Common cause

A tech-savvy screening project for noncommunicable diseases has set itself the gigantic task of testing all Indians aged 30 and above — that’s 550 million people and counting

I t has crept up almost by stealth to become the seemingly unstoppable ogre, blasting a hole in India’s healthcare system as it barrels down a ruinous road.

Noncommunicable diseases (NCDs) — principally cardiovascular conditions, chronic respiratory disease, cancers and diabetes — claim nearly 6 million lives a year in India, accounting for more than 60% of all deaths in the country.

That’s a sea change from barely 30 years ago, when communicable illnesses such as malaria and diarrhoea combined to form the biggest killer by category. It’s a transformation fuelled in part by, ironically enough, economic progress.

Despite the increasingly lethal toll they take, NCDs do not get the attention they deserve. For evidence, consider the mindscape occupied currently by Covid-19, which for all its virulence and destructive capacity has done a fraction of the damage in terms of lives lost.

The ground is shifting, though, and it begins with getting a grip on the extent of damage being done by NCDs, identifying the people at risk, and starting early with a treatment course.

The effort to restrain NCDs in India began in right earnest in 2010, when the ‘national programme for the prevention and control of cancer, diabetes, cardiovascular diseases and stroke’ (NPCDCS) was launched. On the table were a bunch of initiatives: strengthening infrastructure, developing human resources, and promoting health, early diagnosis and referrals.

Progress in the years since has been slow and patchy. NCD cells have been created at the national, state and district levels for programme management, and NCD clinics in community centres to provide free diagnosis, treatment and medicine for familiar conditions. Cardiac care units for emergency care and day care facilities for cancer treatment have also come up in some districts.

‘Population-based screening for common NCDs’ is a key feature of the programme matrix. Frontline health workers and the primary healthcare system comprise the vehicle for such screening in NPCDCS, which was integrated with the National Health Mission in 2013 to smoothen and hurry up the testing process.

The big shift

The screening component has undergone a raft of alterations from back then. The big shift happened with the move to a population-based screening model and the placing of this inside Ayushman Bharat, the potentially path-breaking health assurance scheme promulgated by the Indian government in 2018 for about 500 million of its poorest citizens.

Classifying the screening as an essential service and having it unfold through the newly introduced network of health and wellness centres has added strength to the test-and-treat endeavour. The objective is nothing if not ambitious: to screen in excess of 550 million people for common NCDs and cover India’s entire population in quick time.

Break this down and it translates into a gigantic exercise — the screening of every Indian over 30 years of age for a range of NCDs, including hypertension, diabetes, heart conditions, and oral, breast and cervical cancers. Technology, collaboration and commitment are essential elements in the quest.

The Tata Trusts joined the screening mission in august 2018 following the signing of an agreement with the Indian government’s Ministry of Health and Family Welfare (MHFW). The Trusts’ primary partner in the undertaking is American multinational company Dell, which has developed the application for it in consultation with a clutch of experts from varied organisations.

The Trusts have fashioned a technical support unit (TSU), operating at the centre as well as in the states, to implement the project. Monitoring, coordination, capacity building, across-the-board mentoring support, a robust digital platform and, not least, dedicated personnel — a raft of methods and constituents has been employed to realise the screening goal.

Different arms of the TSU have been installed at the national, state and district levels to ensure effective execution. The central unit rests within MHFW and there are 14 state-level units. Accredited social health activists (Ashas) and auxiliary nurse-midwifes (ANMs) — equipped with mobile phones and tablets — comprise the army of workers breathing life into the project in the field.

The process starts with a population enumeration, followed by screenings of individuals and the recording of their data. Those with health problems are referred to the medical officer at the designated primary health centre. Well-defined treatment protocols happen from there on. All the information gathered is made available digitally for the district and state officials involved in the initiative.

A ‘cascade training model’ has been used to bring everybody in the programme up to par, in field practices and with the application software. There are master trainers to train people working in the districts and subdistricts. Monitoring and supervision are also part of the package.

Numbers add up

The success of the effort is reflected in the numbers notched up. The programme has found its feet in 28 state and union territories and, as of March 2020, there have been 53.4 million enrolments in it and more than 20 million screenings done. The figures point to the scale of the attempt in what is a singular initiative for India.

