Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries

David J Heller,Sandeep P Kishore,Rohina Joshi,Anirudh Kumar,Rajesh Vedanthan,Carol R Horowitz

doi:10.1001/jamanetworkopen.2019.16545

Abstract

Cardiovascular disease, cancer, and other noncommunicable diseases (NCDs) are the leading causes of mortality in low- and middle-income countries. Previous studies show that nonphysician health workers (NPHWs), including nurses and volunteers, can provide effective diagnosis and treatment of NCDs. However, the factors that facilitate and impair these programs are incompletely understood. To identify health system barriers to and facilitators of NPHW-led care for NCDs in low- and middle-income countries. All systematic reviews in PubMed published by May 1, 2018. The search terms used for this analysis included "task shifting" and "non-physician clinician." Only reviews of NPHW care that occurred entirely or mostly in low- and middle-income countries and focused entirely or mostly on NCDs were included. All studies cited within each systematic review that cited health system barriers to and facilitators of NPHW care were reviewed. Assessment of study eligibility was performed by 1 reviewer and rechecked by another. The 2 reviewers extracted all data. Reviews were performed from November 2017 to July 2018. All analyses were descriptive. All barriers and facilitators mentioned in all studies were tallied and sorted according to the World Health Organization's 6 building blocks for health systems. This systematic review and qualitative analysis identified 15 review articles, which cited 156 studies, of which 71 referenced barriers to and facilitators of care. The results suggest 6 key lessons: (1) select qualified NPHWs embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles. Although the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address nearly all of these challenges. These facilitating approaches-which relate chiefly to strong, consistent NPHW training, guidance, and logistical support-generate a blueprint for the creation and scale-up of such programs adaptable across multiple chronic diseases, including in high-income countries.

Highlights

Noncommunicable diseases (NCDs) are the leading causes of premature death worldwide.[1]
The results suggest 6 key lessons: (1) select qualified nonphysician health worker (NPHW) embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles
AND RELEVANCE the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address most of these challenges

Summary

Introduction

Noncommunicable diseases (NCDs) are the leading causes of premature death worldwide.[1]. Evidence demonstrates that nonphysician health workers (NPHWs) (ie, persons without a medical doctorate degree who render health care)[7,8,9,10] can render multiple aspects of care presumed to require a physician.[7,8] Models of care that employ NPHWs—including health professionals (eg, nurses) and laypeople (eg, community health workers [CHWs])—have successfully treated many causes of death and disability, especially maternal-child mortality and HIV/AIDS.[7,8,9]. NPHWs can screen for and treat risk factors associated with cardiovascular disease, such as depression,[14,15] diabetes,[16] and hypertension,[16] including by prescribing medication, and can track and improve patients’ adherence to these therapies. Nonphysician health workers can screen for cancers[17,18] and treat epilepsy[19] and asthma,[20] among other chronic diseases

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