Are Urban Primary Health Care Centres in Bangladesh Prepared to Manage Non-communicable Diseases? A Mixed Methods Study

Are Urban Primary Health Care Centres in Bangladesh Prepared to Manage Non-communicable Diseases? 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A Mixed Methods Study Deepa Barua, Helen Elsey, Umme Salma Anee, Nondita Hasan, Maisha Ahsan, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8439762/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Introduction With the dual challenges of rapid urbanization and increasing prevalence of non-communicable diseases (NCDs), urban health primary health care (PHC) system in Bangladesh, like many other developing countries, is facing challenges to respond to the health needs of their populations. The objectives of the study were to: ( 1 ) assess the readiness of the urban PHC centres in managing NCDs (focusing on diabetes, hypertension and cardiovascular diseases); ( 2 ) assess the gaps in provision of NCD diagnosis, prevention and treatment within primary care in urban areas; and ( 3 ) understand the extent to which NCDs are integrated into the urban PHC system. Methods A convergent mixed methods study design was adopted. We analysed secondary data of Bangladesh Health Facility Survey, 2017, a national survey, to assess the readiness of the urban primary health-care centres to manage diabetes and cardiovascular diseases. In addition, we collected primary data through semi-structured interviews with policy makers and urban PHC centre staff in Dhaka to identify gaps in the urban primary health-care system in managing these diseases. Data was collected between March and November 2022. Results Although the urban PHC centres are required to provide all types of PHC services including NCDs, they mainly prioritise maternal and child health (MCH) and sexual and reproductive health (SRH) services, hence, male patients seldom come to these centres to seek healthcare services. NCD care has not been prioritised in the urban PHC centres. The health workforce in the urban PHC centres lacked training in NCD management. Due to lack of a strong follow-up system, it is often hard to track patients, therefore making it difficult to identify and treat patients who are at risk of developing or have already developed NCDs. The centres follow a paper-based recording system, which records particulars of patients attending the centres, however, NCD-related reporting is absent. One of the major challenges is the non- coordination of the two ministries – health and local government – for providing urban PHC including NCDs. Conclusion Integrating NCD care within urban PHC facilities needs to be prioritized by the MOHFW and MOLGRD. This would require restructuring of PHC service delivery modalities and investment in human resources, information systems and equipment, and strong leadership across ministries to mitigate the existing barriers to deliver NCD cares at PHC level. Urban health system primary health care non-communicable diseases Bangladesh Figures Figure 1 Figure 2 INTRODUCTION Longitudinal analysis of the causes of mortality in cities reveals the rising contribution of non-communicable diseases (NCDs such as cardiovascular disease, chronic respiratory disease, cancer, diabetes, and mental illnesses) in low- and high-income countries; with NCDs accountable for 7 out of the top 10 causes of deaths globally( 1 ). And a study of 173 countries over the period of 1980–2008, found that urbanisation contributed consistently to increasing NCD risk factors including body mass index (BMI) and total cholesterol levels( 2 ). This is of concern for Bangladesh since 52 million out of the 165 million people currently reside in urban areas and the majority of the population will be urban by 2039( 3 , 4 ). Surveys reveal that in urban areas of Bangladesh, consumption of fruits and vegetables and moderate to vigorous activity were low while alcohol consumption was high compared to that in rural areas( 5 ). Urban residents have higher levels of blood cholesterol and are more likely to suffer from hypertension and diabetes than those living in rural areas( 5 , 6 ). With these dual challenges of rapid urbanization and increasing prevalence of NCDs, health systems in LMICs are struggling to respond to the health needs of their populations. The complex structure of urban primary health care (PHC) systems with varying types of service providers in urban Bangladesh – public, private, and non-governmental organisations (NGOs) – further complicates this situation. Moreover, two different ministries provide PHC to urban population through different service provision modalities and limited coordination. The urban PHC system is mainly the responsibility of the Ministry of Local Government, Rural Development and Cooperatives (MoLGRDC), as per the Local Government (City Corporation) Act 2009 and Local Government (Municipality) Ordinance 2010( 7 ). However, the MoLGRDC lacks the infrastructure, human resources, budget and capability in providing quality PHC to the large and diverse urban population including slum dwellers and migrants( 8 ). Thus, MoLGRD has contracted out PHC service provision to NGOs under the Asian Development Bank (ADB), which mainly serve the poor and disadvantaged groups focusing predominantly on maternal, new-born, child and reproductive health services( 9 ). Simultaneously, urban outdoor dispensaries, outpatient departments of tertiary hospitals run by the Ministry of Health and Family Welfare (MOHFW), and private providers including consultation chambers, private clinics/diagnostic centres, pharmacies, dentist chambers, and non-formal traditional medicine doctors also provide PHC to urban( 8 , 9 ). The rapidly urbanizing population, increasing prevalence of NCDs and the complex nature of urban primary care provision makes it important to understand the extent to which NCD services are currently provided by the different urban PHC service providers to develop a more responsive and accessible urban PHC care system. Thus, the objectives of the study were to: ( 1 ) assess the readiness of the urban PHC centres in managing NCDs (focusing on diabetes, hypertension, and cardiovascular diseases); ( 2 ) assess the gaps in provision of NCD diagnosis, prevention and treatment within primary care in urban areas; and ( 3 ) understand the extent to which NCDs are integrated into the urban PHC system. METHODS Study design A convergent mixed methods study design ( 10 ) was undertaken. We analysed secondary data of a national survey Bangladesh Health Facility Survey (BHFS) ( 11 ) to assess the readiness of the urban primary health-care centres to manage diabetes and cardiovascular diseases (objective 1). In addition, we collected primary data through semi-structured interviews with policy makers and urban PHC centre staff in Dhaka to identify gaps in the urban primary health-care system in managing these diseases (objectives 2 and 3). Both the components were conducted in parallel between March and November 2022. Secondary data analysis Data source and sample The study used data from the Bangladesh Health Facility Survey (BHFS) conducted in 2017( 11 ). The BHFS is a nationally representative survey which collected data through stratified random sampling of 1600 health centres out of 19,811 registered centres. Centres included six types of public centres (community clinics, union sub-centres, union health and family welfare centres, upazila health complexes, maternal and child welfare centres (MCWC) and district hospitals (DH)), NGO clinics, NGO hospitals and private hospitals across all divisions of the country. Out of the 1600 centres randomly selected, 76 did not consent to participate in the survey. For our analysis, we included all NGO clinics located in urban areas and were either managed by the MoLGRD or by other NGOs. These centres were 66 in number and were defined as urban Primary Health Care (PHC) centres for this study. All rural PHC centres, and secondary and tertiary hospitals were excluded from the analysis. A total of 221 health care practitioners across the 66 urban PHC centres were included in our analysis. BHFS 2017 data analysis Questions and variables related to NCD services, workforce, and drugs and equipment were identified. WHO Package for Essential Non-Communicable Disease (PEN)( 12 ) was used as a reference to identify equipment and medications essential in a primary health care setting. To capture the health system factors that could potentially influence NCD service provision, questions and variables pertaining to health financing, health information system and leadership and governance were identified. Descriptive analysis was conducted of relevant variables with 95% confidence intervals (CI). This was followed by the calculation of a Facility Index (FI)( 13 – 15 ). The index was calculated by identifying 5 domains that are critical to the functioning of NCD services, namely: ( 1 ) NCD training for staff; ( 2 ) NCD guidelines; ( 3 ) NCD drugs; ( 4 ) Basic equipment; ( 5 ) Laboratory diagnostics, each of which had a set of tracer indicators. The availability of each tracer indicator per domain was assessed, across centres. This was followed by the calculation of a Domain Index (DI) across Centres. $$\:DI\:=\:\frac{Number\:of\:tracer\:indicators\:available}{Number\:of\:tracer\:indicators\:supposed\:to\:be\:available}\:X\:100$$ A Facility Index (FI) for each facility was calculated as the mean of all domain indices. $$\:FI\:=\:\frac{DI1\:+\:DI2\:+\:DI3\:+\:DI4\:+\:DI5}{5}\:$$ FI of each facility was compared to a cut-off score of 70%, as was done in other studies ( 13 – 15 ). Several of the Health System Building Block domains (see Additional File 1) did not have NCD specific data within the BHFS. Therefore, analysis of these domains was conducted based on availability in general, across PHC Centres. All analysis was done by Stata Version 14. Qualitative Study We conducted key informant interviews and in-depth interviews to identify any gaps within the urban primary health care system in managing DM, hypertension, and CVD from the perspective of policy makers and health personnel. Participants, Setting and Data collection Participants were purposively selected from both public (urban outdoor dispensaries run by MOHFW) and NGO urban PHC centres (under MOLGRD) in Dhaka North City Corporation to include a range of healthcare practitioners, project manager, Management Information System (MIS) officer and administrative staff. In addition, relevant policy makers from the Non-Communicable Disease Control (NCDC) Programme of the MoHFW and the Local Government Division (LGD) of MoLGRD&C were identified. Interviews were conducted by a team of trained postgraduates from diverse academic backgrounds with varied experience in qualitative research methods. Additionally, they received training for two days on qualitative data collection methods on topics such as taking informed consent, rapport building, orientation with the topic guide and probing. This was followed by a day for role-play and feedback. All participants were contacted by phone, prior to the interviews, to explain the research and its objectives and seek informed consent. Following consent of the participants, appointments were taken accordingly. A total of 21 semi structured interviews were conducted in Bengali following the Health System building blocks ( 16 ) domains as described in Additional File 1 [See Additional File 1]. Healthcare practitioners and facility managers were interviewed about services, guidelines, training, medications, and equipment related to NCD. In addition, they were also asked about NCD related supervision, monitoring, reporting, recording, and financing. Policy makers were questioned about the overall urban PHC system, coordination between MoLGRD and MoHFW and roles of both ministries in integrating NCD with the urban PHC system. Field notes were also made during interviews. The topic guides were refined during the data collection process, to explore emerging themes. The duration of interviews with healthcare practitioners and facility managers ranged from 40 to 60 minutes, while that of the policy makers ranged from 55 to 80 minutes (as additional explanation of questions was needed in some cases). All interviews were audio recorded and then anonymized, transcribed verbatim and cross checked for accuracy against the audio-recordings by the interviewer. While all the transcripts were typed up in Bengali, portions of them were translated into English, to share with non-Bengali speakers to support the development of the coding frame. Analysis of qualitative data Three team members involved in data collection began analysis by familiarising themselves with the interview transcripts and recordings. NVivo version 20 was used to manage the analysis. Framework approach was used to guide the analysis ( 17 ) with the Health System Building Blocks ( 16 ) as the overarching framework. Within each of these domains, sub-themes were identified based on discussion among the three independent coders who came to a consensus. The subsequent thematic framework was used to code all transcripts and then develop charts with relevant quotes added. The charted data were then reviewed to identify patterns and connections, followed by descriptive summaries of themes. In case of differences in coding arising between two researchers, the third researcher would help in clarification. Mixed Methods Integration Integration was done in order to understand the extent to which the quantitative and qualitative data corroborated or contradicted each other., we organised the results from both methods in a table under the overarching framework of the WHO Health System Building Blocks( 16 ). The similarities and differences between the quantitative and qualitative findings under each building block were considered by the research team. Descriptive analysis was conducted on relevant variables from the BHFS 2017 data which were compared to the thematic summaries from the interviews. A final column indicating the overall message, or inference, from both data sources was then completed, and comparison was done between both to identify corroborative or contradictory findings between descriptive analysis and thematic summaries( 18 – 20 ). RESULTS The 66 urban PHC centres were sampled from all the eight divisions in Bangladesh. Most of the centres were from Barisal division (25.76%), followed by Dhaka (16.67%), Khulna (15.15%), Chattogram (13.64%), Rajshahi (10.61%), Rangpur (9.09%), Mymensingh (4.55%) and Sylhet (4.55%). Out of the 21 respondents interviewed, 12 were female. There were three physicians, five paramedics, one administrative assistant, and two lab technicians, project managers and MIS officers. In addition, five policy makers were interviewed (Table 1 ). Table 1 Participant characteristics Category ID Gender Role Health Care Provider HP_A_d_02 Female Physician HP_A_d_01 Male Physician HP_B_d_01 Female Physician HP_B_d_02 Female Physician HP_A_e_01 Female Paramedic HP_A_k_01 Female Paramedic HP_B_e_01 Female Paramedic HP_A_g_01 Female Pharmacist HP_B_g_01 Male Pharmacist HP_B_f_01 Female Lab Technician HP_A_f_01 Male Lab Technician Manager and Administrative officer PM_A_a_01 Female Project Area Manager PM_B_a_01 Female Project Area Manager PM_B_b_01 Male MIS Officer PM_A_b_01 Male MIS Officer PM_A_c_01 Male Administrative Assistant Policy Maker KII_i_h_01 Female Assistant Health Officer, LGD, MoLGRDC KII_ii_i_01 Female Health System and Policy Expert KII_ii_i_02 Male Programme Manager, DGHS, MoHFW KII_ii_i_03 Male Deputy Programme Manager, DGHS, MoHFW KII_ii_i_04 Male Assistant Health Officer, LGD, MoLGRDC Health facility readiness Among the 66 urban PHC facilities from the BHFS, no centre reached the cut-off score of 70%. The highest FI scored by a facility was 68.29% while 0% was the lowest. Only 15% of the facilities scored an FI above 50% (Fig. 1 ). Additionally, while the centres may have reached the cut-off score in domains such as availability of equipment and laboratory facilities, the FI was affected by the low DI in the remaining 3 domains. The average DI for all domains was below 70%, with equipment availability scoring the highest, versus availability of drugs. 