EquitableaccesstoqualitygenericmedicinesforpatientswithNCDinTumkur,India:Ahealthsystemsresearch

InterventionplandocumentMaya Annie Elias, Manoj K Pati, Praveen Aivalli, Bhanuprakash, Mune Gowda,

andNSPrashanth

(withinputsfromBartCriel,,NDevadasan&SadhanaSM)

Introduction Institute of Public Health, Bangalore (IPH), Karnataka State Health Systems

Resource Centre, Bangalore (KSHSRC) and Institute of Tropical Medicine,

Antwerp (ITM) are jointly conducting a research study titled “Improving

equitable access to quality generic medicines for patients with Non

Communicable Diseases” in Tumkur district, Karnataka. The study is being

supported by WHO-Alliance for Health Policy & Systems Research (WHO-

Alliance)foraperiodofthreeyearsfromMay2013-April2016.

This study seeks to understand if (and how) improvements in health services

andstrengtheningofcommunitymechanismscouldimproveaccesstomedicines

for people with non-communicable diseases (diabetes and hypertension) in

Tumkur district. It is designed as a quasi-experimental study using a cluster-randomized control trial design. An intervention at taluka-level will beimplemented and its effectswill be studied through a baseline-endline survey

amonghouseholdsandhealthfacilities.Amixedmethodsapproachwillbeused

to verify and refine the initial programme theory of the intervention and

understandthePHC-levelchangesinresponsetosuchanintervention.

We first began taluka selection with a taluka health systems assessment, in

whichweexcludedthreetalukasasnotmeetingthecriteriaforimplementation

of the intervention. From the other seven talukas, three talukas were chosen

randomly. The talukas are Koratagere, Turuvekere and Sira. PHCs in these

talukaswillberandomlyallocatedtothreearmsoftheintervention:community

platforms strengthening (A), community platforms strengthening + health

services optimisation (AB) and control (C). The baseline and endline survey

make use of standardized household and facility survey tools that were

developed and tested in low- and middle-income country (LMIC) settings by

WHO. We will use qualitative methods (in-depth interviews, focus group

discussions and observation notes of field visits) during and after the

intervention to understandhow healthworkers and patientswithin the PHCs,talukaanddistrictlevelrespondedtotheintervention.

Thepurposeofthisdocumentis:

1. Toprovideastepbystepplanfortheproposedinterventionofthestudy,alongwiththerationale

2. Toaidasareferencemanualfortheresearchteamthroughouttheprojectinterventionperiod

BackgroundIndia is going through major transition with regards to its socioeconomic

parameters, demographic profile and disease patterns. Along with the high

burdenof communicable diseases, non-communicable diseases are also on the

rise.We are supposed to be the diabetic capital of theworldwith the highest

number of diabetic and hypertensive patients1. Non-communicable diseases

contributedtotwo-thirdsofalldeathsgloballyin2011andaround80%ofsuch

NCD deaths occurred in low- and middle-income countries2. According to the

WHOestimates,non-communicablediseasesinIndiaaccountedforanestimated

53%ofallmortalityin20113.Whiledisability-adjustedlife-years(DALY)dueto

NCDsandassociatedeconomic implicationshavebecome topicsof interest for

public health researchers, other important aspects of greater interest to

policymakersisthecostoftreatmentandthewaystoimproveaccesstoessential

medicines.Inadequateresourceallocation,supplyandmanagementofmedicines

inthepublicsectorandresultanthighout-of-pocket(OOP)expediturehavebeen

highlighedasimportantissuesinNCDcare4.

Globally, there has been a lot of discussion on organising care for chronic

diseases, especially in LMICs. The 2012 United Nations General Assembly

declarationonchronicdiseaseswasamajorstepinthisdirection.Itemphasized

theneedforcoordinatedactionamongallnationstodealwiththeNCDburden

and put forth various intervention strategies such as improving access to

medicines, better technology and international collaborative efforts for NCD

control5.

