Integrating services for maternal, newborn and child health and noncommunicable diseases at district-level facilities: Kyrgyzstan, Tajikistan and Viet Nam

1 Kyrgyzstan, Tajikistan and Viet Nam REPORT Integrating services for noncommunicable diseases & maternal, newborn and child health at district-level facilities Photo © WHO/ Sergey Volkov Integrating services for maternal, newborn and child health and noncommunicable diseases at district-level facilities 2 Integrating services for maternal, newborn and child health and noncommunicable diseases at district- level facilities: Kyrgyzstan, Tajikistan and Viet Nam ii Integrating services for maternal, newborn and child health and noncommunicable diseases at district-level facilities: Kyrgyzstan, Tajikistan and Viet Nam (Integrating services for maternal, newborn and child health and noncommunicable diseases at district-level facilities) ISBN 978-92-4-007817-8 (electronic version) ISBN 978-92-4-007818-5 (print version) © World Health Organization 2023 Some rights reserved. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use iii Acknowledgements ................................................................................................................... iv Abbreviations ............................................................................................................................. v 1. Introduction ........................................................................................................................ 1 2. Methodology ...................................................................................................................... 2 3. Country profiles ................................................................................................................. 3 4. Health systems ................................................................................................................... 4 5. Maternal, newborn and child health: situation analysis ..................................................... 7 6. Noncommunicable diseases: country profiles and trends .................................................. 8 7. Integrating NCDs into maternal, newborn and child health services at district-level facilities: challenges and opportunities ...................................................................................... 9 8. Recommendations ............................................................................................................ 12 References ................................................................................................................................ 15 Tables Table 1. Country characteristics and key socioeconomic indicators ......................................... 3 Table 2. Key health financing indicators, by country ................................................................ 5 Table 3. Maternal, newborn and child health indicators, by country ........................................ 7 Table 4. Noncommunicable disease risk profiles, by country ................................................... 8 Table 5. Key findings in the three project countries ................................................................ 11 CONTENTS iv Acknowledgements This report was made possible thanks to the support and contribution of many individuals from the World Health Organization Secretariat at headquarters, the WHO Regional Offices for Europe and the Western Pacific, country offices in Tajikistan, Kyrgyzstan and Viet Nam, and external experts. Due to the COVID-19-related restrictions travel was limited to Kyrgyzstan and Tajikistan, and not possible to Viet Nam. Thus, the analysis relies on data collected from secondary sources of available evidence and informal interviews with selected experts conducted in October- November 2021. Overall direction and coordination: Svetlana Akselrod, Téa Collins Research and analysis: Ketevan Chkhatarashvili, Flaminia Ortenzi Editorial support: John Dawson Contributors: Aliina Altymysheva, Daria Berlina, Annie Chu, Socorro Escalante, Pavel Esin, Jill Farrington, Aigul Kuttumuratova, Oleg Kuzmenko, Moise Muzigaba, Pham Thi Quynh Nga, Van Hien Pham, Mekhri Shoismatuloeva, Howard L. Sobel, Nurshaim Tilenbaeva, Igor Toskin, Özge Tuncalp, Martin Willi Weber, Wilson Milton Were, Nuhu Omeiza Yaqub JR, Shoira Yusupova. Special thank you to the WHO Project Steering Committee for their support: Shambhu Acharya, Svetlana Akselrod, Pascale Allotey, Nazira Artykova, Anshu Banerjee, Nino Berdzuli, Sergey Diorditsa, Rudolf Eggers, Zsuzsanna Jakab, Ana Carina Jorge Dos Santos Ferreira Borges Bigot, Bente Mikkelsen, Natasha Muscat, Victor Stefan Olsavszky, Kidong Park, Huong Tran, Melita Vujnovic. ACKNOWLEDGEMENTS v Abbreviations GDP gross domestic product NCD noncommunicable disease PHC primary health care PPP purchasing power parity SDG Sustainable Development