|Year : 2019 | Volume
| Issue : 3 | Page : 73-79
Readiness of primary health centers and community health centers for providing noncommunicable diseases-related services in Bengaluru, South India
Karthika Parameswaran1, Twinkle Agrawal2
1 Department of Public Health, Rajiv Gandhi Institute of Public Health and Centre for Disease Control, Bengaluru, Karnataka, India
2 Department of Community Health, St. Johns Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||27-Sep-2019|
Dr. Twinkle Agrawal
Department of Community Health, St. Johns Medical College, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Context: India is experiencing a rapid health transition with a rising burden of noncommunicable diseases (NCDs). Primary health centers (PHCs) and community health centers (CHCs) are the key health-care delivery institutions providing majority of health-care services to the Indian population.
Aim: We assessed the service readiness of PHCs and CHCs to bear the responsibility of providing NCD-related services.
Settings and Design: This design was a facility-based quantitative cross-sectional study.
and Methods: The study was conducted on randomly selected 36 PHCs and six CHCs from five taluks of Bengaluru Urban District. Data were collected using an interviewer-administered questionnaire and observation of key items. Descriptive statistics were calculated using SPSS software (SPSS Inc., IBM corp., Chicago, Illinois, United States). Ethical approval was obtained before the data collection.
Results: Medical professionals were available only in 47.2% PHCs and 16.6% CHCs. About 94.4% PHCs and all CHCs were reported to have medical equipment. The percentage availability of necessary laboratory services was reported by 44.4% PHCs and 58.3% CHCs. Essential medicines were available only in 55.5% PHCs and 50% CHCs. Guideline materials and training for NCD prevention were given by 8.3% PHCs and 26.6% CHCs.
Conclusion: This study found that readiness of PHCs and CHCs for providing NCD-related services was suboptimal. Therefore, primary health-care system strengthening in the form of human resources, functional laboratories, and equipment and supply of medicines is essential at PHCs and CHCs.
Keywords: Community health centers, noncommunicable diseases, primary health centers, readiness of facilities
|How to cite this article:|
Parameswaran K, Agrawal T. Readiness of primary health centers and community health centers for providing noncommunicable diseases-related services in Bengaluru, South India. Int J Non-Commun Dis 2019;4:73-9
|How to cite this URL:|
Parameswaran K, Agrawal T. Readiness of primary health centers and community health centers for providing noncommunicable diseases-related services in Bengaluru, South India. Int J Non-Commun Dis [serial online] 2019 [cited 2019 Oct 16];4:73-9. Available from: http://www.ijncd.org/text.asp?2019/4/3/73/268141
| Introduction|| |
Noncommunicable diseases (NCDs) are the leading causes of death globally, killing more people each year than all other causes combined. The World Health Organization (WHO) had released a report on NCDs Global Survey in 2015, according to which, one in four Indians face the risk of death from NCDs before they hit the age of 70, mainly from heart and lung diseases, stroke and diabetes.
Genetic predisposition and age, some behavioral risk factors such as unhealthy diet, tobacco use, physical inactivity, and excessive use of alcohol over a prolonged period are identified as the major causative factors for NCDs. They gradually mature to metabolic risk factors such as hypertension, impaired glucose tolerance, dyslipidemia, and ultimately develop into full blown NCDs.,
The Government of India has responded to the increasing burden of NCDs through the launch of a National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) in 2008 under the National Health Mission. During 2010–2012, the program was implemented in 100 districts across 21 states. As on March 2016, the program is under implementation in all 36 states/union territories.
Public health delivery system in rural India consists of primary health centers (PHCs; population coverage 20000–30000 lakh) as a level 1 facility and a community health center (CHC; population coverage 80,000–1.2 lakh) as level 2 facility. Together, these facilities are designed to meet most primary care needs through medical doctors, paramedical staff, basic investigations, and essential drugs.
It is well known that the tertiary and secondary level hospitals are providing curative care and contributing to secondary and tertiary preventions. In India, there is an increasing demand for secondary and tertiary prevention that leads to increase the out of pocket expenditure for diseases management. It is important to give emphasis on coordinated NCDs service delivery based on primary health-care services. PHCs have become centers only for maternal and child health (MCH) care and infectious diseases response, even though PHCs are the important point of delivery of comprehensive primary care services. Health-care staffs at PHCs themselves view their role in line with MCH care and infectious diseases responses. Primary care facilities play an important role in the prevention of diseases through public awareness, health education, early detection, treatment, and early referral. Primary care counselling of people at risk, notably because of unhealthy lifestyles, can be one of the most effective ways of changing behavior and curbing obesity and NCDs, especially if advice is delivered collectively by different groups of health professionals.
