Population Level Prevention Screening And Control Of Common

Population Level Prevention, Screening And Control Of Common NCDs Hypertension, Diabetes And Cancer(breast, Oral, Cervical) & NCD Service Delivery Ayushman Bharat-CPHC Health And Wellness Centers

Premature mortality among adults age 30 -69 years due to NCDs Cause specific mortality estimates for 2015 Other NCDs; 13% Communicable, Maternal and Nutritional; 18% Injuries; 12% Diabetes; 3% Chronic Respiratory Diseases; 9% Cancers; 13% Cardiovascula r Diseases; 32% Four common NCDs – CVDs, Cancers, Diabetes and Chronic Respiratory Diseases accounts for 57% of total mortality in 3069 age group • Country stands to lose $4. 58 trillion between 2012 - 2030 • NCDs and poverty are interlinked

Rationale for Population Based Intervention • Health Policy 2017: – Integrated approach to NCD – Health Promotion and Prevention • NCD Service delivery - Ayushman Bharat –CPHC - Health and Wellness Centers • Population Based Screening in 219 districts • Early detection can help in better management of diseases – Lesser load on tertiary care • Awareness generation on the risk factors: Identifying the population at risk – Equity and information asymmetry • Follow up and treatment adherence. • Linkages with NPCDCS, RCCs, Tertiary care institutions, SCIs and TCCCs

Workflow • Everyone above 30 years of age is to be covered (about 37%) • Sub Centre/HWC is the nodal unit • Leveraging ASHAs for population enumeration and CBAC through home visits • ANM-CBAC review, supportive supervision and home visits for motivating people for attending the screening

Workflow cont. . • Sub Centre/HWC - Weekly- ANM – BP, RBS, referral and follow up • Oral- Breast- Cervical cancer screening at PHC/CHC/DH level • Medical officers, Nurses, Technicians at PHC/CHC for supportive supervision, confirmation, drugs dispensing and follow up • Nurses and LHVs to serve as mentors and trainers and assist in case of staff shortages • Navigation services by ASHA

CPHC – NCD Software Package • Dell is technical partner and Tata Trusts is implementation partner • Tablet App for ANM and Web based module for PHC and above • Tablet for ANM, and PC /Laptop with internet connectivity at PHCs and above for MO and triage Nurse. • Has programmatic and clinical decision support – Comprehensive CDSS will be incorporated for Hypertension and Diabetes • Inbuilt support for upward/downward referral/ treatment adherence/ drugs inter alia • E Aushadhi will be integrated with the software

Comprehensive Primary Healthcare Population-based NCD Screening Program CPHC-NCD Application

CPHC-NCD Solution Apps 6 Apps which provide Continuum of Care across facilities and locations * ASHA Mobile App * ANM Tablet App * PHC MO Web Portal * CHC Portal * Administrator’s Portal * Health Officials Dashboard

ASHA and ANM Android Apps ü Multi Language Support (9 Languages) ü Offline Applications ü User Friendly UI ü Training Manuals, Audio Video Help & IEC Materials ü Easy Autoupdate of App ü 2 -step Authentication for Login ü Data Entry portal for Enrolment & CBAC ü EHR Compliance – HL-7, SNOMED CT, MDDS. First version

NCD Platform Features Scalability • Multi Clustered deployment provides High Availability • Rapid Vertical and Horizontal scaling deployment using containers • On demand scalable services based on real-time data load i. e. Metric based scaling • Application Disaster Recovery Performance • Robust incremental 2 -way sync for offline capability • Multi clustered, multi zone database for distributed load • Built in Application performance metrics • Elastic Search Stack for lighting fast look up on health ID. i. e. parallel processing Security • Policy, Identity and Roles Management • Roll based Access Control (RBAC) • Data at REST and Intransit encryption • 2 -factor authentication • Audit Trail for data update and delete Interoperability • Unique health identifier • Data interoperability through HL 7 standard • Omni channel notification to Citizen and NCD users • Services are based on REST API standard • E. H. R. 2014 Compliance

