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Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria: an operational cohort study

Hendriks, Marleen E.a; Bolarinwa, Oladimeji A.b; Wit, Ferdinand W.N.W.a; Brewster, Lizzy M.c; Odusola, Aina O.a; Rosendaal, Nicole T.A.a; Bindraban, Navin R.d; Adenusi, Pejue; Agbede, Kayodef; Lange, Joep M.A.a,*; Akande, Tanimola M.b; Schultsz, Constancea

doi: 10.1097/HJH.0000000000000401
ORIGINAL PAPERS: Therapeutic aspects

Objective: To assess the feasibility of providing guideline-based cardiovascular disease (CVD) prevention care within the context of a community-based health insurance program (CBHI) in rural Nigeria.

Methods: A prospective operational cohort study was conducted in a primary healthcare clinic in rural Nigeria, participating in a CBHI program. The insurance program provided access to care and improved the quality of the clinics participating in the program, including CVD prevention guideline implementation. Insured adults at risk of CVD were consecutively included upon clinic attendance. The primary outcome was quality of care determined by scoring of quality indicators on patient files of the cohort, 1.5 year after guideline implementation.

Results: Of the 368 screened patients, 349 were included and 323 (93%) completed 1 year of follow-up. The majority of patients (331, 95%) had hypertension. Process indicators showed that 114/115 (99%) new hypertension cases had a record of CVD risk assessment and 249/333 (75%) eligible cases a record of lifestyle advice. Outcome indicators showed that in 292/328 (64%) hypertension cases, blood pressure was on target. Barriers to care included limited human resources, limited affordability of diagnostic tests and multidrug regimes for the healthcare provider, frequent doctor's appointments, and inefficient drug supplies.

Conclusion: Implementation of CVD prevention care within the context of a CBHI program resulted in high-quality care in rural sub-Saharan Africa, comparable to high-income countries. However, guideline implementation was resource-intense and specific recommendations were not feasible. Simple models of care delivery are needed for rapid scale-up of CVD prevention services in sub-Saharan Africa.

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aDepartment of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands

bDepartment of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria

cDepartments of Internal and Vascular Medicine

dDepartment of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands

eHygeia Nigeria Ltd, Lagos, Nigeria

fOgo Oluwa Hospital, Bacita, Kwara State, Nigeria


Correspondence to Marleen E. Hendriks, Amsterdam Institute for Global Health and Development, Pietersbergweg 17, 1105 BM Amsterdam, the Netherlands. Tel: +31 205667800; fax: +31 205669557; e-mail:

Abbreviations: BP, blood pressure; CBHI, community-based health insurance; CVD, cardiovascular disease; HCHC, Hygeia Community Health Care; HDL, high-density lipoprotein; HIF, Health Insurance Fund; LDL, low-density lipoprotein; LMICs, low and middle-income countries; LVH, left ventricular hypertrophy; OOH, Ogo Oluwa Hospital; QOF, Quality and Outcome Framework; QUICK, QUality Improvement Cardiovascular care Kwara; SSA, sub-Saharan Africa; TOD, target organ damage; WHO, World Health Organization

Received 26 May, 2014

Revised 26 August, 2014

Accepted 27 August, 2014

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