Objectives
To operationalise a state-wide, comprehensive diabetes and hypertension management programme at primary care level, through enhanced public primary service delivery, incl. COVID-19 preparedness, strengthened health system and empowered communities.

Approach
The project will leverage public primary care, for example strengthening mobile medical units (MMUs) and primary level clinics to address non-communicable diseases (NCDs) during and after the COVID-19 epidemic.  

The project builds on platforms created during WDF15-956 and WDF11-654, i.e. telemedicine system, electronic medical records and peer educators.  

Project activities include strengthening of service delivery through three tracks:

Advocacy and knowledge generation:

-   Biannual health facility assessments conducted jointly with National Health Mission (NHM) to facilitate operationalisation of  NCD service delivery aligned with national primary health care reform (Ayushman Bharat); action plan to address gaps co-created with NHM.

-   Provision of technical support to district and state level health authorities to streamline supply chain processes, incl. biannual assessments of indenting, procurement and distribution of drugs and consumables related to NCDs. Findings to be shared with authorities and action plan for improvements to be agreed and jointly rolled out.
-   Substantial M&E component to be rolled out, incl. HR structure (district programme coordinators) to facilitate implementation embedded within the public system. Facilitation of knowledge & best-practices exchange by convening annual diabetes conference in North Eastern India. Health system strengthening

-   Capacity building of primary level  health care professionals (HCPs) on prevention and care of NCDs and COVID-19. Refinement of training modules in consultation with NHM; modules to be tailored for each level of HCPs (CHW (community health worker), nurse, doctor). Trainings to be convened using Training of Trainers (ToT) approach. 

-    Quality of care to be strengthened through a) creating managerial capacity of HCP supervisors (part of public health care set-up) to provide supportive supervision to trained HCPs, b) provision of quarterly continuing medical education (CME) and technical training to HCPs on NCD guidelines and COVID-19. Telemedicine platform to be used for mentoring sessions, c) provision of mentoring support to CHWs through existing government health helpline (call centre).  

-    Leveraging of telemedicine and electronic health record system; IT infrastructure to be upgraded and operational; staff at MMUs and primary level clinics to be trained to operate the system. Telemedicine hub to be established and linked to provide distance consultations. 

-    Roll out of comprehensive NCD programme across primary level clinics and MMUs. Programme to be based on continuum of care concept; prevention, screening and diagnosis to be provided at point of care; referral gaps and loss to follow-up to be mitigated by deployment of telemedicine consultations. 

-    Piloting of innovative point of care technology, incl. HbA1c testing and artificial intelligence (AI) based equipment for screening of complications at selected MMUs to assess feasibility. Results to be presented to NHM for potential scale-up.
Community engagement:

-    Operationalisation and activation of community health committees (Jan Arogya Samitis) in relation to selected primary level clinics as envisaged under the Ayushman Bharat. Committees to ensure community ownership, health promotion action and accountability of service providers. Situational analysis and action plan to be co-created with NHM. Peer educators from previous projects to be empowered to form peer support groups for diabetes patients. Groups to address DM self-management, psychosocial support and COVID-19 prevention.

Expected results

• NCD service delivery strengthened across Assam state (all 33 districts)
• 1,139 primary level doctors trained as Master trainers (ToT) within NCD care and COVID-19 management; 9,900 CHWs trained through cascade training
• 78 MMUs equipped with upgraded telemedicine technology and electronic medical records
• 536 primary level clinics linked with telemedicine services and 400 HCPs trained to operate the system
• One telemedicine hub established and operational, and 72,000 telemedicine consultations provided
• 240,000 people screened for risk factors; 4,800 diagnosed with diabetes and 9,600 diagnosed with hypertension, and treatment provided.
• Two pilot studies implemented at 4 MMUs each
• Selected MMUs strengthened with HbA1c analysers and point-of-care and AI based equipment screening for complications; 11,250 high risk persons received HbA1c test; 3,750 patients screened for complications (eye and foot). 
• 70 model community health committees made functional; 70 peer educators trained and peer support group established