1. Overview of NCD & Other Programes (NPCDCS)PBS.pptx

non communicable diseases

1. 1 OVERVIEW OF NON - COMMUNICABLE DISEASE PROGRAM

2. NCD - GLOBAL BURDEN OF DISEASES

3. India: Health of the Nation’s States- Years of Life Lost (YLL)

4. India: Health of the Nation’s States- Years of Life Lost to Disability (YLD)

5. India: Health of the Nation’s States- Change in DALY pattern

6. India: Health of the Nation’s States- Change in Risk factors

7. Demographic Transition in Tamil Nadu Proportion of Population Aged 60+ Proportion of Population Aged 65+ (Projection) Source: India Registrar General Source: Population foundation of India & Population Reference Bureau

8. DALYs rate of diseases in TN which is significantly higher than India   ISCHAEMIC HEART DISEASE ROAD INJURIES SELF-HARMS DIABETES FALLS OTHER MUSCULOSKELETAL DISORDERS CHRONIC KIDNEY DISEASE DEPRESSIVE DISORDERS TAMIL NADU 4788 1121 1435 1628 921 638 1026 857 INDIA 3062 1009 884 792 652 584 583 581 Source: GBD Report, 2016

9. Timelines of Events

10. Scaling up to all 32 districts in a phased manner ; four NCDs Phase I (16 districts) -2012 Phase II (16 districts) -2013 Thanjavur Thiruvallur Virudhunagar Thiruvannamalai Sivagangai Vellore Theni Salem Chennai Namakkal Cuddalore Krishnagiri Kanchepuram Dharmapuri Villupuram Karur Trichy Coimbatore Perambalur Tirupur Dindigul Niligiris Erode Nagapattinam Madurai Tirunelveli Thiruvarur Thoothukkudi Pudukottai Kanniyakumari Ramanathapuram Pilot and Upscaling implemented under WB supported TNHSP. Since 16.09.2016, program continues under NPCDCS.

11. ORGANOGRAM NCD Medical Officer JD (NCD) Nodal Officer JD. DPH&PM Nodal Officer Nodal Officer DISTRICT DD (NCD)

12. Comprehensive overview of NCD services

13. NCD Flexi pool Components National Program for Prevention and Control of Cancer CVDs and Stroke (NPCDCS) National Program for Health Care of Elderly (NPHCE) National Mental Health Program (NMHP) National Tobacco Control Program (NTCP) National Program for Control of Blindness (NPCB) Other Components under NCD National Program for Palliative Care (NPPC) National Oral Health Program (NOHP) Day care cancer centers Dialysis units Cardiac care units Prevention & Control of RHD/ COPD/ CKD Integration with RNTCP/ AYUSH Population based screening

14. National Program for Prevention and Control of Cancers Diabetes CVDs and Stroke (NPCDCS) Health promotion through behavior change with involvement of community, civil society, community based organization, media etc., Opportunistic screening at all levels in the health care delivery system for early detection of Diabetes, hypertension and common cancers Prevent and control chronic NCDs Build capacity at various levels of health care for prevention, early diagnosis, treatment, IEC/BCC, operational research and rehabilitation. Provide support for diagnosis and cost effective treatment at primary, secondary and tertiary levels of health care. Provide support for development of database of NCDs through surveillance system and to monitor NCD morbidity and mortality and risk factors All districts are covered

15. NPCDCS - Packages of Services S.No Health Facility Package of Services 1 Sub- centre /HWC Health promotion for behavior change and counselling Population based screening for common NCDs and cancer through WHV Awareness generation of early warning signals of common cancer Referral of suspected cases to CHC/nearby health facility 2 Primary Health Centre facilities (including corresponding urban facilities)- also applicable to Mini Clinics Health promotion for behavior change and counselling Screening of Diabetes (DM) using glucometer and Hypertension(HT) Diagnosis and treatment of Common CVDs including HT,DM,COPD, chronic kidney disease Identification of early warning signals of common cancers and screening for complications Screening of common cancers (Oral, Breast and Cervix) Referral of suspected cases to CHC. 3 Community Health Centre/ First Referral Unit Prevention and health promotion including counseling Early diagnosis through clinical and laboratory investigations Management of common CVDs,COPD , diabetes and stroke cases Lab.investigations and Diagnostics: Blood sugar, Lipid Profile, Blood Urea,X-Ray,ECG,USG Screening of common cancers ( Oral,Breast and Cervix) Referral of complicated cases to District Hospital/higher health care facility.

