Revised Operational Guidelines of NP-NCD (2023-2030) PDF

OPERATIONAL GUIDELINES NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES (2023-2030) Ministry of Health & Family Welfare Government of India 2023...

OPERATIONAL GUIDELINES NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES (2023-2030) Ministry of Health & Family Welfare Government of India 2023 1 2 i ii iii iv v vi vii viii ix x  TABLE OF CONTENTS Abbreviations xiii Executive summary xix Chapter 1: Introduction 1 Chapter 2: Non Communicable Diseases – An overview 7 Chapter 3: Organizational structure of NP-NCD 11 Chapter 4: Operational strategies 14 Chapter 5: Human resources 26 Chapter 6: Communication strategies 40 Chapter 7: Training and capacity building 48 Chapter 8: Monitoring, supervision and evaluation 51 Chapter 9: Finances 57 Chapter 10: Linkages with other programmes 60 References 58 List of experts and contributors 62 Annexures 66 xi xii  ABBREVIATIONS AB-HWC Ayushman Bharat Health and Wellness Centre ABHA ID Ayushman Bharat Health Account Identification Card AERB Atomic Energy Regulatory Board AIIMS All India Institute of Medical Sciences AMRIT Affordable Medicines and Reliable Implants for Treatment ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activists AWW Anganwadi workers AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy BCC Behaviour change communication BMI Body Mass Index BP Blood pressure BPHC Block primary health centre BPPI Bureau of Pharma PSUs of India CAPD Continuous ambulatory peritoneal dialysis CBAC Community based assessment checklist CCU Cardiac care unit CDSS Clinical decision support system CHC Community health centres CKD Chronic kidney diseases CHO Community Health Officer CMO Chief Medical Officer CMHO Chief Medical Health Officer COPD Chronic obstructive pulmonary diseases CoE Centre of excellence Covid Coronavirus disease CPHC Comprehensive primary healthcare package CRM Common review mission CSCU Cardiac and Stroke Care Unit CT Computed tomography CTA CT angiography CTD Cumulative trauma disorder CVD Cardiovascular disease DALY Disability adjusted life years DEIC District early intervention center DEO Data entry operator DH District hospital xiii DHS District health society DMU District management unit DMHP District mental health program DNB Diplomate of National Board DPI Directorate of Public Instruction DPM District program manager Dte.GHS Directorate General of Health Services DVDMS Drugs and Vaccine Distribution Management System ECG Electrocardiogram ECHO Echocardiogram EHR Electronic health record ENT Ear nose throat EPC Empowered programme committee ESRD End-stage renal disease EV Electric vehicles FCTC Framework Convention on Tobacco Control F/PP Fasting/postprandial glucose FPC Family physician concept FMG Financial management group FMR Financial management report FoPL Front-of-package Warning Labelling FSSAI Food Safety and Standards Authority of India FSS Food Safety and Standards Act GATS Global Adult Tobacco Survey GDMO General duty medical officer GDP Gross domestic product GFR Glomerular filtration rate GNM General nursing and midwifery HBV Hepatitis vaccination HCV Hepatitis C virus HIV Human immunodeficiency virus HPS Health promoting schools HR Human resources HFSS High in fat, salt and sugar HMIS Health management information systems HWC Health and wellness centres ICMR Indian Council of Medical Research ICU Intensive care unit IDA Indian dental association IEC Information education and communication IHCI India hypertension control initiative IMA Indian medical association IMC Inter-ministerial committee xiv  Integrated Tracking Referral Electronic Decision Support and Care Coordina- I-TREC tion IT Information technology JAS Jan Arogya Samiti KFT Kidney function test LABA Laser-assisted balloon angioplasty LFT Liver function test LMIC Low- and middle-income countries MAS Mahila Arogya Samiti MHCA Mental healthcare act MLHP Mid-level health provider MO Medical Officer MO I/c Medical Officer in-charge MPW Multi-purpose worker MRA Magnetic resonance angiography MRI Magnetic resonance imaging NAFLD Non-alcoholic fatty liver diseases NAM National AYUSH Mission NCCT Non-contrast computed tomography scan NCD Non Communicable Diseases NGO Non-Government Organization NIMHANS National Institute of Mental Health and Neuro-Sciences National Programme for Prevention and Control of Cancer, Diabetes, Cardio- NPCDCS vascular Diseases and Stroke NPCB&VI National Programme for Control of Blindness and Visual Impairment NFHS National Family Health Survey NHM National Health Mission NLEM National List of Essential Medicines NMAP National Multi-sectoral Action Plan NMHP National Mental Health Programme NPCC National Program Coordination Committee NPHCE National Programme for Health Care of Elderly NTCP National Tobacco Control Programme NUHM National Urban Health Mission NVBDCP National Vector Borne Disease Control Programme OHA Oral hypoglycaemic agent OOPE Out-of-pocket expenditure OPD Out-patient department OVE Oral visual examination PAD Peripheral artery disease PBS Population-based screening PFT Pulmonary function test PG Postgraduate xv PHC Primary health centres PIP Programme implementation plan PPP Public Private Partnership PMBJP Pradhan Mantri Bhartiya Janaushadhi Pariyojana PMJAY Pradhan Mantri Jan Arogya Yojana PMNDP Pradhan Mantri National Dialysis Program PMSSY Pradhan Mantri Swasthya Suraksha Yojana RBSK Rashtriya Bal Swasthya Karyakram RCH Reproductive child health RF Rheumatic fever RFT Renal function test RHD Rheumatic heart disease RUCO Repurpose of used cooking oil RWA Residential Welfare Association NTEP National Tuberculosis Elimination Programme SAG Self-help affinity group SCI State Cancer Institute SCTIMST Sree Chitra Tirunal Institute for Medical Sciences and Technology SDG Sustainable Development Goals SDH Sub-district hospital SHC Sub-health centre SHG Self-help group SHSRC State Health Systems Resource Centre SIRAS Stroke Identification Rehabilitation Awareness and Stabilisation Program SNO State Nodal Officer SNP Supplementary Nutrition Program SOP Standard operating procedures SPO State Program Officer STEMI St elevated myocardial infarction SWAAS Step wise approach to airway syndromes programme in family health centers TB Tuberculosis TCCC Tertiary care cancer centers TeleMANAS Tele Mental Health Assistance and Networking Across States UCHC Urban Community Health Centres UHC Universal Health Coverage ULB Urban local bodies UPHC Urban primary health centre UT Union territories VHND Village health and nutrition days VHSNC Village Health, Sanitation and Nutrition Committee VIA Visual inspection using acetic acid WHO World Health Organization WHR Waist-to-hip ratio xvi xvii xviii  EXECUTIVE SUMMARY i. Health systems in India are evolving in alignment with shifting health needs and disease burden with expanded emphasis on Non Communicable Diseases. Realizing the role of prevention and control of NCDs in improving the overall health outcomes and addressing the three pillars of Sustainable Development Goals (SDGs) i.e., economic growth, social equity and environmental protection, it was identified as a prerequisite to accelerate sustainable development. The 2030 Agenda for Sustainable Development adopted by the United Nations in 2015 recognized NCDs as a major public health challenge and included SDG target 3.4 to reduce premature mortality from NCDs by one‐third. ii. The National Health Policy (NHP), 2017 recognizes the pivotal importance of SDGs and highlighted the need to halt and reverse the growing incidence of chronic diseases including NCDs. The NHP 2017 defined this objective as “Improve health status through concerted policy action in all sectors and expand preventive, promotive, curative, palliative and rehabilitative services provided through the public health sector with focus on quality.” Addressing the growing burden of NCDs and carving the route towards progressive attainment of Universal Health Coverage (UHC), the policy outlined indicative, quantitative goals and objectives for reducing prevalence and incidence for NCDs, aligned to achieve SDGs in keeping with the policy thrust. iii. The National Programme for Prevention and Control of Non Communicable Diseases (NP-NCD) erstwhile National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) was launched in 2010 in 100 districts across 21 states with an objective to prevent and control major NCDs. The programme was scaled up in a phased manner and now covers all the districts across the country. The focus of NPCDCS was to enable opportunistic screening for common NCDs at District Hospital and Community Health Centres level, through the setting up of NCD clinics. iv. In order to expand the services and bring them closer to the community, Population Based Screening (PBS) for common NCDs was launched in year 2016. The PBS includes screening of individuals of 30 years and above age group for five common NCDs i.e., Hypertension, Diabetes, Cancers of the oral cavity, cervix and breast. The key components of this initiative include population enumeration, assessment of risk factors, mobilizing communities for screening at Sub- Centres (SC), Primary Health Centres (PHC) in rural and urban areas, health promotion, initiation of treatment at a PHC, referral to higher centres for further treatment, if required. Both upward and downward referral, follow up is provided under the programme to ensure continuum of care. v. Comprehensive Primary Health Care (CPHC) has an important role in the primary and secondary prevention of several disease conditions, including NCDs which today contribute to 63% of the mortality in India. The provision of primary health care reduces morbidity, disability and mortality at much lower costs and significantly reduces the need for secondary and tertiary care. vi. As a step towards ensuring provision of promotive, preventive, curative, palliative and rehabilitative aspects of Universal Healthcare, Government of India launched its flagship programme of Ayushman Bharat in 2018. Ayushman Bharat has two components to ensure Universal Health Coverage (UHC) viz Ayushman Bharat – Health and Wellness Centre and Ayushman Bharat – Pradhan Mantri Jan Aarogya Yojana (PM-JAY). This ensures Comprehensive Primary Health xix  Care at the primary level and provision of financial protection for accessing curative care at the secondary and tertiary levels through engagement with both public and private sector. vii. In order to ensure primary health care which is close to the community, health facilities in urban and rural areas are being strengthened. At the SHC-HWC level, a new cadre of Community Health Officer (CHO) has been introduced to lead the HWC team and provide expanded range of twelve services. The Medical officer of the Primary Health Centre (rural and urban) would supervise the functioning of the HWC. viii. Focussing on the technology and IT based solution in healthcare, Ayushman Bharat Digital Mission (ABDM) was launched with an aim to strengthen the accessibility and equity of health services, including continuum of care with citizen as the owner of data. The initiative provides a platform for all existing and upcoming IT applications to function in an integrated approach, maintaining the interoperability. Ayushman Bharat Health Account (ABHA) is an unique identifier (self-declared username) that enables