Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review.

BACKGROUND: Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery. METHODS: A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT). RESULTS: We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed. CONCLUSION: Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers. TRIAL REGISTRATION: PROSPERO registration number CRD42022340059 .

Sri Lanka's COVID-19 response and maintaining health services: implications for future pandemics.

This study examines how Sri Lanka, a lower-middle income country, managed its COVID-19 response and maintained health services. It draws on an extensive document review, key informant interviews and a national survey of public experience and opinion to assess what Sri Lanka did, its effectiveness and why.Owing to a strong health system and luck, Sri Lanka stopped the first wave of COVID-19 infections, and it adopted a 'Zero-COVID' approach with the explicit goal of stopping outbreaks. This was initially effective. Outbreaks reduced healthcare use, but with minimal impact on health outcomes. But from end-2020, Sri Lanka switched its approach to tolerating transmission and mitigation. It took proactive actions to maintain healthcare access, and it pursued a COVID-19 vaccination effort that was successful in covering its adult population rapidly and with minimal disparities. Despite this, widespread transmission during 2021-2022 disrupted health services through the pressure on health facilities of patients with COVID-19 and infection of healthcare workers, and because COVID-19 anxiety discouraged patients from seeking healthcare. This led to substantial mortality and more than 30 000 excess deaths by 2022.We find that Sri Lanka abandoned its initially successful approach, because it failed to understand that its chosen strategy required symptomatic PCR testing in primary care. Failure to invest in testing was compounded by groupthink and a medical culture averse to testing.Sri Lanka's experience confirms that strong public health capacities, robust healthcare systems and intersectoral action are critical for pandemic response. It shows that civilian-military collaboration can be beneficial but contested, and that lack of fiscal space will undermine any response. It also demonstrates that pandemic preparedness cannot guarantee a successful pandemic response. Policy and research must pay more attention to improving decision-making processes when faced with pandemics involving novel pathogens, rapid spread, and substantial scientific uncertainty.

Optimizing cardiovascular disease risk screening in a low-resource setting: cost-effectiveness of program modifications in Sri Lanka modelled with nationally representative survey data.

BACKGROUND: While screening for cardiovascular disease (CVD) risk can help low-resource health systems deliver low-cost, effective prevention, evidence is needed to adapt international screening guidelines for maximal impact in local settings. We aimed to establish how the cost-effectiveness of CVD risk screening in Sri Lanka varies with who is screened, how risk is assessed, and what thresholds are used for prescription of medicines. METHODS: We used data for people aged 35 years and over from a 2018/19 nationally representative survey in Sri Lanka. We modelled the costs and quality adjusted life years (QALYs) for 128 screening program scenarios distinguished by a) age group screened, b) risk tool used, c) definition of high CVD risk, d) blood pressure threshold for treatment of high-risks, and e) prescription of statins to all diabetics. We used the current program as the base case. We used a Markov model of a one-year screening program with a lifetime horizon and a public health system perspective. RESULTS: Scenarios that included the WHO-2019 office-based risk tool dominated most others. Switching to this tool and raising the age threshold for screening from 35 to 40 years gave an incremental cost-effectiveness ratio (ICER) of $113/QALY. Lowering the CVD high-risk threshold from 20 to 10% and prescribing antihypertensives at a lower threshold to diabetics and people at high risk of CVD gave an ICER of $1,159/QALY. The findings were sensitive to allowing for disutility of daily medication. CONCLUSIONS: In Sri Lanka, CVD risk screening scenarios that used the WHO-2019 office-based risk tool, screened people above the age of 40, and lowered risk and blood pressure thresholds would likely be cost-effective, generating an additional QALY at less than half a GDP per capita.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: protocol for a systematic review.