42% of the facilities scored more than 70% in equipment availability, while 21% facilities crossed the cut-off point in availability of laboratory facilities. Meanwhile only 18% and 4.54% of the facilities scored more than 70% in guideline availability and health workforce training, respectively (Fig. 2 ). Service Delivery The respondents stated that the urban PHC centres under the MoLGRD were set up to provide primary healthcare services to the urban poor, especially, women and children. Hence, male patients seldom come to these centres to seek healthcare services. “Speaking from my 17 years of experience, males do not generally come here. We have also hung a banner outside to draw their attention to the fact that we provide services for them too, but maybe there is a misconception that only mothers and children are treated here.” [PM_A_a_01, Project Manager, Urban Primary Healthcare Service Delivery Project, Female] According to the BHFS data, the patient flow was under 2000 per month in the majority of the urban PHC centres while for 36.4% of the centres, it was below 1000. A couple of the centres reported the flow to be more than 5000 patients per month but that was very rare (Table 2 ). Table 2 No. of outpatient visits per month calculated from the BHFS 2017 data Population coverage n % 95% CI 1-1000 24 36.4 24.87–49.13 1001–2000 23 34.8 23.53–47.58 2001–3000 9 13.6 6.43–24.31 3001–4000 5 7.6 2.51–16.80 4001–5000 2 3 0.37–10.52 5001–6000 1 1.5 0.04– 8.15 More than 9990 1 1.5 0.04–8.15 Don’t know 1 1.5 0.04–8.15 Around 85% of the 66 urban PHC centres reported availability of NCD diagnosis and management services in the BHFS data (Table 3 ). In-depth interviews revealed that while NCD diagnosis and management facilities are available at the centre, maternal and child health (MCH) is prioritized and NCD services are provided predominantly to pregnant women through screening and management of pre-eclampsia (a disorder of pregnancy characterised by high blood pressure) and gestational diabetes (a condition in pregnancy characterised by high blood sugar). “All the components of Primary health care are supposed to be provided in our centre, as discussed in the agreement and the Development Project Proposal. Even after that, I state in different forums that when I visit a centre it seems like the centres are only for pregnant mothers and the Expanded Programme on Immunisation for children.” [KII_ii_i_01, Policy Maker, City Corporation, Female] Many respondents stated that to be screened for Diabetes Mellitus (DM), patients are recommended to have random and fasting blood sugar tests solely based on the providers’ clinical judgement and the patients’ history. However, due to lack of a strong follow-up system, it is often hard to track patients, therefore making it difficult to identify patients who are at risk of developing, or have already developed DM. Respondents also said that patients identified to be at risk of developing NCDs are counselled about lifestyle modification while diagnosed cases are prescribed with medications in addition to being counselled, and complicated cases are referred to the nearest government or specialised hospitals. However, these practices seldom follow specific guidelines due to the lack of availability and awareness among providers about their existence. The findings from the BHFS also suggest that a little more than one-third of the 66 urban PHC centres had guidelines available (Table 3 ). “We have not worked much on the guidelines of diabetes and hypertension in our service centres, the way we have been working on communicable diseases like tuberculosis, maternal health, child health and everything. In this [NCD] case, we are lagging.” [KII_i_h_01, Policy Maker, City Corporation, Female] Table 3 Availability of NCD services and guidelines to deliver NCD care calculated from the BHFS 2017 data Report Diagnosing and managing n = 66 % 95% CI Diabetes 56 84.85 73.89–92.49 Hypertension 38 57.78 44.78–69.66 Coronary heart disease 56 84.85 73.89–92.49 Availability of Guidelines n = 66 % 95% CI Diabetes 23 34.85 23.53–47.58 Hypertension and CVD 14 21.21 12.11–33.02 Coronary Heart Disease (CHD) 20 30.3 19.59–42.85 Diagnostic facilities provided n = 66 % 95% CI Blood cholesterol testing 10 15.15 7.51–26.10 Blood glucose testing 56 84.85 73.89–92.49 Serum Creatinine testing 9 13.64 6.42–24.31 Urine protein testing 42 63.64 50.87–75.13 Urine glucose testing 42 63.64 50.87–75.13 Health Workforce The BHFS data and the interviews confirm that the health workforce in the urban PHC centres lacked training in NCD management. Even though they managed NCDs to some extent, the existing workforce made it clear during the interviews that they have never received any NCD-specific training. “The training we had was minimal in this part. Whoever works in this sector, already has prior knowledge of the technology. Though there will always be some exceptions. But the training we get is not enough compared to the training that we need to work in this sector. I doubt if I even got 8–10 training courses in my whole 22 years of career. It is also very rare that we get refresher training.” [PM_B_b_01; Project Manager, Urban Primary Healthcare Service Delivery Project, Male] The BHFS data also showed that only 41% of the centres had staff who received some training on DM management, while the number of centres with staff receiving some CVD management training was only 18% (Table 4 ). Table 4 Readiness of health workforce to deliver NCD care calculated from BHFS 2017 data Centres with workforce managing NCD n = 66 % 95% CI Diabetes 55 83.33 72.13–91.38 Cardiovascular Disease 49 74.24 61.99–84.22 Distribution of the workforce across centres for diabetes n = 221 % 95% CI Specialist 2 0.90 0.11–3.23 Medical officer 36 16.29 11.68–21.83 Paramedic 61 27.60 21.82–34.00 Nurse 1 0.45 0.01–2.5 Health Educator / Counsellor 2 0.90 0.11–3.23 Other Clinical staff 1 0.45 0.01–2.5 TOTAL 103 46.61 39.89–53.42 Distribution of the workforce across centres for CVD n = 221 % 95% CI Specialist 3 1.36 0.28–3.92 Medical officer 37 16.74 12.07–22.33 Paramedic 61 27.60 21.82–34.00 Nurse 6 2.71 1.00–5.82 Health Educator / Counsellor 3 1.36 0.28–3.92 Other clinical staff 2 0.90 0.11–3.23 TOTAL 112 50.68 43.89–57.45 Centres with staff who have received NCD training within last 2 years (from the date of the survey) n = 66 % 95% CI Diabetes 27 40.91 28.95–53.71 CVD 12 18.18 9.76–29.61 Distribution of the workforce who received DM training across centres n = 221 % 95% CI Medical officer 9 4.07 1.88–7.59 Paramedic 19 8.60 5.26–13.1 Nurse 1 0.45 0.01–2.5 Health Educator / Counsellor 2 0.90 0.11–3.23 TOTAL 31 14.03 9.73–19.32 Distribution of the workforce who received CVD training across centres n = 221 % 95% CI Specialist 1 0.45 0.01–2.5 Medical officer 4 1.81 0.50–4.57 Paramedic 7 3.17 1.28–6.42 Nurse 2 0.90 0.11–3.23 Health Educator / Counsellor 1 0.45 0.01–2.5 TOTAL 15 6.79 3.85–10.95 46.61% and 50.68% of the 221 healthcare practitioners in BHFS were reported to manage diabetes and CVD respectively among whom around 95% were females. In-depth interviews of respondents revealed this to be a deliberate recruitment criterion, as patients were often uncomfortable taking healthcare from the workforce of the opposite gender and most patients at centres are in practice women and children. However, this was also attributed as a reason for a smaller number of male patients at the centres: “Males come here for vaccination now but not for general treatment. It may be because most of our service providers are women. It is seen that males do not prefer female doctors and females do not prefer male doctors. This is a practice among slum dwellers.” [PM_B_a_01; Project Manager, NGO urban PHC centre, Female] There were only three specialists working across all the centres, of whom two were gynaecologists and one was a paediatrician. Most centres had medical officers who were medical graduates, while paramedics were the most common staff cadre across the centres. Drugs and Equipment The NGO urban PHC centres buy drugs from pharmaceutical companies quarterly based on their need as identified by prescribing practitioners. “We get a requisition from the doctor every quarter and purchase medicine according to that.” [PM_B_a_01, Project Manager, NGO urban PHC centre, Female] “We consult about the necessary medicine with our doctors and send the requisition list to the Project Management office. it is approved from here and they give the medicine during the quarterly medicine supply”. [HP_B_g_01, Service Provider, NGO urban PHC centre, Male] Majority of the respondents during the interviews stated that NCD medications recommended by the WHO PEN protocol were seldom seen at urban PHC centres. This is consistent with BHFS data, according to which more than 50% of the centres did not have any NCD medications (Table 5 ). In centres which did have them, antihypertensive medications were found to be more common in contrast to drugs for DM. According to the respondents, the availability of NCD medications at urban PHC centres often depends on those safe for use during pregnancy and breastfeeding and need of the same at the centres. “Basically, diabetic drugs are not available here, but antihypertensive medicines are available. We take Amlodipine, and Nifedipine (antihypertensive medicines) since we deal with pregnant mothers and these drugs are required during pregnancy.” [PM_A_a_01, Project Manager, NGO urban PHC centre, Female] Similarly, screening for hypertension is generally easier to obtain than for DM at urban PHC centres due to the higher availability of sphygmomanometers compared to Glucometers, as stated by the respondents. Though Glucometers exist in some urban PHC centres, in some cases health workers were found to be unfamiliar with how glucometers are operated. Table 5 Availability of basic equipment and essential medicines across facilities as per WHO PEN protocol to deliver NCD care calculated from BHFS 2017 data Basic Equipment as per WHO PEN protocol Basic Equipment available n = 66 % with equipment available 95% CI Weighing scale 56 84.85 73.89–92.49 Stadiometer 48 72.73 60.36–82.97 Measuring tape 45 68.18 55.56–79.11 Thermometer 55 83.33 72.13–91.38 Manual BP apparatus 54 81.82 70.39–90.24 Stethoscope 55 83.33 72.13–91.38 Pulse Oximeter 10 15.15 7.51–26.10 Filled oxygen cylinder 23 34.85 23.53–47.58 Glucometer 46 69.70 57.15–80.41 Glucometer strips 44 66.67 53.99–77.80 Essential Medications as per WHO PEN protocol Medications for HTN and CVD n = 66 % with medicines available 95% CI Amlodipine 9 13.64 6.42–24.31 Atenolol 17 25.76 15.78–38.01 Captopril 2 3.03 0.37–10.52 Enalapril 2 3.03 0.37–10.52 Losartan Potassium 10 15.15 7.51–26.10 Epinephrine Injection 1 1.52 0.03–8.16 Frusemide 7 10.61 4.37–20.64 Thiazide 1 1.52 0.03–8.16 Heparin Injection 1 1.52 0.03–8.16 Clopidogrel 2 3.03 0.37–10.52 Aspirin 6 9.09 3.41–18.74 Isosorbide Dinitrate 1 1.52 0.03–8.16 Glycerine Trinitrate 3 4.55 0.95–12.71 Nifedipine 8 12.12 5.38–22.49 Simvastatin 2 3.03 0.37–10.52 Atovastatin 8 12.12 5.38–22.49 Rosuvastatin 2 3.03 0.37–10.52 Medicines for Diabetes n = 66 % with medicines available 95% CI Glibenclamide 2 3.03 0.37–10.52 Glucose Injectable 4 6.06 1.68–14.80 Insulin Injections 1 1.52 0.03–8.16 Metformin Tablets 14 21.21 12.11–33.02 Gliclazide Tablet 6 9.09 3.41–18.74 Glimepiride Tablet 2 3.03 0.37–10.52 Health Financing Interviews of respondents revealed that NGO run urban PHC centres under the Urban Primary Health care Project operate on funds received from MoLGRDC and Asian Development Bank (80%), while the remainder is generated from patients. The budget allocated by MoLGRDC is spent mostly on purchasing MCH and SRH-related drugs and equipment leading to a low supply of NCD-related equipment and medications. “There is no disease-wise allocation. I mean, it runs through the funds we receive but when we apply for the project, we set certain targets that we would provide a particular percentage of funds for a particular service, e.g. this much percentage for a certain number of deliveries. We do not have any separate target for NCDs and no separate fund for it or other diseases.” [PM_A_a_01; Project Manager, NGO under Urban Primary Healthcare Service Delivery Project, Female] The respondents stated that NGO centres provide free services to at least 30% of households in their catchment area. Each centre has a list of slums in their operational area, and they use a survey tool developed by the MoLGRDC to identify the most financially needy people in those slums. A scorecard is filled up through the survey where the slum population is classified into 3 categories; impoverished (scoring 0–20), poor (scoring 21–30) and not poor (scoring 31–40). “They have a form designed by ADB and LGD (Local Government Division). It contains what we will ask…if his score is under 20, he is impoverished, and if within 20–30, he is poor.” [PM_B_a_01; Project Partnership Area Manager, Urban Primary Healthcare Project, Female] The poverty-stricken households which are identified through the survey receive an Essential Health Card (commonly known as the “Red Card”) which allows them to avail all services for free at the centres. The lower the score of someone, the higher the possibility of them getting a Red card. “We need to bring at least 30 percent of the population under the red card scheme that will allow us to provide them completely free healthcare from normal delivery to C-section and all other services. After their detection as impoverished, we provide a red card for the whole family with photos of all family members attached to it. When any one of the family members shows us the card, we provide them free treatment.” [PM_A_a_01; Project Partnership Area Manager, Urban Primary Healthcare Project, Female] The non-poor population, on the other hand, pay user fees for services and medicines. This service fee was found to be 50 Bangladeshi taka (around USD 0.47) across all the urban PHC centres included in the qualitative study, which is usually supposed to be affordable for most of the patients. The BHFS data showed that this fee is routinely collected in all the urban PHC centres but in most centres, the fee is subsidised for the extremely needy (see in Table 6 ). The respondents stated that there is no proper regulation or guideline regarding how this is implemented. In most cases, the amount of subsidy or who receives the benefit depends on the service providers of that centre. Of the non-poor patients, those who cannot afford to pay the full amount for the services or medications may get a 15–30% discount, once approved by the facility manager. “To provide drugs to patients who are poor but don't have a red card, at a discounted rate, we need to get a signature from the doctor & administration of the facility.” [HP_A_f_01, Service Provider, NGO under Urban Primary Healthcare Service Delivery Project, Male] In terms of financing of the health Centres, it was found that most of the urban PHC centres were funded by development partners, while user fees were the 2nd most predominant source of financing (Table 6 ). Table 6 Types of health financing, availability of health information system, supervision and quality control at urban PHC centres, calculated from BHFS 2017 data. HEALTH FINANCING n = 66 % 95% CI Sources of Revenue/Fund Donor agencies / NGOs 55 83.33 72.13–91.38 User fees 30 45.45 33.14–58.19 Govt. contribution to private 6 9.09 3.41–18.74 Community Programmes 4 6.06 1.68–14.80 Public ministries 3 4.55 0.95–12.71 Others (not specified) 2 3.03 0.37–10.52 Collection of regular user fee 66 100 94.56–100 Exemption/Subsidised user fee 63 95.45 87.29–99.05 HEALTH INFORMATION SYSTEM Computer 50 75.76 63.64–85.46 Access to internet 52 78.79 66.98–87.89 System to compile health service data 64 96.97 89.48–99.63 Person designated for health statistics 27 42.19 28.95–53.71 LEADERSHIP AND GOVERNANCE n = 49 % 95% CI External supervision 65 98.48 91.84–99.96 Routine quality assurance activities conducted n = 66 % 95% CI Yes 49 74.24 61.99–84.22 No 17 25.75 15.78–38.01 Maintenance of yearly official records of quality assurance n = 49 % 95% CI Yes 44 89.80 77.77–96.60 No 5 10.20 3.40–22.23 Activities during supervisory visit n = 49 % 95% CI Using a checklist to assess the quality of available health services data 52 83.87 66.98–87.89 Discussing the performance of the facility based on available health services data 61 98.39 83.20–97.49 Provision of written comments by supervisors 62 93.94 85.20–98.32 Health Information System Majority of the respondents stated that the centres follow a paper-based recording system, which records particulars of patients attending the centres, and the service for which they may have come. There are multiple register books at every provider’s desk for data entry, which are aggregated by the Administrative Assistant based on templates and sent to the Management Information System (MIS) officer of the project area every month. The MIS officer prepares a digital report to be sent to the project implementation unit (PIU), which is then passed on to the Project Management Unit (PMU) at the Local Government Division