title: Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years.
abstract: BACKGROUND
  The burden of non-communicable chronic diseases, such as hypertension and diabetes, increases in sub-Saharan Africa. However, the majority of the rural population does still not have access to adequate care. The objective of this study is to examine the effectiveness of integrating care for hypertension and type 2 diabetes by task shifting to non-physician clinician (NPC) facilities in eight rural health districts in Cameroon.
  
  
  METHODS
  Of the 75 NPC facilities in the area, 69 (87%) received basic equipment and training in hypertension and diabetes care. Effectiveness was assessed after two years on status of equipment, knowledge among trained NPCs, number of newly detected patients, retention of patients under care, treatment cost to patients and changes in blood pressure (BP) and fasting plasma glucose (FPG) among treated patients.
  
  
  RESULTS
  Two years into the programme, of 54 facilities (78%) available for re-assessment, all possessed a functional sphygmomanometer and stethoscope (65% at baseline); 96% stocked antihypertensive drugs (27% at baseline); 70% possessed a functional glucose meter and 72% stocked oral anti-diabetics (15% and 12% at baseline). NPCs' performance on multiple-choice questions of the knowledge-test was significantly improved. During a period of two years, trained NPCs initiated treatment for 796 patients with hypertension and/or diabetes. The retention of treated patients at one year was 18.1%. Hypertensive and diabetic patients paid a median monthly amount of 1.4 and 0.7 Euro respectively for their medication. Among hypertensive patients with ≥ 2 documented visits (n = 493), systolic BP decreased by 22.8 mmHg (95% CI: -20.6 to -24.9; p < 0.0001) and diastolic BP by 12.4 mmHg (-10.9 to -13.9; p < 0.0001). Among diabetic patients (n = 79) FPG decreased by 3.4 mmol/l (-2.3 to -4.5; p < 0.001).
  
  
  CONCLUSIONS
  The integration of hypertension and diabetes into primary health care of NPC facilities in rural Cameroon was feasible in terms of equipment and training, accessible in terms of treatment cost and showed promising BP- and FPG-trends. However, low case-detection rates per NPC and a very high attrition among patients enrolled into care, limited the effectiveness of the programme.
authors.affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland. niklaus.labhardt@gmail.com
authors.forename: Niklaus D
authors.initials: ND
authors.lastname: Labhardt
authors.forename: Jean-Richard
authors.initials: JR
authors.lastname: Balo
authors.forename: Mama
authors.initials: M
authors.lastname: Ndam
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Grimm
authors.forename: Engelbert
authors.initials: E
authors.lastname: Manga
mesh_terms: D000328:Adult; D002163:Cameroon; D002983:Clinical Competence; D019033:Delivery of Health Care, Integrated / Q000592:standards / Q000706:statistics & numerical data*; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis / Q000517:prevention & control / Q000628:therapy*; D004864:Equipment and Supplies / Q000600:supply & distribution; D005260:Female; D006268:Health Facilities / Q000592:standards; D006297:Health Services Accessibility / Q000592:standards*; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000517:prevention & control / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000145:classification / Q000523:psychology / Q000592:standards*; D057184:Practice Patterns, Nurses' / Q000706:statistics & numerical data / Q000639:trends; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000592:standards*; D012424:Rural Population; D011795:Surveys and Questionnaires; D013647:Task Performance and Analysis; D000078329:Workforce