To handle the increased service demand and utilization of the population, readiness of health facilities and orientation toward prevention and management of NCDs has an important role. Readiness is defined as the availability of components required to provide services such as infrastructure/amenities, basic supplies/equipment including small surgery, standard precautions, laboratory tests, medicines and commodities, and health professionals.
Over the years, the focus of primary care in India has been communicable diseases and reproductive and child health services. As a consequence, it is likely that some key facility-based elements required for NCD care may be lacking. NPCDCS program is being implemented in a phased manner in Karnataka. By 2015–2016, the program covered 15 districts in the state. The current study was performed to assess the readiness of PHCs and CHCs for delivering NCDs-related services in the state of Karnataka.
| Subjects and Methods|| |
The study was conducted in Bengaluru Urban District of the Indian State of Karnataka with 91% of its population living in urban areas. According to the 71st National Sample Survey Organization 2014, Karnataka is the only state other than Andhra Pradesh, which has seen a decline in the utilization of public health services in the past decade from 34% to 26%. Bengaluru Urban District has the distinction of being Karnataka States Capital. According to the 2011 census, Bengaluru Urban District has a population of 9,588,910. The district has a sex ratio of 916 females for every 1000 males and literacy rate of 87.67%. Bengaluru Urban District comprises five Taluks, namely Bengaluru North, Bengaluru North (Additional-Brihat Bengaluru Mahanagara Palike (BBMP)), Bengaluru South, Bengaluru East, and Anekal. The district has 86 gram panchayats and 613 villages.
A cross-sectional study design was employed for this study.
Sample size estimation
Sampling was done in a systematic way to ensure that the findings are representative of the district. The study unit was a primary and CHC in Bengaluru Urban District. Sample size of PHCs was estimated using Cochrane formula for calculating a sample for proportions. Based on a study conducted in Bengaluru Urban District, Karnataka, to assess the compliance of PHCs according to the Indian Public Health Standards (IPHS), the proportion of availability of drugs and supplies was 71%. Using this as an estimated proportion of an attribute that was present in our study, we estimated the minimum sample size with a fixed precision of 15%. The minimum required number of PHCs was 35; however, a total of 36 PHCs were included in this study.
A simple random sampling technique was utilized to select PHCs and CHCs. A total of 36 PHCs was selected randomly from five taluks proportional to the total number of PHCs in the corresponding taluks. A sample of six CHCs was then selected based on respective PHCs from each taluk.
Starting point of the assessment was to get the list of all PHCs and CHCs in Bengaluru Urban District. Permission to conduct the study and the list of facilities were obtained from Directorate, Health and Family Welfare Bengaluru, and Chief Health Office (BBMP), Bengaluru. The quantitative questionnaire was prepared based on the World Health Organization's (WHO) Service Availability and Readiness Assessment (SARA) guidelines adopted with modifications from the national health facility standard manuals IPHS to reflect the needs and specificity of our Indian health-care system. The WHO has proposed a measurement tool for SARA to address critical gaps in service availability and readiness. There are three main focus area of SARA, namely service availability, general service readiness, and service-specific readiness. Service-specific readiness questionnaire for NCDs, which refer to the ability of health facilities to offer a specific service, and the capacity to provide that service measured through consideration of tracer items that include trained staff, guidelines, equipment, diagnostic capacity, and medicines and commodities. We took most items from the SARA and relevant items from the IPHS in the current study.
The quantitative data collection was done by a visit to individual facilities from September 1, 2017 to September 31, 2017. Data were collected from doctors, staff nurses, health workers, laboratory technicians, and pharmacists. The questionnaire had five sections, expected answer was to be either yes or no or do not know (coded as 1, 0, and 99, respectively). The first section contained questions to assess the availability of health professionals. The second section contained questions to assess the availability of guidelines for the management of NCDs. The third section contained questions to assess availability of equipment/supplies; the fourth section assessed the laboratory capacity; and the fifth section assessed the availability of essential medicines. We included drugs needed for the management of diabetes (metformin capsule/tablet, glibenclamide capsule/tablet, and insulin regular injection), cardiovascular diseases (CVDs) (angiotensin-converting enzyme inhibitors [ACEI] [e.g., enalapril, lisinopril, ramipril, and perindopril], beta-blockers [e.g., bisoprolol, metoprolol, carvedilol, and atenolol], calcium channel blockers [e.g., amlodipine], and aspirin capsule/tablets), and chronic respiratory tract diseases (salbutamol capsule/inhaler and beclometasone inhaler).
A schedule of visits to health facilities was then prepared. The number of days required for data collection was estimated on the basis of number of facilities to be visited in each geographical area and distance between them and the mode of transport available.
