Assessment of Hypertension and Diabetes Care in Public Health Facilities Across India: A Multicentric Cross-Sectional Study

Abstract

Introduction:

Non-communicable diseases (NCDs), particularly hypertension and diabetes, are major contributors to India’s growing disease burden. Strengthening public health systems for effective prevention and management is imperative. So, the aim was to assess and improve the quality of hypertension and diabetes care and control in healthcare facilities in India.

Methods:

A multicentric cross-sectional study was conducted across six purposively selected states of India encompassing Uttarakhand, Punjab, Gujarat, Maharashtra, Assam, and Arunachal Pradesh. In each state, data were collected from one district hospital, two Community Health Centers (CHCs), and two Health and Wellness Centers (HWCs)—one rural and one urban—capturing services at all public healthcare levels. A questionnaire based on National Programmer for Prevention and Control of non-communicable diseases (NP-NCD) and Indian Public Health Standards (IPHS) guidelines, along with supervision checklists, was used. Ethical approvals were obtained, and field teams were regularly monitored for quality assurance.

Results:

Significant urban–rural disparities were observed in NCD service delivery. Rural HWCs had better availability of NCD clinics, essential medicines, and follow-up mechanisms, whereas urban HWCs showed higher diagnostic testing, but lower treatment adherence and control. Rural CHCs demonstrated superior service utilization and clinical outcomes compared to urban CHCs. District hospitals offered the most comprehensive care, achieving the highest treatment-adherence (71.2%) and hypertension-control rates (45.3%). System-wide issues such as medicine stock-outs and limited staff training were prevalent. Statistical analysis revealed a significant association between facility type and clinical control of NCDs (P < 0.001).

Conclusion:

Rural CHCs and district hospitals outperformed urban primary care facilities in managing hypertension and diabetes. To meet national NCD targets, strategic strengthening of urban HWCs through workforce training, uninterrupted drug supply, digital tracking, and governance reforms is essential.

INTRODUCTION

Infectious illness research has made tremendous strides and exhibited an unparalleled level of focus in recent decades. Meanwhile, several social, cultural, and environmental factors, including dietary modifications, physical inactivity, and longer life expectancy, have contributed to a sharp rise in the prevalence of cardiometabolic illnesses such as diabetes mellitus and hypertension.[1,2] The World Health Organization (WHO) has projected that cardiovascular disease (CVD) alone will account for nearly a quarter of global deaths by 2030.[3] Similarly, the International Diabetes Federation estimated that the number of individuals living with diabetes would increase from approximately 65 million in 2013 to 100 million by 2035.[4]

India, the world’s most populated nation, is one instance of how the burden of non-communicable diseases (NCDs) is changing quickly. NCDs were expected to represent 52% of India’s overall disease burden in 2013, a significant increase from 32% in 1990.[2] Following the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 India has set a goal to reduce premature death from NCDs by 25% by 2025.[5,6] To achieve this goal, the National Programmer for Prevention and Control of non-communicable diseases (NP-NCD) was initiated in the country during 2010–2012. This Program is being successfully implemented in all the 31 states and Union Territories. A National study entitled ICMR-INDIAB conducted in the country in that adults more than 20 years were included from Urban and Rural areas of all the 31 states and Union Territories found that the prevalence of Diabetes of 11.4%, Pre-Diabetes was 15.3% and Hypertension was 35.5%. During 2015–2016, more than 1.29 crore persons were screened in the designated NCD clinics. It was found that 8% had Diabetes and 12% were suffering from Hypertension.[7] The Ministry of Health and Family Welfare launched an ambitious initiative of screening and placing 75 million people with hypertension or diabetes on Standard Care by 2025. This announcement was made at a G20 co-branded event “Accelerating the Prevention and Management of Hypertension and Diabetes,” which was organized jointly by the Union Health Ministry in collaboration with the WHO Country office in India.[8]

Study rationale

There is a lack of data on Hypertension and Diabetes care and control provided at healthcare facilities in India under the NP-NCD program in India. The study was conducted to assess whether NCD clinics are functioning as per the NP-NCD program in healthcare facilities in India. An attempt was made to identify the gaps in the effective functioning of NP-NCD program in Hypertension and Diabetes care and control.