under MoLGRD. While most of the centres were found to have an existing health information system, less than 50% of the urban PHC centres had personnel allocated to manage health-related data. “As you can see here, we have so many books for keeping records of the patients. For one patient you need to keep so many records, so of course, it’s very tough to maintain them all the time. We deliver written reports. It would have been easier if we had a computer or printer. Writing 50 reports manually for 50 patients with many of them having 7 to 8 different tests, is a very difficult task. Handwriting varies from person to person and often doctors struggle to read poor handwriting. Having a computer would have made it better. We could get a good quality report as well.” [HP_A_f_01, Service Provider, NGO under Urban Primary Healthcare Service Delivery Project, Male] There is no separate register book for keeping the information of patients at risk of developing any NCDs, and records for even those already diagnosed with NCDs are not maintained. Hence, NCD-related reporting is absent too. The services provided for hypertension and DM are recorded as “Limited Curative Care” (LCC) in a column on the master register, and not reported in detailed categories. “We have an LCC (Limited Curative Care) category system. There is no separate category of hypertension patients, so the reporting is not proper. Though we do not keep a record of hypertension separately, we provide diagnosis and treatment.” [HP_A_d_01, Service Provider, NGO under Urban Primary Healthcare Project, Male] Patients attending the Centres are given an ID in the form of a registration number and are given a patient card which is usually valid for 5 years. However, in case the patient misplaces the card, or when it is time for renewal, he/she is given a new registration number which is not linked to the previously given ID. In addition, individual patient recordrecords are not maintained for NCD management, follow-up, or referral of patients. Hence, specific records pertaining to referrals or follow-up visits are absent. Leadership and Governance Interviews have revealed the lack of coordination between the MoHFW and MoLGRDC. The MoHFW is responsible for developing health-related policies including several that prioritise the control of major NCDs in the country. In addition, the Directorate General of Health Services (DGHS) under MoHFW has a dedicated programme for NCD Control (NCDC). But a lack of coordination across the ministries means that these policies are not translated by the MoLGRDC into implemented service provisions in urban areas. “So far, I know our Ministry of Health is doing plenty of work on NCD, but NCD is not quite focused on in our (urban) primary health care system. ” [KII_i_h_01; Policy Maker, City Corporation, Female] This lack of coordination has been acknowledged by both ministries, especially the MoHFW. Interviews revealed that the increase in NCD risk factors predominantly among urban slum dwellers should lead to greater prioritisation of the urban primary health care system in the national policies, such as the Strategic Investment Plan of the 5th Health, Nutrition and Population Sector Programme. The current plan, the 4th Health, Population and Nutrition Sector Programme (HPNSP) focuses policy more on NCD services in rural areas. “It is true, while NCD services have been prioritised in the rural health system, the urban primary health care system has been completely neglected. However, there are plans of prioritising the urban health system in the upcoming HPNSP. Even within the current HPNSP, we can support the urban primary health care centres by developing their capacity or conducting Training of Trainers with their Chief Health Officer. We can coordinate with the Health department existing within the MoLGRDC to identify ways of supporting them to control NCDs.” [KII_i_h_01; Policy Maker, City Corporation, Female] Necessary supervision and regular monitoring are required for ensuring quality control of the urban PHC centres. The data from BHFS showed that almost all the urban PHC centres (98.48%) had some sort of external supervision. According to the BHFS data, in 49 of the 66 urban PHC centres included in the study routine quality assurance was conducted. Out of these 49, 44 centres maintained official records of quality assurance activities for the past year. A checklist was used to assess the quality of available health services data in almost 84% of the centres during supervisory visits. During those visits, the supervisory team discussed the performance of the centres with the relevant staff of that centre based on this health service data. Additionally, almost 94% of the centres reported that the supervisors provided written comments about various aspects during these visits. However, they were not NCD-specific. Information from the qualitative interviews also revealed that most of the centres have a monitoring and supervision mechanism. Doctors posted in all the urban PHC centres also work as clinical in-charge of their centres and supervise the overall activity of that centre. Moreover, the urban PHC centres fall under different project areas, and in each project area, there is a project manager (PM) and an MIS officer who supervises all the centres in that specific area. Apart from them is the Project Management Unit which consists of the project director and deputy project directors. The Project Management Unit visits all the urban PHC centres in the city corporation area one by one and each centre is inspected quarterly. “There are monitoring officers. We have two units in this project. One is the project management unit, and one is the project implementation unit. Our chief health officer is the program manager in the project implementation unit. There are program officers and monitoring officers working under him. [PM_A_a_01, Project Manager, Urban Primary Healthcare Service Delivery Project, Male] “We have visitors from the city corporations. They visit after 15 days or 1 month and we even get visitors from our PM office. They visit twice or once a month. They do an overall check of whether everything is working well or not, whether we are keeping the record or not, whether Patients have any objections or not, tests are running smoothly or not, freezing temperature is ok or not- so all these. They check the freezer, its temperature, expiry date of a reagent, register book, patient volume and all. ” [HP_A_f_01, Service Provider, NGO under Urban Primary Healthcare Project, Male] However, supervising the NCD management at the urban primary health system, which operates under a different ministry, has been close to none from the NCDC, MOHFW. DISCUSSION The objective of this study was to identify the readiness of the urban primary health care centres to manage major NCDs particularly Diabetes, Hypertension and Cardiovascular disease. Our findings suggest that the urban PHC system does not prioritize NCD management to achieve national NCD targets. We found that most of the urban PHC centres do not comply with the WHO recommendations to manage NCDs( 21 ). Primary health care approach offers a wider opportunity for NCD prevention and control; however, its potential is not fully utilized in the many developing countries ( 22 , 23 ). We also found that primary health care facilities in urban areas in Bangladesh lack trained health workforce, nationally agreed essential medicines and equipment to manage NCD care, and the urban PHC system does not prioritize NCD management. The findings are similar to other South East Asian countries, where primary health care systems provide reactive and episodic responses, and inadequate capacity to manage lifelong long-term chronic care remained one of the key reasons for low performance in NCD control and management( 22 ). Evidence suggests that addressing NCD burden requires a primary care approach based on a trained primary care team providing a people-centric, comprehensive, integrated and equitable care ( 22 , 23 ). The urban primary health care systems in Bangladesh provide ample opportunities to improve management of NCD services through primary health care facilities. Appropriate policies, cost-effective interventions, sustained efforts and commitments are required for integrating NCD control at urban primary health care level ( 22 , 23 ). There is a striking contrast between the clear structure of rural PHC and the less clear and often chaotic structure of urban PHC. In rural areas, MOHFW has a consistent hierarchy of community clinics, Union Sub-Centres and Upazilla Health Complexes with referral between. In contrast, the structure of urban PHC services depends on NGO and private providers to deliver services( 8 ). Additionally, while rural health centres have dedicated NCD provision through the NCD corners with a dedicated medical officer for the management of NCDs ( 24 ), no such areas or dedicated workforce exists in the urban PHC centres. With the aim of achieving Universal Health Coverage (UHC) by 2030, the MoHFW has revised the Essential Service Package (ESP) and included NCDs. While the package, including the NCD component, is being delivered at rural PHC centres ( 15 , 25 ) it is largely absent in urban PHC centres. Urban PHC centres in Bangladesh predominantly provide MCH and SRH services ( 26 ) with most of the patients being pregnant women ( 27 ), whose blood pressure and glucose levels are often checked to prevent preeclampsia and gestational diabetes, which was found to be similar to urban PHC centres in Nigeria( 28 , 29 ). It would, therefore, be inaccurate to say that NCD services are not provided at urban PHC centres at all. However, screening of men and non-pregnant women for hypertension and diabetes depends solely on the clinician’s judgement, based on their history. This has now become a vicious circle - as majority of the patients are pregnant women, the centres provide MCH care; and as they provide mainly MCH care, NCD patients who do not require MCH care do not generally visit these centres. This scenario is a contrast to neighbouring country India wherein majority of patients visiting urban PHC centres are males ( 30 ), and 89.5% urban PHC centres provide screening services for NCDs( 31 ). Another study in an urban PHC centre in a municipal area in Nigeria reported providing various NCD services ranging from screening to follow-up( 28 ). While most rural PHC facilities have medicine specialists (in addition to gynaecologists and paediatricians) who are often responsible for managing NCD related complications. In contrast, specialists at urban PHC facilities are limited to gynaecologists and paediatricians due to prioritization of MCH and SRH at these facilities. Urban PHC medical staff are seldom invited to NCD-focused training conducted by the MoHFW although some training may occur through NGOs running the services. Contrarily, rural PHC providers are provided NCD training through the MoHFW although even in these areas the training remains inadequate ( 15 , 25 , 32 ). Consequently, most of the patients attending the urban PHC centres are managed by staff who have received little or no training since their graduation ( 33 ). Alternatively, 95% of appointed urban PHC workforce in Myanmar have reported receiving NCD management training( 14 ). Hence, well-timed training of urban primary health care workforce needs to be planned so the urban primary health care workforce can prevent and manage NCDs effectively. Though often inadequate, rural PHC centres receive NCD medications from the NCDC program under the MoHFW which are given to patients for free ( 32 , 34 , 35 ). Urban PHC centres, on the other hand mainly procure medications for MCH and SRH, and place low priority on buying NCD drugs, leading to poor availability of NCD drugs at these centres. In contrast, around 80% and 90% urban PHC centres in report the availability of NCD medication such as Amlodipine (an antihypertensive drug) and Metformin (anti-diabetic medication) in India and Myanmar respectively( 14 , 31 ). Adequate budgetary allocation for the urban PHC system especially for medicine and equipment is required. In rural PHC centres, NCD registers are maintained to record newly and already diagnosed NCD patients ( 24 ), which are reported to the MoHFW for the MIS dashboard ( 34 , 36 ). In urban areas, in contrast, there is no such record keeping making it difficult to track both aggregate workloads of health centres and treatment for individual patients. Meanwhile, in Myanmar 100% PHC centres in an urban area reported the availability of NCD patient record forms and patient register ( 14 ). Additionally, separate NCD monitoring and reporting mechanism was reported in primary health care centres in a municipal area in Nepal followed by discussion of NCD data during monthly monitoring meetings, which was then used in annual reports at a federal level( 37 ). While a study India, reported the use of paper based, patient-held medical records for NCD patients at urban PHC centre, although inadequate( 38 ), another study reported better maintenance of NCD records at urban PHC compared to private centres( 39 ). Integration of NCD management and risk data from the urban primary health care centres into the MoHFW dashboard can provide a comprehensive view of the urban primary health care centres, thereby supporting the MoHFW to develop urban friendly evidence-based policies for NCD management ( 34 ). There remains a financial barrier to access urban health services for most of the population. The urban PHC centres provide all services inclusive of NCD care for free only to those who are registered with an ‘Entitlement Card’ ( 40 ). Yet, those with the cards form only 30% of the urban dwellers, and individuals who are still poor but are above the threshold to qualify for a red card must pay for primary care services. Meanwhile, 94.8% urban PHC centres in Myanmar reported availability of free of charge services which was in line with their health policy( 14 ). Evidence suggests that many developing countries have prioritised strengthening PHC systems to achieve Universal Health Coverage (UHC); hence provide free primary care to all citizens( 41 ). The National Health Policy 2011 and Multisectoral Action Plan have highlighted the need for collaboration between MoHFW and MoLGRD and capacity development of urban PHC staff for NCD management in urban areas ( 42 , 43 ). However, inadequate coordination between MoHFW and MoLGRD has led to an absence of MoHFW initiatives to control NCDs, such as development of the guidelines for Management of Diabetes and ( 44 ), handbooks enlisting the roles and responsibilities of PHC centre staff in NCD management, NCD registers, patient cards, flip books and medications among urban PHC centres. Studies in similar contexts suggest that multisectoral collaboration is essential to tackle NCDs at primary care level( 45 ). Stronger coordination is required between the MoLGRDC and MoHFW to strengthen NCD management at urban PHC centres. The study had some limitations. First, in the absence of any latest national survey data, the BHFS 2017 data had been used for the analysis. Though the in-depth interviews and several documents suggest that the scenario had not changed much since 2017, the scope of analysing latest data would have strengthened the study. Despite the limitations, this is the first study that presents the FI and DI for NCD management in urban primary health care facilities using the BHFS data in Bangladesh. Second, the healthcare practitioners for in-depth interviews were selected mainly from Dhaka. Interviewing respondents from other urban areas could have brought additional insights. A further study is required to identify the sustainable solutions to overcome the barriers in providing NCD care in urban PHC facilities, and to design, implement and assess the effectiveness and cost-effectiveness of innovative interventions to integrate the NCD care within urban primary health care systems. CONCLUSION A rapidly growing urban population, coupled with a rise in the prevalence of NCD risk factors in the urban slums, calls for prioritisation of NCD management within the urban primary health system. Though the current Health, Population and Nutrition Sector Programme (4th HPNSP, 2017–2024) focuses on strengthening the primary health care centres to manage NCDs, this has been focused towards the rural PHC centres, while the urban PHC centres are yet to be prioritized in the programme ( 46 ). The MOHFW has a strong commitment to combating NCDs, and similar prioritisation is required to integrate NCD at the urban primary health care level. Strengthening PHC systems for NCDs would