Health System Capacity and Access Barriers to Diagnosis and Treatment of CVD and Diabetes in Nepal

Abstract

Background: Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions -availability, affordability, accessibility, acceptability, and quality -is crucial yet rarely performed, especially in low-and middle-income countries. Objective: To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal. Methods: We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public sector: 11; private sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during May-July 2017. Data for 13 routine diagnostics were obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 day's wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepal's adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality. Results: We found that mean availability of generic medicines is low (<50%) in both public and private sectors, and less than one-third medicines met WHO's availability target (80%). Mean (SD) availability of diagnostics was 73.1% (26.8%). Essential medicines appear locally unaffordable. On average, the lowest-paid worker would spend 1.03 (public sector) and 1.26 (private sector) days' wages to purchase a monthly medicine supply. For a person undergoing CVD secondary-prevention interventions in the private sector, the associated expenditure would be 7.5-11.2% of monthly household income. Exit interviews suggest that a long/expensive commute to health facilities and poor medicine affordability constrain access. Conclusions:This study highlights critical gaps in Nepal's health system capacity to offer basic health services to CVD and diabetes patients, owing to low availability and poor affordability and accessibility. Research and policy initiatives are needed to ensure uninterrupted supply of affordable essential medicines and diagnostics.

Access to Essential Medicines and Diagnostic Tests for Cardiovascular Diseases in Maputo City, Mozambique

“…These results reveal lower availability of medicines compared to that reported from urban areas in Cameroon (36.4 to 59.1%) [23] and from Nepal (around 50%) [19]. Regarding affordability, the cost of managing individuals with high cardiovascular risk was comparable to that found in Cameroon (USD 28.8 to 34.2 in Mozambique versus 30.7 in Cameroon); however, medicines were less affordable in Mozambique compared to Nepal where on average, the lowest-paid worker would spend 1.03 (public-sector) and 1.26 (private-sector) days' wages to purchase a monthly supply [19].…”

Developing Nepal’s medicines pricing policy: evidence synthesis and stakeholders’ consultation

“…The price variations for antihypertensive drugs, cardiovascular medicines, and oral hypoglycemic drugs were also noted in several other studies (Karki et al, 2021 ; Khanal et al, 2019 ; Mishra et al, 2015 ; Sharma et al, 2021 ; Shrestha, 2015 ). The average percentage price variation for different brands of the same oral hypoglycemic drugs manufactured in Nepal is wide (Shrestha, 2015 ).…”

Electrocardiogram abnormalities and renal impairment in patients with type 2 diabetes mellitus: A healthcare facilities‐based cross‐sectional study in Dang district of Nepal

“…In addition, smoking, inadequate amount of fruit and vegetable intake, and physical inactivity were prevalent among diabetes patients in the current study. Therefore, it is also essential to scale up the health system to minimize behavioral risk factors, deliver treatment to lower blood glucose, manage hypertension and dyslipidemia 3 , 66 , 67 . According to a study in 55 low‐ and middle‐income countries, fewer than one out of 10 patients with diabetes mellitus received comprehensive treatment according to guidelines 3 .…”

“…Critical barriers to effective chronic disease management are insufficient population awareness of disease risk factors, understanding of the disease and its complications; limited access to health services and medication; financial constraints these patients face; and inadequate policies and chronic disease guidelines 67 , 68 , 69 . Therefore, Nepal must strengthen policies and programs to increase awareness, availability, affordability, and accessibility of essential medicines and diagnostics for patients with diabetes, CVD and CKD 66 .…”