Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Abstract

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Keywords: delivery of health care, integrated; global health; implementation research; nepal; non-communicable diseases.

Conflict of interest statement

Competing interests: PA, AA, NC, DC, BD, SD, BG, TG, SH, DJ, SKa, RM, SPa, MP, SPo, IR, AR, PR, AT and RT are employed by and AK, DS, BA, GD, SMa, SMe, RS, LW and DM work in partnership with, a non-profit healthcare company (Nyaya Health Nepal, with support from the USA-based non-profit, Possible) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic and private foundation sources. AK is a medical student at and DC, SKi, SMa and DM are faculty members at a private medical school (Icahn School of Medicine at Mount Sinai). DS and RS are employed at an academic medical centre (Brigham and Women’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. DS and RS are faculty members at a private medical school (Harvard Medical School). DS is employed at an academic medical centre (Beth Israel Deaconess Medical Center) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. DS is employed at an academic research centre (Ariadne Labs) that is jointly supported by an academic medical centre (Brigham and Women’s Hospital) and a private university (Harvard TH Chan School of Public Health) via public sector research funding and private philanthropy. BA is a faculty member at a public university (University of California, San Francisco). DC is a faculty member at and DC and SH are employed part-time at a public university (University of Washington). GD, BG, SMe, PR and LW are fellows with a bidirectional fellowship programme (HEAL Initiative) that is affiliated with a public university (University of California, San Francisco) that receives funding from public, philanthropic and private foundation sources. GD is employed part-time at a public medical centre (Natividad Medical Center). MD and DJ are employed by the Government of Nepal (Ministry of Health and Population, Nepal Health Research Council and Department of Health Services, respectively). SKa is a graduate student at a private university (Eastern University). BKa and AS are employed at a private university (Kathmandu University). BKa is a faculty member at a public research university (Sun Yat-sen University). SKi is the founding executive director at an advocacy and leadership network (Young Professionals Chronic Disease Network) that receives funding from individual philanthropy. BKo is a faculty member at a public university (Tribhuvan University, Institute of Medicine). LK is a fellow at a public university (Virginia Commonwealth University) and is supported by a Hubert H Humphrey Fellowship from the US Department of State. SMa is a voting member on the Board of Directors with Group Care Global, a position for which she receives no compensation. SMe works in partnership with a public medical center on the border of a Native American reservation (Gallup Indian Medical Center) that is managed using public sector funding through the Indian Health Services. IN is a graduate student at and AS is a postdoctoral fellow at a private university (Harvard T H Chan School of Public Health). IN is a voting member on the Board of Directors with Possible, (a position which she joined after the conclusion of the research described in this manuscript), BP is a member on the Board of Advisors with Nyaya Health Nepal, and DM is a non-voting member on the Board of Directors with Possible, positions for which they receive no compensation. BP is employed at a private medical centre (Hospital for Advanced Medicine and Surgery) that receives revenue from fee-for-service transactions. RS is employed at an academic medical centre (Massachusetts General Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. PT is a graduate student at a public university (University of New South Wales). LW works in partnership with a medical center (Gallup Indian Medical Center) that receives revenue through fee-for-service medical transactions and private sector grants. All authors have read and understood BMJ Global Health’s policy on declaration of interests and declare that they have no competing financial interests. The authors do, however, believe strongly that healthcare is a public good, not a private commodity.

Figures

Figure 1

Enrolment of patient cohorts and inclusion within cohort analysis. COPD, chronic obstructive pulmonary disease; LTFU, loss-to-follow-up; NCD, non-communicable disease.

Figure 2

Change in proportion of cohort patients ‘at-goal’ status from baseline to endline, by condition. COPD, chronic obstructive pulmonary disease. *denote statistical significance.