Service Readiness For Noncommunicable Diseases Was Low In Five Countries In 2013–15

It is estimated that over 70 percent of all deaths worldwide are caused by noncommunicable diseases (NCDs)¹—chiefly cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. These deaths, many of which are classified as premature because they occur before age seventy, disproportionately occur in low- and middle-income countries.² NCDs also cause substantial economic burden by way of direct illness-related costs and indirect costs due to lost productivity.³

Policy makers at the global and national levels have demonstrated their commitment to addressing NCDs. For example, in 2013 the World Health Assembly endorsed the World Health Organization’s Global Action Plan for the Prevention and Control of NCDs 2013–2020, which provides specific policy and program recommendations for addressing the rising NCD burden.⁴ But NCD diagnosis and treatment require a well-functioning health system, which may be challenging for the low- and middle-income countries that bear the greatest NCD-related burden.⁵ Health system constraints on delivering NCD care have been recognized as a key global challenge and a priority area for investment and improvement.^6,7 It is therefore essential to understand service availability and readiness for delivering NCD care in high-burden, system-constrained countries to identify areas for further investment and opportunities for service strengthening.

Recent analyses have identified low NCD service availability in low- and middle-income countries, based on proxy measures composed of general inputs (such as numbers of health workers and hospital beds)⁸ and single-country studies of NCD screening and treatment services.^9–15 However, the literature has so far lacked an empirically driven generalizable analysis of NCD service availability and quality in low-resource settings. This study used nationally representative, standardized, comparable, and publicly available data to analyze the availability and readiness of selected NCD services (diagnosis and management of diabetes, cardiovascular disease, and chronic respiratory disease) in five low- and lower-middle-income countries: Bangladesh, Haiti, Malawi, Nepal, and Tanzania. (These diseases were selected because they are the focus of new NCD-specific questions on standardized service provision questionnaires implemented by the World Health Organization, described in more detail below.) The study also assessed the degree of access to these services, with a particular focus on geographic distribution (accessibility) and differences between facilities that offer services for free versus those that charge a fee (affordability).

Study Data And Methods

Data Source

This study used data from Service Provision Assessments (SPAs), which are surveys administered by the Demographic and Health Surveys Program.¹⁶ SPAs entail the collection of health facility data about service delivery inputs, outputs, and quality. The current survey tool includes indicators that correspond to the Service Availability and Readiness Assessment methodology of the World Health Organization and the US Agency for International Development.¹⁷ SPA data and this methodology can be used to generate valid, reliable, and standardized estimates of access to specific types of health services (availability) and inputs that are critical for the provision of high-quality health services (readiness).

SPA surveys include standardized facility inventory and health provider interview instruments. For the facility inventory, interviewers speak to the most knowledgeable person available about service readiness—namely, the availability of amenities, equipment, supplies, laboratory tests, and medicines—both generally and for specific services including diabetes, cardiovascular disease, and chronic respiratory disease. Additionally, health provider interviews are conducted with a random sample of approximately eight clinical personnel per facility. (See online appendix 1 for further details on the data sets.)¹⁸

This analysis included all publicly available cross-sectional Demographic and Health Surveys Program SPA data sets that included questions about NCDs: those for Bangladesh in 2014, Haiti in 2013, Malawi in 2013–14, Nepal in 2015, and Tanzania in 2014–15.^19–23

Study Setting

Exhibit 1 presents background information on the study countries and the SPA data sets. The low- and lower-middle-income countries are in three geographic regions (Latin America and the Caribbean, South Asia, and sub-Saharan Africa).²⁴ Haiti is the smallest country studied, with a population of approximately 11 million people, and Bangladesh is the largest, with over 164 million people.²⁵ Most of the countries have majority rural-dwelling populations (with the exception of Haiti, where over 60 percent of the population lives in urban areas).²⁵ All of the countries have high prevalences of NCDs. According to recent surveillance and survey data, over 25 percent of adults in these countries have hypertension (except in Bangladesh, where the prevalence is only approximately 18 percent), and 4–10 percent have diabetes.^26–32

The SPA data sets for these countries contain results from assessments of approximately 800–1,300 health facilities, most of which are at the primary care level and in rural areas. The data sets include both public and private health facilities, but the split between public and private sectors varied substantially across countries.

