|Year : 2022 | Volume
| Issue : 3 | Page : 245-250
Preparedness of healthcare facilities of manipur in the management of noncommunicable diseases: A cross-sectional study
Avantika Gupta1, Takhellambam Gitanjali2, Soubam Christina1, L Janani1, M K Mohammed Jamsheer2, Brogen Singh Akoijam3
1 Senior Resident, Professor, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Post Graduate Trainee, Professor, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
3 Professor and Head, Professor, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Submission||07-Jan-2022|
|Date of Decision||21-Jul-2022|
|Date of Acceptance||22-Jul-2022|
|Date of Web Publication||22-Sep-2022|
Brogen Singh Akoijam
Department of Community Medicine, Regional Institute of Medical Sciences, Lamphelpat, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: India is experiencing a rapid health transition with a rising burden of noncommunicable diseases (NCDs), causing significant morbidity and mortality. Cost-effective interventions for comprehensive NCD management can only be designed after assessing the readiness of various health facilities. Objectives: This study aimed to assess the preparedness of healthcare facilities of Manipur in the management of NCDs and to assess the knowledge of doctors regarding NCDs. Methods: A cross-sectional study was conducted in 21 public healthcare facilities in seven districts of Manipur during October 2021. Readiness of these facilities was assessed through observation and interview of doctors and nurses using a checklist adapted from the WHO Package of Essential NCDs. Knowledge of 153 doctors was also assessed using a self-administered, structured questionnaire. Data were entered in SPSS-26 and expressed using descriptive statistics. Results: General readiness index of primary health centers (PHCs), community health centers (CHCs), district hospitals (DHs), and tertiary care centers (TCCs) was 47%, 66.3%, 73.2%, and 70%, respectively. CHCs were ready in the domains of patient care services (80%), human resources (75%), and advocacy (91.7%). DHs and TCCs were ready in terms of patient care services, human resources, record maintenance, referral system, and advocacy. PHCs were not ready in any of the nine domains. Majority of the doctors (88%) had inadequate knowledge regarding NCDs. Conclusion: PHCs and CHCs were not adequately prepared, but DHs and TCCs were ready to manage NCDs. More than four-fifth of the doctors had inadequate knowledge. Strengthening PHCs and CHCs and training of healthcare workers are needed for integrated NCD management.
Keywords: Healthcare facilities, India, noncommunicable diseases preparedness, WHO Package of Essential Noncommunicable Diseases
|How to cite this article:|
Gupta A, Gitanjali T, Christina S, Janani L, Jamsheer M K, Akoijam BS. Preparedness of healthcare facilities of manipur in the management of noncommunicable diseases: A cross-sectional study. Indian J Public Health 2022;66:245-50
|How to cite this URL:|
Gupta A, Gitanjali T, Christina S, Janani L, Jamsheer M K, Akoijam BS. Preparedness of healthcare facilities of manipur in the management of noncommunicable diseases: A cross-sectional study. Indian J Public Health [serial online] 2022 [cited 2022 Sep 27];66:245-50. Available from: https://www.ijph.in/text.asp?2022/66/3/245/356608
| Introduction|| |
Each year, noncommunicable diseases (NCDs) account for 71% of all deaths globally. More than 15 million people die from an NCD aged between 30 and 69 years; 85% of these premature deaths occur in low- and middle-income countries. One in four Indians has a risk of dying from an NCD before they reach the age of 70. Rapid epidemiological transition in India has escalated “disability-adjusted life years” (DALYs) due to NCDs from 30% in 1990 to 55% in 2016 and proportion of deaths due to NCDs from 37% in 1990 to 61% in 2016. All states of India had an epidemiological transition ratio of 0.75 or less in 2016.
Manipur, a northeastern state of India, has lower-middle epidemiological transition level with a ratio of 0.41–0.55. The number of DALYs due to NCDs increased by 68.5% in lower-middle group. In 2019–2020, Manipur had 30.3% men and 34.1% women who were overweight/obese, an increase by 10.5% and 8.1%, respectively, from 2015 to 2016. Men and women having very high blood sugar level (>160 mg/dL) were 8.3% and 6.3% and those having moderately/severely elevated blood pressure (≥160/100 mmHg) were 9.3% and 5.9%, respectively. NCDs accounted for 59.5% of all deaths in the age group of 40–69 years, 56.6% in >70 years, and 34.1% in 15–39 years in 2016.
