International Journal of Noncommunicable Diseases

REVIEW ARTICLE
Year
: 2021  |  Volume : 6  |  Issue : 1  |  Page : 4--9

Integrated digital approach for prevention and control of noncommunicable diseases: Review of the progress of “mukhyamantri nirog yojna” in the state of Himachal Pradesh, India


Gopal Chauhan1, Jarnail Singh Thakur2,  
1 Department of Health, National Health Mission, Shimla, Himachal Pradesh, India
2 Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India

Correspondence Address:
Dr. Gopal Chauhan
National Health Mission, Shimla, Himachal Pradesh
India

Abstract

Noncommunicable diseases (NCDs) are on the rise globally. The proportional mortality by NCDs in India is 72% (including 12% due to injuries). Most of the NCDs share common risk factors. The approach of delivery for NCD related programs in India is vertical and fragmented. In order to address the rising burden of NCDs, the state of Himachal Pradesh in India has adopted a comprehensive approach known as Mukhyamantri Nirog Yojna by integrating all existing NCD-related vertical programs for the purpose of implementation, surveillance, and to ensure continuum of care from November 2018. The digital surveillance of all NCDs risk factors, cancers, diabetes, cardiovascular diseases, stroke, chronic obstructive pulmonary disease, chronic kidney disease, blindness, deafness, mental illness, and stroke is ensured through E-Health card software. Till March 31, 2020, a total of 1.78 million (41.43% of the entire +18 population) individuals have been enrolled under the surveillance. More than 67% are at risk of developing NCDs. About 38% of all on risk have been screened for NCDs by the auxiliary nurse midwife, out of which 12.3% have high blood pressure, 6.2% have increased waist circumference, and 5.4% have increased blood sugar. About 73% of the screened positive has been diagnosed by the doctors for further management. The basic health services such as risk assessment, screening, diagnoses drugs, and follow-ups are available free to all through the public health system under this strategy. This approach is an efficient, cost-effective, and reliable strategy to address the common NCDs collectively and can be considered for upscaling in other states and low- and middle-income countries.



How to cite this article:
Chauhan G, Thakur JS. Integrated digital approach for prevention and control of noncommunicable diseases: Review of the progress of “mukhyamantri nirog yojna” in the state of Himachal Pradesh, India.Int J Non-Commun Dis 2021;6:4-9


How to cite this URL:
Chauhan G, Thakur JS. Integrated digital approach for prevention and control of noncommunicable diseases: Review of the progress of “mukhyamantri nirog yojna” in the state of Himachal Pradesh, India. Int J Non-Commun Dis [serial online] 2021 [cited 2021 Jul 24 ];6:4-9
Available from: https://www.ijncd.org/text.asp?2021/6/1/4/314212


Full Text



 Introduction



Noncommunicable diseases (NCDs) are the leading cause of death in the world. In the year 2016, 71% (41 million) of the total deaths (57 million) in the world were caused due to NCDs mainly cardiovascular diseases (44% of all NCD deaths), cancers (22%), chronic respiratory diseases (9%), and diabetes (4%). The proportional mortality due to NCDs in India is 63% (excluding 11% due to injuries) and cause-specific mortality data indicate that cardiovascular diseases (CVDs) (27%) are the most frequent cause of NCD-related deaths, followed by chronic respiratory diseases (11%), cancers (9%), and diabetes (3%).[1] According to the”India: Health of the Nation's states” report 2016, the disease burden due to NCDs and injuries in the state of Himachal Pradesh (a North Indian state with a population of about 7 million) is 64.5% and 12.5%, respectively, which is higher than the national average.[2] NCDs are emerging as one of the biggest barriers in achieving the Sustainable Development Goals and as per the World Economic Forum report 2011, NCDs will consume major portion of the economy in low- and middle-income countries if not addressed at the earliest.[3] Majority of NCDs share common risk factors. Out of the four major risk factors, tobacco contributes for 6.3 million deaths, alcohol for 4.9 million deaths, unhealthy diet for 4.9 million deaths, and physical inactivity for 3.2 million deaths per year in the world.[4] This study highlights the progress of the integrated and digital approach for the prevention and control of NCDs called Mukhyamantri Nirog Yojna in Himachal Pradesh so as to decide the future course of action.

