National Institute of Public Health, Phnom Penh, Cambodia.
Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium.
Front Public Health. 2023 Jun 2;11:1136520. doi: 10.3389/fpubh.2023.1136520. eCollection 2023.
Non-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) pose a massive burden on health systems, especially in low- and middle-income countries. In Cambodia, to tackle this issue, the government and partners have introduced several limited interventions to ensure service availability. However, scaling-up these health system interventions is needed to ensure universal supply and access to NCDs care for Cambodians. This study aims to explore the macro-level barriers of the health system that have impeded the scaling-up of integrated T2D and HTN care in Cambodia.
Using qualitative research design comprised an articulation between (i) semi-structured interviews (33 key informant interviews and 14 focus group discussions), (ii) a review of the National Strategic Plan and policy documents related to NCD/T2D/HTN care using qualitative document analysis, and (iii) direct field observation to gain an overview into health system factors. We used a health system dynamic framework to map macro-level barriers to the health system elements in thematic content analysis.
Scaling-up the T2D and HTN care was impeded by the major macro-level barriers of the health system including weak leadership and governance, resource constraints (dominantly financial resources), and poor arrangement of the current health service delivery. These were the result of the complex interaction of the health system elements including the absence of a roadmap as a strategic plan for the NCD approach in health service delivery, limited government investment in NCDs, lack of collaboration between key actors, limited competency of healthcare workers due to insufficient training and lack of supporting resources, mis-match the demand and supply of medicine, and absence of local data to generate evidence-based for the decision-making.
The health system plays a vital role in responding to the disease burden through the implementation and scale-up of health system interventions. To respond to barriers across the entire health system and the inter-relatedness of each element, and to gear toward the outcome and goals of the health system for a (cost-)effective scale-up of integrated T2D and HTN care, key strategic priorities are: (1) Cultivating leadership and governance, (2) Revitalizing the health service delivery, (3) Addressing resource constraints, and (4) Renovating the social protection schemes.
非传染性疾病（NCDs），如 2 型糖尿病（T2D）和高血压（HTN），对卫生系统造成了巨大负担，尤其是在低收入和中等收入国家。在柬埔寨，为了解决这个问题，政府和合作伙伴已经引入了一些有限的干预措施，以确保服务的可及性。然而，需要扩大这些卫生系统干预措施的规模，以确保柬埔寨全民能够获得 NCD 护理。本研究旨在探讨阻碍柬埔寨综合 T2D 和 HTN 护理扩大规模的卫生系统宏观层面障碍。
采用定性研究设计，包括（i）半结构化访谈（33 次关键知情人访谈和 14 次焦点小组讨论），（ii）对国家战略计划和与 NCD/T2D/HTN 护理相关的政策文件进行定性文献分析，以及（iii）实地观察以全面了解卫生系统因素。我们使用卫生系统动态框架，通过主题内容分析，将宏观层面的障碍映射到卫生系统要素上。
T2D 和 HTN 护理的扩大受到卫生系统主要宏观层面障碍的阻碍，包括领导力和治理薄弱、资源限制（主要是财政资源）以及当前卫生服务提供的安排不佳。这些是卫生系统要素相互作用的结果，包括缺乏作为卫生服务提供中 NCD 方法的战略计划的路线图、政府对 NCD 的投资有限、关键行为者之间缺乏合作、由于培训不足和缺乏支持资源，医疗保健工作者的能力有限、药品供需不匹配以及缺乏用于决策的本地数据以产生基于证据的决策。
卫生系统在通过实施和扩大卫生系统干预措施来应对疾病负担方面发挥着至关重要的作用。为了应对整个卫生系统的障碍以及每个要素的相互关系，并为综合 T2D 和 HTN 护理的（成本）有效扩大规模，朝着卫生系统的结果和目标前进，关键的战略重点是：（1）培养领导力和治理，（2）振兴卫生服务提供，（3）解决资源限制，以及（4）改造社会保护计划。
