Table 2.

Main themes identified pertaining to NCD care as per the Bigdeli et al framework

Health system components	Main themes
Individuals, households and communities	Private sector dependence: More than 90% of respondents depended on private facilities for NCD medicines. An important driver seemed to be fragmented care in the public sector. Views on medicine availability: Poor availability of medicines at PHCs was reported to be the key reason for private sector dependence. Views on medicine quality: There is a perception that medicines supplied in the public sector are of inferior quality.
Resources: human resources and infrastructure	Shortage of health workers: 30% of PHCs did not have a doctor (due to a vacant post). Similarly, in 31% of PHCs, there was no full time pharmacist and in 39% of PHCs there was no laboratory technician posted. Poor laboratory facilities: Only 38% of PHCs had a functional laboratory (a designated area with basic laboratory equipment and a laboratory technician), where diagnostic tests related to NCDs (blood cholesterol and blood sugar levels) were conducted.
Health service delivery	Medicine availability at PHCs: More than 60% of PHCs reported more than 1 month of stockout of basic medicines for diabetes. Thirty per cent of PHCs reported more than 6 months stockout of metformin and 33% of PHCs had a stockout of glibenclamide (both drugs for diabetes) for more than 6 months. Only 5% of facilities reported availability of any statin at the time of visit. Inadequate primary care component of NPCDCS: The national programme is limited to sporadic screening camps in the community and other activities at the secondary and tertiary levels. At the PHC level, health workers had not received training in the management of diabetes/hypertension, nor were they given specific guidance on what aspects of care ought to be provided at the PHC level.
Governance	NCD prioritisation at district/taluka local health systems: The local health system agenda is strongly influenced by state and national programme priorities. NCDs do not appear among the top priorities for medical officers or health managers based on discussions during monthly review meetings. In review meetings and discussions, communicable diseases and reproductive and child health get most attention in terms of time spent on review and monitoring. Financial and managerial resource allocation for NCDs in general, and for diabetes and hypertension in particular is relatively low.
Market forces	Promotion of combination medicines by doctors and preference for combination medicines by patients. Private practitioners influence patients’ perceptions related to quality of medicines and/or care at government centres.
Transparency	Corruption and informal payments: Demand for informal fees for care at PHCs, setting up private practice either during work hours or diversion of PHC time/resources to private practice.

NCD, non-communicable disease; NPCDCS, National Programme for the Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke; PHC, primary health centre.