management and care of diabetes in public sector...

2nd National White Paper

A JOINT INITIATIVE OF

Ministry of Health and Family Welfare &

Department of Public EnterprisesGovernment of India

KNOWLEDGE PARTNER

Insights from Multi Stakeholder Consultations

Management and Care of Diabetes in Public Sector Enterprises

Eli Lilly and Company Disclaimer “This National NCD Summit is funded by Eli Lilly and Company (India). The content has been generated in public interest and for the well-being of the society. Lilly was not involved in the creation of this content and the views expressed are participants own independent views. This shall in no way be considered a substitute to any personalized advice of HCPs on the disease state of an individual. Lilly makes no representations or warranties of any kind express or implied in relation to the content and the views posted thereon and shall not be bear any liabilities that may arise out of the use or misuse of this information” CII Disclaimer No part of this publication may be reproduced, stored in, or introduced into a retrieval system, or transmitted in any form or by any means (electronic, mechanical,photocopying, recording or otherwise), in part or full in any manner whatsoever, or translated into any language, without the prior written permission of the copyright owner. CII has made every effort to ensure the accuracy of the information and material presented in this document. Nonetheless, all information, estimates and opinions contained in this publication are subject to change without notice, and do not constitute professional advice in any manner. Neither CII nor any of its office bearers or analysts or employees accept or assume any responsibility or liability in respect of the information provided herein. However, any discrepancy, error, etc. found in this publication may please be brought to the notice of CII for appropriate correction.

Published by Confederation of Indian Industry (CII), The Mantosh Sondhi Centre; 23, Institutional Area, Lodi Road, New Delhi 110003, India, Tel: +91-11-24629994-7, Fax: +91-11-24626149; Email: [email protected]; Web: www.cii.in

2nd National White PaperInsights from Multi Stakeholder Consultations





KNOWLEDGE PARTNER

2


3

Contents

PRELUDE ........................................................................................................................................5

EXECUTIVE SUMMARY ..............................................................................................................7

DISEASE BURDEN OF DIABETES ......................................................................................... 10

FOCUSING ON PUBLIC SECTOR ENTERPRISES .............................................................. 18

THE REGIONAL ROUNDTABLE FRAMEWORK ................................................................. 24

LEARNING FROM REGIONAL ROUNDTABLES ................................................................ 32

BEST PRACTICES IN DIABETES MANAGEMENT ............................................................. 42

SURVEY OUTCOMES ............................................................................................................... 60

THE WAY FORWARD ................................................................................................................ 70

4


5

Prelude

Diabetes is no longer a disease specific to the urban population and in the last two

decades, there has been a marked increase in the prevalence of diabetes among both urban as well as the rural Indians. Industrialization, large scale migration to urban environment from rural settings, economic development, genetic predispositions along with increasing transitions in lifestyle have led to an increase in diabetes prevalence in India. Diabetes affects 8.3% people worldwide and 80% of them live in low and middle income countries. India is home to more than 65 million people with diabetes, which is about 17% of the global diabetes burden.

The Confederation of Indian Industry (CII) is deeply committed towards combating the emerging epidemic of Non Communicable diseases (NCDs) by actively leveraging the private sector in unique public private partnership models that are both replicable and scalable. Recently CII has undertaken the unique Drive Against Diabetes [DAD] – a massive awareness and sensitization campaign across Mumbai. CII seeks to continue its initiatives in the space of NCDs.

Several initiatives have been undertaken by Public Sector Enterprises (PSEs) in recent past for strengthening management of Diabetes. While the policies and initiatives among PSEs are evolving and improving, investment in diabetes care and management is also increasing. At this juncture of epidemiological transition with a growing burden of non-communicable disease, a strong need was felt to understand the enablers, barriers and

good initiatives for diabetes management at the PSU level. This would provide an impetus and direction to strengthen diabetes management and care in PSEs.

CII in continued partnership with Eli Lilly & Company has taken a lead in creating a national level learning platform for strengthening public health strategies for comprehensive diabetes management in PSEs through the 2nd National NCD Summit 2014. This common learning platform intends to strengthen the ongoing PSU initiatives in diabetes management to help the health system tackle diabetes in a more cost-effective and efficient way.

This National White Paper is intended to gain a comprehensive view of good practices for diabetes management in PSEs, key challenges and enablers, gathered through a discourse with a diverse range of stakeholders from PSEs, Government and research institutions. The recommendations in this report will be useful while emulating or scaling up of initiatives in similar settings or for planning of interventions for diabetes prevention. The recommendations included herein are derived from the experience and knowledge of professionals who have been working in the Health systems of PSEs for many years and thus reflect on the real-life situations in the field.

CII is confident that this report would be a useful instrument in the hands of policy makers, programme managers, healthcare providers and other agencies working in

Prelude

6


the field of Non Communicable Diseases, and particularly for strengthening diabetes management at PSEs. This report can serve as a ready reckoner for planning and implementing diabetes management interventions in PSUs.

CII would like to thank all the partners for their efforts in analyzing and collating the proceedings of the Regional level roundtables and drafting this White Paper. CII would like to specially thank Eli Lilly and Company for their partnership and guidance which has facilitated in creating a pioneering and much needed platform for knowledge sharing on diabetes management in PSEs.

CII expresses sincere gratitude to the Government officials from Ministry of Health and Family Welfare and the Department of Public Enterprises (DPE) for their constant guidance and support through out this initiative.

CII also thanks the NCD Advisory Group for their invaluable inputs and suggestions towards development of this report. Finally, it would not have been possible to prepare this report without the rich inputs from our PSE partners.

7

BACKGROUND

As India makes development progress, it also faces a growing threat from non-communicable diseases (NCDs) which add to India’s already substantial health burden from communicable diseases. Diabetes has emerged as a major NCD in India and it is home to more than 65 million people with diabetes, which is about 17% of the global diabetes burden.

RATIONALE

Rapid urbanization and industrialization have produced advancement on the social and economic front in India which has resulted in dramatic lifestyle changes leading to NCDs. There is an alarming shift in the age of onset of diabetes to younger age groups and particularly the working population, which is driven by nutrition transition, and increasingly sedentary lifestyles. In this context, a need for a high-level dialogue in India was deduced to provide an impetus and direction to strengthen diabetes management and care in Public Sector Enterprises (PSEs), as they contribute to ~5% of the employment generation in the organized sector, employing over 14.44 lakh people, making them one of the largest employers in the country.

The Confederation of Indian Industry (CII) in partnership with Eli Lilly & Company and support from the Department of Public Enterprises (DPE) is creating a national level learning platform for strengthening public health strategies for comprehensive diabetes management in PSEs through the 2nd National NCD Summit 2014. This common

learning platform intends to strengthen the ongoing PSE’s initiatives in diabetes management to help the health system tackle diabetes in a more cost-effective and efficient way.

OBJECTIVES

The National NCD Summit 2014 is focusing on working extensively with PSEs and builds on the theme of ‘Strengthening Policies for Diabetes Control in PSEs’. The objectives of this multi-stakeholder collaborative initiative were to review the health system landscape of the PSEs, create a platform for learning and sharing of best practices in diabetes management and build capacities to engage the employees and the health workforce in PSEs for better management of diabetes.

METHODOLOGY

The collection of evidence was through five regional round tables in selected state capitals including Hyderabad, Bangalore, Mumbai, Raipur and Kolkata, witnessing the participation from a diverse group of stakeholders ranging from PSEs, government organizations and academic institutions. The roundtables included thematic discussions to identify best practices, enablers, barriers and viable recommendations around diabetes management in the PSEs. This was followed by a questionnaire survey and key informant interviews to capture initiatives undertaken by the respective PSEs for diabetes management. The learning compiled culminated in the

Executive Summary

8


development of this ‘National White Paper’. The key expected outcome of the National NCD Summit 2014 is to help shape the development of policies within PSEs for diabetes management, supported by robust data and evidence.

The qualitative and quantitative analysis resulting from the roundtables, 1:1 interviews and questionnaire survey were classified under the following thematic areas:

· Prevention of Diabetes

· Screening and Early Diagnosis

· Treatment Strengthening

· Capacity Building

· Technology based initiatives

FINDINGS

The discussions and analysis yielded the following key insights into each of the thematic areas:

· Prevention of diabetes – Absence of standard policies and guidelines for diabetes management, limited awareness about diabetes and obesogenic environment were recognized as impediments for the prevention of diabetes in PSEs. It is essential to develop and enforce policies for diabetes management eg. nutrition policy, smoke free workplace policy etc. Appropriate messaging and Implementing Behavior Change Communication (BCC) interventions and developing communication strategies through mass media, peer education etc can possibly

aid in reducing the diabetes incidence among PSEs.

· Screening and Early Diagnosis – Limited test consumables and equipments for screening of diabetes, absence of a uniform screening guideline across all PSEs and fear of the disease and its treatment were cited as major barriers for screening. The possible solutions which came up during the deliberations were- to have mandatory guidelines for the PSE clinics/hospitals to have basic consumable, equipment and trained staff available for diabetes testing, design new policies for screening and diagnosis and allow greater flexibility to re align funds for diabetes screening. Developing a communication strategy where employees are informed about the medical facilities available for continuity of care which would increase their willingness to come forward for screening and detection.

