Aligning policymaking in decentralized health systems: Evaluation of strategies to prevent and control non-communicable diseases in Nigeria

Resilience of Primary Health Care in Ukraine: Challenges of the Pandemic and War

This commentary examines the resilience of primary health care in Ukraine amidst the ongoing war, drawing a few reflections relevant for other fragile and conflict-affected situations. Using personal observations and various published and unpublished reports, this article outlines five reflections on the strengths, challenges, and necessary adaptations of Primary Health Care (PHC) in Ukraine. It underscores the concerted efforts of the government to maintain public financing of PHC, thereby averting system collapse. The research also highlights the role of strategic adaptations during the COVID-19 pandemic in fostering resilience during the war, including the widespread use of digital communication and skills training. The commentary emphasizes the role of managerial and financial autonomy in facilitating quick and efficient organizational response to crisis. It also recognizes emerging challenges, including better access to PHC services among the internally displaced persons, shifting patient profiles and service needs, and challenges related to reliance on local government financing. Finally, the authors advocate for a coordinated approach in humanitarian response, recovery efforts, and development programs to ensure the sustainability and effectiveness of PHC in Ukraine.

Economic burden of non-communicable diseases on households in Nigeria: evidence from the Nigeria living standard survey 2018-19

BACKGROUND

The importance of non-communicable diseases (NCDs) in Nigeria is reflected in their growing burden that is fast overtaking that of infectious diseases. As most NCD care is paid for through out-of-pocket (OOP) expenses, and NCDs tend to cause substantial income losses through chronic disabilities, the rising NCD-related health burden may also be economically detrimental. Given the lack of updated national-level evidence on the economic burden of NCDs in Nigeria, this study aims to produce new evidence on the extent of financial hardship experienced by households with NCDs in Nigeria due to OOP expenditure and productivity loss.

METHODS

This study analysed cross-sectional data from the most recent round (2018-19) of the Nigeria Living Standard Survey (NLSS). Household-level health and consumption data were used to estimate catastrophic health expenditure (CHE) and impoverishing effects due to OOP health spending, using a more equitable method recently developed by the World Health Organization European region in 2018. The productivity loss by individuals with NCDs was also estimated from income and work-time loss data, applying the input-based human capital approach.

RESULTS

On average, a household with NCDs spent ₦ 122,313.60 or $ 398.52 per year on NCD care, representing 24% of household food expenditure. The study found that OOP on cancer treatment, mental problems, and renal diseases significantly contribute to the cost of NCD care. The OOP expenditure led to catastrophic and impoverishing outcomes for households. The estimations showed that about 30% of households with NCDs experienced CHE in 2018, using the WHO Europe method at the 40% threshold. The study also found that the cost of NCD medications was a significant driver of CHE among NCD-affected households. The results showed heterogeneity in CHE and impoverishment across states and geographical regions in Nigeria, with a higher concentration in rural and North East geopolitical locations. The study also found that 20% of NCD-affected households were impoverished or further impoverished by OOP payment, and another 10% were on the verge of impoverishment. The results showed a negligible rate of unmet needs among households with NCDs.

CONCLUSIONS

The study highlights the significant effect of NCDs on Nigerian households and the need for effective policy interventions to address this challenge, particularly among the poor and vulnerable.

Assessment of hypertension service availability in some primary health centres in Nigeria: a mixed-methods study

OBJECTIVE

Strengthening primary health centre (PHC) systems is a potentially effective strategy to reduce the burden of non-communicable diseases in Nigeria, a low/middle-income country with limited resources. The aim of this study was to assess hypertension service availability in some PHCs in Nigeria and seek recommendations that could facilitate improved services from PHC workers.

DESIGN

Explanatory sequential mixed-methods study.

SETTINGS

PHCs in the six geopolitical zones and Federal Capital City of Nigeria.

PARTICIPANTS

Eighteen PHC workers and 305 PHC facilities.

METHOD

Hypertension service availability and readiness were assessed in PHCs across Nigeria using a pro forma adapted from the WHO Service Readiness and Assessment tool. Eighteen workers in the PHCs were subsequently interviewed for in-depth exploration of hypertension service availability and readiness.

FINDINGS

Among the 305 health facilities assessed, 96 (31.5%) were in urban, 94 (30.8%) in semiurban and 115 (37.7%) in rural local government areas. Majority of the health facilities (43.0%) were manned by community extension workers. Only 1.6% and 19.7% of the health facilities had physicians and pharmacy technicians, respectively. About 22.3% of the providers had training in hypertension in the last 1 year. All the PHCs lacked adequate supply of essential antihypertensive medications. The identified deficiencies were less common in the urban PHCs compared with others. Qualitative analysis showed that the personnel, essential facilities and medicines required to provide hypertension services in the PHCs were inadequate. Suggested recommendations to successfully provide these services were provision of performance-based incentives; adequate staffing and training; supportive supervision of staff; provision of adequate equipment and essential medicines for hypertension management; provision of conducive environment for clients; and community engagement and participation.

CONCLUSION

Majority of the PHCs are currently not adequately equipped to provide hypertension services. Addressing identified gaps and using suggestions provided will guarantee successful provision of effective services.

Decision makers perceptions and experiences of developing population-level interventions targeting risk factors for hypertension and diabetes in South Africa: a qualitative study

BACKGROUND

People in low- and middle-income countries are disproportionately affected by Noncommunicable diseases (NCDs). NCD's such as heart disease, cancer, chronic respiratory disease, and diabetes, are the leading cause of premature death worldwide and represent an emerging global health threat. The purpose of this qualitative study was to explore decision makers perceptions of developing population-level interventions (policies and programmes), targeting risk factors for hypertension and diabetes, in South Africa.

METHODS

Using purposive sampling we recruited fifteen participants, who were well informed about the policies, programs or supportive environment for prevention and management of diabetes and hypertension in South Africa. We conducted 12 individual interviews and 1 group interview (consisting of 3 participants). Data was analysed thematically in NVivo. The results were shared and discussed in two consultative stakeholder workshops, with participants, as part of a member validation process in qualitative research. All communication with participants was done virtually using MS Teams or ZOOM.

RESULTS

For development of population-level interventions, key enablers included, stakeholders' engagement and collaboration, contextualization of policies and programs, and evaluation and organic growth. Challenges for supportive policy and program formulation, and to enable supportive environments, included the lack of time and resources, lack of consultation with stakeholders, regulations and competing priorities, and ineffective monitoring and evaluation. The main drivers of population-level interventions for diabetes and hypertension were perceived as the current contextual realities, costs, organizational reasons, and communication between various stakeholders.

CONCLUSION

To address the risk factors for hypertension and diabetes in South Africa, policies and programs must account for the needs of the public and the historical and socio-economic climate. Feasibility and sustainability of programs can only be ensured when the resources are provided, and environments enabled to promote behavior change on a population-level. A holistic public health approach, which is contextually relevant, and evidence informed, is considered best practice in the formulation of population-level interventions.

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.