Mid-level healthcare workers knowledge on non-communicable diseases in Tanzania: a district-level pre-and post-training assessment.

INTRODUCTION: Over the past two decades, Tanzania's burden of non-communicable diseases has grown disproportionately, but limited resources are still prioritized. A trained human resource for health is urgently needed to combat these diseases. However, continuous medical education for NCDs is scarce. This paper reports on the mid-level healthcare workers knowledge on NCDs. We assessed the knowledge to measure the effectiveness of the training conducted during the initiation of a Package for Essential Management of Severe NCDs (PEN Plus) in rural district hospitals in Tanzania. METHODS: The training was given to 48 healthcare employees from Dodoma Region's Kondoa Town Council District Hospital. For a total of five (5) days, a fundamental course on NCDs featured in-depth interactive lectures and practical workshops. Physicians from Tanzania's higher education institutions, tertiary university hospitals, research institutes, and medical organizations served as trainers. Before and after the training, a knowledge assessment comprising 28 questions was administered. Descriptive data analysis to describe the characteristics of the specific knowledge on physiology, diagnosis and therapy of diabetes mellitus, rheumatic fever, heart disease, and sickle cell disease was done using Stata version 17 (STATA Corp Inc., TX, USA). RESULTS: Complete assessment data for 42 out of the 48 participants was available. Six participants did not complete the training and the assessment. The mean age of participants was 36.9 years, and slightly above half (52%) were above 35 years. Two-thirds (61.9%) were female, and about half (45%) were nurses. The majority had the experience of working for more than 5 years, and the average was 9.4 years (+/- 8.4 years). Overall, the trainees' average scores improved after the training (12.79 vs. 16.05, p < 0.0001) out of 28 possible scores. Specifically, trainees' average scores were better in treatment than in diagnosis, except for sickle cell disease (1.26 vs. 1.83). Most were not able to diagnose rheumatic heart disease (47.6% able) compared to diabetes mellitus (54.8% able) or sickle cell disease (64.3% able) at baseline. The proportion of trainees with adequate knowledge of the treatment of sickle cell disease and diabetes mellitus was 35% and 38.1%, respectively, and there was a non-statistical difference after training. Those working for less than 5 years had a higher proportion of adequate knowledge (30.8%) compared to their more experienced colleagues (6.9%). After the training, participants' knowledge of NCDs increased by three times (i.e., aPR 3, 95% CI = 1.1, 1.5, and 6.0). CONCLUSION AND RECOMMENDATIONS: PEN Plus training improved the knowledge of healthcare workers at Kondoa Town Council District Hospital. Training is especially needed among nurses and those with a longer duration of work. Continuing education for human resources for health on the management of NCDs is highly recommended in this setting.

Cost analysis for initiating an integrated package of essential non-communicable disease interventions (PEN-Plus) in Kondoa District Hospital, Tanzania: a time-driven activity-based costing (TDABC) study protocol.

INTRODUCTION: Non-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted life years attributed to NCDs has doubled over the past 30 years, from 18% to 36%. To mitigate the escalating burden of severe NCDs, the Tanzanian government, in collaboration with local and international partners, seeks to extend the integrated package of essential interventions for severe NCDs (PEN-Plus) to district-level facilities, thereby improving accessibility. This study aims to estimate the cost of initiating PEN-Plus for rheumatic heart disease, sickle cell disease and type 1 diabetes at Kondoa district hospital in Tanzania. METHODS AND ANALYSIS: We will employ time-driven activity-based costing (TDABC) to quantify the capacity cost rates (CCR), and capital and recurrent costs associated with the implementation of PEN-Plus. Data on resource consumption will be collected through direct observations and interviews with nurses, the medical officer in charge and the heads of laboratory and pharmacy units/departments. Data on contact times for targeted NCDs will be collected by observing a sample of patients as they move through the care delivery pathway. Data cleaning and analysis will be done using Microsoft Excel. ETHICS AND DISSEMINATION: Ethical approval to conduct the study has been waived by the Norwegian Regional Ethics Committee and was granted by the Tanzanian National Health Research Ethics Committee NIMR/HQ/R.8a/Vol.IX/4475. A written informed consent will be provided to the study participants. This protocol has been disseminated in the Bergen Centre for Ethics and Priority Setting International Symposium, Norway and the 11th Muhimbili University of Health and Allied Sciences Scientific Conference, Tanzania in 2023. The findings will be published in peer-reviewed journals for use by the academic community, researchers and health practitioners.

Differences in integrated assessment and management of non-communicable diseases (NCDs) for people with HIV across the WHO European region.

