Programmes

NPCDCS
(National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke )

Burden of NCDs

In 2008, out of the 57 million global deaths, 36 million deaths, or 63%, were due to NCDs, principally cardiovascular diseases, diabetes, cancers and chronic respiratory diseases. In India, the estimated deaths due to NCDs in 2008 were 5.3 million (World Health Organization - NCD Country Profiles, 2011). The overall prevalence of diabetes, hypertension, Ischemic Heart Diseases (IHD) and stroke in India is 62.47, 159.46, 37.00 and 1.54 respectively per 1000 population. (Indian council for Medical Research, 2006. It is estimated that there are about 28 lakh cases of different type of Cancer in the country with new occurrence of about 11 lakh cases and about 5 lakh deaths annually. The common cancers are breast, cervical and oral cancer.

Main Components of NPCDCS during 11th Five Year Plan

The programme was initiated in October 2010 towards the end of the 11th Plan i.e. 2010-11 & 2011-12 in 100 districts of 21 states including Gandhinagar, Surendranagar, Rajkot, Jamnagar, Porbandar and Junagadh districts of Gujarat. Focus of the programme was on health promotion, early detection and management of chronic non-communicable diseases; Cancer, Diabetes, Cardio Vascular Diseases and Stroke. All interventions including Tertiary Cancer Care were in the same programme.

NCD Flexi-pool under NRHM

In 12th plan (2013-17) all interventions of the NPCDCS up to District level and below are integrated within NRHM. Funds to carry out the activities under the programme would be released under NCD flexi-pool through NRHM. Tertiary Cancer care component will be taken up separately.

Objectives
  • Health promotion through behavior change.
  • Prevention and early detection of NCDs.
  • Building capacity at various levels of health care facilities for prevention, early diagnosis, treatment and rehabilitation in respect of NCDs.
  • Supporting development of database for NCDs through regular surveillance.
  • Monitoring risk factors, morbidity and mortality associated with NCDs.
Coverage of District

Unto 50% of the total districts in the country are proposed to be taken up in 2013-14. Therefore each State Govt. can take up 50% of their districts. The selection criteria would be as follows:

  • All districts taken up already in year 2010-13
  • Districts identified as high priority under NRHM based on health indicators
  • Districts having Mobile Medical Units
  • Any other district as per the felt need/priority
Prevention through behavior change
  • Prevention of identified risk factors for NCDs by creating general awareness about the Non Communicable Diseases.
  • Promotion of healthy life style and habits in the community through use of inter alia mass media (electronic and print), community education and interpersonal communication.
Screening/Early diagnosis
  • Opportunistic screening of persons above the age of 30 years for diabetes and hypertension, at the point of primary contact with any health care facility.
  • The screening would be carried out at various levels of health care delivery and opportunity such as mobile medical units visit, check-ups by RBSK teams and observation of VHND as well as selected days for NCDs clinics at all levels.
  • Providing support for strengthening screening services at sub centre, PHC, CHC and District Hospitals.
  • All pregnant women will be screened in the ANC clinic for diabetes and hypertension.
Establishing and strengthening affordable treatment facilities

To strengthen the facilities for management of cancer, diabetes, hypertension, cardio vascular diseases and stroke at various government health care facilities upto the district level and below by providing additional human resources and infrastructural support.

Treatment of NCDs

Appropriate treatment and management of various NCDs will be provided at PHC/CHC and district hospital level. The uncomplicated diabetes and hypertension can be treated up to district level. The cancer cases may require referral to higher facilities i.e medical colleges and Regional cancer centres. The follow up chemotherapy can be given in the district hospitals with advised from higher centres.

Linkages with Medical Colleges

Linkages with medical colleges, nursing colleges/schools and Dental colleges is proposed. Nearby Govt. leading institution need to be linked by the State Govt. for the purpose of mentoring, guidance, capacity building and monitoring. In case, if there is no Govt. institution, then private medical college can be taken up for linkages with district and transparent guidelines followed for the purpose.

