension c)Chronic renal disease 2.Insulin-dependent diabetes 3.Severe hypertension 4.Asthma and other chronic lung diseases 5.Epilepsy 6.Malarial hyper-reactive splenomegaly  We are currently working on the development of a chronic care team (2 physicians and 3 nurses)