We performed descriptive analysis for the collected data and analyzed frequencies separately for PHCs and CHCs. We averaged proportions of items under each domain to indicate the coverage in a particular domain. To indicate overall drug availability, we averaged the proportions of all drugs included in the survey. Statistical analysis was performed in the Microsoft Excel version 2010.
Before field work was started ethical clearance was obtained from the University Ethical Review Board, Rajiv Gandhi University of Health Sciences. Before starting data collection, approval letter was taken from the Government authorities such as Director, Health and Family Welfare-Karnataka, District Health Officer-Bengaluru Urban District, and Chief Health Officer, BBMP. At each facility, the purpose of the study was explained, and oral consent was obtained before administering the questionnaire.
| Results|| |
Overall availability of facilities was low in all the domains surveyed. In the human resources domain, among 36 PHCs surveyed, 34 (94.4%) had the availability of medical officer, 31 (86.1%) had staff nurses, 33 (91.6%) had laboratory technician, 35 (97.2%) had pharmacist, 16 (44.4%) had community health worker, 23 (63.8%) had female health assistant, and 17 (47.2%) had health assistant male. All CHCs had medical officer, laboratory technician, and pharmacist, but 3 (50%) CHCs where NPCDCS had been piloted lacked staff nurses at the NCD clinic. Data entry operator was present in 7 (19.4%) PHCs and 3 (50%) CHCs [Table 1]. Nutritionist post was vacant in all the CHCs. Only one CHC had physiotherapist or community-based rehabilitation worker. Health educator was absent in all the facilities surveyed.
|Table 1: Percentage of availability of key items in primary health centers and community health centers|
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In equipment domains such as stethoscope, sphygmomanometer, weighing machine, and glucometer were available at all PHCs and CHCs. Two (5.5%) PHCs lacked measuring tape or stadiometer. Electrocardiography machine was available in only one CHCs. Cusco's speculum for the diagnosis of cervical cancer was absent in all the PHCs, but this was available in 3 (50%) CHCs. Twenty-three (63.8%) PHCs and 3 (50%) CHCs had the availability of oxygen concentrators. Peak flow meter and spirometer were absent in all the facilities [Table 1].
Under diagnosis domain, all the facilities surveyed had availability of uristix for urine albumin and sugar analysis. Blood glucose estimation test was available in all the CHCs and 29 (80.5%) PHCs. Serum creatinine and serum lipid profile test were available in one CHC and 3 (8.3%) PHCs [Table 1].
Under guidelines and training domain, none of the PHCs had any written guidelines for the management of NCDs, but one CHC was found to have a guideline on the management of diabetes. Medical officers from three PHCs and one CHC had received training on prevention and management of NCDs in the past 2 years.
Drugs used for the management of diabetes including metformin capsule/tablet and glibenclamide capsule/tablet were largely available in all the facilities. Insulin regular injection was available in 3 (50%) CHCs and 4 (11.1%) PHCs. Beta-blockers and calcium channel blocker (amlodipine) were available in 16 (44.4%) PHCs and one CHC and 35 (97.2%) PHCs and all the CHCs. ACEI was available in 13 (36.1%) PHCs and 4 (66.6%) CHCs. Twenty-nine (80.5%) PHCs and 3 (50%) CHCs had the availability of salbutamol either as tablet or syrup, and 20 (55.5%) PHCs and one CHC had the availability of beclometasone inhaler [Table 1].
| Discussion|| |
In this study, we attempted to assess the readiness of NCDs-related services in primary and CHCs. Despite extensive review of literature, we found only few studies are available worldwide, and no studies in India regarding the assessment of health facilities readiness based on SARA guidelines regarding NCDs.
A similar study was conducted by Katende et al. in Ugandan health services to assess the readiness to growing burden of chronic, NCDs. Results showed that many health facilities lacked guidelines, diagnostic equipment, and essential medicines for primary management of chronic diseases. The study revealed the importance of strengthening existing health systems through the provision of standard guidelines, essential diagnostic equipment and drugs, training health workers, and improved referral systems.
Another study on the assessment of primary care facilities for CVDs preparedness in Madhya Pradesh, India, showed that the availability of facilities was least in laboratory services, human resources domain followed by drugs and better in equipment. Our study found that availability of facilities for NCDs readiness for PHCs was least in guidelines and training, laboratory and human resources domains followed by medicines and better in equipment. In CHCs, availability of facilities was least in guidelines and training domain, human resources, and medicines followed by diagnosis and better in equipment. Even though this study did not include the private sector facilities, these gaps in the service delivery component of health systems at primary care level may leads into the private sector dependence of patients with NCDs.