· Treatment – In PSEs Non adherence to treatment, clinical inertia and weak referral linkages were identified as barriers to receiving timely and appropriate treatment. Strengthening the doctor patient relationship by adopting a patient centered approach, making anti diabetic medications freely available to employees and developing linkages with higher facilities for referral and treatment of complications could ensure higher compliance to treatment. Increasing provider awareness and knowledge on

9

addressing clinical inertia through training and capacity building was also recognized as the need of the hour.

· Capacity Building – Deficiencies in skilled human resources for health, limited health care provider orientation regarding NCDs and inadequate number of training institutes for providing training on NCDs were highlighted as roadblock for diabetes management in PSEs. It is important that all healthcare providers be linked to Continued Medical Education (CME), which will provide them with opportunities to stay updated with the treatment modalities for diabetes. Conducting a Training Needs Assessment (TNA) periodically to identify individual training needs of health staff and fostering collaboration with training institutions will significantly strengthen the health systems capacity to address diabetes.

· Technology – Limited use of technology results in lowering the effectiveness and efficiency of the system to provide appropriate diabetes care to employees. A robust Integrated and standardized IT system such as diabetes registry to generate reports to help analyze a patient’s key diabetes-related measures and track patient’s progress can greatly help in making interventions effective and efficient.

During the course of deliberations and consultations, many examples of effective and efficient interventions in PSEs were identified which could be emulated and scaled up.

CONCLUSION

There is a pressing need for a coordinated health system, adopting innovative strategies and streamlining the existing resources to provide diabetes prevention and management services at the PSE level. Specific programs and innovative strategies are needed for prevention and early detection of diabetes in high risk and vulnerable groups. A multi stakeholder approach is key to the success of the various initiatives taken by PSEs. Different stakeholders have different roles to play, and the strengths of each should be concerted and explored to facilitate the accomplishment of clear goals and objectives. Monitoring and evaluation are essential for the success of workplace health promotion and need to be incorporated into the implementation of policies and programmes.

Executive Summary

DISEASE BURDEN OF DIABETES

NCDs account for 63% of all deaths

12


Sour

ce: I

DF

Dia

bete

s Atla

s- 6

th E

ditio

n

Disease burden of diabetes

GLOBAL DISEASE BURDEN

Non-communicable diseases (NCDs) impose a huge burden on health worldwide and constitute one of the major challenges for public health in the twenty-first century. Diabetes is the leading non-communicable disease in both developed and developing countries. In 2013, it was estimated that 8.3% (382 million) people worldwide have diabetes; the majority are aged between 40 and 59, and 80% of them live in low and middle income countries1.

According to the International Diabetes Federation (IDF) projection, the prevalence of diabetes will increase to 55% by 2035. In both human and financial terms, the global burden of diabetes is enormous – leading to 5.1 million deaths and costing approximately USD 548 billion dollars (11% of the total health expenditure worldwide) in 20131. In addition, there are approximately 175 million people currently living with undiagnosed diabetes.

Global projections of the number of people with diabetes (20-79 years), 2013 and 2035, in millions

North America and Caribbean

South and Central America

Middle East and North Africa

Africa

Europe

Western Pacific

South East Asia

13

Top 10 countries with highest number of people with diabetes (20-79 years), 2013

Prevalence of diabetes in top 10 countries, 2013

Due to the rapid cultural and social changes, the diabetes epidemic has grown exponentially in South East Asia, accounting

for close to one-fifth (72.1 million) of all cases worldwide, and is projected to increase to 123 million by 2035.

Sour

ce: I

DF

Dia

bete

s Atla

s- 6

th E

ditio

nSo

urce

: ID

F D

iabe

tes A

tlas-

6th

Edi

tion

7.2 7.5 6.6 8.5 8.7 10.9 11.924.4

65.1

98.4

6.713.1 11.8 14.2 15.7 11.2

19.229.7

109

142.7

0

20

40

60

80

100

120

140

1 60

Japan Egypt Turkey Indonesia Mexico Russian Federation

Brazil USA India China

in m

illio

n

Top 10 countries with highest number of people with diabetes (20-79 years), 2013

2013 2035

7.6

15.614.6

5.6

11.810

910.9

8.69.6

8.2

18.6 18.5

6.7

15.2

11.6 11.7 11.610.5

13

02468

101214161820

Japan Egypt Turkey Indonesia Mexico Russian Federation

Brazil USA India China

in %

2013 2035

Disease Burden of Diabetes

14


The diabetes epidemic has moved to low and middle-income countries, and threatens to reverse development gained through Millennium Development Goals made in these countries.

As the prevalence of diabetes grows in low and middle-income countries, so do the complications associated with it. People with diabetes are at risk of developing life-threatening complications like cardiovascular disease, blindness, kidney failure, and lower-limb amputation.

Studies have revealed that people with diabetes have a two-fold increase in the risk of stroke2 and it is also the leading cause for renal failure in many populations worldwide. Lower limb amputations are at least 10 times more common in people with diabetes than in non-diabetic individuals in developed countries3. Diabetes is also one of the leading causes of visual impairment and blindness in developed countries4. In addition, the risk of infectious diseases like tuberculosis is much higher among people with diabetes5.

Proportion of cases of diabetes (20-79 years) that are undiagnosed, 2013

Sour

ce: I

DF

Dia

bete

s Atla

s- 6

th E

ditio

n

62%

48% 49%

24%

27%

54%

36%

15

239 B

26 B

147 B

88 B4 B

14 B 6 BNorth America and Caribbean

South and Central America

Middle East and North Africa

Africa

Europe

Western Pacific

South East AsiaIndia:

Expenditure on Diabetes

2013: US$ 823 million

Global health spending on treating diabetes and managing complications aggregated to USD 548 billion in 2013, with a large disparity between countries and regions. Only 20% of global health expenditure on diabetes incurred in low and middle income countries, where 80% of people with diabetes live. South East Asia has the second highest prevalence of diabetes in the world, yet the region’s healthcare spending in diabetes accounts for less than 1% of the global total, with India estimated to have spent the largest proportion.

Sour

ce: I

DF

Dia

bete

s Atla

s- 6

th E

ditio

n

Health expenditure (USD) due to diabetes (20-79 years), 2013


16


DIABETES BURDEN: INDIA

India is home to more than 65 million people with diabetes, which is about 17% of the global diabetes burden. This number is expected to increase to 109 million by 2035. The nationwide prevalence of diabetes in India is now 9%, while the regional prevalence is as high as 20% in the relatively well-developed South Indian states1. With the increasing prevalence of diabetes in India, the complications associated with it are also growing manifold6. Studies in India have shown that the prevalence of coronary artery disease and diabetic retinopathy are much higher in the population with known

diabetes. Mortality due to cardiovascular and renal causes was also higher among diabetic compared to non-diabetic population7.

The mean medical expenditure per diabetes patient in India was estimated to be 84 USD Diabetes treatment accounts for around 2.1% of the total GDP, out of which only 0.2% is direct healthcare cost, while the indirect cost is almost 10 fold higher (1.9% of the GDP). In monetary terms, this accounts for USD 20.4 billion: USD 20 billion due to mortality and disability and USD 0.4 billion due to morbidity8-10.

17

Comparative prevalence of type 2 diabetes in Indian States, 20121

The western diet and lifestyle that have accompanied India’s growing prosperity have also brought an alarming rise in the cases of type 2 diabetes11.

The epidemic is not surprising in urban areas. However, the disease is now also becoming common in rural villages, especially in wealthy southern states.

6.6%

10.9%

10.8%

4.2%

8.4%

14.1%

16.6%

10.7%

7.7%

Ludhiana

Delhi Lucknow

Nagpur

Pune

Hyderabad

Bangalore

Coimbatore

Trivandrum

2.3%

Dibrugarh


FOCUSING ON PUBLIC SECTOR ENTERPRISES

80% of NCDs deaths occur in low & middle-income countries

20


Focusing on Public Sector Enterprises

DIABETES BURDEN IN THE WORKING POPULATION

Over the last three decades, the status of diabetes has changed from being considered as a health condition of the elderly to one of the major causes of morbidity and mortality affecting the youth and middle-aged people. In middle and low income countries, the working age population is growing substantially relative to the non-working population. The rise of NCDs in the working population may endanger the ‘demographic dividend’ of a country, including the economic benefits expected to be generated during the productive years of the working age group12. This epidemic is primarily driven by rapid urbanization, nutrition transition, and increasingly sedentary lifestyles13. The National Family Health Survey-III (2005-06) reported that 5.59% diabetics were in the age group of 15-49 years14, which is clearly the working age. Over the past few decades, a huge number of the working population has shifted from manual labor associated with the agriculture sector to physically less demanding office jobs. The transition from a traditional to modern lifestyle, consumption of diets rich in fat and calories combined with a high level of mental stress, decreased physical activity and sedentary occupational habits have compounded the problem further. Studies have revealed that people with office jobs and a sedentary lifestyle have a significant association with diabetes15-18.

The fact that there is an alarming shift in age of onset of diabetes to younger age groups and particularly the working population, implies that people are developing diabetes in the most productive years of their life, which could cause an adverse effect on the nation’s economy.