Aim

To assess and improve the quality of hypertension and diabetes care and control in healthcare facilities in India.

Objectives

• Objective 1: To assess the implementation of the NP-NCD program for the diagnosis and management of Hypertension and Diabetes at different levels of health care delivery in both rural and urban settings across India.

• Objective 2: To assess the quality of hypertension and diabetes care and control services provided in healthcare facilities in terms of:

  • (a)Percentage of eligible population aged 30 years and above, diagnosed with Hypertension and Diabetes
  • (b)Percentage of eligible population aged 30 years and above, put on standard of care (lifestyle modifications and treatment) for Hypertension and Diabetes.

METHODOLOGY

Study design

A multicentric cross-sectional study.

Study sites

This multicentric cross-sectional study was conducted, utilizing meticulously selected records from diverse study sites strategically distributed across the country. The selection process for study sites was carried out with scientific rigor, aiming to capture a comprehensive spectrum of economic disparities, physical landscapes, and sociocultural diversities prevalent across the country. The study was carried out in six purposively selected states of India: Uttarakhand, Punjab, Gujarat, Maharashtra, Assam, and Arunachal Pradesh. From each State, it was proposed to collect data from all three levels of healthcare facilities in both rural and urban areas that is, Under the public health facilities, one district hospital, two Community Health Centers (CHCs), and two Primary Health Centers (PHCs) were selected as per the sampling plan. By including sites from various regions, the study aims to capture a broader perspective of hypertension and diabetes control, accounting for regional variations in hypertension and diabetes and their control measures. Approval from the Institutional Ethics Committee was obtained at each study site to ensure the study’s compliance with ethical guidelines and participant protection.

Sampling framework

The study was conducted in six purposively selected states of India: Uttarakhand, Punjab, Gujarat, Maharashtra, Assam, and Arunachal Pradesh. The accompanying map visually highlights these states [Figure 1]. The selection of study sites was undertaken with methodological rigor to ensure representation of the country’s diverse economic conditions, geographical terrains, and sociocultural contexts. In each selected state, one district was chosen. Within each district, two PHCs—one urban and one rural—were selected. Additionally, two CHCs and one District Hospital were included from the same district [Supplementary Figure 1 ^{(478.1KB, tif)} ].

Figure 1.

Geographic distribution of selected study sites in India (n = 6)

Study tool

A pre-tested semi-structured questionnaire was used to collect data from each Health facility. A checklist for the Supportive supervision and other annexures were consulted from the NP-NCD and IPHS guidelines for the finalization of the questionnaire. All the required funds were provided for data collection, travel, and quality control. Supervisory visits were also made from coordinating sites to maintain uniformity and for supportive supervision.

RESULTS

The study was conducted in six states of India: Uttarakhand, Punjab, Gujarat, Maharashtra, Assam, and Arunachal Pradesh—each representing diverse geographic and health system contexts. From each state, one district was selected, and within each district, a total of five health facilities were included: two PHCs; one urban and one rural, two CHCs, and one District Hospital (DH). In total, 29 health facilities were assessed, comprising 12 PHCs (six urban and six rural), 11 CHCs (five urban and six rural), and six DHs. All facilities were part of the public health system and functioned under the National Health Mission. Most PHCs and CHCs catered to a population ranging from 30,000 to 120,000, and DHs served as the highest referral units at the district level. The availability of NCD-specific infrastructure, trained staff, and essential medicines varied across facilities and states.