In all the debates related to NCDs, it has been pointed out that a continuous,

integratedhealthcaredeliverysystemisaprerequisitefortherequiredcarefor

NCDs.ButoftenweseethatthehealthinformationsystemsforNCDsareweakin

mostLMICsandhealthcaredeliverysystemsinthesecountriesaremoretuned

1Patel,V.,Chatterji,S.,Chisholm,D.,Ebrahim,S.,Gopalakrishna,G.,Mathers,C.,…Reddy,K.S.(2011).

ChronicdiseasesandinjuriesinIndia.Lancet,377(9763),413–28.doi:10.1016/S0140-6736(10)61188-92WHO|Noncommunicablediseases.(n.d.).Retrievedfromhttp://www.who.int/mediacentre/factsheets/fs355/en/3WorldHealthOrganization.(2011c).WHONCDCountryProfiles.Geneva:WorldHealthOrganization.

4 Bhojani,U.,Thriveni,B.,Devadasan,R.,Munegowda,C.,Devadasan,N.,Kolsteren,P.,&Criel,B.(2012).Out-of-pockethealthcarepaymentsonchronicconditionsimpoverishurbanpoorinBangalore,India.BMCpublichealth,12(1),990.doi:10.1186/1471-2458-12-990

5UnitedNationsGeneralAssembly.ResolutionadoptedbytheGeneralAssembly:66/2:PoliticalDeclaration

oftheHigh-levelMeetingoftheGeneralAssemblyonthePreventionandControlofNon-communicable

Diseases.AdoptedSeptember19,2011;publishedJanuary24,2012.

todealwiththeacuteandinfectiousdiseasesratherthanchronicconditions6.A

recentreviewofevidenceonburdenofchronicdiseasesandpossibleresponses

fromthehealthsystemhighlights,amongothers“strengthenedpublichealthand

primary healthcare systems”7. Good primary health care, supported by family

andself-careisbelievedtobethebackboneofcost-effectiveNCDcare8.

Community and health services intervention models have been tried out to

improve thecare forNCDs inbothhigh-incomeandLMICsettings.Community

interventions for NCDsmainly concentrate on prevention andmany countries

havesuccessfully implementedawarenessgenerationandlifestylemodification

programmes9. Health services interventions primarily focus on improving

compliance (through better follow-up, use of telephones or through health

workers) and improving the informationbasis for lifestylemodification advice

by health workers (building capacities of health workers to deliver lifestyle

modificationadvice,nurse-orpharmacist-aidedcounseling)10,11.

Another intervention suggested for effective NCD control is community

involvement in planning, implementation andmonitoring ofNCDmanagement

programmes and advocacy for increasing the governments’ commitment

towardsNCDs12.InIndia,thereisalonghistoryofsuchcivilsocietyinvolvement

6Dans,A.,Ng,N.,Varghese,C.,Tai,E.S.,Firestone,R.,&Bonita,R.(2011).Theriseofchronicnon-

communicablediseasesinsoutheastAsia:timeforaction.Lancet,377(9766),680–9.doi:10.1016/S0140-6736(10)61506-1 7Patel,V.,Chatterji,S.,Chisholm,D.,Ebrahim,S.,Gopalakrishna,G.,Mathers,C.,…Reddy,K.S.(2011).

ChronicdiseasesandinjuriesinIndia.Lancet,377(9763),413–28.doi:10.1016/S0140-6736(10)61188-9

8BeagleholeR,Epping-Jordan J,PatelV,ChopraM,EbrahimS,etal. (2008) Improvingthepreventionand

managementofchronicdiseaseinlow-incomeandmiddle-incomecountries:apriorityforprimaryhealth

care.Lancet372:940–994.doi:10.1016/S0140-6736(08)61404-X9Puoane, T. R., Tsolekile, L., & Sanders, D.(2013). A case study of community-level intervention for non-

communicable diseases in khayelitsha , Cape Town Empowerment of Women and Girls. Institute of

DevelopmentStudies,UniversityoftheWesternCape.

10Hirimuthugoda, L. K., Wathudura, S. P. K., Edirimanna, H., Vithanage, T. K., & de Silva, P. A. (2013).

