Comprehensive primary health care and non-communicable diseases management: a case study of El Salvador

Clinico-Epidemiological Profile of Patients with Chronic Kidney Diseases of Unknown Etiology: A Hospital-Based, Cross-Sectional Study from Central India

Background

Chronic kidney disease (CKD) not associated with known risk factors, called CKD of unknown etiology (CKDu), has been reported from several geographically distinct regions across the world. This study reports the clinical and epidemiological profile of patients with CKDu from a new hotspot in central India.

Materials and Methods

This cross-sectional study describes the sociodemographic, clinical, and laboratory profile of the patients diagnosed with CKDu visiting a tertiary care public hospital in the state of Chhattisgarh in central India between June 2019 and June 2021. CKDu was diagnosed as progressive CKD, minimal proteinuria, absence of hematuria, diabetes, severe hypertension, systemic illness, glomerulonephritis or other urinary tract diseases, and presence of symmetrically contracted kidneyon ultrasound.

Results

A total of 166 (3.1%) out of 5365 patients with CKD were diagnosed with CKDu. The mean age was 53.6 ± 11.8 years. The patients were predominantly male (n = 113, 68.1%), belonged to rural areas (n = 147, 88.6%), and were engaged in farming (n = 105, 63.3%). The estimated glomerular filtration rate (eGFR) at presentation was 21.5 ± 15.1 ml/min/1.73m2. Forty-four (26.5%) had stage 3 CKD, 57 (34.3%) had stage 4 CKD, and 65 (39.2%) had stage5 CKD. There was an over-representation of CKDu cases in patients with CKD from Gariyaband (36.0%) and Mahasamund (25%) districts of Chhattisgarh and Nuapada (35.0%) and Balangir (30.0%) districts of Odisha.

Conclusion

The study suggests clustering of cases of CKDu in certain districts of Orissa and Chhattisgarh.

A review and analysis of accountability in global health funding, research collaborations and training: towards conceptual clarity and better practice

INTRODUCTION

Accountability is a complex idea to unpack and involves different processes in global health practice. Calls for accountability in global health would be better translated to action through a better understanding of the concept and practice of accountability in global health. We sought to analyse accountability processes in practice in global health funding, research collaborations and training.

METHODS

This study is a literature review that systematically searched PubMed and Scopus for articles on formal accountability processes in global health. We charted information on processes based on accountability lines ('who is accountable to whom') and the outcomes the processes were intended for ('accountability for what'). We visualised the representation of accountability in the articles by mapping the processes according to their intended outcomes and the levels where processes were implemented.

RESULTS

We included 53 articles representing a wide range of contexts and identified 19 specific accountability processes for various outcomes in global health funding, research collaborations and training. Target setting and monitoring were the most common accountability processes. Other processes included interinstitutional networks for peer checking, litigation strategies to enforce health-related rights, special bodies that bring actors to account for commitments, self-accountability through internal organisational processes and multipolar accountability involving different types of institutional actors. Our mapping identified gaps at the institutional, interinstitutional and broader system levels where accountability processes could be enhanced.

CONCLUSION

To rebalance power in global health, our review has shown that analysing information on existing accountability processes regarding 'who is accountable to whom' and 'accountability for what' would be useful to characterise existing lines of accountability and create lines where there are gaps. However, we also suggest that institutional and systems processes for accountability must be accompanied by political engagement to mobilise collective action and create conditions where a culture of accountability thrives in global health.

Multisectoral actions in primary health care: A realist synthesis of scoping review

BACKGROUND

Multisectoral actions (MSAs) on health are key to implementation of primary health care (PHC) and achieving the targets of the Sustainable Development Goal 3. However, there is limited understanding and interpretation of how MSAs on health articulate and mediate health outcomes. This realist review explored how MSAs influence on implementing PHC towards universal health coverage (UHC) in the context of multilevel health systems.