WHY PUBLIC SECTOR ENTERPRISES (PSES)?

Taking into account the increasing prevalence of diabetes in the working population, several industries in public and private sector have started focusing towards management of NCDs and particularly diabetes amongst employees. Public Sector Enterprises (PSEs) have been a strategic lever in the country’s economic development and industrial growth in both pre independence and post independence era. There are around 254 Central PSEs employing over 14.44 lakh people19 and contributing to ~5% of the employment generation in the organized sector20, making them one of the largest employers in the country. It’s disconcerting to see that out of 14 lakh employees in the PSEs; more than 1.5 lakh employees are suffering from diabetes.

Several attempts are being made at various levels to combat the increasing burden of diabetes in India. Government of India announced a national program on managing Cancer, Diabetes, Cardiovascular diseases

21

and Stroke (NPCDCS). Industries in public and private sector have also started focusing towards management of the NCDs for their employees. Several employee initiatives that have been undertaken by PSEs in recent past for strengthening management of diabetes are having variable impact. While the policies and initiatives among PSEs are evolving and improving, investment in diabetes care and management is also increasing.

At this juncture of epidemiological transition with a growing burden of non-communicable disease, there is a need for a high-level dialogue in India to provide an impetus and direction to strengthen diabetes management and care in PSEs.

The Confederation of Indian Industries (CII) in partnership with the Department of Public Enterprises (DPE) and Eli Lilly & Company is creating a national level learning platform for strengthening public health strategies for comprehensive diabetes management in PSEs through the 2nd National NCD Summit 2014. The 2nd National NCD Summit and its corresponding white papers will build on the learning and recommendations from the first national NCD summit held in June 2013 in collaboration with Ministry of Health and Family Welfare and ICMR. This common learning platform intends to strengthen the ongoing PSE initiatives in diabetes management to help the health system tackle diabetes in a more cost-effective and efficient way.

OBJECTIVES OF THE PARTNERSHIP

To help facilitate an evidence-based and transparent process for prioritizing measures, the Confederation of Indian Industries (CII) and Eli Lilly & Company (India) Pvt. Ltd established a partnership with the following broad objectives:

• Review the health system landscape of the PSEs on policies related to diabetes management; setting priorities to strengthen existing policies or formulate new ones

• Articulate diverse stakeholders’ persp-ectives and views, and create a platform for learning and sharing of best practices in diabetes management that could be emulated and scaled up

• Mobilize, sensitize and build capacities of employees and the health workforce in PSEs to identify their potentials, and engage themselves for better management of diabetes


22


METHODOLOGY AND DESIGN

The collection of evidence was through five regional round tables in selected state capitals including Hyderabad, Bangalore, Mumbai, Raipur and Kolkata. Each roundtable was a brainstorming session with participation from an eclectic group of stakeholders from PSEs, government organizations and academic institutions. The roundtables included thematic discussions to identify best practices, enablers and barriers around diabetes management in the PSEs.

The representatives from the PSEs at the roundtables were administered with a questionnaire followed by personal interviews to capture initiatives undertaken by their respective PSEs for diabetes management. The learning compiled culminated in the development of this ‘National White-paper’. The key expected outcome of the National NCD Summit 2014 is the development of policies within PSEs for diabetes management, supported by robust data and evidence.

23

Ou

tcom

esO

utp

uts

Col

lect

ion

of E

vide

nce

Primary/ Secondary Research

C

onduct

ed fi

ve re

gio

nal

roundta

bles

in s

tate

cap

ital

s

Str

uct

ure

d q

ues

tion

nai

re a

dm

inis

tere

d to

the

hea

lth

syst

em in

-char

ge

of P

SU

s

In

dep

th e

xplo

ration

of be

st p

ract

ices

in d

iabe

tes

man

agem

ent i

n P

SU

s th

rough p

erso

nal

inte

rvie

ws

Und

erta

king

a

part

icip

ator

y

situ

atio

nal

asse

ssm

ent

Org

aniz

ing

the

Reg

iona

l ro

undt

able

s in

st

ate

capi

tals

Dat

a co

llec

tion

th

roug

h su

rvey

qu

esti

onna

ires

Con

duct

ing

prim

ary

rese

arch

/ in

terv

iew

s

Met

hod

olog

yIn

puts

Rep

ort

Tr

iangula

tion

and a

nal

ysis

of t

he

qual

itat

ive

and

quan

tita

tive

dat

a

D

ocum

enting

best

pra

ctic

es a

nd c

ompi

ling the

whitep

aper

C

onsu

ltat

ion

with k

ey s

take

hol

der

s to

final

ize

the

whitep

aper

Documenting the National White

Paper

Adv

ocac

y ev

ent

D

elib

erat

ion o

n a

wid

e ra

nge

of top

ics

on d

iabe

tes

man

agem

ent,

pol

icy

issu

es, b

est pr

actice

s et

c in

PS

Us

D

isse

min

atio

n o

f the

Nat

ional

Whitep

aper

National NCD Summit

Find

ings

, Dat

a A

naly

sis

and

Rec

omm

enda

tion

Whi

tepa

per

Rel

ease

Bra

inst

orm

ing

Sess

ions

Sum

mar

y P

rese

ntat

ion

Pos

t Su

mm

itA

ctiv

itie

s

12

3

45

6

Sen

sitiza

tion

an

d c

apac

ity

dev

elop

men

t of

med

ical

m

anag

ers

of

PSU

s fo

r be

tter

m

anag

emen

t of

Dia

bete

s

Red

uce

exp

osure

to

the

mod

ifia

ble

risk

fac

tors

like

to

bacc

o use

, unhea

lthy

die

t,

alco

hol

etc

. th

rough p

olic

ies

Impr

ovem

ent i

n

the

continuity

of

dia

bete

s ca

re in

PS

Us

Iden

tify

op

port

unitie

s to

supp

ort

wor

kpla

ce

inte

rven

tion

s in

PSU

s fo

r pr

even

tion

of

Dia

bete

s

Impr

oved

kn

owle

dge

abou

t dia

bete

s an

d it

s m

a nag

emen

t

Mon

itor

ing a

nd

surv

eilla

nce

of

behav

iora

l and

met

abol

ic ri

sk

fact

ors

asso

ciat

ed w

ith

dia

bete

s

Ana

lytic

al F

ram

ewor

k an

d M

etho

dolo

gy


THE REGIONAL ROUNDTABLE FRAMEWORK

More than 9 million of all deaths attributed to NCDs occur before the age of 60

26


27

The Regional Roundtable Framework

Leading up to the 2nd National NCD Summit, a series of consultations in the form of

roundtables have taken place in 5 state capitals in India i.e. Hyderabad, Raipur, Mumbai, Bangalore and Kolkata. The roundtables highlighted best practices, challenges and recommendations for diabetes management in PSEs. It was an important forum where diverse stakeholders from PSEs, government and academic institutions congregated to have a discourse on the current situation of diabetes management in the PSEs, and to discuss the pathway to integrate diabetes management in the overall health system of PSEs.

The main issues discussed in each roundtable were around the thematic areas including:

• Prevention of Diabetes

• Screening and Early Diagnosis

• Treatment Strengthening

• Capacity Building

• Technology based initiatives

These thematic areas form the core features of national approaches and strategies for diabetes management.

It was recognized that various challenges are encountered by the PSEs when attempting to improve diabetes management in the sector, and this led to a detailed discussion during the roundtables. The discussions on challenges were followed by recommendations to address the challenges. This deliberation will support in tailoring interventions to address specific challenges, and make use of specific enablers.


28


Total number of Central Public Sector Enterprises in India, 2012-13 (Holding)*

60New Delhi & Haryana Uttar

Pradesh

14

Uttarakhand

4

Maharashtra

18

Andhra Pradesh

1

97

54

32

2Rajasthan

Madhya Pradesh

Karnataka

Tamil NaduKerala

20 West Bengal

Meghalaya

Assam

1 Orissa

2

Bihar

Conducted 5 regional roundtables; overall 87 members participated from 69 PSEs (both holding and subsidiary) across India

* CP

SEs h

eadq

uart

ers

29

Hyderabad

No. of PSE members 16

No. of PSEs 10

Government Leaders andProgram Officers 1

Medical Institutions 1

Raipur


No. of PSEs 7



Mumbai


No. of PSEs* 14


Medical Institutions --

Bangalore


No. of PSEs 17



Kolkata


No. of PSEs 18


Medical Institutions --

* Both holding and subsidiary PSEs

Regional Roundtable Discussions across India

A total of 254 Central Public Sector Enterprises are in India (154 Holding and 100 Subsidiary)

Participant logos consulted during Regional Roundtable

* Bo

th h

oldi

ng a

nd su

bsid

iary

PSE

s


30


During the deliberations in the roundtable meeting, 1:1 interviews and surveys, the existing status of the program was assessed, strengths, issues and gaps identified and the way forward charted out. Guided by recommendations and brainstorming during the roundtables, the ‘Diabetes Care Model’ is developed and organized around elements that have been shown to improve the outcomes. The elements of the Diabetes Care Model include factors required for change, stakeholders who should be involved, and expected outcomes.

