Understanding the modifiable health systems barriers to hypertension management in Malaysia: a multi-method health systems appraisal approach.

Isabelle Risso-Gill,Charlotte Kuhlbrandt,Khalid Yusoff,J.-D Schwalm,Koon K Teo,Kien Keat Ng,Salim Yusuf,Tara Mccready,Dina Balabanova,Fadhlina Majid,Feisul Mustapha,Martin Mckee,Robby Nieuwlaat

doi:10.1186/s12913-015-0916-y

Abstract

BackgroundThe growing burden of non-communicable diseases in middle-income countries demands models of care that are appropriate to local contexts and acceptable to patients in order to be effective. We describe a multi-method health system appraisal to inform the design of an intervention that will be used in a cluster randomized controlled trial to improve hypertension control in Malaysia.MethodsA health systems appraisal was undertaken in the capital, Kuala Lumpur, and poorer-resourced rural sites in Peninsular Malaysia and Sabah. Building on two systematic reviews of barriers to hypertension control, a conceptual framework was developed that guided analysis of survey data, documentary review and semi-structured interviews with key informants, health professionals and patients. The analysis followed the patients as they move through the health system, exploring the main modifiable system-level barriers to effective hypertension management, and seeking to explain obstacles to improved access and health outcomes.ResultsThe study highlighted the need for the proposed intervention to take account of how Malaysian patients seek treatment in both the public and private sectors, and from western and various traditional practitioners, with many patients choosing to seek care across different services. Patients typically choose private care if they can afford to, while others attend heavily subsidised public clinics. Public hypertension clinics are often overwhelmed by numbers of patients attending, so health workers have little time to engage effectively with patients. Treatment adherence is poor, with a widespread belief, stemming from concepts of traditional medicine, that hypertension is a transient disturbance rather than a permanent asymptomatic condition. Drug supplies can be erratic in rural areas. Hypertension awareness and education material are limited, and what exist are poorly developed and ineffective.ConclusionDespite having a relatively well funded health system offering good access to care, Malaysia's health system still has significant barriers to effective hypertension management.DiscussionThe study uncovered major patient-related barriers to the detection and control of hypertension which will have an impact on the design and implementation of any hypertension intervention. Appropriate models of care must take account of the patient modifiable health systems barriers if they are to have any realistic chance of success; these findings are relevant to many countries seeking to effectively control hypertension despite resource constraints.

Highlights

The growing burden of non-communicable diseases in middle-income countries demands models of care that are appropriate to local contexts and acceptable to patients in order to be effective
Appropriate models of care must take account of the patient modifiable health systems barriers if they are to have any realistic chance of success; these findings are relevant to many countries seeking to effectively control hypertension despite resource constraints
The importance of developing robust responses to the growing burden of non-communicable disease (NCD) has been highlighted by two recent events, the 2010 update of the Global Burden of Disease demonstrating the scale of the epidemiological transition to NCDs [1] and the 2011 United Nations High-Level Meeting calling for urgent action to tackle NCDs [2]

Summary

Introduction

The growing burden of non-communicable diseases in middle-income countries demands models of care that are appropriate to local contexts and acceptable to patients in order to be effective. The achievable health benefits are large as exemplified by the rapid declines in strokerelated mortality that have occurred in most high income countries during the past four decades [6]. These gains have been elusive in many low and middle income countries, with most hypertensive individuals unaware of their risk and, even if they are aware, unable to receive treatment or achieve blood pressure control [7]

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Conclusion