Primary healthcare system readiness for the prevention and management of non-communicable diseases in Nepal: a mixed-methods study

Background: Non-communicable diseases (NCDs) contribute to two-thirds of Nepal's total deaths. In 2016, Nepal adopted the World Health Organization’s Package of Essential Non-Communicable Disease Interventions (WHO-PEN) to curb the growing burden of non-communicable diseases (NCDs). This study evaluated the primary healthcare system's readiness for the prevention and management of non-communicable diseases (NCDs), including cardiovascular diseases (CVDs), diabetes mellitus (DM), and chronic respiratory diseases (CRDs), and investigated factors associated with NCD-specific service readiness. Methodology: We employed a convergent parallel mixed-methods study design. We adapted the WHO Service Availability and Readiness Assessment (SARA) tool and assessed 105 primary healthcare facilities, which were selected using a multistage stratified random sampling approach. We performed a weighted descriptive analysis and fitted survey-weighted multivariable linear regression to identify factors associated with NCD-specific service readiness. Simultaneously, we conducted 23 key informant interviews with health authorities and 47 in-depth interviews with health service providers involved in the PEN implementation. All interviews were audio recorded, transcribed verbatim, and analyzed using a thematic approach. Results: The overall NCD service readiness score for primary healthcare facilities was highest for CVDs at 48.4 (95% CI: 43.2-53.6), followed by DM at 40.8 (95% CI: 34.5-47.2), and CRDs at 34.8 (95% CI: 29.2-40.5). Primary Healthcare Centers (PHCCs) had higher NCD service readiness than health posts. In regression analysis, we found that primary healthcare facilities located in hilly regions and imposing user fees for some NCD services had significantly higher NCD-specific service readiness compared to those in the mountainous areas and those not imposing user fees, respectively. Qualitative findings revealed that higher NCD service readiness in PHCCs and certain regions was due to better infrastructure, training opportunities, accessibility to medicines and equipment, and social health insurance schemes. High staff turnover and limited supply of NCD drugs and equipment hindered NCD service delivery, particularly in health posts and remote regions. Conclusion: Primary healthcare facilities in Nepal lack equipment, medicines, trained staff, and guidelines for NCD management. The government of Nepal could enhance NCD-specific service readiness by equipping health service providers with medical supplies and building their capacity through regular PEN training and peer coaching sessions.