DIABETES CARE MODEL

The Diabetes Care Model provides a framework for comprehensive, accessible and efficient provision of coordinated diabetes prevention and management services for all PSEs. The key objective of the Diabetes Care Model is to ensure that challenges are addressed and diabetes services are optimally configured to:

• Prevent and delay the onset of diabetes;

• Prevent and slow progression of diabetic complications; and

• Improve the quality of life of people who have diabetes

The Diabetes Care Model addresses the following stages of diabetes prevention and management:

• Awareness and education

• Prevention and early diagnosis in high-risk groups

• Optimal initial and long-term management

• Early detection and optimal management of complications

• Coordinated prevention and management of acute episodes

KEY PRIORITIES FOR IMPLEMENTATION OF THE DIABETES CARE MODEL

• Enhance promotion of healthy environment and lifestyle to prevent diabetes and increase awareness of the health impact of diabetes and its complications

• Improve coordination of community-based diabetes prevention and management services, including patient self-management

• Ensure ready access to guidelines, protocols and policies at workplace

• Develop systems of information and communication technology support to improve communication and data sharing between patients, health care providers and other service providers, to improve service quality, and to monitor services and outcomes

• Increase investment in workforce training and development

While the model is intended for application throughout PSEs, implementation will require coordinated, multi-stakeholder collaboration.

31

•D

octo

rs•

Die

ticia

ns•

Dia

bete

s Ed

ucat

ors

•N

urse

s•

Phys

icia

ns•

Tech

nici

ans

•H

R/ A

dmin

Dia

beti

c Pa

tien

t

•O

nlin

e Su

ppor

t•

Dia

betic

s Su

ppor

t•

Trai

ning

/ Ed

ucat

ion

grou

p•

Fello

w D

iabe

tics

•Th

erap

ists

•G

over

nmen

t/

NG

Os/

CBO

s

•Sp

ouse

•Chi

ldre

n•

Pare

nts

•Si

blin

gs•

Rel

ativ

es•

Co-

wor

kers

Prev

enti

on

Scre

enin

g &

D

iagn

osis

Trea

tmen

t

Capa

city

B

uild

ing

Tech

nolo

gy

•R

egul

ator

y/

Pol

icy

bott

lene

cks

•O

beso

geni

c en

viro

nmen

t

•A

war

enes

s an

d ed

ucat

ion

•In

adeq

uate

nu

mbe

r of

sk

illed

hea

lth

wor

kfor

ce

•In

fras

truc

ture

an

d te

chno

logy

de

velo

pmen

t

Cha

llen

ges

•B

CC/

IEC

inte

rven

tion

s an

d ac

tion

pl

an

•D

raft

ing

and

enfo

rcin

g po

licie

s

•P

atie

nt

cent

ered

ap

proa

ch

•A

dvan

ced

tech

nolo

gica

l de

velo

pmen

t

•Ca

paci

tate

pa

ram

edic

al

staf

f and

al

lied

heal

th

prof

essi

onal

s

Key

Str

ateg

ies

Com

mun

ity

awar

enes

s &

pr

even

tion

Prev

enti

on &

ea

rly

diag

nosi

s

Opt

imal

init

ial

& lo

ng te

rm

man

agem

ent

Earl

y de

tect

ion

& o

ptim

al

man

agem

ent

of

com

plic

atio

ns

Trai

ning

and

ca

paci

ty

build

ing

Dia

bete

s M

anag

emen

tFa

ctor

s fo

r C

han

ge

Sta

keho

lder

s

Out

com

es

•Pr

even

t or d

elay

the

ons

et o

f di

abet

es

•Pr

even

t and

slo

w p

rogr

essi

on o

f di

abet

ic c

ompl

icat

ions

, es

peci

ally

hea

rt d

isea

se,

rena

l fai

lure

, im

pair

ed

visi

on a

nd lo

wer

lim

b am

puta

tions

•Im

prov

e ac

cess

ibili

ty a

nd q

ualit

y of

dia

bete

s se

lf-m

anag

emen

t edu

catio

n

•En

hanc

e se

rvic

e qu

ality

by

incr

easi

ng the

use

of gu

idel

ines

, lo

cal p

roto

cols

, ser

vice

direc

tories

, re

gist

ers,

re

call

syst

ems

a nd

patie

nt-h

eld

man

agem

ent p

lans

to

ensu

re t

hat

all p

eopl

e w

ith d

iabe

tes

rece

ive

com

preh

ensi

ve, o

ngoi

ng c

are

•Im

prov

e lo

cal s

ervi

ce c

oord

inat

ion

and

incr

easi

ng k

now

ledg

e of

ava

ilabl

e re

sour

ces

by h

ealth

car

e pr

ovid

ers

and

peop

le w

ith d

iabe

tes

Dia

bete

s C

are

Them

atic

Are

as

Inte

grat

ed I

T sy

stem

s

Dia

bete

s Ca

re M

odel

Fra

mew

ork


LEARNING FROM REGIONAL ROUNDTABLES

Around the world NCDs affect women and men equally

34


Key Constraints Key Recommendations

PREVENTION

Obesogenic environment encourages low levels of physical activity and access to energy-rich diets

• Adopt a ‘healthy environment’ e.g. create spaces friendly for walking, encourage activity breaks, increase availability of healthy food choices in canteens, integrate wellness centers with gyms and fitness centers

• Deploy mass media campaigns for behavior change and generate awareness regarding healthy dietary practices, physical activity and stress management

• Establish health promotion teams in the workplace to actively raise awareness about diabetes prevention and empower employees to make healthy decisions

Absence of policies and guidelines for diabetes management

• Develop a common framework for the NCD policy in consensus with the PSEs and other stakeholders and authorize the top management to enforce the policy

• Develop and implement nutrition policies in PSEs to limit the intake of excessive calories, extravagant food portion sizes and high-energy or high-sugar food and non-alcoholic beverages

• Enforce a formal ‘smoke-free workplace policy’, with support available to help staff quit

Learning from Regional Roundtables

35

Lack of awareness and knowledge about diabetes

• Implement Behavior Change Communication (BCC) interventions and develop communication strategies through mass media, peer education etc. to promote physical activity, increase intake of fruits and vegetables, and motivate employees to avoid smoking, alcohol and other modifiable risk factors

• Provide educational information to create a supportive environment through internal publications, intranet, employee newsletters, emails etc.

• Hire an in-house nutritionist/dietician in the PSEs to encourage healthy eating among all employees

• Invite or employ a diabetes educator in the workplace to discuss topics such as nutrition and the importance of exercise

• Create a peer support group that connects employees living with diabetes to share information, experience and support

• Execute advertising campaign to raise awareness to help employees recognize the early signs and symptoms of diabetes and prevent the development of serious complications

• Set up diabetes education kiosks in the PSEs to empower employees with key health knowledge on diabetes

• Conduct employee health surveys in the workplace to gather baseline employee health data for counseling and NCD follow-up based on individual needs

• Use digital communication for short messages and reminders

Stress at workplace triggers the onset of diabetes and impedes prevention and control

• Encourage stress control activities at the workplace, such as meditating and playing music during meal hours

• Promote the understanding of the impact of stress on health and incorporate such trainings into the overall management framework

• Conduct training on stress management for all employees


36


Risk factors associated with diabetes – Behavioral and Physiological

• Implement programs to address key risk factors in the workplace and support behavior change

• Verify the smoking status of all employees, record this in each employee’s clinical records, and encourage smokers to reduce smoking or to quit

• Mandate regular blood glucose level screening for early detection of diabetes among employees with risk factors

Co-morbidities associated with diabetes, such as hypertension, dyslipidemia etc.

• Reinforce patient-centered approaches to care among healthcare providers

• Encourage multidisciplinary collaboration among specialized care teams

Limited infrastructure, trained manpower and awareness on gestational diabetes mellitus (GDM) screening

• Improve the infrastructure by making basic equipments including MCH care kits accessible

• Create awareness about GDM amongst the health workforce and antenatal women in particular

• Collaborate with national programs like the NPCDCS, NRHM etc. to follow up on GDM case referrals, tracking and loss

• Mandate gestational diabetes mellitus screening by OGTT for pregnant women between 24-28 weeks of gestation

Lack of awareness on the importance of diet and sustained physical activities at schools and colleges which are run by PSEs or located at close proximity to the plant location

• Improve and intensify efforts to conduct awareness camps at schools and colleges

• Re-introduce and encourage activities such as physical training and National Cadet Corps in schools and colleges

• Conduct programs and policies on diet management for children and periodic canteen audit

• Implement a regulation/Act prohibiting fast food outlets around schools and colleges

• Mandate sports/physical training as part of the school curriculum

37

SCREEENING AND DIAGNOSIS

No uniform guidelines for diabetes screening across PSEs

• Design a new policy/guideline or revise existing health policies for screening and diagnosis of NCDs at the workplace

• Allow greater flexibility for the PSEs to re-align funding for NCD activities

• Conduct Periodic Medical Examination (PME) in addition to regular follow-up for employees, as per the advice of the treating physician based on age and location

• Conduct type 2 diabetes screening, including risk assessment questionnaires, biochemical tests on blood/urine glucose and HbA1c, and combinations of the two

• Mandate opportunistic diabetes screening for patients who visit health facilities for other problems

Limited test consumables and equipment for screening, detection and management of diabetes