OBJECTIVES: We aimed to assess the extent of integration of non-communicable disease (NCD) assessment and management in HIV clinics across Europe. METHODS: A structured electronic questionnaire with 41 multiple-choice and rating-scale questions assessing NCD assessment and management was sent to 88 HIV clinics across the WHO European Region during March-May 2023. One response per clinic was collected. RESULTS: In all, 51 clinics from 34 countries with >100 000 people with HIV under regular follow-up responded. Thirty-seven clinics (72.6%) reported shared NCD care responsibility with the general practitioner. Systematic assessment for NCDs and integration of NCD management were common overall [median agreement 80%, interquartile range (IQR): 55-95%; and 70%, IQR: 50-88%, respectively] but were lowest in central eastern and eastern Europe. Chronic kidney disease (median agreement 96%, IQR: 85-100%) and metabolic disorders (90%, IQR: 75-100%) were regularly assessed, while mental health (72%, IQR: 63-85%) and pulmonary diseases (52%, IQR: 40-75%) were less systematically assessed. Some essential diagnostic tests such as glycated haemoglobin (HbA1c) for diabetes (n = 38/51, 74.5%), proteinuria for kidney disease (n = 30/51, 58.8%) and spirometry for lung disease (n = 11/51, 21.6%) were only employed by a proportion of clinics. The most frequent barriers for integrating NCD care were the lack of healthcare workers (n = 17/51, 33.3%) and lack of time during outpatient visits (n = 12/51, 23.5%). CONCLUSION: Most HIV clinics in Europe systematically assess and manage NCDs. People with HIV appear to be screened more frequently than the general population at the same age. There are, however, larger gaps among eastern European clinics in general and for clinics in all regions related to mental health, pulmonary diseases and the employment of some essential diagnostic tests.

Service readiness for the management of non-communicable diseases in publicly financed facilities in Malawi: findings from the 2019 Harmonised Health Facility Assessment census survey.

INTRODUCTION: Non-communicable diseases (NCDs) are rising in low-income and middle-income countries, including Malawi. To inform policy-makers and planners on the preparedness of the Malawian healthcare system to respond to NCDs, we estimated NCD service readiness in publicly financed healthcare facilities in Malawi. METHODS: We analysed data from 564 facilities surveyed in the 2019 Harmonised Health Facility Assessment, including 512 primary healthcare (PHC) and 52 secondary and tertiary care (STC) facilities. To characterise service readiness, applying the law of minimum, we estimated the percentage of facilities with functional equipment and unexpired medicines required to provide NCD services. Further, we estimated permanently unavailable items to identify service readiness bottlenecks. RESULTS: Fewer than 40% of PHC facilities were ready to deliver services for each of the 14 NCDs analysed. Insulin and beclomethasone inhalers had the lowest stock levels at PHC facilities (6% and 8%, respectively). Only 17% of rural and community hospitals (RCHs) have liver and kidney diagnostics. STC facilities had varying service readiness, ranging from 27% for managing acute diabetes complications to 94% for chronic type 2 diabetes management. Only 38% of STC facilities were ready to manage chronic heart failure. Oral pain medicines were widely available at all levels of health facilities; however, only 22% of RCHs and 29% of STCs had injectable morphine or pethidine. Beclomethasone was never available at 74% of PHC and 29% of STC facilities. CONCLUSION: Publicly financed facilities in Malawi are generally unprepared to provide NCD services, especially at the PHC level. Targeted investments in PHC can substantially improve service readiness for chronic NCD conditions in local communities and enable STC to respond to acute NCD complications and more complex NCD cases.

Projected impact of population aging on non-communicable disease burden and costs in the Kingdom of Saudi Arabia, 2020-2030.

BACKGROUND: The number of people aged greater than 65 years per 100 people aged 20-64 years is expected to almost double in The Kingdom of Saudi Arabia (KSA) between 2020 and 2030. We therefore aimed to quantify the growing non-communicable disease (NCD) burden in KSA between 2020 and 2030, and the impact this will have on the national health budget. METHODS: Ten priority NCDs were selected: ischemic heart disease, stroke, type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, dementia, depression, osteoarthritis, colorectal cancer, and breast cancer. Age- and sex-specific prevalence was projected for each priority NCD between 2020 and 2030. Treatment coverage rates were applied to the projected prevalence estimates to calculate the number of patients incurring treatment costs for each condition. For each priority NCD, the average cost-of-illness was estimated based on published literature. The impact of changes to our base-case model in terms of assumed disease prevalence, treatment coverage, and costs of care, coming into effect from 2023 onwards, were explored. RESULTS: The prevalence estimates for colorectal cancer and stroke were estimated to almost double between 2020 and 2030 (97% and 88% increase, respectively). The only priority NCD prevalence projected to increase by less than 60% between 2020 and 2030 was for depression (22% increase). It is estimated that the total cost of managing priority NCDs in KSA will increase from USD 19.8 billion in 2020 to USD 32.4 billion in 2030 (an increase of USD 12.6 billion or 63%). The largest USD value increases were projected for osteoarthritis (USD 4.3 billion), diabetes (USD 2.4 billion), and dementia (USD 1.9 billion). In scenario analyses, our 2030 projection for the total cost of managing priority NCDs varied between USD 29.2 billion - USD 35.7 billion. CONCLUSIONS: Managing the growing NCD burden in KSA's aging population will require substantial healthcare spending increases over the coming years.