Goal STEPS STEPwise approach to chronic disease risk factor surveillance UNICEF United Nations Children’s Fund WASH water, sanitation and hygiene WHO World Health Organization 1 1. Introduction Much improvement in maternal, newborn and child mortality over recent decades can be attributed to the increased availability of health care services. However, the quality of care continues to remain a problem, as nearly 300 000 women still lose their lives globally each year as a result of pregnancy or childbirth, and almost 6 million children die, mostly from preventable causes, especially in low- and middle-income countries (1). While the absolute number of maternal deaths has declined, indirect maternal deaths from pre- existing chronic conditions have been rising, with noncommunicable diseases (NCDs) now accounting for almost 15% of all maternal deaths in low- and middle-income countries. Apart from maternal deaths, NCDs during pregnancy may increase the risk of spontaneous abortion, stillbirth, congenital malformations, infant respiratory death syndrome and birth injuries. Furthermore, the medical complications due to pre-existing conditions can affect not only the current pregnancy, but also future pregnancies and long-term health, and can lead to developmental challenges and poor health of future generations (1, 2). Many NCDs can be prevented and effectively managed with appropriate interventions across the maternal and child health cycle, throughout the years of reproductive age (especially before conception and continuing through pregnancy), and during infancy, childhood and adolescence. However, the integration of NCD prevention and control into maternal, newborn and child health services is often challenging, especially in resource-constrained settings. The 2030 Agenda for Sustainable Development provides a great opportunity to emphasize not only survival but also the health and well-being of mothers and children. This requires multisectoral and multistakeholder actions, including evidence-based interventions to address the burden of NCDs and mental health conditions among women and children. Within this framework, the WHO project on Improving the Quality of Hospital Care to Reduce Maternal, Newborn and Child Deaths and Accelerate the Achievement of the SDG Health Targets aims to institutionalize and scale up the quality-of-care improvement mechanisms to reduce maternal, neonatal and childhood mortality and morbidity. The project targets four countries: Kyrgyzstan, Mongolia, Tajikistan and Viet Nam. In three of the four countries (Kyrgyzstan, Tajikistan and Viet Nam), the project also includes an NCD and mental health component that focuses on integrating interventions targeting these conditions into existing maternal, newborn and child health services, to improve health before and during pregnancy, as well as future parents’ infant and young child care practices. The project aims to provide support to over 40 hospitals and includes the following activities: (a) strengthening institutional mechanisms for quality improvement in the health sector, with a particular focus on maternal, newborn and child health care; (b) building quality improvement capabilities and learning platforms; (c) conducting capacity-building activities and supporting the adoption and implementation of maternal, newborn and child health intervention packages based on current national norms and standards, as well as international guidelines; (d) developing or updating WHO guidance and tools, including an intervention package for NCD 2 prevention and management as part of maternal, newborn and paediatric care; (e) providing technical assistance for the integration of NCD prevention, diagnosis and treatment into existing maternal, newborn and child health services; and (f) improving health-seeking behaviour among mothers, families and communities. 2. Methodology As part of the project, a baseline situation analysis was conducted to identify opportunities and challenges for integrating NCD prevention, diagnosis and treatment into maternal, newborn and child health care. The situation analysis consisted of: ¨ An initial desk review of the available evidence, including WHO reports and guidelines, global, regional, and national policy documents, evaluation reports, peer- reviewed articles, facility quality assessments, and other relevant documents. The desk review was carried out in consultation with country NCD focal points. ¨ A mapping exercise to identify existing projects related to the quality of care, maternal, newborn and child health, and NCDs implemented by various stakeholders (for example, the national ministry of health, World Health Organization (WHO), United Nations Children’s Fund (UNICEF), World Bank) in each country. ¨ In-person interviews with key informants at the national and subnational levels in Kyrgyzstan and