Health systems in LMICs countries are poorly prepared for people with high blood pressure

Health systems in low- and middle-income countries (LMICs) are poorly prepared for the increasing number of people with high blood pressure, with more than two-thirds of people affected going without treatment, according to a new study led by researchers at Harvard T.H. Chan School of Public Health in collaboration with colleagues from more than 40 institutions around the world, including several ministries of health.

The study examined household survey data for 1 million people living in 44 LMICs and found that less than half of those with high blood pressure are properly diagnosed.

Among those with the condition, only 30% are treated and only 10% have the disease under control.

These proportions, however, varied widely between countries, with some performing consistently better than others even after taking into account differences in economic development.

The study will be published in The Lancet on Thursday, July 18, 2019.

“Our study shows not only that care for hypertension in these countries is severely inadequate, but also where exactly patients in each country are being lost in the care process,” said Pascal Geldsetzer, postdoctoral research fellow at Harvard T.H. Chan School of Public Health and first author of the study.

For the study, researchers used a cascade of care approach, which looked at the numbers of people with hypertension who had been screened, diagnosed, treated, and controlled, to determine how well the health systems of the various countries are treating people with hypertension.

The group carried out its research using household surveys, including the World Health Organization’s STEPS survey, in order to have a uniform approach when obtaining data on established risk factors.

Researchers first determined how many people suffered from high blood pressure.

They also determined how many of these patients had ever had their blood pressure measured prior to the survey, as well as how many were diagnosed and were taking treatment.

Finally, they analyzed how many patients successfully controlled the disease with medication.

“The low proportion of patients with high blood pressure getting the treatment they need, along with the growing number of patients with high blood pressure, suggests the very urgent need for population-level prevention, especially policies that get salt and trans fat out of the food supply, promote fruits and vegetables, reduce air pollution, and address excessive consumption of tobacco and alcohol,” said Lindsay Jaacks, assistant professor of global health at Harvard Chan School.

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The rise of non-communicable diseases (NCDs) and the continued burden of communicable diseases have caused a double burden on low- and middle-income countries (LMICs). According to the ‘Global Burden of Disease Study’ of 2017, NCDs comprised 73% of global deaths [1], with a 40% increase in global ‘Disability-Adjusted Life Years’ [2].

High systolic blood pressure was the main risk factor attributing to ‘Disability-Adjusted Life Years’ [3]. For this reason, high or raised blood pressure, also called hypertension (HTN), is considered a global public health threat with significant economic and social impact [1,4].

At the same time, early detection, adequate treatment and good control of HTN are effective and cost-effective interventions to reduce disability, morbidity and mortality from HTN and its complications such as stroke, ischaemic heart diseases and kidney diseases [1,4–6].

In LMICs, ensuring access to quality HTN care for affected populations is a complex intervention that is better implemented through an integrated primary health-care approach.

Such integrated intervention must consider the patient’s health needs for long-term care across time and disciplines which poses significant challenges to the weak health systems and constrained resources in LMICs [4,7].

In Vietnam, a recent Systematic Review and Meta-Analysis showed that the pooled prevalence of measured HTN (i.e. blood pressure ≥140/90 mmHg) was 21% ± 2.6, with lower estimates for the pooled prevalence of those aware of their HTN status (9%) and treated for HTN (5%); these three pooled estimates were significantly lower in rural settings [8].

Since 2008, the Vietnamese Ministry of Health (MoH) implemented several interventions to prevent and manage HTN at the national, provincial, district and commune levels [9].

What remains unclear is the status of patient access to HTN care and services across the primary health-care settings in the Vietnamese health system; synthesising the literature concerning such status would help policymakers and researchers to develop evidence-informed policies, formulate questions for further research, and share lessons learned from Vietnam’s experiences to improve HTN care in resource-constrained settings.

Objective

This article aims to perform a systematic narrative review of the evidence available in the literature on access to HTN care and services in primary health-care settings in Vietnam.

