Abstract

Chronic non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases,have reached epidemic proportions worldwide. Health systems, especially those in low- andmiddle-income countries, such as India, struggle to deliver quality chronic care. A reorganization ofhealthcare service delivery is needed to strengthen care for chronic conditions. In this study, weevaluated the implementation of a package of tailored interventions to reorganize care, which wereidentified following a detailed analysis of gaps in delivering quality NCD care at the primary carelevel in India. Interventions included a redesign of the workflow at primary care clinics, a redistribu-tion of tasks, the introduction of patient information records and the involvement of communityhealth workers in the follow-up of patients with NCDs. An experimental case study design waschosen to study the implementation of the quality improvement measures. Three public primarycare facilities in rural South India were selected. Qualitative methods were used to gain an in-depthunderstanding of the implementation process and outcomes of implementation. Observations,field notes and semi-structured interviews with staff at these facilities (n¼15) were thematicallyanalysed to identify contextual factors that influenced implementation. Only one of the primaryhealth centres implemented all components of the intervention by the end of 9 months. The mainbarriers to implementation were hierarchical arrangements that inhibited team-based care, theamount of time required for counselling and staff transfers. Team cohesion, additional staff andstaff motivation seem to have facilitated implementation. This quality improvement research high-lights the importance of building relational leadership to enable team-based care at primary careclinics in India. Redesigned organization of care and task redistribution is important solutions to de-liver quality chronic care. However, implementing these will require capacity building of local pri-mary care teams

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