Dr. Dorothy Lall has started her PhD in Aug 2015 and is registered at Maastricht University, School for Public Health and Primary Care. She is guided by Prof. Klasien Horstman (Maastrict University, The Netherlands) , Prof Bart Criel (Institute of Tropical Medicine, Antwerp), Dr Nora Engel (Maastricht university, The Netherlands) and Dr Devadasan (Institute of Public Health, Bengaluru). During her PhD she will be studying the organization and quality of health care service delivery for chronic Non Communicable Diseases such as diabetes and Hypertension in both the public and private sector using a contextual Chronic Care Model as a lens/ framework. Further, during the course of this 4 year PhD program she will develop and test effectiveness of interventions that are feasible to implement at the primary care level. This study will be conducted in Kolar District of Karnataka and will involve both private and public health care delivery services.

Improving the performance of health care delivery systems to provide quality care for persons with chronic diseases at the primary level of healthcare in rural Karnataka, India

This research study aims to understand how health care services are organized and delivered in both public and private health care sectors and further how we can improve quality of care for persons with a chronic disease (Diabetes and Hypertension) at primary care level in rural Indian. Chronic Non Communicable diseases (NCDs) have emerged as a major public health challenge, in India, with a rapidly escalating burden within a health system that is still largely geared towards acute care. There is however a paucity of literature regarding how we can improve service delivery to provide quality care for a person with a chronic NCD in a middle income country like India. It is this gap in literature we hope to address in this research study. The study has 2 phases (1st phase of 15 months +2nd Phase of 18 months). The objective of this 1st phase of the study is to describe and critically analyze the current service delivery for diabetes and hypertension at primary health care both in the public and private health care delivery systems. In order to understand the organization and delivery of health care services for diabetes and hypertension at the primary health care level from both patient and provider perspectives, the study uses the Chronic Care Model (CCM) as a lens/ framework, complementing it, when deemed appropriate, with additional elements relevant to the Indian context, based on literature and field experiences. The CCM is a widely used framework to organize health services for chronic diseases, and is well supported with evidence of improved quality of care for persons with a chronic disease. It is not a prescriptive model, but identifies a number of domains to be addressed in planning delivery of services, such as having clearly identified roles and tasks for the team delivering care, the need for leadership of the team and support for clinical decision making and information systems to manage regular follow up. It also highlights the role of patients themselves in managing their illness, participating in decision making regarding clinical management, and utilizing community resources to support them. In addition to these domains, we further identified from literature other elements that impact quality of care such as training of the doctors in clinical management, availability of drugs and human resources, referral mechanism in caring for persons with a chronic Non Communicable disease (NCD) such as diabetes and hypertension. 

We propose to use a mixed methods approach for this 1st phase. We will purposively select 7 health care facilities (4 public and 3 private) that are accessed for chronic NCDs, specifically Diabetes and Hypertension based on the availability of basic infrastructure and a medical doctor. The quantitative strand of the study is a survey of persons detected to have high blood glucose or high blood pressure during screening activities of the national control program to determine if they accessed care for treatment and if so where. This survey will enable us to identify persons who do not seek care and also the health facilities (public and private) most accessed for care. We will conduct semi structured interviews with the persons who did not seek care to understand barriers related to the health system that prevent them  At the health care facilities selected we will collect data through participant observations and semi structured interviews with treating physicians and patients with a chronic NCD. Data will be thematically analyzed and findings will be compared with the theoretical assumptions/starting points and the implications for the theoretical framework will be discussed. The emerging results will be used to identify gaps in service delivery of the organization of care for Diabetes and Hypertension. Based on these findings, we shall develop interventions to strengthen care for patients with Diabetes and Hypertension and this will implemented and evaluated in the second phase of our research.

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