Tajikistan (it was not possible to conduct a mission to Viet Nam due to the pandemic restrictions), including policy-makers, programme managers, providers and experts, to obtain feedback on the adaptation of WHO quality improvement tools to the local context, and identify additional relevant documents that were not identified during the desk review. ¨ Hospital-level facility assessments to understand the current conditions and challenges related to the provision of maternal, newborn and child health services, and the integration of NCD prevention, diagnosis and treatment into antenatal care. Several primary care facilities were also visited to identify opportunities for improving the quality of maternal, newborn and child health services, and integrating NCD care into antenatal care. A variety of tools were used for facility assessment, including tools developed by WHO and other international partners, to build comprehensive assessment checklists that would look at the quality of care and the health system barriers to the improved delivery of integrated services. Results from the situation analysis enabled the identification of gaps in facility readiness (for example, with regard to essential infrastructure inputs and equipment to diagnose and treat NCDs); identification of shortcomings in health workforce competencies and skills as prerequisites for delivering standardized quality care (for example, the inclusion of NCD prevention and management in standard treatment protocols); and development of recommendations for improvement. 3 3. Country profiles Among the three project countries, Viet Nam is the most densely populated, experiencing rapid urbanization and population ageing processes; in comparison, Kyrgyzstan and Tajikistan have larger proportions of young people and higher rural populations (Table 1) (3–5). Table 1. Country characteristics and key socioeconomic indicators Characteristic/indicator Kyrgyzstan Tajikistan Viet Nam Region Central Asia Central Asia South-East Asia Population (millions) 6.7 9.8 98.0 Average age (years) 26.0 22.4 32.5 Urban population (% total population) 37.2% 27.7% 38.1% Rural population (% total population) 62.8% 72.3% 61.9% GDP growth (annual % in 2021) 3.6% 9.2% 2.6% Poverty rate (at the international poverty line of $3.65 a day; 2017 PPP) 18.7%a 14.6%b 5.3%c PPP = purchasing power parity. a. Most recent value (2020). b. Most recent value (2021). Most recent value (2018). Sources: United Nations, Department of Economic and Social Affairs, Population Division. Available at: https://esa.un.org/unpd/wpp/. World Bank Group. World Bank Development Indicators (online database). Available at: https://databank.worldbank.org/source/world-development-indicators. Over recent decades, all three countries have made significant progress in achieving economic growth and reducing poverty rates. As an example, Tajikistan’s economy has been growing at an average rate of 7% per year since 2010, which is much higher than the average reported growth in Europe and Central Asia, and the poverty rate fell from 83% in 2000 to 14.6% in 2021 (6, 7). However, all three countries were hit hard by the COVID-19 pandemic, with Kyrgyzstan being the most affected. While national economies recovered quickly and gross domestic product (GDP) growth resumed, the pandemic led to rising food prices, increased food insecurity, lower real incomes, and limited job opportunities, greatly affecting people’s socioeconomic well- being. Moreover, all three countries are highly vulnerable to climate change impacts and natural disasters, which represent a constant threat to their economies (6, 8, 9). 4 4. Health systems In all three project countries, the health systems remain largely state owned, although the private health care sector is growing. Ministries of health are responsible for developing health policies and technical guidelines, as well as for regulating health service provision (10–12). The three countries have developed several strategies to support universal health coverage and improved population health outcomes. For example, Kyrgyzstan is currently implementing the Healthy Person, Prosperous Country (2019–2030) strategic programme, and Tajikistan has recently adopted the Strategy for Population Health Protection until 2030. Both strategies aim to ensure access to essential quality services, strengthen primary health care (PHC), and decrease the financial burden for the population (12, 13). Kyrgyzstan, Tajikistan and Viet Nam have highly hospital-oriented health service delivery models, focused on curative care. Patients are allowed to visit any health facility or specialist at any level. Therefore, given the limited capacity of PHC facilities to provide a broad range of services and make essential medicines available, many patients prefer to bypass the PHC level and go directly to hospitals. This leads