Out-of-pocket expenditure (OOPE) associated with acute and long-term effects of NCDs results in catastrophic health expenditure for households. A large national survey in India found that spending on NCDs accounted for 5.17% of household expenditure. A macroeconomic analysis estimated that each 10% increase in NCDs is associated with a 0.5% lower rate of annual economic growth in terms of loss of productivity and decrease in GDP.
Under National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) till December 2021, 677 NCD clinics at district level, 187 district cardiac care units, 266 district day care centers, and 5392 NCD clinics at community health center (CHC) level have been set up to ensure the treatment of common NCDs, which will help reduce OOPE by providing range of services. Around 6.61 crore persons attended the NCD clinics and were screened for common NCDs during 2019–2020. In addition, during outreach activities, 5.6 crore NCD checkups were conducted. However, there have been critical gaps in areas such as availability of trained human resource, essential drugs and laboratory services, referral systems, NCD guidelines, adherence to NPCDCS, lack of maintenance of records and reports in healthcare facilities of India, and inadequate provider knowledge as well as community awareness.,,,,,,,,,,,,,
Efficient use of limited healthcare resources, sustained health financing mechanisms, access to basic diagnostics and essential medicines, and organized medical information and referral systems are essential for the provision of equitable care for people with and at risk of NCDs. To achieve Sustainable Development Goal 3.4, targeting and building strong primary healthcare systems, which are the first point of contact from the grass-root levels, are needed.
Thus, the objective of this study was to assess the readiness of the health facilities of Manipur in the management of NCDs and to assess the knowledge of doctors. This will enable to take necessary actions to strengthen the domains that are deficient.
| Materials and Methods|| |
Study design and duration
A cross-sectional study was conducted from October 2 to 25, 2021, in public healthcare facilities in different districts of Manipur.
Manipur has 16 districts of which ten are hill and six are valley districts. Five valley districts (Imphal East, Imphal West, Kakching, Bishnupur, and Thoubal) were included in this study. Only one valley district (Jiribam) was not included due to travel inconvenience. Of the ten hill districts, two (Churachandpur and Kangpokpi) were randomly selected for the survey. Health facilities such as primary health centers (PHCs), CHCs, and district hospitals (DHs) from each of these districts were selected purposively based on travel and time convenience as well as availability of healthcare providers. A tertiary care center (TCC) in Imphal West was also included.
Ethical approval was obtained from the Research Ethics Board of the institute (A/REB/Prop (Sp)/B2/21/2021). Permission was taken from the Director, Directorate of Health Services, Manipur. Informed written consent was taken from the doctors and nurses before the interview. Confidentiality was maintained by not taking the names of the health facilities. Results are presented in a cumulative manner where the individual data cannot be recognized. Privacy was maintained by interviewing the healthcare workers in a separate space.
For health facility readiness assessment, a checklist adapted from the WHO Package of Essential NCDs (WHO-PEN) was used. It comprised nine domains on “patient care services,” “human resource,” “records/reports,” “monitoring and evaluation,” “referral system,” “advocacy,” “essential drugs,” “essential technology,” and “essential tools,” under which certain questions were assessed. For the knowledge, an assessment tool to support capacity building from the WHO-PEN with added questions on NPCDCS was used.
Domains of “patient care services,” “human resources/staffs,” “records and reports,” “monitoring and evaluation,” “referral systems,” and “advocacy” were assessed using both observational and face-to-face interview techniques from doctors of the health facility. Remaining three domains were assessed via interview and observation from the nurses of respective health facilities. Knowledge questionnaire was self-administered among all the doctors of those health facilities available on the day of data collection.
After checking for completeness and consistency, data were entered into SPSS 26 for windows (IBM Corp. Chicago, U.S). Data were analyzed and presented in the form of descriptive statistics (frequency, percentage) using bar graphs, radar diagram, and pie chart.
For domain-wise readiness index, the averaged percentage of each of the nine domains was compared to cutoff at 70% based on review of literature. Facilities scoring ≥70% were interpreted to be ready in that domain. Similarly, for general readiness index, averaged percentage of all domains was compared to cutoff at 70% and facility score of ≥70% was interpreted to be ready in the management of NCDs. Averaged percentage score of 19 questions under knowledge questionnaire was compared to a cutoff of 50%. Those doctors ≥50% were interpreted to have “adequate knowledge.”
| Results|| |
A total of 21 healthcare facilities, i.e., 12 PHCs, four CHCs, four DHs, and one TCC, were included in the study. 17 facilities were from valley districts of Manipur.
