In Paraguay the burden of NCDs is increasing. In the last 10 years the number of people affected by diabetes has increased from 6.5% to 9.7% in the adult population, hypertension from 35 to 45% and overweight from 36 to 57%. The problem with patients with NCDs differs from patients with acute illness. This is because they are generally silent, asymptomatic diseases with long-term progression, which in many cases result in late diagnosis. It has thus, become necessary to have health teams sufficiently trained to acknowledge the current situation and who are capable of providing appropriate care improvement in the patient’s quality of life.ObjectiveThe objective is to provide care for people with NCDs by training team members of Family Health Units and polyclinics according to the Chronic Care Model (CCM). Furthermore, the polyclinics of the Health Regions in the area of medical care will be strengthened.
The project will be developed in three stages including all the components of the CCM. In the first stage a central coordination group under the responsibility of the National Diabetes Programme will be formed. This coordination group will take charge of the training of the health team and the preparation of the necessary materials for the project. Furthermore, a regional coordination in each of the three health regions will be established. The coordinators will be selected among professionals already working in the Diabetes Care Centres. The coordinators will receive a monthly fee to support the implementation.In the second stage, this project seeks to implement and develop a CCM, which is used on primary care within the framework of the National Diabetes Programme in the three health regions. Moreover, the medical care will be provided with a clinical doctor trained in the management of chronic diseases, and there will also be the possibility of consultation with other specialists. Education will also be provided in self-care and prevention of complications.In the final stage, evaluation, follow-up and monitoring will be the main focus, where tools for communication between the different level and the monitoring mechanisms will be implemented. In addition, FHUs will receive supervision visits by the central and regional committee and monthly records of actives will be developed. Each region will set up meetings for evaluation of activities and achievements with health team involved.
- Chronic Care Model implemented at 112 primary health care units in three provinces, with the Model now being replicated nationwide in all provinces.- At least 900 health care professionals working at the targeted primary health care units trained- At least 127,000 patients provided improved care for diabetes and other NCDs at the targeted primary health care units targeted- At least 400,000 people reached through community sensitisation and awareness activities.