Primary health centers (PHCs): Urban vs. rural

The assessment revealed notable differences in the availability and utilization of NCD-related services between urban and rural PHCs. NCD clinics were operational in a greater proportion of rural Health and Wellness Centers (HWCs) (66.7%) compared to their urban counterparts (33.3%), suggesting better integration of dedicated NCD services in rural settings. Furthermore, inpatient department (IPD) services were more frequently available in rural PHCs (83.3%) than in urban ones (50%), potentially indicating enhanced service capacity in rural areas. However, outpatient department (OPD) attendance was marginally higher in urban PHCs, with a monthly average of 567 patients compared to 559 in rural areas. Regarding diagnostic capabilities, urban PHCs showed a higher mean number of laboratory investigations (416/month) compared to rural PHCs (260/month), although point-of-care testing (POCT) for common NCDs such as diabetes and hypertension was universally available across both urban and rural facilities. Service uptake also differed slightly; a greater number of patients were screened for diabetes in urban PHCs (21,658) than in rural ones (5,570), similarly screening for hypertension was more frequent in urban PHCs (28,519) compared to rural (13,841). Notably, rural PHCs exhibited superior availability of essential logistics and supplies, including functional glucometers, BP instruments, and weighing scales. Additionally, rural facilities had better medicine availability, particularly for key NCD drugs such as metformin, amlodipine, losartan, and insulin, in comparison to urban PHCs [Table 1].

Table 1.

Anti-diabetic and Anti-hypertensive drug availability among the selected health centers

Name of drug	Type of facility
	U-PHC	R-PHC	U-CHC	R-CHC	DH
Anti-diabetic drug
Glimepiride	5	5	5	6	6
Metformin	5	5	5	2	6
Glibenclamide	2	3	0	0	0
Glucose Injections	3	1	4	1	3
Insulin	2	1	1	1	3
Anti-hypertensive drug
Amlodipine	6	5	5	6	6
Atenolol	3	4	4	4	5
telmisartan	5	5	4	3	6
Enalapril	3	2	1	3	5
Hydrochlorothiazide	1	3	1	1	3
Methyldopa	1	0	0	0	2
Labetalol	3	2	4	1	5
Ramipril	2	1	0	0	0
Digoxin	2	2	0	1	3
Nor-adrenaline	2	2	1	1	3
Sodium Nitroprusside injection	1	1	0	0	2
Propanolol	2	1	2	0	2
Total	6	6	5	6	6

*Values indicate the number of health facilities out of total selected facilities. U-PHC=Urban Primary Health Centers; R-PHC=Rural Primary Health Centers; U-CHC=Urban Community Health Centers; R-CHC=Rural Community Health Centers; DH=District Hospital

Community health centers (CHCs): Urban vs. rural

Among CHCs, NCD services were relatively well established across both urban and rural settings, with clinics present in 83.3% of rural CHCs and 80% of urban CHCs. All CHCs, regardless of location, offered IPD and OPD services, with rural CHCs recording a higher mean monthly OPD attendance (3,592 patients) compared to urban CHCs (3,222). Laboratory testing was more extensive in rural CHCs (1,206/month) versus urban CHCs (740/month), reflecting a stronger diagnostic capacity in rural institutions. Screening for diabetes and hypertension was notably higher in rural CHCs, with an average of 480 diabetes and 589 hypertension screenings per month, compared to 273 and 392, respectively in urban CHCs. The availability of diagnostic instruments and logistics was adequate in both settings; however, rural CHCs were better equipped in terms of manpower, with a higher proportion having both medical officers and staff nurses in place.

The availability of antidiabetic medications varied across health facilities. Glimepiride was universally available at all surveyed CHCs, while Metformin was missing in one urban and one rural CHC, despite being a first-line therapy. Glibenclamide was absent in all urban CHCs but available in one rural CHC. Insulin availability highlighted a notable urban–rural disparity, with all three types: soluble, intermediate-acting, and premixed—available only in one urban CHC, and none in rural CHCs. Regarding antihypertensive medications, amlodipine was universally available across CHCs, whereas atenolol was present in four CHCs, evenly distributed between urban and rural settings. Telmisartan and Enalapril were more frequently available in urban CHCs. However, essential medications such as Methyldopa, Ramipril, and Sodium Nitroprusside were not available at any facility, underscoring critical gaps in the pharmaceutical supply chain [Table 1].