require restructuring of PHC service delivery modalities to mitigate the existing barriers to PHC service delivery for NCDs. Declarations FUNDING This study is a part of a larger study titled “Strengthening the Urban Primary Health Care System to Deliver Essential Non-Communicable Disease Care to the Urban” under the project titled Community-Led Responsive and Effective Urban Health Systems (CHORUS) and is funded by the UK Aid from the UK Government, Grant 301132; however, the views expressed do not necessarily reflect the UK government’s official policies. CONFLICT OF INTEREST None ETHICAL APPROVAL AND CONSENT TO PARTICIPATE The study has received Ethical Clearance from the University of Leeds (No. MREC 21-008 CHORUS) and Bangladesh Medical and Research Council (BMRC) (BMRC/NREC/2019 -2022 / 485). All participants gave written informed consent to participate in the study. As data from BHFS 2017 was secondary for this study, ethical clearance was not required its’ analysis. CONSENT FOR PUBLICATION Yes DATA AVAILABILITY The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. MATERIALS AVAILABILITY Not Applicable CODE AVAILABILTY Not Applicable AUTHORS’ CONTRIBUTION Conceptualized and supervised the study: DB, HE, TE, KI, RC, RH Conducted and analysed interviews, coded and drafted narrative summaries: USA, NH, MA Supervised analysis of interviews: HE Analysed secondary data and drafted quantitative results: USA, MS Supervised secondary data analysis: TE Integrated quantitative and qualitative findings and drafted results: FK Supervised integration: HE and TE Contributed to the writing of the manuscript: DB, MS, FK Reviewed and made comments for important revisions in the draft manuscript: RH, HE, TE, KI, RC ACKNOWLEDGEMENTS We are grateful to the respondents of the study who participated in this study, and would also like to thank the healthcare facilities and the following individuals for facilitating the study: Dr. Mahmuda Ali, Assistant Health Officer, Dhaka North City Corporation. Dr. Shamsunnahar, Project Manager, Dhaka North City Corporation. Rehana Akter Mita, Project Manager, Dhaka North City Corporation Additionally, we would like to thank other members of our research team: Dr. Joseph Hicks, Lecturer in Medical Statistics, University of Leeds. Dr. Mahua Das, Lecturer in International Health, University of Leeds S M Abdullah, Associate Professor, Department of Economics, University of Dhaka. Sushama Kanan, Research Fellow, ARK Foundation. Dr. Mumtahena Nabi, Research Associate, ARK Foundation Fatema Al Kadri, Research Assistant, ARK Foundation. Md. Shakhawat Hossain Rana, Research Assistant, ARK Foundation Finally, we would like to extend our gratitude to our families for their constant support. References Khor N, Arimah B, Otieno R, Van Oostrum M, Mutinda M, Martins J. World Cities Report 2022 Envisaging the Future of Cities. United Nations Human Settlements Programme (UN-Habitat); 2022. Goryakin Y, Rocco L, Suhrcke M. 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Ministry of Health and Family Welfare, Government of peoples republic of Bangladesh; 2017. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 17 Feb, 2026 Reviewers invited by journal 17 Feb, 2026 Editor invited by journal 31 Dec, 2025 Editor assigned by journal 31 Dec, 2025 Submission checks completed at journal 31 Dec, 2025 First submitted to journal 24 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8439762","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":584220768,"identity":"185bcc24-9f19-473b-9bbf-85f1392feea8","order_by":0,"name":"Deepa 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Anee","email":"","orcid":"","institution":"ARK Foundation","correspondingAuthor":false,"prefix":"","firstName":"Umme","middleName":"Salma","lastName":"Anee","suffix":""},{"id":584220771,"identity":"4e897ac9-dcd1-44a1-93d6-2556896d10a0","order_by":3,"name":"Nondita Hasan","email":"","orcid":"","institution":"ARK Foundation","correspondingAuthor":false,"prefix":"","firstName":"Nondita","middleName":"","lastName":"Hasan","suffix":""},{"id":584220772,"identity":"fbeead64-fffd-4a7d-b5d4-ff1c75c98578","order_by":4,"name":"Maisha Ahsan","email":"","orcid":"","institution":"ARK Foundation","correspondingAuthor":false,"prefix":"","firstName":"Maisha","middleName":"","lastName":"Ahsan","suffix":""},{"id":584220773,"identity":"e1faf9f7-751c-4904-8dcb-761d9e78b71a","order_by":5,"name":"Masroor Salauddin","email":"","orcid":"","institution":"ARK Foundation","correspondingAuthor":false,"prefix":"","firstName":"Masroor","middleName":"","lastName":"Salauddin","suffix":""},{"id":584220774,"identity":"22185be4-1089-4852-b3d4-ceb0f2aa615a","order_by":6,"name":"Fatema Kashfi","email":"","orcid":"","institution":"ARK Foundation","correspondingAuthor":false,"prefix":"","firstName":"Fatema","middleName":"","lastName":"Kashfi","suffix":""},{"id":584220775,"identity":"649ff160-f445-46ff-8c06-a5d27d48434c","order_by":7,"name":"Khaleda Islam","email":"","orcid":"","institution":"ARK Foundation","correspondingAuthor":false,"prefix":"","firstName":"Khaleda","middleName":"","lastName":"Islam","suffix":""},{"id":584220776,"identity":"0767abc4-fa80-458d-89e0-153f5067a918","order_by":8,"name":"Rahat Chowdhury","email":"","orcid":"","institution":"Directorate General of Health Services","correspondingAuthor":false,"prefix":"","firstName":"Rahat","middleName":"","lastName":"Chowdhury","suffix":""},{"id":584220777,"identity":"01cbb726-86a1-48cc-96ab-207bc144973f","order_by":9,"name":"Tim Ensor","email":"","orcid":"","institution":"University of Leeds","correspondingAuthor":false,"prefix":"","firstName":"Tim","middleName":"","lastName":"Ensor","suffix":""},{"id":584220778,"identity":"6cd7c4d9-6994-48e4-9c50-4a3e71ab3c99","order_by":10,"name":"Rumana Huque","email":"","orcid":"","institution":"ARK Foundation","correspondingAuthor":false,"prefix":"","firstName":"Rumana","middleName":"","lastName":"Huque","suffix":""}],"badges":[],"createdAt":"2025-12-24 06:53:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8439762/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8439762/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102311240,"identity":"fa442183-9340-4d13-a241-4e3fd30c1f49","added_by":"auto","created_at":"2026-02-10 11:57:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":135054,"visible":true,"origin":"","legend":"\u003cp\u003eFacility Readiness across urban PHC centres\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8439762/v1/dd3c5f27c033a8bcddb9bb36.png"},{"id":102310720,"identity":"6a3e935f-1b9d-4bb6-af0a-5ca77359c0c2","added_by":"auto","created_at":"2026-02-10 11:55:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":123959,"visible":true,"origin":"","legend":"\u003cp\u003eMean, maximum and minimum Domain indices scored by facilities\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8439762/v1/3e5f77e15d25b267b880ab00.png"},{"id":102311987,"identity":"4f8ee479-3668-42ea-afc0-a1493e29cd73","added_by":"auto","created_at":"2026-02-10 11:59:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1938435,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8439762/v1/51665da3-92ed-4dba-80b9-578ca871376c.pdf"},{"id":102310776,"identity":"0956ba87-b3a5-49d2-a135-832dfcdc178f","added_by":"auto","created_at":"2026-02-10 11:56:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":29570,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8439762/v1/80d906aabd21d064303eb2ea.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAre Urban Primary Health Care Centres in Bangladesh Prepared to Manage Non-communicable Diseases? A Mixed Methods Study\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eLongitudinal analysis of the causes of mortality in cities reveals the rising contribution of non-communicable diseases (NCDs such as cardiovascular disease, chronic respiratory disease, cancer, diabetes, and mental illnesses) in low- and high-income countries; with NCDs accountable for 7 out of the top 10 causes of deaths globally(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnd a study of 173 countries over the period of 1980\u0026ndash;2008, found that urbanisation contributed consistently to increasing NCD risk factors including body mass index (BMI) and total cholesterol levels(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This is of concern for Bangladesh since 52\u0026nbsp;million out of the 165\u0026nbsp;million people currently reside in urban areas and the majority of the population will be urban by 2039(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Surveys reveal that in urban areas of Bangladesh, consumption of fruits and vegetables and moderate to vigorous activity were low while alcohol consumption was high compared to that in rural areas(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Urban residents have higher levels of blood cholesterol and are more likely to suffer from hypertension and diabetes than those living in rural areas(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith these dual challenges of rapid urbanization and increasing prevalence of NCDs, health systems in LMICs are struggling to respond to the health needs of their populations. The complex structure of urban primary health care (PHC) systems with varying types of service providers in urban Bangladesh \u0026ndash; public, private, and non-governmental organisations (NGOs) \u0026ndash; further complicates this situation. Moreover, two different ministries provide PHC to urban population through different service provision modalities and limited coordination. The urban PHC system is mainly the responsibility of the Ministry of Local Government, Rural Development and Cooperatives (MoLGRDC), as per the Local Government (City Corporation) Act 2009 and Local Government (Municipality) Ordinance 2010(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, the MoLGRDC lacks the infrastructure, human resources, budget and capability in providing quality PHC to the large and diverse urban population including slum dwellers and migrants(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Thus, MoLGRD has contracted out PHC service provision to NGOs under the Asian Development Bank (ADB), which mainly serve the poor and disadvantaged groups focusing predominantly on maternal, new-born, child and reproductive health services(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSimultaneously, urban outdoor dispensaries, outpatient departments of tertiary hospitals run by the Ministry of Health and Family Welfare (MOHFW), and private providers including consultation chambers, private clinics/diagnostic centres, pharmacies, dentist chambers, and non-formal traditional medicine doctors also provide PHC to urban(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe rapidly urbanizing population, increasing prevalence of NCDs and the complex nature of urban primary care provision makes it important to understand the extent to which NCD services are currently provided by the different urban PHC service providers to develop a more responsive and accessible urban PHC care system. Thus, the objectives of the study were to: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) assess the readiness of the urban PHC centres in managing NCDs (focusing on diabetes, hypertension, and cardiovascular diseases); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) assess the gaps in provision of NCD diagnosis, prevention and treatment within primary care in urban areas; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) understand the extent to which NCDs are integrated into the urban PHC system.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA convergent mixed methods study design (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) was undertaken. We analysed secondary data of a national survey Bangladesh Health Facility Survey (BHFS) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) to assess the readiness of the urban primary health-care centres to manage diabetes and cardiovascular diseases (objective 1). In addition, we collected primary data through semi-structured interviews with policy makers and urban PHC centre staff in Dhaka to identify gaps in the urban primary health-care system in managing these diseases (objectives 2 and 3). Both the components were conducted in parallel between March and November 2022.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSecondary data analysis\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData source and sample\u003c/h2\u003e \u003cp\u003eThe study used data from the Bangladesh Health Facility Survey (BHFS) conducted in 2017(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The BHFS is a nationally representative survey which collected data through stratified random sampling of 1600 health centres out of 19,811 registered centres. Centres included six types of public centres (community clinics, union sub-centres, union health and family welfare centres, upazila health complexes, maternal and child welfare centres (MCWC) and district hospitals (DH)), NGO clinics, NGO hospitals and private hospitals across all divisions of the country. Out of the 1600 centres randomly selected, 76 did not consent to participate in the survey.\u003c/p\u003e \u003cp\u003eFor our analysis, we included all NGO clinics located in urban areas and were either managed by the MoLGRD or by other NGOs. These centres were 66 in number and were defined as urban Primary Health Care (PHC) centres for this study. All rural PHC centres, and secondary and tertiary hospitals were excluded from the analysis. A total of 221 health care practitioners across the 66 urban PHC centres were included in our analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBHFS 2017 data analysis\u003c/h3\u003e\n\u003cp\u003eQuestions and variables related to NCD services, workforce, and drugs and equipment were identified. WHO Package for Essential Non-Communicable Disease (PEN)(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) was used as a reference to identify equipment and medications essential in a primary health care setting. To capture the health system factors that could potentially influence NCD service provision, questions and variables pertaining to health financing, health information system and leadership and governance were identified.\u003c/p\u003e \u003cp\u003eDescriptive analysis was conducted of relevant variables with 95% confidence intervals (CI). This was followed by the calculation of a Facility Index (FI)(\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The index was calculated by identifying 5 domains that are critical to the functioning of NCD services, namely: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) NCD training for staff; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) NCD guidelines; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) NCD drugs; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Basic equipment; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Laboratory diagnostics, each of which had a set of tracer indicators. The availability of each tracer indicator per domain was assessed, across centres.\u003c/p\u003e \u003cp\u003eThis was followed by the calculation of a Domain Index (DI) across Centres.\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:DI\\:=\\:\\frac{Number\\:of\\:tracer\\:indicators\\:available}{Number\\:of\\:tracer\\:indicators\\:supposed\\:to\\:be\\:available}\\:X\\:100$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA Facility Index (FI) for each facility was calculated as the mean of all domain indices.\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:FI\\:=\\:\\frac{DI1\\:+\\:DI2\\:+\\:DI3\\:+\\:DI4\\:+\\:DI5}{5}\\:$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFI of each facility was compared to a cut-off score of 70%, as was done in other studies (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral of the Health System Building Block domains (see Additional File 1) did not have NCD specific data within the BHFS. Therefore, analysis of these domains was conducted based on availability in general, across PHC Centres.\u003c/p\u003e \u003cp\u003eAll analysis was done by Stata Version 14.\u003c/p\u003e\n\u003ch3\u003eQualitative Study\u003c/h3\u003e\n\u003cp\u003e We conducted key informant interviews and in-depth interviews to identify any gaps within the urban primary health care system in managing DM, hypertension, and CVD from the perspective of policy makers and health personnel.