Individual-Level Health Care Costs Attributable to Noncommunicable Diseases: A Longitudinal Study Based on the Older Adults in China.

Noncommunicable chronic diseases among the elderly population represent a significant economic burden in China. However, previous disease-related health cost studies lacked representation of older adults and comparability of the burden of multiple chronic diseases. The objective of this study was to determine the fraction of health care costs attributable to the 6 most prevalent chronic diseases and comorbidities in the sample of older adults. This study employed data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), with 3 waves in 2011, 2014, and 2018, and included 18 349 observations in total. Outpatient costs, inpatient costs, and total health care costs were included in this study. Based on a 2-part random effects model, the effect of chronic disease on health service utilization was first explored by constructing a dummy variable for whether or not to utilize health care, followed by estimation of attributable costs in the population with health care utilization. Among the older adults in the sample, hypertension, heart disease, cataracts, arthritis, stroke or Cerebrovascular disease (CVD) and chronic lung disease are the 6 most prevalent chronic conditions. The costs attributable to the 6 chronic diseases mentioned above were 36.00% of outpatient costs, 55.92% of inpatient costs, and 45.05% of total health care costs for older adults. Of these, heart disease, stroke or CVD, and chronic lung disease accounted for 22.11%, 13.24%, and 10.56% of total health care costs, respectively. Moreover, the proportion of health care costs attributable to chronic diseases was higher for older adults who were male, lived in urban areas, and had a lower level of education. The proportion of health care costs attributable to chronic diseases is substantial among older adults in China. Health care costs associated with chronic diseases can be decreased with well-targeted interventions and comprehensive access to health services.

Access to healthcare services for people with non-communicable diseases during the COVID-19 pandemic in Ibadan, Nigeria: a qualitative study.

BACKGROUND: Desirable outcomes for people with non-communicable diseases (NCDs) are achieved when they access routine monitoring and care services. Expectedly, the COVID-19 pandemic severely impacted access to healthcare services, leading to poor health outcomes among people with NCDs. We aimed to [1] explore the delays in accessing healthcare services and [2] understand alternative actions adopted by people with NCDs to overcome these delays. METHODS: We conducted an exploratory qualitative research guided by the "Three Delays" model to unpack the barriers to healthcare access for people living with NCDs in Ibadan, Nigeria. The "Three Delays" model conceptualizes the reasons for negative/adverse healthcare outcomes related to the patient's decision-making to seek healthcare, reaching an appropriate healthcare facility, and receiving adequate care at the healthcare facility. Twenty-five (25) people with NCDs were purposively selected from the University College Hospital's medical outpatient department to participate in in-depth interviews. Interview recordings were transcribed verbatim and analyzed using a deductive-inductive hybrid thematic analysis. RESULTS: At the level of individual decision-making, delays were related to fear of contracting COVID-19 in the hospital (considered a hotspot of the COVID-19 pandemic). Regarding reaching an appropriate healthcare facility, delays were mainly attributed to the intra- and inter-city lockdowns, limiting the movements of persons. For those who successfully arrived at the healthcare facilities, delays were related to the unavailability of healthcare professionals, prioritization of COVID-19 patients, and mandatory adherence to COVID-19 protocols, including COVID-19 testing. To overcome the delays mentioned above, people with NCDs resorted to (i) using private healthcare facilities, which were more costly, (ii) using virtual consultation through mobile phone Apps and (iii) self-management, usually by repeating previously prescribed prescriptions to obtain medication. CONCLUSION: Pandemic conditions provide unique challenges to people with chronic illnesses. Recognizing the need for continuous access to monitoring and care services under such conditions remains critical. Alternative health service provision approaches should be considered in pandemic situations, including remote healthcare services such as Mobile health apps (mHealth) that can help manage and prevent NCDs.

A situational analysis of human resource and non-communicable diseases management for community health workers in Chengdu, China: a cross-sectional study.

