Non-communicable disease care for all

In the first few months of working in Rajpur, we are assured that is not only the hospitals but also the entire healthcare system that needs strengthening to address the growing burden of non-communicable diseases.

Here are a couple of stories from late 2017.

Story of Rambahadur: a blindness that could not be prevented

Rambahadur (name changed), 43 years old, was brought to the Rajpur clinic by his mother (65 years old), and father (67 years old). He was diagnosed with diabetes about two years back and had been prescribed medication at a hospital in a city about 4 hours away by bus. They had heard of a new doctor that had recently started serving at the Rajpur clinic from the neighbors and decided to pay a visit.

Our physician was not able to provide complete care due to the lack of proper laboratory facilities and anti-diabetic medications. He had to refer Rambahadur to the hospital in the city.

Story of Haricharan: little help to prevent an impending disaster

Haricharan (name changed), 45 years old, came to the Rajpur health clinic with his wife from a neighborhood nearby. He was diagnosed with hypertension about 7 months back. He had received anti-hypertensive medication, Atenolol tablets from the clinic before. He informed us that he was taking them regularly. However, upon examination, our physician noted that this blood pressure was not under control. Atenolol, alone, was not enough to control Haricharan’s high blood pressure. Our physician noted that Haricharan needed different anti-hypertensive medication which was not available at the Rajpur health clinic.

As the discussion was going on, the physician inquired about Haricharan’s diet and noted that he had not been able to restrict salt in his diet. Haricharan’s wife agreed that it is not practical to put less salt on occasions like when the guests are visiting at home. 

The couple was counseled on various ways salt restriction could be achieved for Haricharan at his home. Haricharan was also advised to follow up after a month. Our physician informed them that if the blood pressure will remain uncontrolled even after a month of salt restriction, Haricharan would have to be referred to another health center for other medications.

What do these stories tell us about Public-sector Primary Healthcare for non-communicable diseases control?

1. Lack of non-communicable diseases control programs:

Established health centers like that of Rajpur do not even have basic setups for the diagnosis and treatment of non-communicable diseases. There is a lack of a basic laboratory to diagnose or monitor even the commonest non-communicable diseases. Similarly, there are not enough drugs that can be used to manage diseases like diabetes and hypertension.

Ensuring that the health facilities serving at the lowest level of the public health system are equipped with trained clinicians, basic medical equipment and appropriate drugs can allow patients with such non-communicable diseases to receive adequate care. In a country, where >60% of adult mortality can be attributed to non-communicable diseases [World Health Organization — Noncommunicable Diseases (NCD), Country Profile: Nepal, 2014], this has to become a new priority.

2. Lack of community outreach for non-communicable diseases:

The existing healthcare systems of Nepal do not have proper community services and outreach. People often have to travel long distances even for basic health checkups which can be easily transferred to outreach clinics. Blood pressure measurement and basic laboratory tests are some of the basic services that can be easily provided through outreach clinics. These fairly simple services have the potential to increase follow-ups at the health clinics and ensure continuity of care. Similarly, an outreach clinic could be a great avenue to refill a prescription that does not need to be adjusted. Providing basic laboratory tests and refilling prescribed medications for cases that are under control, aided by proper clinical guidelines at the outreach clinics closer to people’s homes or workplaces will cut a lot of burden for patients. 

3. Lack of focused individualized care:

The Female Community Health Volunteers (FCHVs) of Nepal do not receive formal training in non-communicable diseases. Because of this, we have not been able to mobilize a highly successful cadre of community health workers in the key areas of prevention and management of non-communicable diseases that are based on lifestyle like diet modification, physical activity, smoking cessation, and alcohol moderation.

FCHVs can be instrumental in providing focused individualized care to patients with non-communicable diseases. Allowing patients of Hypertension to have their blood pressure checked, encouraging patients of Diabetes to self-examine their feet at night, reporting unusual symptoms, or obtaining counseling on risk factors at homes and workplaces through FCHVs can go a long way in preventing costly and even life-threatening complication of non-communicable diseases.

4. Lack of trust in public sector healthcare:

As outlined above, health care services for non-communicable services are nearly absent in the public healthcare facilities of Nepal, more specifically at the primary level. This chronic inadequacy of services has decreased the trust of the people towards what can be expected from the public sector. As the supply remains inadequate in public health facilities, the demand for services for non-communicable diseases is also less. In a country where 57% of people have a daily wage below $2 [Asian Development Bank, Country Poverty Analysis (Detailed), 2013], it is unfortunate that the public sector is unable to provide even the basic services for the diseases that afflict a significant percent [Percentage with raised BP 25.7%; Percentage with raised fasting blood glucose 3.6 %, STEPS Survey 2013, Government of Nepal, Nepal Health Research Council and World Health Organization] of the adult population. As a result, people have no option but to rely on the unregulated and expensive private sector.

An online news portal presents news coverage about the decreasing utilization of public hospitals in the region. The headline reads: “Trust towards public health facilities declining in Dang.”

Karma Health’s mission to turn the tide

Karma Health, an organization fixated on creating systems that ensure dignified healthcare for all, realizes the situation of non-communicable in the public health sector of Nepal. To continue with this commitment, Karma Health has partnered with the Rajpur municipality where this situation persists, to build a system within the public sector with personnel, supplies, and services to address the growing burden of non-communicable diseases. Through this engagement, Karma Health hopes to revive common trust in public sector healthcare. Some of the ways Karma Health is trying to build the system are listed below.

1. Strengthening health facilities of the public sector

Karma Health has already deployed a physician who is serving at one of the municipal clinic health facilities of the Rajpur municipality. Previously, Karma Health also lobbied at the Rajpur municipality to allocate a budget to start a basic laboratory at the municipal clinic where our physician is serving. Karma Health is currently seeking to build partnerships with various helping hands, so that, basic supplies and appropriate drugs for non-communicable diseases can be made available in Rajpur municipality.

2. Establishing effective outreach

Karma Health will deploy mid-level clinicians to start outreach clinics for non-communicable diseases at the selected hard-to-reach sites of Rajpur municipality. Karma Health wants to ensure that the patients treated at the clinics for non-communicable diseases such as Hypertension and Diabetes will receive continuous monitoring and care beyond the health facilities. Such outreach clinics will guarantee regular checkups and diagnostics to assess the progression and control of such non-communicable diseases, and continuous replenishment of prescription medicines for cases under control as per the clinical protocols.

3. Individualized care at homes

Karma Health will support the existing cadre of Female Community Health Volunteers (FCHVs) with proper training and benefits, so that, they will be able to provide individualized care at the homes of patients with non-communicable diseases. Providing benefits to the FCHVs is one of the key steps that Karma Health is taking to professionalize this cadre of health providers in the community into Community Health Workers (CHWs). Karma Health believes that these professional CHWs will be more accountable in completing their responsibilities. Since they are appointed by the community members, we hope that this will cascade the phenomenon of the community taking an active role in appointing and demanding only those individuals as the community health workers who are capable of providing the care that the community needs.

An illustration of how patients with chronic non-communicable diseases, like Rambahadur and Haricharan, would receive care in Karma Health’s integrated system comprising health clinics, community outreach clinics, and community health workers.

Karma Health is committed to implementing this unique model of community-driven management of non-communicable diseases. It is common in global public healthcare delivery to build isolated centers of excellence, but such systems are too costly, unsustainable, and only offer band-aids to deep-rooted challenges in delivering quality healthcare. Karma Health is determined to replace such inadequate systems with a resilient and responsive system built in the cost and design that the governments of low and middle-income countries can accommodate now and in the decades to come.