to the underutilization of PHC and overcrowding of hospitals for conditions that could be managed on an outpatient basis (11, 14, 15). With population ageing – especially in Viet Nam – and the growing burden of NCDs and mental health conditions, the governments of all three countries recognize the urgent need to strengthen PHC and reduce the burden on hospitals (11, 14, 15). Viet Nam has already taken concrete steps to shift its hospital-oriented health system towards a more PHC-oriented model. As an example, since 2016 PHC facilities are being upgraded with modern equipment to enable them to diagnose and treat NCDs and bring services closer to the communities (11). Photo © WHO/ Asad Zaidi 5 Another challenge is significant health workforce shortages, with Tajikistan being the most severely affected. After the dissolution of the Soviet Union in 1991 and the civil war that followed, Tajikistan experienced a massive out-migration of health workers – especially to the Russian Federation – in search of higher wages and better working conditions (16). Both in Tajikistan and Kyrgyzstan, health workers’ average salaries are lower than the average wages of other professional categories, resulting in informal payment systems (10, 15, 17). In Viet Nam, health workers’ basic salaries are comparable to other professional categories; however, this seems to be insufficient, given that a significant part of the health workforce has left the sector because of low remuneration and poor work environments (11, 18). The numerical shortages of health care workers are compounded by inadequate health workforce skills and competencies as well as uneven geographical distribution in all three countries. Hospitals in urban settings have better equipment, offer higher salaries and better conditions, and provide more opportunities for professional development, thus attracting more qualified staff, and contributing to shortages in rural and remote facilities (10, 11, 15). In Tajikistan, while three quarters of the population live in rural areas, the highest density of health workers is in the capital, Dushanbe, and the lowest densities are observed in rural and remote areas (10). Both in Kyrgyzstan and Tajikistan, the government health expenditure per capita is much lower than the average in Europe and Central Asia; while Viet Nam’s government health expenditure per capita is significantly higher than the average in South Asia (10, 12, 19). In all three countries, high out-of-pocket payments represent a major barrier to accessing health services, resulting in large inequalities in utilization between the poor and the rich. This is especially the case in Tajikistan, where out-of-pocket payments make up more than 70% of total health expenditure (Table 2) (10, 12, 19). Table 2. Key health financing indicators, by country Indicator Kyrgyzstan Tajikistan Viet Nam Domestic general government health expenditure per capita, PPP (current international $) 133.9 68.5 244.8 Domestic general government health expenditure (as % of current health expenditure) 51.4% 27.3% 43.8% Out-of-pocket expenditure (as % of current health expenditure) 36.2% 71.2% 43.0% External health expenditure (as % of current health expenditure) 2.3% 1.3% 1.0% Note: Figures are most recent values (2019). Source: World Bank Group. World Bank Development Indicators (online database). Available at: https://databank.worldbank.org/source/world-development-indicators. 6 The governments of Kyrgyzstan, Tajikistan and Viet Nam all provide essential benefits packages, but the population coverage and services included in the packages vary across the three countries. Viet Nam has a national social health insurance programme, which in 2018 covered almost 87% of the population (19). The government fully subsidizes insurance premiums for children aged under 6 years, the elderly, poor persons, and ethnic minorities, and provides partial subsidies for the near-poor and students (20). The country’s social health insurance benefits package is comprehensive, as it covers all ambulatory services, as well as basic and advanced hospital services, and includes a long list of subsidized medicines (20). In Tajikistan, the types of services provided and population groups entitled to these services free of charge (by social or health status) are listed in Decree No. 600 of 2008. Services provided include emergency medical care, PHC and specialized outpatient services, as well as inpatient and hospital care (14). In addition, a basic benefits package was introduced in some regions, which provides a defined set of health services free of charge to certain population groups, while all other patients are subject to co-payments (14). Kyrgyzstan has a single-payer system, whereby public funds are pooled into the Mandatory Health Insurance Fund to purchase a standardized package of services from health facilities (12). Service provision is regulated by the State Guaranteed Benefits Package and the Additional Drug Package for ambulatory patients. The former grants all citizens free access to emergency and primary care, free outpatient specialist care with referral, and inpatient care with referral and co-payments (except for population groups exempted from co-payments by social or health status) (21). The latter defines a list of outpatient medicines that are subsidized for those who are enrolled in the mandatory health insurance scheme, which is about 74% of the population (15, 21). Regarding the health information systems, the three project countries face similar challenges (15, 22, 23), including poor data quality due to the absence of verification, supervision, and monitoring mechanisms of data collection and reporting processes; lack of quality indicators in some programmatic areas; limited reach of data collection; inadequate information and communications technology for digitalization; fragmentation due to multiple vertical information systems within the same country; limited availability of disaggregated data by age, sex, region and socioeconomic status; and lack of qualified human resources to collect and analyse data. Physical and financial access to essential medicines remains challenging in Tajikistan, with significant regional differences in the availability of certain medicines across the country – especially those frequently used for chronic conditions – and large price variations (24). Kyrgyzstan has partially addressed these issues through a series of health reforms that led to the establishment of a well developed pharmacy network and made a wide range of medicines available across the country. In addition, in 2020, the government started regulating prices for selected medicines on the Additional Drug Package, to decrease the financial hardship experienced by the population due to the price of medicines (12). Kyrgyzstan’s national list of essential medicines is largely in line with the WHO Model List of Essential Medicines (15); while Viet Nam’s list far exceeds the WHO Model List, as it 7 comprises a very broad selection of medicines, including some expensive ones that are not mentioned in the WHO list (20). 5. Maternal, newborn and child health: situation analysis The improvement of maternal, newborn and child health is a priority for the governments of Kyrgyzstan, Tajikistan and Viet Nam. Over the past two decades, all three countries have made significant progress in maternal, newborn and child health outcomes (Table 3). According to data from UNICEF, the maternal mortality ratio in Viet Nam fell from 68 deaths per 100 000 live births in 2000 to 43 in 2017; in Tajikistan, it decreased from 53 deaths per 100 000 live births in 2000 to 17 in 2017; and in Kyrgyzstan, it fell from 79 deaths per 100 000 live births in 2000 to 60 in 2017, but remains one of the highest in the WHO European Region (25–27). These achievements can largely be attributed to improvements in health services. However, the current maternal mortality ratios remain high. Reasons for this include poor water, sanitation and hygiene (WASH) conditions, the inadequacy or deterioration of infrastructure and equipment of health facilities, delays in seeking care because of low health literacy and access barriers, and suboptimal practices in maternal, newborn and child health care at health facilities (14, 15, 28). In Viet Nam, almost 75% of maternal deaths are due to severe bleeding, infections, hypertensive disorders (pre-eclampsia and eclampsia), complications from delivery and unsafe abortion (29). Similarly, an investigation into maternal deaths in Kyrgyzstan during 2014–2015 found that the most frequent direct causes of death were obstetric bleeding, hypertensive disorders (of which eclampsia was the most common) and obstetric sepsis. The investigation also revealed that in about 60% of cases the quality of antenatal care provided was not adequate, with health workers underestimating the severity of women’s conditions, failing to recognize conditions outside their specific area of competence, or not following national clinical protocols. As a result, even though 70% of maternal death cases received antenatal care, in 78% of cases death was preventable (30). Table 3. Maternal, newborn and child health indicators, by country Indicator Kyrgyzstan Tajikistan Viet Nam Maternal mortality ratio (no. of deaths per 100 000 live births)a 60 17 43 Infant mortality rate (no. of deaths per 1000 live births)b 15.7 28.4 16.7 Under-5 mortality rate (no. of deaths per 1000 live births)c 17.5 32.3 20.9 a. Most recent values (2017). b. Most recent values (2020). c. Most recent values (2020). Source: United Nations Children’s Fund (UNICEF). UNICEF Data Warehouse. Cross-sector indicators. Available at: https://data.unicef.org/resources/data_explorer/unicef_f/. 