BACKGROUND: Non-communicable diseases (NCDs) pose a major challenge to health economic cost and residents' health status. Community health workers (CHWs) are the gatekeeper of primary health care. OBJECTIVE: This study aimed to conduct a situational analysis of current human resource and requirements of NCDs-related training among CHWs in Chengdu with regard to address to understand the suggestions for improvement of challenges and barriers. METHODS: A descriptive online cross-sectional survey was conducted among CHWs (doctors and nurses) from 23 districts and counties in Chengdu. Sociodemographic and NCDs-related variables were collected. Univariate analysis and multiple response analysis were used to describe the characteristics of these variables. RESULTS: 711 doctors and 637 nurses completely responded. There were significant differences among gender, age, educational levels, professional title, working year, type of institution, urban circle and registration in general practice between doctors and nurses (P < 0.001). 60.6% of doctors were female, compared to 98.0% for nurses. 58.2% of doctors held a bachelor's degree compared with 45.4% of nurses, while 48.3% of nurses held a junior college degree compared with 25.7% of doctors. Higher levels of professional title and registration in general practice were found in doctors compared with nurses. The proportions of NCDs' category, NCDs-related roles and tasks, NCDs-related training contents and forms that CHWs have attend and hoped to gain more were significantly different between doctors and nurses (P < 0.001). In general, the proportions in nurses were much lower than those of doctors (P < 0.05). The top five diseases managed by CHWs were hypertension, diabetes, cerebrovascular disease, chronic respiratory diseases and mental diseases. The five most reported roles performed among doctors included the distribution of health education (91.4%), following up (85.9%), establishing archives (71.3%), medicine adjustment (64.7%) and treatment implementation (52.0%). The top three diseases managed by nurses were same with doctors. The top four and five tasks were contact with patients or health services (39.6%) and referral (16.6%) in nurses. Most CHWs had received primary and common diseases-related trainings, but they had few opportunities to study in a tertiary hospital (40.4% in doctors and 20.9% in nurses, respectively), attend domestic academic conferences (26.9% in doctors vs. 9.7% in nurses), and take part in training courses (44.9% in nurses). CHWs hoped that the above-discussed training contents and forms could be provided more in the future. Besides basic skills related trainings, some specific skills related trainings should be strengthened. CONCLUSION: The qualifications in doctors were much better than those of nurses. The roles performed by CHWs in NCDs management are varied form common and frequent disease management to subsequent follow up and supervision. CHWs hope to receive more desired and oriented trainings. There is a need for building capacity of CHWs, optimizing and defining CHWs' role, facilitating postgraduate medical education support and strengthening multidisciplinary collaboration would be effective in NCDs management.

Trends in health service needs, utilization, and non-communicable chronic diseases burden of older adults in China: evidence from the 1993 to 2018 National Health Service Survey.

BACKGROUND: Aging is associated with an increased prevalence of non-communicable chronic diseases (NCDs), functional impairments, and diverse demands for health services. This study analyzed the trends in older adults' needs and utilization of health services from 1993 to 2018 in China, as well as chronic disease-related economic burdens. METHODS: The research data were collected from the six cross-sectional National Health Service Survey (NHSS), implemented every 5 years from 1993 to 2018. A multi-stage stratified random cluster sampling method has been adopted in the NHSS. The data on the older population's socio-economic characteristics, health service needs, and utilization were collected from the 6 waves National Health Service Survey (NHSS) 1993-2018. In the 2013 and 2018 NHSSs, EQ-5D-3L and visual analogue scale were used to evaluate the health condition. And the prevalence of NCDs and related Out-of-pocket (OOP) expenditures were collected. Functional dependency and impairment were collected in 2018. The Katz Activities of Daily Living scale was used to evaluate six functions, including self-feeding, dressing, bathing, transferring, toilet hygiene, and controlling bowel movements. RESULTS: The two-week morbidity rate and prevalence of NCDs showed a rapid upward trend in older adults. With the development of health system reform and universal health insurance coverage, older adults' two-week medical consultation rate increased from 25.6% in 1993 to 40.1% in 2018, and the hospitalization rate rose from 6.1% to 24.9%. The difference in health service needs and utilization between urban and rural areas decreased, and the hospitalization rate in rural areas (26.3%) exceeded that in urban areas (23.6%) for the first time in 2018. Functional independence become more severe as aged. The proportion of severe functional impairment was 6.9% and 2% in the group aged 80 or over and group 70-79 years, respectively. Regarding disability status, 32.5% had hearing problems and 31.4% had visual impairment. The highest prevalence rates of NCDs in older adults were found in hypertension (36.9%), followed by diabetes (10.6%), cerebrovascular disease (5.4%), ischemic heart disease (4.5%), and intervertebral disc disease (4.2%). The average annual OOP expenditures attributed to NCDs increased from ¥2481.8 RMB in 2013 to ¥8255.9 RMB in 2018 for older adults. About 90.7% of older adults prefer to live in the residential community, leading to the demands for preventive healthcare (30.4%), medical treatment (14.1%), and elderly education (8.6%). CONCLUSION: The elevated risks of age-related impairments and chronic morbidities, and increased demands for preventive healthcare are critical public health issues. Policymakers should strengthen primary healthcare and move towards integrated delivery to improve access and quality of care for older adults. The integration of healthcare and social security constitutes an adaptive trend in meeting the multi-level demands of an aging society.