Capacity building of human resource

Training of medical and paramedical personnel, health workers in health promotion, prevention, early detection and management of cancer, diabetes, hypertension, cardiovascular diseases and stroke to be carried out by the states is nearby well established training centre/institution.

Rehabilitation

Appropriate provisions for physiotherapy for patients suffering from various NCDs will be made at various levels of health care facilities.

Sub Centre
  • Health promotion for behavior change and counseling.
  • ‘Opportunistic’ Screening using B.P measurement and blood glucose by Glucostrip method.
  • Identification of early warning signals of common cancer.
  • Referral of suspected cases to CHC/ nearby health facility with referral card.
  • Designate one day for NCD clinic.
  • Screening of common cancers (oral, breast & cervical) if possible.
Primary Health Centre
  • Health promotion for behavior change and counseling.
  • ‘Opportunistic’ Screening using B.P measurement and blood by Glucostrip.
  • Clinical diagnosis and treatment of simple cases of Hypertension and Diabetes.
  • Identification of early warning signals of common cancer.
  • Referral of suspected cases of NCDs to CHC.
  • Designate one day for NCD clinic.
Community Health Centre
  • Prevention and health promotion including counseling
  • Early diagnosis through clinical and laboratory investigations
  • (Common lab investigations: Blood Sugar, lipid profile, ECG, ultrasound, X ray etc.,if not available, may be outsourced)
  • Management of common CVD, diabetes and stroke cases
  • ‘Opportunistic’ Screening of common cancers (Oral, Breast, Cervix and prostate)
  • Referral of difficult cases to District Hospital/higher level of health care facility
  • User charges may be considered, as per state Govt. policy, for those who are not poor and needy
District Hospital
  • Early diagnosis of diabetes, CVDs and Cancer
  • Investigations: Blood Sugar, lipid profile, Kidney Function Tests (KFT), Liver Function Tests (LFT), ECG, Ultrasound, X ray, mammography etc.
  • Outsource investigations for poor and needy if not available.
  • Medical management of cases (outpatient , inpatient and intensive Care )
  • ‘Opportunistic’ Screening of common cancers
  • Referral of difficult cases to higher level of health care facility
  • Health promotion for behavior change and counseling
  • Follow up chemotherapy for cancer patients
  • Rehabilitation and physiotherapy services
Health Promotion and prevention activities using IEC
  • Generating awareness regarding prevention of risk factors and promoting healthy life style habits in the community.
  • Undertake community education and behavior change through inter personal communication and use of relevant media.
  • Existing IEC material may be modified and adapted to suit the needs of community.
  • Involve local civil society, community based organization, panchayats/local bodies, other government departments and private sector in undertaking awareness generation activities for health promotion.
  • The platforms under various ongoing national health programmes/initiatives such as School Health Programme, ICDS, ARSH and Weekly Iron Folic Acid Supplementation should be used to inculcate healthy dietary habits among children.

The focus of health promotion activities shall be on the following:

  • Promoting intake of healthy foods and avoiding junk food
  • Reducing salt in the diet
  • Increased physical activity/regular exercise
  • Avoidance of tobacco and alcohol
  • Prevention of obesity
  • Avoiding and managing stress by using appropriate strategies
  • Awareness about early warning signs of common cancers
  • Importance of early diagnosis and treatment
  • Regular health check-up
Screening, diagnosis and treatment
  • Screening (opportunistic screening i.e. wherever the service delivery and opportunity exists e.g. Mobile Medical Units, Rashtriya Swasthya Bal Karyakram (RSBK), melas etc.) for early detection of non-communicable diseases especially diabetes, high blood pressure and common cancers may be carried out.
  • The screening of target population (age 30 years and above, and pregnant women) shall be conducted either through opportunistic and/or camp approach at different levels of health facilities and also in urban slums of large cities.
  • Screening of pregnant Women would be integrated and through Ante natal Clinic under RCH program of NRHM. This is expected to be done for all pregnant women.
  • The screening of the urban slum population would be carried out by the local government/municipalities in cities with population of more than 1 million.
  • The screening of school children shall be carried out during the routine school health check-up activity under the school health program.
  • Mobile Medical Units under NRHM/RSBK are to be utilised for the purpose of screening.
  • The suspected cases of diabetes and high blood pressure shall be referred to higher health facilities for further diagnosis and treatment/management.
  • Opportunistic screening for common cancers (breast, cervical and oral) among the population 30 years and above, at different level of health facilities shall be carried out. Patients with high risk factors e.g. smoking or chewing tobacco, family history, obesity etc. would be screened. In case of breast self-examination is to be promoted while the clinical examination may be done only in 50 years above.
  • The ANMs shall be trained for conducting screening for NCDs at sub centre level.
  • Each district shall be linked to nearby tertiary cancer care facilities to provide referral and outreach services.
  • The suspected cases of various cancers shall be referred to District Hospital and tertiary cancer care (TCC) facilities.
  • For screening of diabetes, support for Glucometers, Glucostrips and lancets are provided to the state under NRHM. The procurement is now decentralized and it is for state Govt. to procure the equipment as per their need and requirement.
  • The common infrastructure/manpower available under different programmes such as National Program for Health Care of Elderly, National Tobacco Control Program, National Mental Health Program and overall NRHM etc. shall be utilized for early detection of cases, diagnosis, treatment, training and monitoring under NPCDCS.
Community Health Centers
  • Support is provided to the CHC/FRU to establish a ‘NCD clinic’ (NCD here refers to Cancer, Diabetes, Hypertension, cardiovascular diseases and stroke) where comprehensive examination of patients referred by the Health Worker as well as reporting directly will be conducted for early diagnosis and treatment.
  • Strengthening of First Referral Units (FRUs) (approx. 2315) shall get priority. These can be involved in screening of common cancers (oral, breast and cervix), conducting regular NCD clinic, undertaking laboratory investigations and referral services.
  • Each FRU/CHC needs to be supported with contractual staff (1Doctor, 1Nurse, 1Technician, 1 Counselor and 1 Data Entry Operator). The State Govt. may identify the gaps and seek financial assistance as per the need.
  • Funds can also be provided for consumables and essential drugs for NCDs etc.
  • Ambulance services under the NRHM needs to be used for transport of emergency referred cases.
District Hospital
  • District hospital is to be strengthened /upgraded for management of Cancer, Diabetes, Cardiovascular Disease and Stroke.
  • Support can be provided for non-recurring and recurring costs, where non-recurring grants would be for equipment, renovation and laboratory strengthening while recurring grants would be towards the remuneration of staff, drugs, training and IEC etc.
NCD clinic

All districts under the programme shall establish regular NCD clinic for screening, treatment/management of NCDs.

  • These clinics shall also provide for counseling services and undertake awareness generation activities regarding NCDs and associated risk factors.
  • The NCD clinic shall conduct comprehensive examination of patients referred by lower health facility /health workers as well as of those reporting directly to the clinic.
  • The clinics will advise laboratory investigations of the patients to rule out complications or advanced stages of common NCDs.
  • The district NCD clinic is to be supported with common essential drugs for NCD management including for stroke patients.
  • The clinic will maintain regular database and send reports in the prescribed formats at regular intervals.
Cardiac Care unit

6 to 10 bedded Cardiac Care Unit can be established / strengthened at the district hospital (up to 25 % of districts taken).

  • The CCU is to be supported by the human resource available in the NCD clinic.
  • Special skill based training shall be provided to health professionals and nurses in handling the patients in CCU/ ICU.
Support for cancer

District hospitals needs to be supported for diagnostic facilities for common cancers.

  • In case the facility is not available for diagnosis of common cancers in the district hospital, these investigations may be outsourced. District hospital can consider outsourcing certain laboratory investigations that are not available at the facility, however relevant rules must be followed and transparent guidelines be formed.
  • Support is also provided for chemotherapy drugs for cancer treatment (up to 25 % of districts taken under the program). All efforts should be made by State government to provide follow up chemotherapy at district level. Till such time, patients should be referred to designated Tertiary Cancer Center for treatment.
  • State shall ensure the availability of requisite human resource at district hospital for Cancer care (Gynecologist, Physician, General surgeon/ENT Surgeon and two nurses). However there is no separate financial provision under the programme.

