1. Non Communicable Disease(NCD)-Global Scenario & Role of family Physician
Dr Rajesh Jain MD
EX-Medical Officer- WHO
Project Manager Diabetes Prevention Control Project-
Uttar Pradesh(NRHM)
&
Supported by World Diabetes Foundation,Denmark

43. Global NCD Targets 20%15% <15.0% 23%15% 32.2%24.0% HED* <1.2%
8.7 6.0 gm
35.2%30.0%
* Heavy episodic drinking
Source of icons: World Heart Federation Champion Advocates Programme

44. Seven Strategies: Prevention and Promotion Clinical Management
Increasing Patient Compliance
Action with NGOs, Professional Bodies & Other Stakeholders
Monitoring, Research and Surveillance
Capacity Building
Policy and Regulatory interventions

45. Seven Strategies: Prevention and Promotion Clinical Management
Increasing Patient Compliance
Action with NGOs, Professional Bodies & Other Stakeholders
Monitoring, Research and Surveillance
Capacity Building
Policy and Regulatory interventions

46. Translating Chronic Care Model into Our Primary Care
Coordinated, Continuous and
Comprehensive Care
Productive Interactions
Multidisciplinary NCD Team
Physician MO
Nurse / DE
Dietician
Pharmacist
Informed, Empowered Patient
Self-management support 46
Decision support
Efficient Clinical Information System
Community Resources

47. Focus 2015: Initiatives to Improve Clinical Outcome of NCDsNo
Strategy
Activity 1.
Informed, Empowered Patient
1. Development and implementation of
Peer Support Diabetes Program. 2.
Multidisciplinary NCD Team
2. Development and implementation of
an appraisal system / incentive to
recognize health center with excellent
Diabetes care, based on QA
achievement.
3. Personalized NCD care by Medical
Officer and Diabetes Educator in
health centres. 47 47

48. Focus 2015: Initiatives to Improve Clinical Outcome of NCDsNo
Strategy
Activity 3.
Self-management support
4. Development and implementation of
Hypertension audit as a new Quality
Assurance / National Indicator
Approach.
5. Development of CVD Record Book
(merging the current Diabetes and
Hypertension Book) to facilitate
management according to the
Global Cardiovascular Risk. 4.
Efficient Clinical Information System
6. Strengthening the National Diabetes
Registry. 48 48

49. 1. Peer Support Diabetes Program
The program module was reviewed twice and now in the final stage of preparation.
NCD will be responsible for developing the program and training modules, conduct training, implement and monitor the program.

50. Peer Support Diabetes Program
Rationale:
Informed, Empowered Patient is one of the crucial component of the Chronic Care Model.
Patients are more likely to accept advise from their peers or people living with the same condition.
Successful implementation of a Peer Support Group Program in other countries (e.g. US, Canada) have shown to:
Help patients understand and in control of their disease better;
Help patients achieve good disease control; and
Reduce rates of referral to hospitals due to complications.

51. Certified Training for GPs
This program has been carried out by 100 centers across India by 200 trainers across country
PRAYAS – since , “mentor-mentee system”.
Lucknow ,Prayas (and Aventis,Bohreinger,WDF) – peer as trainers during diabetes education session.

52. 2. Appraisal System for Excellent Diabetes Health Centre ,Uttar Pradesh
This appraisal system will act as a motivational drive for healthcare providers to improve quality of Diabetes care at 42 District hospitals and 634 CHC by 2018 in Uttar Pradesh.
NCD Clinic at CHC & District hospital 2014, involving officers from the Family Health Development Division, State Epidemiologist (NCD), Family Medicine Specialists, Medical Officers and Diabetes Educators.
3000 Doctors & 6000 Staff Nurse and 1 lakhs ASHA to be trained in Diabetes & NCD Control by 2018
Programme is supported by World Diabetes Foundation,WDF,Denmark.
NCD Training for Doctors and Nurse in 20 Districts with Bohreinger already started.

53. 3. Personalised NCD Care Definition: Rationale:
Personalised care planning empowers individuals (patients with chronic diseases), promotes independence and helps people to be more involved in decisions about their care.
It centres on listening to individuals, finding out what matters to them and finding out what support they need.
Rationale:
Individuals with long term conditions will be at a point be able to take more control over their condition and understand how it affects their lives.
70% of individuals with a long term condition say their care has improved as a result of personalised care planning (GP Patient Survey 2009/10, Department of Health, UK).

54. ASHA, ANM & Volunteers as agent of change
Basic concept of
Coverage of NCD
ASHA, ANM & Volunteers as agent of change
Positive behavioural change at the community level through effective interventions
Extensive coverage through collaboration between NGOs, ASHA & Volunteers
Target Uttar Pradesh:
200 Trainers
1,00000 ASHA,
6000 ANM,GNM 3000 GP
Trained by 2018

55. Strategies Scope Increasing awareness & knowledge Healthy eating
Health-promoting living environment
Translation of knowledge into sustainable actions
Scope
Healthy eating
Active living
Smoke-free
Weight management
Early detection of NCD risk factors

56. Behavioural Changes Scope Behavioural changes Healthy eating
Separating sugar/creamer from hot beverages
Increasing availability of fruits and vegetables
Increasing availability of plain drinking water
Increasing understanding on relationship between intake, calories and activity physical
Smoke-free
Smoke-free areas – enforcement of existing regulations and voluntary smoke-free areas
Active living
Walking 10,000 steps
Regular and planned physical activity/exercise sessions
Weight management
Regular self-monitoring of BMI
Early detection of NCD risk factor
Regular self-monitoring of BMI, blood pressure and blood sugar
Use of “health diary” – regularly updated

57. Environmental Changes
Scope
Health-promoting living environment
Healthy eating
Community events – separates sugar/creamer from hot beverages
Community events – availability of fruits & vegetables
Community events – availability of plain drinking water
Healthy stalls or food vendors
Smoke-free
Enforcement of smoke-free areas gazetted under regulations
Smoke-free announcement for community events
Recognition for voluntary smoke-free homes
Active living
Creation of walking tracks with health messages notices on eating, calories and physical activities
Weight management
Self-monitoring facilities
Early detection of NCD risk factor

60. Summary
In order to achieve the voluntary NCD global targets, we need to prioritise our actions
NCD prevention
NCD control / management
What are the biggest contributors or determinants?
What factors are within our control? What factors are beyond?
Can we do more beyond clinical care?
Social determinants of health