Experimental design: impact of an intervention to improve clinic attendance of patients with non-

communicable diseases through telephone follow-up. The Lancet, 381, S63. doi:10.1016/S0140-6736(13)61317-3

11Saleem, F., Hassali, M. a, Shafie, A. a, Ul Haq, N., Farooqui, M., Aljadhay, H., & Ahmad, F. U. D. (2013).

Pharmacist intervention in improving hypertension-related knowledge, treatment medication adherence

and health-related quality of life: a non-clinical randomized controlled trial. Health expectations : aninternationaljournalofpublicparticipationinhealthcareandhealthpolicy.doi:10.1111/hex.1210112Bonita,R.,Magnusson,R.,Bovet,P.,Zhao,D.,Malta,D.C.,Geneau,R.,Beaglehole,R.(2013).Countryactions

tomeetUNcommitmentsonnon-communicablediseases:astepwiseapproach.Lancet,381(9866),575–84.doi:10.1016/S0140-6736(12)61993-

in healthcare and the National Rural HealthMission (NRHM)13has formalized

the channel for this engagement through the formation of Village Health and

Sanitation Committees (VHSC) at the village level andArogyaRakshaSamithis(ARS;healthprotectioncommittees in the local language,Kannada)at thePHC

level. Similar committeeshavebeen formed at secondary and tertiaryhospital

levels.ThoughARScommitteesareexpectedtoplayanactiveroleinsupporting

andimprovingtheoverallqualityofservices,studiesconductedacrossdifferent

states report that these committees often lack the understanding of their

expected role and suggest capacity-building as a means to improve their

functioning14,15.

ItisinthiscontextthatweproposetheinterventionsundertheATMproject,for

strengtheningthecommunityparticipationplatformsandoptimisingthehealth

servicestoimproveaccesstomedicinesforNCDsinTumkur.

The details about data collection, the tools used, analysis proposed and

dissemination of lessons learnt are available in the study protocol. The study

protocolhasreceivedapprovalfromtheethicscommitteesofWHO,Genevaand

IPH, Bangalore. The Government of Karnataka has provided permission to

conductthestudyinTumkur.

Intervention plan StudysettingTumkur district is one of the 30 districts inKarnataka state in southern India

withapopulationof2.67million (2011census).There isamixofgovernment

and private sector, formal and informal providers aswell as a range of single

doctor clinics to secondary and tertiary level hospitals. Despite significant

achievements in providing and managing health services, inter-district

disparities in health outcomes persist. A recent government task force

categorized Tumkur as an average district with respect to health and

developmentoutcomes.Tumkur,intermsofperformanceofhealthservicesand

health outcomes, is comparable to most other districts in Karnataka. IPH has

13TheNationalRuralHealthMissionwaslaunchedin2005.UndertheNRHM,theIndiangovernment

committeditselftoincreasingitsexpenditureonhealth(thenestimatedtobelessthan0.9%ofitsGDP).

NRHMlisted“communitization”ofthehealthservicesasoneofitscorestrategiesforimprovingthequality

andperformanceoftheIndianhealthsystem14AnexploratorystudyofVHSCandARSfunctioning.(2012).KarnatakaStateHealthSystemResource

Centre,Bangalore

15Adsul,N.,&Kar,M.(2013).Studyofrogikalyansamitisinstrengtheninghealthsystemsundernational

ruralhealthmission,districtpune,maharashtra.Indianjournalofcommunitymedicine :officialpublicationofIndianAssociationofPreventive&SocialMedicine,38(4),223–8.doi:10.4103/0970-0218.120157

beenworkingwith theTumkur district health team since 2009. IPH’s focus in

Tumkur has been to strengthen the management capacities of the Tumkur

district and taluka teamsaswell as conductingoperational research,problem-

solving visits and action research at PHC level. In figure 2, the talukas

(administrativesub-divisionsofdistricts)ofTumkurareshownhighlightingthe

talukaschosenfortheATMstudy.Selectionofstudytalukas-RapidhealthsystemassessmentTumkur has 10 talukas16and they vary widely in terms of socio-economicdevelopment indicators. The state government-appointed committee for

