Examining The Ugandan Health System'S Readiness To Deliver Rheumatic Heart Disease-Related Services

Author summaryRheumatic heart disease is a major cause of cardiovascular death and disability, especially in less-developed parts of Africa and Asia. Unfortunately, medications and surgical procedures to prevent or treat rheumatic heart disease and its precursor rheumatic fever are greatly under-used, even though they are very effective. This study conducted an assessment of health system gaps in delivery of RHD related care in Uganda. We used quantitative and qualitative methods to find out, firstly, what percentage of health facilities are currently providing rheumatic heart disease services and, secondly, what things need to be fixed in order to improve service availability. We found that only 1-2% of health facilities are currently fully equipped to provide rheumatic heart disease prevention and treatment. The two biggest problems are that frontline health workers know very little about the condition and that the tests used to diagnose rheumatic fever and rheumatic heart disease are not widely available in many districts. Our assessment can serve as a baseline in monitoring the implementation of future interventions in Uganda. We are making our methods and tools publicly available so that ministries of health in other countries can use them to develop or expand their rheumatic heart disease programs.BackgroundIn 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda.Methodology/Principal findingsThis was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare.Conclusions/SignificanceUganda's readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.