Challenges in primary care for diabetes and hypertension: an observational study of the Kolar district in rural India

Abstract

BackgroundChronic diseases have emerged as the leading cause of death globally, and 20% of Indians are estimated to suffer from a chronic condition. Care for chronic diseases poses a major public health challenge, especially when health care delivery has been geared traditionally towards acute care. In this study, we aimed to better understand how primary care for diabetes and hypertension is currently organised in first-line health facilities in rural India, and propose evidence-based ways forward for strengthening local health systems to address chronic problems.MethodsWe used qualitative and quantitative methods to gain insight into how care is organised and how patients and providers manage within this delivery system. We conducted in-depth interviews with the medical doctors working in three private clinics and in three public primary health centres. We also interviewed 24 patients with chronic diseases receiving care in the two sub-sectors. Non-participant observations and facility assessments were performed to triangulate the findings from the interviews.ResultsThe current delivery system has many problems impeding the delivery of quality care for chronic conditions. In both the public and private facilities studied, the care processes are very doctor-centred, with little room for other health centre staff. Doctors face very high workloads, especially in the public sector, jeopardising proper communication with patients and adequate counselling. In addition, the health information system is fragmented and provides little or no support for patient follow-up and self-management. The patient is largely left on their own in trying to make sense of their condition and in finding their way in a complex and scattered health care landscape.ConclusionsThe design and organisation of care for persons with chronic diseases in India needs to be rethought. More space and responsibility should be given to the primary care level, and relatively less to the more specialised hospital level. Furthermore, doctors should consider delegating some of their tasks to other staff in the first-line health facility to significantly reduce their workload and increase time available for communication. The health information system needs to be adapted to better ensure continuity of care and support self-management by patients.Electronic supplementary materialThe online version of this article (10.1186/s12913-019-3876-9) contains supplementary material, which is available to authorized users.

Team-based primary health care for non-communicable diseases: complexities in South India

“…We developed the interventions based on the results of an analysis of the quality of service delivery for diabetes and hypertension at PHCs in Kolar district that we reported elsewhere ( Lall et al , 2019 ). Doctor-centred care processes, lack of information to maintain continuity of care, fragmented care processes, poor support for self-management and decision-making that was not evidence-based or patient-centred were identified as factors impacting the quality of care for NCDs ( Lall et al , 2019 ). We presented these findings to the DHO and programme managers of the NPCDCS in Kolar district to identify possible interventions to address the gaps.…”

“…We conducted QI research to improve care for chronic NCDs, specifically diabetes and hypertension, at public primary health centres (PHCs) in a rural district in South India. The interventions to improve quality of services for diabetes and hypertension care were developed to address specific gaps identified through a situational analysis in the same setting as reported previously ( Lall et al , 2019 ).…”

Managing diabetes mellitus with comorbidities in primary healthcare facilities: a qualitative study among physicians in Odisha, India

“…[14] Lall et al in their study conducted in a rural district of India on challenges in primary care for diabetes and hypertension management have found fragmented care and a poor health information system as major barriers faced by physicians in quality management. [15] The public health care system in India has a three-tier structure comprising of primary, secondary and tertiary levels. Tertiary health care is provided by medical college hospitals, and the district and subdivisional hospitals render secondary care.…”

Managing diabetes mellitus with comorbidities in primary healthcare facilities: a qualitative study among physicians in Odisha, India

“…[14] Lall et al in their study conducted in a rural district of India on challenges in primary care for diabetes and hypertension management have found fragmented care and a poor health information system as major barriers faced by physicians in quality management. [15] Though, these studies in India have looked into the health system perspective in managing patients with diabetes, there is a lack of studies addressing primary care providers' perception on management of patients with diabetes and comorbidities. The present study explored the primary care physicians' perceived barriers and facilitators in managing patients with diabetes and comorbidities.…”