Before we strengthened the health center at Rajpur, we were quickly reminded of the fact that it 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 December 2017.
A blindness that could not be prevented
Rambahadur (alias name), 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 a 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.
Rambahadur’s vision had increasingly decreased since the last year and was now unable to walk or do activities on his own. He had to take support of a walking stick and his parents, who themselves needed walking sticks because of their age. During the examination, Rambahadur showed the medication that he takes two times a day to the physician. Unfortunately, his medication is not available in the Rajpur health clinic. Also, he told the physician that when he went to a private hospital at the city two months back, his blood sugar level was way above the safe range.
Rambahadur’s mother observes her husband helping their son to take the steps at the health clinic at Rajpur. They left the clinic with an advice to go to a hospital in the city.
Rambahadur’s eyes that lost the vision: Blindness and other complications of Diabetes can be prevented in patients like Rambahadur through continuous care systems that Karma Health will implement in the rural community of Rajpur.
Sadly, 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.
Little help to prevent an impending disaster
Haricharan (alias name), 45 years old, came to the Rajpur health clinic with his wife from a neighbourhood nearby. He was diagnosed with hypertension about 7 months back. He had received anti-hypertensive medication, Atenolol tablets from the clinic before. He informed 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 occassions like when the guests are visiting at home.
The couple were counselled of 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 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 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 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], it is urgent that this has to become a new priority.
2. Lack of community outreach for non-communicable diseases:
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, outreach clinic could be a great avenue to refill the prescription the 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. However, Government of Nepal has given little thought about these.
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 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 up, encouraging the 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 the non-communicable services are nearly absent in 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 the public health facilities, the demand of services for non-communicable diseases is also less. In a country where 57% of people have 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 unregulated and expensive private sector.
An online news portal presents a 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:
As 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 public sector with personnel, supplies and services to address growing burden of non-communicable diseases. Through this engagement, Karma Health hopes to revive common trust in the 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 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 the 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 step that Karma Health is taking to professionalizing 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 active role in appointing and demanding only those individuals as the community health workers who are capable of providing the care that the community really 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 of health clinics, community outreach clinics and through community health workers.
Karma Health is committed to implement this unique model of community-driven management of non-communicable diseases. It is common in global public health care 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.