Overall findings
Current study draws from a nationally representative sample of 940 health facilities and shows that majority of health facilities across all seven provinces had sub-optimal readiness to manage CVDs, diabetes and CRDs based on WHO SARA guideline [13]. Against the backdrop of WHO’s target strategy to reduce 25% of mortality due to NCDs by 2025 [13], health systems in developing countries such as Nepal face significant challenges in providing services to NCDs [14-16]. Private health facilities were better equipped to provide services related to CVDs, than public health facilities. Most of the facilities lacked trained human resources, equipment, drugs, and standard guidelines for effective NCDs care and management.
Readiness of public and private health facilities for NCDs
Compared to the service readiness of private health facilities, the readiness scores for public health facilities was low. There is an increasing trend to visit private health facilities in Nepal for the pursuit of better health care, particularly patients from average to high socio-economic status [10, 21]. Healthcare expenditure in Nepal is mostly out of pocket and constitutes one-third of the total expenses involving both private and public hospitals [22]. In such a context, lack of readiness of public facilities where patients resort for quality health care, poses a major challenge in diagnosis of NCDs and its management. Similar findings have been found in other resource constrained settings of low- and middle- income countries (LMICs) [23, 24]. In general, driven by the lack of political stability and economic constraints, LMICs face significant challenges in maintaining preparedness of health system, coverage and quality of care.
One of the major challenges in Nepal’s health system is the disproportionate lack of human resources, medicines, equipment and supply chain logistics in remote regions of Nepal [6, 7, 25]. In addition, other factors such as patient’s socio-economic status, distance to health centres, transportation, direct and indirect costs associated with attending health centres further compound the utilization of health services in rural regions of Nepal [7, 26] and resonate with other LMICs [27]. Standing at the forefront of health services, health care providers, particularly in PHCs and HPs, significantly lack adequate training and experiences in the management of NCDs echoing with the health systems in sub-Saharan Africa [28]. Even if human resources were ready to serve the patients, the health facilities often lack simple diagnostic materials, equipment such as glucometer or a basic lab equipment to measure blood glucose level.
Most of the public health facilities faced shortfall in the availability of medicines for CVDs and diabetes. Although, the basic diagnostic items such as sphygmomanometer and stethoscope were readily available, unavailability of glucose strips and essential medicines such as blood pressure lowering drugs and anti-diabetics hinder the quality NCDs care by health care providers. Our findings resonate with the studies from LMICs settings of Africa and Asia [29-32]. Despite the ample evidence that essential medicines for NCDs reduce the burden of NCDs, public health facilities often lack essential medicines; and health care is often unaffordable in the private sector, particularly for the population from low socio-economic status. Management of NCDs requires prolonged follow-ups with regular access to medicines and health care; any impediment to access and care can prompt patients to discontinue their treatment and may fall prey to poly-visits to both formal and informal health care providers. The latter can include traditional healers who often sell unknown chemical compounds [33] and others constitute drug peddlers, locally known as ‘Jhole doctors’ in Terai region of Nepal [34]. Although these informal drug peddlers are illegal, the ease of access and their local availability can mean that patients rely on their poor diagnostic skills and sub-standard, and counterfeit medications which can delay the health seeking behavior, distort the symptoms and develop complications and death [34]. Although WHO advocates for the global priorities in increasing an access to essential, quality-assured, safe, effective and affordable medical products, countries in LMICs struggle to achieve the universal health coverage [35, 36].
In this study, unavailability of guidelines for early detection, management and prompt referral of CVDs, diabetes and CRDs; poor monitoring and evaluation system for tracking NCDs; and weak referral linkages between primary and higher health care facilities were found to be the major barriers in NCDs prevention and care. Several studies have reported the low service readiness in health facilities in rural parts of the country compared to the health facilities in urban areas [7, 37, 38]. Similar findings were observed in the current study where many health facilities in rural areas were located in hard to reach areas, and often lacked qualified health workers, with high attrition and lack of policy supporting establishment of health care institutions in the rural regions [25, 39]. Such a chronic shortage of health workforce and resources in the rural regions is likely to persist and can be compounded by the transitioning federal health system of Nepal with high level of unwillingness of health care workers to serve in the rural regions [40]. Although government of Nepal reinforced policy to promote the retention of qualified health human resources particularly doctors in the rural regions, such as through promotion, provision of incentives, opportunities in higher education, in addition to compulsory placement of government funded doctors in the rural settings, the attrition remains a major problem [41, 42]. Chronic shortfall of qualified health human resources in the rural settings are attributed to manifold factors including lack of health infrastructure, shortage of equipment, poor academic/clinical stewardship and urban centric health care system in Nepal [39, 41-43]. The primary health care centers in rural regions of Nepal thus share the disproportionate burden of scarcity in providing health services.