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipants, Setting and Data collection\u003c/h2\u003e \u003cp\u003eParticipants were purposively selected from both public (urban outdoor dispensaries run by MOHFW) and NGO urban PHC centres (under MOLGRD) in Dhaka North City Corporation to include a range of healthcare practitioners, project manager, Management Information System (MIS) officer and administrative staff. In addition, relevant policy makers from the Non-Communicable Disease Control (NCDC) Programme of the MoHFW and the Local Government Division (LGD) of MoLGRD\u0026amp;C were identified.\u003c/p\u003e \u003cp\u003eInterviews were conducted by a team of trained postgraduates from diverse academic backgrounds with varied experience in qualitative research methods. Additionally, they received training for two days on qualitative data collection methods on topics such as taking informed consent, rapport building, orientation with the topic guide and probing. This was followed by a day for role-play and feedback.\u003c/p\u003e \u003cp\u003e All participants were contacted by phone, prior to the interviews, to explain the research and its objectives and seek informed consent. Following consent of the participants, appointments were taken accordingly. A total of 21 semi structured interviews were conducted in Bengali following the Health System building blocks (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) domains as described in Additional File 1 [See Additional File 1]. Healthcare practitioners and facility managers were interviewed about services, guidelines, training, medications, and equipment related to NCD. In addition, they were also asked about NCD related supervision, monitoring, reporting, recording, and financing. Policy makers were questioned about the overall urban PHC system, coordination between MoLGRD and MoHFW and roles of both ministries in integrating NCD with the urban PHC system. Field notes were also made during interviews. The topic guides were refined during the data collection process, to explore emerging themes.\u003c/p\u003e \u003cp\u003eThe duration of interviews with healthcare practitioners and facility managers ranged from 40 to 60 minutes, while that of the policy makers ranged from 55 to 80 minutes (as additional explanation of questions was needed in some cases). All interviews were audio recorded and then anonymized, transcribed verbatim and cross checked for accuracy against the audio-recordings by the interviewer. While all the transcripts were typed up in Bengali, portions of them were translated into English, to share with non-Bengali speakers to support the development of the coding frame.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalysis of qualitative data\u003c/h3\u003e\n\u003cp\u003eThree team members involved in data collection began analysis by familiarising themselves with the interview transcripts and recordings. NVivo version 20 was used to manage the analysis. Framework approach was used to guide the analysis (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) with the Health System Building Blocks (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) as the overarching framework. Within each of these domains, sub-themes were identified based on discussion among the three independent coders who came to a consensus. The subsequent thematic framework was used to code all transcripts and then develop charts with relevant quotes added. The charted data were then reviewed to identify patterns and connections, followed by descriptive summaries of themes. In case of differences in coding arising between two researchers, the third researcher would help in clarification.\u003c/p\u003e\n\u003ch3\u003eMixed Methods Integration\u003c/h3\u003e\n\u003cp\u003eIntegration was done in order to understand the extent to which the quantitative and qualitative data corroborated or contradicted each other., we organised the results from both methods in a table under the overarching framework of the WHO Health System Building Blocks(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The similarities and differences between the quantitative and qualitative findings under each building block were considered by the research team. Descriptive analysis was conducted on relevant variables from the BHFS 2017 data which were compared to the thematic summaries from the interviews. A final column indicating the overall message, or inference, from both data sources was then completed, and comparison was done between both to identify corroborative or contradictory findings between descriptive analysis and thematic summaries(\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe 66 urban PHC centres were sampled from all the eight divisions in Bangladesh. Most of the centres were from Barisal division (25.76%), followed by Dhaka (16.67%), Khulna (15.15%), Chattogram (13.64%), Rajshahi (10.61%), Rangpur (9.09%), Mymensingh (4.55%) and Sylhet (4.55%).\u003c/p\u003e \u003cp\u003eOut of the 21 respondents interviewed, 12 were female. There were three physicians, five paramedics, one administrative assistant, and two lab technicians, project managers and MIS officers. In addition, five policy makers were interviewed (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRole\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003eHealth Care Provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_A_d_02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_A_d_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_B_d_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_B_d_02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_A_e_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParamedic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_A_k_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParamedic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_B_e_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParamedic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_A_g_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_B_g_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_B_f_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLab Technician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP_A_f_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLab Technician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eManager and Administrative officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePM_A_a_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProject Area Manager\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePM_B_a_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProject Area Manager\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePM_B_b_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMIS Officer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePM_A_b_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMIS Officer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePM_A_c_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdministrative Assistant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003ePolicy Maker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKII_i_h_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAssistant Health Officer, LGD, MoLGRDC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKII_ii_i_01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealth System and Policy Expert\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKII_ii_i_02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProgramme Manager, DGHS, MoHFW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKII_ii_i_03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDeputy Programme Manager, DGHS, MoHFW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKII_ii_i_04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAssistant Health Officer, LGD, MoLGRDC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eHealth facility readiness\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAmong the 66 urban PHC facilities from the BHFS, no centre reached the cut-off score of 70%. The highest FI scored by a facility was 68.29% while 0% was the lowest. Only 15% of the facilities scored an FI above 50% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Additionally, while the centres may have reached the cut-off score in domains such as availability of equipment and laboratory facilities, the FI was affected by the low DI in the remaining 3 domains.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe average DI for all domains was below 70%, with equipment availability scoring the highest, versus availability of drugs. 42% of the facilities scored more than 70% in equipment availability, while 21% facilities crossed the cut-off point in availability of laboratory facilities. Meanwhile only 18% and 4.54% of the facilities scored more than 70% in guideline availability and health workforce training, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eService Delivery\u003c/h2\u003e \u003cp\u003eThe respondents stated that the urban PHC centres under the MoLGRD were set up to provide primary healthcare services to the urban poor, especially, women and children. Hence, male patients seldom come to these centres to seek healthcare services.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Speaking from my 17 years of experience, males do not generally come here. We have also hung a banner outside to draw their attention to the fact that we provide services for them too, but maybe there is a misconception that only mothers and children are treated here.\u0026rdquo;\u003c/em\u003e [PM_A_a_01, Project Manager, Urban Primary Healthcare Service Delivery Project, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAccording to the BHFS data, the patient flow was under 2000 per month in the majority of the urban PHC centres while for 36.4% of the centres, it was below 1000. A couple of the centres reported the flow to be more than 5000 patients per month but that was very rare (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNo. of outpatient visits per month calculated from the BHFS 2017 data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePopulation coverage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1-1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.87\u0026ndash;49.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1001\u0026ndash;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.53\u0026ndash;47.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2001\u0026ndash;3000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.43\u0026ndash;24.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3001\u0026ndash;4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.51\u0026ndash;16.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4001\u0026ndash;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5001\u0026ndash;6000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u0026ndash; 8.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 9990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u0026ndash;8.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u0026ndash;8.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAround 85% of the 66 urban PHC centres reported availability of NCD diagnosis and management services in the BHFS data (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In-depth interviews revealed that while NCD diagnosis and management facilities are available at the centre, maternal and child health (MCH) is prioritized and NCD services are provided predominantly to pregnant women through screening and management of pre-eclampsia (a disorder of pregnancy characterised by high blood pressure) and gestational diabetes (a condition in pregnancy characterised by high blood sugar).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;All the components of Primary health care are supposed to be provided in our centre, as discussed in the agreement and the Development Project Proposal. Even after that, I state in different forums that when I visit a centre it seems like the centres are only for pregnant mothers and the Expanded Programme on Immunisation for children.\u0026rdquo;\u003c/em\u003e [KII_ii_i_01, Policy Maker, City Corporation, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany respondents stated that to be screened for Diabetes Mellitus (DM), patients are recommended to have random and fasting blood sugar tests solely based on the providers\u0026rsquo; clinical judgement and the patients\u0026rsquo; history. However, due to lack of a strong follow-up system, it is often hard to track patients, therefore making it difficult to identify patients who are at risk of developing, or have already developed DM. Respondents also said that patients identified to be at risk of developing NCDs are counselled about lifestyle modification while diagnosed cases are prescribed with medications in addition to being counselled, and complicated cases are referred to the nearest government or specialised hospitals. However, these practices seldom follow specific guidelines due to the lack of availability and awareness among providers about their existence. The findings from the BHFS also suggest that a little more than one-third of the 66 urban PHC centres had guidelines available (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;We have not worked much on the guidelines of diabetes and hypertension in our service centres, the way we have been working on communicable diseases like tuberculosis, maternal health, child health and everything. In this [NCD] case, we are lagging.\u0026rdquo;\u003c/em\u003e [KII_i_h_01, Policy Maker, City Corporation, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAvailability of NCD services and guidelines to deliver NCD care calculated from the BHFS 2017 data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReport Diagnosing and managing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.89\u0026ndash;92.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.78\u0026ndash;69.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.89\u0026ndash;92.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAvailability of Guidelines\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;66\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.53\u0026ndash;47.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension and CVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.11\u0026ndash;33.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary Heart Disease (CHD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.59\u0026ndash;42.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnostic facilities provided\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;66\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood cholesterol testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.51\u0026ndash;26.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood glucose testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.89\u0026ndash;92.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum Creatinine testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.42\u0026ndash;24.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrine protein testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.87\u0026ndash;75.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrine glucose testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.87\u0026ndash;75.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHealth Workforce\u003c/h2\u003e \u003cp\u003eThe BHFS data and the interviews confirm that the health workforce in the urban PHC centres lacked training in NCD management. Even though they managed NCDs to some extent, the existing workforce made it clear during the interviews that they have never received any NCD-specific training.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The training we had was minimal in this part. Whoever works in this sector, already has prior knowledge of the technology. Though there will always be some exceptions. But the training we get is not enough compared to the training that we need to work in this sector. I doubt if I even got 8\u0026ndash;10 training courses in my whole 22 years of career. It is also very rare that we get refresher training.\u0026rdquo;\u003c/em\u003e [PM_B_b_01; Project Manager, Urban Primary Healthcare Service Delivery Project, Male]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe BHFS data also showed that only 41% of the centres had staff who received some training on DM management, while the number of centres with staff receiving some CVD management training was only 18% (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReadiness of health workforce to deliver NCD care calculated from BHFS 2017 data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentres with workforce managing NCD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.13\u0026ndash;91.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.99\u0026ndash;84.