Community-based diabetes and hypertension prevention and care in Kaski district of Nepal

Objectives

To scale up a proof-of-concept community-based NCD prevention and care model in rural areas of Kaski district.

Approach

The proposed project is an expansion of a community-based NCD prevention and care model previously tested in semi-urban areas. The model mobilises Female Community Health Volunteers (FCHV) for the screening and management of diabetes and has demonstrated effectiveness in lowering blood glucose and blood pressure levels. Based on evidence from the first phase, the Ministry of Health and Population (MoHP) has replicated this model in two provinces. The project aims to test the model in rural areas to inform further expansion.

Main activities - Strengthening the capacity of Female Community Health Volunteers (FCHV) for the prevention and care of diabetes and hypertension.

• Strengthening the care cascade by training health post staff, improving treatment protocols and workflows, and upgrading four health posts to referral clinics with the capacity to manage minor complications.

• Strengthening the health information system by integrating community and health post NCD patient registries into National Health Management Information System (NHMIS) reporting flows, and strengthening capacity for data collection, storage, processing, and supply forecasting at all levels.

• Delivering community-based diabetes and NCD services through FCHV, including household-level risk factor assessment, screening, health education, and regular follow-ups.

• Increasing community awareness through home visits and community events, including World Diabetes Day celebrations.

Expected results

• 360 FCHV trained to provide diabetes and hypertension screening and management, health promotion, and outreach, covering approximately 80,000 people.
• 90 health staff (health assistants, auxiliary health workers, community health assistants), representing 40 health posts, trained in diagnosis and management of NCDs (PEN package), covering the entire target area.
• At least 25,000 people screened, with an estimated 2,000 people diagnosed and enrolled in comprehensive care.
• Approximately 9,000 high-risk people counselled on healthy lifestyles.
• 30,800 people with improved awareness of diabetes, NCDs, and healthy lifestyles.
• Improved performance and clinical impact indicators, including blood glucose and blood pressure control, and changes in BMI and behaviours.