 Noncommunicable Diseases Prevention and Control in India



In order to reduce the NCDs burden, the Government of India has started a comprehensive program called the National Program for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) from the year 2010 in selected 100 difficult districts. The program was started in three hard districts (difficult geography and extreme environmental conditions) in Himachal Pradesh, namely Chamba, Kinnaur, and Lahaul and Spiti. Now, NPCDCS has been expanded to all the 12 districts of the state from 2015 to 16 onward. The NPCDCS envisages for annual screening of the entire + 30 aged population for diabetes and hypertension and 5 yearly screening for three cancers (cervical, breast, and oral). The main objectives of NPCDCS are to prevent and control common NCDs through behavior and lifestyle changes, to provide early diagnosis and management, to build capacity at various levels of health care for prevention, diagnosis, and treatment, to train human resource within the public health setup to cope with the increasing burden of NCDs, and to develop capacity for palliative and rehabilitative care.[5] In spite of the adequate funds, the NPCDCS has not been able to bring a considerable change in the burden of NCDs so far.[6] Currently, there are multiple vertical NCD-related programs with the common mandate which includes the NPCDCS, National Mental Health Programme (NMHP), National Programme for Health Care of Elderly (NPHCE), National Tobacco Control Programme, National Program for Control of Blindness (NPCB), National Program for Prevention and Control of Deafness (NPPCD), National Program for Palliative Care (NPCC), and Drug De-Addiction Program. The poor physical and financial performance for NCDs prevention and control programs can be attributed to multiple factors including scattered approach, lack of awareness, low priority, and poor capacity within the health systems.[7] Apart from the issue-based and setting-based approaches, the WHO recommends STEP survey as the basic step for NCDs prevention and control.[8] India with huge population of more than 1.3 billion and limited resources is facing a huge challenge to tackle NCDs. Majority of NCDs share common risk factors and have a similar course of progression, hence integrated interventions are required to address them collectively.[9]'

 Mukhyamantri Nirog Yojna in Himachal Pradesh



Keeping in view the huge load of NCDs, scarcity of resources, and limited reach of individual programs, an integrated and digital approach has been adopted for prevention and control of all common NCDs and associated risk factors as Mukhyamantri Nirog Yojna (Chief Minister Healthy Citizen Scheme) in Himachal Pradesh from the year 2019 to 2020. This approach is following the Government of India strategy with the integration of all existing NCDs related programs, extension of the screening services to 18–30 aged population, and digital surveillance. A draft plan was prepared for the integration of all NCD-related vertical programs for the purpose of implementation as a cost-effective approach in the year 2016. However, it was made clear that the related NCDs program division in the Government of India and Himachal Pradesh will be getting the required reports as per their existing patterns. The draft was circulated to the selected NCDs experts at the national and subnational level including the Heads of the Departments of the concerned specialties in Medical College Shimla, NCDs experts in PGIMER Chandigarh, NGOs working in the field of NCDs, and NCD division in Government of India on E-mail for suggestions. After that, the experts' meeting was organized in the presence of the field level implementers including doctors, health workers, and Accredited Social Health Activists (ASHA workers) in November 2016 at the state capital at Shimla, and the draft strategy was prepared. In the second round, the same experts and implementers were invited with prior circulation of the draft strategy, and the detailed action plan was developed in May 2017. Simultaneously, the E-Health card application was developed for the NCDs and associated risk factors surveillance. On the analogy of the National Program for Prevention and Control of NCDs, a comprehensive checklist was prepared where the key questions from all the related programs were enlisted and it was pretested on 100 individuals (50 rural and 50 urban). Based on this experience, the plan was finally approved by the experts after the detailed discussions. Accordingly, the Mukhyamantri Nirog Yojna was notified by the Government of Himachal Pradesh on November 20, 2018. After the huge capacity building exercise for doctors, health workers, and ASHA workers, the strategy was rolled out throughout the state from April 2019 as annual risk assessment of all + 18 population by ASHA workers, annual screening and referral by health workers/auxiliary nurse midwife (ANM), management of NCDs by doctors including monthly follow-up of patients. The entire surveillance is ensured through android-based application – “E-Health card” being operated by ANM through ANMOL tablet or mobile phones. The service provisions for advanced management of NCDs include 12 cardiac care units (in all 12 district hospitals), 14 dialysis units, 10 cancer care units (with the facility of chemotherapy services), 19 stroke units, and 11 palliative care units in the state.[10]