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistribution of the workforce across centres for diabetes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;221\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u0026ndash;3.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.68\u0026ndash;21.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParamedic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.82\u0026ndash;34.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Educator / Counsellor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u0026ndash;3.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Clinical staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e103\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e46.61\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e39.89\u0026ndash;53.42\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistribution of the workforce across centres for CVD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;221\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u0026ndash;3.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.07\u0026ndash;22.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParamedic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.82\u0026ndash;34.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u0026ndash;5.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Educator / Counsellor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u0026ndash;3.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther clinical staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u0026ndash;3.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e112\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e50.68\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e43.89\u0026ndash;57.45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCentres with staff who have received NCD training within last 2 years (from the date of the survey)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;66\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.95\u0026ndash;53.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.76\u0026ndash;29.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistribution of the workforce who received DM training across centres\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;221\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.88\u0026ndash;7.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParamedic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.26\u0026ndash;13.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Educator / Counsellor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u0026ndash;3.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e31\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e14.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e9.73\u0026ndash;19.32\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistribution of the workforce who received CVD training across centres\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;221\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.50\u0026ndash;4.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParamedic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.28\u0026ndash;6.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u0026ndash;3.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Educator / Counsellor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e6.79\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.85\u0026ndash;10.95\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e46.61% and 50.68% of the 221 healthcare practitioners in BHFS were reported to manage diabetes and CVD respectively among whom around 95% were females. In-depth interviews of respondents revealed this to be a deliberate recruitment criterion, as patients were often uncomfortable taking healthcare from the workforce of the opposite gender and most patients at centres are in practice women and children. However, this was also attributed as a reason for a smaller number of male patients at the centres:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Males come here for vaccination now but not for general treatment. It may be because most of our service providers are women. It is seen that males do not prefer female doctors and females do not prefer male doctors. This is a practice among slum dwellers.\u0026rdquo;\u003c/em\u003e [PM_B_a_01; Project Manager, NGO urban PHC centre, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere were only three specialists working across all the centres, of whom two were gynaecologists and one was a paediatrician. Most centres had medical officers who were medical graduates, while paramedics were the most common staff cadre across the centres.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDrugs and Equipment\u003c/h2\u003e \u003cp\u003eThe NGO urban PHC centres buy drugs from pharmaceutical companies quarterly based on their need as identified by prescribing practitioners.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We get a requisition from the doctor every quarter and purchase medicine according to that.\u0026rdquo;\u003c/em\u003e [PM_B_a_01, Project Manager, NGO urban PHC centre, Female]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We consult about the necessary medicine with our doctors and send the requisition list to the Project Management office. it is approved from here and they give the medicine during the quarterly medicine supply\u0026rdquo;.\u003c/em\u003e [HP_B_g_01, Service Provider, NGO urban PHC centre, Male]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMajority of the respondents during the interviews stated that NCD medications recommended by the WHO PEN protocol were seldom seen at urban PHC centres. This is consistent with BHFS data, according to which more than 50% of the centres did not have any NCD medications (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). In centres which did have them, antihypertensive medications were found to be more common in contrast to drugs for DM. According to the respondents, the availability of NCD medications at urban PHC centres often depends on those safe for use during pregnancy and breastfeeding and need of the same at the centres.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Basically, diabetic drugs are not available here, but antihypertensive medicines are available. We take Amlodipine, and Nifedipine (antihypertensive medicines) since we deal with pregnant mothers and these drugs are required during pregnancy.\u0026rdquo;\u003c/em\u003e [PM_A_a_01, Project Manager, NGO urban PHC centre, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, screening for hypertension is generally easier to obtain than for DM at urban PHC centres due to the higher availability of sphygmomanometers compared to Glucometers, as stated by the respondents. Though Glucometers exist in some urban PHC centres, in some cases health workers were found to be unfamiliar with how glucometers are operated.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAvailability of basic equipment and essential medicines across facilities as per WHO PEN protocol to deliver NCD care calculated from BHFS 2017 data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eBasic Equipment as per WHO PEN protocol\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic Equipment available\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% with equipment available\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeighing scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.89\u0026ndash;92.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStadiometer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.36\u0026ndash;82.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasuring tape\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.56\u0026ndash;79.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThermometer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.13\u0026ndash;91.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManual BP apparatus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.39\u0026ndash;90.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStethoscope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.13\u0026ndash;91.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse Oximeter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.51\u0026ndash;26.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFilled oxygen cylinder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.53\u0026ndash;47.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucometer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.15\u0026ndash;80.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucometer strips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.99\u0026ndash;77.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEssential Medications as per WHO PEN protocol\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedications for HTN and CVD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;66\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e% with medicines available\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmlodipine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.42\u0026ndash;24.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtenolol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.78\u0026ndash;38.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaptopril\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnalapril\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLosartan Potassium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.51\u0026ndash;26.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpinephrine Injection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u0026ndash;8.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrusemide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.37\u0026ndash;20.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThiazide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u0026ndash;8.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeparin Injection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u0026ndash;8.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClopidogrel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspirin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.41\u0026ndash;18.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIsosorbide Dinitrate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u0026ndash;8.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlycerine Trinitrate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u0026ndash;12.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNifedipine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.38\u0026ndash;22.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSimvastatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtovastatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.38\u0026ndash;22.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRosuvastatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedicines for Diabetes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;66\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e% with medicines available\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlibenclamide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose Injectable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.68\u0026ndash;14.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsulin Injections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u0026ndash;8.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetformin Tablets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.11\u0026ndash;33.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGliclazide Tablet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.41\u0026ndash;18.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlimepiride Tablet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eHealth Financing\u003c/h2\u003e \u003cp\u003eInterviews of respondents revealed that NGO run urban PHC centres under the Urban Primary Health care Project operate on funds received from MoLGRDC and Asian Development Bank (80%), while the remainder is generated from patients. The budget allocated by MoLGRDC is spent mostly on purchasing MCH and SRH-related drugs and equipment leading to a low supply of NCD-related equipment and medications.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There is no disease-wise allocation. I mean, it runs through the funds we receive but when we apply for the project, we set certain targets that we would provide a particular percentage of funds for a particular service, e.g. this much percentage for a certain number of deliveries. We do not have any separate target for NCDs and no separate fund for it or other diseases.\u0026rdquo;\u003c/em\u003e [PM_A_a_01; Project Manager, NGO under Urban Primary Healthcare Service Delivery Project, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe respondents stated that NGO centres provide free services to at least 30% of households in their catchment area. Each centre has a list of slums in their operational area, and they use a survey tool developed by the MoLGRDC to identify the most financially needy people in those slums. A scorecard is filled up through the survey where the slum population is classified into 3 categories; impoverished (scoring 0\u0026ndash;20), poor (scoring 21\u0026ndash;30) and not poor (scoring 31\u0026ndash;40).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They have a form designed by ADB and LGD (Local Government Division). It contains what we will ask\u0026hellip;if his score is under 20, he is impoverished, and if within 20\u0026ndash;30, he is poor.\u0026rdquo;\u003c/em\u003e [PM_B_a_01; Project Partnership Area Manager, Urban Primary Healthcare Project, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe poverty-stricken households which are identified through the survey receive an Essential Health Card (commonly known as the \u0026ldquo;Red Card\u0026rdquo;) which allows them to avail all services for free at the centres. The lower the score of someone, the higher the possibility of them getting a Red card.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We need to bring at least 30 percent of the population under the red card scheme that will allow us to provide them completely free healthcare from normal delivery to C-section and all other services. After their detection as impoverished, we provide a red card for the whole family with photos of all family members attached to it. When any one of the family members shows us the card, we provide them free treatment.\u0026rdquo;\u003c/em\u003e [PM_A_a_01; Project Partnership Area Manager, Urban Primary Healthcare Project, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe non-poor population, on the other hand, pay user fees for services and medicines. This service fee was found to be 50 Bangladeshi taka (around USD 0.47) across all the urban PHC centres included in the qualitative study, which is usually supposed to be affordable for most of the patients. The BHFS data showed that this fee is routinely collected in all the urban PHC centres but in most centres, the fee is subsidised for the extremely needy (see in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The respondents stated that there is no proper regulation or guideline regarding how this is implemented. In most cases, the amount of subsidy or who receives the benefit depends on the service providers of that centre. Of the non-poor patients, those who cannot afford to pay the full amount for the services or medications may get a 15\u0026ndash;30% discount, once approved by the facility manager.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;To provide drugs to patients who are poor but don't have a red card, at a discounted rate, we need to get a signature from the doctor \u0026amp; administration of the facility.\u0026rdquo;\u003c/em\u003e [HP_A_f_01, Service Provider, NGO under Urban Primary Healthcare Service Delivery Project, Male]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn terms of financing of the health Centres, it was found that most of the urban PHC centres were funded by development partners, while user fees were the 2nd most predominant source of financing (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTypes of health financing, availability of health information system, supervision and quality control at urban PHC centres, calculated from BHFS 2017 data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHEALTH FINANCING\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSources of Revenue/Fund\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDonor agencies / NGOs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.13\u0026ndash;91.