Article Text

Original research
Improving primary care for diabetes and hypertension: findings from implementation research in rural South India
  1. Dorothy Lall1,
  2. Nora Engel2,
  3. Prashanth N Srinivasan3,
  4. Narayanan Devadasan4,
  5. Klasien Horstman2,
  6. Bart Criel5
  1. 1Health Services, Institute of Public Health Bengaluru, Bangalore, Karnataka, India
  2. 2CAPHRI Care and Public Health Research Institute, Faculty of Health and Medicine and Life Sciences, Maastricht University, Maastricht, Limburg, The Netherlands
  3. 3Health Equity Research, Institute of Public Health Bengaluru, Bangalore, Karnataka, India
  4. 4Primary Care, Health Systems Transformation Platform, New Delhi, India
  5. 5Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
  1. Correspondence to Dr Dorothy Lall; dorothylall{at}


Background Chronic conditions are a leading cause of death and disability worldwide. Low-income and middle-income countries such as India bear a significant proportion of this global burden. Redesigning primary care from an acute-care model to a model that facilitates chronic care is a challenge and requires interventions at multiple levels.

Objectives In this intervention study, we aimed to strengthen primary care for diabetes and hypertension at publicly funded primary healthcare centres (PHCs) in rural South India.

Design and methods The complexities of transforming the delivery of primary care motivated us to use a ‘theory of change’ approach to design, implement and evaluate the interventions. We used both quantitative and qualitative data collection methods. Data from patient records regarding processes of care, glycaemic and blood pressure control, interviews with patients, observations and field notes were used to analyse what changes occurred and why.

Interventions We implemented the interventions for 9 months at three PHCs: (1) rationalise workflow to include essential tasks like counselling and measurement of blood pressure/blood glucose at each visit; (2) distribute clinical tasks among staff; (3) retain clinical records at the health facility and (4) capacity building of staff.

Results We found that interventions were implemented at all three PHCs for the first 4 months but did not continue at two of the PHCs. This fadeout was most likely the result of staff transfers and a doctor’s reluctance to share tasks. The availability of an additional staff member in the role of a coordinator most likely influenced the relative success of implementation at one PHC.

Conclusion These findings draw attention to the need for building teams in primary care for managing chronic conditions. The role of a coordinator emerged as an important consideration, as did the need for a stable core of staff to provide continuity of care.

  • primary care
  • organisation of health services
  • quality in health care
  • general diabetes

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  • Contributors DL, ND and BC designed and planned the study. DL, ND, BC, NE and KH participated in analysis of the data. DL and BC conceived the paper and this was substantially shaped by KH, PNS and NE. All authors contributed to the manuscript and approve of the final submission.

  • Funding The primary author and the research was supported by a PhD scholarship from the Institute of Tropical Medicine, Antwerp, Belgium. PNS time contributions were supported by a DBT/Wellcome Trust India Alliance fellowship (number IA/CPHI/16/1/502648) awarded to him.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The study received ethical approval from the ethics committees at the Institute of Tropical Medicine, Antwerp, the University of Antwerp, Belgium and the Institute of Public Health in Bengaluru, India.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. The data are available with the corresponding author and will be shared on reasonable request. We have not stored in a publicly accessible data base as the qualitative information may allow identification of location and site.