INTRODUCTION: The burden of non-communicable diseases (NCDs) has increased substantially in low- and middle-income countries (LMICs), and adapting health service delivery models to address this remains a challenge. Many patients with NCD seek private care at different points in their encounters with the health system, but the determinants and outcomes of these choices are insufficiently understood. The proposed systematic review will help inform the governance of mixed health systems towards achieving the goal of universal health coverage. This protocol details our intended methodological and analytical approaches, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). METHODS AND ANALYSIS: Following the PRISMA approach, this systematic review will develop a descriptive synthesis of the determinants and outcomes of private healthcare utilisation for NCDs in LMICs. The databases Embase, Medline, Web of Science Core Collection, EconLit, Global Index Medicus and Google Scholar will be searched for relevant studies published in English between period 1 January 2010 and 30 June 2022 with additional searching of reference lists. The study selection process will involve a title-abstract and full-text review, guided by clearly defined inclusion and exclusion criteria. A quality and risk of bias assessment will be done for each study using the Mixed Methods Appraisal Tool. ETHICS AND DISSEMINATION: Ethical approval is not required because this review is based on data collected from publicly available materials. The results will be published in a peer-reviewed journal and presented at related scientific events. PROSPERO REGISTRATION NUMBER: CRD42022340059.

Prevalence of diabetes and pre-diabetes in Sri Lanka: a new global hotspot-estimates from the Sri Lanka Health and Ageing Survey 2018/2019.

INTRODUCTION: This study's objective was to produce robust, comparable estimates of the prevalence of diabetes and pre-diabetes in the Sri Lankan adult population, where previous studies suggest the highest prevalence in South Asia. RESEARCH DESIGN AND METHODS: We used data on 6661 adults from the nationally representative 2018/2019 first wave of the Sri Lanka Health and Ageing Study (SLHAS). We classified glycemic status based on previous diabetes diagnosis, and either fasting plasma glucose (FPG), or FPG and 2-hour plasma glucose (2-h PG). We estimated crude and age-standardized prevalence of pre-diabetes and diabetes and by major individual characteristics weighting the data to account for study design and subject participation. RESULTS: Crude prevalence of diabetes in adults was 23.0% (95% CI 21.2% to 24.7%) using both 2-h PG and FPG, and age-standardized prevalence was 21.8% (95% CI 20.1% to 23.5%). Using only FPG, prevalence was 18.5% (95% CI 7.1% to 19.8%). Previously diagnosed prevalence was 14.3% (95% CI 13.1% to 15.5%) of all adults. The prevalence of pre-diabetes was 30.5% (95% CI 28.2% to 32.7%). Diabetes prevalence increased with age until ages ≥70 years and was more prevalent in female, urban, more affluent, and Muslim adults. Diabetes and pre-diabetes prevalence increased with body mass index (BMI) but was as high as 21% and 29%, respectively, in those of normal weight. CONCLUSIONS: Study limitations included using only a single visit to assess diabetes, relying on self-reported fasting times, and unavailability of glycated hemoglobin for most participants. Our results indicate that Sri Lanka has a very high diabetes prevalence, significantly higher than previous estimates of 8%-15% and higher than current global estimates for any other Asian country. Our results have implications for other populations of South Asian origin, and the high prevalence of diabetes and dysglycemia at normal body weight indicates the need for further research to understand the underlying drivers.

Cost-Effectiveness and Distributional Impact of Opportunistic Screening for People at High-Risk of Cardiovascular Disease in Sri Lanka: A Modelling Study.

