Implementation outcomes of national decentralization of integrated outpatient services for severe non-communicable diseases to district hospitals in Rwanda

Trop Med Int Health. 2021 Aug;26(8):953-961. doi: 10.1111/tmi.13593. Epub 2021 May 16.


Objectives: Effective coverage of non-communicable disease (NCD) care in sub-Saharan Africa remains low, with the majority of services still largely restricted to central referral centres. Between 2015 and 2017, the Rwandan Ministry of Health implemented a strategy to decentralise outpatient care for severe chronic NCDs, including type 1 diabetes, heart failure and severe hypertension, to rural first-level hospitals. This study describes the facility-level implementation outcomes of this strategy.

Methods: In 2014, the Ministry of Health trained two nurses in each of the country's 42 first-level hospitals to implement and deliver nurse-led, integrated, outpatient NCD clinics, which focused on severe NCDs. Post-intervention evaluation occurred via repeated cross-sectional surveys, informal interviews and routinely collected clinical data over two rounds of visits in 2015 and 2017. Implementation outcomes included fidelity, feasibility and penetration.

Results: By 2017, all NCD clinics were staffed by at least one NCD-trained nurse. Among the approximately 27 000 nationally enrolled patients, hypertension was the most common diagnosis (70%), followed by type 2 diabetes (19%), chronic respiratory disease (5%), type 1 diabetes (4%) and heart failure (2%). With the exception of warfarin and beta-blockers, national essential medicines were available at more than 70% of facilities. Clinicians adhered to clinical protocols at approximately 70% agreement with evaluators.

Conclusion: The government of Rwanda was able to scale a nurse-led outpatient NCD programme to all first-level hospitals with good fidelity, feasibility and penetration as to expand access to care for severe NCDs.

Keywords: Africa; Rwanda; first-level hospital; national scale-up; non-communicable disease; rheumatic heart disease; rural; type 1 diabetes.

MeSH terms

  • Ambulatory Care / organization & administration*
  • Ambulatory Care / standards
  • Delivery of Health Care, Integrated / organization & administration*
  • Delivery of Health Care, Integrated / standards
  • Diabetes Mellitus, Type 1 / therapy
  • Health Services Accessibility*
  • Heart Failure / therapy
  • Humans
  • Hypertension / therapy
  • Noncommunicable Diseases / therapy*
  • Outcome and Process Assessment, Health Care*
  • Politics
  • Retrospective Studies
  • Rural Health Services
  • Rwanda