Department of Community Programs, Dhulikhel Hospital Kathmandu University Hospital, Kathmandu University, Dhulikhel, Nepal.
National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University, Canberra, ACT, Australia.
Front Public Health. 2022 Feb 9;10:763784. doi: 10.3389/fpubh.2022.763784. eCollection 2022.
Nepal, in recent years, is witnessing an increasing problem of type 2 diabetes that has resulted significant premature deaths and disability. Prevention and management of non-communicable diseases (NCDs) including diabetes have been prioritized in the national policies and guidelines of the Nepal Government. However, research looking at the overview of the implementation of the existing policies and guidelines for diabetes prevention and control is scarce. Hence, this study reviewed diabetes related existing policies and its implementation process at the primary health care level in Nepal.
This study involved two phases: Phase I: situation analyses through review of documents and Phase II: qualitative exploratory study. In phase I, four databases (Medline, Web of Science, Embase and PubMed) were systematically searched using key search terms related to diabetes care and policies between January 2000 and June 2021. Also, relevant gray literature was reviewed to understand the trajectory of policy development and its translation with regards to diabetes prevention and management at primary health care level in Nepal. Following the phase I, we conducted in-depth interviews (IDI) and key informant interviews (KII) with health care providers, policy makers, and managers (IDI = 13, and KII = 7) at peripheral and central levels in Kavrepalanchowk and Nuwakot districts of Nepal. The in-depth interviews were audio recorded, transcribed, and coded. The triangulation of data from document review and interviews was done and presented in themes.
Four key themes were identified through triangulating findings from the document review and interviews including (i) limited implementation of policies into practices; (ii) lack of coordination among the different levels of service providers; (iii) lack of trained human resources for health and inadequate quality services at the primary health care level, and (iv) inadequate access and utilization of diabetes care services at primary health care level. Specifically, this study identified some key pertinent challenges to the implementation of policies and programs including inadequate resources, limited engagement of stakeholders in service design and delivery, lack of trained health care providers, lack of financial resources to strengthen peripheral health services, fragmented health governance, and weak reporting and monitoring systems.
This study revealed that the policies, plans, and strategies for prevention and management of NCDs in Nepal recognized the importance of diabetes prevention and control. However, a major gap remains with adequate and lack of clarity in terms of implementation of available policies, plans, strategies, and programs to address the problem of diabetes. We suggest the need for multisectoral approach (engaging both health and non-health sectors) at central as well as peripheral levels to strengthen the policies implementation process, building capacity of health care providers, ensuring adequate financial and non-financial resources, and improving quality of services at primary health care levels.
近年来，尼泊尔见证了 2 型糖尿病问题的日益严重，导致了大量过早死亡和残疾。尼泊尔政府的国家政策和准则已将包括糖尿病在内的非传染性疾病（NCD）的预防和管理列为优先事项。然而，研究很少关注现有糖尿病预防和控制政策和准则的实施概况。因此，本研究审查了尼泊尔初级卫生保健层面上与糖尿病相关的现有政策及其实施过程。
本研究分为两个阶段：第一阶段：通过审查文件进行情况分析；第二阶段：定性探索性研究。在第一阶段，使用与糖尿病护理和政策相关的关键搜索词，系统地在四个数据库（Medline、Web of Science、Embase 和 PubMed）中进行搜索，时间范围为 2000 年 1 月至 2021 年 6 月。此外，还审查了相关灰色文献，以了解政策制定的轨迹及其在尼泊尔初级卫生保健层面上与糖尿病预防和管理相关的转化。在第一阶段之后，我们在尼泊尔卡瓦普巴乔克和努瓦科特地区的周边和中心层面上对医疗保健提供者、政策制定者和管理人员进行了深入访谈（IDI=13，KII=7）。深入访谈进行了录音、转录和编码。通过文件审查和访谈进行数据三角剖分，并以主题形式呈现。
通过对文件审查和访谈的结果进行三角剖分，确定了四个关键主题，包括：（i）政策在实践中的实施有限；（ii）不同服务提供者之间缺乏协调；（iii）初级卫生保健层面缺乏经过培训的卫生人力和不充分的优质服务；以及（iv）初级卫生保健层面获取和利用糖尿病护理服务不足。具体而言，本研究发现了实施政策和方案的一些关键挑战，包括资源不足、利益相关者在服务设计和提供方面的参与有限、缺乏经过培训的卫生保健提供者、缺乏加强周边卫生服务的财政资源、分散的卫生治理以及薄弱的报告和监测系统。
本研究表明，尼泊尔预防和管理非传染性疾病的政策、计划和战略认识到了预防和控制糖尿病的重要性。然而，在实施现有政策、计划、战略和方案以解决糖尿病问题方面，仍然存在差距，且这些政策、计划、战略和方案的执行情况不够充分，也不够明确。我们建议需要在中央和周边层面采取多部门方法（包括卫生和非卫生部门），以加强政策执行过程，建设卫生保健提供者的能力，确保充足的财务和非财务资源，并提高初级卫生保健层面的服务质量。