• Set mandatory guidelines for the PSE clinics/hospitals to have basic consumable, equipment and trained staff available for diabetes testing

• Conduct periodic facility assessments and strengthen the infrastructure for diabetes diagnosis based on the assessment results

• Outsource laboratory investigations that are not available at PSEs health facility

Absence of a well-maintained database of information on the risk factors that individual employees are exposed to

• Set up an employee database for tracking follow-ups with those who were screened

• Maintain an employee database containing clinical data from patients and pre-diabetic subjects, to coordinate the delivery of interventions and self-management support activities

• Create a disease registry in collaboration with the NPCDCS and other government programmes that will be crucial to the management of the employees with chronic illness


38


Fear of the disease and its treatment, and uncertainty about where to go with a positive test result

• Develop a communication strategy where employees are informed about the medical facilities available for continuity of care if they have a positive test result. The message should also convey that diabetes well treated allows normal life to prevent fear of job loss and career development

• Develop written patient management plans that are reviewed and revised annually with the assistance of a diabetes support team consisting of the physician, diabetic educator and dietician

Limited outreach of screening programmes

• Partner with local NGOs and CBOs to conduct extensive community outreach programmes

• Ensure that glucometers are made available at all health facilities/departments

• Equip mobile health units with diabetes screening facilities

• Integrate and collaborate with screening systems established in the National Program on Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)

39

TREATMENT

Non-adherence to treatment

• Focus on ‘patient-centered approach’ and encourage healthcare providers to actively involve their patients in developing self-care regimens

• Establish targeted Outreach Programmes to increase adherence to treatment

• Link health check-up results to the employee’s performance appraisal

• Offer wellness incentives or financial rewards to employees who work toward getting healthier

• Provide messages to high-risk population through various mediums to increase participation in proven prevention programs and adherence to treatment

• Initiate counseling and health education by doctors/ counselors

• Make anti-diabetic medications freely available to employees. “The National List of Essential Medicines” has identified glibenclamide, metformin, and insulin as anti-diabetic drugs that needs to be available universally

• Ensure the coverage of of chronic conditions like diabetes and hypertension, and associated complications in reimbursement systems/ health insurance in PSEs

‘Clinical inertia’ contributing to high glycosylated haemoglobin (HbA1C) levels

• Increase provider awareness and knowledge on addressing clinical inertia through training and capacity building

• Ensure the effective use of electronic medical records to assist physicians when making decisions about a patient’s care pathway

• Provide practical management tools and support, such as treatment algorithms to healthcare providers


40


Weak referral linkages and follow-up systems

• Create linkage whereby employees referred to specialized clinics/hospitals for the treatment of diabetes and related complications can be tracked back for follow up

• Establish referral transportation system for emergencies arising out of NCDs

Lack of a standard treatment guidelines

• Provide doctors with a standard guidelines for treatment, appropriate references and CME meetings so that they become confident and shed the fear of prescribing insulin

CAPACITY BUILDING

Lack of skilled health work-force for health care delivery in PSEs

• Offer scholarships, traineeships or mentoring programs in NCDs should be offered to the health workers in the PSEs

• Broaden the roles of paramedical staff and nurses and develop their skills for providing basic diabetes care and counseling

Lack of training institutes to provide training in NCDs and chronic care

• Foster collaboration with other eminent hospitals and training institutions to provide training to the health workforce in PSEs

• Allocate an appropriate proportion of organization’s budget to training the health workforce in the PSEs

Limited healthcare provider orientation regarding NCDs

• Use innovative tools like diabetes conversation maps, etc. to train medical staff in PSEs

• Organize Continuing Medical Education (CME) programs in PSEs for healthcare providers to address provider attitudes toward diabetes and update their knowledge

• Coordinate standardized orientation programs for the medical teams managing NCDs in PSEs

Unknown training needs of the healthcare providers

• Conduct a Training Needs Assessment (TNA) periodically to identify individual training needs of health staff

• Monitor the impact of training on chronic diseases management and prevention

41

TECHNOLOGY

Database/registry maintained at the plant location is not integrated at the central level

• Integrate a standardized IT system such as diabetes registry to generate reports to help analyze a patient’s key diabetes-related measures and track patient’s progress

Use of outdated invasive glucose monitoring devices

• Invest in non-invasive glucose monitoring devices

Limited disease surveillance systems

• Maintain clinical registry of the employees suffering from diabetes and assigning each employee with a unique ID

Lack of technological solution to the severe shortage of health staff

• Collaborate with government agencies, premier medical and technical institutions to utilize already-existing Information and Communication Technologies (ICT) platforms like telemedicine


BEST PRACTICES IN DIABETES MANAGEMENT

NCDs are not only a health problem but a development challenge as well.

BEST PRACTICES IN DIABETES MANAGEMENT

44


There have been several efforts and reforms on management of diabetes by many

PSEs have met with varying levels of success and impact. However, documentation has been scant and the transfer of knowledge between the actors and application in

Healthcare Systems at IOCL

IOCL has a robust healthcare system in place to control communicable and non-communicable diseases at their workplace. The company has its own hospital and empanelled hospitals providing health care services to more than 1 lakh people including both existing and retired employees and their families. The health infrastructure includes:

• 8 refineries – 8 hospitals with 25 beds each, catering to IOCL employees

• Hospitals under CSR initiative:

~ 1 hospital at Digboi refinery with 200 beds, catering to local population and IOCL employees

~ 1 hospital at Mathura refinery with 50 beds, catering to local population and IOCL employees

INDIAN OIL CORPORATION LIMITED, NEW DELHI

The company provides medical benefits to all its employees even after retirement. ‘Medical cards’ are provided to retired employees for availing medical benefits from any IOCL location. In addition, the company has various policies and guidelines in place for its employees such as:

• Medical policy for overall healthcare system, which includes reimbursement rules, medical leaves, medical insurance etc

• HIV/ AIDS policy

• Corporate Occupational Standards Manual

• Food safety guidelines based on FSSI guidelines

different settings has been inadequate. This chapter would enable sharing and cross-learning of initiatives/best practices in diabetes management across PSEs and other stakeholders.

45

Diabetes Management at IOCL

IOCL focuses on all the facets of diabetes management, primarily prevention of diabetes at workplace. Some of the key inter-ventions undertaken by IOCL for managing diabetes are:

Workshops and Awareness Programmes

• IOCL conducts lectures and workshops for Human Resources/ Administrative employees on corporate occupational standards and stress management at their Indian Oil Institute of Petroleum Management (IiPM) in Gurgaon, Haryana every quarter The company has published books and periodicals on lifestyle and stress management for enhancing knowledge and awareness amongst employees. For screening and monitoring of diabetes, the company organizes health camps and reimburses 10 glucometer strips to the diabetic employees every month.

Other Health Initiatives for employees

• A customized diet plan is prepared individually for the Senior IOCL Executives to help them achieve a healthy and nutritious lifestyle

• Drinking water analysis is also performed at IOCL where physical, chemical and bacteriological properties of drinking water are analyzed as prescribed in BIS (105 N)

• Analysis of raw & cooked food items and cooking oil & milk is performed compliant with the Prevention of Food adulteration (PFA) norms to check for any adulteration

• One of the unique initiatives taken by IOCL for prevention of diabetes is the ‘Canteen Hygiene Audit’, which is described below.

Best Practices in Diabetes Management

46


CANTEEN HYGIENE AUDIT

Background

In order to promote health and hygiene at workplace, IOCL implemented Total Preventive Maintenance (TPM) practice at its Guwahati Refinery Industrial Canteen. The Corporate HSE Department of IOCL conceived the idea of initiating nutritional evaluation (Health and Hygiene) audit of all IOCL canteen/ kitchens in order to develop its existing canteens into ‘Model Industrial Canteens’

Intervention

IOCL started ‘Project Indian Oil’ in 2010 across all the IOCL locations. Under this programme, a team of qualified nutritional experts and medical doctors with additional qualification in occupational health carried out audits of 115 canteens/ kitchens of IOCL establishments during 2012-2013. To streamline the auditing process, the company hired renowned nutritionist and dietician, Dr. Shikha Sharma as the consultant for lifestyle management to support in re-adapting the canteen menus to include healthy food.

The audit areas assessed were dry storage, cold storage, washing area, food processing, pest control, food preparation, equipment handling, kitchen hygiene and garbage disposal. The gaps identified by the team are consolidated in the form of report with matching recommendations for improvement. The implementation of recommendations is being monitored at the local level, divisional level and corporate level. Evaluation of all the canteens are done based on the audit report and the highest-scoring canteen is recognized with awards.

Corporate Guidelines for good kitchen practices have been formulated for the maintenance and upkeep of canteen / kitchens at all IOCL locations. In addition, Guidelines on Healthy Life Style, Nutrition and Occupational Health were formulated by the company in 2012.

47

Outcome

An audit review of these locations has shown considerable improvement in health and hygiene practices across canteens/ kitchens. Also, the awareness on health issues and healthy eating increased amongst the employees. The canteens are assisted to adopt healthier cooking practices and provide healthier food choices for the staff.

