Enhancing care quality and accessibility through digital technology-supported decentralisation of hypertension and diabetes management: a proof-of-concept study in rural Bangladesh

Abstract

Objective: The critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for non-communicable diseases (NCD) in low-income and middle-income countries. In this proof-of-concept study, we aimed to test a decentralised model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care.

Design and setting: The study is a single-cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring and dispensing of medication refills from a doctor-managed subdistrict NCD clinic to non-physician health worker-managed village-level community clinics; a digital care coordination platform was developed for electronic health records, point-of-care support, referral and routine patient follow-up. The study was conducted in the Parbatipur subdistrict, Rangpur Division, Bangladesh.

Participants: A total of 624 participants were enrolled in the study (mean (SD) age, 59.5 (12.0); 65.1% female).

Outcomes: Changes in blood pressure and blood glucose control, patient retention and patient-visit volume at the NCD clinic and community clinics.

Results: The proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (incidence rate ratio 0.44; 95% CI 0.33 to 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively.

Conclusion: The proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much-needed services to patients with hypertension and diabetes in Bangladesh and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralised hypertension and diabetes care.

Keywords: diabetes & endocrinology; health services accessibility; hypertension.

Figure 1

NCD service delivery hierarchy and coordinated NCD care. CC, community clinic; CHCP, community healthcare provider; CHW, community health worker; GHRU, global health research unit; NCD, non-communicable disease; UHC, Upazila Health Complex. *Government community health workers include family welfare assistants, health assistants and multipurpose health volunteers; however, a designated community health worker was recruited and trained for NCD-related tasks in the present study. Union subcentres were not involved in this present study. Union subcentres are at a higher level of hierarchy than community clinics.

Figure 2

Digital platform designed to support multiple healthcare personnel roles along the care pathway.

Figure 3

Change in the proportion of uncontrolled conditions over follow-up visits. Results adjusted age and sex. Uncontrolled blood pressure is defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, while uncontrolled blood glucose is defined as fasting blood glucose ≥7 mmol/L or random blood glucose ≥11.1 mmol/L. HTN, hypertension; T2D, type 2 diabetes.