to share and access health records digitally. It serves as a common linkage between healthcare programmes. ix. Realizing the growing burden of NCDs, associated morbidities and mortalities, Government of India has identified other priority NCD conditions beyond common NCDs and widened the ambit of the programme by including Chronic Obstructive Pulmonary Disease (COPD) and Asthma, Chronic Kidney Disease (CKD), Non-Alcoholic Fatty Liver Disease (NAFLD), Pradhan Mantri National Dialysis Programme (PMNDP). Hence, the NPCDCS is now renamed as NP-NCD. x. All the guidelines were shared with States/UTs for implementation by programme managers and other healthcare providers to strengthen health care services for the NCDs across all levels of care, and also to enable a continuum of care approach. The Additional Chief Secretary/Principal Secretary (Health), Mission Director (NHM), Director of Health Services of the States/UTs have to ensure proper implementation of the guidelines across India. xx xxi xxii  CHAPTER I INTRODUCTION Non Communicable Diseases: Non Communicable Diseases (NCDs) are chronic diseases that are not transmissible from one person to another. Taking this definition into account, NCDs may thus include wide spectrum of medical disorders both acute and chronic like Cancers, Diabetes, Hypertension, Cardiovascular Diseases and Stroke, Chronic Kidney Diseases (CKDs), Chronic Obstructive Pulmonary Diseases (COPDs) and Asthma, Non- Alcoholic Fatty Liver Disease (NAFLD), and a gamut of other diseases. As per WHO, the NCDs are collectively responsible for more than 74 percent of all deaths worldwide including heart disease, stroke, cancer, chronic respiratory diseases and diabetes.1 These diseases have public health importance globally and in India. NCDs cause significant morbidity and mortality, both in urban and rural population and across all socio-economic strata, with considerable loss in potentially productive years of life. NCDs are also responsible for the maximum out-of-pocket expenditure on health.2 The economic output lost due to NCDs excluding mental conditions is estimated to be $ 3.55 trillion for India for the period of 2012-2030.3 Taking cognizance of these facts, Sustainable Development Goal 3 (Target 3.4) aims to reduce premature mortality from NCDs by one-third by 2030 in the world. SDG-3 also stresses on prevention and control of tobacco and alcohol use.4,5 The National Health Policy, 2017 also emphasises the need to halt and reverse the incidence of NCDs and seeks to focus on common NCDs.6 NCDs are emerging as a major public health challenge worldwide and people above the age of 30 years are most at risk of getting such diseases. India is also experiencing rapid demographic and epidemiological transitions with a steep rise in the burden of lifestyle related chronic NCDs. With rapid epidemiological transition with higher Disability-Adjusted Life Years (DALYs) and mortalities, prevention and control measures for NCDs are required to be accelerated to reduce the burden of NCDs in India. Burden of Non Communicable Diseases Global Scenario: The global NCD burden remains unacceptably high. NCDs are responsible for 41 million of the world’s annual deaths. 17 million of these deaths were premature (30 to 70 years). Burden is greatest within low- and middle-income countries, where 77 percent of all NCD deaths and 80% of premature deaths occurred.1 Among NCDs, the four top killers that together account for more than 80% of all premature NCD deaths annually include cardiovascular diseases (17·9 million), cancers (9.3 million), chronic respiratory diseases (4.1 million), and diabetes (2.0 million).1 Indian Scenario: As per the WHO – NCD India profile - 2018, NCDs are estimated to account for 63% of all deaths in country of which the cardiovascular diseases lead with 27% overall mortality cause followed by chronic respiratory diseases (11%), cancers (9%), diabetes (3%) and others (13%) (Figure 1).7 1 Figure 1: Global Burden of Non Communicable Diseases1 As per India State-Level Disease Burden Initiative CVD Collaborators - 2016, there were 54.5 million cases of cardiovascular diseases, 23.8 million cases of ischemic heart diseases, 6.5 million cases of stroke, 55 million cases of COPD, 38 million cases of asthma and 65 million cases of diabetes.8 In 2016, cardiovascular diseases were responsible for 28.1 percent deaths, while chronic respiratory diseases contributed to 10.9 percent deaths and cancers contributed to 8.3 percent deaths.7 Four common NCDs (Cardiovascular Diseases, Cancers, Chronic Respiratory Diseases and Diabetes) account for 23 percent of the total premature mortality in 30-70 years age group.1 Figure 2: Burden of Non Communicable Diseases in India7 As per the report of National Cancer Registry Program (2020), the incidence of cancer in India is 13.92 lakhs. Among males, cancers of lung, mouth, oesophagus and stomach are the leading sites across most of the registries. Among females, breast cancer is the commonest cancer followed by cervical cancer.9 2 Risk factors: Most NCDs are strongly associated with major risk factors such as: 1. Tobacco use (smoking and smokeless) 2. Alcohol use 3. Unhealthy diets 4. Insufficient physical activity 5. Air pollution (indoor and outdoor) If the above risk factors are not managed/modified, they may lead to the following biological risk factors: 1. Overweight/obesity 2. Raised blood pressure 3. Raised blood sugar 4. Raised total cholesterol/lipids The other factors due to which an individual might develop NCDs are: 1. Stress 2. Hereditary factors Figure 3: Behavioural and physiological risk factors associated with NCDs and the disease outcome As per National NCD Monitoring Survey (NNMS), 2017-18, the prevalence of risk factors associated with NCDs amongst adults (18-69 years) such as current tobacco use, current alcohol use, inadequate intake of fruits and/or vegetables intake and insufficient physical activity are 32.8%, 15.9%, 98.4% and 41.3% respectively in India.10 However, as per the report of the 2nd round of the Global Adult Tobacco Survey (GATS-2) conducted in 2016-2017 among 15 years and above, there are 266.8 million tobacco users in India, i.e., around 28.6 percent of all adults use tobacco in any form (smoking or smokeless).11 Evolution of National Programme for Prevention and Control of Non Communicable Diseases: Government of India launched NP-NCD erstwhile NPCDCS in 100 districts of 21 states to combat NCDs in 2010 as per the 11th Five Year Plan. The rationale was to provide technical, financial and logistics support to the State Governments, and thereby supplement the efforts of the States towards the prevention 3 and control of NCDs. The programme focuses on health promotion, screening, early diagnosis and management of individuals with NCDs along with addressing their risk factors. During the 12th Five Year Plan, it was proposed to scale up the programme in a phased manner and cover all districts of the country. In 2013-2014, the programme was subsumed under the National Health Mission (NHM) for optimization of resources and provide seamless services to the patients, and for ensuring long term sustainability of the programme interventions. Thus, the institutionalization of the programme at state level and district level within the State Health Society (SHS) and District Health Society (DHS) respectively, sharing administrative and financial structure of NHM becomes a crucial programme strategy. NCD Division was established at National, State, and District level to ensure planning, implementation, monitoring and evaluation of the programme activities. Health facilities were strengthened at different levels for NCD service delivery. The NCD clinics are identified at the district (District Hospital) and Block (Community Health Centre) levels for opportunistic screening, diagnosis and management of common NCDs. Further, Cardiac Care Units and Day Care Centres were set up in selected District Hospitals to provide emergency cardiac care and cancer chemotherapy respectively. The Population-Based Screening (PBS) of common NCDs as a part of Comprehensive Primary health Care (CPHC) was initiated in 2016, in selected districts across States/UTs, and was scaled up in a phased manner under the programme, and this intervention was scaled-up to cover more district in later stage in a phased manner. With the integration of the programme with Ayushman Bharat - Health and Wellness Centres, universal screening of common NCDs was identified as a functionality criterion for primary level facilities to be upgraded as HWCs. The key component of the initiative spanning community level risk assessment using Community Based Assessment Checklist (CBAC), followed by facility level screening activities and follow up activities towards continuum of care approach were included as an essential service under the Sub Health Centres-Health and Wellness Centres (SHC-HWC) and PHC-HWC and health promotion, management and referral services were strengthened. There are several newer initiatives that have been included under the programme. From 2016 onwards, the National Multisectoral Action Plan (NMAP) is introduced to offer roadmap and policy options to guide multisectoral efforts involving other Ministries/Departments.12 There are several other disease interventions such as Chronic Obstructive Pulmonary Diseases (COPD) and Asthma, Chronic Kidney Diseases (CKD), Stroke, Non-Alcoholic Fatty Liver Disease (NAFLD) and ST- Elevated Myocardial Infarction (STEMI), which were included in phased manner under the programme. Further, the name of the programme is changed from NPCDCS to National Programme for Prevention and Control of Non Communicable Diseases (NP-NCD). Objectives of National Programme for Prevention and Control of NCDs: The objectives of NP-NCD are as follows: 1. Health promotion through behaviour change with involvement of community, civil society, community-based organizations, media and development partners. 2. Screening, early diagnosis, management, referral and follow-up at each level of healthcare delivery to ensure continuum of care. 4 3. Build capacity of health care providers at various levels for prevention, early diagnosis, treatment, follow-up, rehabilitation, IEC/BCC, monitoring and evaluation, and research. 4. Strengthen supply chain management for drugs, equipment and logistics for diagnosis and management at all health care levels. 5. Monitoring, supervision and evaluation of programme through proper implementation of uniform ICT application across India. 