General readiness index for PHCs and CHCs was 47% and 66.3%, respectively. Hence, they were not ready to manage NCDs, whereas DHs and TCC with readiness index of 70% and 73.2%, respectively, were ready to manage NCDs, as shown in [Figure 1].
|Figure 1: Distribution of health facilities according to their “general readiness index” (N = 21). PHC: Primary health center, CHC: Community health center|
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Domain-wise readiness index
[Figure 2] shows that PHCs were not ready in any of the nine domains. As is highlighted in [Table 1], CHCs did not meet the 70% cutoff in the domains of records and reports (58.3%), monitoring and evaluation (55%), referral systems (66.7%), essential drugs (45%), technologies (64.8%), and tools (60%). DHs were not ready in the domains of monitoring and evaluation (50%), essential drugs (36%), technologies (59.1%), and tools (60%). Similarly, TCC did not meet the cutoff in the domains of monitoring and evaluation (60%), referral systems (33.3%), essential drugs (48.5%), technologies (68.2%), and tools (40%).
|Table 1: Distribution of health facilities according to their domain-wise readiness index (%) (N=21)|
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|Figure 2: Distribution of health facilities according to their domain-wise readiness index (N = 21). PHC: Primary health center, CHC: Community health center|
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Patient care services
Majority, i.e., 12 of the facilities, had no dedicated NCD clinic and no separate NCD days. Of nine having separate NCD days, majority (14.3%) had 3 days per week. One-fourth of the PHCs, half of CHCs, and all DHs had dedicated NCD clinic. NCD guidelines were not available in five PHCs. Individual counseling for NCDs was not done in two PHCs. Screening for NCDs was done in all the health facilities.
Dedicated staff for NCD was available in 12 facilities. Dedicated staff for NCD was absent in seven PHCs and two CHCs. Trained staff for NCD management were absent in five PHCs.
Maintenance of patient unique ID, separate NCD register, and computerized records was not done in 52.4%, 19.0%, and 66.7% facilities, respectively. Patient unique ID was not maintained in eight PHCs, two CHCs, and one DH. Separate NCD register was not maintained in four PHCs. Computerized records were not available in ten PHCs, three CHCs, and one DH.
Monitoring and evaluation
Dashboard was not maintained in 47.6% of facilities, of which majority that is eight were PHCs. Out of 11 facilities maintaining dashboard, only eight facilities had it up to date. Performance indicators were not maintained in 57.1% facilities, of which eight were PHCs, two were CHCs, and two were DHs. Reminder system for patients was unavailable in majority, 71.4% of all the facilities, i.e., eight being PHCs, three being CHCs, three being DHs, and one TCC. NCD patient's record book was not given in 61.9% of health facilities. Around nine PHCs, one CHC, two DHs, and TCC did not give patient's record book.
Center for referral was available for all facilities, but referral slip was available in only 52.4%, out of which back-referral system was present in 63.6% of facilities. Six PHCs, two CHCs, and three DHs had referral slip. Back-referral system was present in three PHCs, two CHCs, and two DHs but absent in TCC.
Outreach sessions for NCD were not conducted by 50.0% of PHCs. Community participation that is involvement of local leader/clubs, village head, or panchayat members to manage NCDs was not done in seven of the facilities; six PHCs and one CHC. IEC materials for NCDs were unavailable in four PHCs.
Essential drug list was absent in 52.4% of the facilities, of which eight were PHCs and three were CHCs. According to the National List of Essential Medicines of India, 2021, among anesthetic agents, oxygen was available in 19 facilities, while morphine was not available. Among analgesics, paracetamol was available in 16, ibuprofen in 18, and aspirin in only 7 facilities. Among anti-allergics, epinephrine and prednisolone were unavailable in 12 and 16 facilities, respectively. Among anticonvulsants, diazepam was available in 17 facilities. Under anti-infective medicines, amoxicillin was available in 12 facilities. For cardiovascular, glyceryl trinitrate was available only in one DH and heparin in only TCC, but isosorbide dinitrate was unavailable in any of the facilities. Amlodipine was available in 19, thiazide diuretics and statins in ten, atenolol in nine, enalapril in six, and spironolactone in only two of health facilities. Among antidiabetics, insulin was available in only five but metformin in 15 facilities. Glucose injectable solution was available in 12 facilities. For electrolyte disturbances, sodium chloride infusion was available in 15 facilities.
