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PhD defence Lana Meiqari

Completing the Circle: A Case Study of Hypertension Care and Continuity of Care at Primary Healthcare Settings in Vietnam

13 Oct 2020

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Supervisor

  • Prof. dr. Bruno Marchal (ITM)
  • Prof. dr. Fedde Scheele (VU Amsterdam)
  • Dr. Dirk Rombout Essink (VU Amsterdam)

Abstract

Providing care for patients with non-com- municable diseases needs to incorporate a chronic model of care for both prevention and disease management. Therefore, countries need to create or redesign their healthcare systems to more effectively meet the needs and expectations of patients with long-term health problems and to improve access, quality, and the provision of continuity of care. Conti- nuity of care is defined as the provision of coordinated care and services over time and across levels and disciplines, which is coherent with the patient's health needs and personal circumstances. Continuity of care has three components, namely, longitudinal care, coordinated care, and the nature of the patient-provider relationship. However, there has been limited consensus on how a health system can integrate chronic care and continuity of care for non-communicable diseases in order to pro- vide horizontal services to meet the population's needs, particularly in low- and middle-income countries that are facing additional resource constraints. Vietnam is an ideal example of a low- and middle-income country facing the double burden of communicable and non-commu- nicable diseases. Since 2000, a higher burden of hypertension has been reported and studied; in addition, services for hypertension have been established and developed at the national, provincial, district, and com- mune levels. This thesis investigates the relevance and practice of con- tinuity of care for hypertension patients in Vietnam as a case study of health systems in a resource-constrained setting, in order to expand the evidence-based knowledge on how health systems can integrate conti- nuity of care for chronic non-communicable diseases.

The structure of the thesis comprises ten chapters divided into five sec- tions. Section I (Chapters 1 to 3) lays out the theoretical and methodolog- ical dimensions employed for this thesis. Section II (Chapter 4) reviews the conceptual frameworks on continuity of care for chronic diseases in resource-constrained settings. Section III contextualizes the research by reviewing previously published literature in relation to the research ob- jective by providing an up-to-date assessment of the magnitude of hy- pertension in Vietnam (Chapter 5), and synthesizing evidence on access to hypertension care and services in primary healthcare (PHC) settings in Vietnam (Chapter 6). Section IV analyzes the primary data gathered during fieldwork at primary healthcare facilities in a rural and an urban district at Thai Nguyen and Hue provinces and discusses the findings. This section includes a description of the capacity and service delivery of hypertension care (Chapter 7) and an account of the experiences of patients and providers in regard to continuity of care for hypertension patients (Chapter 8). Section V ties together findings from various the- oretical and empirical inquiries to discuss their implications for practice and future research (Chapter g) and methodological reflections on the use of qualitative and quantitative evidence in causal reasoning (Chapter 10).

Several methodologies and methods are used across the case study. The findings show that hypertension is a significant public health problem in Vietnam. Almost one in five people may have hypertension; half of which are aware of their status, and half of those aware are treated. Awareness and treatment were much lower in rural areas. Meanwhile, patients rec- ognize their need to life-long monitoring and treatment and fear of com- plications, especially stroke. The proposed framework of continuity of care and its three dimensions has provided a good tool to conceptualize and investigate chronic care—including the interaction between patients and the health system—especially within the complexity of health sys- tems. In Vietnam, primary health care plays a key role in ensuring conti- nuity of care for many patients. Therefore, the strengthening of primary health care —as a strategic goal for healthcare delivery—enables col- laborations within the health sector and with other sectors in the pro- vision of care, including long-term care and continuity of care. For this reason, the availability and training of human resources for health at the primary healthcare level should be based on the needs of hypertension patients and the provision of continuity of care, such as expanding the role of Village or Community Health Workers. Additionally, it is necessary to provide patients with a defined minimum package of care. Within this package, improved access to primary health care guarantees proper and continuous access to essential medications, during repeat visits, within a reasonable timespan. Also, there is a need to strengthen the information management practices at the different levels of care; however, the prac- tices must also undergo a paradigm shift to go beyond programmatic monitoring and focus on patient outcomes to contribute to continuity of care. The private sector, including workers at drug stores, pharma- cies, and other types of healthcare workers, can play a role in the provi- sion of continuity of care for hypertension patients such as opportunistic screening and primary health care. Finally, the space and opportunities for experience and knowledge sharing are not limited to intercountry in- teractions but are also crucial in a decentralized system-between prov- inces or contexts in the country.

In conclusion, continuity of care and its three components of longitudinal care, coordinated care, and the nature of patient-provider relationship are key aspects of chronic or long-term care for patients with non-com- municable diseases; these can be achieved by improving access to quality primary health care at the lowest level of care. Such improve- ments must leverage on the context and the existing resources available at primary health care, and are consistent with global calls and actions towards achievement of universal health coverage, strengthening of pri- mary health care, and promotion of integrated people-centered health services.