Since this systematic narrative review focuses on the concept of access to care, it follows a framework synthesis methodology [10] utilising the framework on people-centred access to health care proposed by Levenseque et al. [11]. Such methodology is useful in building and consolidating knowledge by accommodating a large number of different types of studies [10].

Context

The Socialist Republic of Vietnam is a lower-middle-income country with a population of over 90 million, of which 34% is urban [12].

Vietnam has been experiencing demographic and epidemiological transitions. Life expectancy at birth was 76 years in 2016 [13], with a remarkable decline in premature death and disability caused by most communicable, maternal, neonatal and nutritional causes [14,15].

The health-care system (Figure 1) comprises four levels providing preventive and curative services [16,17].

The commune health station (CHS) is the entry point of care, often comprising a doctor or assistant doctor, a midwife, nurses, an assistant pharmacist and a network of village health workers, and serves a population of 5,000–20,000; CHS team is responsible for providing preventive care programmes, managing common illnesses, providing health counselling, and referring advanced or severe illnesses [16,17].

At the district level, the ‘District Health Bureau’ provides administrative supervision to health services funded by ‘District People’s Committee’, while the ‘District Hospital’ is responsible for managing curative care and ‘District Preventive Medicine Centre’ manages preventive care [16,17].

In some provinces, the last two are integrated into one entity as the ‘District Health Centre’, while in other provinces they operate independently [16,17].

The district facilities provide technical support to the CHSs [16,17].

The commune and district levels are considered to be the grassroots level or the providers of primary health care in Vietnam.

The ‘District Hospital’ offers the first referral level of in-patient care [18].

The third level operates at each of the 63 provinces through a ‘Provincial Health Bureau’ or ‘Provincial Department of Health’ which oversees the district and provincial health services, in addition to private health-care facilities [16,17].

The provincial health services include curative care at one general and one or more specialised hospitals and preventive care at the ‘Provincial Preventive Medicine Centre’ [16,17].

The MoH has several departments, national research institutes and national or central hospitals (general and specialised) as the final referral level for therapeutic services [16,17].

The MoH formulates national health policies and national target programmes (NTPs) on health, such as the expanded programme on immunisation and tuberculosis control, most of which are preventive; each NTP focuses on a disease or intervention and is a vertical programme [16,17].

A national hospital, institute or centre manages one NTP and works directly with provincial health entities, which in turn gives direction to district entities to implement the programme at the commune level [16,17].

Central and provincial governments are the primary funders for NTPs; a few of them receive international development assistance [19]. In 2017, the Prime Minister’s office approved the NTPs on health and population for 2016–2020 with eight sub-projects, including the prevention of NCDs [20,21].

Following the adoption of the economic reform plan (i.e. Doi Moi) in 1986, fees were introduced at all levels of the public sector, so public funding covered only part of the medical costs; additionally, the private sector was legalised [22].

Total health expenditure as a percentage of GDP has been consistent at roughly 6% since 2010. In 2014, total health expenditure accounted for 53% of general government expenditure and 46% as private health expenditure [23].

Only 3% of total health expenditure was development assistance for health [23].

Out-of-pocket spending accounted for 37% of total health expenditure and 80% of private health expenditure [23].

The health insurance policy underwent successive changes as shown in Table 1, and recent changes are due to Vietnam’s commitment to achieving universal health coverage [18].

Vietnam Social Security manages the health insurance programme and includes mandatory contributory insurance for formal employees and social health insurance for the rest of the population [18,24].

In 2015, enrolment in social health insurance became compulsory, and the premium was set at 5% of a salary or a minimum wage (~30 USD) [18,24].

For employees, the employer’s contribution is 60% of the total premium [18,24].

The government subsidised the premium for specific population groups, including 100% of the premium for the poor, ethnic minorities, and children under six years of age, at least 70% for the near-poor, and at least 30% for students [18,24]. The insurance coverage by December 2016 was 82% [25].

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More information: Pascal Geldsetzer et al. The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults, The Lancet (2019). DOI: 10.1016/S0140-6736(19)30955-9

Journal information: The Lancet
Provided by Harvard T.H. Chan School of Public Health