Context

We are implementing this project, funded by the Landmark Group, in an Urban PHC (UPHC) area in Mysuru City focusing on the NCD care continuum. The project consists of two phases; Phase I consists of population level screening of diabetes, hypertension, understanding the levels of risk factors in the population, qualitative research involving diabetics, hypertensive, service providers, and series of consultations with the officials from Government of Karnataka with an aim of developing the continuum of care package. Phase II consists of implementing the intervention package to establish a continuum of care in the UPHC area of Mysuru city.

After the completion of the Phase I period (July 2017- March 2018) of the project, currently Phase II interventions are being implemented.

Implementation

The primary objective of the Phase II project is to develop a model that will result in high coverage and quality of NCD services across the prevention to care continuum. The secondary or sub objectives include the following:

• To attain high coverage of NCD screening, treatment, care and counselling services
• To provide high quality of NCD screening, treatment, care and counselling services
• To improve awareness and healthy behaviours around NCDs in the community intervention strategy

The Phase I evidence across the prevention to care continuum helped to design a comprehensive NCD program.

An established NCD care continuum framework to design interventions across community, facility and larger health systems was utilised. To build an impactful chronic disease control model, a three pronged intervention approach at facility-health services (supply side), at community (demand side) and at a larger embedding health systems for supporting health policies, and supply of resources (staff, diagnostics and drugs) was adopted.

Through the ongoing interventions, we are also stressing upon important facets for NCD control, i.e. quality improvement at facility, health systems (essential diagnostics, medicines, etc.), decision support (adherence to medications, to follow up, communication with specialists), and human resources (staff training, dedicated NCD staff).

This intervention model is an iterative one and will be further evaluated through a series of formative research and impact evaluation during next phases of this project.

Context

Despite the efforts made by the government to improve quality of services and community accountability in the past, health care is still not accessible to many of the urban and rural poor in India. Public health facilities are underprepared and high cost at private facilities limits many access care at time of need.

Adding to the worries, people in remote areas are more challenged as often health care facilities are far from their reach. Delivering technology enabled health care services through local entrepreneurs at the door step with minimal cost could be a game changer in improving the health status of people in remote areas.

We propose to test the feasibility of a health entrepreneur model in improving access to health care in Chincholi, one of the most backward taluka in Karnataka, through a project funded by the Landmark Group.

Implementation

We aim to assess the feasibility and scalability of implementing a health entrepreneurship model that aims to improve accessibility and affordability of health services in a backward taluka of northern Karnataka. We use a pre-post intervention evaluation design within which formative research and process learning are embedded. This approach helps us to identify barriers and design scalable models, implementation of these models in community settings.

Health Entrepreneurs (HEs) are women and men entrepreneurs from the local community who will work towards improving accessibility and affordability of health services in their community.

They offer services, including:

• Screening / diagnostic services (FBS, PPBS, RBS, BP, HB%, HbA1c, renal function tests etc.)

• The sale of health products (Nutrient rich fortified food, sanitary pads etc.)
• Referrals and linkages to higher facilities if tertiary level care is required

The project has extended initial support by procuring health kit and products. It enables HEs to sustain on their own through income generated by selling health and nutritional products, doing blood tests and measuring vital parameters. HEs will receive initial training to learn about basic health care, health care products, entrepreneurship skills, counselling skills, communication skills, doing blood tests, measuring vital parameters like blood pressure and referral to the health facilities. HEs will also receive regular updates about newer effective diagnostic services, health products, nutritional products etc.

Each entrepreneur receives a kit with point of care devices, health products and a tablet to provide health services to their local community. Apart from health education, tablet is also used for promoting new products and ordering new stock. The implementation support team will also use the tablet to monitor the entrepreneurs’ activity.

Context

This project, seeks to implement an innovative community health worker model embedded within the existing urban health system. The focus remains to bring more patient-centricity in the community outreach, mobilization and communication efforts as well as in improving quality care at the facilities to achieve better treatment outcomes. KHPT has designed and is implementing this innovative model in partnership with Government of Karnataka to support, scale and sustain the program over time.

This model uses community health workers (CHW) and community health worker supervisors (CHW-S), integrated into primary care teams, to bring customized care closer to home for diabetic and hypertensive patients and help patients meet treatment goals with timely referrals and effective follow-ups. The community-level efforts are also complemented by strengthening patient-centric counselling and quality care in the facilities.

Geography and Target Population

The proposed pilot will be undertaken in the catchment area of one of the urban primary health centres (UPHCs) covering a population of around 58,000, of which around 3100 were living with diabetes and/or hypertension.

Among all those diagnosed, around 2100 (700 approx. were hypertensive; 600 approx. were diabetics; 800 approx. were both diabetic and hypertensive) are currently available for follow-up in the Kumbarakoppalu UPHC area. Among this group of patients, only 38% has demonstrated optimal disease control (48% for hypertension and 29% for diabetes).

The major reasons for poor control among the rest of the patients can be attributed to irregular follow-up, non-adherence to medicines and to their poor lifestyle. Many are unaware of the risk factors of NCDs and the importance of regular visits to a healthcare facility. We will assess the feasibility and effectiveness of the proposed CHW model to achieve disease control levels to more than 60% during the project period.

Specific objectives of the proposed model:

• To test the feasibility of an incentive-based community health worker model in an urban setting
• To implement patient centric care for improved NCD outcomes for at least 60% of the diagnosed population
• To integrate, embed and sustain the model within the existing urban health system

Implementation model

The implementation model focuses on four core domains such as community outreach, quality of care and referrals, measurement and evaluation, and adoption, and scale with support from the government. A cadre of CHWs will be trained on core competencies pertaining to patient centric care and will be instrumental for patient outreach and mobilisation for care.

Customised Behaviour Change Communication (BCC) based on individual patient risk and health care needs will be delivered by the CHWs at doorstep of the patients. Supportive supervision of CHWs and mentoring for project staff will be an integral part of the model.

Similarly, on the facility front, quality improvement initiatives will be prioritised, regular supply of drugs and consumables will be ensured, in addition to provision of individual counselling and adherence to standards of treatment protocols. Data quality management, regular monitoring, technology led patient tracking and follow-up will all be part of robust measurement domain of the project.

Advocacy with the government and policy bodies at all levels will be inherent and follow a continuous process; they will be key for adoption and scale up of innovations emerging from the project, in addition to ensuring regular supply of drugs and consumables to the health centres.

An implementation research for developing a CPHC model in Mysuru city to reduce costs, morbidity and mortality by increasing the proportion of persons covered by the CPHC