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Introduction Community Health Worker (CHW) programs have long been used to provide acute care for children and women in healthcare shortage areas, but their provision of comprehensive longitudinal care for chronic problems is rare. The Village Health Worker (VHW) program, initiated in 2007, is an example of a long standing “horizontal” CHW program in rural Southwestern Uganda that has delivered village-level care for chronic disease based on a biannual village health census that identifies individual and family health risks. To facilitate continuity of care for problems identified, health census data were electronically transformed into family-specific Family Health Sheets (FHS) in 2016 which summarize the pertinent demographic and health data for each family, as well as health topics the family would like to learn more about. The FHS, evaluated and discussed here, serves as an epidemiologically-informed “bedside” tool to help VHWs provide longitudinal care in their villages. Methods 48 VHWs in the program completed a survey on the utility of the FHS and 24 VHWs participated in small discussion groups. Responses were analyzed using both quantitative and standard conceptual content analysis models Results 46 out of 48 VHWs reported that the FHS made them a “much better VHW.” In addition to helping target interventions in child health, women’s health, and sanitation, the FHS assisted follow-up of non-communicable diseases in the community. In discussion groups, VHWs reported that the FHS helped them understand risks for future disease, facilitated earning stipends, and increased credibility and trust in the community. Limitations cited were the infrequent updates of the FHS, only biannually with the census, and the lack of cross-reference capability by health problem. Discussion The FHS supports VHWs in providing longitudinal and comprehensive healthcare of chronic diseases in their villages. Limitations, potential solutions, and future directions are discussed.

Objective Evaluate the effectiveness of home talks (HTs), a novel model of health education delivered by village health workers (VHWs) with primary-level education to rural African mothers. Talk recipients were assessed by health census to be at risk for ill-health in one of 5 ways: malnutrition, diarrhea, respiratory disease, HIV, and poverty due to family size. Methods Each participant received a pre-test, immediate post-test and delayed post-test on their assigned HT topic and a pre-test and delayed post-test on a randomly assigned control topic. Differences in scoring were examined against controls and over time using paired t-tests and general linear regression analysis, respectively. Results Subjects lost knowledge gained from the HTs over time, but what they retained at 3 months was far greater than what they learned about the control topics (p-values Conclusion Targeted HTs to people with health census-identified risk factors resulted in learning and significant retention of knowledge. Practice implications Positive behavioral change resulting from health education has been shown in diverse contexts. This personal model of home talk education by VHWs targeting vulnerable families is flexible and effective and may be used to improve community health in other impoverished settings worldwide.

Countries building sustainable, cardiac surgical care must ensure that the local health system has the capacity to support routine postoperative follow-up and generate the infrastructure required to provide timely diagnosis and management of common postoperative complications. Following valvular cardiac surgery, most patients will need management of residual symptoms of heart failure, adjustment and monitor of anticoagulation, administration of lifelong penicillin prophylaxis and guidance on how to navigate family planning. Anticoagulation has historically been seen as an insurmountable challenge in the rural poor; however, in this chapter, we present the PEN-Plus model for decentralized postoperative management—and provide insight into how its application can guide the way forward to support sustainable post-surgical capacity and appropriate patient follow-up in resource-constrained settings. Warfarin, for example, is a standard anticoagulant prescribed following most routine cardiovascular procedures, and its management requires careful consideration in under-resourced settings. Given its teratogenicity and associated untoward effects, if not managed properly, warfarin can present life threatening complications. As such, district hospitals must be equipped with the capacity to diagnose anticipated complications, to treat mild cases and to refer more severe cases of bleeding, valve thrombosis, or thromboembolic events toward tertiary levels of care in a timely and efficient manner. Patients must be counselled on the attendant risks of anticoagulation, and be provided education on how to maintain a consistent diet. Health systems must ensure that district hospitals have a reliable supply of both warfarin and INR testing supplies. Providers must be trained to diagnose and manage common ongoing complications including endocarditis, sternal wound infection and dehiscence, pericardial and pleural effusions, atrial fibrillation, valve thrombosis, valve dehiscence and hemolytic anemia. Furthermore, health systems need to set up comprehensive support systems for patients, including cardiac rehabilitation, nutritional, socioeconomic and mental health supports.

