In Assam, a roadmap to improved diabetes care

This World Diabetes Day, WDF highlights one Indian state’s decade-long effort to improve diabetes care – and its lessons for others working to do the same.

14 November 2022 Gwendolyn Carleton

In Nalbari, monthly visits by a Mobile Medical Unit (the jeep in the background) have transformed diabetes prevention and care for thousands of residents.

Today is World Diabetes Day, a moment to take stock of the impact of diabetes on individuals and communities worldwide - and imagine a better future. 

Millions of people with diabetes around the world lack access to the knowledge, care, medicine and support they need to manage their condition and avoid complications. Healthcare systems worldwide, already strained by COVID-19 and other acute, overlapping health challenges, are under pressure to change this. 

But how? There’s no one-size-fits all solution. Yet after 20 years of diabetes partnerships in low- and middle-income countries, WDF has found that with commitment, adequate financing and a focus on integrated care, sustainable change is possible.

A series of WDF-supported projects in Assam, India, provide an excellent example.

Building on success

In 2010, the Piramal Swasthya Management and Research Institute (PSMRI) in Assam approached WDF. They proposed training more than 10,000 health workers to do diabetes risk assessments in villages. Clinics would be strengthened, and Mobile Medical Units (MMUs) would be launched to help residents in need of care.

“Long-term sustainability is expected,” a WDF assessment noted at the time, citing the project’s wide referral network and government support.   

The project, Comprehensive type 2 diabetes care, did indeed prove sustainable – and effective. It brought care to more than 30,000 people with diabetes, trained more than 15,000 health workers and paramedics and raised diabetes awareness in a population of 6.5 million. 

A first-generation MMU visiting a rural clinic in 2013.

The first project was followed by Comprehensive diabetes management in Assam. Embedded within the state-wide village health outreach programme, this project added new elements to the model such as primary prevention activities for at-risk people and school children and expanded basic diabetes screening, referral and care for other rural areas.

Now a third project, Strengthening NCD services in Assam, is building on the achievements of the first two. A partnership with PSMRI and the National Health Mission in Assam, the project is working to enhance NCD services at the primary care level throughout the state – population 32 million. Since 2021, PSMRI has been a partner of Anamaya, the Tribal Health Collaborative. This project has an increased focus on Assam’s most vulnerable residents, reflecting Anamaya’s focus on ending preventable deaths among tribal and marginalised communities of India. 

Mobile units with cutting-edge solutions 

The project is rolling out a state-wide, comprehensive diabetes and hypertension management programme at the primary care level. MMUs – so effective in the earlier projects – play an important role. The MMU Programme, called Sanjeevani (immortality in Hindi), deploys 80 nurse-led MMUs to nearly 3,500 hard-to-reach villages on a fixed day each month. 

Training is key. More than 1,000 primary level doctors will become Master Trainers, ultimately reaching 9,900 community health workers through cascade training, by the project’s end in 2023. 

So is technology. The project is equipping the MMUs with upgraded telemedicine technology and electronic medical records, allowing nurses to link up with doctors in the capital who can then diagnose patients and prescribe treatment. Selected MMUs are even piloting new cutting-edge solutions.

For example, they are screening patients for complications such as diabetic retinopathy and diabetic foot with portable devices linked to artificial intelligence solutions - providing the results on the spot. This means that referral and care can be initiated right away, reducing the time and cost involved for patients, as well as loss to follow-up. 

“Training is in focus because this ensures that the frontline health workers have the necessary skills to provide care,” explains Mette Skar, WDF Programme Manager.  “Digital health solutions allow trained healthcare providers to bring more advanced services to underserved areas.” 

Healthcare workers trained by the ‘Strengthening NCD services in Assam’ project with WDF’s Mette Skar (centre) and Kirza Kristensen in 2022.

‘Wonderful and brilliant

During a visit to Assam in September, Ms Skar met with health workers associated with the project, and residents benefitting from it. One of them was an auxiliary nurse midwife named Bhanita Kalita.

Ms Kalita explained that she is one of the nurses who drives to rural areas in the MMUs to screen patients for seven chronic conditions, including diabetes and hypertension. Those with risk factors are sent to the closest healthcare facilities for confirmation and care, including free medication through the flagship government scheme Ayushman Bharat, she said.

Delivery of care is occasionally hampered by a lack of medicines and impassable roads in rural areas. “But as health workers, we do our best to get through these obstacles and reach the unreached,” she said. 

“Trainings given by subject matter experts increased my knowledge,” she added. “Sanjeevani has given me a new identity as a committed healthcare professional.”
A retired teacher named Kiran Devi told Ms Skar what the monthly visit by the MMU, or ‘camp’, means to her.

“I visit the camp in Nalbari every month to check my blood pressure, blood sugar, and for other minor health related issues,” she said. “The service that they are providing is very helpful for the rural people as we are getting treatment at our doorstep free of cost. The paramedical staff are very polite and provide guidance in case of referral. And sometimes we connect with doctors through video consultation if required.”

Calling the diabetes neuropathy and retinopathy services provided by the MMU “wonderful and brilliant,” she said: “I am very happy with the services that Sanjeevani is providing - without them we would have to travel to take advantage of government health facilities.”

A patient receiving an eye exam, one of the ‘wonderful and brilliant’ services now provided to rural patients, in 2022.

Leif Fenger Jensen, Managing Director of the World Diabetes Foundation, says that the project’s long-term track record of collaboration with the authorities in Assam is especially noteworthy.

“Piramal is responsible for rolling out state-wide diabetes and NCD services,” he said. “By adding capacity building, supportive supervision, managerial capacity and digital solutions to existing programmes, our long-term partnership with Piramal is catalysing change. It’s demonstrating how sustainable models can work even in the most vulnerable settings.”

The International Diabetes Federation’s theme for World Diabetes Day 2021-23 is Access to Diabetes Care. Learn more on the IDF website

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