All districts will have support for diagnostic facilities for NCDs. In case the facility is not available in the district hospital, these investigations may be outsourced. The state government/CGHS/CS (MA) rates may be followed whichever is lower and as per state government policy.

Laboratory strengthening
  • Laboratory services at district hospital are supported to provide necessary investigations for cancer, diabetes, hypertension and cardiovascular diseases.
  • District hospital can consider outsourcing certain laboratory investigations that are not available at the facility, however relevant rules must be followed and transparent guidelines be formed.
  • The District Hospital shall display the list of Laboratories in which these investigations would be outsourced.
Manpower development
  • Health professionals and health workers at various levels of health care delivery shall be trained for health promotion, NCD prevention, early detection and management of Cancer, Diabetes, CVDs and Stroke.
  • The training shall include components of programme management and specialized training for diagnosis, treatment of cancer, diabetes, CVDs and strokes.
  • The nodal agency/agencies shall be identified in consultation with the national and state NCD cells for adaptation of training material as per requirement of the state/district and also conducting training of health care providers at different levels.
  • Establish mechanisms for regular monitoring of the quality of training.
Drugs and consumable
  • Financial support is provided to district and CHC/FRU/PHC for procurement of common essential drugs for treatment of Cancer, Diabetes, CVDs and Stroke.
  • The procurement is to be decentralized and to be done at the state level as per relevant norms/procedures in a transparent manner.
  • AYUSH doctors shall play an important role in prevention and control of NCDs through primary health care network. They shall be involved in health promotion activities, counseling of patients and their relatives on healthy lifestyle (healthy diet, physical activity, salt reduction, avoidance of alcohol and tobacco), meditation, Yoga, opportunistic screening for early detection of non-communicable diseases and their risk factors, and treatment using Indigenous System of Medicines.
  • The AYUSH practitioners shall be involved in supplementing the efforts to operationalizing various activities under NPCDCS.
  • NGOs, civil society organizations and private sector can be involved in health promotion activities, early diagnosis and treatment of common NCDs at district levels and below level.
  • The states can identify credible NGOs/CSOs as per established guidelines to involve them in the NPCDCS activities at local level.
  • Any involvement of NGOs/private organizations must be as per relevant rules and done in a transparent manner.

The surveillance for common NCDs and their risk factors needs to be done on a regular basis under guidance/collaboration with ICMR or any leading institution for uniformity and synergies in accordance with national priorities and needs.

District NCD cell will submit regular reports in the prescribed Performa to the state NCD cell which will compile, analyze and submit the information to National NCD Cell. HMIS under NRHM shall be used for sending regular feedback under NPCDCS.

  • The financial resources under NPCDCS would be on a cost sharing basis of 75: 25 (with 75% as share of Government of India (GOI) and 25% as State share) except States in North East and hilly areas, where the share would be 90: 10 between Centre and the State Governments.
  • The funds would be provided to the States as an envelope with identified activities at each health facility level with inter-usability of funds from one component to another, in order to impart operational flexibility in implementation of the programme as per respective needs of the States.
  • Procurement of Glucometers, Gluco-strips and lancets for screening of diabetes will be done by the State governments in accordance with the established procedures/norms in respective states.
  • For the Cardiac Care Unit at the district hospital level, there is provision of requisite equipment such as beds, monitors, ventilators, defibrillators, Pulse Oximeter, ECG machine etc. The requirement would vary from state to state since at some places this will be a completely new setup, while at other places the existing setup would be strengthened.
  • The equipment will be procured by state/ district as per established procedure/norms.
  • The models of equipment would depend on the availability and suitability, without compromising the quality.
National Disease Control Programmes(NDCPs)

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