Integrating NCDs in Health System: Experiences in India
Transcript of Integrating NCDs in Health System: Experiences in India
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Integrating NCDs in Health System:
Experiences in India
Dr. Damodar Bachani, MD, MPHMDeputy Commissioner (NCD)
Ministry of Health & Family Welfare
Government of India, New Delhi1
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Spectrum of Population & NCDs
Healthy, Low Risk
At Risk & Undiagnosed
Diagnosed, not
adequately treated
Adequately treated
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Healthy
populationPersons
at risk
Subclinical
disease
Established
disease
Multiple co-
morbidities
Relatively
low
Relatively
high
Population level
interventions
predominate
Highly
individualised
care
Level of Risk
Intensity of Population, Community and Individualised Interventions
Integrating population and personal management
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Requisites of Integration1. Structural integration
– Extended primary care with effective referral system
with secondary and tertiary care
– Networks and clusters – integrating public health
functions
2. Integrated care delivery process
– Integrating population and individual health care needs
– Team-centric approach to integrated care
3. Patient centred Integration
– Individually focused care to manage multi-morbidity
and risks
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Benefits of Integrated Care
Improved efficiency
• Integration of activities
• Information use
• Co-ordination
• User participation
• Reduced duplication
• Optimal use of technology
Improved effectiveness
• Reduce lag time from evidence to implementation
• Real time information
• Reduced variability in outcome
• Improved user satisfaction
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Building Blocks of Health Systems
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Efforts towards integration of
NCDs in Health System in India
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Governance & Leadership
• Structural reforms in health sector by launching
National Rural Health Mission (NRHM) in 2005
• Initially National programs for Reproductive &
Child Health and communicable diseases
covered under NRHM
• Decision taken to also include NCD programs
under NRHM in 2013 to facilitate linkages
• National Urban Health Mission & NRHM merged
as National Health Mission
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Vision of National Health Mission
Vision: Attainment of Universal Access to Equitable,
Affordable and Quality health care services, accountable
and responsive to people’s needs, with effective inter-
sectoral convergent action to address the wider social
determinants of health
Guiding Principle: Build an integrated network of all
primary and secondary care, providing a continuum from
community level to the district hospital, with robust referral
linkages to tertiary care.
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Leadership StructureMission Steering Group
Empowered Program Committee
National Mission Directorate
State Health Mission
District Health Mission
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NRHM
State Health Mission State Health Society
State Project Management
Unit
District Health Mission District Health Society
Block Health & Sanitation committee
CHC
District Project Management
Unit
PHC
Village Health & Sanitation committee
Sub Centre UntiedFund
ASHA Other CHW
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Financing• Decentralized Planning: Districts & State
• State submits Annual Implementation Plans for
funding to Mission Directorate
• Funds released under three pools: RCH,
Communicable Disease Flexipool, NCD Flexipool
• Funds released in two installments
• Second installment is based on expenditure
patterns
• Funds are released by components with fair
amount of flexibility
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Human Resources
• State Governments employ personnel
at all levels through State Budget.
• Additional human resources supported
under NHM/various programs
• Emphasis is on utilization of available
human resources; multitasking
encouraged
• Structured standard training of human
resources at identified institutions
• Capacity building for NCD programs
underway
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Service Deliveryin Public Health Sector
PRIMARY LEVEL
• Sub-Centre for 5000 population
• Primary Health Centre for 30,000 popn.
• Community Health Centre for 100,000 popn.
SECONDARY LEVEL
• Sub-District/ Rural Hospitals
• District Hospitals
TERTIARY LEVEL
• Medical College Hospitals
• Other National Institutes
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NCD Services at Sub- Centre
Manpower available
ANM(1) , Male Health worker(1)
Services
• Screening of persons above 30 yrs. &
Pregnant women by Health Workers for :
�NCD risk factors (dietary habits,
physical inactivity, alcohol abuse and
tobacco use)
�Random blood sugar (Glucometers)
�BMI, Blood Pressure
• Health Promotion, Early warning signals
of cancer
• Referral16
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NCD Services at PHCs
Manpower available
Medical Officers, Nurses, Health Supervisors,
Laboratory Technician, Health Educator etc.