6. To coordinate and collaborate with other programmes, departments/ministries, civil societies. Strategies of NP-NCD: Following are the strategies of the programme: Health promotion for prevention of NCDs and reduction of risk factors. Screening, early diagnosis, management, referral and follow up of common NCDs. Capacity building of health care providers. Evidence based standard treatment protocols. Uninterrupted drug and logistics supply. Task sharing and people-centered care. Information system for data entry, longitudinal patient records. Monitoring, supervision, evaluation and surveillance including technology enabled interventions. Multi-sectoral coordination and linkages with other National Programmes. Implementation research and generation of evidences. Some of the other health programmes related to NCDs where linkages with NP-NCDs is required5: National Mental Health Programme (NMHP) National Programme for Control of Blindness and Visual Impairment (NPCB&VI) National Programme for Prevention and Control of Deafness (NPPCD) National Programme for Prevention and Control of Fluorosis (NPPCF) National Programme for Health Care of the Elderly (NPHCE) National Programme for Tobacco Control and Drug Addiction Treatment (NPTCDAT) National Oral Health Programme (NOHP) National Programme for Prevention and Management of Trauma and Burn Injuries (NPPMTBI) National Organ Transplant Program (NOTP) National Programme for Palliative care (NPPC) National Iodine Deficiency Disorders Control Programme (NIDDCP) This operational guideline for NP-NCD has been developed for policy makers of different levels, the Government officials, NGOs, peripheral health care providers and also other stakeholders with the purpose of providing an understanding of the promotive, preventive and curative approach to reduce morbidity and mortality due to NCDs. The document provides guidance to the programme managers for effective implementation of NCD strategies with purpose of significant improvement of various NCD indicators in the next seven years by 2030. However, the individual States/UTs can prepare the strategic plan according to the NCD situations and socio-demographic profile to achieve state-specific targets. 5 6  CHAPTER 2 NON COMMUNICABLE DISEASES – AN OVERVIEW The common NCDs - Cardiovascular Diseases (CVDs), Cancers, Diabetes and Chronic Respiratory Diseases, share common modifiable behavioural risk factors such as tobacco use, unhealthy diet, lack of physical activity and alcohol consumption. Air pollution is also considered as one of the major risk factors for NCDs. These risk factors lead to overweight and obesity, raised blood pressure, raised blood sugar, and raised cholesterol, which in turn can contribute to occurrence of NCDs. A large proportion of NCDs are preventable. Hypertension: Blood pressure is the force exerted by circulating blood against the walls of the arteries of body. Hypertension is abnormally elevated blood pressure. It is a pathological condition in which there is increased workload on cardiovascular system. Blood pressure is measured as systolic and diastolic blood pressure. It is of two types such as a) Primary or Essential Hypertension and b) Secondary Hypertension. Hypertension is diagnosed when the measured systolic blood pressure is ≥140 mmHg and/or diastolic blood pressure is ≥90 mmHg on two different occasions. Hypertension is a major cause of premature death worldwide. An estimated 1.28 billion adults aged 30–79 years have hypertension. Globally, prevalence of hypertension among adult aged 30-79 years is around 33%.13 Most often hypertension is asymptomatic, however, when blood pressure is very high it may manifest with headache, nasal bleeding, irregular heart rhythms, vision changes, fatigue, nausea etc. Hypertension is managed with drugs and maintaining healthy lifestyle. Reducing salt intake is one of the key interventions in management of hypertension. Hypertension if not controlled for a long time may result into heart attack, stroke, renal failure, retinal damage and other life-threatening conditions. Diabetes: Diabetes is a chronic disease in which the body does not produce or properly use the hormone insulin, which is required to convert sugar, starches and other foods into energy. It is classified into three types namely Type I diabetes, Type II diabetes and Gestational Diabetes. Type 1 Diabetes Mellitus (T1DM) results from the pancreas failure to produce enough insulin. This form was previously referred to as “Insulin-Dependent Diabetes Mellitus” (IDDM) or “Juvenile Diabetes”. Type 2 Diabetes Mellitus (T2DM) is the commonest type of Diabetes which occurs usually after thirties. It begins with insulin resistance, a condition in which cells fail to respond to insulin properly. As the disease progresses a lack of insulin may also develop. This form was previously referred to as “Non- Insulin-Dependent Diabetes Mellitus” (NIDDM) or “Adult-onset Diabetes”. Type 2 diabetes is primarily due to lifestyle factors and genetics. The primary cause is excessive body weight and inadequate physical activity. 7  Gestational Diabetes (GD) mellitus resembles Type 2 Diabetes in several aspects but occurs during pregnancy. It occurs in about 2–10% of all pregnancies and may improve or resolve after childbirth. However, after pregnancy approximately 5–10% of women suffering from Gestational diabetes are found to have Diabetes mellitus, most commonly type 2. Gestational diabetes is fully treatable but requires careful medical supervision throughout the pregnancy. Management may include dietary changes, blood glucose monitoring, and insulin administration, if needed. Pre-diabetes indicates a condition when a person’s blood glucose levels are higher than normal but not high enough for a diagnosis of Type 2 DM. In 2019, diabetes was the direct cause of 1.5 million deaths and has prevalence of 9% among adults 18 years and above.14 Over the time the diabetes can damage the heart, blood vessels, eyes, kidneys and nerves. Simple lifestyle measures have been shown to be effective in prevention or delaying of diabetes. Early diagnosis can be done through blood sugar testing. Treatment of diabetes includes drugs, diet and physical activity to lower the blood glucose level and reduce the risk factors that can damage blood vessels. Cancer: As per National Cancer Registry Program, the prevalence of cancer is estimated to be around 3.6 million. Nearly 800,000 persons die every year due to cancer in India.8 The most common cancers are oral cancer, breast cancer, and cervical cancer. Costs of care for cancer treatment are high, and studies show that almost three quarters of cancer expenditure in India is paid out of pocket.8 Cancer mortality is reduced when cases are detected and treated early. Therefore, screening of common cancers such as oral, breast and cervical was introduced in the programme with the aim to identify individuals with findings suggestive of any cancer or pre-cancer before they develop any symptoms. Treatment usually includes surgery, radiotherapy and/or chemotherapy. Palliative care is provided for relief rather than to cure the symptoms and suffering caused by cancer and to improve the quality of life of patients. Stroke: India accounts for 1.17 million cases and 7,00,000 deaths every year.15,16 Community awareness, telemedicine, timely medical intervention and lifestyle modification can prevent most of the stroke events. Increased public literacy in the FAST method (Facial drooping, Arm weakness, Speech difficulty and Timely emergency service) can significantly reduce the incidence and impact of stroke. Stroke patients are treated with antiplatelet therapy, thrombolytics and surgery along with physiotherapy. More details are available in Technical Guidelines for Prevention and Management of Stroke.17 Chronic Kidney Disease: Conventionally in medical terminology, chronic kidney disease (CKD) means kidney disease persisting for more than 3 months. CKD is progressive in nature (may be very slow at times) and it will ultimately go into End Stage Renal Disease “ESRD”. Globally, the burden of CKD is approximately over 690 million.18 In India, the population prevalence of CKD has been shown to be 8-17% in different surveys.19 Every year about 220,000 new patients of ESRD get added in India resulting in additional demand for 34 million dialysis every year.20 Diabetes mellitus, hypertension, glomerulonephritis and tubulo-interstitial diseases are the most common causes of chronic kidney disease (CKD). For people at risk of CKD, it is important to abstain 8 from smoking and alcohol consumption, focus on weight control, salt restriction and physical activities. Haemodialysis and Peritoneal dialysis are major modes of treatment for patients with ESRD. More details are available in Operational Guidelines for Pradhan Mantri National Dialysis Programme and Peritoneal Dialysis20 and Medical Officer’s Manual for Prevention and Management of Chronic Kidney Diseases.21 Chronic Obstructive Pulmonary Disease and Asthma: Common chronic respiratory diseases are COPD, asthma, occupational lung diseases, interstitial lung disease. Among them, COPD and asthma are major public health problems, contributing to 251 million and 388 million cases respectively worldwide in 2016 and 3.17 million and 0.39 million deaths respectively in 2015 (i.e., both caused >5% of all deaths globally). Chronic respiratory diseases resulted in 10.9% of all deaths in India.22 Tobacco use, air pollution, allergen, occupational agents, unhealthy diet, physical inactivity, obesity are few of the risk factors. Early detection, management, appropriate referral, and continuum of care for COPD and asthma patients under the NP-NCD programme is envisioned. Awareness for indoor air pollution should be the main priority. As tobacco cessation has been demonstrated to reduce mortality, every patient at every visit would be asked about their tobacco use status. Spirometry is considered to be the gold standard for diagnosis. Patients are managed with medications such as bronchodilators, steroids, or combinations, etc. More details are available in Medical Officer’s Manual for Prevention and Management of Chronic Obstructive Pulmonary Disease and Asthma.23 Non-Alcoholic Fatty Liver Disease: Non-Alcoholic Fatty Liver Disease (NAFLD) is the build-up of extra fat in liver cells that is not caused due to alcohol consumption. It is estimated to afflict approximately 1 billion individuals worldwide. Various epidemiological studies from India suggest prevalence of NAFLD around 9% - 32% of the general population in India.24 Obesity and Diabetes are the major risk factors for NAFLD. NAFLD interventions have been included within the broad structure of NP-NCD to guide a range of strategies including health promotion activities which are crucial to prevent NAFLD. An Operational Guidelines for the Integration of Non-Alcoholic Fatty Liver Disease (NAFLD) into NPCDCS24 was developed and disseminated to enhance the capacity of the program managers at the state, district and sub- district level, to operationalize the introduction of NAFLD interventions under the overall ambit of NP-NCD programme. ST elevation Myocardial Infarction: It is estimated that about 28.1% people die due to cardiovascular diseases (CVDs) in India. Further, Ischemic Heart Diseases and Strokes account for 80% of all CVDs. Contribution of CVDs to Disability Adjusted Life Years (DALYs) is also highest at 14.1%, including 8.7% DALYs caused by ischemic heart diseases alone.25 Myocardial infarctions are clinically classified into ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI), based on changes in ECG. STEMI accounts for about 40% of myocardial infarctions. Risk factors of MI include high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet and excessive alcohol intake, among others. It is estimated that STEMIs occurs about twice more often in men than in women. For STEMI, timely intervention is critical in order to save lives by restoring blood flow to the heart. Therefore, interventions such as thrombolysis and Percutaneous Coronary Intervention (PCI) are required to be done in the shortest possible time. More details are available