Cardiac surgery is an essential health service required to prevent mortality and morbidity among patients with valvular and other cardiac disease. Access to cardiac surgery has historically been limited in low and lower-middle income countries (LLMICs), especially among the rural poor. Decentralization of noncommunicable disease (NCD) care from national tertiary care hospitals to local district hospitals can help achieve equity and increase access to cardiac surgery. Within the described PEN-Plus model for NCD management, nurses at the district hospital level are trained to diagnose heart disease by simple physical examination and echocardiography, and manage heart disease using a locally validated protocol, with the assistance of cardiologists from large tertiary care hospitals. This decentralized model provides medical preoperative management and identifies patients eligible for cardiac surgery earlier in their natural history of disease. Case selection can be challenging in LLMICs, but must take into consideration the risks vs benefits of the cardiac surgery for each patient, age of the patient, disease severity, complexity of proposed surgery, local capacity in the operating room and intensive care unit, and likelihood of good surgical outcomes, all with an emphasis on equity. Decisions regarding types of interventions must be made with a patient-centered approach, taking into account not only medical information, but also social and cultural considerations. Cardiac surgery programs must have a national coordinator who is in close communication with local NCD nurses, national cardiologists, and cardiac surgery teams. This coordinator should maintain a dynamic database of patients eligible for surgery, as well as patients who have been operated on and require follow-up and anticoagulation.

Between 30% and 60% of hospital outpatient clinic patients were lost to follow-up. A defaulter-tracking service using performance-based remuneration for outreach workers, cutting across different clinical services, improved patient retention overall but varied by disease, with the poorest outcomes among patients with HIV., Among the many challenges facing health systems grappling with the explosive growth of chronic disease in Africa are continuity of care, particularly in poor, rural areas. We report the strategy, field experience, and results of an ongoing 6-year follow-up program operating in a rural district hospital in Kisoro, Uganda, that attempts to locate and reengage patients lost to follow-up (LTFU) from communities that are largely without phones, addresses, or paved roads. The program works with diverse hospital clinics, including chronic diseases, HIV, tuberculosis (TB), nutrition, and women's health, to identify patients who have not returned to care, employing a modest staff who spend about 20 days monthly making outreach visits by motorcycle in search of approximately 130 patients. We describe the organization of this unique “horizontal” program and report on follow-up outcomes between November 2015 to October 2016. Between 30% and 60% of patients were found to have lapses in care. The follow-up program was able to locate 64% of patients, with a reengagement rate of 54% to 92% (average, 69%) depending on the clinic. The program costs approximately US$5 per patient LTFU but about US$40 per patient maintained in care. The hospital-based follow-up program that cuts across diverse clinics and wards was novel and feasible in this rural sub-Saharan African setting.

This is a novel case of a 16-month-old boy with a history of prematurity with intrauterine growth restriction, severe failure to thrive, microcephaly, pachygyria, agenesis of the corpus callosum, and postnatal embolic stroke, who presented with new-onset diabetes mellitus with diabetic ketoacidosis in the setting of severe acute respiratory syndrome coronavirus 2 infection, with a course complicated by atypical hemolytic syndrome (aHUS). This patient demonstrated remarkable insulin resistance in the period before aHUS diagnosis, which resolved with the first dose of eculizumab therapy. There is increasing evidence that COVID-19 is associated with thrombotic disorders and that microangiopathic processes and complement-mediated inflammation may be implicated. In this case report, we describe a pediatric patient with COVID-19 and a new complement-mediated microangiopathic thrombotic disease. Because whole-exome sequencing and extensive workup returned without a clear etiology for aHUS, this is likely a COVID-19 triggered case of aHUS versus an idiopathic case that was unmasked by the infection.

The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tri-partite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD risk-based treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of "stockouts" and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a granular description of the solutions we devised will be of benefit to others managing chronic disease in similar rural African communities.