Organization of services for severe chronic Noncommunicable diseases at first-level hospitals in nine lower-income countries: Results from a Baseline assessment of PEN-Plus initiation

Abstract

Severe chronic noncommunicable diseases pose a significant health burden and challenges for health systems globally. This study aims to advance our understanding of the current organization of care for these conditions in low and lower-middle-income countries. The study was conducted as part of a baseline assessment of facilities prior to the initiation of the Package of Essential NCD Interventions -Plus (PEN-Plus) strategy, which is designed to enhance outpatient care for conditions including rheumatic and congenital heart disease, sickle cell disease, type 1 diabetes, severe asthma, and advanced chronic kidney disease. We employed a cross-sectional survey methodology to collect baseline data from 16 hospitals in nine LLMICs. The survey assessed the organization of common and severe NCD services, focusing on the availability and management of severe NCDs, organized into domains of integrated services. Data were analyzed using summary statistics and heatmaps to evaluate care patterns. We document gaps in the availability of services for both common and severe NCDs. We find that the majority of NCD care occurs in the general outpatient settings, with a smaller proportion provided in specialized internal medicine wards. Despite some hospitals implementing specialized clinics and teams, limitations in specialist access, variability in service fees, and inconsistent definitions of patient follow-up were prominent issues affecting patient care access and continuity. Despite the spectrum of strategies employed by these hospitals to cater to chronically and severely ill patients, notable gaps in care persist, particularly for diagnostic and treatment options that require specialist training or equipment. The sustainable decentralization of effective care for individuals with severe chronic NCDs will require integrated teams and customized systems to ensure seamless and comprehensive care through the entire care continuum-from screening and diagnosis to care linkage, ongoing management, handling of complications, uninterrupted supply of medicines and commodities and maintaining patient retention.

Fig 1. NCD Service availability across hospital spaces. This image This image presents on the location of disease-specific care at responding hospitals. Reported availability anywhere in the hospital (“Any”) is presented at the far left, followed by “Any Outpatient” availability. Care at specific outpatient sites (e.g., emergency department or general OPD) are presented. In the middle of the graphic, Any Inpatient care is presented, followed by specific inpatient areas.

Fig 2. Staffing of interventions targeting cardiac care.

These heatmaps illustrates the availability and staffing of clinical services across 16 hospitals. On the left, each row represents a different service category, with color-coded cells indicating the number of hospitals that do not offer the service: yellow signifies that the service is not offered at any hospital, and dark blue indicates the service is not offered at one hospital only. The subsequent columns detail the staffing responsible for each service at the hospitals where it is available, using the same color scheme to maintain consistency in visualization. Clinical Officer*: Clinical officer or other non-nurse diploma level clinician.

Fig 3. Staffing of interventions targeting type 1 diabetes.

These heatmaps illustrates the availability and staffing of clinical services across 16 hospitals. On the left, each row represents a different service category, with color-coded cells indicating the number of hospitals that do not offer the service: yellow signifies that the service is not offered at any hospital, and dark blue indicates the service is not offered at one hospital only. The subsequent columns detail the staffing responsible for each service at the hospitals where it is available, using the same color scheme to maintain consistency in visualization. Clinical Officer*: Clinical officer or other non-nurse diploma level clinician.

Fig 4. Staffing of interventions targeting sickle cell disease.

These heatmaps illustrates the availability and staffing of clinical services across 16 hospitals. On the left, each row represents a different service category, with color-coded cells indicating the number of hospitals that do not offer the service: yellow signifies that the service is not offered at any hospital, and dark blue indicates the service is not offered at one hospital only. The subsequent columns detail the staffing responsible for each service at the hospitals where it is available, using the same color scheme to maintain consistency in visualization. Clinical Officer*: Clinical officer or other non-nurse diploma level clinician.