To achieve the universal health coverage, there is a need to strengthen primary care delivery in India. This study identified deficiencies in human resources, laboratory capacity, and availability of essential medicines as the main challenges for providing NCD-related services [Figure 1].
|Figure 1: Radar diagram depicting average availability of facilities for all indicators in five domains (human resource, equipment, laboratory service, guidelines and training, and drugs). CHC - Community health center, PHC - Primary health center|
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Human resources need to be strengthened the most. The availability of health professionals at PHCs and CHCs are lacking in line with national IPHS standards. A medical doctor is considered necessary for the first diagnosis and subsequent follow-up for the management of NCDs. As the management of NCDs require behavioral change of the people, various task components need to be shifted to nonphysician health workers, for example, community health workers, health educator, nutritionists, and physiotherapists. According to the IPHS, CHCs should have a dietician. Our study shows that this post is vacant in all the CHCs. In PHCs, it will not be feasible to employ nutritionists or physiotherapists, so this can be achieved by strengthening the training of existing community health workers and by promoting the health educator post from desirable to required category. Even though posts are allotted, only 16 PHCs had the availability of community health workers. Furthermore, the shortage of health assistants and data entry operator can affect the routine data collection and reporting of data regarding NCDs.
Preventing and managing NCDs require systematic and integrated approaches. The WHO has been advocating the development of evidence-informed guidelines for the major NCDs to strengthen health-care systems to address NCDs. The National guidelines (NPCDCS) are available for the management of NCDs, but none of the facilities had written NPCDCS guidelines available and medical officers or staff who had been trained in the prevention and management of NCDs are very insignificant.
Interventions such as blood pressure measurement and blood glucose measurement are widely available in both the facilities. Similarly, there should be a good coverage of serum creatinine and lipid profile measurement for managing CVD. Although many of the basic technologies necessary for managing risk factors and preventing and diagnosing NCDs are available in primary healthcare, efforts to expand the coverage for CVD, and cancer screening are still needed. Blood sugar checking-both fasting and postprandial glucose leve were available in all the facilities, only one facility (CHC) had the capacity to conduct serum creatinine and serum lipid profile. One facility had an X-ray machine, but it was not functional.
Drug therapies in NCDs are complex because of the availability of multiple drugs. We included ACEI, beta-blockers (antihypertensive), amlodipine tablet or suspension, beclometasone inhaler (respiratory), metformin tablet, glibenclamide tablet, insulin regular injection (antidiabetic), and aspirin capsule/tablet. Availability of medicines for the management of diabetes was good in all the facilities. For hypertension, calcium channel blocker was widely available in all the facilities, but availability of beta-blockers was low. This indicates a lack of standard protocol and guidelines for the management of NCDs. Lack of availability of medicines at government facilities poses a huge challenge in NCD management which, in turn, increases out of pocket expenditure.
This study recommends that the improvement of PHCs should be emphasized on and importance given to future NPCDCS activities. Existing CHCs also need to be strengthened in terms of staff, equipment, diagnostic capacity, and medicines. Community mobilization, follow-ups and screening for risk factors are important tasks for health-care staffs for the management of NCDs. Strengthening existing health-care staffs by proper training and employing staffs for the vacant posts is an important requirement.
In the current study, we were able to perform facility assessment with minimal resources and in a short period of time. This study has got some limitations. First, the study took place in an urban setting Bengaluru, one of the well-performing districts of Karnataka, and hence may not reflect the true situation in other less served areas in the state as well as compared to other states. The second limitation is that this study does not address the other dimensions of service delivery, which includes accessibility and affordability of services. Hence, this study does not generate data on quality of services. Final limitation is that due to the nonavailability of national standards to measure facility readiness in India, we modified SARA guidelines based on national health standards. The main strength of this study is that we were able to do random sampling for the selection of PHCs and CHCs, so there was not any selection bias. Since the investigator did the site visit herself, she was able to obtain in depth genuine data and interview people from all cadres at the facilities.
| Conclusion|| |
This study concludes that readiness of PHCs and CHCs for the providing NCDs-related services is suboptimal. The major reasons were nonavailability of skilled and trained staffs, laboratory services, and lack of essential medicines. Therefore, health system strengthening in the form of human resources, functional laboratories and equipment, and supply of medicines are essential at PHCs and CHCs. As NCDs are becoming the leading causes for mortality and morbidity in India, focused attention is needed from decision makers and policy planners. NPCDCS program has been launched, and this program itself has very broad dimensions, that is, infrastructure and staffs required for the management of cancer is entirely different from one required for diabetes and CVDs. Like disease-specific programs implemented for the prevention and management of communicable diseases, the time has come for us to understand the need for disease-specific program for NCDs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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