HealthRise Needs Assessment Overview India: Shimla and Udaipur Prepared by: Marie Ng, PhD Marissa Reitsma, BS Rose Gabert, MPH Bryan Phillips, BA Blake Thomson, BA Emmanuela Gakidou, PhD Institute for Health Metrics and Evaluation University of Washington March 23, 2015 1
Introduction The HealthRise project, funded by Medtronic Philanthropy, aims to improve access to quality care for non-communicable diseases (NCDs) in select geographies across the globe: India, Brazil, the United States, and South Africa. The project will work with key stakeholders in the public and private sector to implement innovative, locally-integrated interventions designed to strengthen the continuum of care for non-communicable diseases. With rigorous, independent evaluation of interventions in diverse populations, HealthRise will contribute to global knowledge of what works and what doesn t in addressing the growing NCD epidemic at the community-level. HealthRise will focus on two NCDs that are highly prevalent in the chosen countries, and account for the greatest fraction of disease burden across the globe: cardiovascular disease, and diabetes. After consultations with the government and local stakeholders the districts of Shimla in Himachal Pradesh and Udaipur in Rajasthan were chosen as intervention sites in India. The first step in launching this project in all sites is comprehensive assessment of demand and supplyside factors that support or constrain effective prevention, diagnosis, and treatment of NCDs at the community-level. This report presents the findings of a needs assessment that was carried out in Shimla and Udaipur between 2012 and 2015. The needs assessment was carried out in two phases; Phase I was implemented by MAMTA, while Phase II was implemented by IHME. This report synthesizes findings from both phases and includes results from all components of the needs assessment: districtrepresentative household surveys, health facility capacity surveys, and qualitative data collected from key informant interviews with health officials, providers, NCD-patients, and community members. Prevalence of NCDs In both Shimla and Udaipur, there is considerable burden attributable to NCDs. Specifically, prevalence of hypertension, estimated through direct blood pressure measurement, was 29.2% in Shimla and 25.6% in Udaipur, while measured diabetes prevalence was 3.3% in Shimla and 3.7% in Udaipur. As expected, prevalence of hypertension increases steadily over age for both males and females. Prevalence is below 20% until about age 40 and goes up to 50% or higher among individuals over age 60. Prevalence of hypertension is similar between males and females. For diabetes, prevalence is below 3% until the age of 40, and increases to 8% or higher in those over age 55. Prevalence of risk factors for NCDs Prevention of NCDs is based primarily on reducing the prevalence of major risk factors, like smoking and obesity, and by improving knowledge of the causes of these diseases. We examined the prevalence of three major risk factors associated with NCDs: tobacco use, alcohol use and obesity. While men were prone to risks associated with tobacco and alcohol use, women were prone to risks associated with overweight and obesity. Over 40% of the male respondents in Udaipur and over 30% in Shimla reported ever using tobacco, while only approximately 6% of women in Udaipur and 2% of women in Shimla had. Furthermore, over 30% of male respondents reported having ever drunk alcohol in Shimla and over 20% in Udaipur, while fewer than 2% of women had ever drunk alcohol in either district. In Shimla, nearly 15% of female respondents were obese compared to nearly 5% of male respondents. In Udaipur, 12% of female respondents were obese compared to 5% of male respondents. These risks were highly associated with adverse health outcomes. As an example, the figures below show that the prevalence of 2
diabetes and hypertension is much higher among obese individuals (compared to non-obese individuals) in both Shimla and Udaipur. Figure 1: Hypertension Prevalence Among Obese and non-obese Individuals by District Hypertension Prevalence by Obesity Status Diabetes Prevalence by Obesity Status 50% 10% 40% 8% 30% 6% 20% 4% 10% 2% 0% Shimla Udaipur 0% Shimla Udaipur Obese (BMI>=30) Non-Obese (BMI<30) Obese (BMI>=30) Non-Obese (BMI<30) Despite the relatively high prevalence of these risk factors, most people in the household survey did not realize these were risk factors for hypertension and diabetes. This may partially be due to the fact that no public facilities in Udaipur, and only some Community Health Centers (CHCs) in Shimla, reported providing any NCD preventive services. In Udaipur, only private hospitals and private clinics reported offering preventive services, and for a very limited amount of time each week. In Shimla, only Primary Health Centers (PHCs) offered preventive services, and again, only a limited amount of time per week was spent on this. Furthermore, in focus groups, doctors and health officials noted that