Saving Mankind

The policy and strategic framework for prevention, detection, referrals and treatmentof Non- Communicable Diseases (NCDs)creates environment conducive to not only managing their burden but also propagating holistic health By Dr Suneela Garg/ Dr Akanksha Tomar

India is experiencing a rapid health transition with a rising burden of Non-Communicable Diseases (NCDs). According to the Global Status Report on NCDs 2014, these diseases contributed to 5.8 million deaths, accounting for 60 percent of all deaths in India. The World Health Organization (WHO) estimates indicate that the probability of death between thirty and seventy years of age due to any of the four major NCDs, namely cancer, diabetes, cardio-vascular disease (CVD) and stroke in India is about 26 percent. The main preventable behavioural risk factors for NCDs are tobacco consumption, poor dietary habits like low dietary fibres, high intake of saturated fat and trans-fat,harmful use of alcohol, sedentary life style and stress. Changing lifestyle due to rapid urbanisation and industrialisation is causing increase in these harmful behavioural risk factors leading to biological risk factors like obesity, hypertension,raised blood glucose and impaired lipid profile.

Realising the rising burden of NCDs, the Government of India initiated a National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) during 2010-11 after integrating the National Cancer Control Programme (NCCP) with NPDCS. The focus of NPCDCS is on promotion of healthy lifestyles, early diagnosis and management of diabetes, hypertension, cardiovascular diseases & common cancers e.g. cervix cancer, breast cancer & oral cancer.

The NPCDCS aims at integration of NCD interventions in the NRHM framework (now NHM) foroptimization of scarce resources and for ensuring long term sustainability of interventions. It attempt to create a wider knowledge base in the community foreffective prevention, detection, referrals and treatment strategies through convergence withthe ongoing interventions of NHM, National TobaccoControl Programme (NTCP), and National Programme for Health Care of Elderly (NPHCE)and build a strong monitoring and evaluation system through the public healthinfrastructure.

Objectives of NPCDCS:

1. Prevent and control common NCDs through behaviour and lifestyle changes,
2. Provide early diagnosis and management of common NCDs,
3. Build capacity at various levels of healthcare for prevention, diagnosis and treatmentof common NCDs,
4. Train human resource within the public health setup viz doctors, paramedics andnursing staff to cope with the increasing burden of NCDs, and
5. Establish and develop capacity for palliative & rehabilitative care.

Attempts are focussed towards creating general awareness about the NCD and associated behavioural risk factors and promoting healthy lifestyle habits like increased intake of healthy foods, increased physical activity, avoidance of tobacco and alcohol, stress management, warning signs of cancer, among the community by involving peripheral health functionaries and NGOs.

Prevention through behaviour change
Attempts are focussed towardscreating general awareness about the NCD and associated behavioural risk factors and promoting healthy lifestyle habitslike increased intake of healthy foods, increased physical activity, avoidance of tobacco and alcohol, stress management, warning signs of cancer, among the community byinvolving peripheral health functionaries and NGOs.

The various approaches such as mass media, community education and interpersonalcommunication are used for behaviour change focusing on some key messages to promote healthy lifestyle.Interpersonal communication through grassroots level workers and other community leaders/groups is being done.It will also help in social mobilization for diagnostic camps. Targeted intervention programmes focusing on the at-risk population are designed to bring awareness in schools and workplaces for prevention of NCDs. School-based interventions includeevaluation of the existing school health programme components viz. physical education, nutrition and food services, health promotion for school personnel, health education and health services followed by activities to make health promotion a defined agenda in the school curriculum.

Early diagnosis
The strategy for early diagnosis of chronic NCDs consists of the screening of persons above the age of 30 years at the point of primary contact with any healthcare facility. It means that any contact of the individual with the healthcare facility is being taken as an opportunity to screen him/her for the presence of risk factor for NCDs. Opportunistic screening has in built components of mass awareness creation, self-screening and trained health care providers. The investigations which may not be carried out in the health facilities can be outsourced.

Treatment
“NCD clinic’’ are established at CHC and District Hospital where comprehensive examination of patients referred by lower health facility /health worker as well as of those reporting directly is conducted for ruling out complications or advanced stages of common NCDs. Screening, diagnosis and management and home based care are the key functions to be performed here.