Acquiring the capability to pull the programme off has not been easy for the Tata Trusts. It began with a pilot project in Andhra Pradesh in 2015-16 to devise a health checkup scheme for women. This evolved further through a similar screening intervention in neighbouring Telangana about a year later. The concept and its implementation caught the eye of the central government, then considering ways to get going with a digitised, pan-India population-based screening structure.

Schoolgirls at a health awareness rally in Vastavai in Andhra Pradesh’s Krishna district

On call and on the ball…

I t does not have the heft or the cachet of the nationwide screening programme for noncommunicable diseases, but the telemedicine project being implemented by the Tata Trusts — in Hyderabad in Telangana, Vijayawada in Andhra Pradesh and Mathura in Uttar Pradesh — shares similarities in its use of technology for health and secures similarly high impact, even if on a smaller scale. 

The premise is straightforward and the means employed sophisticated: use a hub-and-spoke model and innovative technology to reach and serve a wide section of the rural populace by delivering desperately needed health services.

What the programme does most effectively is deal with the three ‘Ds’ in the cost equation that bedevils poor people trying to access private medical care: doctors, drugs and diagnostics. There is a fourth D — distance — that the telemedicine initiative bridges.

The programme was seeded in Vijayawada in 2016 and the manner in which it has matured there shows its strengths. The way this operates, there is a city-based hub out of which six-seven general physicians connect via computer screens and the internet to 20 semi-urban and rural spokes (the telemedicine centres), which are run by paramedics and service 265 villages.

The focus is noncommunicable diseases, consultations are free and medicines are subsidised. A recently opened laboratory pitches in with diagnostics, as do mobile units. If a patient needs to see a specialist, he or she is referred to a government hospital. Remote villages are reached by mobile medical units with a doctor in attendance.

Vijayawada is an all-Tata Trusts operation. In Mathura, the Trusts have partnered the Ramakishna Mission to offer the same set of services, albeit to a lesser extent. The biggest and most ambitious is the version in Hyderabad, where the collaboration is with the Telangana government. There are four doctor hubs here, more than 100 spoke clinics, a coordination centre and a helpline.

“Lots of people and organisations came and made presentations on how to roll out such a screening initiative, but the [central government] opted for the Trusts, simply because our work stood out,” says Aman Kumar Singh, who heads the programme from the Tata Trusts side. “They had faith in us.”

The NPCDCS programme screens for hypertension, diabetes, heart conditions, and oral, breast and cervical cancers

For all the experience garnered in Andhra Pradesh and Telangana, shaping an analogous project to be spread all over India was another matter. “We are looking to screen in excess of 550 million people who fall in this category of 30 years and above,” reiterates Dr Singh. “We needed a specific set of tools and a robust framework to record data. The idea was to catch these diseases at an early stage, intervene at an early stage, track and follow the intervention, and deliver services close to where the affected live.”

The backbone of the programme, Dr Singh adds, are the primary health centres and their Asha and ANM workers. Each of these workers serves some 1,000 people in two-three villages. “They have a set of questions and they go out and get the answers to these. That’s the basis of the community-based assessment checklist we keep in our records.”

A unified platform

The screening story has gone so well that the government has approached the Trusts to design a unified software platform where applications from other centrally run programmes can rest and be delivered. “This is a work in progress,” says Dr Singh. “We have been delayed by the Covid-19 crisis but 80-85% of the platform is already ready.”

For the Trusts, the blue riband remains the original. “There have been plenty of challenges and there are some places where you have to keep on working and working till you finally succeed,” says Dr Singh. “Ups and downs are inevitable, but largely it has been smooth sailing. That’s why 480 [out of 739] districts in India have the programme.”

That’s good news for the country, despite Dr Singh’s humility about what has been accomplished so far. “I feel we could have progressed faster but there is a sense of satisfaction, for sure. We have a few more years left and we should be able to achieve the goals we have set for ourselves. More crucially, in another 10 years all of us may well have our own ‘health passports’ thanks to the programme.”