European Journal of Cardiovascular Medicine

Health systems in India are evolving in alignment with shifting of health needs and disease burden, with expanded emphasis on Non-Communicable Diseases (NCDs). The 2030 Agenda for Sustainable Development Goals adopted by the United Nations in 2015 recognized NCDs as a major public health challenge and included Sustainable Development Goal (SDG) target 3.4 to reduce premature mortality from NCDs by one‐third¹.

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. 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 group².

In India, there are estimated 77 million people above the age of 18 years suffering from diabetes (type 2) and nearly 25 million are prediabetics. More than 50% of people are unaware of their diabetic status which leads to health complications if not detected and treated early³. In 2019, globally; diabetes was the direct cause of 1.5 million deaths, 48% of which were due to diabetes occurring before the age of 70 years. Another 460 000 kidney disease deaths were caused by diabetes and raised blood glucose causes around 20% of cardiovascular deaths². Adults with diabetesb have a two- to three-fold increased risk of heart attacks and strokes⁵

The government of India launched the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD) erstwhile known as National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) in 2010 in 100 districts across 21 states with an objective to prevent and control major NCDs as most people with diabetes and hypertension do not seek health care even when they know they have the condition, until symptoms appear⁶. The rationale behind the NP-NCD was to provide technical, financial and logistics support to the State Governments with the focuses on health promotion, screening, early diagnosis, and management of individuals with NCDs along with addressing their risk factors.

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 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 component of this initiative includes population enumeration, assessment of risk factors, mobilizing communities for screening at Health Sub- Centers (HSC), Primary Health Centres (PHC) in rural and urban areas, health promotion, initiation of treatment at a PHC, referral to higher centres for further treatment, and follow up to ensure continuum of care.

Darbhanga district, located in northern Bihar, India, has a total population of 3,937,385 according to the 2011 census, with a population density of 1,101 person per square kilometer. According to the study conducted in district Darbhanga 7.03% of rural participants had Type 2 diabetes and 8.04% of participants had a prediabetic diagnosis in district Darbhanga. Diabetes affected 28% of participants over the age of 70, compared to 11% of those in the 25 -39 age group⁸.

The assessment of diabetes surveillance under the NP-NCD program was conducted in accordance with United States Centers for Disease Control and Prevention guidelines, focusing on five attributes i. e. sensitivity, simplicity, flexibility, acceptability, and stability. This study aims to describe the existing diabetes surveillance system under the NP-NCD program in Darbhanga by assessing selected attributes and provide evidence-based recommendations based on the findings. A descriptive cross-sectional study was carried out in two blocks of Darbhanga district, Bihar, from January to December 2023, with field data collection occurring between March and April 2024.

A two-step simple random sampling method was employed, selecting two blocks from the district and subsequently choosing two Health Sub-Centres/Health and Wellness Centres (HSC/HWC) from each block. Key informants included district-level officials, block medical officers, nurses, data entry operators, community health workers, ASHAs. Data collection involved interviews using a piloted semi-structured questionnaire and secondary data analysis from the national NCD portal

Attributes selected to assess the Diabetes surveillance system under NP-NCD:

As per the Operational Guideline on Prevention, screening and control of Non communicable Diseases: Hypertension, Diabetes, Common Cancers (Oral, Breast, Cervix) (Part of Comprehensive Primary Health care), Ministry of Health and Family Welfare, Government of India, 2016, individuals aged 30 years and above comprise 37% of the total population, which is relevant for population-based screening⁶.

1. Sensitivity: The sensitivity refers to the proportion of cases of a disease (or other health-related event) detected by the surveillance system and / or the ability to detect outbreaks, including the ability to monitor changes in the number of cases over time. Method of assessment: Analysis of the National NCD portal data was conducted to calculate the percentage of individuals enrolled in PBS against to the target, the percentage of individuals screened, the percentage referred for diagnosis, and the percentage diagnosed with diabetes.
2. Simplicity: The simplicity of a public health surveillance system refers to both structure and ease of operation. Surveillance systems should be as simple as possible while still meeting their objectives. Method of assessment: Interview of key respondent and calculation of the responses on awareness about the NP-NCD, steps of PBS, diagnosis and referral system.
3. Flexibility: A flexible public health surveillance system can adapt to changing information needs or operating conditions with little additional time, personnel, or allocated funds. Method of assessment: Interview of key respondent regarding their capacity to transition from a paper based to electronic method for PBS and referral for diagnosis reporting system.
4. Acceptability: Acceptability reflects the willingness of persons and organizations to participate in the surveillance system. Method of assessment: Interview of key respondent regarding their willingness and practices to update data on National NCD portal.
5. Stability: Reliability (i.e., the ability to collect, manage and provide data properly without failure) and availability (the ability to be operational when it is needed) Method: Interview of key respondent about their training status and ability to collect and manage data in National NCD portal.