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUser fees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.14\u0026ndash;58.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovt. contribution to private\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.41\u0026ndash;18.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity Programmes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.68\u0026ndash;14.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic ministries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u0026ndash;12.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers (not specified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;10.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCollection of regular user fee\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.56\u0026ndash;100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExemption/Subsidised user fee\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.29\u0026ndash;99.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHEALTH INFORMATION SYSTEM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComputer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63.64\u0026ndash;85.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess to internet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.98\u0026ndash;87.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystem to compile health service data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.48\u0026ndash;99.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerson designated for health statistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.95\u0026ndash;53.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLEADERSHIP AND GOVERNANCE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternal supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.84\u0026ndash;99.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRoutine quality assurance activities conducted\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;66\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.99\u0026ndash;84.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.78\u0026ndash;38.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintenance of yearly official records of quality assurance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.77\u0026ndash;96.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.40\u0026ndash;22.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eActivities during supervisory visit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing a checklist to assess the quality of available health services data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.98\u0026ndash;87.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscussing the performance of the facility based on available health services data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.20\u0026ndash;97.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvision of written comments by supervisors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.20\u0026ndash;98.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eHealth Information System\u003c/h2\u003e \u003cp\u003eMajority of the respondents stated that the centres follow a paper-based recording system, which records particulars of patients attending the centres, and the service for which they may have come. There are multiple register books at every provider\u0026rsquo;s desk for data entry, which are aggregated by the Administrative Assistant based on templates and sent to the Management Information System (MIS) officer of the project area every month. The MIS officer prepares a digital report to be sent to the project implementation unit (PIU), which is then passed on to the Project Management Unit (PMU) at the Local Government Division under MoLGRD. While most of the centres were found to have an existing health information system, less than 50% of the urban PHC centres had personnel allocated to manage health-related data.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;As you can see here, we have so many books for keeping records of the patients. For one patient you need to keep so many records, so of course, it\u0026rsquo;s very tough to maintain them all the time. We deliver written reports. It would have been easier if we had a computer or printer. Writing 50 reports manually for 50 patients with many of them having 7 to 8 different tests, is a very difficult task. Handwriting varies from person to person and often doctors struggle to read poor handwriting. Having a computer would have made it better. We could get a good quality report as well.\u0026rdquo;\u003c/em\u003e [HP_A_f_01, Service Provider, NGO under Urban Primary Healthcare Service Delivery Project, Male]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere is no separate register book for keeping the information of patients at risk of developing any NCDs, and records for even those already diagnosed with NCDs are not maintained. Hence, NCD-related reporting is absent too. The services provided for hypertension and DM are recorded as \u0026ldquo;Limited Curative Care\u0026rdquo; (LCC) in a column on the master register, and not reported in detailed categories.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have an LCC (Limited Curative Care) category system. There is no separate category of hypertension patients, so the reporting is not proper. Though we do not keep a record of hypertension separately, we provide diagnosis and treatment.\u0026rdquo;\u003c/em\u003e [HP_A_d_01, Service Provider, NGO under Urban Primary Healthcare Project, Male]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePatients attending the Centres are given an ID in the form of a registration number and are given a patient card which is usually valid for 5 years. However, in case the patient misplaces the card, or when it is time for renewal, he/she is given a new registration number which is not linked to the previously given ID. In addition, individual patient recordrecords are not maintained for NCD management, follow-up, or referral of patients. Hence, specific records pertaining to referrals or follow-up visits are absent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLeadership and Governance\u003c/h2\u003e \u003cp\u003eInterviews have revealed the lack of coordination between the MoHFW and MoLGRDC. The MoHFW is responsible for developing health-related policies including several that prioritise the control of major NCDs in the country. In addition, the Directorate General of Health Services (DGHS) under MoHFW has a dedicated programme for NCD Control (NCDC). But a lack of coordination across the ministries means that these policies are not translated by the MoLGRDC into implemented service provisions in urban areas.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So far, I know our Ministry of Health is doing plenty of work on NCD, but NCD is not quite focused on in our (urban) primary health care system. \u0026rdquo;\u003c/em\u003e [KII_i_h_01; Policy Maker, City Corporation, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis lack of coordination has been acknowledged by both ministries, especially the MoHFW. Interviews revealed that the increase in NCD risk factors predominantly among urban slum dwellers should lead to greater prioritisation of the urban primary health care system in the national policies, such as the Strategic Investment Plan of the 5th Health, Nutrition and Population Sector Programme. The current plan, the 4th Health, Population and Nutrition Sector Programme (HPNSP) focuses policy more on NCD services in rural areas.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It is true, while NCD services have been prioritised in the rural health system, the urban primary health care system has been completely neglected. However, there are plans of prioritising the urban health system in the upcoming HPNSP. Even within the current HPNSP, we can support the urban primary health care centres by developing their capacity or conducting Training of Trainers with their Chief Health Officer. We can coordinate with the Health department existing within the MoLGRDC to identify ways of supporting them to control NCDs.\u0026rdquo;\u003c/em\u003e [KII_i_h_01; Policy Maker, City Corporation, Female]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNecessary supervision and regular monitoring are required for ensuring quality control of the urban PHC centres. The data from BHFS showed that almost all the urban PHC centres (98.48%) had some sort of external supervision. According to the BHFS data, in 49 of the 66 urban PHC centres included in the study routine quality assurance was conducted. Out of these 49, 44 centres maintained official records of quality assurance activities for the past year. A checklist was used to assess the quality of available health services data in almost 84% of the centres during supervisory visits. During those visits, the supervisory team discussed the performance of the centres with the relevant staff of that centre based on this health service data. Additionally, almost 94% of the centres reported that the supervisors provided written comments about various aspects during these visits. However, they were not NCD-specific.\u003c/p\u003e \u003cp\u003eInformation from the qualitative interviews also revealed that most of the centres have a monitoring and supervision mechanism. Doctors posted in all the urban PHC centres also work as clinical in-charge of their centres and supervise the overall activity of that centre. Moreover, the urban PHC centres fall under different project areas, and in each project area, there is a project manager (PM) and an MIS officer who supervises all the centres in that specific area. Apart from them is the Project Management Unit which consists of the project director and deputy project directors. The Project Management Unit visits all the urban PHC centres in the city corporation area one by one and each centre is inspected quarterly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There are monitoring officers. We have two units in this project. One is the project management unit, and one is the project implementation unit. Our chief health officer is the program manager in the project implementation unit. There are program officers and monitoring officers working under him.\u003c/em\u003e [PM_A_a_01, Project Manager, Urban Primary Healthcare Service Delivery Project, Male]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have visitors from the city corporations. They visit after 15 days or 1 month and we even get visitors from our PM office. They visit twice or once a month. They do an overall check of whether everything is working well or not, whether we are keeping the record or not, whether Patients have any objections or not, tests are running smoothly or not, freezing temperature is ok or not- so all these. They check the freezer, its temperature, expiry date of a reagent, register book, patient volume and all.\u003c/em\u003e \u003cb\u003e\u0026rdquo;\u003c/b\u003e [HP_A_f_01, Service Provider, NGO under Urban Primary Healthcare Project, Male]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, supervising the NCD management at the urban primary health system, which operates under a different ministry, has been close to none from the NCDC, MOHFW.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe objective of this study was to identify the readiness of the urban primary health care centres to manage major NCDs particularly Diabetes, Hypertension and Cardiovascular disease. Our findings suggest that the urban PHC system does not prioritize NCD management to achieve national NCD targets. We found that most of the urban PHC centres do not comply with the WHO recommendations to manage NCDs(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrimary health care approach offers a wider opportunity for NCD prevention and control; however, its potential is not fully utilized in the many developing countries (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). We also found that primary health care facilities in urban areas in Bangladesh lack trained health workforce, nationally agreed essential medicines and equipment to manage NCD care, and the urban PHC system does not prioritize NCD management. The findings are similar to other South East Asian countries, where primary health care systems provide reactive and episodic responses, and inadequate capacity to manage lifelong long-term chronic care remained one of the key reasons for low performance in NCD control and management(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEvidence suggests that addressing NCD burden requires a primary care approach based on a trained primary care team providing a people-centric, comprehensive, integrated and equitable care (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The urban primary health care systems in Bangladesh provide ample opportunities to improve management of NCD services through primary health care facilities. Appropriate policies, cost-effective interventions, sustained efforts and commitments are required for integrating NCD control at urban primary health care level (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is a striking contrast between the clear structure of rural PHC and the less clear and often chaotic structure of urban PHC. In rural areas, MOHFW has a consistent hierarchy of community clinics, Union Sub-Centres and Upazilla Health Complexes with referral between. In contrast, the structure of urban PHC services depends on NGO and private providers to deliver services(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Additionally, while rural health centres have dedicated NCD provision through the NCD corners with a dedicated medical officer for the management of NCDs (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), no such areas or dedicated workforce exists in the urban PHC centres. With the aim of achieving Universal Health Coverage (UHC) by 2030, the MoHFW has revised the Essential Service Package (ESP) and included NCDs. While the package, including the NCD component, is being delivered at rural PHC centres (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) it is largely absent in urban PHC centres.\u003c/p\u003e \u003cp\u003eUrban PHC centres in Bangladesh predominantly provide MCH and SRH services (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) with most of the patients being pregnant women (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), whose blood pressure and glucose levels are often checked to prevent preeclampsia and gestational diabetes, which was found to be similar to urban PHC centres in Nigeria(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). It would, therefore, be inaccurate to say that NCD services are not provided at urban PHC centres at all. However, screening of men and non-pregnant women for hypertension and diabetes depends solely on the clinician\u0026rsquo;s judgement, based on their history. This has now become a vicious circle - as majority of the patients are pregnant women, the centres provide MCH care; and as they provide mainly MCH care, NCD patients who do not require MCH care do not generally visit these centres. This scenario is a contrast to neighbouring country India wherein majority of patients visiting urban PHC centres are males (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and 89.5% urban PHC centres provide screening services for NCDs(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Another study in an urban PHC centre in a municipal area in Nigeria reported providing various NCD services ranging from screening to follow-up(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile most rural PHC facilities have medicine specialists (in addition to gynaecologists and paediatricians) who are often responsible for managing NCD related complications. In contrast, specialists at urban PHC facilities are limited to gynaecologists and paediatricians due to prioritization of MCH and SRH at these facilities. Urban PHC medical staff are seldom invited to NCD-focused training conducted by the MoHFW although some training may occur through NGOs running the services. Contrarily, rural PHC providers are provided NCD training through the MoHFW although even in these areas the training remains inadequate (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Consequently, most of the patients attending the urban PHC centres are managed by staff who have received little or no training since their graduation (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Alternatively, 95% of appointed urban PHC workforce in Myanmar have reported receiving NCD management training(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Hence, well-timed training of urban primary health care workforce needs to be planned so the urban primary health care workforce can prevent and manage NCDs effectively.