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International audience; Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. ‘At-goal’ status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial.

Background: Vitiligo has an immense psychological impact on the affected individual and a reason for low self-esteem. Considering the disappointing outcomes, A multicentric open clinical study was undertaken by the Central Council for Research in Homoeopathy, at five institutes and units in India from October 2005 to September 2010. Aims and Objectives: This observational study aimed to see the usefulness of homoeopathic therapy in the management of vitiligo. Materials and Methods: 432 patients of all age groups suffering from vitiligo were enrolled in the study. Out of that, 169 patients completed 2 years of follow-up and were considered for analysis. Homoeopathic medicines, based on the totality of symptoms and repertorization were prescribed. The analysis of the cases was based on the Vitiligo Symptom Score (VSS) and photographs of the patients. Result was analyzed using statistical method of SPSS version 20. Results: The changes in the mean VSS at intervals of every 6 months was found to be statistically significant. Homoeopathic treatment was found to be useful in relieving vitiligo in varying degrees in 126 patients, out of which 4 (2.94%) cases showed marked improvement, 15 (11.03%) cases showed moderate improvement, 77 (56.62%) cases showed mild improvement, and 30 patients although improved, fell in the category of not significant improvement group (below 25% improvement). Ten homoeopathic medicines were found useful in the study of which Sulphur ( n = 27), Arsenicum album ( n = 19), Phosphorus ( n = 19), and Lycopodium clavatum ( n = 10) were the most commonly indicated and useful medicines.

BackgroundChronic obstructive pulmonary disease accounts for a significant portion of the world’s morbidity and mortality, and disproportionately affects low/middle-income countries. Chronic obstructive pulmonary disease management in low-resource settings is suboptimal with diagnostics, medications and high-quality, evidence-based care largely unavailable or unaffordable for most people. In early 2016, we aimed to improve the quality of chronic obstructive pulmonary disease management at Bayalpata Hospital in rural Achham, Nepal. Given that quality improvement infrastructure is limited in our setting, we also aimed to model the use of an electronic health record system for quality improvement, and to build local quality improvement capacity.DesignUsing international chronic obstructive pulmonary disease guidelines, the quality improvement team designed a locally adapted chronic obstructive pulmonary disease protocol which was subsequently converted into an electronic health record template. Over several Plan-Do-Study-Act cycles, the team rolled out a multifaceted intervention including educational sessions, reminders, as well as audits and feedback.ResultsThe rate of oral corticosteroid prescriptions for acute exacerbations of chronic obstructive pulmonary disease increased from 14% at baseline to >60% by month 7, with the mean monthly rate maintained above this level for the remainder of the initiative. The process measure of chronic obstructive pulmonary disease template completion rate increased from 44% at baseline to >60% by month 2 and remained between 50% and 70% for the remainder of the initiative.ConclusionThis case study demonstrates the feasibility of robust quality improvement programmes in rural settings and the essential role of capacity building in ensuring sustainability. It also highlights how individual quality improvement initiatives can catalyse systems-level improvements, which in turn create a stronger foundation for continuous quality improvement and healthcare system strengthening.