providers at government hospitals do not have sufficient time to educate and counsel patients. These factors limit the likelihood of patients recognizing risk factors for hypertension and diabetes, and therefore exposes them to continued risk behaviors and becoming more susceptible to NCDs. Diagnosis of NCDs One alarming finding that emerged during this needs assessment is that a high proportion of individuals with NCDs have never been diagnosed in both Shimla and Udaipur. Among those with hypertension, approximately 60% had not been previously diagnosed. The situation was slightly better, but still very worrisome, for diabetes: 23% of individuals with elevated blood glucose levels had never been previously diagnosed with diabetes. Figures 2 and 3 demonstrate that in both Shimla and Udaipur a large proportion of individuals with hypertension and diabetes have never been diagnosed. Diagnosis of NCDs depends on a number of factors, including awareness of NCDs, knowledge of NCDrelated symptoms that lead to seeking care, and accessibility of the healthcare system. Overall, respondents in the household survey were not very familiar with NCDs. Although approximately 9 out of 10 respondents in each district reported being familiar with major NCDs, respondents were not very knowledgeable of the symptoms associated with these diseases. Individuals don t know to seek care for 3
NCDs if they don t recognize the symptoms, leading them to not get diagnosed. This was identified as a severe barrier to care for hypertension in each district. Focus group participants were not aware that early stages of hypertension and diabetes can be asymptomatic, and this may help explain the norm of seeking care only after symptoms develop. This suggests that many people are not aware that NCDs can be asymptomatic, and even when they are symptomatic, if people don t recognize the symptoms, they won t seek care. Lack of diagnosis may also be driven by the ability of health facilities to accurately diagnose these diseases. On the provision side, based on the results of the health facilities assessment, we found that significant gaps exist in the availability of equipment across all facility platforms. For example, 75% of all public hospitals, CHCs and PHCs sampled do not meet the guidelines for number of blood pressure cuffs. Additionally, none of the CHCs have an adequate number of stethoscopes. It is worth noting that certain essential equipment for diagnosing NCDs, such as glucometers (necessary for diagnosing high blood sugar levels indicative of diabetes), were only available at public hospitals or in the private sector. This indicates a service gap in the provision of diagnostic services for NCDs. Furthermore, comparing the two districts, equipment shortages were more severe in Shimla than Udaipur. These findings were echoed by patients and providers in the focus group discussions. Public health education was the most commonly cited intervention in focus group discussions. Specifically, most interviewees recommended increasing awareness of prevention methods and the importance of regular check-ups. A large majority of participants thought camps for screening and raising awareness would be beneficial, as long as these camps were held on weekends or at other times when people were not required to be at work. Treatment of NCDs The needs assessment demonstrated that among those diagnosed with either hypertension or diabetes, treatment rates are very high in both Shimla and Udaipur. In other words, once an individual receives a diagnosis of either diabetes or hypertension, they are very likely to be put on treatment and receive medication. The proportion of individuals who have been diagnosed with one of these conditions and are not on treatment is very low in both Shimla and Udaipur (less than 4% for either hypertension or diabetes). However, the challenge among those on treatment is the achievement of treatment targets; in other words, reducing their blood pressure and blood sugar levels back to normal. Effective treatment has two major components: giving patients the necessary medications, and monitoring the condition over time to adjust those medications as needed. The grey part of Figures 2 and 3 show the proportion of individuals who are receiving treatment but are not meeting treatment targets. For hypertension, this is 17.4% of hypertensive individuals in Shimla and 19.2% in Udaipur who are on treatment but remain hypertensive. For diabetes, 39.1% of diabetic individuals in Shimla and 22.1% in Udaipur are receiving medications but their blood sugar is not at the target level for treatment. These individuals represent missed opportunities for the health systems. These are individuals who are accessing services and interacting with the health system, but are not receiving the maximum health benefit out of these interactions. The needs assessment tried to explore the reasons behind this gap. There are several potential explanations for this. In interviews, many patients said that they were less likely to continue taking their 4
