An Implementation Research to Strengthen DIGItal technologies for optimizing the Continuum of CARE for Diabetes and Hypertension Management in the Public Healthcare System in India DIGICARE

The cascade of care for non-communicable diseases (NCD) such as diabetes and hypertension management involve a series of interlinked functions of enrolment, risk assessment, screening, diagnosis and treatment, follow-up and referral. Ensuring the continuum of care from sub-centre level up to district hospitals with up and down referrals as required, poses a great challenge to the public healthcare system. These could be due to several factors like the huge burden of the condition,disease requirements of continuous monitoring and follow-up, insufficient public awareness about the need for a continuum of care, and other prioritized demands of the health system. Digital health tools, including telemedicine and mobile health apps offer the potential to bridge gaps in care by providing real-time data, facilitating remote consultations, and enabling continuous patient monitoring. Currently, there are several digital health solutions within the public healthcare system, but disconcertingly their uptake and utilisation are sub-optimal. Poor digital infrastructure, technical issues, inadequate training, and suboptimal clinic workflows are commonly cited challenges.Behavioral resistance to digitization and continued use of paper-based records further hinders adoption. Given this context, better integration of existing digital health solutions and increased uptake and utilisation can likely advance care of major NCDs, enhance disease monitoring, improve patient engagement, and optimize resource allocation, leading ultimately to better health outcomes.In the National Program for Non communicable Diseases (NP-NCD), several digital applications and services aim to achieve better screening, compliance, and control of NCDs and improve access to healthcare. The national NCD portal (or equivalent alternative systems of a state) forms the backbone of digital health interventions for NCD care delivery in the public healthcare system, along with the eSanjeevani telemedicine platform (or similar alternative in states). For widespread rollout of thesedigital technologies in the NP-NCD, the health system faces several challenges like poor digital infrastructure, inadequacy in training, technical and usability challenges and lack of primary user motivation. To address the aforementioned, in this multi-site multi-institutional collaborative project, we aim to develop and implement a digital health system model that would enable increased adoption and effective use of existing digital health interventions under the NP-NCD. The study will be implemented in one district of each of the following states: Rajasthan (Barmer), Assam (Kamrup), Chhattisgarh (Suguja), Puducherry (Puducherry), Himachal Pradesh (Solan), and Kerala (Ernakulam). The proposed implementation strategies will be directed towards strengthening the digital infrastructure within the district, building capacity of healthcare providers for digital competence, redesigning NCD workflows and task reorganisation for digital adaptation, developing motivational strategies to improve digital technology adoption and utilisation, and enhancing data quality and data use for monitoring. The intervention development will be guided by a theory of change and this will be modified as required based on the findings from the formative phase. In this project spanning three years, the initial formative phase (9 months) will include setting up a centralized technical and research support team, describing the existing digital technologies in the NP-NCD program, and understanding enablers and challenges in their adoption and use. We will build on the barrier analysis work already conducted by the teams and use these insights to inform co-production workshops with district health authorities, healthcare providers and community members in the following co-production phase (7 months). This phase will involve the co-designing of the interventions to increase adoption among the stakeholders. A base model of the proposed interventions will be developed, and implemented in two blocks for a period of 3 months. Model iterations will be conducted using the “Plan-Do-Study- Act” (PDSA) cycles based on feedback and periodic performance assessments. An ‘optimised model’ will be ready after 2-3 PDSA cycles for implementation in the final intervention implementation and evaluation phase. In this phase, the implementation strategies will be scaled up across the study districts for a period of 18 months and a concurrent evaluation will be undertaken using a pre-post quasi-experimental design. Facilities will be assessed using checklists, and healthcare provider knowledge and practice changes will be evaluated through assessments and interviews. Patient exit interviews and dashboard review for care indicators will also be done. In the last 2 months, findings and insights will be shared with relevant stakeholders to ensure alignment to the program. Ongoing monitoring and feedback mechanisms will be established to sustain and evolve improvements.