8 Regarding child mortality, according to UNICEF data, the under-5 mortality rate in Viet Nam fell from 29.8 deaths per 1000 live births in 2000 to 20.9 in 2020; in Tajikistan, it decreased from 83.6 deaths per 1000 live births in 2000 to 32.3 in 2020; and in Kyrgyzstan, it fell from 49.8 deaths per 1000 live births in 2000 to 17.5 in 2020. Infant mortality rates also decreased significantly in all three project countries (31). However, these reductions did not take place equally in all regions within countries, and stark disparities remain between urban and rural areas (14, 32, 33). Despite the encouraging reductions, rates of infant and child mortality remain high. Preventable illnesses still account for a considerable proportion of all child deaths. Acute infections, including acute respiratory illness, pneumonia and acute diarrhoea, are the leading cause of death in the post-neonatal period. Moreover, the burden of undernutrition and micronutrient deficiencies remains high in the three project countries, contributing to preventable deaths and impaired physical and cognitive development among children (14, 32, 34). 6. Noncommunicable diseases: country profiles and trends In all three project countries, noncommunicable diseases are the leading cause of mortality, accounting for more than 70% of total deaths. A person living in Tajikistan or Kyrgyzstan has about a one in four chance of dying prematurely from NCDs, while a Viet Nam citizen has about a one in six chance. Among the four main NCDs, cardiovascular diseases are the major killer in all three countries, followed by cancers, chronic respiratory diseases and diabetes (35) (Table 4). Table 4. Noncommunicable disease risk profiles, by country Indicator Kyrgyzstana Tajikistanb Viet Namc NCD-related mortality (% out of all-cause mortality) 83% 73% 77% Risk of premature mortality between 30–70 years from NCDs (%) 25% 28% 17% Proportional mortality from cardiovascular diseases (%) 53% 42% 31% Proportional mortality from cancers (%) 11% 10% 19% Proportional mortality from chronic respiratory diseases (%) 4% 4% 6% Proportional mortality from diabetes (%) 1% 2% 4% a. Most recent values (2016). b. Most recent values (2019). c. Most recent values (2016). Source: World Health Organization. Noncommunicable diseases country profiles. Available at: https://apps.who.int/iris/handle/10665/274512. 9 The latest STEPwise approach to chronic disease risk factor surveillance (STEPS) surveys on risk factors for NCDs conducted in Kyrgyzstan, Tajikistan and Viet Nam revealed low awareness levels among individuals and communities about NCD risk factors, as well as significant gaps in health service delivery concerning prevention, early diagnosis and treatment of NCDs. For example, the 2015 STEPS survey in Viet Nam (36) found that the prevalence of hypertension in the study population was almost 19%, of which only 43% of cases had been diagnosed before the study, and only 14% were being treated at a health facility. The 2017 STEPS survey in Tajikistan (37) showed that more than 87% of the study population had never been tested for blood sugar levels, and only half of those with high blood sugar were taking treatment. Similar results were obtained by the 2013 STEPS survey in Kyrgyzstan (38), which found that about 94% of the study population had at least one risk factor for the development of NCDs. These findings are important not only for the overall health status of the population but also for the provision of quality antenatal and postnatal care to pregnant women – for example, concerning pre-eclampsia and eclampsia. 7. Integrating NCDs into maternal, newborn and child health services at district-level facilities: challenges and opportunities Integrated health service delivery has the potential to address evolving population health needs, reduce pressure on health systems, improve the quality of services delivered and promote health equity. However, the current health service delivery models of Kyrgyzstan, Tajikistan and Viet Nam, which are highly hospital oriented and focused on episodic curative care, are ill-suited to providing continuous integrated care, with a person-centred approach. Strengthening primary health care and improving the quality of services at the grass-roots level is an essential prerequisite for implementing integrated care models in Kyrgyzstan, Tajikistan and Viet Nam. Without stronger PHC networks and integration of NCDs into maternal, newborn and child health care at all levels, it will be difficult to achieve further improvements in maternal and child health and avoid preventable mortality. This is because antenatal and postnatal care is the primary responsibility of PHC facilities, and if NCDs are not prevented, promptly detected and effectively treated at the PHC level, it becomes very difficult (sometimes impossible) to manage complicated cases at the hospital level (14, 15, 38). One of the main challenges to strengthening PHC and integrating NCDs into antenatal and postnatal care at all levels is the underutilization of primary care facilities. Other barriers to integration include fragmentation of health service provision and health information systems; insufficient financial resources for care integration; lack of political will; lack of adequate policies and legal frameworks; and outdated health workforce training programmes (14, 15, 38, 39). 