in Guidelines for Management of ST- Elevated Myocardial Infarction.25 9 10  CHAPTER 3 ORGANIZATIONAL STRUCTURE OF NP-NCD The response of Government of India to NCD has been robust and aligned with political declaration conveyed in the high-level meeting on the prevention and control of NCDs at the United Nations General Assembly (UNGA) in 2011, 2014 and 2018. The National Health Policy, which was published in 2017, recognized the need to halt and reverse the growing incidence of chronic diseases. It has supported an integrated approach where screening of the most prevalent NCDs with secondary prevention would make impact on reduction of morbidity and mortality. Also, it would be incorporated into comprehensive primary healthcare with linkages to specialist consultation and follow-up at the primary level. The NP-NCD Programme has been expanded to cover the entire country. The integration of services at district level and below has been brought under the umbrella of National Health Mission. NCD Division: For effective management of the programme, the NCD divisions have been established at National, State and District headquarters to ensure planning, implementation, monitoring and evaluation of the programme activities. The details of each of these NCD Divisions are mentioned below: National NCD Division: The National NCD Division is headed by Joint Secretary (NCD), MoHFW and Deputy Director General (DDG) is the technical head at the Directorate General Health Services (Dte. GHS) along with officials, staffs and consultants from Ministry of Health & Family Welfare. The roles and responsibilities of the National NCD Division are as follows: Nodal agency for implementation of NP-NCD in the country.Plan, implement, coordinate, monitor and support all the activities at the National and State level. Implementation of National Multi-sectoral Action Plan for Prevention and Control of NCDs. Develop Technical and Operational Guidelines, Standard Operating Procedures (SOP), Treatment Protocols, Training modules, Quality benchmarks, Monitoring and reporting systems and tools, IEC materials. Monitoring of the programme through collection, collation, compilation, and analysis of data. Review of reports generated from data of National NCD Portal and timely sharing with the States/UTs for action. Conduct or commission implementation research/evaluation studies. Joint Supportive Supervision Mission visit to the States/UTs. Release of funds as per State PIP approved in the NPCC meeting and monitoring of the same through key deliverable indicators. Capacity building through various well-designed training programmes. Integration with other related National Health Programmes. 11 State NCD Division: The State NCD Division is headed by Mission Director, NHM. The technical support is provided by a senior- level officer from the health services, designated by the State Government as the State Nodal Officer/State Program Officer - NCD (SNO/SPO - NCD). The contractual staffs (State Programme Coordinator, Finance cum Logistics Consultant and Data Entry Operator) are hired under NP-NCD to support the program. The roles and responsibilities of State NCD Division are as follows: Preparation of State action plan including physical and financial targets for implementation of NP- NCD. Implementation of National Multi-sectoral Action Plan. Ensure presence of identified key human resources [regular or contractual] for various facilities. Maintain district-wise epidemiological profile for identified NCDs. Ensure regular supply of drugs, diagnostics and logistics etc. Monitor implementation of NP-NCD through analysis of routine reports generated under National NCD Portal and/or other IT based solutions, field visits, review meetings and research etc. Designing IEC materials, media plan and its dissemination. Preparation of State PIP for submission to NHM. Release of funds to the districts as per the district PIPs. Ensure timely preparation and submission of Statement of Expenditure and Utilization Certificates. Organize state and district level trainings for capacity building of all cadres of human resources. Coordination with other related National Health Programmes. District NCD Division: The District NCD Division is usually located in the vicinity of the District Programme Management Unit (DPMU) of NHM, or any other space provided by the District CMO. It is responsible for overall planning, implementation, monitoring and evaluation of the different activities and achievement of physical and financial targets planned under the programme in the district. One regular State government officer is designated as District Nodal Officer/District Programme Officer - NCD (DNO/DPO - NCD). The District NCD Division functions under the overall supervision of the DNO and is supported by the contractual staff hired under NP-NCD (District Programme Coordinator, Finance cum Logistics Consultant and Data Entry Operator). The roles and responsibilities of District NCD Division are as follows: Preparation of District action plan (incorporating NP-NCD strategies) including physical and financial targets for implementation of NP-NCD. Ensure the presence of identified key human resources [regular or contractual] at various health facilities. Maintain district epidemiological profile for identified NCDs. Ensure regular supply of drugs, diagnostics and logistics. Monitor implementation of NP-NCD through analysis of routine reports generated under National NCD Portal and/or other IT based solutions, field visits, HMIS and review meetings. Prepare the media plan. Conduct health promotion and public awareness activities. Preparation of District PIP for submission to State NHM. Ensure timely preparation and submission of Statement of Expenditure and Utilization Certificates. Organize trainings for capacity building at all levels of human resources. Coordination with other related National and State Health Programmes. 12 Technical support group and committee: Several support groups and committees have been formed to provide technical support to the programme. Through their guidance the programme progress is reviewed to ensure quality of implementation. The States also devise their own mechanisms for providing the State specific technical inputs for issues related to NP-NCD, from time to time. 13  CHAPTER 4 OPERATIONAL STRATEGIES Service delivery mechanism under NP-NCD Service delivery framework consists of primary, secondary, and tertiary levels. Preventive, promotive, curative, rehabilitative and supportive services (core and integrated services) for common NCDs are being provided through various levels of government health facilities. Government of India’s flagship programme of Ayushman Bharat-Health and Wellness Centres (AB -HWCs) has clearly laid out the activities covered across level of primary care i.e., HWC-PHC/UPHC, HWC-SHC and community. The secondary level facilities such as CHC/SDH and DH are also now being strengthened to respond to the growing burden of NCDs, and to function as the referral linkages for facilities below this level of care. The range of NCD services includes health promotion, psycho-social counselling, screening, case management (out-and-in-patient), emergency cardiac and stroke care services, day care and palliative care services for cancer, as well as referral for specialized services, as needed. Bi-directional referral linkages covering all levels of health care facilities shall be established to assure care both for NCDs and associated unforeseen emergencies and follow up care. Whenever feasible and appropriate, teleconsultation services with higher centres would be organized. As needed, referral to specialists at the secondary or tertiary level is to be ensured. Such referrals shall be with specific instructions regarding facility name and location, day and time of visit, person to contact etc. Two-way referrals between various facility levels are to be ensured, which can be facilitated through established IT system or teleconsultation. The loop between the primary care medical provider and the specialist must be closed. This can be achieved when the specialists at district facility or higher are able to communicate to the medical officer about the adequacy of treatment, any change in treatment plans, and further referral action. Package of services Level of care Package of services Active enumeration of the eligible population and registration of the families, risk assessment of NCDs using Community Based Assessment Checklist (CBAC), Community Mobilization of community for screening of NCDs at nearest AB-HWC. level Health promotion, lifestyle modification, follow up for treatment compliance and lifestyle modification. 14  Health education for awareness generation and behaviour change, organising wellness activities. Screening of Diabetes, Hypertension, three common cancers (oral, breast and cervical). Sub-centre / Referral of suspected cases to PHC/PHC-HWC or nearby health facility for diagnosis SHC-HWC confirmation and management. SHC- HWC team to also facilitate the referrals and follow up on referred suspected patients. Dispensing of prescribed medicines and follow up of patient for treatment compliance and lifestyle modification. Teleconsultation services from SHC-HWC to HWC- PHC/UPHC. Maintaining Electronic Health Records (EHR) and generation of ABHA IDs. Health promotion activities including wellness activities for behaviour change. Screening of Diabetes, Hypertension, three common cancers (oral, breast and cervical), COPD and Asthma, CKD, NAFLD among OPD attendees. PHC / PHC- Confirmation of diagnosis, treatment initiation, and management of common HWC/ UPHC- NCDs as per standard management protocol and guidelines. HWC Referral of complicated NCD cases to higher facilities. Bi-directional referral linkages to be established and follow up to be ensured. Teleconsultation services and counselling services. Maintaining Electronic Health Records (EHR) and generation of ABHA IDs. Health promotion including counselling. Opportunistic screening of Diabetes, Hypertension, three common cancers (oral, breast and cervical). Screening of COPD and Asthma, CKD, NAFLD, STEMI among suspected cases. Confirmation of diagnosis, treatment initiation, and management of common CHC/SDH NCDs as per standard management protocol and guidelines. Teleconsultation services and counselling services. Maintaining Electronic Health Records (EHR) and generation of ABHA IDs. Management of cases of common NCDs and regular follow-up. Referral of complicated cases to District Hospital/higher healthcare facility. Opportunistic screening of Diabetes, Hypertension, three common cancers (oral, breast and cervical). Screening of COPD and Asthma, CKD, NAFLD, STEMI among suspected cases. Diagnosis and management of cases of common NCDs: outpatient and inpatient care, including emergency care particularly for cardiac and stroke cases. Management of complicated cases of common NCDs, or referral to higher healthcare facility. Follow-up cancer chemotherapy and palliative care services for cancer cases, District Hospital physiotherapy services for NCDs including Stroke patients, Dialysis facilities for CKD patients, etc. Health promotion for behaviour change and counselling for NCD cases. IEC activities on important Health Days. Bidirectional referral linkages and follow up mechanism to be established