Services
�Opportunistic Screening for common NCDs
�Strengthening of laboratory services
�Health Promotion
�Referral
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NCD Services at CHCs
Infrastructure available
� First referral unit for NCDs
� Four Specialists; Physician, Surgeon,
Gynecologist & Paediatrician
� OPD & Inpatient Facility (30 beds)
� Common lab. Investigations
� NCD clinic: 1 Doctor, 2 Nurses, 1Counselor, 1 Data Entry
Operator
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NCD Services at CHCs– Early detection of common NCDs (Diabetes, CVDs
& Stroke) and appropriate treatment– Investigations : blood sugar, ECG, Total
Cholesterol, Serum creatinine Blood Urea, Urine albumin, etc.
– Referral of complicated cases– Home based care of bedridden cases– Health Promotion – Screening for oral, cervical and breast Cancer &
palliative care – Data recording and reporting
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NCD Services in District Hospital
�NCD clinic for management of NCDs
�Additional HR: 1 Doctor, 2 Nurses, 1 Physiotherapist,
2 Counselor, 1 Care Coordinator, 1 Data Entry Operator
�Cardiac care unit (CCU): with 6-8 beds & equipped
with ventilator and other necessary CCU equipments
�Day care cancer facility
�Geriatric OPD & Ward
�Laboratory diagnostic facilities: such as lipid
profiles, ECG, ECHO, CT Scan etc.
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District HospitalNCD Clinic, Geriatric Clinic, Cardiac Care Unit,
Cancer Care Facility etc.[Health Promotion; Early diagnosis & Management; Home Based
Care; Day Care Facility]
Community Health CenterNCD Clinic, Geriatric Clinic
[Health Promotion, Early diagnosis & Management; Laboratory Investigations, Home Based Care, Referral]
Sub CenterScreening Services
[Health Promotion; Opportunistic Screening; Referral]
Tertiary level InstituteMedical Colleges, Tertiary Cancer Centres,
Regional geriatric Centres, Centres of Excellence
[Tertiary care, Training, Research]
Referral
NCD Services in Health System
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Medicines & Technology
• Standard list of equipment, medicines, diagnostic
kits and other consumables as per Indian Public
Health Standards (2012)
• Most of the items are procured by States as per
standard procurement guidelines
• Poor persons with BPL cards get free services
• Procurement of generic medicines encouraged
• Many States have computerized inventory
management system
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Health Management Information System
• HMIS developed and in use
• Some National Health programs have dedicated
MIS
• Periodic independent evaluation
• Annual Common Review Mission in selected
districts
• National Family Health Survey (3 conducted, 4th
planned for 2014-15)
• STEPS RF survey 2006-07; planned for 2015
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NCD surveillance Card
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Convergence with other Health Programs
Reproductive & Child Health Program:
• Screening for Gestational Diabetes
• Screening for Cervical & Breast
cancer
• Hepatitis B vaccination
• Promoting breast feeding
National Adolescent Health Program &
School Health Program
• Risk Factor screening during bi-
annual check up
• Health promotion
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Convergence with other Health Programs
• Revised National TB Control
Program (COPD & Diabetes)
• National Blindness Control
Program (Screening for Diabetic
Retinopathy)
• National Program for Health care of
the Elderly
• National Mental Health Program
(Alcohol Control)
• National AIDS Control Program
(HIV-TB & HIV-HPV infection)
• Trauma Care Centre
• Integrated Diseases Surveillance
Program
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Issues & Challenges
• Full integration of vertical programs in Health
System
• Involvement of Voluntary Organizations
• Role of Private Health Sector
• Shortage and unequitable distribution of health
care personnel
• Allocation of budget for Health Sector
(specifically NCDs)
• Priority of some State Governments continue to
be RCH & Communicable Diseases
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Thanks