Decentralising healthcare for diabetes and hypertension from secondary to primary level in a humanitarian setting in Kurdistan, Iraq: a qualitative study

Background:

Experts suggest that Non-Communicable Disease (NCD) care is best delivered at the primary level, including in humanitarian crisis settings. In many crisis-affected countries, NCD care is predominantly delivered by specialists at secondary care level, and there is limited evidence on decentralising NCD care in such settings. We aimed to explore health actor and patient experiences of decentralising diabetes and hypertension (DM/HTN) care from a hospital to primary care clinics in the humanitarian setting of Duhok, Kurdistan Region of Iraq.

Methods and results:

We conducted a qualitative study including 30 semi-structured interviews with a purposive sample of patients (n = 16), healthcare providers (n = 7), and key stakeholders (n = 7) involved in the decentralisation project. Guided by a conceptual framework, data were analysed thematically using deductive and inductive approaches. The decentralisation project achieved its stated goals of (a) increasing patients’ access to DM/HTN care, by reducing cost and distance, and (b) decreasing workload at secondary care level. The approach appeared acceptable from patient, provider and stakeholder perspectives. Key health system inputs were put in place to support the decentralisation project, including medicines, equipment and health workforce training, but gaps remained. While access and quality seemed to improve, integration, continuity and sustainability were more challenging to achieve. Key systemic challenges to sustainability included a lack of health financing, and weak national supply chains and information systems. Patients’ trust in the service was important and was closely linked to having access to a continuous supply of trusted medications.

Conclusions:

While it is possible to decentralise diabetes and hypertension care from secondary to primary level in a humanitarian setting, multiple contextual factors must be considered, including supply chain strengthening and adaptation to existing workforce capacity. Our study findings may inform other actors exploring the decentralisation of NCD care elsewhere in Iraq and in other humanitarian settings.