To support the Government of India with a national-level scale-up of a proven model for strengthening the detection and quality care of diabetes and hypertension at the primary level.
This project is a collaborative effort between the World Health Organization (WHO) and the Ministry of Health (MoH) to achieve the goals outlined in the 75 by 25 roadmap. This initiative was launched to bring 75 million people with diabetes (DM) and hypertension (HTN) in India under care by 2025, grounded in key government reforms, including Ayushman Bharat, the India Hypertension Control Initiative, and the National NCD programme.This project represents a crucial step in implementing strategies to meet these targets by expanding a proven model for comprehensive management and care at the primary level. The project model draws from the experiences of the India Hypertension Control Initiative (IHCI) and is built on five key components:• Evidence-based treatment protocols available at the primary level.• Team-based care and task-shifting to involve nurses.• People-centric services and decentralised care.• Uninterrupted availability of core drugs and supplies (i.e., strips and glucometers).• Information systems to facilitate monitoring, follow-up, and referral.These model components will be institutionalised in the health system through a partnership between WHO NCD technical advisors and MoH counterparts (MoH NCD technical advisors) to build capacity in the system.The model will be implemented in a phased manner across 400 districts in all 28 states and 8 Union Territories of India. Phase 1 enrolled the 155 districts that were part of the IHCI. Phase 2 will enroll 145 new districts, and Phase 3 will enroll an additional 100+ new districts. All 400 districts and all states will receive support as part of this project.The project comprises the following main components:• Policy, Programme, and Financing Strengthening: Technical support will be provided to states to develop state-specific clinical protocols based on national guidelines, annual implementation plans, and budgetary planning.• Capacity Building: Healthcare providers at the primary level will be trained on protocol-based management of DM and HTN, risk factor mitigation, and digital tools for data collection. Community health workers will be trained in patient education, follow-up, and population-based screening as per MoH guidelines.• Patient Care Pathway Strengthening: The patient care pathway will be strengthened by leveraging existing human and technological resources. This includes the roll-out of a unique health ID, utilization of the existing Health Information System (NCD portal), and teleconsultations.• Quality of Care Improvement: The quality of care will be improved through enhanced glucose monitoring and strengthening the use of the existing NCD portal at the facility level for consistent monitoring and follow-up.• Supply Chain Management Improvement: The supply chain management at the state, district, and facility levels will be improved by forecasting drugs and streamlining the drug distribution system.• Data Collection, Analysis, and Review: Regular data collection, analysis, and review will be conducted to support data-driven decision-making and document best practices and innovations for broader dissemination.
• Nationwide improved access to diabetes and hypertension care across all states in at least 400 out of 785 districts with a total target population over 30 years of 342 million.• Placing 75 million people with diabetes and/or hypertension on treatment. 26 million already registered through IHCI.• At least 48,000 clinics (50% of all primary care clinics) in target districts with trained HCPs and CHWs delivering protocol-based care. • At least 48,000 clinics in target districts using digital health information systems.• At least 75% of target districts have adequate availability of essential diagnostics and medicines for diabetes and hypertension.• Increase in annual utilisation of funds received from the government for NCDs at the state level by at least 10% per year.