25

58

13

42 4132 28

1625

3647 47

36 38

5643

35

16 1929

45

0

20

40

60

80

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Mar

ks O

btai

ned

IOCL Locations

Nutritional evaluation audit summary of115 IOCL canteens / kitchens


48


• Executive Health Check up: For employees above the age of 35 years, the company conducts executive health check up once every two years

• Workshops and Awareness Programmes

~ GAIL introduced a ‘Corporate Wellness Programme’ in which employees are exposed to information pertaining to wellness through video conferencing facility across 24 work centres of GAIL

~ For early detection and prevention of complication from NCDs, GAIL conducted education and awareness programmes such as ‘Joy of Living’ and periodical meetings and counseling session with nutrition experts

~ In order to promote overall well being of the employees and their families, GAIL organizes a programme every year to present the ‘Health Family Award’ to the employees and their families who have no medical expenditure, nor medical leave, and are found medically fit by the in house or empanelled doctor

One of the unique initiatives taken by GAIL for diabetes management is the ‘Health/NCD Index and Canteen Hygiene Index’, which is described below.

GAIL (INDIA) LIMITED

a. Healthcare Services at GAIL

GAIL is the largest state-owned natural gas processing and distribution company in India. The company has its own hospital and also has collaborated with hospitals providing health care services to both existing and retired employees including their families.

GAIL owns and operates 2 plants at Vijaipur in Madhya Pradesh and Pata in Uttar Pradesh. The company owns 2 hospitals, each fully equipped with 30 beds, latest medical equipment.

Diabetes Management at GAIL

GAIL focuses on all the facets of diabetes management at its workplace. Some of the key diabetes management and interventions by GAIL are:

• Occupational Health Services: GAIL undertakes occupational health check- up for every employee at three levels:

~ Pre-employment health check up: This is done for every candidate prior to joining at the time of employee induction/ orientation

~ Occupational health check up: Annual occupational health check up of regular employees and contractual employees at all the work centres as per the guide-lines of Occupational Health & Safety Advisory Services (OHSAS)

49

Health Index or NCD Index and Canteen Hygiene Index

i. Health Index or NCD Index

Background

The need for a foundation tool to assess the individual health of employees in GAIL was realized and eventually it led to the development of the ‘Health Index’. The objective of introducing this index was to identify groups/ individuals at risk of acquiring lifestyle- related diseases, target interventions and reduce the morbidity and mortality associated with chronic diseases at workplace.

Intervention

GAIL ‘Health Index or NCD Index’ is a numerical index to assess the health of individual employees and is used to improve the health policies and programs in the company.

The Index is based on a scoring system and measures health based on 15 parameters related to physical, physiological and biochemical test results. The maximum score awarded for the first five parameters is ‘10’, and ‘5’ for the remaining ten parameters. The higher the number, the lower the health risk of acquiring chronic diseases. Normal values receive full score (either 10 or 5) and values depicting a health risk score ‘0’. For e.g.: A person with BMI less than 25 will score 10, while a person with BMI more than 28 will score ‘0’.

Health measured is on a scale ranging from 0-5/10. The health index values are grouped into health risk categories as shown below. The total score for an employee can be in the range of minimum ‘0’ to maximum ‘100’. For e.g.: An employee scoring 90 has a lower risk of acquiring chronic disease then his/her counterpart who has scored 20.

• ‘0’- Very high health risk/ abnormal values• ‘5’- Very low risk or normal value for parameters 6 to 15 and moderate health risk for parameters 1 to 5• ‘10’- Very low risk or normal value for parameters 1 to 5

Max score for parameters 6 - 15

0 5 10

Max score for parameters 1-5

Scoring Scale


50


MEDICAL PARAMETERS TO ASSESS THE HEALTH SCORE OF THE INDIVIDUAL EMPLOYEE

SAMPLE SCORES OF AN EMPLOYEE

Parameters Range Score

BMI

<25 1025-28 5

>28 0

Blood PressureNormal 10Controlled with Drugs 5Uncontrolled/Newly Diagnosed 0

Blood SugarNormal 10Controlled with Drugs 5Uncontrolled / Newly Diagnosed 0

ECG / TMT / Coronary EngymesNormal 10Abnormal 0

Lipid ProfileNormal 10Controlled with Drugs 5Uncontrolled / Newly Diagnosed 0

Serum Uric AcidNormal 5Controlled with Drugs 3Uncontrolled / Newly Diagnosed 0

Thyroid ProfileNormal 5Controlled with Drugs 3Uncontrolled / Newly Diagnosed 0

Liver Function Test (LFT)Normal 5Abnormal 0

Renal Function TestNormal 5Abnormal 0

Vision including Colour BlindnessNormal 5Abnormal 0

51

Audiometry

Normal 5Mild Hearing Loss 4Moderate Hearing Loss 3Severe Hearing Loss 0

Addiction to tobacco chewing / smoking

No 5

Yes 0

History of Alcohol DrinkingNo 5Yes 0

No other Medical Problem / No any other investigation is positive

No 5Yes 0

Psychological Tests / Questionnaire

Normal 5Mild Stress 3Moderate Stress 3Severe Stress 0

Total Health Score of Individual

CANTEEN HYGIENE AUDIT

In order to promote health and hygiene practices across all the work centres of GAIL, the company implemented ‘Canteen Hygiene Index’ across all the canteens / kitchens. The index measures the canteen performance across 30 parameters under the following seven heads:

• Quality of raw material

• Storage and shelf-life of ingredients / products

• Kitchen utensils / cook-wares and electrical appliances

• Food prepartion and hygiene

• Kitchen / Canteen / Pantry hygiene

• Food handler’s health and hygiene

• Quality of food


52


a. Healthcare Services at BHEL

BHEL has a robust healthcare system in place to control diabetes at their workplace. The company has a 157 bedded hospital in Hyderabad, which treats more than 3,000 diabetic patients annually. Specialty services like General Medicine, Surgery, Pediatrics, Gynecology & Obstetrics, Anaesthesia, Ophthalmology, ENT, Dermatology & Dental etc., are available at the hospital.

b. Diabetes Management at BHEL

Employees diagnosed with diabetes are advised life-style changes and a holistic diabetes management plan that includes- taking medication as directed, having a balanced diet and regular exercise, monitoring glucose, etc. and to periodically review it for better management of the condition.


BHEL is active in promoting awareness on diabetes through various education programmes.

~ The company over the last 15 years is conducting patient education programme on the 3rd Sunday of every month. This programme serves as a forum for patients i.e. BHEL employees and local population to discuss and clarify doubts regarding diabetes with the healthcare team. At the end of the

programme a questionnaire is given to the participants to get feedback. Besides this, the corporation also prepares ‘Medical Cards’ that record the medical history including weight, BMI, blood glucose, ECG, ultrasound etc. for each patient.

~ The company organizes regular health talks by doctors on the prevalence of diabetes, conducts workshop twice in a year, performs random blood sugar (HbIAC) check-ups, raises awareness on the complication of diabetes through education magazines, articles, posters, ensures food quality, and implements incentive programs.

c. Other Activities

• For its employees residing at the BHEL housing complex, facilities like gym, yoga, badminton, basketball etc. are available. BHEL also organizes an inter-unit sports competition, which encourages employees to exercise and keep fit

BHARAT HEAVY ELECTRICALS LIMITED (BHEL), HYDERABAD

53

One of the unique initiatives taken by BHEL for diabetes management is:

Swasth Karamchari Samman Programme

In order to promote the overall well being of the employees and improve the quality and productivity of the workforce, employees are selected and awarded the ‘Swasth Karamchari Samman’ award, during an annual function on World Health Day.

The Swasth Karmchari Samman is given for generating health awareness among fellow employees and staying fit in the factory environment. The Samman is for employees who do not claim any medical reimbursement and also do not avail any leave on account of sickness in the previous financial year.

Stress control and lifestyle modifications

For maintaining a healthy lifestyle in the workplace, BHEL follows a practice of serving lunch to the employees at his/ her table. The lunch is termed as ‘working lunch’ where the portions of the food are fixed and no extra serving is served. For stress control, the company has a practice of playing light music during lunch hours.


54


a. Healthcare Services at NLC

NLC’s health care system is an integrated one providing both Allopathic and Ayurvedic medical care services. The company’s general hospital is a 350 bedded secondary level acute care facility fully equipped with the latest medical equipment. The facilities include ICU, 3 modern OT complexes, 2 state of the art Renal Care units, highly automated Lab facility and OHS. The hospital has a 76-member doctor team providing services across broad specialties. NLC has ties with all leading private hospitals for provision of super specialty care treatment to employees and their dependents for free of cost.

The general hospital also provides medical care at tertiary level to 17,000 employees and their family members, secondary level to 10,500 contract workmen and their dependants, and primary level to rural population (in its catchment area) that is free of cost.

The hospital annually treats more than 8.0 lakh patients in various clinics in the OPD and around 16,000 in various in-patient units. It performs an average of 800 major and 1800 minor surgeries including laparoscopic procedures, and 15,000 dialysis for End Stage Renal Disease (ESRD) patients in 2 units. The company also has its own diabetic clinic, which treats 3,000 patients annually.

NEYVELI LIGNITE CORPORATION LTD.