The supply chain logistics providing essential medicines including equipment in such hard to reach areas is compounded by the poor road condition, seasonal flooding and landslides. For instance, year round availability of essential medicines in Nepal was 16.6% in health facilities from the Mountains, 57.1% in the Hills and 52.2% in the Terai [44]. A study in Bangladesh reported that the poor supply chain management for essential medicines affected the management of NCDs in the rural settings.[45]
Implications for health policy and planning
Sub-optimal availability of NCDs services in Nepal has major implications for country’s aims for sustainable development goal-3. Also, it shows that Nepal is inadequately prepared to achieve the “Global action plan for the prevention and control of NCDs 2013-2020” [13] which has an ambitious target to reduce premature cardiovascular mortality by 25% by 2025 [4]. Although Nepal has set steps and promises towards curbing the current under coverage of health services to rural regions, the multi-sectoral plan on management of NCDs faces challenges intertwined in the current health system’s functioning. Nepal should strive towards ensuring the functional capacities of PHCs (for example, improving supply chain logistics and provision of adequate number of health human resources, training, capacity development and addressing attrition) together with stringent policy stewardship to improve NCDs care in both PHCs and private hospitals.
The current restructuring of health system in Nepal in alignment with federal setup can be an excellent opportunity for strengthening health facilities in delivering NCDs services. With the increased devolvement of responsibility to provincial and local government in federal context including revenue collection through taxes on tobacco, alcohol and sugary drinks, financial independence thus achieved can be channeled to the management of NCDs.
In order to improve the retention of qualified health human resources in rural regions, augmenting current policies together with infra-structural development is necessary. For instance, physicians may feel motivated when there is an availability of professional supervision, better opportunities for specialized training in addition to current policies of incentives and compulsory placements. In addition, Nepal can adopt the principles inherent in community engagement [46, 47], wherein community and public-private partnership can serve the population in terms of early diagnosis, treatment and management. The intervention approaches to reduce NCDs in low resource settings as recommended by the WHO includes early detection and diagnosis that could curtail medical costs, improve quality of life and productivity in LMICs such as Nepal [16]. Recent evidence of training and mobilization of female community health volunteers in the management of hypertension shed some promising steps for Nepal [48]. Such a strategy could be scaled up together with the partnership of community-public and private health service providers through various means including subsidization of health care services to enhance the current coverage for the management of NCDs.
Strengths and limitations
This is the first study exploring the challenges and readiness of health systems in tackling the NCDs in Nepal and utilized the first nationally representative sample of health facilities across all seven provinces in Nepal, thus the findings from this study are generalizable for all regions of Nepal. The other major strengths of this study are that the medicine, diagnostics and guidelines availability was recorded based on the observations of health facilities by trained survey enumerators. Although several areas were examined in this study such as availability of medicines, diagnostics, and guidelines, most of these were basic assessments and many other equipment and tools required for management of NCDs such as electrocardiogram and other technologies were not considered. Information were missing on one to several items depending on the domains analyzed. Consequently, the sample size was limited to all non-missing items. Our findings are approximate to the original report of Nepal SPA report, 2015 (link: https://dhsprogram.com/pubs/pdf/SPA24/SPA24.pdf), so discrepancies may have occurred due to partitioning of data for analysis. Although reported data were triangulated by observation and through cross-validation (through multiple respondents), information on qualifications, training, clinical experience, and perceptions of the service delivery environment may have incurred desirability and recall bias. Nevertheless, authors’ experience of health services and review of the literature suggest that these public health services, specifically in rural regions suffer from multitude of constraints.