 Innovations



This strategy comprises of three major innovations; the first one is the integration of all NCD-related vertical programs mainly NPCDCS, NPHCE, NPCB, NPPCD, NMHP, National Oral Health Program, and NPPC by preparing a common checklist for risk assessment, screening, diagnosis, and follow-ups. The second is to adopt the life cycle approach as a continuum of care by adding the 18–30 age groups under this scheme because the NPCDCS program already covers the + 30 age group and 0–18 age group is covered under Rashtriya Bal Swasthya Karyakram. The third is the digital surveillance through E-Health Card Software developed by the software development partner (E-Tech Services Pvt. Ltd. 325, Qutab Plaza DLF City Phase-1 Gurugram, Haryana 122002 India) in collaboration with the NCDs experts and Health Rise Project team. Overall, 15 NCD risk factors and 10 NCDs including cancers, diabetes, CVDs, stroke, chronic obstructive pulmonary disease, chronic kidney disease, blindness, deafness, mental illness, and epilepsy are covered under this strategy. In the first step, the ASHA worker is filling the manual checklist comprising 15 questions in the door-to-door survey on the NCDs risk factors and past/family history of individuals. She is trained for the counseling and referral services and ASHA is getting 10 Rupees (INR) for collecting this information as per NPCDCS guidelines. Any individual having signs or symptoms of NCDs, family history, and exposure to NCDs risk factors is provided a referral slip and referred to the nearest health subcenter for NCDs screening immediately. Those not having any risk are also advised to go for annual screening. Simultaneously, the ASHA worker is submitting the risk assessment checklist to the local ANM at the subcenter and the ANM is doing the screening for the common NCDs (diabetes, hypertension, cancers, etc.) The ANM is also providing the referral and counseling services.

As per the plan, the entire healthy +18 populations have to be screened on yearly basis by ASHA/ANM and examined by MO at least once in 5 years, but those at risk are referred for further diagnosis and treatment immediately. The ANM is uploading the demographic details, risk profile, and screening observations in the E-Health card application through the ANMOL tablet with due consent of the individual. The information is appearing to the patient and to the service providers immediately through the software. The ASHA is also ensuring the monthly follow-up visits to the patients and provides the information to the ANM for further uploading in the software. ASHA is getting 100 Rupees (INR) per year for monthly follow-up as per NPCDCS guidelines. The individuals are getting the service reminders through SMS- Short Message Service and those not having mobile are linked with the mobile number of the nearest ASHA/ANM. In order to maintain the privacy of the health records of the individual, there is a provision for access through auto-generated OTP -One Time Password. The level of risk appears to the individual on their mobile phone with the appropriate bar as green tag for no risk, yellow tag for having risk, and red tag for having disease. The data for this study have been retrieved from the yearly progress report of the Mukhyamantri Nirog Yojna in the state of Himachal Pradesh.[11] The data sheets have been created in the form of population enumeration (question-based risk assessment) by ASHA workers from the house-to-house survey, the screening outputs at health worker/ANM level, and as per the diagnosis made by the doctors.