NLC provides OHS, cardiac screening for all employees and cancer screening for women employees. The hospital has telemedicine facilities including Tele CME, Tele CNE programmes and Tele-ECG consultations.

b. Diabetes Management at NLC

NLC focuses on all the facets of diabetes management at its workplace. Specific interventions for diabetes management include:


~ School level screening and lifestyle management for obesity in adolescent and children

~ Circulation of ‘Lignite Lifeline’ newsletter, where articles on lifestyle management, healthy practices and diabetes management of doctors are published

~ Health awareness programmes for lifestyle modification, obesity, smoking, alcohol, sedentary life and stress management. The company promotes health education through trilingual language videos for its employees and local population

~ Annual book fair with free check up for BMI, blood pressure and blood sugar

~ Regular monitoring of treatment adherence done by trained family physicians, teachers and health kiosks

55

~ Regular Eye and Fundus exam along with periodic Micral and HbA1c tests conducted by the hospital for its employees

~ Screening for diabetic complications like neuropathy, retinopathy, nephropathy, cardiovascular, PVD, Macrovascular disease, Dyslipidemia.

~ Counselling session on lifestyle modification including diet, physical exercise etc. and genetic counseling sessions for Type I Diabetics

• Training and Capacity Building

~ Conducts Continuing Medical Education / Continuing Neonatal Education programmes for physicians, doctors, nurses, and paramedical staff to update their knowledge. The doctors are given training in diabetic management

Telemedicine Centre

NLC General Hospital established telemedicine centre in 2009. The centre has a satellite communication facility provided by the Indian Space Research Organisation and ground equipment by the Prognosis Medical System, Bangalore.

The centre helps the hospital in getting live expert opinion on emergency cases from specialists in Sri Ramachandra Medical College Hospital, Kanchi Kamakoti Child Welfare Hospital and Narayana Hridalaya Hospital, Bangalore, with whom the NLC has established ties with. The Telemedicine centre, established as a component of the new system, compiles data on the employees and also prepares the disease profile of the patients. The information thus gathered could be studied with the help of a renowned research centre on the nature of ailments that the NLC employees were susceptible to, and so as to take necessary curative and preventive measures. It also reduces the clerical work of the medical staff. In the case of chronically ill patients who could not be taken to specialists, the medical reports could be sent online to the specialists concerned to get their expert opinion and treatment recommendations. The centre will enhance healthcare delivery of the 350-bed NLC General Hospital and benefit over 18,000 regular employees, 10,000 contract labourers and people from neighbouring villages. For rural coverage, telemedicine mobile units are established.

~ Provides Infant and Young Child Feeding counseling training and national workshop along with yoga training session for its employees

• Database management

~ An integrated Hospital Management Information System (HMIS) designed by TCS is established at the hospital. The system is linked at the plant and central level

Some of the unique initiatives taken by NLC for diabetes management are Telemedicine Centre and Crisis Intervention Centre as described below:

Crisis Intervention Centre – ‘MITHRA’

NLC general hospital started a crisis intervention centre, ‘Mithra’ to treat people affected by anxiety and other behavioural problems like drug addiction. A 24 hour dedicated phone lines are installed for the counselling of patients and doctors.


56


South Eastern Coalfields Ltd. is a subsidiary of Coal India Ltd. present in Chhattisgarh and Madhya Pradesh, and producing 25% of the total coal produced in Coal India Ltd. SECL has 89 coal mines spread across 7 Districts of Chhattisgarh and 3 Districts of Madhya Pradesh.

a. Healthcare Services at SECL

SECL has an extensive healthcare system in place. The company has 11 hospitals, 55 dispensaries, 131 ambulances, 845 beds, 238 doctors and 11 mobile medical units covering more than 70,000 employees.

b. Diabetes Management at SECL

SECL focuses on all the facets of diabetes management at its workplace. Specific interventions for diabetes management include:

• Occupational Health Units

~ Occupational health units are functioning at all the hospitals at regional level. These units are under the supervision of OH Physician and managed by trained doctors from different parts of India. These units detect occupational health burden of diabetes and hypertension among employees

~ For diabetes management, these units conduct mandatory pre-medical examination (PME) for employees in different age groups i.e. up to 45 years (once in 5 years) and above 45 years (once in 3 years). For executives, heath check-up is performed every year

~ Regular screening and follow-up on NCDs and diabetes are performed. Each employee from lower level to top management is required to submit a ‘health report card’, which is directly linked to the employee’s performance appraisal report and holds a substantial weight in the appraisal process.

• Health Camps

~ The corporation has set up different camps for screening diabetes, such as village health camps, diagnostic camps, senior citizen health camps, stress management & yoga camps, and mega health camps

• Other Activities

~ Celebration of World Diabetic Day - via IEC activities such as Walk for Health programme, seminars/ workshops, health camps, lighting of diabetes blue ring logo at workplace etc. to spread awareness for prevention and cure of diabetes

SOUTH EASTERN COALFIELDS LTD., BILASPUR

57

Some of the unique initiatives taken by SECL for diabetes management are described below:

Special Clinics for Diabetes• The company has created special clinics for diabetes management functioning at all

the hospitals at regional level. These clinics are managed under the supervision of Specialist Physicians

• The facilities such as lab investigations; counseling; free medical treatment to employees and their dependents; free medicines and distribution of glucometer strips etc. are available at these special clinics

• For specialized treatments, these clinics the patients to specialized hospitals for further treatment

Wellness Clinics• Wellness clinics for diabetes management are functioning at all the hospitals at

regional level. These clinics are managed under the supervision of General Medical Duty Officers (GDMOs)

• The main activity of these clinics is to generate awareness on diabetes, provide regular counseling for physical activity, exercise and diet, and perform regular follow-up of diabetes with employees

Training and Capacity Building• Training for Trainers through Eli Lilly & Company – the corporation has signed an MoU

with Eli Lilly & Company to provide certified training programmes to paramedical staff, nurses and doctors

• Diabetes Educator Patient Support programme with Eli Lilly & Company – the corporation provides regular screening programmes for its sedentary workers. The patients diagnosed with diabetes are sent to ‘Diabetes Educator Patient Support’ programme for generating awareness as per Eli Lilly & Company guidelines


58


In addition to the above good practices in diabetes management, there are many ongoing efforts by other PSEs to combat the growing burden of diabetes in PSEs.

~ Medical/ Health Camps: conducted in rural areas around SAIL Plant/Unit locations. A total of Seven Health centres (Kalyan Chikitsalaya) are being run at plants exclusively for providing free medical care including medicines to poor and needy families.

~ Primary Health Centres have been set up and operationalized to address the most neglected but essential requirement of health in rural India. Regular health camps, eye camps and free distribution of medicines are common phenomenon in MSVs. Moreover, persons diagnosed with major illness in the camps are referred for treatment in SAIL’s super specialty hospitals located at its steel plants.

~ Community sensitization and outreach through awareness programmes and use of Print and Electronic Media i.e. Health Education Pamphlets, OHS Bulletins, In house Magazines, Intra net, Cable TV etc.

• Treatment: primary, secondary as well as tertiary level of treatment is provided to all the entitled beneficiaries absolutely free by ensuring availability of health care providers, logistics and supplies.

• Screening: Regular screening through health checkups and investigations is carried out for early diagnosis, monitoring and prevention of complications.

• Training: Awareness and training of paramedical staff and doctors is carried out in house as well as through CMEs and Guest Lectures.

STEEL AUTHORITY OF INDIA (SAIL)

SAIL focuses on all the facets of Diabetes Management at its workplace. Some of the key interventions by SAIL for managing Diabetes are:

• Prevention: primordial, primary, secondary and tertiary prevention are carried out at the Occupational Health Centres and empanelled hospitals through various interventions. Some of them are as mentioned below:

~ Pre-employment Health Check up of all the candidates prior to their induction

~ Periodic Medical Examination (PME) and Pre-Retirement (Exit) Medical Examinations of all the employees and contractual workers as per the guidelines of Occupational Health & Safety Advisory Services (OHSAS).

~ Workshops and awareness programmes on health education, life style modification, and control of risk factors are undertaken for employees at workplace; for students at schools and colleges; and for dependents of employees and general population at community centres

59

• Data Management: Computerized Hospital Management System is available at all the Occupational Health Centres and at all the SAIL Plant / Unit Hospitals.

• Other initiatives: in 2011, the company started a ‘Programme of Direct interaction’ with employees at their work place. This programme includes power point presentation alongwith question & answer sessions on lifestyle diseases.

NTPC, KORBA, CHHATTISGARH

NTPC Korba plant has robust healthcare system in place which focuses on all the facets of Diabetes Management. Some of the key interventions by NTPC for managing Diabetes are:

Specific intervention for diabetes management:

• Prevention: for preventing the development of risk factors for diabetes, awareness programmes for weight gain, smoking, alcohol, sedentary life and stress management are conducted by the company

• Treatment: primary, secondary as well as tertiary level of treatment is provided to all the entitled beneficiaries and employees are encouraged for lifestyle modifications programmes

• Screening: Regular screening through health checkups and investigations is carried out for early diagnosis, monitoring and prevention of complications.

• Health education and awareness programmes on behavioral education, health education, physical exercise etc.

Promotes SMBG (self BG monitoring), home insulin injection, regular foot examination etc. among employees.