Unique Health Identifier For CPHC - Interoperability: 1) Common Health ID 2) Common Master Data (Facilities, Users, Locations) 3) E. H. R. Compliance Common HID Registry Health Program 1 Health Program 2 NCD Server Enrolment by NCD Health Provider APIs – CREATE, UPDATE, SEARCH Sync to NCD server 1. Check for mandatory fields – NAME, AGE, GENDER. AADHAAR or MOBILE NUMBER 2. Check if already enrolled, and for duplicates 3. If Aadhaar, encrypted & stored on tablet 4. If no ID proof, need photo, parent/spouse name and village 5. Temp ID generated 1. Potential duplicates flagged. ANM must manually verify and resolve possible duplicates 2. If PAN, Voter or Driver’s license, ID format validated and checked for duplicates Disambiguation of duplicates can be resolved only if online 1. If Aadhaar given, authenticated with UIDAI server. Aadhaar token stored 2. If PAN, Voter or Driver’s license, ID format validated, mobile number verified through OTP 3. If no ID-proof is given, photo, parent/spouse name and village needed to resolve duplicates. 4. Assurance level attached based on strength of ID 5. If none given, rejected 6. On success, HID returned HID sent to Individual by SMS

NCD Management – PHC, CHC, DH Portals ü Simple User Interface for effective care coordination between medical staff at PHC/CHC/DH ü Initial Assessment with sub-sections. ü Vitals; Patient History; Current Medication ü Signs & Symptoms; Physical Examination ü MO/Doctor screens aligned to GOI protocols ü ANM pre-populated data verified by Nurse ü Disease-specific screens ü Quick data entry by MO; minimum fields ü District Level admin portal ü Add - Facilities eg. PHC, SC. VIllages üUsers ANM, MLHP, ASHA, MO, Nurse, Pharmacist, Lab

Comprehensive Referral Pathway ü Referral pathway - movement of records across various levels of care. ü Follow-up instructions available for Doctors to help specify care plan. ü A Patient can moves across different statuses across different facilities ü Role-based access of health record; Workplans - GOI Protocols and guidelines Enrolmen t Screening Examinati on Refer SC/HWC Follow-up Diagnosis Treatment PHC Follow-up CHC/DH

CDSS End to end workflow ü Comprehensive Decision Support Solution by AIIMS experts. ü Comprises 2000+ rules, validated over 10 years of extensive study. ü Caters to Hypertension and Diabetes Mellitus. ü Integrated workflows patient ü Designed for low-resource settings (Internet connectivity) ü Intelligent decision support at different levels of care – PHC/CHC/DH ü Integrated Referral and Follow-up pathway for longitudinal record access ü Allows customization of rules using an admin module CDSS Integrated Patient pathway

Training • Cascade model • Training for Population Based Screening (PBS) – ASHA, ANM, Nurses and MOs – National To. Ts Done – being done by states • Training of NCD Software Application: – National To. Ts done – Training of Field level functionaries ( ANM, ASHA, MO, Staff Nurse, DEO, DDM) by states – Tata Trusts is providing training and implementation Support

Training Status ( 2018 -19) ANM/ Particular MPHW ASHA Staff Nurse MO On NCD Manage 37584 155084 10135 11024 ment On NCD 6015 Software 838 456 478 DEO/D DM/SN O/CHO Total 0 213827 3248 11035

State Wise Training on Go. I CPHC-NCD Application States Numbers Telangana 2694 Arunachal Pradesh 171 Rajasthan 1547 Manipur 146 Haryana 1181 Assam 99 Odisha 1146 Jammu & Kashmir 98 Madhya Pradesh 854 Meghalaya 82 Jharkhand 705 Uttarakhand 78 Karnataka 549 Chhattisgarh 490 Goa 74 Uttar Pradesh 363 Mizoram 25 Puducherry 300 Delhi 20 Maharashtra 269 Punjab 230 Bihar 224 Tripura 209 Nagaland, Sikkim, Daman & Diu, Dadra & Nagar Haveli, Andaman & Nicobar, Chandigarh, Lakshadweep, West Bengal 0

Go. I CPHC- NCD Software usage status Particulars State Name 19 States Odisha, Telangana, Madhya Pradesh, Haryana, Rajasthan, Punjab, Karnataka, Chhattisgarh , Uttar Pradesh, Manipur using Go. I Jharkhand, Tripura, Meghalaya, Arunachal Pradesh, Goa NCD Maharashtra, Assam, Bihar , Jammu & Kashmir software 6 States using their own software Gujarat, Andhra Pradesh, Tamil Nadu, Himachal Pradesh, Kerala, Dadra & Nagar Haveli 11 States yet to start Puducherry, Uttarakhand, Sikkim, Delhi, Daman & Diu, Dadra & Nagar Haveli, Andaman & Nicobar, Chandigarh, Lakshwadeep , Mizoram, West Bengal

Status of NCD Application Usage ( 2018 -19) States Enrollment Screening Go. I NCD Software 45. 53 lakh 23. 88 lakh Application Data Migrated from state owned NCD software 4. 31 cr 30. 41 lakh Pan India : Total 4. 77 cr 54. 29 lakh