Thermometer, blood pressure apparatus, weighing machine, and pulse oximeter were available in all the health facilities. Peak flow meter, spacers for inhalers, urine protein test strips, urine ketone test strips, urine microalbuminuria test strips, troponin test strips, tuning fork, electrocardiography and defibrillator were absent in majority i.e., 17, 16, 15, 16, 14, 16, 14, 12 and 16 of the health facilities respectively.
More than three-fourth of the health facilities had patient clinical records and medical information register. However, WHO-CVD Risk Prediction Chart, evidence-based clinical protocols, flowcharts with referral criteria and audit tools were absent in majority i.e., 14, 13, 16 and 15 health care facilities respectively.
Knowledge on noncommunicable diseases
Of 153 doctors, majority, 59.5%, were from TCC followed by DHs (20.3%), CHCs (11.1%), and PHCs (9.2%). Majority, 100 (67%), had heard of NPCDCS, but only 43% had adequate knowledge on the diseases covered under NPCDCS. Of 31% of the doctors who were aware of NPCDCS services, only 5% had adequate knowledge on the packages of services under NPCDCS. Majority, 90.2% and 97%, had not heard of reporting form and of patient-centered care, respectively. Majority, 137 (88%), of the doctors had inadequate knowledge regarding NCDs, as shown in [Figure 3].
|Figure 3: Distribution of participants according to adequacy of knowledge regarding noncommunicable diseases (N = 153)|
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Challenges and suggestions
Impact of COVID-19 pandemic, lack of trained staff and funds, inadequate drug supply, lack of proper transport facilities for referral, patient's noncompliance, and lack of community awareness are some of the common challenges cited by doctors of all the healthcare facilities. They further suggested having a separate NCD clinic with a dedicated trained staff.
| Discussion|| |
In this health facility assessment, DHs and TCC were prepared for NCD management, but PHCs and CHCs had general readiness index of only 47% and 66.3%, respectively. This is consistent with the findings of Pakhare et al. in Madhya Pradesh where PHCs were 37% ready and CHCs were 58.2% ready. Similarly, the governorate centers in Gaza strip, Palestine, in 2019 had scored a mean index lower than the 70% cutoff and was considered as “not ready.” National NCD Monitoring Survey (NNMS) during October 2017 to April 2018 highlighted that NPCDCS was being implemented in majority of CHCs (72.8%) and DHs (86.8%), which might explain higher percentage of general readiness index at these centers.
Readiness in this study was lowest in domains of essential “drugs,” “technologies,” and “tools” for all the levels of health facility. Average availability of drugs (44.27%), equipment (55.16%), and laboratory services (11.86%) for PHCs in Madhya Pradesh is similar with our findings. CHCs in the same study also showed a similar picture as our study. Percentage availability of necessary laboratory services was reported by 44.4% of PHCs and 58.3% of CHCs, and essential medicines were available only in 55.5% of PHCs and 50% of CHCs in Bengaluru. Similar gaps in the availability of diagnostics, laboratory services, and equipment have been assessed in various studies.,,,,,, In NNMS, the availability of all essential technologies and medicines for NCDs in primary care varied from 1.1% (95% confidence interval [CI]: 0.3–3.3) in rural to 2.3% (95% CI: 1.0–5.1) in urban public facilities.
In terms of patient care services, all the health facilities screened for NCDs in this study which is in line with NNMS survey findings, whereas 87.9% of PHCs, 92.0% of CHCs, and 98.8% of DHs provided screening services for NCDs. In this study, NCD guidelines were absent in five PHCs. A study by Parameswaran and Agrawal in 2019 showed that none of the PHCs had any written guidelines for the management of NCDs. Peck et al. in 2014 and Ahir in 2016 also documented unavailability of diagnostic and treatment protocols in health facilities of Tanzania and Gujarat, respectively., Similarly, readiness score in regard to “guidelines availability” was very poor in Bangladesh. Nine-tenth of the facilities in this study provided individual counseling for NCDs which is comparable to 70% of health facilities providing counseling services in a study by Aryal et al. Readiness index score for counseling services was 83.1% in Gaza strip.
