An Assessment of Provisions of Noncommunicable Disease Services on Health Promotion, Prevention and Control at Primary Health Care: A Case Study from Two Divisions of Bangladesh

Sadia Sobhan Pinki (  sadiasiyana@gmail.com ) National Institute of Preventive and Social Medicine https://orcid.org/0000-0001-5620-0210 Irfan Nowroze Noor National Institute of Preventive and Social Medicine Bayzid Amin National Institute of Preventive and Social Medicine Md. Ziaul Islam National Institute of Preventive and Social Medicine Baizid Khoorshid Riaz National Institute of Preventive and Social Medicine

(MoLG & RD). These UPHCCs cover city corporation or municipality area only. In rural areas, the rural PHC consists of UHC, USC, and CC, which are run under the Ministry of Health and Family Welfare (MOH&FW). Health facility of Upazila is called Upazila Health Complex (UHC, total 424), in union 'Union Sub-Center' (USC, total 1312), and in community-level, it is Community Clinic (CC, total 13779). In this study, we randomly chose ten urban and 12 rural PHC facilities of both high-income Division (HID) and low-income division (LID), according to the 'Household Income and Expenditure Survey (HIES) 2016' ( Table 1). The Dhaka division represented the HID as it got the highest average monthly household nominal income of BDT 19058 ($ 244) which exceeded the national average of BDT 15988 ($ 205, 1$=78 BDT in 2016), and Rangpur division represented the LID due to the least record of BDT 10547 ($ 135) in 2016 [21].

Study samples:
This study included different study subjects to collect diverse, relevant data, considering PHCC locations (urban/rural) as well as health workforces. We invited 14 key informants and 26 PHC staff for their interview. Except four PHC staff, all other respondents participated in the study. Two of them denied due to their time constrain, one was not willing to talk regarding the issue, and the other one had to take leave from work. Finally we interviewed 14 key informants (KI) and 22 other PHC staff ( Table 2 and T able 3). The KIs were center physicians for urban and the Upazila Health and Family Planning O cers (UH&FPO), in-charge of the UHC for rural of both HID and LID. The sampling selection method is described in Figure  1.

Study tool:
The study was conducted through an in-depth interview containing both open-ended and semi-structured questionnaires which was piloted prior to nal data collection process. Question by question guideline was developed by the researchers for interview to ensure the quality of the data. The study also used a checklist to assess the facilities' readiness in providing NCD services in context to the aim of the study.

Data collection:
Main approaches used for data collection in this study were: (i) Desk reviews of some relevant national documents, including, e.g., Health Bulletin 2018, Population and housing census report 2011 Bangladesh, Household Income and Expenditure survey 2016; (ii) In-depth qualitative interviews of KIs and health facility staff; (iii) Researcher's observations together with brief semi-structured questionnaires and checklist for PHCC characteristics. Through informed written consent, participants were informed about goals and reasons to conduct the research. Prior to data collection privacy and con dentiality was ensured to create a favourable environment for the respondent. Face-to-face interviews were conducted at participants' working station within their working hour for about 45 mins to one hour by trained data enumerators. It was done in the local language (Bangla), and tape-recording and detailed notes were taken simultaneously with the permission of the interviewees. Among the researchers one person was responsible for two districts for mentoring the data collection process. They helped the enumerators of their designated districts to prevent bias or assumption that can in uence the data collection. Again, they also helped in setting communication with respondents and data management. At the end of the day of the data collection period, the individual interview schedule was edited through checking and rechecking to see whether it was lled completely and consistently.

Data analysis:
After cleaning and corrections, data were analyzed using an inductive thematic analysis through comprehensive considerations of important codes or phrases or condensed meaning units immerged during the interviews. Coding was done by four data enumerators under direct supervision of two researchers experienced in qualitative research. Moreover, researchers provided a detail description of coding tree. The themes were derived from the data. All interview information was triangulated with related documents, other interviews, as well as researcher observations.

