Assessing coverage, inequalities, and frontline provider workflows for hypertension and diabetes screening, treatment, and follow-up in two Indian states


Cardiovascular diseases (CVD) are now the leading cause of mortality in India, with diet, high blood pressure, air pollution and other risk factors contributing to the rising burden. CVDs also contribute to the escalating health expenditure both within the health care system and by individuals, particularly in the case of multiple morbidities. Further, CVD mortality, morbidity, and risk factors affect sub-populations variably in India: those with lower socio-economic status (i.e. lower incomes and education) are more vulnerable than those with higher socio-economic status.

Given the growing burden of and inequalities in CVD nationwide, there is a need for India to incrementally build capacity at the state level- expanding the scope of health care delivery heretofore designed primarily to deliver Maternal and Child Health (MCH) and communicable disease interventions.

In the lead up to AYUSHMAN BHARAT, in 2016, the Government launched a policy and guidelines for rollout of Comprehensive Primary Health Care including prevention and control of Non-Communicable Diseases (CPHC-NCD). The programme envisions a key role for frontline health workers – Auxiliary Nurse Midwives (ANMs) and community health workers (ASHAs) - in CVD prevention and control.

These frontline health workers will enumerate populations, implement a risk profile checklist, motivate those over 30 years for screening and prevention of hypertension and diabetes, promote cessation of tobacco use and lifestyle modification, refer them for treatment, and monitor uptake of services to minimize exclusion. Processes are in underway for adaptation and rollout of CPHC-NCD, particularly in states like Delhi and Uttar Pradesh, where health systems are focused on MCH service delivery, and the burden of CVDs is substantial. However, even in these states, there is an abysmal lack of a mechanism by which to understand the CVD primary care coverage achieved by frontline health workers, what key populations, if any, are being left out, and finally, how these workers are structuring their workflow in order to accommodate these expanded duties. The rollout of the CPHC-NCD programme represents a critical opportunity to build in process evaluation so as to fill these gaps in knowledge.


This study is embedded within the national programme, will assist with state and district level decision-making to improve the delivery of CVD-related services, and engage frontline health workers in quality appraisal and equity analysis of data gathered by them. Workflow data will also assist frontline health workers in improving their time management, while providing data to scale and rationalise the nature, amount and periodicity of team performance incentives for CVD-related primary care services. Finally, this assessment model is intended to be replicable in other states of India, while also being scalable in other countries with community health worker programmes.

The research employs state of the art methods to assess coverage, inequalities, and workflow of frontline workers involved with screening, treatment, and follow-up for hypertension and diabetes in two Indian states.

  1. To assess the coverage of screening, treatment and follow-up for hypertension and diabetes by frontline health workers in two States (Delhi and Uttar Pradesh);
  2. To determine inequalities in screening, treatment, and follow-up coverage by gender, poverty and caste status at facility level across these two states; and
  3. To characterise the workflow of frontline health workers undertaking screening, treatment and follow-up monitoring for hypertension and diabetes in these two states

Research Methodology:

This is an implementation research study that will employ Lot Quality Assurance Methods and Time-Motion Study methodology. Lot Quality Assurance Sampling (LQAS), is a method, employed in a range of LMIC contexts that employs stratified random sampling to assess whether coverage/quality in a stratum exceeds a specific threshold. The benefit of this method is that it allows local use and application of data, while also not placing a high burden on data collection. Time Motion studies assess the allocation of time in the workflow of individuals and groups.

This is the first instance of the use of this methodology to examine quality of NCD data anywhere. We are using the Lot Quality Assurance Sampling method to recruit at least 19 individuals in four sampling groups from each ANM’s area (the 4 groups were Female, Male, APL and BPL). For the time motion study component, three random days of the week shall be chosen, over the course of which the activities of all of the ANMs and one of her corresponding ASHAs are being consented for observation using an observation sheet followed by an interview.

Current Status:

The study has obtained ethics approval and a data collection agency, engaged by the National Health Systems Resource Centre (NHSRC) and trained extensively by the George Institute for Global Health (TGI) has completed LQAS fieldwork. All survey data was exported into a simple excel spreadsheet and then imported into STATA for analysis by a statistician. Basic descriptive and logistic regression analyses are being generated in keeping with the requirements of LQAS analysis. The study was approved by the Institutional Ethics Committee of TGI.

The second component of the Lown study is still ongoing; but dissemination of LQAS findings is also underway, in order to receive feedback from frontline workers, medical officers, supervisors, district and state officials.