Go. I CPHC-NCD App: Pan India Monthly status 3600000 3450000 3300000 3150000 3000000 2850000 2700000 2550000 2400000 2250000 2100000 1950000 1800000 1650000 1500000 1350000 1200000 1050000 900000 750000 600000 450000 300000 150000 0 3433912 2083715 713018 3480 326 April 33 21 14958 May June 625 298 July 583 264 6506 1134 August Sept Enrollment 70121 8653 5119 2621 1741 19226 Oct Screening Nov Dec 278507 161211 Jan 234655 Feb Mar

State wise use of GOI CPHC- NCD Application States Enrolment Screening India Orissa Telangana Madhya Pradesh Haryana Rajasthan Punjab Karnataka Chhattisgarh Uttar Pradesh Manipur Jharkhand Tripura Meghalaya Arunachal Pradesh Goa 45. 53 lakh 33. 42 lakh 7. 09 lakh 93960 78715 69769 44977 39125 32958 31724 31323 24644 15909 10401 6714 6138 23. 88 lakh 18. 74 lakh 4. 87 lakh 880 797 0 1393 2452 777 4629 5456 3589 2 324 400 2797

State wise use of GOI CPHC- NCD Application States Maharashtra Assam Bihar Nagaland Puducherry Jammu & Kashmir Uttarakhand Sikkim Delhi Daman & Diu Dadra & Nagar Haveli Andaman & Nicobar Chandigarh Lakshadweep Mizoram Enrolment 5453 5304 4314 256 200 127 26 25 19 5 1 0 0 Screening 2674 1226 435 237 190 40 13 11 11 0 0 0

Status - States Using their own software Application States Enrolment Screening Gujarat Andhra Pradesh Telangana* Tamil Nadu Himachal Pradesh Uttar Pradesh 3. 76 cr 22. 01 lakh 15. 93 lakh 7. 71 lakh 3. 98 lakh 2. 49 lakh 0 13 15. 73 lakh 7. 79 lakh 3. 98 lakh 66 Kerala 3. 02 lakh 6887 * Telangana was using its own application in 7 districts and data from these districts was migrated.

Tablet & Login Status in Go. I CPHC- NCD Application • 9854 ANM and 505 MO have Logged in past 30 days -- 103855 Tablets are available States Orissa Telangana Madhya Pradesh Punjab Chhattisgarh Karnataka Tripura Jharkhand Haryana Maharashtra Arunachal Pradesh Meghalaya Manipur Bihar Goa Assam Uttar Pradesh Jammu & Kashmir Rajasthan Tablets in Hand ANM Log In MO Log In 6688 8000 6973 3272 273 1500 70 6000 2735 171 50 50 220 144 14 16 28934 200 0 3602 3129 1739 546 98 251 82 33 49 43 39 39 54 126 13 5 84 3 0 23 135 0 0 11 13 0 0 0 4 0 6 3 0 2 2 3 0 303

Tablet & Login Status in Go. I CPHC- NCD Application • 9853 ANM and 505 MO have Logged in past 30 days -- 103855 Tablets are available States Nagaland Puducherry Uttarakhand Sikkim Delhi Daman & Diu Dadra Nagar Haveli Andaman and Nicobar Chandigarh Mizoram West Bengal Gujarat Andhra Pradesh Tamil Nadu Himachal Pradesh Kerala Lakshadweep Tablets in Hand ANM Log In MO Log In 20 9 0 0 0 80 147 0 71 10 0 14162 12298 148 2000 9600 0 1 0 0 0 0 0 0 0 0 0

Way Forward • Training for Software and Population Based Screening – Monitoring of schedule and ensure quality • Upward referral and downward follow up linkage • Arrangement of supplies – IEC, forms, equipment, diagnostics, drugs • Availability of medicines – Necessary drugs in EDL of the States – 3 months supply • Monitoring mechanism

Way Forward • Tablet Procurement to be completed soon • IT infrastructure to be made ready (Desktop/Laptop, Internet facilities) in PHC, CHC and District hospitals – PC for MO and Nurse • All the functional HWC to use NCD Application • Medical Officers to start using NCD application so as to bring focus on care continuum

Way Forward • Monitoring of the programme through State and district NCD cells • NCD Division has to take lead • May require coordination with different divisions such as the one dealing with ASHAs. • Action Plan for field training • Cervical cancer screening on field – Action plan • Monitoring of quality of interventions

Thank You