and ensured. Teleconsultation services and counselling services. Maintaining Electronic Health Records (EHR) and generation of ABHA IDs. 15  Diagnosis and management of complicated cases of common NCDs acts as tertiary referral facility. Comprehensive cancer care including prevention, early detection, diagnosis, treatment, palliative care and rehabilitation at Tertiary Cancer Centres. Medical Support programme in capacity building of health staff. College/ Support programme in preparing standard guidelines and protocols. Tertiary Cancer Support in supervision, monitoring, evaluation and operational research. Centres Bidirectional referral linkages and follow up mechanism to be established and ensured. Teleconsultation services and counselling services. Maintaining Electronic Health Records (EHR) and generation of ABHA IDs Details of medicines available and tests performed at each level of facility is placed as Annexure 1.1 and 1.2. Activities and interventions at various levels: i. Individual/family/community level: a) Active enumeration of the eligible population and registration of families and maintenance of family folder which is done by ASHA. b) Risk assessment using Community Based Assessment Checklist (CBAC) for all individuals: Through CBAC administration, a scoring is done for individuals, which is not a point of elimination but a means to highlight risk factors of NCDs and for customization of health promotional activities and prioritizing for screening. CBAC form, which is used for community-based assessment, is placed as Annexure 2, along with reporting formats for various levels of public health facilities under NP- NCD. c) Health promotion through appropriate and effective Information Education and Communication (IEC) and BCC strategies with special emphasis on prevention of NCDs and healthy lifestyle. Wellness activities including Yoga and integration with intervention like Fit India movement and Eat Right movement at the level of community. d) Educating community about healthy lifestyles. Family-centric care for sustainable acceptance of healthy lifestyle and ensuring treatment adherence. e) Community level forum like Village Health Sanitation and Nutrition Committee (VHSNC)/ Mahila Aaarogya Samiti (MAS), Jan Aarogya Samiti (JAS), Self Help Groups (SHG) and local bodies in both rural and urban areas to be strengthened and established as a platform for community awareness and promotive and preventive care activities. f) Frontline workers, ASHA, Multiple Purpose Worker/Auxiliary Nurse Midwife (MPW/ANM) to be skilled for Primary, basic diagnostic and community level preventive care for NCD related problems. g) Community follow up of identified individuals to be carried out by ASHA making visits for behavioural changes, treatment compliances, and encouraging patients to go to the HWCs for regular check-up of BP/blood glucose. h) Counselling and appropriate referral of patients requiring medical interventions. 16 ASHA would administer Community Based Assessment Checklist (CBAC) for all individuals of 30 years and above age group in the population. Through CBAC administration, a scoring is done for individuals, which is not a point of elimination but a score of 4 or more implies high risk. In addition, the tool includes questions related to symptoms of cervical cancer, breast cancer, oral cancer and Chronic Obstructive Pulmonary Diseases (COPD) and Asthma. All the identified individuals of age 30 years and above are referred for screening of common NCDs. ii. SHC-HWC/U-HWC: The following activities are carried out at the level of Sub Health Centre - Health and Wellness Centres (HWCs): a) Health promotion: Behaviour and life-style changes through health promotion is an important component of the programme at sub centre/SC -HWC level and to be carried out by the frontline health workers, ANMs and/or Multi-Purpose Worker (MPW) - Male/Female and Community Health Officer (CHO) for all age groups (preferably 18 years and above). Various approaches can be used such as organising camps, interpersonal communication (IPC), posters, banners, billboards, etc. to educate people at community/ school/workplace settings. Health Promotion activities can be carried out at the community level during the Village/Urban Health, Sanitation and Nutrition Days (VHSND)/ Community based platforms and/ or outreach activities including Annual Health calendar activities. Forty-two health calendar days are celebrated by each AB-HWCs apart from wellness-related activities like Yoga, Zumba, Meditation etc., which not only enable improved physical health but also mental wellbeing of the community. The health workers can discuss the various aspects of a healthy lifestyle and its benefits with the target groups, mobilise the community to get screened at nearest HWCs and motivate them to adopt a healthy lifestyle for prevention of common NCDs. b) NCD screening activities: Under CPHC, HWCs are functioning as the first point of contact for screening of NCDs and risk factors. Community Health Officers (CHO) would provide primary level care at the Health and Wellness Centres but a dedicated Medical Officer (MO) is posted at Urban HWCs (UHWCs) to undertake activities related to NCDs. The MO will screen NCDs along with primary management of conditions, following treatment protocols. At the HWC level in rural areas, the CHOs and associated team (ANMs/MPWs) would be trained to undertake screening for disease conditions, thus enabling early identification, timely detection and appropriate referral, if needed. HWC team maintains a record of NCD patients in general OPD, camps and their subsequent referral to higher centres. The CHOs should be alert for the possibility of complications among the NCD patients. c) Referral and Follow up: The suspected cases for NCDs are referred to higher health facilities for further diagnosis, treatment initiation and management. The suspected cancer cases are referred to District Hospital for confirmation. The AB-HWCs provide teleconsultation services using e-Sanjeevani platform, whereby every level of service provider from CHO to medical officer can access higher level consultation, including with specialists in secondary and tertiary centres. d) Drugs and Logistics Supply: Medicines listed as per essential list of medicines for public health care facilities need to be ensured at respective facility. At least one month supply of medicine should be provided to the patients. Accordingly, 17 one month medicine needs to be maintained as per patient load at the facility. The drug status is recorded by the CHO/ ANM/ MPW while dispensing the medicine. For a patient suspected of a chronic disease, confirmation and initiation of treatment will be by the MBBS Medical Officer at the PHC or a higher referral centre. However, for continuation of treatment, medicines will be dispensed at SHC-HWCs by CHO to avoid patient hardship and ensure that the clinical condition is monitored regularly. Any uncontrolled condition must be referred to MO for necessary management. CHO/ ANM/ MPW is undertaking the monitoring of the patients and then issue the next month’s supply. Patients would be encouraged to come to the HWC so that their health status can be monitored. Home based distribution is recommended only for patients who are not able to travel. e) Data recording and reporting: The Ayushman Bharat-Health Account IDs (ABHA IDs) are generated through National NCD Portal by CHO/ANM/MPW at HWCs. She/he maintains NCD data record and register in prescribed digital formats on National NCD Portal. It is utilised to capture the real-time data on screening and management of NCDs. The CHO/ ANM/ MPW is using the tablet/ mobile/ laptop/ desktop for entering data into it. She/he cross checks 10% of CBAC format duly filled by ASHAs. Wherever the application/ devices are not available, the frontline health workers could maintain physical NCD screening and follow-up registers of 30 years and above beneficiaries and submit monthly reports to the MO (PHC-HWC/UPHC-HWC) on the last day of every month. Digitalization of the data from physical registers has to be done at the PHC-HWC/UPHC- HWC level. f) Linkages: Linkages have to be done with the NGOs/ Samitis/ Yuva Kendras etc., through support group meetings for health promotional activities. Linkages with the other Government departments, Panchayati Raj Institutions (PRIs), Urban Local Bodies (ULBs) etc.. are to be done to facilitate access to entitled- Government welfare schemes for the benefit of the individual. iii. Primary Health Centre (PHC-HWC/UPHC-HWC): Primary Health Centre should be able to provide preventive, promotive and curative NCD services. Medical Officer of PHC/ PHC-HWC/ UPHC-HWC would implement the NCD services and supervise the activities of HWCs under the catchment area. The following activities are carried out at this level: a) Health promotion: Health promotional activities for behavioural change is conducted to reduce risk factors for NCDs. The promotional activities are carried out by the frontline health workers for all age groups (preferably 18 years and above). They have the responsibility to disseminate the information for NCDs through IEC materials (Posters, banners, leaflets, billboards etc.) at different settings and gatherings such as educational institutes, workplace, religious festivals etc. to educate people. IEC activities can be carried out on special NCD day. MO would mentor ASHA, MPW and CHO to impart preventive and promotive NCD care. 18 b) Screening: 1. Population Based Screening: After screening persons aged 30 years and above for Hypertension, Diabetes, Oral Cancer, Breast Cancer and Cervical Cancer, the CHO/ ANM/ MPW refers suspected cases to the PHC Medical Officer to identify those individuals who have NCDs and warranting them further investigations, management and counselling. The Visual Inspection using Acetic Acid (VIA) for cervical cancer screening is also done by trained Staff Nurse/MO at PHC-HWC/UPHC-HWC. 2. Opportunistic Screening: For persons of 30 years and above age who report directly in OPD of PHC, NCD screening should be carried out by a Medical Officer, aided by the PHC Nurse. Such screening involves history-taking (such as family history of NCDs, personal history of behavioural risks factors e.g. alcohol consumption, tobacco use, unhealthy dietary habits, physical inactivity etc.), general physical examination and calculation of BMI, blood pressure measurement, blood sugar estimation etc. to identify those individuals who have NCDs as well as those at risk of developing NCDs. The diagnosed individuals are counselled and put on lifestyle modifications and treatment. a) Clinical diagnosis and management of common NCDs: All those suspected NCD cases referred from the HWC or reported directly to the PHC-HWC/UPHC-HWC would undergo clinical examination and laboratory investigation for confirmation. Once the diagnosis of diabetes, hypertension, COPD and asthma is established, then lifestyle modifications is done and appropriate treatment is initiated as per the standard treatment protocol and guidelines. b) Drugs and Logistics Supply: It is expected that above NCD patients must receive at least one month supply of medicines from the PHC. Once the condition is stable, three-month supply of drugs could be stocked with the CHO/ ANM/ MPW at SHC-HWC, to be given as per