Capacity building of human resource
Health personnel at various levels are trained for health promotion, prevention, early detection and management by a team of trainers at identified Training Institutes/Centres, as identified by the state in consultation with the Centre.

Supervision, monitoring and evaluation
Regular monitoring and review of the scheme is conducted at the district, state and Central level through monitoring formats and periodic visits and review meetings. NCD cell at different levels is envisaged to supervise and monitor the programme and also other NCD programmes. The evaluation will be carried out concurrently and periodically, as & when required.

Package of Services
In the programme, it is envisaged to provide preventive, promotive, curative and supportive services (core and integrated services) for the mentioned NCDs.

The package of services depend on the level of health facility. The range of services being provided include health promotion, psycho-socialcounselling, management (out-and-in-patient) including diet counselling, lifestyle management, day care services, home based care andpalliative care as well as referral for specialized services as needed.For operationalization of NCD clinic at CHC level, hiring of one doctor, two nurses, one counsellor and one data entry operator on contractual basis is envisaged. At district level 1 specialist, 2 nurses, 1 physiotherapist, 2 counsellors, 1 data entry operator and 1 care coordinator are provided on contractual basis. For cancer care, 1 medical oncologist, 1 cytopathologist, 1 cyto-pathologist technician and 2 nurses are hired on contractual basis.Financial and technical support isprovided for strengthening laboratory services at CHC and District Hospitals for investigations like blood sugar, lipid profile, ultrasound, X-ray and ECG. Linkages of District Hospitals to private laboratories and NGOs provide continuum of care and support for outreach services. The district is linked to tertiary cancer care health facilities for providing comprehensive care.

The NCDs are expensive to treat. National strategies focus on prevention and health promotion as key to reduce disease burden. Health education programme are some of the key interventions that need to be promoted at various levels of health facilities and through outreach sessions.

Institutional framework:

1. Framework for management: Opportunistic screening, health promotion and referral are done at sub centres. NCD clinic at CHCs provides early diagnosis and treatment by offering lab investigations, home based care and referral to higher centres. NCD clinics, cardiac care unit and cancer care facility are located at district hospitals which provide all the above mentioned services under District NCD cells as well as day cancer chemotherapy facilities and training to the health personals at CHCs as per guidelines issued by national NCD cell. Tertiary cancer care centres are situated in medical colleges/RCC under state NCD cells. States are also bestowed with the task of community awareness, planning monitoring and supervision, training of human resources and financial management under the programme.
2. Technical guidance: To provide technical guidance, advice and review the progress of the programme for enhancing the quality of implementation of NPCDCS, two Technical Resource Groups (TRG) have been constituted, one for cancer component and other for Diabetes, Cardiovascular Diseases and Stroke with certain term of references (TORs).
3. Financial management: Financial management group (FMG) of Programme Management support units at state and district level, which is established under NRHM, is responsible for financial management. It is envisaged to merge the programme at State and District into the SHS and DHS respectively in order to ensure sustaining the current momentum and continued focus.

Management Structure:
National NCD Cellisthe nodal body to roll out NPCDCS in the country. It functionsunder the guidance of Programme in-charge from the MoHFW and supported by the identified officers/officials from the DGHS.State NCD Cell is established preferably in the Directorate of Health services or any otherspace provided by the State Government. The Cell functions under the guidance of State programme Officer (SPO NCD), supported by the identified officers/ officials from the Directorate /Director General of Health Services. District NCD Cell is established preferably in the Directorate of Health services or anyother space provided by District headquarters.

The NCD Cell is responsible for overallplanning, implementation, monitoring and evaluation of the different activities andachievement of physical and financial targets planned under the programme in the District. TheCell functions under the guidance of District programme Officer (DPO NCD) and supported by the identified officers/officials from the District health system.

Conclusion
Thus, the preventive and integrated approach adopted under the programme creates environment conducive to not only managing the burden of NCDs but also propagating overall health promotion. Targeting the identified behavioural risk factors and creating general awareness about the diseases as well as providing efficient management starting from grassroots level of health delivery will certainly pay in the long run to curb the emerging evil of NCDs.