In this study, more than two-fifth of the facilities did not have dedicated staff and two-fifth of the staffs in PHCs were not trained for NCD management. In Madhya Pradesh, PHCs and CHCs had an average availability of 18.2% and 49%, respectively, in the domain of human resource. Various studies have presented a paucity of trained health personnel in managing NCDs.,,,,,,,, In the nationwide survey by Krishnan et al., DHs were well-staffed, CHCs had shortfall in physiotherapist and specialist positions, whereas PHCs recorded a shortage of nurse-midwives and health assistants, and training under the NPCDCS was uniformly poor across all facilities.
Around four-fifth of health facilities maintained separate NCD register in this study, but computerized records were unavailable in more than three-fifth of the centers. 94.6% health facilities kept general outpatient department record of the patient in study by Aryal et al. All the facilities in survey by Nyarko et al. had medical registers, but computerized version was unavailable. Peck et al. found that supervision and reporting systems were significantly weaker for hypertension and diabetes than for HIV which coincides with low readiness index in domain of “monitoring and evaluation” in this study.
In this study, PHCs, CHCs, and TCC were not ready in the domain of “referral system.” Weak referral system was also cited as one of the barriers in the study by Panda et al. Referral criteria were unavailable in all the health facilities assessed by Ahir. Of 91.3% of the facilities referring emergency chronic disease in study by Aryal et al., only 16.7% of the referred facilities met the criteria of being in distance of <30 min. Feedback on referred patients from referral centers was a major challenge cited by all the PHCs in a study by Nyarko et al.
PHCs in this study were only 56% ready in terms of “advocacy,” but CHCs, DHs, and TCC were more than 70% ready. Eighteen of 24 health centers conducted outreach activities for health promotion in Tanzania. In Ghana, 56% of health centers had health promoters involved in giving health education through house to house, schools, and at church programs.
More than four-fifth of the doctors had inadequate knowledge regarding NCDs in this study which is comparable to the results of Onagbiye et al. and Akinwumi et al., Pati et al. in their narrative review identified lack of provider knowledge on the standards of NCD care as one of the challenges in the provision of integrated care for NCDs in India. This highlights the need of training of healthcare providers to deliver integrated NCD care at all levels. Tools such as WHO-PEN can be utilized.
Determining knowledge of the doctors in addition to health facility readiness assessment is one of the strengths of this study. This information can be used for capacity building. Further, evaluation of challenges and suggestions from doctors who are one of the key stakeholders gave an in-depth understanding. Results of this study can be used by the policymakers to take necessary action to upgrade PHCs and CHCs in all the domains and to strengthen and sustain DHs and TCC in the management of NCDs.
Disease-wise readiness index was not evaluated in this study which could be emphasized in future studies. Travel and time inconveniences made it difficult to randomly select health facilities which might affect the generalizability of study findings. Future large-scale studies assessing all the health facilities across the state will give a more comprehensive overview.
| Conclusion|| |
PHCs and CHCs were not adequately prepared, but DHs and TCC were ready to manage NCDs. More than four-fifth of the doctors had inadequate knowledge of NCDs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
India State-Level Disease Burden Initiative Collaborators. Nations within a nation: Variations in epidemiological transition across the states of India, 1990-2016 in the global burden of disease study. Lancet 2017;390:2437-60.
Ministry of Health and Family Welfare. National Family Health Survey-5 2019-21. India: International Institute for Population Sciences; 2021. p. 7. Available from: http://rchiips.org/nfhs/factsheet_NFHS-5.shtml
. [Last accessed on 2021 Dec 05].
Kundu MK, Hazra S, Pal D, Bhattacharya M. A review on noncommunicable diseases (NCDs) burden, its socio-economic impact and the strategies for prevention and control of NCDs in India. Indian J Public Health 2018;62:302-4.
] [Full text]
Pakhare A, Kumar S, Goyal S, Joshi R. Assessment of primary care facilities for cardiovascular disease preparedness in Madhya Pradesh, India. BMC Health Serv Res 2015;15:408.
