Background information of PHCCs in Bangladesh:
The urban and rural PHCCs of Bangladesh are running under two different ministries. So, some basic differences in charecteristics of PHCCs are present between these two.(Table 4)
Results of thematic analysis:
Theme 1: Magnitude of NCD burdens in Bangladesh is increasing
The majority of the participants agreed that, in Bangladesh, the burden of NCDs and the number of patients experiencing NCD related problems are increasing in both urban and rural areas and is emerging as a public health challenge. The most common reasons for patient’s visits to the facility were DM, hypertension (HTN), and sometimes respiratory problems. The other associated NCDs were mental health, road traffic accident, and injuries.
Some respondents said that, in most cases, patients visit health facilities with symptomatic complaints before they were diagnosed as NCD patients. As one participant noted:
“We face various difficulties to identify and treat patients with NCDs as people do not usually come to treat NCDs. Most of them come with general weakness, vertigo, nausea, blurred vision. Sometimes they even forget to mention symptoms that might help us identify NCD cases.” KI-2
Theme 2: Demand for staff training for better NCD services
The study found that most health staff either in HID or LID could screen and diagnose DM and HTN. For other NCDs, they needed a physician’s opinion. All of them could assess common risk factors like smoking, obesity, and physical inactivity and could also provide counseling to the patients on lifestyle modification. Almost all the urban and few rural PHCC physicians said that they did not receive any on-the-job training regarding NCD. According to their perception, more training on developing skills in diagnostic, treatment, and referral process could have increased their efficiency in delivering better services. . One urban physician quoted-
“No staff of this facility got training on NCD. I give treatment based on my working experience, previous knowledge, experience from previous patients, and by using a reference book. This facility is a bit far from the main town. So, patients come here first for primary management before going to secondary/ tertiary level hospitals. So, we need training on NCD to serve the patients more efficiently and effectively before referral.”KI-11
Theme 3: Limited supportive resources in PHC facilities without a special initiative project
The Non-Communicable Disease Control (NCDC) program under the Directorate General of Health Services (DGHS) is currently piloting the NCD management model in some selected UHCs following the WHO PEN protocol both in HID and LID. In this study, we called them PEN pilot UHC.5 Among the selected facilities of this study, two of them were under this model (one in HID, one in LID). Participants of PEN pilot UHCs (physicians, nurses) got training from the NCDC program on PEN protocol and have guidelines and standardized protocol on DM and HTN. So, the staff could follow the protocols for diagnosis, treatment, referral, and follow-up of NCD patients. Moreover, these centers were getting regular supplies of medicine and medical equipment when compared to other PHCCs. So they are managing uncomplicated NCD patients more efficiently than the rest of the facilities. One UH&FPO of HID stated –
“Generally, the patients receive basic NCD services, including consultation, basic investigation, treatment, and advice from us. Sometimes we get patients who are too serious, difficult to manage in UHC, and need an expert opinion. We refer those patients to the district hospital where the specialists are available.” KI-8.
On the other hand, in non-pilot UHCs irrespective of HID or LID, skilled human resource, the supply of medicine and equipment was not adequate. They are not accustomed to using any guideline on HTN or DM management during serving the patients. So, the competency and capacity of the participants of those UHCs, were not compatible enough to provide the expected service. This study found that most USCs and CCs had little capacity to manage NCDs. So, they referred to all the NCD cases to UHC after screening. Some CHCPs got basic training on early detection for prevention and control of DM and HTN from the corresponding UHCs. They use referral slip for the referral process. One participant of LID mentioned about the treatment and referral process-
“This UHC is not under the PEN pilot project. There is no treatment guideline, and I did not receive any training from NCDC, DGHS, on PEN protocol. Moreover, there are a shortage of essential medicines, and sometimes patients have to buy medicine from outside. We also get NCD patients from the USCs and CCs. With all these obstacles, we try to give treatment to NCD patients and refer if not within our capacity.” HS-18
Theme 4: Patients perspective in availing the NCD services at PHCs
This study found that there were three important problems of NCD service provision at PHCs arising from the patient’s perspective. First, many of the patients don’t know about the availability of NCD service mainly at UPHCCs. One counsellor expressed the situation as-
“Urban PHCCs were mainly established to provide Maternal and Child health care. Many patients do not know about the availability of NCD services here. We have some regular outdoor patients of NCDs who are ‘Red card’ holders. They got full free treatment but very few in number.” HS-4