16. NPCDCS - Packages of Services S.No Health Facility Package of Services 4 District Hospital Diagnosis and management of cases of CVDs, Diabetes, Stroke, COPD, CKD and Cancer (outpatient, inpatient and intensive Care) including emergency services particularly for Myocardial Infarction & Stroke Lab investigations and Diagnostics: Blood Sugar, Lipid Profile, Kidney function test,HbA1c,X-Ray,ECG,USG,ECHO,CT Scan cytopathology etc. Referral of complicated cases to higher health care facility Health promotion for behavior change and counselling Screening of NCDs including common cancers (Oral, Breast and Cervix) Follow up chemotherapy in cancer cases Rehabilitation and physiotherapy services 5 Medical College, State Cancer Institutes and other tertiary centers Mentoring of District Hospitals and outreach activities Early diagnosis and management of Cancer, Diabetes, CVDs, COPD, CKD and other associated illnesses Training of health personnel Comprehensive cancer care including prevention, early detection, diagnosis, treatment, palliative care and rehabilitation Operational Research

17. COLPOSCOPY

18. Incorporating EQAS / IQAS as external quality assurance systems through CMC, Vellore

19. Population Based NCD screening Tamil Nadu A successful Public-Public Partnership

20. Population Based NCD Screening Program Main focus: To improve NCD detection, referral and follow up by enumerating all the population in the community through House-to-House visits. Main objective is improving the screening rate and follow up rate as well as control rate by involving a dedicated volunteer who is from the community Collaboration with TNCDW to engage WHV/CP-Health ( MoU now renewed from 24.08.2019 for 3 years) Performance Based Incentives: Rs . 3500 Linkage of Population Based Screening (PBS) and UHC HSC & UHC PHCs Women Health Volunteer (WHV) 2 nd VHN @ UHC HSC NCD Staff Nurse @ UHC PHC Referring to PHC for confirmation Line list of NCDs confirmed at UHC PHC to UHC HSCs during Weekly review Line list of NCDs confirmed shared to WHVs by VHN

21. Rationale for Population Based NCD Program Tamil Nadu has good network of primary health services - 1736 PHCs, 8712 HSCs, 336 Urban Health centers,310 Secondary Care Hospitals & 22 Medical Colleges / attached hospitals. In the current NCD program, opportunistic screening services provided for those attending Public health facilities aged 30 years and above - men screened for HTN and DM & women in addition for Cervical and Breast cancer. Only 30 to 40 % of the population attend public health facilities The remaining population do not visit the public health facilities and outside the reach of the opportunistic screening and do not get covered

22. In addition, individuals screened positive for NCDs especially cancer patients can not be followed up effectively due to lack of field level volunteer for NCD program. We know situations where this gap is wide. So- improving screening rates, follow up rates, control rates and providing appropriate health education to the community was the major rationale for starting the program To address the above issues, ‘ Population based NCD Program’ has been proposed with a public-public collaboration

23. Government Orders OBTAINED: S.NO ROP APPROVAL G.O NO & DATE NAME OF DISTRICTS NO. OF HSC PROPOSED NO OF ASHAS/ WHVS 1. Supplementary RoP 2016-17 & RoP 2017-18   Approved Rs. 3.39Crore G.O ( Ms ) No. 481 dt- 18.12.2017 Pudukottai , Perambalur Krishnagiri Ramanathapuram Karur Tirunelveli Corporation Coimbatore Corporation 1203 HSC     ASHAs= 177 WHVs =1026 2. RoP 2018-2019   Approved Rs. 8.43Crore  G.O ( Ms ) No. 501 dt- 29.10.2018 35 UHC blocks covering 834 Sub- centres GCC covering 140 Urban PHCs (each UPHC with 4 WHVs)  834 HSC and 140 UPHC 35 UHC Block ASHAs= 126 WHVs = 708 GCC WHVs = 560 3. Supplementary RoP 2018-19 & RoP 2019-20 Approved Rs. 0.76Crore G.O ( Ms ) No. 02 dt- 02.01.2020 Aspirational district of Virudhunagar ( 2 HUDs) 113 urban PHCs in 8 Corporation 205 HSC and 113 U PHCs Aspirational district WHVs= 205   8 Corporations WHVs= 452 Table I: Details of Government Orders obtained

24. Level of screening Level: HSC level activity; 1 WHV per HSC Each HSC will be assigned to one field level functionary who may be WHV through SHG network/ ASHA / AWW House to house visits and enumeration of the family folder forms the basic foundation of this approach

25. Unit for incentive distribution: Health Sub Centre (HSC)/ VPRC Level Periodicity: Monthly  Means of Verification: The data for calculation of these indicators would be derived primarily from the manual entries in registers (Master Register and Line list Register) kept at HSC level. The VHN at the HSC will validate the data first. The data would then be validated by the NCD staff Nurse & the Medical Officer of the concerned PHC. The Block Account Assistant (BAA), NHM will verify the monthly consolidation sheet validated by the VHN, NCD SN & PHC MO, before onward submission to VPRC, for release of performance based incentives based on the weightage scoring shown in the Table A. The Block Account Assistant, NHM will keep a record of the incentive disbursement in the block at the field level. The District Program Officer (NCD) will oversee the overall implementation and disbursement of incentive. The DPO (NCD) & PO (Magalirthittam) should ensure that the performance based incentives to the WHVs are based on this monthly consolidation sheet through respective VPRCs and it should reach them on timely manner. Once PBS app gets ready to be used, the data would be validated from the app only. Guidelines for paying Performance based incentives (PBI) for Population Based NCD Screening Program