Readiness of health facilities to provide services related to non-communicable diseases in Nepal: evidence from nationally representative Nepal Health Facility Survey 2021.

OBJECTIVE: To assess the readiness of public and private health facilities (HFs) in delivering services related to non-communicable diseases (NCDs) in Nepal. METHODS: We analysed data from nationally representative Nepal Health Facility Survey 2021 to determine the readiness of HFs for cardiovascular diseases (CVDs), diabetes mellitus (DM), chronic respiratory diseases (CRDs) and mental health (MH)-related services using Service Availability and Readiness Assessment Manual of the WHO. Readiness score was measured as the average availability of tracer items in per cent, and HFs were considered 'ready' for NCDs management if they scored ≥70 (out of 100). We performed weighted univariate and multivariable logistic regression to determine the association of HFs readiness with province, type of HFs, ecological region, quality assurance activities, external supervision, client's opinion review and frequency of meetings in HFs. RESULTS: The overall mean readiness score of HFs offering CRDs, CVDs, DM and MH-related services was 32.6, 38.0, 38.4 and 24.0, respectively. Guidelines and staff training domain had the lowest readiness score, whereas essential equipment and supplies domain had the highest readiness score for each of the NCD-related services. A total of 2.3%, 3.8%, 3.6% and 3.3% HFs were ready to deliver CRDs, CVDs, DM and MH-related services, respectively. HFs managed by local level were less likely to be ready to provide all NCD-related services compared with federal/provincial hospitals. HFs with external supervision were more likely to be ready to provide CRDs and DM-related services and HFs reviewing client's opinions were more likely to be ready to provide CRDs, CVDs and DM-related services. CONCLUSION: Readiness of the HFs managed by local level to provide CVDs, DM, CRDs and MH-related services was relatively poor compared with federal/provincial hospitals. Prioritisation of policies to reduce the gaps in readiness and capacity strengthening of the local HFs is essential for improving their overall readiness to provide NCD-related services.

Patient trust and positive attitudes maximize non-communicable diseases management in rural Tanzania.

The objectives of this study were to identify difficulties and their related contexts non-communicable disease (NCD) patients in rural Tanzania experienced, examine how patients managed the situation by seeking better treatment of the diseases, and propose a realistic approach for optimizing disease management with long-term perspectives in resource-limited settings, based on views of patients (PTs), health-care providers (HPs), and health volunteers (HVs). Nine focus group discussions were performed with 56 participants of PTs, HPs, and HVs in three district hospitals in the Dodoma region. Their views and self-care practices were extracted, and the verbatim data were analyzed to derive codes and categories. The types of NCDs reported by the PTs were hypertension (HT), diabetes mellitus (DM), and HT/DM comorbidity. Reported barriers to disease management included discontinuation of treatment due to various factors and a lack of positive messages regarding disease management in NCD care. The following points were addressed in relation to the improved management of NCDs: (i) positive attitudes and coping skills, (ii) support from family members, (iii) good communication between PTs and HPs, and (iv) trustworthy relationships with HVs. The findings suggest that to gain the trust of PTs in optimizing disease control in overstretched health-care systems, patient support systems should be strengthened by empowering positive attitudes.

Non-communicable diseases (NCDs) are the leading cause of death globally. NCDs are common in low- and middle-income countries and their prevalence has been growing more prominent. In Tanzania, one-third of all deaths are NCD-related. This study aims to identify the factors that may lead to the improved management of NCDs in rural Tanzania based on actual situations in patients' daily lives. We conducted focus group discussions with three different groups (patients with hypertension and/or diabetes mellitus [PTs], health volunteers [HVs], and health-care providers [HPs]). The results revealed that PTs faced various barriers such as treatment discontinuation and a lack of positive messages regarding disease management in NCD care. However, the following points were indicated by the participants for the improved management of NCDs: (i) positive attitudes and coping skills, (ii) support from family members, (iii) good communication between PTs and HPs, and (iv) trustworthy relationships with HVs. Thus, to gain the trust of PTs in optimizing disease control and complications in overstretched health-care systems, patient support systems need to be strengthened by adopting a community empowerment approach, delivering supportive messages, and building reliable relationships.

Health system adaptions to improve care for people living with non-communicable diseases during COVID-19 in low-middle income countries: A scoping review.

