What happens when public primary care is ill-prepared to respond to non-communicable diseases: a mixed-method study of diabetes and hypertension care in urban Nepal

BACKGROUND: With rapid urbanisation in low- and middle-income countries, public primary care is struggling to respond to the growing prevalence of hypertension and diabetes, while the private sector has grown to meet demand. We aimed to understand current use and readiness of public and private primary care diabetes and hypertension services, and how readiness impacts perceptions and practices of urban communities. METHODS: We conducted a convergent mixed-methods study in Nepal, including mapping of diabetes and hypertension services in 134 public and private facilities; participatory social mapping, transect walks combined with six focus groups and nine interviews with marginalised urban communities and 15 city and health system actors to understand perceptions and service use. We used descriptive statistics to assess service readiness and thematic analysis of our qualitative and participatory data. RESULTS: Of the 660 facilities mapped, 134 facilities provided diabetes and hypertension services, and 63% were private. Median service readiness scores were similarly low for hypertension and diabetes across public and private primary care. Trained human resources and the availability of guidelines scored the lowest within this overall score. Qualitative findings highlighted a lack of willingness to take long-term medication, high use of pharmacies, and acceptance of hypertension and diabetes as part of ageing. Attempts to improve behaviours were undermined by the living and working conditions facing marginalised urban communities. CONCLUSIONS: While both public and private primary care services are diagnosing and managing hypertension and diabetes, few have appropriate training or guidelines. This undermines patient trust, with many self-managing through pharmacies and non-allopathic medicines. Limited population and routine health data, coupled with a lack of data about the urban poor, weaken the ability of city and health system actors to plan health services, particularly targeting marginalised city residents.