In all of the study countries, national health policies have specified that NCD screening and treatment services should be provided across the health system, including at the primary care level.^33–37

Dependent Variables

Service availability and readiness were defined according to the Service Availability and Readiness Assessment approach.³⁸ In that approach, availability is defined as the proportion of facilities offering each service and is presented as a dichotomous variable based on a yes/no question answered by the survey respondent: “Providers in the facility diagnose, prescribe treatment for, or manage patients with [condition X].”

Readiness is defined as whether specific people or items were available on the day of the survey: staff (at least one staff member trained in the diagnosis and management of the specific disease during the preceding two years), guidelines (national guidelines, visible in the service area), equipment (for disease-specific diagnosis or care, available and functional in the service area), diagnostics (on-site test capability, functional equipment, and supplies such as reagents), and medicines or commodities (in stock). A facility was classified as “ready” to provide services for a specific NCD if all of these components were present. Additionally, a readiness score was calculated, with one point for each of the following: guidelines, at least one provider, each piece of equipment, each diagnostic supply, and each medicine or commodity. Scores are reported only for those facilities with complete data on all score parameters. For ease of interpretation, these scores were standardized to a 0–100 scale. (See appendix 3 for additional details on all availability and readiness metrics.)¹⁸ A summary NCD service readiness score was also created by summing all of the disease-specific scores, with 0 assigned for facilities that did not have NCD services available, and standardizing the scores to a 0–100 scale.

Independent Variables

This analysis used Roy Penchansky and J. William Thomas’s “access framework” to analyze variability in NCD service availability and readiness.³⁹ This framework posits that a patient’s ability to access the health care system is shaped by five factors: acceptability (whether services match the patient’s values and norms), accessibility (geographic and physical location), accommodation (presence of services when they are needed), affordability, and availability. Other scholars have added factors, including appropriateness, architecture (organizational structures), adequacy, and awareness.^40–42 For this analysis, the factors of accessibility and affordability were selected as key independent variables because of their correspondence with data collected in the SPA; the robust evidence base indicating their role in shaping service use;^43–47 and their salience for these lower-income, largely rural populations. Accessibility was operationalized as whether the facility was located in an urban or a rural area, as was already done in all of the data sets except the one for Nepal. In that case, this classification was made based on each facility’s GPS location and definitions of urban areas in the Global Rural-Urban Mapping Project Urban Extents data set.⁴⁸Affordability was represented by a dichotomous variable for whether the facility offered services for free. Facilities that charged a flat fee and those that charged for a health card, consultation, medications, or registration were considered not free.

Other covariates included the level of care offered at the facility (primary versus secondary or higher), which was classified based on health system information in the SPA report, patient volume (the number of outpatient visits during the last complete month, except in the case of Nepal—where the recall period was the last complete year), and location based on geospatial data.

Analysis

All facilities in each country’s SPA data set were included, except those that provided only inpatient services. Also, in Nepal stand-alone HIV testing and counseling sites were excluded (following methodology in that country’s SPA report section on NCD services).

Differences between proportions were tested for statistical difference using chi-square tests. Multivariable analyses were conducted, using ordinary least squares estimation for the continuous NCD readiness score and logistic regression for binary availability (yes/no) variables. Robust standard errors were used for all multivariable models, and district fixed effects were included. Survey sample weights at the facility level were used for all descriptive statistics. Analyses were conducted using Stata, version 14.2.

Limitations

The study had several limitations. First, only three NCDs were measured in these five countries’ surveys, and availability of care for other NCDs may differ. Notably, despite their high prevalence, mental and neurological conditions were not included.

Second, although the five nationally representative surveys included here represent an advance in the ability to analyze NCD services in low- and middle-income countries, the results are not generalizable to all such settings.

Third, operationalizing affordability as the presence of free care is a coarse measure. It overlooks important variations across people’s experiences and opinions. However, this definition was as detailed as the SPA data allowed.