\u003c/p\u003e \u003cp\u003eThough often inadequate, rural PHC centres receive NCD medications from the NCDC program under the MoHFW which are given to patients for free (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Urban PHC centres, on the other hand mainly procure medications for MCH and SRH, and place low priority on buying NCD drugs, leading to poor availability of NCD drugs at these centres. In contrast, around 80% and 90% urban PHC centres in report the availability of NCD medication such as Amlodipine (an antihypertensive drug) and Metformin (anti-diabetic medication) in India and Myanmar respectively(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Adequate budgetary allocation for the urban PHC system especially for medicine and equipment is required.\u003c/p\u003e \u003cp\u003eIn rural PHC centres, NCD registers are maintained to record newly and already diagnosed NCD patients (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), which are reported to the MoHFW for the MIS dashboard (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In urban areas, in contrast, there is no such record keeping making it difficult to track both aggregate workloads of health centres and treatment for individual patients. Meanwhile, in Myanmar 100% PHC centres in an urban area reported the availability of NCD patient record forms and patient register (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Additionally, separate NCD monitoring and reporting mechanism was reported in primary health care centres in a municipal area in Nepal followed by discussion of NCD data during monthly monitoring meetings, which was then used in annual reports at a federal level(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). While a study India, reported the use of paper based, patient-held medical records for NCD patients at urban PHC centre, although inadequate(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), another study reported better maintenance of NCD records at urban PHC compared to private centres(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Integration of NCD management and risk data from the urban primary health care centres into the MoHFW dashboard can provide a comprehensive view of the urban primary health care centres, thereby supporting the MoHFW to develop urban friendly evidence-based policies for NCD management (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere remains a financial barrier to access urban health services for most of the population. The urban PHC centres provide all services inclusive of NCD care for free only to those who are registered with an \u0026lsquo;Entitlement Card\u0026rsquo; (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Yet, those with the cards form only 30% of the urban dwellers, and individuals who are still poor but are above the threshold to qualify for a red card must pay for primary care services. Meanwhile, 94.8% urban PHC centres in Myanmar reported availability of free of charge services which was in line with their health policy(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Evidence suggests that many developing countries have prioritised strengthening PHC systems to achieve Universal Health Coverage (UHC); hence provide free primary care to all citizens(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe National Health Policy 2011 and Multisectoral Action Plan have highlighted the need for collaboration between MoHFW and MoLGRD and capacity development of urban PHC staff for NCD management in urban areas (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). However, inadequate coordination between MoHFW and MoLGRD has led to an absence of MoHFW initiatives to control NCDs, such as development of the guidelines for Management of Diabetes and (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), handbooks enlisting the roles and responsibilities of PHC centre staff in NCD management, NCD registers, patient cards, flip books and medications among urban PHC centres. Studies in similar contexts suggest that multisectoral collaboration is essential to tackle NCDs at primary care level(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Stronger coordination is required between the MoLGRDC and MoHFW to strengthen NCD management at urban PHC centres.\u003c/p\u003e \u003cp\u003eThe study had some limitations. First, in the absence of any latest national survey data, the BHFS 2017 data had been used for the analysis. Though the in-depth interviews and several documents suggest that the scenario had not changed much since 2017, the scope of analysing latest data would have strengthened the study. Despite the limitations, this is the first study that presents the FI and DI for NCD management in urban primary health care facilities using the BHFS data in Bangladesh. Second, the healthcare practitioners for in-depth interviews were selected mainly from Dhaka. Interviewing respondents from other urban areas could have brought additional insights.\u003c/p\u003e \u003cp\u003eA further study is required to identify the sustainable solutions to overcome the barriers in providing NCD care in urban PHC facilities, and to design, implement and assess the effectiveness and cost-effectiveness of innovative interventions to integrate the NCD care within urban primary health care systems.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eA rapidly growing urban population, coupled with a rise in the prevalence of NCD risk factors in the urban slums, calls for prioritisation of NCD management within the urban primary health system. Though the current Health, Population and Nutrition Sector Programme (4th HPNSP, 2017\u0026ndash;2024) focuses on strengthening the primary health care centres to manage NCDs, this has been focused towards the rural PHC centres, while the urban PHC centres are yet to be prioritized in the programme (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). The MOHFW has a strong commitment to combating NCDs, and similar prioritisation is required to integrate NCD at the urban primary health care level. Strengthening PHC systems for NCDs would require restructuring of PHC service delivery modalities to mitigate the existing barriers to PHC service delivery for NCDs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eFUNDING\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a part of a larger study titled “Strengthening the Urban Primary Health Care System to Deliver Essential Non-Communicable Disease Care to the Urban” under the project titled Community-Led Responsive and Effective Urban Health Systems (CHORUS) and is funded by the UK Aid from the UK Government, Grant 301132; however, the views expressed do not necessarily reflect the UK government’s official policies.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCONFLICT OF INTEREST\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eETHICAL APPROVAL AND CONSENT TO PARTICIPATE\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe study has received Ethical Clearance from the University of Leeds (No. MREC 21-008 CHORUS) and Bangladesh Medical and Research Council (BMRC) (BMRC/NREC/2019 -2022 / 485). All participants gave written informed consent to participate in the study. As data from BHFS 2017 was secondary for this study, ethical clearance was not required its’ analysis.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCONSENT FOR PUBLICATION\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDATA AVAILABILITY\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMATERIALS AVAILABILITY\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCODE AVAILABILTY\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAUTHORS’ CONTRIBUTION\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eConceptualized and supervised the study: DB, HE, TE, KI, RC, RH\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConducted and analysed interviews, coded and drafted narrative summaries: USA, NH, MA\u003c/p\u003e\n\u003cp\u003eSupervised analysis of interviews: HE\u003c/p\u003e\n\u003cp\u003eAnalysed secondary data and drafted quantitative results: USA, MS\u003c/p\u003e\n\u003cp\u003eSupervised secondary data analysis: TE\u003c/p\u003e\n\u003cp\u003eIntegrated quantitative and qualitative findings and drafted results: FK\u003c/p\u003e\n\u003cp\u003eSupervised integration: HE and TE\u003c/p\u003e\n\u003cp\u003eContributed to the writing of the manuscript: DB, MS, FK\u003c/p\u003e\n\u003cp\u003eReviewed and made comments for important revisions in the draft manuscript: RH, HE, TE, KI, RC\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eACKNOWLEDGEMENTS\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the respondents of the study who participated in this study, and would also like to thank the healthcare facilities and the following individuals for facilitating the study:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr. Mahmuda Ali, Assistant Health Officer, Dhaka North City Corporation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr. Shamsunnahar, Project Manager, Dhaka North City Corporation.\u003c/p\u003e\n\u003cp\u003eRehana Akter Mita, Project Manager, Dhaka North City Corporation\u003c/p\u003e\n\u003cp\u003eAdditionally, we would like to thank other members of our research team:\u003c/p\u003e\n\u003cp\u003eDr. Joseph Hicks, Lecturer in Medical Statistics, University of Leeds.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr. Mahua Das, Lecturer in International Health, University of Leeds\u003c/p\u003e\n\u003cp\u003eS M Abdullah,\u0026nbsp;Associate Professor, Department of Economics,\u0026nbsp;University\u0026nbsp;of Dhaka.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSushama Kanan, Research Fellow, ARK Foundation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr. Mumtahena Nabi, Research Associate, ARK Foundation\u003c/p\u003e\n\u003cp\u003eFatema Al Kadri, Research Assistant, ARK Foundation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMd. Shakhawat Hossain Rana, Research Assistant, ARK Foundation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, we would like to extend our gratitude to our families for their constant support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhor N, Arimah B, Otieno R, Van Oostrum M, Mutinda M, Martins J. World Cities Report 2022 Envisaging the Future of Cities. United Nations Human Settlements Programme (UN-Habitat); 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoryakin Y, Rocco L, Suhrcke M. The contribution of urbanization to non-communicable diseases: Evidence from 173 countries from 1980 to 2008. Econ Hum Biol. 2017;26:151\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBangladesh Bureau of Statistics, Statistics and Informatics Division. Ministry of Planning, Government of the People\u0026rsquo;s Republic of Bangladesh. 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Multisectoral Action Plan for Prevention and Control of Noncommunicable Diseases 2018\u0026ndash;2025: with a three year operational plan. Dhaka, Bangladesh: Noncommunicable Disease Control Programme, Directorate General of Health Services. Health Services Division, Ministry of Health \u0026amp; Family Welfare; 2018. p. 66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational protocols for management of high blood pressure. and diabetes, using total cardiovascular risk approach, at primary health care setting (First Edition). Dhaka: Directorate General of Health Services, Government of Bangladesh; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiong S, Cai C, Jiang W, Ye P, Ma Y, Liu H, et al. Primary health care system responses to non-communicable disease prevention and control: a scoping review of national policies in Mainland China since the 2009 health reform. Lancet Reg Health - West Pac. 2023;31:100390.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e4th Health, Population and Nutrition Sector Programmme. (4th HPNSP): Program implementation Plan January 2017 - June 2022. Ministry of Health and Family Welfare, Government of peoples republic of Bangladesh; 2017.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Urban health system, primary health care, non-communicable diseases, Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-8439762/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8439762/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eWith the dual challenges of rapid urbanization and increasing prevalence of non-communicable diseases (NCDs), urban health primary health care (PHC) system in Bangladesh, like many other developing countries, is facing challenges to respond to the health needs of their populations. The objectives of the study were to: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) assess the readiness of the urban PHC centres in managing NCDs (focusing on diabetes, hypertension and cardiovascular diseases); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) assess the gaps in provision of NCD diagnosis, prevention and treatment within primary care in urban areas; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) understand the extent to which NCDs are integrated into the urban PHC system.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA convergent mixed methods study design was adopted. We analysed secondary data of Bangladesh Health Facility Survey, 2017, a national survey, to assess the readiness of the urban primary health-care centres to manage diabetes and cardiovascular diseases. In addition, we collected primary data through semi-structured interviews with policy makers and urban PHC centre staff in Dhaka to identify gaps in the urban primary health-care system in managing these diseases. Data was collected between March and November 2022.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAlthough the urban PHC centres are required to provide all types of PHC services including NCDs, they mainly prioritise maternal and child health (MCH) and sexual and reproductive health (SRH) services, hence, male patients seldom come to these centres to seek healthcare services. NCD care has not been prioritised in the urban PHC centres. The health workforce in the urban PHC centres lacked training in NCD management. Due to lack of a strong follow-up system, it is often hard to track patients, therefore making it difficult to identify and treat patients who are at risk of developing or have already developed NCDs. The centres follow a paper-based recording system, which records particulars of patients attending the centres, however, NCD-related reporting is absent. One of the major challenges is the non- coordination of the two ministries \u0026ndash; health and local government \u0026ndash; for providing urban PHC including NCDs.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIntegrating NCD care within urban PHC facilities needs to be prioritized by the MOHFW and MOLGRD. This would require restructuring of PHC service delivery modalities and investment in human resources, information systems and equipment, and strong leadership across ministries to mitigate the existing barriers to deliver NCD cares at PHC level.\u003c/p\u003e","manuscriptTitle":"Are Urban Primary Health Care Centres in Bangladesh Prepared to Manage Non-communicable Diseases? A Mixed Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 11:44:38","doi":"10.21203/rs.3.rs-8439762/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"314076287544254384130250436558727605697","date":"2026-02-24T01:15:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136693585476372757362253648980224682094","date":"2026-02-17T09:24:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T09:00:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-31T10:26:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-31T08:19:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-31T08:18:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-12-24T06:42:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f79f7bb-7c93-4d25-9fc2-ff455fa2bfe5","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-17T09:10:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 11:44:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8439762","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8439762","identity":"rs-8439762","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}