10 The WHO project assessment team visited several district-level hospitals and primary care facilities in various regions of Kyrgyzstan and Tajikistan. However, due to COVID-19 travel restrictions, the team was unable to travel to Viet Nam. Thus, the data for Viet Nam were collected through secondary analyses of available evidence and interviews with key informants, with support from WHO country staff. Key findings from the assessment of the three project countries are presented below, based on results available at the time this report was finalized (Table 5). Photo © WHO/ David Spitz 11 Table 5. Key findings in the three project countries Country Key findings Kyrgyzstana • At the PHC level, there are gaps in the timely identification of risk factors and potential complications during pregnancy. • Blood pressure measurements are not performed routinely at PHC facilities, as there is a lack of understanding among health workers of the need to routinely screen patients for hypertension. • A definition of cardiovascular risk was missing in 100% of pregnant women’s medical records. Cholesterol levels were generally not determined even if risk factors for hypercholesterolemia were present (e.g. age over 40, obesity). Weight was not determined in 30% of cases, and body mass index was rarely calculated. • There are no national protocols for the management of NCDs in pregnant women. Existing clinical protocols often do not mention the prescription of calcium supplements and low-dose aspirin. Measurements assessing the risk of eclampsia were only present in 10% of women’s medical records. • Medical records did not include a dedicated section on NCDs and their risk factors, nor did they mention the mental health of pregnant women and new mothers. A 10-year cardiovascular disease (CVD) risk nomogram was not regularly used. • While training of health workers at the PHC level was conducted in 2019, there were no monitoring and evaluation mechanisms in place. Tajikistanb • In all institutions visited by the team, blood pressure was regularly monitored. In most cases, therapists, cardiologists and, if necessary, endocrinologists were consulted. In 100% of cases, a complete blood count was performed to determine platelets, and a urine test was carried out to detect proteinuria. • At the hospital level, in 90% of cases, medical records included the results of an electrocardiogram, and in 100% of cases, if necessary, antihypertensive therapy and magnesium therapy were prescribed. • Medical records (at both primary and hospital levels) did not contain information on risk factors for NCDs, nor did they mention the 10-year risk of CVD on a risk scale. • Echocardiographic examination was not performed in 86% of cases, and arterial wall stiffness was not determined in 100% of cases. This was due to the lack of both equipment and the necessary skills of existing staff. • In 90% of cases, glycated haemoglobin was not checked. Neither at the primary care level nor the hospital level was there adequate monitoring of diabetes mellitus, even in cases of pregnancy with diabetes mellitus. • There were no protocols for the management of gestational diabetes, although guidelines for management existed. Viet Namc Several challenges to the integration of NCD care into existing maternal, newborn and child health services were identified, including the following (39): • There is no cohesive policy on integrated care, and there are also gaps in the legal framework, such as on patient choice and data-sharing processes. 12 Country Key findings • Governance and management of health services continue to follow the hierarchical public service administrative structure, with weak accountability mechanisms for achieving objectives. • Current provider payment mechanisms do not promote a cooperative and complementary relationship among various levels of care. • Health workforce training programmes currently do not include elements of care integration. • There are no established multidisciplinary teams and there is no concept of joint management of patients. • Many patients bypass PHC due to poor quality of care, which undermines the critical role of PHC as the first point of contact for patients. • Clinical guidelines are applied unevenly, and they lack a clear definition of who should deliver each intervention or service, and