Bheemaray Manganavar: Managing hypertension and diabetes in resource poor settings

Bheemaray Manganavar_2015According to the Diabetes Atlas 2006, the number of people with diabetes in India is currently around 40.9 million and is expected to rise to 69.9 million by 2025. Similarly, 118 million people were estimated to have high blood pressure in the year 2000, which is expected to go up to 213 million in 2025.

To address this situation, the Indian government launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke (NPCDCS). The programme was piloted in 100 districts (of the 646 districts in India) during 2010-12. The programme has been extended to other districts at the discretion of the state health ministries—as of now it covers 364 districts, and it has been proposed that it covers all of the districts by the end of the 12th Five Year Plan.

In my last blog, I shared my reflections on the implementation of the NPCDCS programme. In this blog, I want to share my experience of working in Tumkur, one of the rural districts of Karnataka, as part of a research project aiming to strengthen care for hypertension and diabetes in two primary health centres (PHCs). Tumkur is one of the pilot districts in the NPCDCS programme, and activities for the programme have been carried out there since 2012-13. Around the same time, we began the action research (AR) project in two PHCs in the district. “Action research” is a research strategy in which the researcher and a practitioner from the setting work together in projects to generate new knowledge and improve practice.

A detailed situational analysis showed that the resources available in these PHCs were insufficient to manage the patients with diabetes and hypertension. There was no facility for doing laboratory tests for diabetes because of an irregular supply of glucometre strips, the medicine supply was unreliable, there were no medical files or patient retained records, and patients had a poor understanding of their chronic conditions.

In order to enable these PHCs to provide better quality care for patients with diabetes and hypertension, we proposed a package of interventions, such as improved training for the PHC staff so they could provide the necessary care, making sure the supply of medicines was more reliable, counselling patients about their condition(s) so that they felt more empowered to manage them and receive care at an affordable cost. We also introduced individual patient records to ensure continuity of care. All of these efforts were organised with the aim of providing all the necessary care under one roof for patients with diabetes and hypertension.

To implement these interventions within the existing system was not an easy task. However, with the combined effort of the PHC staff and the researchers, we managed to generate the necessary financial resources for printing patient records.

To improve the availability of anti-diabetes and hypertension medicines, we discussed with the district’s/state’s drugs logistics and warehousing society the importance of supplies being delivered on time to these two PHCs; if medicines went out of stock in this period, we made alternative arrangements by buying medicines from ARS funds*. We made sure that the glucometer strips were regularly supplied by coordinating with the district’s non- communicable disease (NCD) cell. At present, the counselling services are provided by a counsellor appointed by the research team. Over a period of time, however, we intend to train the pharmacists and health workers in providing diet and lifestyle modification counselling.

The project has been going on for the past one and a half years and during this period, 638 diabetes and hypertension patients have registered out of a total 1001 patients identified in the PHC area by a door to door survey, which means approximately 64% of potential patients have sought care from these PHCs. Among the patients with hypertension, 42% have showed improvement and 58% were found to have normal blood pressure (BP). Our interactions with patients showed that their awareness of diabetes has improved and they are happy to receive all the necessary care in one facility. This shows that by providing a minimum package of interventions with the available resources at PHCs, it is possible to provide NCD care for rural patients, the majority of whom are older and of modest means, and who wouldn’t otherwise be able to afford care from other high priced facilities.

From our experience, it is evident that it is possible to manage diabetes and hypertension in rural India by using the existing resources in the primary care setting. With a well coordinated approach to ensure timely diagnosis, a reliable supply of medicines, and trained clinical staff, we can reduce the burden of diabetes mellitus and hypertension.

*Arogya Raksha Samithis (ARS) refers to the patient welfare committees that are part of government health facilities, under the National Rural Health Mission.

Bheemaray Manganavar is a researcher at the Institute of Public Health, India. He is interested in strengthening primary health centres and the district health system. 

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.