Changes in the readiness of healthcare systems to provide diabetes- and cardiovascular disease-related services: A comparison of indices using data from the 2014 and 2017 Bangladesh Health Facility Surveys

Introduction

The incidence of non-communicable diseases (NCDs) has been resolutely increasing worldwide over the last few decades.¹ Diabetes mellitus and cardiovascular diseases (CVDs), including coronary heart disease, peripheral arterial disease, and rheumatic heart disease, are among the NCDs that are prevalent and impact individuals of different ages, geographical areas, and nations.² The World Health Organization (WHO) estimates that more than 15 million people between the ages of 30 and 69 years die every year from an NCD worldwide, with low-to-middle-income countries (LMICs) accounting for three-fourths (77%) of all early fatalities. According to the WHO, CVDs cause the death of 17.9 million people every year, whereas diabetes claims the lives of 1.5 million individuals each and every year.

Bangladesh is a prosperous nation that is undergoing both epidemiologic and demographic transitions at the same time. This is due to the fact that the disease burden is moving from communicable illnesses to NCDs.² WHO reported in 2011 that NCDs represent 61% of the overall illness burden in Bangladesh and preliminary research estimates that these diseases are responsible for 51% of the country’s yearly deaths.³ The number of people living with diabetes in Bangladesh is always increasing. According to the International Center for Diarrheal Disease Research in Bangladesh (ICDDR, B), the number of individuals living with diabetes in 2015 was around 7.1 million, and the disease was responsible for approximately 129,000 fatalities. Studies also showed that diabetes raises the chance of debilitating CVDs,⁴ and patients with diabetes have a significantly increased risk of dying from CVDs.⁴

An analysis of a case study set within the parameters of Bangladesh found a variety of healthcare system preparedness challenges; the CVD rate is increasing, making it difficult for Bangladesh to treat these diseases.⁵ In particular, this previous study found that a lack of comprehensive cooperation among many partners hindered the preparedness of the healthcare systems.⁵ With the changing epidemiological and demographic conditions, the healthcare system faces new challenges such as increasing mortality due to CVDs, diabetes and other NCDs in Bangladesh.^6,7 Preventing and managing NCDs differs from addressing acute conditions, in which healthcare system readiness can play an important role.⁶ Without long-term medical support, early identification of NCDs, mental health promotion, identification of risk factors, self-management, behavior modification, palliative care, and adherence to treatments and medications, NCDs are unlikely to be prevented or managed.⁸ The lack of healthcare facilities, inadequate infrastructure, access to healthcare professionals, lack of health literacy, and unavailability of medications negatively impact patients with NCDs.²

However, the readiness of a country’s healthcare system is one of the significant aspects that show a country’s readiness to adopt essential and timely steps to minimize any disease, including NCDs. The idea of healthcare system readiness emphasizes the degree to which healthcare systems are ready to handle any particular sickness as well as any and all general disorders.⁹ Because the readiness identifies possible obstacles that might stand in the way of achievement, it is essential to assess readiness in healthcare systems (U. S. Department of Health and Human Services Health Resources and Services Administration). Diabetes and CVDs are responsible for exponential increases in medical expenses and a diminished capacity for activity.⁴ In addition to this, the enormous expenditures associated with medical treatment have an impact on the financial situation of a family.⁴ Research has shown that diabetes significantly increases the risk of developing severe CVDs.⁷ Heart conditions may create disruptions in the normal flow of fluid out from the lungs, which can result in a variety of abnormalities.¹⁰ All of these diseases are linked to one another and are all accountable for the devastation of human lives and the economy.

The healthcare system in Bangladesh is facing an increasingly difficult task as a result of the prevalence of NCDs, notably CVDs and diabetes.¹¹ Previous research focused on determining whether or not the healthcare system in Bangladesh was prepared to provide treatment for NCDs.^5,12 It would be more beneficial to identify the illnesses specific readiness (for example, readiness for individuals with diabetes and CVDs, etc.) of the healthcare system to offer services for a given condition if we focused on each specific NCD on its own.¹³

Based on the information from the Bangladesh Health Facilities Survey (BHFS) in 2014, there has been only one study done so far that investigates whether or not healthcare institutions are prepared for increasing cases of diabetes and CVDS.¹³ According to what was discovered, just 0.4% to 0.9% of facilities satisfied all four preparedness characteristics (guidelines, trained staff, equipment, and medicine).¹³ Despite the fact that it is vital to understand the preparedness of the healthcare system in Bangladesh, particularly for services connected to diabetes and CVDs. According to our understanding, the preparedness of the healthcare system to deliver services related to diabetes and CVDs utilizing the most recent BHFS 2017 data has not yet been quantified or analyzed. We studied the readiness of the healthcare system in Bangladesh, especially for diabetes and CVD-related services, by comparing the BHFS from 2014 to 2017 and basing our findings on this constraint.