District hospital

The district hospital showed robust service provision across all domains of NCD care. NCD clinics were operational and well-utilized, with a significantly high OPD load averaging over 8,000 patients per month. IPD and diagnostic services were fully functional, with over 2,500 laboratory investigations conducted monthly. The hospital had comprehensive screening programs in place, with over 700 and 650 individuals screened monthly for diabetes and hypertension, respectively. Regarding medications; glimepiride and metformin were universally available, glibenclamide was entirely absent, and insulin (soluble, intermediate-acting, and premixed) was stocked in only half of the facilities. Similarly, although amlodipine and telmisartan were consistently available, other essential antihypertensives like atenolol, enalapril, and labetalol were missing in some facilities, and critical drugs such as methyldopa, propranolol, and sodium nitroprusside were present in only two. These gaps highlight significant challenges in ensuring comprehensive pharmaceutical support for diabetes and hypertension care [Table 1].

Training needs assessment

A cross-cutting observation across all facility types was the urgent need for capacity building and refresher training in NCD service delivery. Many frontline workers lacked adequate training in clinical protocols, use of digital tools for patient tracking, and lifestyle counselling. The majority of PHCs (particularly urban) and CHCs reported the absence of recent skill-building sessions on NCD protocols. Additionally, staff expressed limited familiarity with data entry tools and formats mandated under the National NCD Programmer. Strengthening the competency of service providers in NCD risk assessment, interpretation of clinical parameters, patient engagement strategies, and the use of health information systems was identified as a key strategy to enhance service quality and continuity of care.

Treatment adherence, follow-up, and clinical control [Table 2]

Table 2.

Hypertension and diabetes care cascade across healthcare facilities (treatment adherence, follow-up, and clinical control)

Facilities	Eligible population	Total screened	Uninterrupted treatment (3 months)	Revisited for drug refills	Lost to follow-up	Achieved disease control
Hypertension care cascade
U-PHC	231134	28519 (12.3)	4726 (16.6)	3340 (11.7)	227 (0.8)	816 (2.8)
R-PHC	50899	13841 (27.2)	925 (6.6)	752 (5.4)	200 (1.4)	1406 (10.1)
U-CHC	339795	9699 (2.8)	3057 (31.5)	2312 (23.8)	169 (1.7)	1110 (0.1)
R-CHC	91455	8395 (9.2)	5278 (62.9)	1976 (23.5)	580 (6.9)	5508 (65.6)
DH	1668241	8558 (0.5)	6107 (71.3)	5050 (59)	1013 (11.8)	3881 (45.3)
Diabetes care cascade
U-PHC	231134	21658 (9.3)	1286 (5.9)	1235 (5.7)	89 (0.4)	695 (3.2)
R-PHC	50899	5570 (10.9)	415 (0.8)	417 (0.8)	176 (0.3)	689 (1.3)
U-CHC	339795	3299 (0.9)	1537 (46.6)	1436 (43.5)	117 (3.5)	853 (25.8)
R-CHC	91455	5310 (5.8)	3165 (59.6)	1498 (28.2)	411 (7.7)	2185 (41.1)
DH	1668241	3031 (0.2)	1819 (60)	1330 (43.9)	327 (10.8)	819 (27)

U-PHC=Urban Primary Health Centers; R-PHC=Rural Primary Health Centers; U-CHC=Urban Community Health Centers; R-CHC=Rural Community Health Centers; DH=District Hospital