Background: During the COVID-19 pandemic, access to health care for people living with non-communicable diseases (NCDs) has been significantly disrupted. Calls have been made to adapt health systems and innovate service delivery models to improve access to care. We identified and summarized the health systems adaptions and interventions implemented to improve NCD care and their potential impact on low- and middle-income countries (LMICs). Methods: We comprehensively searched Medline/PubMed, Embase, CINAHL, Global Health, PsycINFO, Global Literature on coronavirus disease, and Web of Science for relevant literature published between January 2020 and December 2021. While we targeted articles written in English, we also included papers published in French with abstracts written in English. Results: After screening 1313 records, we included 14 papers from six countries. We identified four unique health systems adaptations/interventions for restoring, maintaining, and ensuring continuity of care for people living with NCDs: telemedicine or teleconsultation strategies, NCD medicine drop-off points, decentralization of hypertension follow-up services and provision of free medication to peripheral health centers, and diabetic retinopathy screening with a handheld smartphone-based retinal camera. We found that the adaptations/interventions enhanced continuity of NCD care during the pandemic and helped bring health care closer to patients using technology and easing access to medicines and routine visits. Telephonic aftercare services appear to have saved a significant amount of patients' time and funds. Hypertensive patients recorded better blood pressure controls over the follow-up period. Conclusions: Although the identified measures and interventions for adapting health systems resulted in potential improvements in access to NCD care and better clinical outcomes, further exploration is needed to establish the feasibility of these adaptations/interventions in different settings given the importance of context in their successful implementation. Insights from such implementation studies are critical for ongoing health systems strengthening efforts to mitigate the impact of COVID-19 and future global health security threats for people living with NCDs.

'Makkalai Thedi Maruthuvam' scheme in Tamil Nadu: an intersectionality-based analysis of access to NCD care.

There are gross inequities in access to non-communicable disease (NCD) care in India. The Indian state of Tamil Nadu recently launched the "Medicine at people's doorstep" (Makkalai Thedi Maruthuvam - MTM) scheme in which screening and medications for NCDs are delivered at people's doorsteps. This is likely to improve geographical access to NCD services in the community. The objective of this study is to analyse the MTM scheme and recommend policy interventions for improved and equitable access to NCD services in the community. We analysed the MTM policy document using the intersectionality-based policy analysis framework. This analysis was supplemented further with literature review to enhance understanding of the various intersecting axes of inequities, such as gender discrimination, caste oppression, poverty, disabilities and geographical access barriers. The MTM policy document, while it removes the physical access barrier, does not frame the problem of NCDs from an intersectionality perspective. This can increase the chances of inequities in access to NCD services persisting despite this scheme. We also recommend interventions for the short, intermediate and long term to make NCD care more accessible. Creation of a gender, caste, class, geographical access, and disabilities disaggregated database of patients with NCDs, using this database for monitoring the delivery of MTM services, dynamic mapping of vulnerability of the target populations for delivery of MTM services and long term ongoing digital surveillance of factors inducing inequities to access of NCD services can all help reduce inequities in access to NCD care.

Availability and readiness of primary healthcare facilities for the management of non-communicable diseases in different districts of Punjab, Pakistan.

Introduction: Non-communicable diseases (NCDs) and their effects are rising quickly. NCDs such as cardiovascular illnesses, diabetes, cancer, and chronic lung diseases cause 60% of global deaths; of which, 80% occur in developing countries. In established health systems, primary healthcare handles most of the NCD care. Methodology: This is a mixed-method study conducted to analyze the health service availability and readiness toward NCDs using the SARA tool. It included 25 basic health units (BHUs) of Punjab, which were selected through random sampling. Quantitative data were collected using the SARA tools, while qualitative data were collected through in-depth interviews with healthcare providers working at the BHUs. Results: There was a problem of load shedding of both electricity and water in 52% of the BHUs, which leads to the poor availability of healthcare services. Only eight (32%) out of 25 BHUs provide the diagnosis or management of NCDs. The service availability was the highest for diabetes mellitus (72%), followed by cardiovascular disease (52%) and then chronic respiratory disease (40%). No services were available for cancer at the BHU level. Conclusion: This study raises issues and questions about the primary healthcare system in Punjab in two areas: first, the overall performance system, and second, the readiness of basic healthcare institutions to treat NCDs. The data show that there are many persisting primary healthcare (PHC) deficiencies. The study found a major training and resource deficit (guidelines and promotional materials). Therefore, it is important to include NCD prevention and control training in district training activities. NCDs are underrecognized in primary healthcare (PHC).

Direct healthcare cost of hospital admissions for chronic non-communicable diseases sensitive to primary care in the elderly. / Custo direto de internações hospitalares por doenças crônicas não transmissíveis sensíveis à atenção primária em idosos.