 Progress of Mukhyamantri Nirog Yojna



The age and sex distribution of the population covered in Mukhyamantri Nirog Yojna is shown in [Table 1]. The yearly progress report shows that a total of 1,778,154 individuals (1.78 million) have been enrolled in the software which is 41.43% of the entire + 18 population in the state till March 31, 2020. About 457,774 individuals have been screened for diabetes, hypertension, and other NCDs. About 70,294 persons have been diagnosed by doctors and 14,920 have been put on treatment and the rest have been advised lifestyle modifications. However, those on risk or screened positive for NCDs are on surveillance through E-Health card. The burden of 15 NCDs risk factors, screening outputs, and disease burden of the state, district, block, and village levels is available for the desired action. The sociodemographic details including name, age, sex, and complete address with auto-generated unique identification number of all registered individuals with the risk profile and past and family history are also available in the software. The duplication of the data is avoided by the auto-generated unique ID and the individuals are empowered to promote healthy lifestyle through SMS reminders and monthly follow-up visits by ASHA workers. The progress/output at ASHA, ANM level, and diagnosis by a doctor are shown in [Figure 1],[Figure 2],[Figure 3]. The daily- and month-wise progress reports of each ASHA, ANM, and doctor can be monitored and each patient can be followed up through the E-Health card software. The information related to the output can be shared by E-mail, SMS, and WhatsApp for analysis and further desired action.{Table 1}{Figure 1}{Figure 2}{Figure 3}

 Integrated Digital Approach



Mukhyamantri Nirog Yojna is the first of its kind integrated digital health intervention for addressing prevention and control of NCDs using the life course approach in program settings. The global rise in NCDs has also been related to the development and posing a major challenge to the health system in India and HP.[3] Hence, NCDs prevention and control certainly becomes a more complex issue for the underresourced health system. One major challenge is to reduce the demand and supply of the NCDs risk factors mainly tobacco, alcohol, unhealthy diet, physical inactivity, and stress. Simultaneously, the effective management of NCDs has to be ensured through capacity building, mass screening, early diagnosis, and treatment including follow-ups. There is a need for a continuum of care as a life cycle approach to combat NCDs. This requires a strong surveillance of the NCDs and associated risk factors in the entire population. Currently, the vertical and scattered approaches for the prevention and control of NCDs are consuming huge resources in India. As far as the NCDs risk factors are concerned, the state of Himachal Pradesh has shown a substantial reduction (22%–16%) in tobacco use as per GATS-2,[12] good attempts have been made to promote healthy food, physical activities, but the high use of alcohol still remains a big challenge (National Family Health Survey-4).[13] Correct and timely information is the need of the hour and is quite possible by use of IT in the modern era. The E-Health card is a reliable tool for surveillance of the NCDs risk factors, disease burden, and for ensuring treatment compliance. In addition, it empowers the individuals for follow-ups through SMS reminders. Himachal has a good literacy rate with high users of mobile phones.[14],[15] E-Health card also empowers the health system and the public to assess the health needs to take corrective measures at various levels. It also generates the demand for good health and to make adequate provisions of health services.

 Challenges and Opportunities



However, it is a huge task to enroll the entire +18 population (about 4.2 million) in the software as a cohort. But enrollment of more than 41% population in the E-Health card within a short time has shown that the entire population can be enrolled under this surveillance. The capacity building, service provisions, infrastructure development, provisions of adequate diagnostics services, availability of medicine, and follow-up are another challenge. But the integration of vertical programs will surely reduce the cost of implementation of the individual programs. This approach will help in risk assessment, understanding the disease burden/patterns, need for capacity building, and resource allocation and to assess the effectiveness of the interventions for NCDs prevention and control at all levels.

 Conclusion



In order to combat the increasing load of NCDs and associated risk factors, there is a need for an integrated digital strategy in resource constraint settings. The state of Himachal Pradesh has taken a lead to implement this strategy successfully. The yearly progress report has shown that the current strategy is user friendly and making a good impact on the approach of the service delivery and the behavior change in public. This health-promoting strategy is a win-win situation to the service providers and the individuals. It is a cost-effective approach and provides the desired information to the service provider and the individuals for the required interventions. It is creating the demand for better health-care provisions and the health-seeking behavior of the people is also changing. It is a continuum of care and life cycle approach. This strategy can be replicated in similar settings for comprehensive NCDs prevention and control in other states and low- and middle-income countries.

Acknowledgment

The authors would like to thank the National Health Mission, Department of Health, Himachal Pradesh, Health Rise Project Team HP, E- Tech Services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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