Fourth, although the Service Availability and Readiness Assessment methodology includes many important inputs to service delivery, it might not be comprehensive, and its cross-national standardized metric might not capture locally relevant differences, such as varying treatment guidelines. Additionally, SPA surveys use a cross-sectional design, which might not be an accurate reflection of usual service readiness. For example, high availability of supplies could indicate that these supplies are not being used.

Lastly, although several important characteristics were included in the multivariable models, it is possible that salient variables remained unobserved or omitted.

Study Results

In all but one country, most surveyed facilities offered diagnosis, management, or both of at least one noncommunicable disease (exhibit 2). In Bangladesh, fewer than 20 percent of facilities offered any NCD care. Among the three study NCDs (diabetes, cardiovascular disease, and chronic respiratory disease), diabetes care was the least prevalent in all of the countries.

There was substantial variation in the share of facilities having comprehensive NCD service availability (that is, care was available for all of the study NCDs), from below 25 percent in the Asian countries (Bangladesh and Nepal) to almost 80 percent in Haiti (exhibit 2). Across the study countries, comprehensive NCD service availability was lower at primary care facilities and at facilities in rural areas. And in all of the countries except Haiti, these differences were large and highly significant.

Fewer than five of the facilities in each country were classified as fully ready to provide care for each of the three NCDs (see appendix 4).¹⁸ Only one facility (in Tanzania) was fully ready to provide care for chronic respiratory disease.

Among facilities that offered each type of NCD service, the average readiness score was generally highest for diabetes care (45–50 points on a 0–100 scale), and next-highest for cardiovascular disease (32–50 points) (exhibit 3). Chronic respiratory disease had the lowest score (23–36 points). Among all facilities, with those without each NCD service available receiving a readiness score of 0, readiness was highest for cardiovascular disease and lowest for diabetes. This reflects the overall higher availability of the former and low availability of the latter.

In Malawi, Nepal, and Tanzania, the presence of at least one recently trained health worker was the lowest of the readiness components across all three NCDs (exhibit 3): This level of staffing was found at only approximately 13–18 percent of facilities in Malawi, 2–10 percent in Nepal, and 9–12 percent in Tanzania. National guidelines for NCD diagnosis or management were present at fewer than one-third of facilities in any country for any of the three diseases. Equipment was widely available (over 90 percent of facilities that offered each type of NCD service met the readiness criteria), and diabetes diagnostics were relatively common (over 70 percent of such facilities in all countries except Malawi met the criteria).

The availability of essential NCD medicines varied widely across diseases and countries (exhibit 3). In Bangladesh and Tanzania, fewer than 40 percent of facilities had at least one diabetes or CVD medicine, whereas in Malawi, at least one diabetes medicine was found in over 90 percent of facilities. (Appendix 5 contains details on the availability of specific medicines.)¹⁸

In Haiti, Malawi, and Tanzania, urban facilities were more likely to have comprehensive NCD services available, compared to rural facilities (even after service volume, care level, and district were controlled for), and had higher NCD service readiness scores (exhibit 4). In Haiti and Malawi, these differences were substantial and significant: The odds of comprehensive NCD service availability at urban facilities were approximately twice those at rural facilities, and service availability scores were on average approximately 6–7 percentage points higher at urban facilities. The Asian countries—Bangladesh and Nepal—did not exhibit significant urban-rural differences in NCD service availability or readiness.

Significant differences were seen between free facilities and those that charged a fee (exhibit 4). Facilities offering free care were much less likely to have comprehensive NCD services available (adjusted odds ratios: 0.11–0.43)—except in Tanzania, where this difference was less strong and not significant. The NCD service readiness scores were also much lower at free facilities compared to for-fee facilities, by 20 percentage points in Bangladesh and Haiti and 9–13 percentage points in Malawi, Nepal, and Tanzania.

Discussion

Like many low- and middle-income countries, the countries in this study are experiencing a rising burden of noncommunicable diseases, and this study indicates that these countries’ health systems are not well equipped to address this burden.