the State policy. Drug demand should be as per the State list of Essential medicines. Sufficient stock needs to be maintained at PHC-HWC/UPHC-HWC as per the patient load. c) Referral and Follow-up of cases of common NCDs to CHC/DH: The complicated cases of NCDs (diabetes, hypertension, COPD, asthma and CKD etc.) need to be referred to the CHC/ UCHC/ DH for specialist consultation, further management, and thereafter, once every year or sooner, if required. All the VIA positive cases have to be referred to higher facilities for confirmation of diagnosis and management with colposcopy and/or cryotherapy by specialists, wherever available. Individuals with suspected oral cancer/breast cancer has to be referred to higher facilities for confirmation through biopsy and further management. All suspected cases of NAFLD are referred to CHC/DH for further diagnosis and management. The follow-up instructions are to be carried out at the SC/SC-HWC respectively and undertake to refill drugs on a monthly basis. Any uncontrolled conditions to be referred to MO at PHC/PHC-HWC/UPHC-HWC/CHC. MO is responsible for maintaining upward referrals with concerned specialist at secondary level for management support and downward referrals with CHO at HWC for follow up and drug refills/counselling support. d) Data recording and reporting: The Ayushman Bharat-Health Account IDs (ABHA IDs) are generated through National NCD portal by MO. She/he maintains NCD data record and register in prescribed digital formats on National NCD portal. It is utilised to capture the real-time data on screening and management of NCDs. The MO and Staff Nurse is using the tablet/ mobile/ laptop/ desktop for entering data into it. Wherever the application/ devices are not available, the MO/Staff Nurse could maintain physical NCD treatment and follow up registers of 30 years and above beneficiaries and submit monthly reports to the CHC/UCHC on the fifth day of every month. 19 e) Linkages: Linkages have to be done with the NGOs/ Samitis/ Yuva Kendras etc., through support group meetings for health promotional activities. Linkages with the other Government departments, Panchayati Raj Institutions (PRIs), Urban Local Bodies (ULBs) etc., are to be done to facilitate access to entitled Government welfare schemes for the benefit of the individual. iv. Community Health Centre/UCHC: CHC/UCHC NCD clinics: Under NP-NCD, the support is provided to all Community Health Centre (CHC)/UCHC for NCD clinic. The comprehensive management of patients is done, who are referred by lower health facilities. The Medicine Specialist and/or MO would run NCD clinic and implement the NP-NCD program. The CHC/UCHC NCD Clinic provides the following activities: a) Prevention and health promotion: The CHC is involved in promotion of healthy lifestyle through health education and counselling to the patients and their attendants at the time of their visit to CHC. The NCD Counsellor recruited under the programme counsels on the merits of healthy diet, importance of physical activity, harmful effects of tobacco and alcohol, warning signs of cancer, air pollution, obesity, importance of treatment adherence, etc. The promotional activities will be carried out by the frontline health workers, ANMs and/or Multi- Purpose Worker (MPW) - Male/Female and Community Health Officer (CHO) for 18 years and above. b) Screening 1. Population Based Screening: Identified NCD patients of age group of 30 years and above, who are screened and diagnosed with NCDs at HWCs (SHC/ PHC/ UPHC) when referred to CHC, would be examined and treated by the NCD Medical Officer with support of the NCD Nurse on priority at NCD clinics. 2. Opportunistic Screening: The opportunistic screening of persons of all age groups who report to the NCD Clinic is carried out at CHC/UCHC. NCD screening should be carried out by a Medical Officer, aided by the designated staff nurse at CHC NCD clinic. Such screening involves history-taking (such as family history of NCDs, personal history of behavioural risks factors e.g. alcohol consumption, tobacco use, unhealthy dietary habits, physical inactivity etc.), general physical examination and calculation of BMI, blood pressure measurement, blood sugar estimation etc. to identify those individuals who have NCDs as well as those at risk of developing NCDs. The diagnosed individuals are counselled and put on lifestyle modifications and treatment. c) Diagnosis and Management: Laboratory investigations and Diagnostics such as common blood examinations (CBC, FBS, LFT, KFT, LPT, etc.), spirometry, X- Ray, ECG, USG, etc. should be made available (may be outsourced, if not available). Once diagnosed lifestyle modifications needs to be done. Further, management of diabetes, hypertension, COPD, asthma, CKD, NAFLD, Stroke and STEMI along with counselling and follow-up to be undertaken by staff of NCD Clinic. If VIA positive patients have been referred from PHC/ PHC-HWC/ UPHC-HWC, or if invasive pre-cancerous lesions of the cervix found in direct walk-in patients, then the CHC/UCHC could offer colposcopy and/or cryotherapy to them. 20 d) Drugs and Logistics Supply: The NCD patients must receive at least one month supply of drugs from the CHC/UCHC. Once the condition is stable, three-month supply of drugs could be stocked at CHC to be given as per the State policy. Drugs for various common NCDs are made available as per State Essential Drug List. There is a regular update of drug inventory along with buffer stocks. Sufficient stock needs to be maintained at CHC as per the patient load. e) Referral: The complicated cases of NCDs are referred from CHC/UCHC to the District Hospital for further investigations and management. The cases which require biopsy for cancer confirmation are referred to the DH, or to the nearest tertiary centre for further management. Individuals with hypertension and/or diabetes under treatment/referred from PHC-HWC/UPHC-HWC for management at CHC may be referred to respective PHC-HWC/UPHC-HWC once their blood sugar/BP is under control. f) Data recording and reporting: The Staff Nurse would generate ABHA-ID through National NCD Portal. Medicine Specialist/ MO/ Staff Nurse maintains patient related NCD data and reports in prescribed formats on National NCD Portal. She/ he is using the mobile phones/ laptops/ desktops for entering data into it. Wherever the application is not available, the Medicine Specialist/ MO/ Staff Nurse could maintain NCD register with individual diagnosis, treatment, follow-up and referral records, and submit monthly reports to the District NCD Division on the seventh day of every month. e) Linkages Linkages have to be done with the NGOs/ Samitis/ Yuva Kendras etc., through support group meetings for health promotional activities. Linkages with the other Government departments, Panchayati Raj Institutions (PRIs), Urban Local Bodies (ULBs) etc., are to be done to facilitate access to entitled Government welfare schemes for the benefit of the individual. v. District hospital: District NCD Clinics have been set up at District hospitals for management of NCDs. This is further strengthened by setting up of Critical Care Unit [Cardiac Care Unit (CCU)/Cardiac Stroke Care Unit (CSCU)] and Day Care Centres, which offers specialised care. The DH would function as referral unit for all NCDs being identified at the lower level, i.e. CHC and HWCs. District NCD Clinic: a) Screening: 1. Population Based Screening: Identified NCD patients of age group of 30 years and above, which are screened and diagnosed with NCDs at CHCs/SDH and HWCs (SHC/ PHC/ UPHC) when referred to DH, would be examined and addressed on priority at NCD clinics at DH for further management and counselling. 2. Opportunistic Screening: The District NCD Clinics screen individuals of all age groups reporting directly to the Clinic, for common NCDs and NCD risk factors, and identify individuals at risk or with the disease. b) Detailed investigation at District laboratory Facility: Detailed investigation is done at District Hospital for persons screened positive in the NCD clinic, as well as for those referred from lower facilities. Diagnostic services at district hospitals are established/ 21 strengthened to provide necessary laboratory, pathology and radiology support. The indicative list for investigation of common NCDs are such as routine blood examination, blood sugar, blood lipid Profile, KFT, LFT, X-ray, ECG, USG, ECHO, CT scan etc. District hospitals may outsource certain essential laboratory investigations and diagnostics that are not available. The District Hospital should display the list of Laboratories in which these investigations are outsourced. c) Out-patient and In-patient Care: All District Hospitals would have dedicated NCD clinics which may be a separate space, with visible labelling. Persons with suspected or confirmed NCDs may be either referred from other OPDs or may come directly after hospital OPD registration. However, the NCD patients already on treatment may come directly to these NCD Clinics for regular follow-up for drugs or complications. The NCD Clinics would be provided with dedicated manpower and other necessary logistics for screening, diagnosis, lifestyle modifications, treatment, counselling, awareness generation, etc. for common NCDs such as diabetes, hypertension, oral cancer, cervical cancer and breast cancer, COPD, asthma, CKD, NAFLD, Stroke and STEMI under the programme. If VIA positive patients have been referred from a lower health facility, or if invasive pre-cancerous lesions of the cervix found in direct walk-in patients, then the DH could offer colposcopy and cryotherapy. Facilities for specialist consultation with Medicine, Gynaecologists, Surgeons, ENT Surgeon or Dentist, Radiologist should be made available. Provision for fundoscopy and ophthalmologist consultation annually for diabetics and hypertensives should also be undertaken. The complicated cases of NCDs are managed in IPDs and rehabilitation services could be provided to the patient with support of medicine specialists/MO and Counsellor. d) Referral and Transport facility for serious patients: Complicated cases shall be referred to the nearest tertiary health care facility with a referral card. The suspected or diagnosed cancer cases may be referred to concerned Tertiary Cancer Care Centre (TCCC) for further management. To ensure timely and emergency care for patients referred from distant CHC/ UCHC/ PHC/ PHC-HWC/ UPHC-HWC to DH, or for referral of serious cases from DH to the nearest tertiary level facility, there is fund provision for transporting the serious patients. NCD cell would provide facilitation support for referred cases to ensure that the individual get hassle free entry and is able to get specialist consultation with ease. Free transportation is to be made available to the patient using Ambulance services. e) Health promotion: Apart from clinical services, district hospitals are also involved in promotion of healthy lifestyle through health education and counselling to the patients of 18 years and above and their attendants regarding prevention of NCDs and related risk factors. The international and National NCD health days as per Annual Health Calendar are celebrated. Posters, banners, hoardings etc. are displayed at important public gathering places to increase awareness in the communities. Health promotion activities has to be carried out regularly in different settings like school, workplaces and community setting etc. f) Data recording and reporting: The ABHA-ID cane be generated through National NCD Portal by Staff Nurse. Medicine Specialist/MO/ Staff Nurse maintains patient related NCD records and reports in prescribed formats on National NCD Portal. She/He is using the mobile phones/ laptops/ desktops for entering data into it. Wherever the application is not available, the Medicine Specialist/ MO/ Staff Nurse could maintain NCD register with individual diagnosis, treatment, follow-up and referral records, and submit monthly reports to the State NCD Division on the seventh day of every month. 