26. 4. Scoring Criteria: 15 indicators for 12 major activities have been identified as Performance indicators for WHVs in PBS program. Each indicator will be given score 3 to 1 based on the performance levels. Scoring group: score 3, 2 ,1 ( for any performance less than that, the score will be 0) Indicators: 15 Total Incentive: 3000 (in addition, Rs 500 per month would be travel support) Maximum score: 45  5. Eligibility criteria: WHV should obtain minimum score of one for all the 15 indicators, which means that any field functionary getting score less than 15 is not eligible for performance based incentives that month and travel support. 6. Performance Based Incentives (PBI): WHVs will be given the performance based incentives based on the score obtained for 10 indicators. Score 40 to 45 Rs. 3000/month Score 35 to 39 Rs. 2750/month Score 30 to 34 Rs. 2500/month Score 25 to 29 Rs.2000/month Score 15 to 24 Rs.1000/month Score <15 Not eligible. 7. Travel Support: Rs 500 per month is given to all WHVs for travel allowances. Guidelines for paying Performance based incentives (PBI) for Population Based NCD Screening Program

27. S.No Activities Indicator (s) Score 3 Score 2 Score 1 1 Household visits and enumeration of Family Folder 1. No. of families visited by the WHV and enumerated in the family folder during the month. Above 200 150-199 100-149 2 Screening for Hypertension 2. No. of individuals screened for HT in the household& entered in the family folder (including 18-29 age group with risk score > 4) Above 400 350-399 300-349 3 Screening for Diabetes 3. No. of screened for DM in the household & entered in the family folder (including 18-29 age group with risk score > 4)   Above 400 350-399 300-349 4 Referral of the positive suspected patients to PHC 4. Percentage of individuals who visit the PHC/other Govt. institutions for confirmation among those suspected positive in HH screening (HT/DM) 70-100% 60-69 % 50-59 % 5 Referral for CBE , VIA & Oral Cancer 5. No. of women aged 30 years and above who visited PHCs for Clinical Breast Examination Above 300 250-299 200-249 6. No. of women aged 30 years and above who visited PHCs for VIA examination Above 300 250-299 200-249 7. Percentage of individuals who reached at PHCs for Oral cancer examination among suspected by WHV   70-100%   60-69%   50-59% Indicators for monitoring the performance and disbursement of Incentives to the WHVs

28. S.No Activities Indicator (s) Score 3 Score 2 Score 1 6. Referrals for TB 8. Percentage of individuals among suspected in CBAC for TB who have reached PHC/Govt. Institutions & undergone sputum test or other diagnostic tests. 100% 90-99% 80-89% 7. Referrals for Leprosy 9. Percentage of individuals among suspected in CBAC for Leprosy who have reached PHC/Govt. Institutions & undergone the diagnostic test for Leprosy / Clinical Confirmation by concerned PHC MO 100% 90-99% 80-89% 8. Referral of individuals suspected with symptoms of mental diseases & follow up 10. Percentage of individuals among suspected in CBAC for Mental health issues/symptoms of mental diseases who have reached CHC/Govt. Hospitals & undergone the assessment for mental health issues  80-100% 75-79% 70-74% 11. Percentage of patients under treatment at PHC/CHC level for Mental Health Disease who are followed up in the field by WHV during the month 80-100% 75-79% 70-74% 9. Follow up of NCD patients: HT/DM/cancer. (should be verified with the line list register at HSC) 12. Percentage of HT/DM (or both)/cancer patients followed up in the month (among those found positive in screening at PHC) including known patients registered in the PHC 80-100% 75-79% 70-74% Indicators for monitoring the performance and disbursement of Incentives to the WHVs

29. S.No Activities Indicator (s) Score 3 Score 2 Score 1 10 IEC activities at HSC area 13. Number of group counselling/patient support group meeting/ MMU camps/other IEC activities conducted at HSC area  8 6 4 11. Attendance 14. Number of days engaged for house hold visits 25-30 days 23-24 days 20-22 days 12 PHC Review 15. Number of PHC review meetings attended (Tuesday) 4 3 2 Indicators for monitoring the performance and disbursement of Incentives to the WHVs *In addition to the performance / scoring based incentives, the WHVs are also eligible for additional incentives for detection & follow up of TB and Leprosy as per norms approved under RNTCP & NLEP. The WHVs are also entitled to an additional incentive of Rs 1000 under the Makkalai Thedi Maruthuvam scheme.

30. Protocol for Hypertension:

31. Follow-up Protocol for Hypertension:

32. Follow-up Protocol for Hypertension:

33. Protocol for Diabetes Mellitus :

34. Follow Up Protocol for Diabetes Mellitus:

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