At PHCs, treatment adherence among individuals with hypertension was higher in urban settings, with 16.6% maintaining uninterrupted treatment for 3 months, compared to 6.6% in rural PHCs. Similarly, revisit rates for drug refills were greater in urban PHCs (11.7%) than rural ones (5.4%). However, clinical control of blood pressure was paradoxically higher in rural PHCs (10.2%) than urban PHCs (2.9%). Loss to follow-up remained low in both settings, reported at 0.8% in urban and 1.4% in rural PHCs. For diabetes care, the trend reversed, with rural PHCs demonstrating slightly better adherence (7.4%) and revisit rates (7.5%) compared to urban PHCs (5.9% and 5.7%, respectively). Glycemic control was achieved in 12.4% of rural patients versus 3.2% in urban settings. However, loss to follow-up was higher in rural areas (3.2%) compared to urban (0.3%). At CHCs, performance in hypertension management showed significant rural–urban differences. The rural CHC demonstrated markedly higher adherence (62.8%) compared to the urban CHC (31.5%). Revisit rates were similar between the two (23.5% in rural and 23.8% in urban CHC). Despite a higher loss to follow-up in the rural CHC (6.9%) than in the urban CHC (1.7%), blood pressure control was substantially better in the rural setting, with 65.5% achieving control compared to only 11.4% in the urban CHC. In diabetes care, rural CHCs again reported higher uninterrupted adherence (59.6%) than urban CHCs (46.6%). Although revisit rates were higher in urban CHCs (43.5% vs. 28.2% in rural), glycemic control was more frequently achieved in rural CHCs (41.4%) than urban ones (25.8%). Loss to follow-up remained higher in rural CHCs (7.7%) compared to urban CHCs (3.5%). At the district hospital level, hypertension management exhibited the highest treatment adherence across all facilities, with 71.2% of individuals maintaining uninterrupted therapy. Revisit rates were also relatively high (59%), while the loss to follow-up was 11.8%. Notably, 45.3% of individuals achieved blood pressure control, reflecting favorable outcomes. For diabetes, 60% of patients adhered to uninterrupted treatment over 3 months, and 43.8% revisited for refills. However, the loss to follow-up remained substantial at 10.7%, and only 27.7% of individuals achieved glycemic control, highlighting ongoing challenges in diabetes management despite relatively better follow-up adherence at this level of care.

Tables 3 and 4 shows a significant association between facility type and control status of both hypertension and diabetes (P < 0.001). Rural CHCs demonstrated the highest control rates for both conditions—41.1% for glycemic control and 65.6% for hypertension—despite serving fewer individuals than urban PHCs. District hospitals also showed relatively better outcomes, with 27% achieving glycemic control and 45.4% achieving blood pressure control. In contrast, urban PHCs had the lowest control rates (3.2% for diabetes and 2.9% for hypertension) despite screening the highest number of patients. These findings highlight better chronic disease management at higher-level facilities, particularly in rural settings, and point to the need for strengthening primary healthcare services at the PHC level.

Table 3.

Association between facility type and control status of diabetes among patients

Facility type	Glycemic control status			Test of association
	Achieved control n (%)	Not achieved control n (%)	Total screened n (%)
U-PHC	695 (3.2)	20963 (96.8)	21658 (100)	χ2=6358.5/P≤0.001
R-PHC	689 (12.4)	4881 (87.6)	5570 (100)
U-CHC	853 (25.9)	2446 (74.1)	3299 (100)
R-CHC	2185 (41.1)	3125 (58.9)	5310 (100)
DH	819 (27)	2212 (73)	3031 (100)

U-PHC=Urban Primary Health Centers; R-PHC=Rural Primary Health Centers; U-CHC=Urban Community Health Centers; R-CHC=Rural Community Health Centers; DH=District Hospital

Table 4.