addressing regional disparities in development categorized talukas across thestate basedon varioushealth, literacy, socio-economic, political, and economic

indices. In Tumkur, only the headquarter taluka (Tumkur)was categorised as

relatively developed. The other nine were classified as being “backward” to

“most backward”. Considering that the intervention is dependent on several

healthsystemfactorsfor it tosucceed, itwasnecessarytoassess ifall(orhow

many) of the 10 talukas have the necessary conditions to implement theproposed interventions (health services and community mechanisms

strengtheningto improveaccesstomedicines fornon-communicablediseases).

HencewedevisedatoolforthisassessmentusingthehealthsystemframeworkbyVanOlmenetal(figure1)17.

Figure1:HealthsystemframeworkbyOlmenetal

Imagesource:Imagesource:vanOlmen,J.,Marchal,B.,Damme,W.Van,Kegels,G.,&Hill,

P.S.(2012).Healthsystemsframeworksintheirpoliticalcontext:framingdivergent

agendas.BMCPublicHealth.http://doi.org/10.1186/1471-2458-12-774

16ATalukaisanadministrativesub-divisionofdistrict.InKarnataka,atypicaltalukahasapopulationofafewhundredthousandpeople.Panchayats(localgovernmentswithelectedrepresentatives)administerthehealth,educationandsocialwelfareservicesatthedistrict,talukaandvillagelevel.

17van Olmen, J., Marchal, B., Damme, W. Van, Kegels, G., & Hill, P. S. (2012). Health systems frameworks in their political context: framing divergent agendas. BMC Public Health. http://doi.org/10.1186/1471-2458-12-774

Wedevised indicators for the various components of the talukahealth system

and based on this assessment, the talukaswhere the necessary health system

conditionsforimplementingtheinterventiondidnotexistweredropped(three

talukas were dropped). We chose three talukas randomly from among theremainingseven.ThetalukasareKoratagere,SiraandTuruvekere(asshowninfigure1). In these three talukas,PHCswillberandomlyallocated tooneof thethree armsof the intervention (A,B andC).Abrief socio-demographicprofile,

healthanddevelopmentindicatorsofthethreetalukasareshownintable1.Theintervention packages will be implemented in A and B, while C will be the

control.Awill receivePackageA andBwill receiveboth typesof intervention

packages.

Table1:HealthanddevelopmentindicatorsofthestudytalukasIndicators Kortagere Sira TurvekereArea 652Sqkm 1552Sqkm 778Sqkm

Population 160952 301473 174297

Numberofprivatepharmacies 19 30 22

Generalliteracyrate 71% 67% 73%

NumberofPHCs 11 17 11

Avg.PopulationperPHC, 14500 18000 16000

Number of private

hospitals/clinics 21 64 18

IMR 12 10 3

Number of PHCs with qualified

MBBSdoctors11 15 10

PackageA:Strengtheningcommunityparticipationplatforms

In these PHCs, the intervention will focus on the existing community

participationplatforms.Theobjectiveistostrengthentheseplatformstobecome

pressuregroupsforbetterNCDcareinthePHCs.TwothirdofthePHCsfromthe

selectedtalukaswillreceivethispackage.

Thetwokeyassumptionsunderlyingthispackageisthefollowing:

1. Healthworkers of PHCs can themselves encourage and empowerARS18andVHSC19memberstoengagewiththePHCteamtoimproveaccessto

18TheArogyaRakshaSamiti(ARS;Healthprotectioncommittee)areconstitutedatthe

healthfacilitylevelwithamixofhealthworkers,electedrepresentativesofthelocal

governmentandothercommunitymembers.UnderNRHM,ARScommitteeshavebeen

vestedwithimportantoversightresponsibilitiesandfinancingarrangements.

