Diabetes care in public health facilities in India: a situational analysis using a mixed methods approach

Figures & data

Box 1 Packages of services to be made available at different levels under NPCDCS in India

Health Facility	Packages of services
Sub-center	1. Health promotion for behavior change
	2. “Opportunistic” screening using BP measurement and blood glucose by strip method
	3. Referral of suspected cases to CHC
CHC	1. Prevention and health promotion including counseling
	2. Early diagnosis through clinical and laboratory investigations (common lab investigations: blood sugar, lipid profile, ECG, ultrasound, X ray, etc.)
	3. Management of common CVD, diabetes and stroke cases (outpatient and inpatients.)
	4. Home-based care for bed ridden chronic cases
	5. Referral of difficult cases to district hospital/higher health care facility
District hospital	1. Early diagnosis of diabetes, CVDs, stroke and cancer
	2. Investigations: blood sugar, lipid profile, kidney function test (KFT), liver function test (LFT), ECG, ultrasound, X ray, colposcopy, mammography, etc. (if not available, will be outsourced)
	3. Medical management of cases (outpatient, inpatient and intensive care)
	4. Follow-up and care of bed ridden cases
	5. Day care facility
	6. Referral of difficult cases to higher health care facility
	7. Health promotion for behavior change
Tertiary care centre	In addition to the services above, comprehensive cancer care including prevention, early detection, diagnosis, treatment, minimal access surgery, after care, palliative care, rehabilitation

Abbreviations: CHC, Community Health Centre; CVD, cardiovascular disease; ECG, electrocardiogram; BP, blood pressure; NPCDCS, National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke.

Table 1 General information, recording and reporting mechanism for diabetes mellitus in public health facilities in three states of India, 2016

Level of health facility	Tertiary (%)	Secondary (%)	Primary (%)
Number of facilities visited	5	8	17
Number of beds for inpatient care at the visited facilities (range)	300–1,800	30–200	0–5
Daily OPD load (range)	1,500–6000	180–2,500	35–200
Availability of special clinic days for DM	5 (100)	3 (38)	5 (29)
Daily DM load/on special clinic days (range)	45–400	15–100	5–30
DM recorded in general OPD register	0 (0)	0 (0)	10 (59)
Recorded in separate NCD register	2 (40)	8 (100)	6 (35)
Electronic patient record maintained for DM outpatients	1 (20)	0 (0)	0 (0)
DM patient case file/record maintained at the hospital	3 (60)	1 (12)	0 (0)
Patient card/health card with the DM patient	2 (40)	2 (25)	24

Notes: Numbers indicate number of facilities; numbers within parentheses indicate percentage denominator being total number of facilities visited in that category

Abbreviations: DM, diabetes mellitus; OPD, outpatient department; NCD, noncommunicable disease.

Table 2 Availability of laboratory investigations, drugs and lifestyle modification support in public health facilities in three states of India, 2016

Level of health facility	Tertiary	Secondary	Primary
Number of facilities visited	5	8	17
Laboratory investigations
Glucometer/blood glucose	5 (100)	8 (100)	17 (100)
HbA1c	5 (100)	1 (12)	0 (0)
Lipid screening	5 (100)	6 (75)	0 (0)
Fundus examination	5 (100)	7 (88)	0 (0)
Urine examination	5 (100)	8 (100)	12 (71)
Foot care	5 (100)	6 (75)	0 (0)
ECG	5 (100)	6 (75)	0 (0)
Drugs			0 (0)
Glimepiride	5 (100)	6 (75)	8 (47)
Glybenclamide	0 (0)	5 (62)	8 (47)
Glyclazide	2 (40)	2 (25)	0 (0)
Metformin	5 (100)	7 (88)	14 (82)
Gliptin	3 (60)	1 (12)	0 (0)
Insulin	5 (100)	4 (50)	0 (0)
Atenolol/Metoprolol	5 (100)	8 (100)	15 (88)
Amlodipine	5 (100)	6 (75)	13 (77)
Losartan	2 (40)	0 (0)	0 (0)
Enalapril	4 (80)	1 (12)	3 (18)
Atorvastatin	5 (100)	3 (38)	0 (0)
Antidiabetic drugs given for how many days (range)	10–30	7–30	7–30
Lifestyle modification support
Dietary counselling	5 (100)	6 (75)	0 (0)
Smoking cessation counselling	2 (40)	2 (25)	0 (0)
Yoga/physiotherapy/exercise	2 (40)	2 (25)	0 (0)
Patient education on complications and their prevention	2 (40)	1 (12)	2 (12)

Notes: Numbers indicate number of facilities; numbers within parentheses indicate percentage, denominator being total number of facilities visited in that category.

Abbreviations: ECG, electrocardiogram; ECHO, echocardiogram.

Table 3 Operational issues identified and solutions as suggested by physicians in public health facilities of three states in India, 2016

Operational issue identified	Solution proposed
No regular F/U or tracking of patients	Maintenance of patient records electronically or as case files
Patient overload, Too less time for each patient	Patients should not come to tertiary/secondary facilities for drugs only, linkage with primary care facilities for drugs and routine follow-up, drug dispensing for one month
Lack of specialists/manpower	Training existing manpower-doctors/paramedical staff in diabetic care and management
No dedicated team for diabetic care	Specialised training courses for existing manpower to build a team
No system of back referral and linkage with primary health facilities	Develop a mechanism of referral and linkage with primary care facilities along the lines of DOTS in RNTCP
Difficult to manage complications at PHC Lack of lab investigations at PHC	Equip PHCs with diagnostic and follow-up laboratory investigations, provide specialised training on diabetic care to manpower at PHC
Shortage of medicine at PHC	Efficient procurement and indenting mechanism, real time drug procurement system

Abbreviations: PHC, primary health center; F/U, follow-up; RNTCP, Revised National Tuberculosis Control Programme; DOTS, Directly Observed Treatment Short Course.

Figure 1 Pathways to diabetic care for 20 patients.