Association between facility type and control status of hypertension among patients

Facility type	Hypertension control status			Test of association
	Achieved control n (%)	Not achieved control n (%)	Total screened n (%)
U-PHC	816 (2.9)	27703 (97.1)	28,519 (100)	χ2=22095.8/P≤0.001
R-PHC	1406 (10.2)	12435 (89.8)	13,841 (100)
U-CHC	1110 (11.4)	8589 (88.6)	9,699 (100)
R-CHC	5508 (65.6)	2887 (34.4)	8,395 (100)
DH	3881 (45.3)	4677 (54.7)	8,558 (100)

U-PHC=Urban Primary Health Centers; R-PHC=Rural Primary Health Centers; U-CHC=Urban Community Health Centers; R-CHC=Rural Community Health Centers; DH=District Hospital

DISCUSSION

This study presents a comparative assessment of the availability, utilization, and effectiveness of NCD services across urban and rural public health facilities in India. The findings reveal several important insights into the structure, process, and outcomes of hypertension and diabetes care in PHCs, CHCs, and DH. A key observation from our study was that rural CHCs demonstrated higher outpatient utilization and diagnostic activity than urban CHCs, with an average of 3,592 OPD visits and 1,206 laboratory tests per month compared to 3,222 and 740, respectively, in urban CHCs. However, it is supported by previous observations that rural populations tend to depend more heavily on public sector services due to lower affordability of private care.[9] In alignment with our study, the National Family Health Survey (NFHS-5) reported that awareness, treatment, and control of hypertension and diabetes remain suboptimal across both urban and rural India. NFHS-5 shows that among hypertensive adults aged 15+, only 44% of women and 32% of men were aware of their condition, while just 13% of women and 9% of men had their hypertension adequately controlled. These data are consistent with our finding that hypertension control was achieved in 65.5% of patients at rural CHCs but only 11.4% at urban CHCs, suggesting a wide variability across facilities and possible differences in service quality, continuity of care, and patient adherence. Further, availability of essential medications varied substantially. While amlodipine and metformin were widely available, rural facilities faced shortages of other drugs such as insulin, ACE inhibitors, and statins. This is consistent with findings from a cross-sectional study by Prinja et al.[10] which found that only 42% of PHCs and 63% of CHCs had a full supply of first-line antihypertensive and antidiabetic drugs. Similarly, a study by Selvaraj et al.[11] showed that the availability of essential NCD medicines in public health facilities was as low as 50% in some northern and central Indian states.

Our study also found better treatment adherence and blood pressure control at rural CHCs compared to urban CHCs. These findings contrast with the broader literature, where urban populations typically show better NCD outcomes due to proximity to care, better health literacy, and more consistent follow-up.[12] The relatively strong performance of rural CHCs in our study may reflect proactive engagement by specific facility teams, possibly due to local leadership, NGO collaboration, or better implementation of the India Hypertension Control Initiative (IHCI) protocols. IHCI reports from 2022 highlight improved blood pressure control rates—up to 70% in pilot districts—when standard treatment protocols, drug availability, and follow-up mechanisms are in place.[13]

Among HWCs, urban centers had higher rates of laboratory testing and antihypertensive treatment adherence (16.6%), but rural HWCs achieved better blood pressure control (10.2%), suggesting a possible discrepancy between service provision and outcome realization. This may be attributed to inconsistent patient follow-up, lack of digital tracking tools, or suboptimal lifestyle counselling in urban settings. Lall et al.[14] noted similar issues in their qualitative research on NCD management at HWCs, emphasizing the need for better training, counselling, and community engagement strategies.

One of the most consistent gaps across all facility types was the lack of trained personnel and ongoing capacity-building activities. Only a fraction of facilities reported staff trained in NCD protocols within the last 6 months, and even fewer had structured health promotion activities. A multi-country study by Mendis et al.[15] on WHO PEN implementation showed that regular training and supervision improved protocol adherence and clinical outcomes across Low-middle Income Country (LMIC) settings. Moreover, our study highlights a systemic issue with digital and data systems for NCD patient tracking. The inconsistent use of Community bases Assessment Checklist (CBAC) forms, NCD registers, and IT-based follow-up tools impairs the ability to deliver longitudinal care. As per the Operational Guidelines for NCDs under NP-NCD, robust information systems are essential for tracking patient adherence, clinical control, and loss to follow-up.[16]

Limitations

The study, being multicentric cross-sectional is susceptible to several potential biases, including selection bias, observer bias, and information bias. To address these, rigorous efforts were made to ensure methodological robustness and data quality. Study sites were selected purposively to capture geographical, socioeconomic, and health system diversity across India, thereby enhancing external validity. Standardized, pre-tested tools aligned with national guidelines (NP-NCD and IPHS) were used to minimize information bias, while data collectors received comprehensive training to reduce observer variability. Additionally, supervisory visits were conducted, and data were cross-verified with facility records and triangulated through direct observations and staff interviews to ensure accuracy and consistency in findings.