medications after initial symptoms were resolved. Treatment concerns at the facility level were also related both to personnel and pharmaceuticals. The Ministry of Health has requirements and recommendations about the number of different types of personnel that should be present, mandatory equipment, and essential medicines for each facility platform. The facility survey showed that a number of facilities at every platform were under-staffed in terms of both doctors and nurses. As with medical personnel, supply shortages were apparent across platforms. For instance, at the time of survey 50% or fewer public hospitals carried required medicines such as sulphonylureas, alpha agonists, antiplatelet drugs and thrombolytic therapies. Similarly, although insulin, statin and anticoagulants were required at the level of the CHC, none of the CHC facilities sampled had them available at the time of the survey. This implies that delivery of diabetes and CVD-related treatment services was likely restricted in this platform type in the public sector. Patients in focus group discussions described drugs being out of stock at public facilities, which they saw as a major barrier to care. Participants in the interviews identified three types of locations where they could obtain allopathic medicines, specifically at public facilities, private facilities, or local chemists shops. However, medicines are more expensive at private facilities, and healthcare providers recognized that one reason for discontinuing prescription of medicines for chronic diseases was the cost. 5
Figure 2: Hypertension Diagnosis and Treatment Status of Hypertensive Individuals by District. This graph refers to individuals who met diagnostic criteria and shows the distribution of these individuals across four groups: those who have not been diagnosed (in blue), those who have been diagnosed but are not taking medication to control their blood pressure (in red), those who are currently taking medication but are not achieving treatment targets (in grey) and those who are taking medication and achieving treatment targets (in orange). Hypertension Diagnosis and Treatment Status of Patients by District 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Shimla Udaipur Not diagnosed (Target 3) Diagnosed, not treated (Target 2) Under treatment, uncontrolled (Target 1) Under treatment, controlled (Target 1) Figure 3: Diabetes Diagnosis and Treatment Status among Diabetic Individuals in Shimla and Udaipur. This graph refers to individuals who met diagnostic criteria and shows the distribution of these individuals across four groups: those who have never been diagnosed (in blue), those who have been diagnosed but are not taking medication to control their blood sugar (in red), those who are currently taking medication but are not achieving treatment targets (in grey) and those who are taking medication and achieving treatment targets (in orange). Diabetes Diagnosis and Treatment Status of Patients by District 100% 80% 60% 40% 20% 0% Shimla Udaipur Not diagnosed (Target 3) Diagnosed, not treated (Target 2) Under treatment, uncontrolled (Target 1) Under treatment, controlled (Target 1) 6
Recommendations on which components of the continuum of care to target interventions 1. Increase the rate of diagnosis by promoting routine care-seeking behavior (check-ups) A major gap in the continuum of care is drawing patients into the healthcare system. Data from the household survey indicated that generally once patients enter into the healthcare system, a majority of them will continue to seek treatment. However, barriers exist at the early diagnosis seeking stage. Over 70% of the hypertensive individuals and 40% of the diabetic individuals in Shimla and Udaipur reported not having had a previous diagnosis. Based on results from the needs assessment, the following were identified as factors that may have hindered patients from seeking diagnosis: Lack of knowledge: Although respondents have heard of the conditions, a majority did not have a comprehensive understanding of the symptoms and risks related to the conditions. Moreover, rather than seeking routine check-ups, respondents generally sought care only after symptoms appeared. Given that conditions such as hypertension, hyperglycemia and hyperlipidemia do not usually present obvious symptoms at early stage, increasing awareness of the importance of regular check-ups is crucial. Lack of effective NCD-related outreach: One commonly adopted public health strategy to increase community awareness is outreach. However, our results indicated that the responsibility of outreach fell primarily on the sub-center (SC) level of the public facility system. However, SCs in general have the lowest level of financial and human resources. The number of hours and staffing, equipment and infrastructure were not necessarily adequate to handle additional demand for screening services. Further, as revealed in interviews with ASHAs, community health workers maternal and