Methods

Sample size and sampling technique

The number of active healthcare facilities that served as the sample frames for the BHFS in 2014 and 2017 was 19,184 and 19,811 correspondingly. Following a stratified random sample, a total of 1,596 and 1,600 healthcare institutions throughout the nation were chosen for the 2014 BHFS and 2017 BHFS, accordingly. The 2014 and 2017 BHFS samples were planned to contain facilities from the country’s seven administrative divisions (Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, and Sylhet). District hospitals (DHs), maternal and child welfare centers, Upazila health complexes (UHCs), upgraded union healthcare and family welfare centers, union subcenters/rural dispensaries, and community clinics (CCs), as well as private hospitals with at least 20 beds and non-governmental organization (NGO) static clinics/hospitals, were all included. In addition, the number of records that were available for the BHFS in 2014 was 1,548, whereas in 2017 it was 1,524. The research examined the infrastructures that provide services for CVDs in order to evaluate how well they are prepared for CVDs. Additionally, the research also examined the facilities that provide services for diabetes in order to evaluate how well they are prepared for diabetes. The Bangladesh healthcare system provides services for NCDs up to the UHC. The study, therefore, excluded facilities like MCWC, UHFWC and CC and also those with missing values. Based on the exclusion criteria, a total of 407 diabetes facilities and a total of 386 CVDs facilities were included in our study (Figures 1 and 2).

Figure 1. Sample size calculation for diabetes and CVD in 2014.

CVD, cardiovascular disease.

Figure 2. Sample size calculation for diabetes and CVD in 2017.

CVD, cardiovascular disease.

Results

Region-wise readiness index (RI) scores specific to services for diabetes and CVD

Figure 3 depicts the region’s preparedness score. The bar chart shows the readiness score for both diabetes and CVD between 2014 and 2017 and informs us that the readiness score for diabetes and CVD management by region has not exceeded the 70% cutoff limit.¹⁴ In terms of diabetes treatment, the RI score dropped in urban regions, and increased in rural areas. The difference between urban and rural regions was significant (P=0.0001), however it did not hold over time (P=0.4443). However, the availability of CVD services in healthcare institutions is declining in both urban and rural areas. For CVD, the difference between urban and rural areas was substantial (P=0.0001), however it was not significant over time (P=0.3665).

Figure 3. Distribution of facility readiness of diabetes and CVD in 2014 and 2017 by location.

CVD, cardiovascular disease.

Division-wise readiness index scores specific to services for diabetes and CVD

Figure 4 depicts the readiness score for diabetes and CVD services by division. There is no division in which the readiness score has a high RI value. The difference in preparedness scores throughout the division was not statistically significant. Except for the Rajshahi division, the RI score for diabetes management indicated a downward trend. In 2017, all CVD divisions had lower RI scores than in 2014.

Figure 4. Readiness score by division.

CVD, cardiovascular disease.

Discussion

This research was effective in describing a thorough scenario of the availability of services and preparedness of healthcare systems in Bangladesh to deliver care associated with diabetes and CVDs. We have also identified the positive or negative changes that occurred from 2014 to 2017, identified the gaps in facilities regarding readiness towards diabetes and CVD services and compared the findings of previous research.¹³ The public health facilities in Bangladesh consist of CCs, Union health and family welfare centers (UHFWCs), UHCs, and DHs. The UHCs are the focal points for providing NCD services in Bangladesh. Moreover, recently MOHFW published an NCD management protocol and is trying to establish an NCD management model through establishment of a rereferral system between CCs and UHC.¹⁴

Historically, the healthcare system of Bangladesh has focused on infectious diseases, immunization, and maternal, child and reproductive health through public health facilities.¹¹ Although, Bangladesh is among the top countries having large proportion of patients with diabetes, there is still a lack of information on it. The scenario is worse for CVD and it is associated with a large number of mortalities in Bangladesh.¹¹ The overall improvement of healthcare facilities during 2014 to 2017 regarding readiness to provide NCD (DM, CVD) services is not quite satisfactory. In terms of services towards diabetes, the mean readiness score increased in 2017 for district hospitals, UHC, and the NGO clinic from 2014, although this improvement was not statistically significant. However, at the private clinics, the facility readiness score decreased. The MOHFW and owners of the private centers need to take effective actions for significant improvement.

