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

Abstract

Chronic non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, have reached epidemic proportions worldwide. Health systems, especially those in low- and middle-income countries, such as India, struggle to deliver quality chronic care. A reorganization of healthcare service delivery is needed to strengthen care for chronic conditions. In this study, we evaluated the implementation of a package of tailored interventions to reorganize care, which were identified following a detailed analysis of gaps in delivering quality NCD care at the primary care level in India. Interventions included a redesign of the workflow at primary care clinics, a redistribution of tasks, the introduction of patient information records and the involvement of community health workers in the follow-up of patients with NCDs. An experimental case study design was chosen to study the implementation of the quality improvement measures. Three public primary care facilities in rural South India were selected. Qualitative methods were used to gain an in-depth understanding of the implementation process and outcomes of implementation. Observations, field notes and semi-structured interviews with staff at these facilities (n = 15) were thematically analysed to identify contextual factors that influenced implementation. Only one of the primary health centres implemented all components of the intervention by the end of 9 months. The main barriers to implementation were hierarchical arrangements that inhibited team-based care, the amount of time required for counselling and staff transfers. Team cohesion, additional staff and staff motivation seem to have facilitated implementation. This quality improvement research highlights the importance of building relational leadership to enable team-based care at primary care clinics in India. Redesigned organization of care and task redistribution is important solutions to deliver quality chronic care. However, implementing these will require capacity building of local primary care teams.

Monitoring of Non-communicable Diseases in a Primary Healthcare Setting in India: A Quality Improvement Initiative

“…Similar to the other studies done in the past [12,13], we faced challenges such as a shortage of staff and low work motivation during the implementation. It is a usual thing, as people tend to avoid any change in the systems.…”

Refer rather than treat: coping with uncertainty in municipal primary care clinics in India

“…They acknowledged rural MBBS doctors treated NCDs but said people would question this in the city with specialists nearby, thus bounding their services by what was contextually appropriate. Their narratives support arguments that doctors need not only adequate supplemental training for NCD care (Bhojani et al, 2014;Lall et al, 2020) but also empowerment, such as through respecting ground-level knowledge, building upon altruistic and social motives and improving regulatory control (Kane and Calnan, 2017). This is particularly salient in urban settings, where specialists are in high supply and patients may bypass primary care, raising concerns around over-medicalization, efficiency, cost and quality (Rao and Sheffel, 2018;Sriram and Bennett, 2020).…”

“…However, health worker capacity and referral networks have been inadequate (MOHFW, 2013b;Bhojani et al, 2014). Implementation and outcomes of a national NCD program launched in 2008, which included operating procedures and training modules, have been suboptimal (Jayanna et al, 2019;Lall et al, 2020). Recent national efforts through Health and Wellness Centersdenoting upgraded primary care facilities under a program begun in 2018have expanded NCD services (Lahariya, 2020), but treatment, care coordination and health worker capacity remain low (Gandhi et al, 2022).…”

Improving primary care for diabetes and hypertension: findings from implementation research in rural South India

“…We have reported an analysis of the local contextual influences on implementation and refer to it in this paper to communicate a complete understanding of why changes did or did not occur. 19 The insights we gained have implications for the redesign of primary care for chronic conditions and may be informative for similarly resource-constrained settings.…”