Background: While hypertension, diabetes, hypercholesterolemia and high-risk of cardiovascular disease can be easily diagnosed and treated with cost-effective medicines, a large proportion of people remain undiagnosed. We assessed the potential effectiveness, cost, and distributional impact of opportunistically screening for these chronic conditions at outpatient patient departments in Sri Lanka. Methods: We used nationally representative data on biomarkers and healthcare utilization in 2019 to model the screening of people aged 40+ without preexisting CVD and without a reported diagnosis of hypertension, diabetes, or hypercholesterolemia. We modelled an intensive one month program that would screen a proportion of those making an outpatient visit to a public or private clinic and follow-up a proportion of those screened to confirm diagnoses. We also modelled a less intensive one year program. The main outcomes were the new diagnoses of any of the chronic conditions. Program costs were calculated and the socioeconomic distributions of individuals screened, new cases diagnosed, and treatments delivered were estimated. Sensitivity analyses varied the probability of screening and follow-up. Results: Using data on 2,380 survey participants who met the inclusion criteria, we estimated that the one month program would diagnose 8.2% (95% CI: 6.8, 9.6) of those with a chronic condition who would remain undiagnosed without the program. The one year program would diagnose 26.9% (95% CI: 26.5, 27.4) of the otherwise undiagnosed and would have a cost per person newly diagnosed of USD 6.82 (95% CI: 6.61, 7.03) in the public sector and USD 16.92 (95% CI: 16.37, 17.47) in the private sector. New diagnoses would be evenly distributed over the socioeconomic distribution, with public (private) clinics diagnosing a higher proportion of poorer (richer) individuals. Both programs would reduce underdiagnosis among males relative to females. Conclusions: Opportunistic screening for cardiovascular diseases at outpatient clinics in Sri Lanka could be cost-effective and equitable.

Prevalence and Associations of Hypertension in Sri Lankan Adults: Estimates from the SLHAS 2018-19 Survey Using JNC7 and ACC/AHA 2017 Guidelines.

Background: Sri Lanka lacks robust estimates of hypertension (HTN) prevalence owing to few national studies, hindering optimization of control strategies. Evidence on how the revised 2017 American College of Cardiology/American Heart Association (ACC/AHA) HTN definition affects prevalence in low- and middle-income countries (LMICs) is also limited. Objectives: To make robust estimates of HTN prevalence in the Sri Lankan adult population, and to assess impact of the ACC/AHA 2017 definitions. Methods: Data were sourced from the 2018-2019 first wave of the Sri Lanka Health and Ageing Study (SLHAS), a nationally representative longitudinal study of the noninstitutionalized adult population. After excluding those with missing data and aged <18 years, 6,342 participants (95.1%) were included in the analysis. HTN was defined using either the traditional threshold of systolic BP (SBP) ≥140 mmHg or a diastolic BP (DBP) ≥90 mmHg, or the ACC/AHA 2017 threshold of SBP ≥130 mmHg or DBP ≥80 mmHg, or if taking antihypertensive medication. Results: Estimated prevalence of HTN in all Sri Lankan adults was 28.2% using the traditional definition, and it doubled to 51.3% when applying the ACC/AHA 2017 definition. Of those classified as hypertensive according to the older and ACC/AHA 2017 definitions, 53.4% and 31.2%, respectively, were previously diagnosed. Of the 23.2% of adults reclassified as hypertensive by the ACC/AHA 2017 definition, 16.6% had a history of CVD or diabetes. Increased prevalence was associated with urban residence, socioeconomic status, obesity, and Muslim ethnicity. Prevalence increased with age, but the increase was steeper in women from their 30s. Conclusions: Nearly one in three adult Sri Lankans are hypertensive, requiring antihypertensive treatment. Applying the ACC/AHA 2017 definitions almost doubles numbers, but many of those reclassified would require treatment under recent WHO guidelines. Study findings also suggest that design effects in HTN surveys may be higher than usually assumed.

Effects of a lifestyle intervention programme after 1 year of follow-up among South Asians at high risk of type 2 diabetes: a cluster randomised controlled trial.