Availability of services is far from universal: In all countries except Haiti, fewer than half of surveyed facilities offered diagnosis, management, or both of the three NCDs. Service readiness—that is, the availability of requisite care inputs—was extremely weak, particularly because of shortages of trained health workers; guidelines; and, in some countries, essential medicines. Free and rural facilities in all countries had low NCD service availability and readiness. This finding is particularly salient because it may indicate the presence of access barriers for vulnerable patients. These results are consistent with findings from earlier descriptions of NCD services in these countries.^14,49–54

Although all of the study countries have government policies to provide NCD care throughout the health system, these results suggest that there may be challenges in policy implementation. In some countries, such NCD-related policies are relatively recent, so low service availability may reflect a ramp-up implementation period. However, a recent multicountry analysis using SPA data found similarly low service availability and readiness for a broad indicator of primary care readiness, including infrastructure and inputs (medicines, laboratory services, and equipment) for managing prevalent communicable diseases and providing reproductive/maternal health care.⁵⁵ This suggests that these limitations might not be due to recent policy changes or in-progress implementation.

Policy Implications

These findings suggest opportunities for improving service availability and readiness for diagnosing and managing noncommunicable diseases. First, it is important to increase the capacity of the workforce to manage NCDs. This might be accomplished through expanding training opportunities for clinicians or shifting tasks to other providers—although recent systematic reviews have found weak evidence to support the latter approach.^56,57 There are limits to what trained providers can accomplish, however, if other inputs are lacking.

Second, global access to medicines and universal health coverage initiatives have important implications for NCD care.⁵⁸ Many NCD treatments are on essential medicines lists but remain expensive and inaccessible in many countries.⁵⁹ Policies to ensure availability and affordability—including securing adequate financing; monitoring access (availability, use, and prices); improving efficiency and quality in medicine selection, procurement, and use through regulatory mechanisms and clinical guidelines; and strengthening supply chains at global and national levels—will be essential to ensure NCD care within universal health coverage.^7,60

Third, policy makers should seek ways to constructively engage the private sector in addressing NCDs.^7,61,62 Examples from other areas—such as the Affordable Medicines Facility–malaria,⁶³ the GAVI Alliance for vaccine-preventable diseases,⁶⁴ or approaches to delivering sexual and reproductive health services⁶⁵—may offer insights across a range of policy entry points including medicines’ procurement, regulation, and supply; financing and marketing of services; and contracting with and training of providers.

There are two important caveats to these policy recommendations. First, the ingredients of service readiness—supplies, infrastructure, medicines, and trained personnel—do not necessarily equate to high-quality care. A recent analysis of SPA data found that such inputs are weakly correlated with care quality,⁶⁶ which reinforces the need to focus on metrics beyond easy-to-count health service inputs or utilization rates.⁶⁷ It is thus imperative for policy makers and clinical communities to develop and implement robust approaches to measuring quality of care,⁶⁸ and these should be attentive to the chronic life-course trajectory of patients managing NCDs.

Equity and access should be central to policy and system changes intended to strengthen the delivery of NCD services.

Second, the vast and growing burden of NCDs has bolstered interest in broad-based health system strengthening.⁶⁹ The results of this study highlight existing access barriers to NCD care. Equity and access should therefore be central to policy and system changes intended to strengthen the delivery of NCD services. For example, in closing the observed gap of health workers trained in NCDs, attention should be paid to how these trained workers are distributed both geographically and across health system levels and sectors (private and public).

Conclusion

There is global and national commitment to addressing the burden of noncommunicable diseases, but services remain inadequate in these low- and middle-income countries. This analysis is the first to present cross-national findings about standardized service availability and readiness for NCDs in selected low- and middle-income countries. The lack of methodologies to assess NCD care has previously been noted,⁷⁰ so these data offer an important new resource. Analyses such as this one can inform decisions about allocating resources to where they are most needed and suggest policy and program priorities for countries facing a substantial noncommunicable disease burden.

ACKNOWLEDGMENTS

The author thanks Veronika Wirtz and James Macinko for their valuable comments on previous versions of this article.

NOTES

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