19Villagehealthandsanitationcommittees(VHSC)isanotherbodysetupunderthe

NRHMateachofthevillages.TheASHAisakeymemberoftheVHSC.VHSCsare

medicines for NCD through provision of information about NCDs, NCD

careandentitlementstosuchcareatlocalPHCs

2. ExistingcommunityparticipationplatformscantriggerimprovementsinPHCsiftheirmembersaremadeawareoftheirrolesandresponsibilities

andiftheirengagementisfacilitatedbyhealthworkers

Inthecommunitypackage,workshopswillbeheldateachofthePHCswiththe

PHC healthworkers to help them facilitate the participation of ARS and VHSC

membersindiscussionsaboutNCDcareattheirPHCs,needforandavailability

ofmedicinesforNCDatlocalPHCsandaboutlifestylemodificationforsecondary

andprimarypreventionofNCDs.Wewillalsoseek toplaceNCDasa topic for

publicdiscussionduringtheoneormorePHChealthandnutritiondaysthatare

routinelyconductedatthePHC,whereseveralcommunitymembersparticipate.

At present, these events are largely focusing on reproductive and child health

services.

Thefollowingdiagramexplainstheinterventionlogic.Thechoiceofintervention

inputsandthelikelyprocessesthroughwhichtheexpectedoutputmaybeseen

are based on existing theory on what works (body of literature) and our

assumptions(basedonourunderstandingofthestudysetting).

expectedtofunctionasakeylinkbetweenhealthworkerresponsibilitiesand

communityexpectationsatthevillagelevel.Theyalsohaveminimalfinancialallocation.

Figure3:InterventionlogicofpackageA.

Inputs Processes Output Outcome

IEC Material Dissemination through Health Worker

Awareness on Treatment and Investigations

Improved care for NCDs

Reduction of OOP

Better Coordination among Health workforce

Community Empowerment

Workshops for ANMs

Formation and meetings of NCD groups at Subcentres

Training and supervision /support to ANMs/ASHAs

Reinforce PHC to enhance Access to generic medicine towards NCD.

Technical support to PHC MOs

Health Day at PHC

Meeting with ARS Members

Purchase & prioritization of medicines at PHCs

Strengthening of existing community participation platforms

Table2:InputsandactivitiesplannedunderPackageA

Inputs Activity Expectedoutcome

Source/finalise

awareness

material

Compile awarenessmaterial (pamphlets, posters, street play themesand wall-painting templates) in Kannada (local language) from allsources.Awarenessmaterial shall focuson(1) lifestylemodification forNCD,(2) need for long-term follow-up and medication for NCD, and (3)availabilityoffreegenericmedicinesforNCDatlocalPHCsObtain feedback from health workers on their utility for awarenessactivitiesatPHCandvillagelevelDisseminatematerialamonghealthworkers,ARSandVHSCs

Improved awareness among people about NCDtreatmentandprimary/secondarypreventionIncreased utilization of PHCs for treatment forNCDIncreased pressure on PHC for stocking andprovidingmedicinesforNCD

Workshops for

PHC health

workers (ANMs,

Anganwadi

workers and

Orientationtohealthworkerson:(1) lifestyle modification for NCD, (2) need for long-term follow-upandmedicationforNCD,and(3)availabilityoffreegenericmedicinesforNCDatlocalPHCs

ImprovedhealthworkerknowledgeonNCDsDiscussiononNCDsinARSandVHSCsFormationofNCDpatientgroups

20AuxiliaryNurse-midwife(ANM)isthehealthworkerinchargeofasub-centreandisatrainednurse-midwifewithalargefocusonreproductiveandchildhealthandotherdisease-controlprogrammes.Anganwadiworkersareinchargeofpre-schoolsatvillagelevel.ASHAsareacadreofcommunityhealthworkers,establishedundertheNRHMineachvillage;alocalwomanvolunteertrainedformallytoimproveaccessandutilizationofservices,presentlywithalargefocusonreproductiveandchildhealth.