22 g) Linkages: The District Nodal Officer would plan for linkages of NP-NCD program with a) NGOs/ Samitis/ Yuva Kendras etc., for support group meetings and health promotion activities, b) referral and/ integrated/ coordinated care linkages with other national programs and c) Government Departments, Panchayati Raj Institutions (PRIs), Urban Local Bodies (ULBs), etc., to facilitate access to schemes/programmes etc. He would facilitate the intersectoral coordination and better implementation of NP-NCD program with support health and non-health stakeholders. DH should establish linkages with existing tobacco cessation centres and de-addiction centres in respective districts. All facilities under the DH should be made available with the list of such de-addiction centres for linking the identified individuals as and when required. vi. Critical care units: Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) includes Critical Care hospital blocks in all districts with a population of more than 5 lakhs, in State Government Medical Colleges/DH and in 12 Central Institutions. Under it, the support is provided for 50/75/100 bedded Critical Care Units [Cardiac Care Unit (CCU)/Cardiac and Stroke Care Unit (CSCU)] in 602 districts across all States/UTs. Under Emergency Covid Response Plan II (ECRP-II), the funds for Critical Care Units have also been provided. The districts which are not covered under any of the above schemes, the funds are provided for establishing Critical Care Unit along with drugs and logistics under the programme. Six-bedded Critical Care Unit will be established/strengthened in the identified district hospital premises, wherever it is feasible, as per the availability of space and requirement. Priority for Critical Care Unit establishment may be given by States to the districts not having Medical College Hospitals and not covered under ‘Scheme for Up-gradation of District Hospitals to Medical College Hospitals’. Under the programme, there is provision for renovation and purchase of equipment such as ventilators, monitors, defibrillator, beds, portable ECG machine, etc., for cardiac and stroke care. This unit is supported by essential human resources on contract basis, in addition to existing human resources of the District Hospital. Special training is given to health professionals and nurses in handling the patients in Critical Care Unit. All identified district hospitals have to be supported for Integrated Public Health Laboratories, and in case the facility is not available in the district hospital, these investigations may be outsourced in Public Private Partnership (PPP) model/pattern or as per state policy/practice. Thrombolysis services for STEMI or Stroke could be provided through it and referred to higher centres for further management. vii. Day care centres for cancer chemotherapy: Day Care Centres are established for provision of continuation of simple chemotherapy regimens to cancer patients at the District Hospitals to support those already undergoing treatment at TCCC. Financial support is given under NP-NCD for infrastructure (four bedded units), necessary equipment such as IV stands, BP instruments, sterilizer etc. Human Resources (including health professional and nurse) are provided by District Hospital for smooth functioning of the centre. Efforts should be made that once a cancer case has undergone diagnosis and initial management in a tertiary care hospital, the subsequent treatment and follow up of cases may be undertaken at district hospital itself, to minimise the discomfort to patients. The support for chemotherapy drugs should be provided to district hospitals as per the approved pattern of assistance and the mechanism laid down by respective State Governments. The District Hospital is linked with State Cancer Institute and Tertiary Care Cancer Centre wherever available, to ensure continuum of care. 23 Strengthening of tertiary cancer care centres facilities scheme: To enhance the facilities for tertiary care of cancer, the Central Government is implementing ‘Strengthening of Tertiary Cancer Care Facilities’ Scheme. Under the scheme, support is provided to States/UTs for setting up of State Cancer Institutes (SCIs) and Tertiary Care Cancer Centres (TCCCs) in different parts of the country. The financial assistance is for procurement of radio therapy equipment, diagnostic equipment, surgical equipment, enhancement of indoor civil work and patient facility for cancer and such other purposes relevant for diagnosis, treatment and care of cancer. The maximum permissible assistance for SCI is Rs. 120 crores and for TCCC Rs. 45 crores. This is inclusive of State share of 40% (for North-East and Hill States 10%). Up to a maximum of 30% of the sanctioned amount will be permitted to be used for civil/ electrical work (including renovation), and improvement of infrastructure. Till date 39 institutions (19 SCI and 20 TCCC) have been approved. 27 Regional Cancer Centres were financially assisted till 2004 under the earlier National Cancer Control Programme. These erstwhile RCCs continued the work in cancer care. As per the Cabinet Committee approval, the financial support from central government for the said scheme will be continued up to 31st March 2024. India Hypertension Control Initiative (IHCI): The India Hypertension Control Initiative (IHCI) is a multi-partner initiative between the Ministry of Health and Family Welfare, Indian Council of Medical Research, State Governments, World Health Organisation- India and Resolve to Save Lives (Technical Partner). The initiative aimed to accelerate progress towards the Government of India’s NCD targets by supporting evidence-based strategies for strengthening the building blocks of hypertension management and control. IHCI was launched in November 2017 and was implemented in 25 districts across 5 States (Punjab, Kerala, Madhya Pradesh, Telangana and Maharashtra) in first year. The initiative included a Simple Application with following features:Scanning of QR Code of Health ID Card for beneficiary identification. Observe the progress rate of the Programme through a) number of patients on treatment and b) control rate.Follow-up of beneficiaries through Call/SMS. Cohort monitoring to track a set of patients receiving treatment over a time: Based on the positive experiences and lessons learnt from the IHCI sites, and the existing initiatives of MoHFW on prevention, screening and control of common NCDs since 2016 and CPHC rollout in 2018, Government of India has now decided to merge the simple application of IHCI with National NCD Portal to avoid duplication of efforts and ensure maximum utilisation of existing resources. A compilation of good practices under IHCI is placed as Annexure 3. Centre of Excellence : Centre of Excellence (preferably disease specific) needs to be established at State/National level. The activities may be planned as follows: Designing of training manuals Capacity building of master trainers Implementation of NP NCD Operational Guidelines/National Disease Specific Guidelines Development of IEC materials 24 25  CHAPTER 5 HUMAN RESOURCES The NP-NCD programme outlines and supports various Human Resources at National, State and District NCD Division and service providers at District and CHC NCD clinics. The tables below provide the details on the number of positions and requirements for these personnel. The following list is suggestive in nature. The State/UTs may plan for combined Programme Management Unit for NCDs. The State/UTs may make necessary changes as per their requirement. It is also encouraged that available personnel be assigned appropriate tasks across the various initiatives to achieve the programme goals. Moreover, it is essential to utilise newer technologies like telemedicine and digital applications for capturing data on NCDs to improve the efficiency and patient care. Human resources at National NCD Division: At National level, Joint Secretary (NCD) will head the NP-NCD, who will be technically supported by Deputy Director General (NCD). Under DDG (NCD), the following officers will lead the program: Sl. No. Name of Post No. of Posts 1. Central NCD Division- Head (DDG Level) 1 2. Deputy Program Manager (Diabetes, Hypertension, COPD and asthma, 8 Stroke, CKD, NAFLD, CVD, RHD) Addl. DDG/ADG Level 3. Program Manager (Joint-Director Level) 16 4. Assistant Program Manager (Deputy/Assistant Director Level) 16 26 The following contractual staffs are needed to support, strengthen and implement the NP-NCD programme. Sl. No. Name of Position/Post No. of Posts 1. National Programme Coordinator 1 2. Epidemiologist 1 3. Consultant (Training) 1 4. Consultant (Monitoring and Evaluation) 1 5. Consultant (Public Health) 2 6. Consultant (Health Promotion/IEC) 2 7. Consultant (Management Information System/e-Health) 1 8. Consultant (Finance and Logistics) 1 9. Accountant 1 10. Logistics Manager 1 11. Data Analyst 2 12. Data Entry Operators 7 13. Public Health Consultants (Regional/State based) 25 Terms of reference and remuneration structure of contractual staff would be as per NHM norms. Human resources at State NCD Division The staff positions supported at State NCD Division: Sl. No. Name of Post No. of Posts 1. State Programme Officer 1 2. State Programme Coordinator/NCD Consultant 1 3. Finance and Logistics Consultant 1 4. Data Entry Officer 1 The remuneration structure of the contractual staff would be as per NHM norms. Terms of Reference for contractual staff under State NCD Division is as below: State Programme Officer: Essential Qualification: MBBS degree from institution recognized by National Medical Council (NMC), with Diploma/Master’s in Public Health or MD/DNB in Preventive and Social Medicine/Community Medicine/ Community Health Administration/ MBA (Health Care Administration) Experience: Essential: At least 2 years of experience in Health Management/ Public Health Programme/ Health Services after obtaining post graduate degree/Diploma. Desirable: Experience in Non Communicable Disease control program/projects. Age Limit: As per NHM guidelines. Job requirements/responsibilities: Implementing NP-NCD and NMAP activities. Developing Programme Implementation Plan. 27  Organizing review meetings and orientation workshops. Organizing regular capacity building workshops for human resources. Visiting districts and peripheral units to monitor, evaluate and surveil the NCD activities. Facilitating and reviewing programme implementation including IEC activities and National NCD portal at all levels. Planning and linkaging with other National Programmes. Collaborating with Centre, Medical colleges, Districts, NGOs and other sectors. Preparing and submitting