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 tra c 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 di culties 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 modi cation. Almost all the urban and few rural PHCC physicians said that they did not receive any onthe-job training regarding NCD. According to their perception, more training on developing skills in diagnostic, treatment, and referral process could have increased their e ciency 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 rst for primary management before going to secondary/ tertiary level hospitals. So, we need training on NCD to serve the patients more e ciently 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 e ciently 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, di cult 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 su cient 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 le 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/lea et/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) [22]. 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 le 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, di cult 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 e cient. The trained doctors started to train up the other doctors but could not nish it. That is why currently, we do not use these tools. General patient overload is another cause."-HS-8

Discussion
Given the increasing burden of NCDs in the country, there has been a greater need for developing a feasible mechanism that addresses the problems of NCDs, meets the service delivery needs, and ensures the services are provided at the grass-root level with affordable cost [23]. This study provided an overview of the current status of provisions of NCD services in urban and rural PHCCs of high and low-income divisions.
Firstly, we identi ed a shortage of skilled manpower (both physicians and non-physicians) to manage NCDs both in urban and rural facilities of HID and LID. This nding is consistent with previous literature suggesting that healthcare workers working at a PHC level do need proper training to tackle NCDs at an early stage. For example, a study on health workers in Bangladesh said that trained healthcare providers play a vital role in the efforts of prevention and control of NCDs [24]. Some studies in sub-Saharan Africa have reported that major barriers to care and services for NCDs were poor knowledge and experience of front-line health workers [25,26]. Another study in Bangladesh by Rawal LB suggested that trained human resources are very important to address the NCD challenges [23].
Secondly, we found that there have been unequal supportive resources between those with and without government project initiative. Among the facilities with the pilot UHCs of the government, they had a standardized protocol for diagnosis, treatment, follow-up, or referral. On the other hand, the service of other facilities mostly depends on the care provider's residual knowledge, experience, and group discussion. A systematic review of NCD interventions in the Sub-Saharan Africa region gave priority on the use of the standardized protocol for diagnosis, treatment, monitoring, and referral to specialist care [27]. Most of the UHCs reported a poor follow up system and ignorance of the patients to have subsequent visits. A pilot testing on PEN in Bhutan reported that about 50% of patients with NCDs did not come for follow-up after three visits [28].
In addition, the study also found that, among the facilities, only pilot UHCs staff of rural PHCCs were familiar with WHO PEN, and they were getting the bene t of its' use. The health staff perceived that implementation of WHO PEN in PHCCs might provide a better scenario in preventing NCDs within a short time. Patients are getting better health services in a more e cient manner. It was also evident that patients with DM and HTN are completing their follow up visits timely than the previous. These ndings corroborate with a pilot testing of WHO PEN in Bhutan. They got an improvement in blood pressure and diabetes control and reduction in CVD risk by the implementation of the PEN interventions in the primary healthcare setting of Bhutan [28]. Another study on the implementation of WHO PEN protocols in selected polyclinics of the Democratic People's Republic of Korea, reported that WHO PEN protocols related to cardiovascular disease and diabetes have improved risk management [29].
We faced some limitations. First, the study information that was based on participants' perceptions and experience might be prone to be biased under investigation. Nevertheless, we strictly employed qualitative methods. All data information had been triangulated with different sources of information, such as relevant documents, other interviews, and researcher's observations. Second, there were various types of PHC facilities with their speci c contexts. This makes it di cult for discussion and limits some generalizability. Third, as the information system at a PHC level in Bangladesh is still developing, an absence of proper documentation and database management, mostly in urban settings, is another limitation. Lastly, the study was conducted during the period of the Covid-19 pandemic, this limited us for expanding more interviews and/or exploring more in-depth information from our health workers as they had to devote more time with combating the pandemic. This also prevented us from ensuring the saturation of data being collected.

Conclusions
The ndings provide current insights about the situation and the challenges faced by PHC staff to manage NCDs in high and low-income divisions of Bangladesh. Most of the PHCCs are facing di culties in providing recommended services for the prevention and treatment of NCDs. Additionally, unequal distribution of essential medical supplies, as well as skilled healthcare workers, would inhibit their capacity to address NCDs at a PHC level. However, increasing the supply of manpower, logistics, providing training can solve the problem for only a short period of time. Proper evidence-based and facility wise planning is required to overcome these obstacles in the long run. We must emphasize our planning that can ensure the sustainability of the process and standardization of the service to be followed.

Declarations
Ethics approval and consent to participate: To conduct the study, formal ethical approval was obtained from the Institutional Review Board (IRB) of the National Institute of Preventive and Social Medicine (NIPSOM), Dhaka, Bangladesh (Approval ID: NIPSOM/IRB/2020/13/1). Prior to interviews, participants were fully informed about the study objectives and how the obtained data will be used. As all interviews were audio-recorded, informed written consent was obtained from all the participants prior to the interview as well as for audio recording.
Consent for publication: Each and every participants were informed about this study and written consent was taken prior to the interview.