ASHAs20) How to impart information about diabetes and hypertension tocommunitymembersusingtheawarenessmaterialHowtoorganizepatientsandformpatientgroupsInvolving ARS and VHSC members in improving utilization of PHCservices

Improved coverage of patients with NCD asmeasured by increased proportion of NCDpatientswithinthePHC’sdesignatedpopulation,whoseekandreceiveregulartreatmentforNCDatselectedPHCs

Formation of NCD

patientgroups

Support to theANMs in selectedPHCs toorganiseNCDpatientsandinformabouttheimportanceofregulartreatmentandtheadvantagesofgenericmedicinesNCD patient groups work with the ARS and VHCs to ensureavailabilityofgenericdrugsforNCDsatPHC.

Better awareness in the community leading toincreasedregistrationofnewpatientsDecreaseinstock-outofNCDdrugsatPHC

IEC at community

level

The health workers of the intervention PHCs will receive a foldercontaining-Informationleafletsaboutdiabetes&hypertension-InformationaboutthedesignatedNCDcheckupday- The PHC health day event held 1-3 times per year at the PHCwillalsoincludeactivitiesrelatedtoNCD,ledbyARSmembersandhealthworkers

Better awareness among community membersabouttheillnessandtreatmentIncreasedpatientregistrationatPHCSBettertreatmentadherenceDecreasedout-of-pocketexpenditure

Also the information about diabetes and hypertension will bedisplayedatprominentplacesinthePHCandlocalvillages

Meeting with ARS

members

Orientation/capacitybuildingforARSmembersabouttheirfunctionsandpossibilityofutilizinguntiedfundsforpurchasingmedicinesFacilitatetheirinteractionwithpatientgroupsandPHCstaff

Decreaseinstock-outsofNCDdrugsatPHCduetoARSinvolvementanduseofuntiedfundsBetter coordination betweenARSmembers andcommunity

PackageB:HealthserviceoptimizationOne-thirdof thePHCs in thestudy talukaswouldreceive inputs foroptimizingtheirhealthservicesso thatNCDpatientscouldberegisteredat theirPHCandperiodicfollow-upcouldbestarted.Atpresent,PHCsarenotgearedtoprovidecontinuouscareforpeoplewithNCD.Forexample,mostPHCsinTumkurdonotusepatientorfamilycards.Theuseofpatientorfamilycardsisvitaltoensurecontinuous care for people with NCD. In addition, the use of simple clinicalprotocols for diagnosis and management of diabetes and hypertension atprimaryhealthcareareavailable,butrarelyfollowed.The logic of Package B is that merely the formation of patient groups andpressure on existing community participation platforms will be inadequate toimprovetheprovisionofgoodqualityNCDcareatthePHC.Thecommunitylevelactivitieswill increase thenumberofpatients seekingcare fromPHC,whereasthere is aneed toensure that thePHC is able toprovidegoodquality care forNCDs. PHCs that receive Package B PHCs shall also receive inputs to optimizetheirexistingoutpatientconsultationarrangementstoaccommodatethespecificneedsofensuringcontinuouscare forpeoplewithNCD(sufficientconsultationtime to allow for counseling on lifestyle issues, medicines as per establishedprinciplesofrationaltreatmentandregularfollow-upthroughpatient-heldcaserecords).Theinterventionassumptionscouldbesummarizedasfollows:

(1) PHCs in Tumkur are focused on care for acute episodes of infectiousdiseases;theyrequireinputstohelpmodifytheiroutpatientcareprocessforensuringcontinuouscareforNCD

(2) Improving access to medicines for NCD at PHCs requires support toimproveservice-deliveryarrangementsatthePHC,includingasystemofregistration of patients, implementation of patient-held treatmentrecords, increased consultation time for counseling on lifestylemodificationandinvolvementofhealthworkers(especiallypharmacists).

(3) Community-levelinterventionstoimproveaccesstomedicinesshouldbeaccompaniedbyhealthservicesinterventionstoimproveavailabilityandcareforNCDinordertoimproveaccesstomedicinesforNCD.