Aging has imposed changes in the epidemiological profile and an increase in the prevalence of chronic non-communicable diseases (CNCDs). The aim was to estimate the direct cost related to hospital admissions of elderly people affected by CNCDs (hypertension, heart failure and diabetes mellitus) sensitive to primary care, in a medium-sized hospital, in the period 2015-2019. Secondly, we investigated whether clinical and demographic factors explain the costs and length of stay. The medical records of 165 elderly people were analyzed. We found a predominance of women with a mean age of 76.9 years. The most frequent cause of hospitalization was heart failure (62%), and the average length of stay was 9.5 days, and 16% of hospitalizations corresponded to rehospitalizations. Of these, 81% were caused by complications from the previous hospitalization. The estimated total cost was R$ 3 million. Male patients had a longer hospital stay compared to female patients. Hypertension and the total number of procedures were significant predictors of cost and length of stay. We found that in 5 years, the costs of hospital admissions for conditions sensitive to primary care in the elderly are considerable, indicating the relevance of investments in primary care.

O envelhecimento tem imposto mudanças epidemiológicas e aumento na prevalência de doenças crônicas não-transmissíveis (DCNT). O objetivo foi estimar o custo direto relacionado às internações hospitalares de idosos acometidos por DCNT (hipertensão arterial, insuficiência cardíaca e diabetes mellitus) sensíveis à atenção primária, em hospital de médio porte, no período de 2015-2019. Secundariamente, investigamos se fatores clínicos e demográficos explicam o custo e tempo de permanência. Foram analisados prontuários de 165 idosos. Verificamos predominância de mulheres com média de idade de 76,9 anos. A causa de internação mais frequente foi insuficiência cardíaca (62%) e o tempo médio de permanência foi de 9,5 dias, e 16% das internações corresponderam a idosos reinternados. Dessas, 81% foram causadas por complicações da internação anterior. O custo total estimado foi de R$ 3 milhões. Pacientes do sexo masculino ficaram mais tempo internados, comparado ao sexo feminino. Hipertensão e o total de exames realizados foram preditores significantes do custo e tempo de permanência. Verificamos que em 5 anos, os custos com internações hospitalares por condições sensíveis à atenção primária em idosos são consideráveis, indicando a relevância de investimentos na atenção primária.

What affects the direct economic burden of non-communicable diseases on middle-aged and older adult people in Shaanxi Province?

Non-communicable diseases (NCDs) are the leading cause of death worldwide. NCDs affect the health status and the quality of life. In addition, continuous NCDs treatment expenses place a heavy economic burden on families and cause huge economic losses to the society. The prevention and treatment of NCDs and reduction of their economic burden are key public health issues. Considering middle-aged and older adult people as the focus, their basic socio-demographic characteristics and health behavior status of this group, and a pooled cross-sections regression model was then used to analyze the main factors affecting the direct economic burden. The results showed that from 2013 to 2018, the prevalence of NCDs among the middle-aged and older adult people in Shaanxi province as well as the direct economic burden of NCDs increased. The effect factors primarily included sex, age, employment status, income level, type of medical insurance, urban or rural residency, level of the health care-providing institutions, visiting times of 2-week, and length of hospital stay. Several measures can be taken to control the onset of NCDs and reduce their direct economic burden.

Examining the Utilization of Social Capital by Ghanaians When Seeking Care for Chronic Diseases: A Personal Network Survey.

Objectives: With limited social security and health protection in Ghana, intergenerational support is needed by those living with NCDs, who incur recurrent costs when seeking NCD care. We measured the level of informal support received by NCD patients and identified factors that influence support provision. Methods: We surveyed 339 NCD patients from three hospitals in Ghana, who listed their social ties and answered questions about their relationship and support frequency. We analyzed the relationship between social support, demographic and health information, characteristics of social ties, and network characteristics. Results: Participants described 1,371 social ties. Nearly 60% of respondents reported difficulties in their usual work or household duties due to chronic illness, which was also the strongest predictor of support. Patients with higher wellbeing reported less social support, while older age and having co-habitant supporters were negatively associated with support, indicating caregiver burnout. Conclusion: Ghanaian NCD patients receive support from various caregivers who may not be able to handle the increasing healthcare and social needs of an aging population. Policies should therefore enhance resource pooling and inclusiveness for old age security.

Economic evaluation of integrated services for non-communicable diseases and HIV: costs and client outcomes in rural Malawi.