There has always been a lack of trained human resources in healthcare facilities of Bangladesh.¹⁵ It a matter of concern that the readiness score of trained staff and guideline domain dropped in all four types of facilities we assessed. The government should revise their training modules and guidelines for the overall improvement of human resources. The MOHFW and DGHS of the Government of Bangladesh need to come forward to take effective action to reduce the human resource gap. Recent studies published in Bangladesh and other countries have observed low number of trained healthcare providers on diabetes management.^15,16 While there is a lack of trained human resources in facilities, the readiness score of the equipment domain is quite satisfactory and increased at all types of facilities during the targeted three years. The effective use of equipment requires trained human resources, which is also very much essential for better service delivery. For diagnostic facility domain, the status increased in DHs, UHCs and NGO clinics, however it decreased for private facilities. A large proportion of our population are dependent on private healthcare facilities.¹⁷ Therefore, the diagnostic facility needs to be improved in private clinics.

According to our data, the score in medicine domain was found to be quite low and the situation was worse in district hospitals and private clinics during 2014 to 2017. The medicine domain’s score increased at the UHC and NGO clinics. These results are consistent with the findings of a large number of studies conducted in LMICs, which suggest that healthcare providers are not yet totally equipped to deliver comprehensive diabetes care services.^18,19 Our results are in line with those of prior research conducted in Bangladesh, which found that basic healthcare facilities had a major deficiency in the availability of relevant and important drugs for diabetes as well as an insufficient or restricted supply of such medicines.¹⁵

The prevalence of CVDs in Bangladesh is around 5%, and this percentage is consistent across all forms of CVD, sex and geographic locations, and for this reason, CVDs are the leading cause of death in Bangladesh.²⁰ There was a decrease in the mean readiness scores of CVDs at the district hospitals, NGO clinics, and private clinics from 2014 to 2017. Similar to diabetes, readiness scores for trained staff and guidelines decreased in all types of facilities. The score of the equipment domain was decreased at district hospitals. The availability of skilled employees to deliver CVD–related healthcare services is of the utmost important. As a result, establishing specialist training for CVDs might provide optimal treatment.²¹ The readiness score of the medicine domain also reduced at district hospitals from UHC and NGO clinics. According to the findings of a number of studies conducted in Bangladesh, one of the primary difficulties faced by public healthcare facilities is a shortage of medications for CVDs.²² According to the findings of a study that was carried out recently, it was found that one of the primary reasons for patients’ disappointment with the government healthcare facilities is that there are not enough drugs or that they are of low quality.²³ Disagreement has also been found in research conducted in India, on the availability of the sorts of pharmaceuticals suggested for the treatment of CVDs.²⁴

In addition, despite the existence of a national standard for the treatment of diabetes, it is not followed appropriately in the vast majority of healthcare institutions at both the primary and secondary levels. Moreover, CVD management is not part of the national NCD management model in Bangladesh. Therefore, the respective authorities must incorporate CVD management guidelines into the national NCD management policy.

This study has identified the changes that took place in terms of facility readiness regarding NCD care from 2014 to 2017. The samples are typical of the nation as a whole and include data from all of Bangladeshi administrative units. On the other hand, this research does have a few restrictions when it comes to the method and the time frame. The BHFS 2017 was completed in 2017 and only covered information about DHs, UHCs, NGO clinics and private facilities. After 2017, no BHFS has been conducted until 2022, therefore most of the data are outdated. The tools used in these surveys are also outdated, which may also require modification for future surveys. These issues make it challenging for our study to reach a specific conclusion. The authors recommend collecting primary data with updated tools for a better understanding of facility readiness towards NCDs. Some further in-depth research and the outcomes of that research might point policymakers in the right path when it comes to taking the required actions.

Conclusions

In summary, there are significant deficiencies in essential categories of facility preparation, such as recommendations on diagnosing and treating diabetes and CVDs. These deficiencies need to be addressed as soon as possible. There is also a lack of skilled workers for services that are diabetes and CVD specific. The supply of medicines for diabetes and CVD is also inadequate. This study has compared the readiness score for diabetes and CVD over two separate survey data in 2014 and 2017. Our analysis concluded that no statistically significant development occurred during the targeted years regarding facility readiness. Since there has been no rise in the number of qualified workers throughout this period, services for diabetes and CVD have been ignored. Therefore, the crucial actions that need to be made are to ensure guidelines on the diagnosis and treatment of illnesses, the capacity to conduct diagnostics, and the capability to have sufficient medication and pharmaceuticals. These steps will help facilities be ready and help provide health coverage to the population. The information presented in this research might assist in the generation of scientific evidence that could be used by policymakers and other relevant stakeholders in establishing policies and programs that would benefit both the institutions and the population.