where. • There are significant gaps in health information systems. Health data are often duplicated and fragmented, and health workers are neither allowed nor required to share patient information for purposes of coordinating patient care across providers and levels. a. Key findings from PHC facility visits conducted in 2021 by the WHO assessment team, based on the analysis of pregnant women’s medical records. b. Key findings from the assessment of several medical institutions located in the city of Dushanbe, based on the analysis of the case histories and outpatient records of pregnant women with hypertension disorders, and on interviews with medical staff. c. Key findings from secondary analyses of existing reports and interviews with key informants. All three project countries have developed and adopted evidence-based standards and protocols for antenatal care and the management of NCDs; however, implementation levels remain low, and poor quality of care is still a major obstacle to the improvement of maternal, newborn and child health outcomes. For instance, Tajikistan has over 40 standards and protocols for antenatal care and pregnancy complications (including one for pre-eclampsia), which have been adapted from WHO guidelines. The country also has protocols for the management of most NCDs, including during pregnancy. However, key informants interviewed as part of the assessment reported that implementation of the protocols is often hindered by a lack of funding, resources and capacity of health workers. A similar situation was found in Kyrgyzstan and Viet Nam (40, 41). 8. Recommendations Even though the WHO project on Improving the Quality of Hospital Care to Reduce Maternal, Newborn and Child Deaths and Accelerate the Achievement of the SDG Health Targets focuses on district-level hospitals, improving the quality of care at the PHC level as well is paramount. Most maternal deaths could be avoided by timely detection of risk factors and potential pregnancy complications at the PHC level. 13 Herewith a set of recommendations are provided to improve the quality of care at different levels, including PHC, that apply to all three project countries. General policy recommendations include the following: 1. Allocate a greater proportion of GDP to health care services to improve access to quality care. 2. Ensure implementation of evidence-based guidelines and protocols for admittance and referral of patients to hospital, by establishing enforcement mechanisms at both the PHC and hospital levels, and ensure means of transportation in case of need. 3. Further strengthen PHC to detect, in a timely manner, and adequately manage NCDs and their shared risk factors, as well as mental health conditions, and identify potential NCD-related pregnancy complications. 4. Develop or strengthen staff retention policies, especially in rural and remote areas. 5. Ensure adequate and targeted funding to reduce informal payments, which represent a major financial barrier to accessing health care. 6. Develop and strengthen a health information system that will provide reliable disaggregated data and enable the process of evidence-based policy-making. 7. Establish mechanisms to enable the systematic monitoring of the quality of care provided at both the PHC and hospital levels. Project recommendations include the following: 1. Develop and deliver trainings on NCDs for maternity hospital staff, and develop standard operating procedures on NCDs at the primary care level. 2. Promote the effective implementation of electronic document management and routing. 3. Create a joint working group of obstetricians, gynaecologists, therapists, cardiologists and endocrinologists to update existing protocols and develop new ones, as needed. 4. Revise existing outpatient medical records to include a section on risk factors for NCDs. Specific project recommendations at the PHC level include the following: 1. Undertake advanced training of family doctors and nurses in the timely detection of high-risk pregnancies, with a focus on hypertension, CVD, diabetes, and pre-eclampsia. 2. Develop clinical protocols for the detection, management, timely referral, and, if necessary, transportation of high-risk pregnant women. 14 Specific project recommendations at the hospital level include the following: 1. Develop criteria for referral to a higher level. 2. Ensure that health care staff are familiar with all clinical protocols and standards of care approved for use in the country. 3. Develop and implement a monitoring system to assess adherence to clinical protocols and standards of care. 4. Advance the infrastructure optimization process to enable the project to pilot horizontal and vertical linkages between health care providers, towards care integration. 5. Prioritize the diagnosis and treatment of NCDs. 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