OBJECTIVE: To evaluate the costs and client outcomes associated with integrating screening and treatment for non-communicable diseases (NCDs) into HIV services in a rural and remote part in southeastern Africa. DESIGN: Prospective cohort study. SETTING: Primary and secondary level health facilities in Neno District, Malawi. PARTICIPANTS: New adult enrollees in Integrated Chronic Care Clinics (IC3) between July 2016 and June 2017. MAIN OUTCOME MEASURES: We quantified the annualised total and per capita economic cost (US$2017) of integrated chronic care, using activity-based costing from a health system perspective. We also measured enrolment, retention and mortality over the same period. Furthermore, we measured clinical outcomes for HIV (viral load), hypertension (controlled blood pressure), diabetes (average blood glucose), asthma (asthma severity) and epilepsy (seizure frequency). RESULTS: The annualised total cost of providing integrated HIV and NCD care was $2 461 901 to provide care to 9471 enrollees, or $260 per capita. This compared with $2 138 907 for standalone HIV services received by 6541 individuals, or $327 per capita. Over the 12-month period, 1970 new clients were enrolled in IC3, with a retention rate of 80%. Among clients with HIV, 81% achieved an undetectable viral load within their first year of enrolment. Significant improvements were observed among clinical outcomes for clients enrolled with hypertension, asthma and epilepsy (p<0.05, in all instances), but not for diabetes (p>0.05). CONCLUSIONS: IC3 is one of the largest examples of fully integrated HIV and NCD care. Integrating screening and treatment for chronic health conditions into Malawi's HIV platform appears to be a financially feasible approach associated with several positive clinical outcomes.

Digital Health Technologies Applied by the Pharmaceutical Industry to Improve Access to Noncommunicable Disease Care in Low- and Middle-Income Countries.

BACKGROUND: There is limited research on how digital health technologies (DHTs) are used to promote access to care for patients with noncommunicable diseases (NCDs), particularly in low- and middle-income countries (LMICs). We describe the use of DHTs in pharmaceutical industry-led access programs aimed at improving access to NCD care in LMICs. METHODS: The Access Observatory is the largest publicly available repository containing detailed information about pharmaceutical industry-led access programs targeting NCDs. The repository includes 101 access program reports submitted by 19 pharmaceutical companies. From each report, we extracted data relating to geographic location, disease area, beneficiary population, use of DHTs, partnerships, strategies, and activities. Data were analyzed descriptively using SAS Statistical Software and categorized according to the World Health Organization Digital Health Classification Framework. RESULTS: A total of 43 access programs (42.6%) included DHTs. The majority of programs using DHTs were clustered across sub-Saharan Africa (72.1%) and targeted cancer (60.5%) followed by metabolic disorders (39.5%). The applied DHTs mostly related to program strategies on health service strengthening (74.4%) and community awareness (41.9%) and were largely directed toward health providers, followed by data services and clients. Only a few DHTs were used for health system management. To promote access, most DHTs focused on improving data collection, management, and use (51.1%); building health provider capacity through training (37.2%); and providing targeted patient information (34.8%). CONCLUSION: The range of DHTs applied by the pharmaceutical industry offers opportunities for more effective access to NCD care. Transparent reporting on DHT use and its contributions to access programs' achievements may reduce duplicative and redundant efforts and provide learnings for private and public stakeholders that may contribute to greater access to NCD care in LMICs.

A rapid assessment of the impact of coronavirus disease (COVID- 19) pandemic on health care & service delivery for noncommunicable diseases in India.

BACKGROUND AND AIM: The coronavirus disease (COVID-19) pandemic had disrupted the availability, access and utilisation of routine health care services. The present study aimed to assess the impact of COVID-19 pandemic restrictions on India's Non communicable Disease (NCD) health care service delivery. METHODS: The study included existing hospitals in disease registry network of the Indian Council of Medical Research-National Centre for Disease Informatics and Research (ICMR-NCDIR), Bengaluru. The study participants comprised site investigators who were clinicians from many specialities, including general medicine, surgery, cancer, neurology, cardiology, and endocrinology. A standardised questionnaire was prepared to collect data on NCD health care services at the respective hospitals over three months from March to May 2020. RESULTS: Out of 153 hospitals approached for the study, 106 (70%) agreed to participate. Of these, 16 hospitals fully converted for COVID-19 care were excluded from the study. Thus, data from 90 hospitals were included in the final analysis. There had been a total disruption of NCD-related healthcare services during the three months in 44% of the hospitals. In April 2020, the outpatient attendance for over one-third of the hospitals was reduced by more than 75%. Admissions for planned surgeries for cancer treatment were reduced by more than 75% for about 40% of the hospitals. Preventive activities and population-based screening for diabetes, hypertension and cancer appear to have been adversely affected, with about one-third of the hospitals reporting total disruption in April and May 2020. As many as 60% of the institutions reported adequate availability of doctors. Over 91% of the institutions had preparedness/action plans to ensure the continuity of NCD services. CONCLUSION: The study shows that despite adequate human and material resources, NCD outpatient services, elective surgeries and population-based screening were severely affected. Most institutions were prepared to overcome the pandemic-imposed disruption and ensure a continuum of care for NCDs'.