Ansbro Éimhín, Schmid Benjamin, Willis Ruth, M-Amen Karwan, Mahmood Kazhan, Abdulkareem Idrees, Frederiksen Signe, Roswall Jytte, Perone Sigiriya Aebischer, Roberts Bayard, Blanchet Karl, Shabila Nazar, Perel Pablo
Department of Non-communicable Disease Epidemiology, LSHTM, London, UK.
Department of Health Services Research and Policy, LSHTM, London, UK.
BMC Health Serv Res. 2025 Apr 15;25(1):548. doi: 10.1186/s12913-025-12571-6.
Experts suggest that Non-Communicable Disease (NCD) care is best delivered at the primary level, including in humanitarian crisis settings. In many crisis-affected countries, NCD care is predominantly delivered by specialists at secondary care level, and there is limited evidence on decentralising NCD care in such settings. We aimed to explore health actor and patient experiences of decentralising diabetes and hypertension (DM/HTN) care from a hospital to primary care clinics in the humanitarian setting of Duhok, Kurdistan Region of Iraq.
We conducted a qualitative study including 30 semi-structured interviews with a purposive sample of patients (n = 16), healthcare providers (n = 7), and key stakeholders (n = 7) involved in the decentralisation project. Guided by a conceptual framework, data were analysed thematically using deductive and inductive approaches. The decentralisation project achieved its stated goals of (a) increasing patients' access to DM/HTN care, by reducing cost and distance, and (b) decreasing workload at secondary care level. The approach appeared acceptable from patient, provider and stakeholder perspectives. Key health system inputs were put in place to support the decentralisation project, including medicines, equipment and health workforce training, but gaps remained. While access and quality seemed to improve, integration, continuity and sustainability were more challenging to achieve. Key systemic challenges to sustainability included a lack of health financing, and weak national supply chains and information systems. Patients' trust in the service was important and was closely linked to having access to a continuous supply of trusted medications.
While it is possible to decentralise diabetes and hypertension care from secondary to primary level in a humanitarian setting, multiple contextual factors must be considered, including supply chain strengthening and adaptation to existing workforce capacity. Our study findings may inform other actors exploring the decentralisation of NCD care elsewhere in Iraq and in other humanitarian settings.
专家建议，非传染性疾病（NCD）护理最好在基层提供，包括在人道主义危机环境中。在许多受危机影响的国家，非传染性疾病护理主要由二级护理层面的专科医生提供，而在这种环境下将非传染性疾病护理权力下放的证据有限。我们旨在探讨在伊拉克库尔德地区杜胡克的人道主义背景下，将糖尿病和高血压（DM/HTN）护理从医院下放到基层医疗诊所的卫生行为者和患者的经验。
我们进行了一项定性研究，对参与权力下放项目的患者（n = 16）、医疗服务提供者（n = 7）和关键利益相关者（n = 7）进行了有目的抽样的30次半结构化访谈。在一个概念框架的指导下，使用演绎和归纳方法对数据进行了主题分析。权力下放项目实现了其既定目标，即（a）通过降低成本和缩短距离，增加患者获得糖尿病/高血压护理的机会，以及（b）减轻二级护理层面的工作量。从患者、提供者和利益相关者的角度来看，这种方法似乎是可以接受的。为支持权力下放项目，已落实了关键的卫生系统投入，包括药品、设备和卫生人力培训，但仍存在差距。虽然可及性和质量似乎有所改善，但实现整合、连续性和可持续性更具挑战性。可持续性面临的关键系统性挑战包括缺乏卫生资金、国家供应链薄弱和信息系统不完善。患者对服务的信任很重要，并且与能够持续获得值得信赖的药物密切相关。
虽然在人道主义环境中可以将糖尿病和高血压护理从二级层面下放到基层层面，但必须考虑多个背景因素，包括加强供应链和适应现有劳动力能力。我们的研究结果可能会为其他在伊拉克其他地区和其他人道主义环境中探索非传染性疾病护理权力下放的行为者提供参考。
