An assessment of health facility service readiness and the quality of care provided to patients with diabetes and hypertension in Lagos State, Nigeria

BACKGROUND: More than 70% of the global premature mortality from NCDs occurs in low- and middle-income countries. These countries, including Nigeria, also have varied but mostly limited health system capacity to respond to cardiovascular disease and diabetes mellitus. Substantial gaps exist in our understanding of the subnational capacity to respond to these conditions in Nigeria. This encompasses a variety of issues, perhaps most importantly the readiness of facilities to provide care and the quality of care provided to patients with these conditions. As the Lagos State government accelerates the rollout of its mandatory state-based health insurance scheme, the number of patients with diabetes and hypertension receiving care will increase, poor management of which can threaten the scheme's financial sustainability. This mixed-methods study was conducted as part of the baseline activities of an impact evaluation of the health insurance program and was designed to answer three questions: 1) What is the capacity and readiness of health facilities in Lagos State to provide hypertension (HTN) and diabetes (DM) care? 2) What is the level of the quality of care provided to patients with HTN and DM, and how does it vary by patient and facility characteristics? 3) What are the barriers to providing diabetes and hypertension care from providers' perspectives? METHODS: The data for this study were collected using three approaches. We conducted a facility survey among public and private facilities (n=84) in Lagos State to assess facility readiness and the functionality of systems required for diabetes and hypertension care. Linear mixed-effects models were used to determine the level and factors associated with the process quality of care provided to patients in 2019 by analyzing clinical data collected via medical chart abstraction. Finally, in-depth interviews were conducted with health care providers (n=20) to explore their practices and the barriers faced in providing care to patients with diabetes and hypertension. RESULTS: The essential inputs needed for diabetes and hypertension care were mostly available; the mean HTN readiness score was 66%, and the DM readiness score was 68.9%. At the same time, systems to facilitate longitudinal care were mostly lacking; 35% had a mechanism for tracking patients who missed appointments, and 52% assigned unique patient identification numbers to NCD patients. Based on the clinical records, the quality of care provided to patients was very low; overall, patients with diabetes and hypertension received less than 30% of recommended care processes. Less than a third of the patients had their blood pressure or blood glucose controlled. There was substantial variation in the mean quality score by patient and across care processes, with lifestyle modification counseling (LSM) counseling the least likely to be delivered. According to providers, the inability to pay for laboratory tests and medications and non-compliance with medications and clinic visits are key barriers to delivery of high-quality services. Barriers at the organizational level included poorly functioning two-way referrals, non-availability of LSM counseling materials, and lack of recall and follow-up systems. CONCLUSION: While the service readiness scores for diabetes and hypertension are moderately high among these health facilities, there are critical deficits in their ability to provide long-term, integrated care of high quality to patients. Addressing these deficits will require the implementation of a comprehensive model of care co-created by providers, health system managers, patients, and insurers. Lessons can be drawn from the implementation of other chronic disease programs to kick start this process.2024-08-30T00:00:00