Table 1: Human Resource Profile in study blocks of Darbhanga district

Human Resource Profile at District NCD Division:

At district level, District Program Officer for NCD, Finance and Logistic Consultant and Data Entry Operator for NCD were available and Senior Treatment Supervisor position

was vacant in Darbhanga district.    Kindly refer to the table 1 for district NCD division HR profile:

Table 2: Human Resource Profile at district level in Darbhanga

Surveillance system attributes:

Five surveillance system attributes were analyzed to assess the Diabetes surveillance under NP-NCD in district Darbhanga i. e. Sensitivity, simplicity, flexibility, acceptability and stability. Kindly refer to the table 3:

• Sensitivity: Person enrolled in Population Based Survey was 21% (308468), 19% (275256) person screened and 0.3% (3784) referred to higher center for diagnosis against the target of 14568320. No cases of Diabetes were diagnosed in the study blocks according to the National NCD portal. The average of all indicators yielded an overall sensitivity score of 10%.
• Simplicity: Simplicity of NP-NCD measured among ASHA was 47%, among ANM/CHO was 90% and

Medical Officers was 80%. Overall simplicity was calculated as 72% at district level.

• Flexibility: Flexibility of NP-NCD scored 0% for ASHA workers and 86% for ANM/CHO, resulting in an overall flexibility score of 24% at the district
• Acceptability: Acceptability of NP-NCD measured among ASHA was 0%, among ANM/CHO was 71% and among Mos was 38%. Overall acceptability calculated 36% at district level.
• Stability: Stability scoring for NP-NCD were 54% among ASHA workers, 67% among ANMs, and 50% among block health officials, and overall stability score of 57% at the district level.

Table 3: Attributes of Diabetes surveillance for NP-NCD for 2023 in Darbhanga district, Bihar

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. Over the time the diabetes can damage the heart, blood vessels, eyes, kidneys and nerves. We analyzed the National NCD portal data, selected surveillance system attributes to assess the Diabetes surveillance under NP-NCD in district Darbhanga.  The surveillance system attributes were classified in three categories based on overall scoring i. e. poor for <50%, moderate 50% - <80% and good ≥80% score.

Overall sensitivity was grades as poor in district Darbhanga and the surveillance system is not enough sensitive to identify all cases of Diabetes in early stage to initiate the treatment.

The program simplicity was measured by assessing the awareness level of health workers at various level regarding the PBS, age group to be surveyed, screening and diagnosis process of Diabetes under NP-NCD. Overall, the simplicity grades as moderate at district level which was poor at community level and good at HSC/HWC and block level, The program flexibility was measured by assessing the willingness of surveyor and FLHW to adopt the paper based to digital reporting system. Overall flexibility graded poor at district level with was poor at community level and good at HSC/HWC level. Acceptability of the program was measured by assessing the data recording and reporting practices in National NCD portal at surveyor, HSC/HWC and PHC level. Overall, the acceptability was graded as poor at district level with was poor at community and block level and moderate at HSC/HWC level. Stability of the program was measured by training status of the staff involved in the program, availability of the essential logistics and accessibility to the National NCD portal and its optimal utilization. Stability of the program was grades as moderate at all levels.

Overall, the NP-NCD's surveillance system attributes of simplicity and stability were assessed as moderate, but its sensitivity, flexibility, and acceptability were assessed as poor in Darbhanga district. The study concludes that the NP-NCD surveillance system in district Darbhanga is not sufficiently sensitive for effective population screening, early diagnosis of the Diabetes, and the national NCD portal is underutilized for reporting individual diagnosis, treatment, follow-up, and referral records during the reference period of January to December 2023. ASHA workers did not adopt the change in reporting system of surveillance from paper based to digital method. Availability of the tools at ASHA and ANM/CHO level is also poor that leaded to suboptimal data reporting in National NCD portal. The study findings reveal the significant vacancies of the staff at community level (ASHA Workers), HSC/HWC level (ANM, CHO), PHC Level (Medical Officers) and at district NCD division level (Senior Treatment Supervisor). Shortage of adequate and trained manpower is the major reason of poor performance of the NP-NCD surveillance system.

Recommendations:

Based on the study’s findings and conclusion, the following recommendations are proposed to strengthen the Diabetes surveillance under NP-NCD in Darbhanga district:

1. Filling Staffing Vacancies: Immediate action should be taken to address the significant staffing vacancies at the district, block, HSC/HWC, and community levels, as well as within the district NCD division.
2. Capacity building of staffs involved in NP-NCD: There is a need for more comprehensive and continuous training programs for all health workers, including ASHAs, ANMs/CHOs, and Medical Officers. Training should emphasize not only the basics of the NP-NCD program but also the use of digital tools for population surveys and screening. Special focus should be placed on encouraging ASHAs to fully transition from paper-based to digital survey forms to improve data accuracy and efficiency.
3. Regular Program Reviews: Establish a system for regular review and monitoring of the NP-NCD program at all levels in district Darbhanga, to identifying gaps in program implementation, ensuring accountability, and ensuring timely corrective actions.
4. Availability of essential logistics: Availability of Smartphone to ASHA workers and ANMOL Tab to ANM/CHO is the basic prerequisite to adopt the transition of surveillance system from paper based to digital method and for timely updation of the data in NCD portal.
5. Timely Reporting in National NCD portal: Strengthen the reporting mechanisms to ensure that all individual diagnoses, treatments, follow-ups, and referrals are documented promptly and accurately.

Limitation:

The study was done only in two block of district Darbhanga for only Diabetes surveillance hence generalization of data for overall NCDs and beyond district Darbhanga is limited.

Acknowledgement:

The authors gratefully acknowledge the support of the District Health Authorities, the Civil Surgeon, the District Nodal Officer for Non-Communicable Diseases, the District Immunization Officer, and all study participants

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