child health-related responsibilities alone were burdensome given their large catchment areas. Nevertheless, from the perspective of ASHAs as well as the general public, community outreach can be an effective way for providing and obtaining health information, particularly in situations where access to hospitals and clinical facilities is restricted in some way. Empowering additional ASHAs and strengthening existing outreach systems may be a potential strategy for an intervention. Physical and financial barriers: As indicated in the focus group discussions, quality, distance and both direct and indirect costs of care were the main deterrents preventing people from seeking diagnosis and follow-up care. Health facility assessments indicated considerable gaps in NCD service provision. For instance, the lack of equipment and essential medicines in CHC, PHC and SC suggested that patients would be required to travel to public hospitals or attend private facilities in order to obtain diagnosis or treatment. Creative solutions are needed to ensure diagnostic and treatment services are reaching people at risk and are offered at reasonable costs. 2. Increase the proportion of individuals meeting treatment targets by improving treatment provision and disease management In general, once individuals were diagnosed with a NCD they were willing and likely to continue seeking treatment. However, large proportions of individuals on treatment were not meeting treatment targets. Interventions focused on improving treatment provision and disease management should take into consideration the following barriers that were revealed during the health facility assessment: 7
Overloaded capacity: Shortage of staff appeared to be common across many public hospitals and clinics. Except in the cases of emergency services and laboratory testing services, many services were generally managed by no more than 2 staff. As patients noted in the focus group discussions, they did not feel that they received sufficient attention from medical staff in public health facilities. Physicians that were interviewed also indicated that due to high patient volume they were restricted to simply prescribing the necessary drugs and were not able to offer more comprehensive health advice. Lack of human resources is a system level constraint that could be challenging to modify, however, it must be taken into careful consideration when designing the potential intervention. Opportunities for task shifting may exist to help accommodate high patient volume. Availability of equipment and pharmaceuticals: The lack of equipment and pharmaceuticals in lower level health facilities creates a barrier to obtaining care. It is concerning that certain fundamental treatment items, such as insulin, were not available in any of the CHC surveyed in this study. In focus group discussions, patients pointed out that because of the lack of pharmaceutical supplies in government hospitals and clinics they were compelled to obtained drugs from local dispensaries which caused inconvenience. Staff at government hospitals mentioned issues in the current drug-supply chain, in which the restocking process lacked efficiency, requiring hospitals to occasionally purchase necessary medicines from private vendors. Ensuring a reliable supply of essential medications is be pertinent to sustaining the Continuum of Care. Continued access to and use of medication: An alarmingly large proportion of patients who reported receiving treatment for a diagnosed NCD did not have their conditions controlled. One contributing factor is the shortage of pharmaceuticals. Another issue is the lack of awareness of the importance of long-term adherence to medication. Patients tend to stop taking medications when their symptoms begin to disappear. Moreover, specialized programs and services for NCD monitoring and management are lacking. Despite the fact that, in general, patients understood the importance of follow-up, those services were not easily accessible. Therefore, in addition to educating patients about the importance of medication adherence, it is crucial to strengthen supply-side capacity to increase medication availability and enhance formal patient support. 3. Risk Factor Control Our results indicated high prevalence of risk factors, such as tobacco use, alcohol consumption and obesity in Shimla and Udaipur. However, most health facilities lack comprehensive preventive services. While effective control of risk factors is critical to preventing NCDs, preventive interventions tend to require a longer time period to achieve measurable impact. Furthermore, based on results from our review of literature, consensus on the best strategy for preventive intervention has not yet been reached. Given the scope and scale of HealthRise project, implementing stand-alone preventive programs may not be the most suitable. A more fruitful approach would be to potentially consider risk factor control as an integral component of a comprehensive disease treatment and management strategy. 8