Lessons for addressing noncommunicable diseases within a primary health-care system from the Ballabgarh project, India

ABSTRACT

Background: Most patients with noncommunicable diseases (NCDs) can bemanaged appropriately at the primary care level, using a simplified standardprotocol supported by low-cost drugs. The primary care response to commonNCDs is often unstructured and inadequate in low- and middle-income countries.This study assessed the feasibility of integration of NCD prevention and controlwithin the primary health-care system of India.Methods: This study was done among 12 subcentres, 2 primary health centres(PHCs) and one subdistrict hospital in a block in north India. All 28 multipurposehealth workers of these subcentres underwent 3-day training for delivering thepackage of NCD interventions as a part of their routine functioning. A time–motionstudy was conducted before and after this, to assess the workload on a sample ofthe workers with and without the NCD work. Screening for risk assessment wasdone at domiciliary level as well as at health-facility level (opportunistic screening),and the cost was estimated based on standard costing procedures. Individualswho screened positive were investigated with electrocardiography and fastingblood sugar. PHCs were strengthened with provision of essential medicines andtechnologies.Results: After training, 6% of the time of workers (n = 7) was spent in the NCDrelated activities, and introduction of NCD activities did not impact the coverage ofother major national health programmes. Loss during referral of “at-risk” subjects(37.5% from home to subcentre and 33% from subcentre to PHC) resulted inscreening efficiency being lowest at domiciliary level (1.3 cases of NCDs identifiedper 1000 screened). In comparison to domiciliary screening (`21 830.6; US$ 363.8per case identified), opportunistic screening at subdistrict level (`794.6; US$ 13.2)was 27.5 times and opportunistic screening at PHC (`1457.5; US$ 24.3) was 15.0times lower. There was significant utilization of NCD services provided at PHCs,including counselling.Conclusion: Opportunistic screening appears to be feasible and a cost-effectivestrategy for risk screening. It is possible to integrate NCD prevention and controlinto primary health care in India.