Implementing noncommunicable disease clinics to improve control of hypertension in Somaliland: An observational study

Noncommunicable diseases (NCDs) are increasingly prevalent in Somaliland. However, context-specific evidence on how to successfully implement proven NCD prevention and control interventions in a variety of resource-constrained health systems like Somaliland remains elusive. In 2022, Somalilands first pilot NCD clinic, modelled after PEN-Plus in Rwanda, opened at Hargeisa Group Hospital, the national referral and teaching hospital, where patients are treated for heart failure, hypertension, diabetes, COPD, and asthma. The clinic is staffed by nurses and general practitioners with the supervision of an Internal Medicine specialist. The clinic has enrolled over 2000 patients. We evaluate the clinics impact on hypertension control to inform improvements and national scale up. A quasi-experimental pre-post study design with mixed effect models was used, analyzing preliminary clinic data from 2022-2024. The outcome was change in systolic blood pressure (SBP) and diastolic blood pressure (DBP) from initial to follow-up visits among hypertensive patients with at least one follow-up. 348 patients (56.6 years and 60% female) were included and had median follow-up of 3 visits (IQR 3) over 114 days (IQR 185). Baseline mean BP was 148.6/96.0 mmHg (95% CI: 139.0-158.3 / 91.9-100.9). Compared with the initial visit, clinic attendance was associated with a significant reduction in SBP ranging from 10.3 mmHg (95% CI: -12.8, -7.7, p<0.0001) at first follow up to 17.3 mmHg (95% CI: -23.4, - 11.1, p<0.0001) at last follow up. Similarly, compared with the initial visit, DBP declined by 5.6 mmHg (95% CI: -7.1, -4.1, p<0.0001) at the first follow up visit and 8.0 mmHg (95% CI: -11.6, -4.3) at the last follow up visit. Implementing NCD clinic was associated with a considerable improvement in hypertension control among NCD clinic patients in Somaliland. Sustaining this reduction in BP would contribute to reducing the risk of major cardiovascular disease events including coronary artery disease, stroke, arrhythmia, and health failure, and ultimately, significant reduction in NCD and all-cause mortality in Somaliland. Lessons learnt while implementing this pilot NCD clinic will help inform successful national scale up of NCD clinic in Somaliland.