Secondly, their preference in reporting to the tertiary level of hospitals directly both in HID and LID in an advantageous environment (short distance, well communication, higher wealth quintile, etc.). Another statement from health staff explains the existence of the issue-
“In this facility, we give treatment which is within our limit. Others got referred to Rangpur Medical College Hospital (RpMCH, Tertiary level hospital) by the physician. But the fact is, most of the NCD patients go to RpMCH/ specialist doctor chamber directly. Those who cannot afford that come to us for NCD treatment.” HS-13
These two issues were also marked by one of the KI (04) while explaining the gaps and challenges in providing NCD services. Again, visit to have a follow up was found to be another point of ignorance by the patients, which was emphasized by one of the health staffs at PHCC from LID-
“This UHC is under the NCD pilot project. We can treat patients by following cost-effective interventions. We have sufficient essential medicines and laboratory facilities to treat mild to moderate cases. Patients get free medicine. Sometimes, we advise for admission. As it is a Government facility, people have to spend less money. Patients come for follow up as per advice, but all of them are not regular”.HS-17
Theme 5: Challenges and barriers in establishing standard practices for providing NCD services at PHCCs
PEN disease protocol recommended some public health solutions which can decrease the risk of NCD through the life span, some interventions which can contribute to declining morbidity and mortality and the simultaneous use of risk prediction tools can identify the vulnerability of the people.
i) NCD service through a lifespan approach-
The data shows among the facilities, there was a similarity in their performances in providing solutions for the prevention and control of NCDs. All the facilities were found not performing the activities related to improvement in life skill education, restricting the marketing of food products high in salt/ sugar/ unhealthy fats, and improvement in availability and affordability of food. (see Additional file 1, Supplementary table 1)
According to the interviews, most participants concurred that counselling during Antenatal care (ANC) and Post-natal care (PNC) sessions, discussion during courtyard meeting and use of Information, Education and Communication (IEC) materials like posters/leaflet/dummy by the staff acted as enabling factors to implement public health solutions both in urban and rural areas. Among the others, advertisements on TV /social media, motivated school teachers in providing health education, and little doctor program were more pronounced.
On the other hand, lack of skills among staff, lack of awareness, and existence of social stigma among the people, patient overload at facilities were pointed as barriers by the participants. Another important aspect was staffs are not familiar with the use of any guidelines or protocol for NCD management during their service delivery process.
ii) A core set of evidence-based interventions:
According to the WHO PEN, these interventions are feasible for implementation in low-resource settings and can help reducing morbidity and mortality from major NCDs (here CVDs and DM) . However, this study found that PHC staff, other than the physicians of both urban and rural areas, did not follow or even know about the WHO PEN. (see Additional file 2, Supplementary table 2)
Compared to pilot project facilities, health professionals of other facilities did not have a clear idea about the WHO PEN. All the facilities performed the activities as their routine work and mentioned counselling, court-yard meeting, and their residual knowledge as enabling factors. Among the barriers, lack of training, or refresher training, familiarity with guideline and skilled manpower were more pronounced. Piloted facilities also mentioned their obstacles. One of the staff from rural pilot UHCs said-
“Our UHC is under NCD pilot project, and some of us had training; so, we know about PEN recommendation by WHO. However, both physicians and nurses had this training, it is to some extent, difficult for nurses to perform these without supervision. In my opinion, lack of skilled manpower, along with failure to retain skilled staff and training of new staff, are the main barriers to implement the interventions.” HS-17
iii) Risk prediction tools:
It is observed that risk prediction tools are not available in most of the facilities except the facilities under the pilot project (one from LID one from HID), and both of the facilities were in the rural area (Table 5). So that clearly shows the inadequate use of risk prediction tools in urban facilities. Moreover, the facilities using those tools also have to combat different situations to ensure the use of the tools. One of the health staff from pilot project UHC explained the challenge in using the tool-
“The physicians who had this training were transferred very recently. One nurse had this training but not that efficient. The trained doctors started to train up the other doctors but could not finish it. That is why currently, we do not use these tools. General patient overload is another cause.”-HS-8