CONCLUSION

This national assessment underscores critical disparities in the delivery and effectiveness of hypertension and diabetes care across levels of public health facilities in India. Despite the broad rollout of the NP-NCD program, the implementation remains uneven—particularly at the primary care level, where urban PHCs lag significantly in clinical control outcomes. Conversely, rural CHCs and district hospitals demonstrate relatively higher adherence, better disease control, and stronger operational capacity, suggesting that performance is often more dependent on local leadership, supply chain stability, and embedded follow-up systems than geography alone.

The findings reveal a systemic challenge in transitioning from screening to sustained care. While screening coverage has expanded, continuity of care—measured through treatment adherence, revisit rates, and clinical control—remains suboptimal. Urban-rural reversals in outcome metrics highlight that infrastructure alone does not guarantee effectiveness; rather, it is the interplay of staff capacity, drug availability, and digital tracking that drives quality. Furthermore, the uneven availability of essential medications and the limited use of digital health tools highlight missed opportunities for optimizing chronic disease management within the public health system.

To translate policy intent into impact, India must now shift from program expansion to strategic consolidation. Strengthening human resources, institutionalizing standard treatment protocols, and embedding accountability through digital health intelligence are immediate priorities. Only through an integrated, patient-centric, and data-driven approach can the health system overcome the bottlenecks identified in this study and move closer to achieving its national targets for non-communicable disease prevention and control by 2025.

Recommendations

To improve hypertension and diabetes care in India, public health infrastructure—particularly PHCs—must be strengthened. This includes ensuring consistent availability of essential diagnostic equipment (e.g., glucometers, BP apparatus) and uninterrupted supplies of first-line medications such as metformin, glimepiride, amlodipine, and insulin. Gaps in logistics and drug supply chains need to be addressed through centralized procurement systems, real-time stock monitoring, and buffer stock policies.

Capacity building of healthcare providers is critical to ensure effective service delivery. Regular, structured training sessions on NP-NCD clinical protocols, patient counselling, and use of digital health tools should be institutionalized for Medical Officers, Auxiliary Nurse Midwifes (ANMs), and Accredited Social Health Activists (ASHAs). This should be supported by refresher courses, blended learning platforms, and supervisory mentoring to enhance adherence to treatment guidelines and improve patient outcomes.

Continuity of care remains a major challenge, particularly at the primary care level. Digital solutions such as the CPHC-NCD application must be scaled up for registration, follow-up, and data capture. ASHAs and ANMs should be trained and incentivized to track defaulters and ensure timely drug refills and counselling. Incorporating follow-up tracking into routine workflows will be essential to reduce dropouts and achieve long-term disease control.

Significant disparities between rural and urban facilities suggest the need for targeted interventions. While rural CHCs performed better in clinical outcomes, urban PHCs showed better outpatient utilization, but poor disease control. Urban primary care facilities require urgent attention, including dedicated NCD staff, improved infrastructure, and enhanced community outreach to underserved populations in slums and peri-urban areas.

Finally, strong governance, monitoring, and intersectoral coordination are needed to sustain progress. Facility-level dashboards, Key Performance Indicators (KPIs) for NCD control, and periodic audits should be embedded within health systems. Customizing NCD action plans at the state level, ensuring robust implementation of protocols, and engaging stakeholders across health, nutrition, and digital sectors will be key to meeting India’s NCD targets.

Conflicts of interest

Nil.

Supplementary Figure 1

Sampling strategy of each selected state

Funding Statement

The Global Health Advocacy Incubator (GHAI) funded this study.