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Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal
  1. Anirudh Kumar1,2,
  2. Dan Schwarz1,3,4,5,6,
  3. Bibhav Acharya1,7,
  4. Pawan Agrawal1,
  5. Anu Aryal1,
  6. Nandini Choudhury1,
  7. David Citrin1,2,8,9,10,
  8. Binod Dangal1,
  9. Grace Deukmedjian1,11,12,
  10. Meghnath Dhimal13,
  11. Santosh Dhungana1,
  12. Bikash Gauchan1,11,
  13. Tula Gupta1,
  14. Scott Halliday1,10,
  15. Dhiraj Jha1,14,
  16. SP Kalaunee1,15,
  17. Biraj Karmacharya16,17,18,
  18. Sandeep Kishore2,19,
  19. Bhagawan Koirala20,
  20. Lal Kunwar21,
  21. Ramesh Mahar1,
  22. Sheela Maru1,2,22,23,
  23. Stephen Mehanni1,11,24,
  24. Isha Nirola25,
  25. Sachit Pandey1,
  26. Bhaskar Pant26,
  27. Mandeep Pathak1,
  28. Sanjaya Poudel1,
  29. Irina Rajbhandari1,
  30. Anant Raut1,
  31. Pragya Rimal1,11,
  32. Ryan Schwarz1,3,4,27,
  33. Archana Shrestha28,29,
  34. Aradhana Thapa1,
  35. Poshan Thapa30,
  36. Roshan Thapa1,
  37. Lena Wong1,11,31,
  38. Duncan Maru1,2,23,32,33
  1. 1Nyaya Health Nepal, Kathmandu, Nepal
  2. 2Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
  3. 3Division of Global Health Equity, Brigham and Women's Hospital Department of Medicine, Boston, MA, USA
  4. 4Department of Medicine, Harvard Medical School, Boston, MA, United States
  5. 5Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
  6. 6Ariadne Labs, Harvard T H Chan Schoo of Public Health and Brigham and Women's Hospital, Boston, MA, United States
  7. 7Department of Psychiatry, University of California, San Francisco School of Medicine, San Francisco, CA, USA
  8. 8Department of Global Health, University of Washington, Seattle, WA, USA
  9. 9Department of Anthropology, University of Washington, Seattle, WA, United States
  10. 10Henry M Jackson School of International Studies, University of Washington, Seattle, WA, United States
  11. 11Health Equity Action Leadership Initiative, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
  12. 12Department of Pediatrics, Natividad Medical Center, Salinas, CA, United States
  13. 13Nepal Health Research Council, Kathmandu, Nepal
  14. 14Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal
  15. 15College of Business and Leadership, Eastern University, St Davids, PA, USA
  16. 16Department of Community Programs, Dhulikhel Hospital-Kathmandu University Hospital, Dhulikhel, Nepal
  17. 17Nepal Technology Innovation Center, Kathmandu University, Dhulikhel, Nepal
  18. 18Sun Yat-sen Global Health Insititute, Sun Yat-sen University, Guangzhou, China
  19. 19Young Professionals Chronic Disease Network, New York, NY, United States
  20. 20Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal
  21. 21Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
  22. 22Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
  23. 23Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
  24. 24Gallup Indian Medical Center, Gallup, NM, United States
  25. 25Harvard University T H Chan School of Public Health, Boston, MA, USA
  26. 26Department of Orthopedic and Trauma, Hospital for Advanced Medicine and Surgery, Kathmandu, Nepal
  27. 27Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
  28. 28Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, MA, USA
  29. 29Division of Research and Development, Dhulikhel Hospital, Dhulikhel, Nepal
  30. 30School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
  31. 31Tuba City Regional Health Care, Tuba City, AZ, United States
  32. 32Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
  33. 33Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
  1. Correspondence to Dr Dan Schwarz; daschwarz{at}gmail.com

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.

  • non-communicable diseases
  • global health
  • nepal
  • delivery of health care, integrated
  • implementation research

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Footnotes

  • AK and DS are joint first authors.

  • Handling editor Valery Ridde

  • Contributors Conceived and developed study design: DS, BA, PA, DC, BD, GD, SD, BG, TG, SH, DJ, SPKa, LK, SMa, SMe, IN, SPa, BP, MP, PR, RS, AT, PT, RT, LW. Intervention implementation and iteration: DS, SD, TG, BG, DJ, LK, MP, PR, AT, PT, RT. Performed the relevant data quality and extraction processes: RM, SPa, AR. Analysed the data: AK, DS, NC. Contributed to writing the manuscript: AK, DS, NC, BA, AA, DC, GD, MD, SH, SKa, BKa, SKi, SMa, SMe, RS, AS, PT, DM. Reviewed and approved the final manuscript: AK, DS, BA, PA, AA, NC, DC, BD, GD, MD, SD, BG, TG, SH, DJ, SKa, BKa, SKi, BKo, LK, RM, SMa, SMe, IN, SPa, BP, MP, SPo, IR, AR, PR, RS, AS, AT, PT, RT, LW, DM. ICMJE criteria for authorship met: AK, DS, BA, PA, AA, NC, DC, BD, GD, MD, SD, BG, TG, SH, DJ, SKa, BKa, SKi, BKo, LK, RM, SMa, SMe, IN, SPa, BP, MP, SPo, IR, AR, PR, RS, AS, AT, PT, RT, LW, DM.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • 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.

  • Patient consent for publication Not required.

  • Ethics approval Approval was obtained from the Nepal Health Research Council (177/2018). All data were routinely collected, de-identified electronic health record data.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data generated and analysed during this study are available from the corresponding author on request and will be deposited in a public data repository.

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