INTRODUCTION: South Asians are at high risk of type 2 diabetes (T2D). We assessed whether intensive family-based lifestyle intervention leads to significant weight loss, improved glycaemia and blood pressure in adults at elevated risk for T2D. METHODS: This cluster randomised controlled trial (iHealth-T2D) was conducted at 120 locations across India, Pakistan, Sri Lanka and the UK. We included 3684 South Asian men and women, aged 40-70 years, without T2D but with raised haemoglobin A1c (HbA1c) and/or waist circumference. Participants were randomly allocated either to the family-based lifestyle intervention or control group by location clusters. Participants in the intervention received 9 visits and 13 telephone contacts by community health workers over 1-year period, and the control group received usual care. Reductions in weight (aim >7% reduction), waist circumference (aim ≥5 cm reduction), blood pressure and HbA1C at 12 months of follow-up were assessed. Our linear mixed-effects regression analysis was based on intention-to-treat principle and adjusted for age, sex and baseline values. RESULTS: There were 1846 participants in the control and 1838 in the intervention group. Between baseline and 12 months, mean weight of participants in the intervention group reduced by 1.8 kg compared with 0.4 kg in the control group (adjusted mean difference -1.10 kg (95% CI -1.70 to -1.06), p<0.001). The adjusted mean difference for waist circumference was -1.9 cm (95% CI -2.5; to 1.3), p<0.001). No overall difference was observed for blood pressure or HbA1c. People who attended multiple intervention sessions had a dose-dependent effect on waist circumference, blood pressure and HbA1c, but not on weight. CONCLUSION: An intensive family-based lifestyle intervention adopting low-resource strategies led to effective reduction in weight and waist circumference at 12 months, which has potential long-term benefits for preventing T2D. A higher number of attended sessions increased the effect on waist circumference, blood pressure and HbA1c. TRIAL REGISTRATION NUMBER: EudraCT: 2016-001350-18; ClinicalTrials.gov: NCT02949739.

Increased Intensity Of PCR Testing Reduced COVID-19 Transmission Within Countries During The First Pandemic Wave.

Experts agree that reverse transcription-polymerase chain reaction (PCR) testing is critical in controlling coronavirus disease 2019 (COVID-19), but decision makers disagree on how much testing is optimal. Controlling for interventions and ecological factors, we used linear regression to quantify testing's impact on COVID-19's average reproduction number, which represents transmissibility, in 173 countries and territories (which account for 99 percent of the world's COVID-19 cases) during March-June 2020. Among interventions, PCR testing had the greatest influence: a tenfold increase in the ratio of tests to new cases reported reduced the average reproduction number by 9 percent across a range of testing levels. Our results imply that mobility reductions (for example, shelter-in-place orders) were less effective in developing countries than in developed countries. Our results help explain how some nations achieved near-elimination of COVID-19 and the failure of lockdowns to slow COVID-19 in others. Our findings suggest that the testing benchmarks used by the World Health Organization and other entities are insufficient for COVID-19 control. Increased testing and isolation may represent the most effective, least costly alternative in terms of money, economic growth, and human life for controlling COVID-19.

The quality of care in outpatient primary care in public and private sectors in Malaysia.

In Malaysia, first-contact, primary care is provided by parallel public and private sectors, which are completely separate in organization, financing and governance. As the country considers new approaches to financing, including using public schemes to pay for private care, it is crucial to examine the quality of clinical care in the two sectors to make informed decisions on public policy. This study intends to measure and compare the quality of clinical care between public and private primary care services in Malaysia and, to the extent possible, assess quality with the developed economies that Malaysia aspires to join. We carried out a retrospective analysis of the National Medical Care Survey 2014, a nationally representative survey of doctor-patient encounters in Malaysia. We assessed clinical quality for 27 587 patient encounters using data on 66 internationally validated quality indicators. Aggregate scores were constructed, and comparisons made between the public and private sectors. Overall, patients received the recommended care just over half the time (56.5%). The public sector performed better than the private sector, especially in the treatment of acute conditions, chronic conditions and in prescribing practices. Both sectors performed poorly in the indicators that are most resource intensive, suggesting that resource constraints limit overall quality. A comparison with 2003 data from the USA, suggests that performance in Malaysia was similar to that a decade earlier in the USA for common indicators. The public sector showed better performance in clinical care than the private sector, contrary to common perceptions in Malaysia and despite providing worse consumer quality. The overall quality of outpatient clinical care in Malaysia appears comparable to other developed countries, yet there are gaps in quality, such as in the management of hypertension, which should be tackled to improve overall health outcomes.