A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India.

BACKGROUND: Low- and middle-income countries (LMICs) account for a higher burden of noncommunicable diseases (NCD) and home to a higher number of premature deaths (before age 70) from NCDs. NCDs have become an integral part of the global development agenda; hence, the scope of action on NCDs extends beyond just the health-related sustainable development goal (SDG 3). However, the organization and integration of NCD-related health services have faced several gaps in the LMIC regions such as India. Although the national NCD programme of India has been in operation for a decade, challenges remain in the integration of NCD services at primary care. In this paper, we have analysed existing gaps in the organization and integration of NCD services at primary care and suggested plausible solutions that exist. METHOD: The identification of gaps is based out of a review of peer-reviewed articles, reports on national and global guidelines/protocols. The gaps are organized and narrated at four levels such as community, facility, health system, health policy and research, as per the WHO Innovative Care for Chronic Conditions framework (WHO ICCC). RESULT: The review found that challenges in the identification of eligible beneficiaries, shortage and poor capacity of frontline health workers, poor functioning of community groups and poor community knowledge on NCD risk factors were key gaps at the community level. Challenges at facility level such as poor facility infrastructure, lack of provider knowledge on standards of NCD care and below par quality of care led to poor management of NCDs. At the health system level, we found, organization of care, programme management and monitoring systems were not geared up to address NCDs. Multi-sectoral collaboration and coordination were proposed at the policy level to tackle NCDs; however, gaps remained in implementation of such policies. Limited research on the effect of health promotion, prevention and, in particular, non-medical interventions on NCDs was found as a key gap at the research level. CONCLUSION: This paper reinforces the need for an integrated comprehensive model of NCD care especially at primary health care level to address the growing burden of these diseases. This overarching review is quite relevant and useful in organizing NCD care in Indian and similar LMIC settings.

Telemedicine in Camp Mode While Screening for Noncommunicable Diseases: A Preliminary Report from India.

Introduction: Noncommunicable diseases (NCDs) are a major cause of disease burden. NCDs are a global epidemic and India is no exception. Risk factors contributing to NCDs can be detected before symptoms occur. Screening is an effective tool. Real-time teleconsultation during screening is a value-added service. This preliminary report documents the process and observations during teleconsultations provided in NCD screening camps, across multiple locations in India. That real-time teleconsultations in camp mode make a difference and are relevant in India is discussed. Materials and Methods: To provide awareness about risk factors of common NCDs such as diabetes, cardiovascular diseases, and anemia, screening camps were conducted. A 22-member field team organizes internet-enabled camps using point-of-care diagnostics. Software was developed to capture participant details and provide decision support to the field team. This resulted in identification of participants eligible for teleconsultations. Participants with risk factors of the targeted NCDs (hyperglycemia and dyslipidemia) were offered teleconsultations during screening. Currently, the program is active across six locations (Bengaluru, Coimbatore, Delhi National Capital Region, Kolkata, Pune, and Vijayawada) in India. Results: Since program inception from August 27, 2015 to October 31, 2018, a total of 757,325 participants have been screened. Twenty-seven thousand three hundred fifty-three participants were eligible for teleconsultations. Thirteen thousand six hundred fifteen availed onsite teleconsultations; 99.8% of the 1409 teleconsultation beneficiaries surveyed were "extremely satisfied and very happy." Conclusion: Providing real-time teleconsultations to 13,615 individuals "at risk" of specific NCDs from six centers across India is doable and well received by beneficiaries.

Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India.

BACKGROUND: India accounts for more than two-third of mortality due to non-communicable diseases (NCDs) in south-east Asia. The burden is high in Karnataka, one of the largest states in southern India. There is a need for integration of disease prevention, health promotion, treatment and care within the national program at primary level. A public-private partnership initiative explored evidence gaps to inform a health system based, integrated NCD programme across care continuum with a focus on hypertension and diabetes. METHODS: The study was conducted during 2017-18 in urban parts of Mysore city, covering a population of 58,000. Mixed methods were used in the study; a population-based screening to estimate denominators for those with disease and at risk; cross-sectional surveys to understand distribution of risk factors, treatment adherence and out of pocket expenses; facility audits to assess readiness of public and private facilities; in-depth interviews and focus group discussions to understand practices, myths and perceptions in the community. Chi-square tests were used to test differences between the groups. Framework analysis approach was used for qualitative analysis. RESULTS: Twelve and 19% of the adult population had raised blood sugar and blood pressure, respectively, which increased with age, to 32 and 44% for over 50 years. 11% reported tobacco consumption; 5.5%, high alcohol consumption; 40%, inadequate physical activity and 81%, inappropriate diet consumption. These correlated strongly with elderly age and poor education. The public facilities lacked diagnostics and specialist services; care in the private sector was expensive. Qualitative data revealed fears and cultural myths that affected treatment adherence. The results informed intervention design across the NCD care continuum. CONCLUSIONS: The study provides tools and methodology to gather evidence in designing comprehensive NCD programmes in low and middle income settings. The study also provides important insights into public-private partnership driving effective NCD care at primary care level.

Impact of air pollutants from surface transport sources on human health: A modeling and epidemiological approach.

This study adopted an integrated 'source-to-receptor' assessment paradigm in order to determine the effects of emissions from passenger transport on urban air quality and human health in the megacity, Delhi. The emission modeling was carried out for the base year 2007 and three alternate (ALT) policy scenarios along with a business as usual (BAU) scenario for the year 2021. An Activity-Structure-Emission Factor (ASF) framework was adapted for emission modeling, followed by a grid-wise air quality assessment using AERMOD and a health impact assessment using an epidemiological approach. It was observed that a 2021-ALT-III scenario resulted in a maximum concentration reduction of ~24%, ~42% and ~58% for carbon monoxide (CO), nitrogen dioxide (NO2) and particulate matter (PM), respectively, compared to a 2021-BAU scenario. Further, it results in significant reductions in respiratory and cardiovascular mortality, morbidity and Disability Adjusted Life Years (DALY) by 41% and 58% on exposure to PM2.5 and NO2 concentrations when compared to the 2021-BAU scenario, respectively. In other words, a mix of proposed policy interventions namely the full-phased introduction of the Integrated Mass Transit System, fixed bus speed, stringent vehicle emission norms and a hike in parking fees for private vehicles would help in strengthening the capability of passenger transport to cater to a growing transport demand with a minimum health burden in the Delhi region. Further, the study estimated that the transport of goods would be responsible for ~5.5% additional VKT in the 2021-BAU scenario; however, it will contribute ~49% and ~55% additional NO2 and PM2.5 concentrations, respectively, in the Delhi region. Implementation of diesel particulate filters for goods vehicles in the 2021-ALT-IV-O scenario would help in the reduction of ~87% of PM2.5 concentration, compared to the 2021-BAU scenario; translating into a gain of 1267 and 505 DALY per million people from exposure to PM2.5 and NO2 concentrations, respectively. These findings suggest that significant health benefits are possible if goods transport is also included while designing strategies and policies in order to improve the overall urban air quality and minimize health impacts in city areas.