Theproposedinterventionlogic isdepictedin figure4.Healthworkerswillnotrespond uniformly to these inputs. Moreover, several local relationships anddynamics within the PHCs are likely to affect (and be affected by) theintervention inputs. However, we hope to be able to understand whichcommunityplatforms and/orPHCs respondpositively andhow their responseaffects(ordoesnot?)theNCDcareandaccesstomedicinesforNCDatthePHC.

Figure4:InterventionlogicofPackageB

State

District

Taluk

Inputs Processes Output Outcome

Training for MO Patient Cards Increased Patient Registration

Improved care for NCDs

Rational treatment and adherence to STG

Increased access to generic medicines

Reduction of OOP

Training for Pharmacists & Lab technician

Standard Treatment Guidelines(STG)

Improved indenting and stock

Better Compliance.

Advocacy and Partnership

Improved investigation and prompt test result

Training for ANMs Follow Up and Coordinate with NCD patient group.

Increased Consultation time.

NCDDay

Drug and Lifestyle modification awareness

Rational Prescription

Reduction of waiting time

Continuous patient flow and improved access for NCD care

Increased trust and motivation for Generics

Improved availability of generic drugs

Table3:InputsandactivitiesplannedunderPackageB(PackageAisalsoincludedinthispackage.Seetable1forPackageA)

Inputs Activitypackage Expectedoutcome

Orientationtraining&workshop for PHCmedicalofficers

OrientationtoMOsintheselectedPHCson- StandardtreatmentguidelinesforNCDs- Rationalprescription- MaintainingtreatmentcardsforpatientswithNCDs

DuringthetrainingtheneedforincreasedconsultationtimeforpatientswillbestressedandtheywillbeencouragedtoincludeNCDmanagementasanagendaforcommunityhealthdaysofthePHC

- Improved awareness on treatmentprotocol

- Rational prescription & focus onlifestylemodification

-

Workshop forpharmacists

TrainingwillfocusonNeedassessmentformedicinesIndentingformedicinesRecordkeepingatPHCsRole of pharmacists in providing advice to patients on medicines, side-effectsandcounsellingonnon-drugtreatmentforNCD.PharmacistswillbeencouragedtogiveprovidetheseinputstopatientswhiledisbursingthemedicinesatPHCs

- Better medicine availability- reducedstockouts

- Improved patient awareness onmedicines&lifestylemodification

- Betterrecord-keepingsysteminPHCs

Workshop for ANMs,ASHAsandAnganwadiworkers

In addition to activitiesunderPackageA, in thesePHCs, the focuswouldbe tohelpANMsandASHAswithfollow-upofNCDpatientsintheirareaandensuringthattheyvisitthePHCregularlyforfollow-upandmedicines.

- Better patient awareness on NCDsresultinginbetterpatientflow

- Better coordination between healthworkersandcommunity

Advocacy andcoordination

Coordination and advocacy at state, district and taluka levels with differentstakeholders to ensure supply of drugs to the PHCswhich ask for these drugseitherthroughroutinesupplychainorthroughdistricthealthactionplans(asaninnovation)orthroughprocurementfromlocalfunds(ARS)

- Improvedmedicinesupply- Reducedstockouts- Improvedqualityofmedicines

Registration of NCDpatientsandfollow-upusing patient-retainedmedicalrecords

Pharmacistswillensureimplementationof:- Registrationandissueofpatient-retainedmedicalrecordstoallpatients

withDiabetesandHypertensionthatcomeforoutpatientconsultationatthePHC

- Monthly follow-up dates will be given to all patients. PHCs will beencouraged to designate a monthly NCD clinic day to ensure thatsufficientconsultationtimemaybegiven

- Pharmacistsparticipateinprovidinglifestylemodificationadviceaswellas clear and detailed instructions to all patients on how to takemedication (unlike short-term episodic medicines for infectiousdiseases)

- Increasedpatientregistration- Improved treatment compliance of

NCD patients due to patient-retainedrecords Improved utilization of PHCservicesforNCD

- ImprovedretentionofpatietnsatPHC,improvedcomplianceandfollow-up