Browsing by Subject "public healthcare facilities"

Abstract

BACKGROUND: Cardiovascular disease (CVD) is the greatest killer of mankind. In Nepal, a small, landlocked country in South Asia and one of the poorest countries in the world, the burden of cardiovascular disease is high; national CVD monitoring has substantial gaps; and CVD risk factors are poorly controlled. Primary healthcare (PHC) is often at the front lines of prevention and control of CVD. Thus, strengthening local and national primary healthcare systems is an essential step toward prevention and management of CVD in low- and middle-income countries (LMICs). To inform further research and policy development, we conducted an exploratory, mixed-methods study to understand patient-side utilization of CVD services in rural and urban areas in Nepal.

METHODS: We surveyed 114 CVD patients from 10 PHC facilities across two regions of Nepal. Survey contents included sociodemographic information, disease history, and data on accessibility, affordability, availability, and utilization of PHC services. We further completed 20 in-depth interviews within our sample to understand patient-side perceptions of CVD-related PHC care.

RESULTS: In the final cohort, 23% had experienced a stroke, 26% had some form of existing heart disease, 76% presented with hypertension, and 67% had diabetes. For all conditions, hospitals were a more common place of diagnosis than PHC facilities. The mean visitation frequency to PHC facilities in the past year was 10.7 times, with healthier patients having higher visitation rates than those with poorer health. 69% of patients reported difficulty obtaining CVD medicine from their local PHC facility. Qualitative data revealed that PHC facilities lacked resources for diagnosing and managing CVD conditions. Additionally, behavior of physicians and affordability were both considered important components of PHC satisfaction. Patient recommendations included increased diagnostic equipment in PHC facilities, free essential medicines, and community awareness initiatives for cardiovascular disease.

CONCLUSION: There are clear shortcomings between national aims and objectives – such as free essential medicines and universal PHC services – and the reality faced by CVD patients in resource-limited settings in Nepal. Despite PHC facilities generally being close to patients, participants reported inadequate resources when seeking care for CVD and expressed a strong desire that such services could be provided locally. Based on the challenges articulated by CVD patients in our study, mhealth may be a relevant direction of future research for connecting hospital-based specialists to CVD patients in rural areas, improving follow-up, and decreasing expensive visits to far away tertiary care centers. Overall, we recommend increased national CVD monitoring, prioritization of NCDs and CVDs in national policymaking and strategizing, and continued provision of PHC facilities close to patients in their communities.

Keywords: primary care, cardiovascular, utilization, Nepal, public healthcare facilities

DEDICATION

Background

Cardiovascular disease (CVD) is increasingly becoming a serious public health challenge in Kenya, contributing not only to mounting mortality, morbidity and healthcare expenditure, but also widening health disparity and lost productivity, which in turn undermine the long-term development of the East African powerhouse.

Hypertension and diabetes are leading CVD risk factors presented at primary healthcare (PHC) centers in Kenya, however inadequate screening, underdiagnoses and suboptimal control of these risk factors have been found evident in both national surveys and small contextual studies, especially in limited-resource settings. Public PHC centers in Kenya, providing subsidized healthcare at community levels, are uniquely positioned to curb the CVD epidemic through early prevention and ongoing management, especially for the underprivileged.

Despite a newly formed enabling policy environment focusing on tackling non-communicable disease with a primary-care approach, there is currently a paucity of literature on the role that primary care plays in the prevention and management of cardiovascular diseases in Kenya. Our study aims to fill such gap by understanding CVD patients’ utilization experience at public PHC centers, in order to form evidence-based policy recommendation for targeted health system strengthening.

Methods

This cross-sectional descriptive study aims to explore the PHC utilization experience of adults who suffered from at least one of the four conditions of hypertension, diabetes, heart diseases and stroke.

Our study was conducted in five public health centers in urban slum settlements (Korogocho and Viwandani) in Nairobi County and five public health centers in the rural areas of Machackos County. A mixed method approach was adopted as we conducted face-to-face interviews with 105 patients who sought CVD-related care at the aforementioned 10 facilities using a structured questionnaire and further in-depth interviews with 12 out of the 105 patients using a semi-structured interview guide. Data on accessibility (travel time and wait time), affordability (travel cost, Out-of-Pocket (OOP) expenditure and ongoing medication cost), procedures received, medication use, emergency knowledge and overall satisfaction was collected to gain a holistic view of the utilization experience of the primary health care for their CVD conditions.

Results

From our study, it was evident that public PHC centers serve as important hubs for the screening, diagnosis and routine management of hypertensive and diabetic patients, as well as the follow-up care for non-emergency stroke and heart diseases conditions. CVD patients face considerable financial and geographic barriers, especially for those in rural areas as stark urban-rural disparity was evident in all dimension of accessibility and affordability. On average, patients who live in urban slums travel for a shorter time and spend less money travelling to a PHC for CVD-related care compared to their rural counterparts. Once they reach the PHC, urban patients wait a shorter time and incur lower OOP payments compared to their rural equivalents. Monthly CVD-related medication costs are also found to be lower in urban patients compared to rural patients. Out-of-pocket expenditure is a significant hindrance to routine care utilization overall although patients travelled far to obtain care. Medication availability is another barrier to long-term care as over half of the respondents had to visit elsewhere to complete their drug prescription. Urban facilities receive higher overall satisfaction ratings compared to their rural counterparts. Overall, a quarter of the patients lack knowledge of where to seek care in case of a CVD emergency especially in the rural area.

Stroke and heart diseases patients who utilized PHC for non-emergency CVD care incur higher expenses than hypertensive/diabetic patients who are yet to experience the onset of CVD, lending support to the cost-effectiveness of early detection and primary prevention of CVD. Financial protection among the sampled patients is especially absent given the remarkably low health insurance coverage of three percent. CVD-related OOP costs per outpatient visit is substantially higher compared to the average of national surveys.

Conclusion

The OOP expenses and ongoing medication costs constitute significant impediments to the management of CVD-related conditions by patients in limited-resource settings. Long distance and travel costs make it hard for rural patients seeking care. Bottlenecks including medication unavailability is prevalent among sampled facilities.

In the backdrop of a devolved political structure and the inspiration to achieve Universal Health Coverage, more strategic and innovative approaches are desired from both state and non-state actors to tackle the long-standing underfinanced nature of CVD care services, in order to improve access and utilization of quality CVD care for all Kenyans, especially the underprivileged.