Health care delivery systems to provide quality care | Institute of Public Health Bengaluru

Health care delivery systems to provide quality care for persons with Cardiovascular Disease

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

Chronic diseases, especially Non Communicable Chronic diseases (NCDs) like Cardiovascular Disease (CVD) and diabetes, are a growing health problem globally with a disproportionately higher burden in low-and middle-income countries (LMICs) like India. Most health care facilities in India, be it in the public or the private sector, are traditionally geared to deliver acute episodic care typically needed for communicable diseases, which by no means is a finished agenda; in addition, however, they now also have to care for chronic diseases, which raise different and unique demands from the health system. This study is an enquiry into the healthcare for persons with a chronic NCD. The first phase of the study seeks to critically analyze the current organization of healthcare for persons with CVD in both private and government facilities in a rural district (Kolar) in the State of Karnataka, India using the Chronic Care Model (CCM) as the principal lens/framework. On the basis of these insights, and after a range of stakeholder consultations, we will design a relevant bundle of contextualized interventions to reorganize delivery of healthcare for chronic conditions and improve the quality of care provided to them. In the second phase of the study, we will implement this intervention in selected health care facilities (public and private) and compare outcomes of care before and after implementation. This study is of significance and relevance given the growing burden of chronic diseases and given the fact that currently the care for persons with chronic disease is suboptimal.  This study will inform and guide the organization of care within both government and private health care delivery systems in rural India.

The Primary objective of this study is – To determine how and to what extent the quality of care for persons with chronic non communicable diseases (cardiovascular disease, diabetes and hypertension) can be improved at primary health care level in rural India by implementing interventions based on the CCM (contextualized and adapted).

Secondary objectives:1. To describe and critically analyze the current organization of health care delivery in public and private health sectors for chronic non communicable diseases using an adapted CCM as the principle lens. 2. To understand the mechanisms (program theory) of organizational change and the effect of interventions based on the adapted CCM on quality of care. 3. To validate an adapted and contextual CCM relevant to the current context of rural health care delivery in India at the primary health care level.

This is a health systems research study and an inquiry into improving the organization of health care services for persons with chronic NCDs in both the public and private sectors of health care delivery. The study includes an observational design for the first phase of enquiry and an experimental design for the second phase. This study utilizes a mix of quantitative and qualitative assessments to answer the research question.

We propose to conduct this study in Kolar district of Karnataka in India as it is one of the 5 districts in the state implementing the pilot phase of the national program for prevention and control for NCDs. Kolar district is reasonably representative of the average situation among Karnataka districts with respect to health care delivery

Health facilities: In the public health sector the PHC’s will be purposively selected from the list of PHCs in Kolar Taluk, based on the inclusion criteria. We will select PHCs in the Kolar taluk only to enable some of the interventions which require collaborations between PHCs and to ensure comparability of the case mix at these health facilities. The NPCDCS also has the NCD cell at District hospital which will also be included.

In the private sector: Hospitals, general practitioners and specialist clinics in Kolar town will be included from a list of relevant health facilities that will be compiled from the medical association databases, state government licensing authorities and on the basis of discussions with key informants in Kolar district. A snowball sampling technique, utilising information from patients and private practitioners themselves will be used to identify health facilities most used by people. The sample we draw from this list will take into account factors such as platform of healthcare delivery (clinic, small or big hospital), size of population served, and capacities (bed number and number of healthcare professionals) in order to represent the prevalent healthcare delivery. In each health facility selected for enrollment in both the public and private health sectors, all persons involved in delivering health care will be included for in depth interviews.

We restrict the study to the allopathic systems of health care delivery, as this is still the largest system in practice and the one we are most familiar with.

The assessments of quality of care outcomes will be made by quantitative and qualitative methods fro 3 groups of participants. The health care providers (physician, nurse, pharmacist, lab technician ), the person with a chronic disease, and their family/ community.

The assessments will be made at baseline, at 3 months, 6 months, 9 months and end of study. These will be compared across facilities and between private and public health facilities.

Duration of project
August 2015 to July 2019

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Phase of Study

Phase 1
Situational analysis and intervention development
Duration :- Initial 6 Months

Observational analysis of the organisation and the delivery of healthcare services for chronic diseases in both public and private healthcare delivery systems using an adapted CCM model as the principal lens.

Stakeholder consultation (workshop) to develop interventions addressing the gaps

Phase 2
Duration :- 18 Months

Assessment of organisational readiness and getting local actors on board

Implementation and evaluation of interventions composed of relevant contextualized elements of the CCM model in both public and private delivery systems using the RE-AIM framework, focusing on mechanisms that led to change and a refined program theory.

Study outputs

A Refined program theory to understand how the interventions had the effects observed
Disseminate findings to Health ministry and private provider organizations, regional conferences
Recommendations to the national program for involvement of PHC
Validated adapted and contextual CCM
Improved care for persons with a chronic NCD


Institute of Tropical Medicine, Antwerp