Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Anirudh Kumar, Dan Schwarz, Bibhav Acharya, Pawan Agrawal, Anu Aryal, Nandini Choudhury, David Citrin, Binod Dangal, Grace Deukmedjian, Meghnath Dhimal, Santosh Dhungana, Bikash Gauchan, Tula Gupta, Scott Halliday, Dhiraj Jha, S. P. Kalaunee, Biraj Karmacharya, Sandeep Kishore, Bhagawan Koirala, Lal KunwarRamesh Mahar, Sheela Maru, Stephen Mehanni, Isha Nirola, Sachit Pandey, Bhaskar Pant, Mandeep Pathak, Sanjaya Poudel, Irina Rajbhandari, Anant Raut, Pragya Rimal, Ryan Schwarz, Archana Shrestha, Aradhana Thapa, Poshan Thapa, Roshan Thapa, Lena Wong, Duncan Maru

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7 Scopus citations


Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care - first-contact access, care coordination, comprehensiveness and continuity - offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Original languageEnglish
Article numbere001343
JournalBMJ Global Health
Issue number2
StatePublished - 1 Apr 2019


  • Nepal
  • delivery of health care
  • global health
  • implementation research
  • integrated
  • non-communicable diseases


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