Assessing readiness of health facilities for hypertension and integration with diabetes care in Bangladesh: Evidence from the National Service Provision Assessment Survey

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Abstract
Background: Hypertension (HT) and diabetes mellitus (DM) are two major noncommunicable diseases (NCDs) with a high rate of comorbidity that utilize similar health system resources. Limited evidence exists, however, on the level of readiness of health facilities in Bangladesh to manage HT and integrated HT–DM care. The objective of this study was an assessment of facility readiness for HT and integrated HT–DM management and to identify key factors influencing levels of readiness. Methods: The study involved the analysis of data from 382 health facilities at or above sub-district level from the most recent nationally representative dataset, the 2017 Bangladesh Health Facility Survey (BHFS). Readiness for HT and integrated HT–DM services was assessed based on composite scores as constructed from the WHO–Service Availability and Readiness Assessment (SARA) indicators. Negative binomial regression models were applied to determine the factors associated with facility readiness. Results: Facilities showed low readiness scores for both HT and integrated HT–DM care, with mean scores of 3.72 (out of 8) and 6.71 (out of 16), respectively. Although most facilities have basic equipment like BP apparatuses (98.7%) and stethoscopes (98.8%), a huge gap is observed in the training of staff (20.5%) and availability of guidelines for management (16.6%) of HT, diagnostic tools for DM, and essential medicines including ACE inhibitors (7.3%), thiazide diuretics (12.0%), and metformin (49.4%). Significant determinants of HT readiness included type of facility, client feedback system, and the number of HT care providers, while for integrated HT-DM readiness, important predictors were a type of facility, treatment-only service provision, client feedback mechanism, and structure of user-fees. Conclusions: In Bangladesh, health facilities are still not adequately ready to deliver integrated HT-DM services, illustrating deficits in human resources, clinical protocols, diagnostics, and availability of medicines at an overall system level. There are several areas that need improvement-the need for strengthening integrated training, free availability of medicines, client feedback systems, and collaboration between the public-private-NGO sectors. The results, though based on 2017 data, remain important in capturing system readiness prior to the reform and serve as a nationally representative baseline to assess the upspring of HT and NCD program improvements in Bangladesh.

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