Service availability and readiness for out-patient integrated management of multimorbidity in public primary health facilities in Malawi: A mixed methods analysis

Background: The presence of multiple medical chronic conditions is a growing burden across Africa where people experience a double burden of communicable and non-communicable diseases (NCD). Integrated chronic disease care at the primary healthcare level is a means to improve person-centred care for people living with multimorbidity. This study aimed to assess public primary healthcare facilities' service availability and readiness to manage multimorbidity in Malawi, through the lens of HIV, type 2 diabetes, hypertension and chronic kidney disease. We explored healthcare workers' perceptions of their capacity to provide care for individuals with multimorbidity and the availability of services and resources at their facility. Methods: We conducted a mixed-methods health facility cross-sectional study in primary healthcare facilities in Blantyre and Chiradzulu districts, Malawi. We used the modified WHO Service Availability and Readiness Assessment Tool to assess 12 facilities, and conducted in-depth interviews with 12 purposively selected health facility leads. Availability is presented as the proportion of facilities offering each service. Facility readiness is defined as the mean(percentage) availability of 44 tracer items with a cutoff point of ≥70%, classified as ready to manage multimorbidity. Readiness score for individual conditions was also calculated based on the availability of tracer items of that condition with a cutoff point of ≥70%. Results: Of the surveyed facilities, 83%(10/12) offered services for all four selected conditions. Only 30%(3/10) of all facilities had a readiness score of ≥70%, indicative of minimum service delivery requirements for multimorbidity were met. The mean readiness score for type 2 diabetes (65.7%) was the highest, followed by HIV (63.8%), hypertension (60.4%), and chronic kidney disease had the lowest readiness score (22.9%). Barriers to service readiness included nonfunctional diagnostic equipment, frequent drug stockouts and insufficient staffing and supervision, and a lack of clinical guidelines or protocols. Conclusion: The assessed sites were inadequately prepared to provide integrated care for chronic kidney disease, type 2 diabetes, HIV and hypertension. The ability to provide integrated screening and management will require functional diagnostic equipment and consistent drugs. Periodic quality assurance and combined multimorbidity audits could further highlight the gaps in service delivery and give clues to improvement.