Krishnan A, Mathur P, Kulothungan V, Salve HR, Leburu S, Amarchand R, et al.
Preparedness of primary and secondary health facilities in India to address major noncommunicable diseases: Results of a national noncommunicable disease monitoring survey (NNMS). BMC Health Serv Res 2021;21:757.
Ahir G. Assessment of facility-level preparedness at primary and secondary health care levels for prevention and control of non-communicable diseases. Natl J Integr Res Med 2018;9:36-9.
Elias MA, Pati MK, Aivalli P, Srinath B, Munegowda C, Shroff ZC, et al.
Preparedness for delivering non-communicable disease services in primary care: Access to medicines for diabetes and hypertension in a district in South India. BMJ Glob Health 2017;2:e000519.
Jayanna K, Swaroop N, Kar A, Ramanaik S, Pati MK, Pujar A, et al.
Designing a comprehensive non-communicable diseases (NCD) programme for hypertension and diabetes at primary health care level: Evidence and experience from urban Karnataka, South India. BMC Public Health 2019;19:409.
Parameswaran K, Agrawal T. Readiness of primary health centers and community health centers for providing noncommunicable diseases-related services in Bengaluru, South India. Int J Noncommunicable Dis 2021;4:73.
Aryal BK, Daud M, Thapa A, Mahotra A, Ale Magar S, Malla CK. Assesssment of health facilities for implementation of non-communicable disease Package. J Nepal Health Res Counc 2018;16:149-55.
Kabir A, Karim MN, Billah B. Primary healthcare system readiness to prevent and manage non-communicable diseases in Bangladesh: A mixed-method study protocol. BMJ Open 2021;11:e051961.
Islam MR, Laskar SP, Macer D. A study on service availability and readiness assessment of non-communicable diseases using the WHO tool for Gazipur district in Bangladesh. Bangladesh J Bioeth 2016;7:1-13.
Nyarko KM, Ameme DK, Ocansey D, Commeh E, Markwei MT, Ohene SA. Capacity assessment of selected health care facilities for the pilot implementation of package for essential non-communicable diseases (PEN) intervention in Ghana. Pan Afr Med J 2016;25 Suppl 1:16.
Bintabara D, Mpondo BC. Preparedness of lower-level health facilities and the associated factors for the outpatient primary care of hypertension: Evidence from Tanzanian national survey. PLoS One 2018;13:e0192942.
Albelbeisi AH, Albelbeisi A, El Bilbeisi AH, Takian A, Akbari-Sari A. Capacity of Palestinian primary health care system to prevent and control of non-communicable diseases in Gaza Strip, Palestine: A capacity assessment analysis based on adapted WHO-PEN tool. Int J Health Plann Manage 2020;35:1412-25.
Peck R, Mghamba J, Vanobberghen F, Kavishe B, Rugarabamu V, Smeeth L, et al
. Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: A cross-sectional survey. Lancet Glob Health 2014;2:e285-92.
Akinwumi AF, Esimai OA, Fajobi O, Idowu A, Esan OT, Ojo TO. Knowledge of primary healthcare workers regarding the prevention and control of non-communicable diseases in Osun State, Nigeria: A rural-urban comparison. Afr J Prim Health Care Fam Med 2021;13:e1-8.
3.4 by 2030 Reduce by One-Third Pre-Mature Mortality from Non-Communicable Diseases (NCDs) through Prevention and Treatment, and Promote Mental Health and Wellbeing – Indicators and a Monitoring Framework. United Nations: Sustainable Development Solutions Network; c2021. Availablefrom: https://indicators.report/targets/3-4/
. [Last accessed on 2021 Dec 27].
Panda R, Mahapatra S, Persai D. Health system preparedness in noncommunicable diseases: Findings from two states Odisha and Kerala in India. J Family Med Prim Care 2018;7:565-70. doi: 10.4103/jfmpc.jfmpc_111_17. PMID: 30112310; PMCID: PMC6069665.
] [Full text]
Onagbiye SO, Tsolekile LP, Puoane T. Knowledge of non-communicable disease risk factors among community health workers in South Africa. Open Public Health J 2020;13:430-7.
Pati MK, Swaroop N, Kar A, Aggarwal P, Jayanna K, Van Damme W. A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India. Public Health Rev 2020;41:8.
[Figure 1], [Figure 2], [Figure 3]