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Table 2 Impact scorecard for SMARThealth intervention, Malang, East Java, Indonesia

From: Strengthening and measuring research impact in global health: lessons from applying the FAIT framework

 

Metrics

Outputs/outcomes

Domains of Benefit

Advance knowledge

• Peer-reviewed papers

• Dissemination of project findings

• Tailored decision support tools

• 2 peer-reviewed publications under review

• Plain language reports written and discussed with Malang District Health Authority and Indonesia’s national health insurance agency

• 1 new clinical decision support algorithm for cardiovascular disease (CVD) screening and treatment, calibrated to Indonesian burden of disease.

Capacity-building and networking

• New research networks

• 5 staff from University of Brawijaya are co-authors on peer-reviewed papers

• 4 University of Brawijaya staff and 1 Malang district health official are co-applicant on two follow-up grants

Health systems strengthening

• Medication supply

• Workforce capacity

• Management of CVD services

• Stock of medication increased by 50% in four primary healthcare facilities participating in the project; medicines procured using local drug procurement system

• 42 lay health workers (Kaders), 14 nurses and 5 doctors trained on risk factors for NCDs, proper management of high-risk CVD and use of the SMARThealth platform

• A new electronic record created for every patient screened, along with a system to share records between Kaders and doctors (working at a different facility), previously none existed

Health outcomes

• Access to CVD care in the community

• Quality of care

• Kaders screened 11,000 people (91% of target cohort)

• 22% of those screened found to be at high-risk of a CVD event, of these 100% referred to a primary healthcare facility

• 91% of those referred followed up by Kaders at least once

• 80% of high-risk patients got appropriate medication, compared to 16% in the control population, resulting in a difference in mean systolic blood pressure of 13 mmHg between high-risk individuals in intervention and control villages

• Modelling suggests there will be 59 fewer CVD events in the intervention villages compared to control population over 5 years; if expanded nationally, 73,000 CVD events could be averted over 5 years

Economic impact

• Health system savings

• Research team income

• New financing

• The research team wages contributed to the local economy

• To date, one follow-up grant of US$ 70,000 secured

• 6 staff employed by the project for 12 months received total wages of 266,953,848 Rupiah

• To date, 1 grant secured (~US$ 700,000)

Social Return on Investment

Cost of research

Total project cost (a)

US$ 1 million over 12 months

Cost of using research

Cost of deploying the interventions trialled (b)

Scaling up the intervention nationally, including primary care, and pharmaceutical costs estimated at US$ 328.3 million over 5 years

Benefit converted US$ values

Economic benefit of deploying the intervention at scale (c)

• Assuming one hospitalisation per CVD event, the intervention would save US$ 333 million over 5 years, nationally

• Estimated productivity gains are US$ 192.4–384.8 million based on 6–12 months average income for those avoiding hospital

• Indirect benefits of avoiding CVD events are estimated at US$ 192.4 million, based on published data

Social return on investment

c / a + b

2.19 under conservative assumptions

2.77 under base case assumptions

Case study

Need: CVDs are the leading cause of death globally, with coronary heart disease and stroke accounting for one-third of mortality worldwide. In Indonesia at least two-thirds of those with, or at high-risk of developing, a CVD do not receive appropriate treatment and there are 470,000 coronary heart disease deaths annually.

Research response: TGI’s Systematic Medical Appraisal, Referral and Treatment (SMARThealth) is a primary care intervention to support the prevention and management of common non-communicable diseases. Deployed successfully in Australia, India and China, the project SMARThealth was delivered in four villages in Malang district, East Java, Indonesia, over 12-months from April 2017. Lay workers (Kaders) were trained to use a mobile tablet device loaded with a clinical decision support system (CDSS) and given a blood pressure monitor and glucometer. Doctors received a different tablet, loaded with a physician-specific CDSS. Kaders screened adults in their community guided by the CDSS, identified those at high risk and referred them to doctors, who in turn used their CDSS to prescribe appropriate medication. Kaders then followed-up on high-risk patients, promoting lifestyle change and adherence to medication.

Research outcome: The project delivered the first comprehensive assessment of CVD burden and access to care in any part of rural Indonesia. A high proportion of the population was screened, high-risk cases referred for treatment, and the majority followed up once back in the community. Complementary health systems support improved medicines supply and the skills of the health workforce. The project received awards from the Malang District Government and the Ministry of Health, Indonesia.

Research impact: Use of recommended medications among people at high-risk was much higher in the intervention villages resulting in significant reductions in blood pressure. A key success factor was delivery of care direct to households. The intervention also enhanced the status of the female Kaders within their communities, improving their motivation. However, there was limited evidence of lifestyle change.

Lessons: A detailed health systems assessment was critical to provide context for the intervention. This identified support needs in staff training, medicines supply and information systems that support sustainability.