METHODS

We reviewed published evidence that reported the MSAs, PHC and UHC. The keywords used in the search strategy were built on these three key concepts. We employed Pawson and Tilley's realist review approach to synthesize data following Realist and Meta-narrative Evidence Syntheses: Evolving Standards publication standards for realist synthesis. We explained findings using a multilevel lens: MSAs at the strategic level (macro-level), coordination and partnerships at the operational level (meso-level) and MSAs employing to modify behaviours and provide services at the local level (micro-level).

RESULTS

A total of 40 studies were included in the final review. The analysis identified six themes of MSAs contributing to the implementation of PHC towards UHC. At the macro-level, themes included influence on the policy rules and regulations for governance, and health in all policies for collaborative decision makings. The meso-level themes were spillover effects of the non-health sector, and the role of community health organizations on health. Finally, the micro-level themes were community engagement for health services/activities of health promotion and addressing individuals' social determinants of health.

CONCLUSION

Multisectoral actions enable policy and actions of other sectors in health involving multiple stakeholders and processes. Multisectoral actions at the macro-level provide strategic policy directions; and operationalise non-health sector policies to mitigate their spillover effects on health at the meso-level. At micro-level, MSAs support service provision and utilisation, and lifestyle and behaviour modification of people leading to equity and universality of health outcomes. Proper functional institutional mechanisms are warranted at all levels of health systems to implement MSAs on health.

Integrating eye care in low-income and middle-income settings: a scoping review

OBJECTIVES

Integrated people-centred eye care has been recommended as a strategic framework for reducing global vision impairment and blindness. The extent to which eye care has integrated with other services has not been widely reported. We aimed to investigate approaches to integrating eye care service delivery with other systems in low resource settings, and identify factors associated with integration.

DESIGN

Rapid scoping review based on Cochrane Rapid Review and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, Embase, Web of Science, Scopus and Cochrane Library databases were searched in September 2021.

ELIGIBILITY CRITERIA

Papers with interventions involving eye care or preventative eye care integrated into other health systems, peer-reviewed in English, conducted in low-income or middle-income countries, and published between January 2011 and September 2021 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened, quality appraised and coded included papers. A deductive-inductive iterative analysis approach was used with a focus on integrating service delivery.

RESULTS

The search identified 3889 potential papers, of which 24 were included. Twenty papers incorporated more than one intervention type (promotion, prevention and/or treatment), but none included rehabilitation. Most articles involved human resources development yet rarely appeared to be people-centred. The level of integration was associated with building relationships and enhancing service coordination. Integrating human resources was challenged by the need for ongoing support and worker retention. In primary care settings, workers were often already at full capacity, had competing priorities, varying capabilities and limited motivation. Additional barriers included inadequate referral and information systems, poor supply chain management and procurement practices and finite financing.

CONCLUSION

Integrating eye care into low resource health systems is a challenging task, compounded by resource limitations, competing priorities and ongoing support needs. This review highlighted a need for people-centred approaches to future interventions, and further investigation into integrating vision rehabilitation services.

Physicians' and nurses' perspective on chronic disease care practices in Primary Health Care in Brazil: a qualitative study

BACKGROUND

Primary health care-oriented systems provide better healthcare, especially for chronic diseases. This study analyzed the perspectives of physicians and nurses performing care for patients with chronic diseases in Primary Health Care in a Brazilian city.

METHODS

A qualitative study was conducted in Vitória da Conquista, Bahia, Brazil, using semi-structured interviews with five physicians and 18 nurses. The interview included questions from an analytical matrix based on three dimensions of healthcare practices: organizational, technical care, and biopsychosocial, following a deductive approach. The interviews were fully transcribed and analyzed using a thematic categorical approach.

RESULTS

The results indicated that the provision of chronic care occurs in a comprehensive way. Potentialities were identified in the diversification of access, offer of care actions and technologies, integration of teamwork, and bringing together social networks to foster autonomy and self-care. Weaknesses were mostly related to the high number of people in the teams, follow-up of several cases, high turnover of support teams, low integration of Primary Health Care with other levels, difficulties in intersectoral articulation and family participation in care.