monthly, quarterly progress report of NP-NCD to National NCD Division by using National NCD Portal.. Any other job assigned by concerned officers, State programme coordinator/NCD consultant: M.B.B.S with Master’s in Public Health or BDS/ AYUSH/ Biosciences with Diploma/Master’s in Public Health or MBA (Health Care Administration). Experience: At least 1 year experience of working in Health Services/Public Health Programme in NCDs. Working Knowledge of operating computers and internet usage Age Limit: As per NHM guidelines. Job requirements/responsibilities: Assisting SNO/SPO in NP-NCD and NMAP planning and implementation. Developing Programme Implementation Plan. Organizing Regional level review meetings and orientation workshops. Organizing regular capacity building workshops for human resources. Visiting districts and peripheral units to monitor, evaluate and surveil the NCD activities as per the quarterly visit plan. Implementation of various guidelines, schemes under NP-NCD at State level. Coordinate standard treatment protocol consensus meetings at State level. Facilitating and reviewing programme implementation including IEC activities and National NCD portal at all levels. Planning and Linkaging with other National Programmes. Collaborating with States, Medical colleges, NGOs and other sectors. Preparing and submitting monthly, quarterly progress report for NP-NCD to SNO/SPO (NCD) using National NCD Portal. Any other job assigned by concerned officers. Finance and logistic consultant: Qualifications: Essential: Inter CA/ Inter ICWA/ M. Com or MBA (Finance/ Material Management) with knowledge of computers. Desirable: At least 1 year of experience in State level in accounting including analysis, financial reporting, budgeting, financial software and reporting system. Experience: Experience of working in Health Care Financing/ National Health Accounts Age Limit: As per NHM guidelines. 28 Job requirements/responsibilities: General: To support all matters relating to accounts, budgeting and financial matters and management of accounting procedures pertaining to NP-NCD in the State. To organize and maintain the fund flow mechanism from Centre to State and then from State to Districts. Accurate and timely submission of quarterly report on expenditure to Centre, annual audited statement of accounts and intensively monitoring the financial management in each District NCD Division. To support all matters related to logistics management (including purchases related to equipment and drugs under NP-NCD). Any other job assigned by concerned officers. Specific: Preparing annual and quarterly budgets for the States. Ensuring that adequate internal controls are in place to support the payments and receipts. Ensuring timely consolidation of accounts/financial statements at the State/District. Training of Finance and Logistics Officer at State and District level in fund flow mechanism and filling up the reporting formats. Supporting the audit of the accounts of the State and District in accordance with the financial guidelines. Monitoring expenditure and receipt of Utilization Certificate (UC) and Statement of Expenditure (SOE) from the States and Districts. Reviewing the accounts and records of the State and District on a periodic basis. Preparing consolidated SOE of NP-NCD on a quarterly basis. Coordinating with the District to address the audit objection/internal control weaknesses, issues of disallowances, if any. Planning, Monitoring, Reviewing and Supporting the SNO/SPO in logistics management. Data entry operator: Qualifications: Graduate in any discipline, with a diploma in computer application. Typing speed of 40 wpm in English. Experience: Minimum 1 year of relevant working experience preferably in health sector. Age Limit: As per NHM guidelines. Job requirements/responsibilities: Ensure regular entry of all relevant data pertaining to various aspects of NP-NCD in a systematic manner to facilitate its analysis. Analyse data and compile reports by using National NCD Portal. Provide troubleshooting support to health facilities for data compilation. Assist in preparing district-wise report based on key performance indicators. Maintenance and upkeep of the computer and its accessories including virus defence. Any other job assigned by concerned officers. 29 Human Resources at District NCD Division: Contractual staff positions supported at District NCD Division: Sl. No. Name of Post No. of Posts 1. District Programme Officer 1 2. District Programme Coordinator/Senior Treatment Supervisor 1 3. Finance and Logistics Consultant 1 4. Data Entry Officer 1 The remuneration structure of the contractual staff would be as per NHM norms. Terms of Reference of contractual posts at District NCD Division. District programme officer: Essential Qualifications: MBBS degree from an institution recognized by the Medical Council of India. With Diploma/Master’s in Public Health or MD/DNB in Preventive and Social Medicine/ Community Medicine/ Community Health Administration/ MBA (Health Care Administration). Experience: Essential: At least 1 year of experience in Health Management/ Public Health Programme/ Health Services after obtaining post graduate degree/Diploma. Desirable: Experience in Non Communicable Disease control program/projects.Age Limit: As per NHM guidelines. Job requirements/responsibilities: Implementing NP-NCD and NMAP activities. Preparing Programme Implementation Plan (PIP). Organizing review meetings and orientation workshops. Organizing regular capacity building workshops for human resources. Visiting blocks and peripheral units to monitor, evaluate and surveil the NCD activities. Facilitating and reviewing programme implementation including IEC activities at field level. Linkaging with other National Programmes. Collaborating with Medical Colleges, NGOs and other sectors. Preparing and submitting monthly, quarterly progress reports for NP-NCD to the State NCD Division by using National NCD Portal. Any other job assigned by concerned officers. District programme coordinator/senior treatment supervisor Essential Qualifications: M.B.B.S from institution recognized by Medical Council of India (MCI) or, Degree in Allied Health Sciences/Biosciences, with Diploma/Master’s in Public Health or MBA (Health Care Administration) Experience: Experience of working in Health Services/Public Health Programme in NCD. Working knowledge of operating computers and internet usage. Age Limit: As per NHM guidelines. 30 Job requirements/responsibilities: Implementing NP-NCD activities Preparing Programme Implementation Plan (PIP). Organizing review meetings and orientation workshops. Organizing regular capacity building workshops for human resources Visiting blocks and peripheral units to monitor, evaluate and surveil the NCD activities. Reviewing programme implementation including IEC activities at field level. Coordination and establish linkages with other National Programmes for prevention and control of NCDs. Collaborating with Medical Colleges, NGOs and other sectors. Preparing and submitting quarterly progress reports for NP-NCD to the State NCD Division by using National NCD Portal. Any other job assigned by concerned officers. Finance and logistic consultant Qualifications: Essential: Inter CA/ Inter ICWA/ M. Com or MBA (Finance/ Material Management) with knowledge of computers. Desirable: At least 1 year of experience in accounting including analysis, financial reporting, budgeting, financial software and reporting system. Experience: Experience of working in Health Care Financing/ National Health Accounts. Age Limit: As per NHM guidelines. Job responsibilities: General: To support all matters related to accounts, budgeting and financial matters and management of accounting procedures pertaining to NP-NCD in the District NCD Division. To organize and maintain the fund flow mechanism from districts to health facilities. Accurate and timely submission of quarterly report on expenditure to State, annual audited statement of accounts and intensively monitoring the financial management in District NCD Division. To support all matters related to logistics management (including purchases related to equipment and drugs under NP-NCD). Any other job assigned by concerned officers. Specific: Preparing annual and quarterly budget plans for the District. Ensuring that adequate internal controls are in place to support the payments and receipts. Ensuring timely consolidation of accounts/financial statements at the District facilities Training at District level on fund flow mechanism and filling up the reporting formats. Supporting audit of accounts of the District in accordance with the financial guidelines. Monitoring expenditure and receipt of Utilization Certificate (UC) and Statement of Expenditure (SoE) from CHC/PHC. Reviewing the accounts and records of the District on a periodic basis. Preparing consolidated SoE of NP-NCD on a quarterly basis. Coordinating with the State to address the audit objection/internal control weaknesses, issues of disallowances, if any. Planning, Monitoring, Reviewing and Supporting the DPO in logistics management. 31 Data entry operator: Qualifications: Graduate in any discipline. 1 year diploma in computer application. Typing speed of 40 wpm in English. Experience: Minimum 1 year of relevant working experience preferably in health sector. Age Limit: As per NHM guidelines. Job requirements/responsibilities: Ensure regular entry of all relevant data pertaining to various aspects of NP-NCD in a systematic manner to facilitate its analysis. Analyse data and compile reports by using National NCD Portal. Provide troubleshooting support to health facilities for data compilation. Assist in preparing district-wise report based on key performance indicators. Maintenance and upkeep of the computer and its accessories including virus protection. Any other job assigned by concerned officers. Human resources at District NCD Clinic: Contractual staff positions supported at District NCD Clinic: Sl. No. Name of Post No. of Posts 1. Consultant (MD Medicine) 1 2. GNM/Staff Nurse 1 3. Physiotherapist 1 4. Counsellor 1 5. Data Entry Operator 1 The remuneration structure of the contractual staff would be as per NHM norms. Terms of Reference of contractual posts at District NCD Clinic. Consultant (MD Medicine): Essential Qualifications: MD (Medicine) from an institution recognized by the National Medical Council. Experience: At least 1 year of experience of working in a Hospital. Age Limit: As per NHM guidelines. Job requirements/responsibilities: To examine and manage NCDs. To refer complicated cases to higher care facilities. To provide follow up care to the patients. To use CPHC NCD IT system for recording and reporting. Any other job assigned by concerned officers. 32 GNM/Staff Nurse: Qualifications: GNM qualification as recognised by Nursing Council of India. Experience: At least one year of experience of working in a hospital. Age Limit: As per NHM guidelines. Job requirements / responsibilities: To assist Medical Officers in Management and follow-up of patients attending the NCD Clinic. To counsel patients and their family members about risk factors of NCDs. To provide home based care. To use CPHC NCD IT system for recording and reporting. Any other job assigned by concerned officers. Physiotherapist (NCD): Essential Qualifications: Bachelor