CONCLUSION

The multidimensional assessment of health care practices aimed at individuals with chronic noncommunicable diseases was useful to portray the strengths and weaknesses of the services. It also ratifies the need to consider the importance of and investment in primary health care by offering the necessary technical, political, logistical and financial support to the units, to ensure the sustainability of the actions by nurses, doctors and entire team.

The organisation of primary health care service delivery for non-communicable diseases in Nigeria: A case-study analysis

As chronic diseases, non-communicable diseases (NCDs) require sustained person-centred and community-based care. Given its direct link to communities and households, Primary Health Care (PHC) is well positioned to achieve such care. In Nigeria, the national government has prioritized PHC system strengthening as a means of achieving national NCD targets. However, strengthening PHC systems for NCDs require re-organization of PHC service delivery, based on contextual understanding of existing facilitators and barriers to PHC service delivery for NCDs. We conducted a mixed method case study to explore NCD service delivery with 13 PHC facilities serving as the cases of interest. The study was conducted in two northern and two southern states in Nigeria-and included qualitative interviews with 25 participants, 13 focus group discussion among 107 participants and direct observation at the 13 PHCs. We found that interprofessional role conflict among healthcare workers, perverse incentives to sustain the functioning of PHC facilities in the face of government under-investment, and the perception of PHC as an inferior health system were major barriers to improved organisation of NCD management. Conversely, the presence of physicians at PHC facilities and involvement of civil society organizations in aiding community linkage were key enablers. These marked differences in performance and capacity between PHC facilities in northern compared to southern states, with those in the south better organised to deliver NCD services. PHC reforms that are tailored to the socio-political and economic variations across Nigeria are needed to improve capacity to address NCDs.

Identifying opportunities to engage communities with social mobilisation activities to tackle NCDs in El Salvador in the context of the global COVID-19 pandemic

BACKGROUND

Social mobilisation is potentially a key tool in the prevention of non-communicable diseases (NCDs) in fragile settings. This formative study addressed existing and potential social mobilisation mechanisms seeking behaviour to tackle NCDs in El Salvador, with an emphasis on the implications in the context of the current COVID-19 pandemic.

METHODS

We conducted 19 semi-structured interviews with health workers, government officials, NGO leaders, and community members. Interviews addressed mechanisms for social mobilisation which existed prior to COVID-19, the ways in which these mechanisms tackled NCDs, the impact of COVID-19 on social mobilisation activities and new, emerging mechanisms for social mobilisation in the wake of the COVID-19 pandemic.

RESULTS

Findings indicate a growing awareness of NCDs within communities, with social mobilisation activities seen as valuable in tackling NCDs. However, major barriers to NCD prevention and treatment provision remain, with COVID-19 constraining many possible social mobilisation activities, leaving NCD patients with less support. Factors linked with effective social mobilisation of communities for NCD prevention included strong engagement of community health teams within community structures and the delivery of NCD prevention and management messages through community meetings with trusted health professionals or community members. There are gender differences in the experience of NCDs and women were generally more engaged with social mobilisation activities than men. In the context of COVID-19, traditional forms of social mobilisation were challenged, and new, virtual forms emerged. However, these new forms of engagement did not benefit all, especially those in hard-to-reach rural areas. In these contexts, specific traditional forms of mobilisation such as through radio (where possible) and trusted community leaders - became increasingly important.

CONCLUSIONS

New mechanisms of fostering social mobilisation include virtual connectors such as mobile phones, which enable mobilisation through platforms such as WhatsApp, Facebook and Twitter. However, traditional forms of social mobilisation hold value for those without access to such technology. Therefore, a combination of new and traditional mechanisms for social mobilisation hold potential for the future development of social mobilisation strategies in El Salvador and, as appropriate, in other fragile health contexts.