~ Every 1st Sunday of each month, the company conducts ‘Walking Day’ to encourage walking and physical exercise among employees as a part of lifestyle modification initiatives

~ Celebration of World Diabetic Day – celebrates World Diabetic Day via IEC activities such as walk of health programme, seminars/ workshops, health camps, lighting of diabetes blue ring logo at workplace etc. to spread awareness for prevention and cure of diabetes

~ Health Ambassador – concept of nominating health ambassador where a doctor is nominated as health ambassador where he/ she holds monthly meetings to discuss lifestyle diseases is carried out at all the plant locations

~ Yoga/ Art of Living and is taught to employees and their dependants on regular basis

~ School health check-ups camps including health education is conducted on regular basis

• Periodic Medical Examination (PME) of all the employees and contractual workers as per the guidelines of Occupational Health & Safety Advisory Services (OHSAS).


SURVEY OUTCOMES

One and a half billion adults, 20 and older, were overweight in 2008

62


63

Information about the health care system in individual PSEs was collected using a self

administered structured questionnaire. The questionnaire was sent to the representatives of the 69 PSEs who participated in the roundtables, out of which 22 PSEs (31%) responded and the responses were further analyzed.

Survey Outcomes

Survey objective

The survey objective was to gauge the situation of existing healthcare systems at PSUs for diabetes management. The key points included:

Prevalence of diabetes

Human resource availability

Availability of protocols/ guidelines

Communication and Awareness Communication and Awareness

Training and Capacity building

Representative of PSUs participated in the

Survey methodology – Three Pronged Approach

Conducted questionnaire survey through emails telephonic conference primary

Representative of PSUs participated in theregional roundtablesCategorized PSUs participated in the regional roundtables

Conducted questionnaire survey

Data collation for quantitative analysis. Compilation of summary of findings

emails, telephonic conference, primaryinterviews and regional roundtables

Conducted questionnaire survey

Response compilation for further analysis

Survey Outcomes

64


Observation – Almost half of the PSEs (41%) provide tertiary (specialized units, advanced diagnostic support services and specialized medical personnel) and secondary (having inpatient beds, preventive and curative services and facilities staffed with doctors and nurses) level of health care.

Implication – This implies that specialized care units are an integral part of half of the PSEs and therefore developing strategies to utilize it to the optimum level, building strong linkages and having a robust and integrated database would improve health and health services delivery.

18%

41% 41%

0%5%

10%15%20%25%30%35%40%45%

Level 1 care Level 2 care Level 3 care

What are different levels of healthcare does the facility caters to?

It should be ensured that all patients suffering from complications of diabetes or conditions that cannot be treated at the primary level are appropriately linked to the secondary or tertiary level of healthcare in PSEs. A standardized and integrated IT system such as a diabetes registry across all levels of health care will support in generating reports for analyzing a patient’s key diabetes-related measures and help track patient’s progress.

What are the different levels of healthcare the facility caters to?

65

Observation – The health workforce availability at the PSEs is highest for doctors, nursing staff, pharmacists and outreach workers. It is observed that the current clinical structure in PSEs mostly comprises of doctors, nurses, pharmacists etc. indicating the focus is on delivery of acute care. A multidisciplinary health care teams comprising of counselors, health educators, nutritionists and endocrinologists is required, allowing individuals with specialized training to maximally utilize their skills, improving the outcomes of diabetes. There is a very limited presence of endocrinologists, nutritionists, health educators and counselors at the PSEs which leads to major gaps in the provision of general nursing and counselling as well as specialist diabetes care.

Implication – PSEs should engage diabetes/ health educators in different regions or train local multipurpose diabetes workers to provide diabetes education, counseling, and clinical care.

0 100 200 300 400 500 600 700 800 900 1000

Doctors

Nursing Staff

Outreach Worker

Pharmacists

Lab. Technician

Diabetic Specialist

Nutritionists

Health Educator

Counselors

No. of staff

What is the overall staff strength at healthcare facility?

Level 3 Level 2 Level 1

What is the overall staff strength at healthcare facility?

Survey Outcomes

66


Is there any policies / guideline for health and safety in the company?

What kind of diabetes awareness and screening activities are performed by the PSEs?

32%36%

73%

41%

68%68%64%

27%

59%

32%

0%10%20%30%40%50%60%70%80%

Food Safety Guideline

Written Treatment Guidelines

Occupational Health Standards

Diabetes Guidelines Medical Rules

Is there any policies/ guideline for health and safety in the company?

Yes No

Observation- Around 36% of the PSEs have written treatment guidelines and 41% have diabetes treatment guidelines.

Implications- This implies that a standard treatment and diabetes guidelines should be shared and enforced throughout the health system within the PSEs to ensure consistency in the management of diabetes.

32%

23%

%23%2336%

27%

14%

23%27%

18%

27%

14%

0%5%

10%15%20%25%30%35%40%

Diabetes awareness camps (IEC / BCC)

Educating on "Self Management of

Diabetes"

Diabetes Screening and Diagnostic

Life Style Modification (Nutrition / Physical

Activity)

%ag

e of

tar

get

ed p

opu

lati

on

Employees Women Children

67

Observation – Less than half of the PSEs are undertaking diabetes awareness programmes for the targeted population. Awareness generation activities among children about importance of diet and sustained physical activities are very low, at around 14%. In addition, only 14% of the PSEs are creating awareness among women on diabetes screening predominantly about gestational diabetes mellitus (GDM) screening. Only one fourth of the employees are provided information and education on self management of diabetes.

Implication – Efforts should be made by the PSEs to improve and intensify efforts to conduct awareness programmes at all levels of healthcare system. Healthcare providers should begin by taking time to evaluate their patients’ perceptions and make realistic and specific recommendations for self management of diabetes.

Is there any other alternative form of medical system prevelant for the treatment / management of Diabetes?

40%

60%

0%10%20%30%40%50%60%70%80%

oNseY

Is there any other alternate form of medical system prevelent for the treatment /

management for Diabetes?

Observation – Less than half (40%) of the PSEs practice alternative medicine/Indian systems of medicine like ayurveda, homeopathy, etc. for diabetes treatment.

Implication – There is a paucity of health workers in PSEs. This can be better managed by a robust public health workforce from different systems of medicine. Mainstreaming of Indian systems of medicine would help to fill the gap of health workforce inadequacy in PSEs.

Survey Outcomes

68


Observation – Overall 95% of the PSEs reported that they have both in-house and referral health care services for the beneficiaries.

Implication – Efforts should be made to establish proper linkage between referral and in house services. A system to track patients and treatments provided should be in place.

5%

95%

0%

20%

40%

60%

80%

100%

Referral Both (referral+in house)

What kind of healthcare system prevalent in the company?

%05%05

0%

10%

20%

30%

40%

50%

60%

oNseY

Does the PSU use any technology for their awareness programs?

What kind of healthcare system is prevalent in the company?

Does the PSE use any technology for their awareness programs?

Observation – The use of technology for diabetes management and care was reported by 50% of PSEs. Although half of the PSEs are using some form of technology for diabetes management, limited usage of technology is seen in 50% of the sample.

Implication – PSEs should strengthen the already existing technology platform or integrate a standardized ITR system which

has the potential to improve care processes, increase awareness and outreach, and delay diabetes complications. IT can be used to provide support to patients, enhance changes in healthcare delivery and provide clinicians with access to expertise and timely, useful data about individual patients and populations. Adequate training and integration into the usual process of care are essential facilitators to implementing IT.

69

Prevalence of diabetes – According to the Department of Public Enterprises (DPE), there are 1.4 million employees and 6 million family members across 254 PSEs in India. Taking into consideration the above figures, total population (employees and families) was calculated as ~0.51 million in the 22 surveyed PSEs. Among the ~0.51 million population, the number of diabetic people were reported at 90,029 constituting 17% of the total population.

Prevalence of diabetes in total targeted population at PSEs

5,19,685 90,029

Total population No. of diabetic population

Prevalence of diabetes in total targeted population at PSUs

Total population* at 254 PSUs

Total6,000,000 Total

5,19,685

Prevalenceof diabetes:

17%

Total population* at surveyed22 PSUs

Prevalence of diabetes insurveyed 22 PSUs

70,00,000 6,00,000

5,00,000

4,00,000

3,00,000

2,00,000

1,00,000

60,00,000

50,00,000

Employees,14,40,000

Fam

ily M

embe

rs,

45,6

0,00

0

Employees,1,24,724

Fam

ily M

embe

rs,

3,94

,96140,00,000

30,00,000

20,00,000

10,00,000

No.

of p

eopl

e

No.

of p

eopl

e

*total population includes employees and their family members

Survey Outcomes

THE WAY FORWARD

Nearly 43 million children under five years old were overweight in 2010

72


The Way Forward

Although diabetes prevention and control action has been initiated in many PSEs

across India, efforts are fragmented and are not of high priority as communicable diseases. Effective management is imperative for reducing morbidity and premature mortality related to diabetes in all workplaces including the PSEs. Strategies that produce mutually supportive changes in behavior, policies and environments at the workplace, synergized with structured lifestyle and pharmacotherapy interventions is the need of the hour.

The following five key strategies that address diabetes risk factors in a comprehensive way can alleviate the diabetes burden in PSEs.

1 Create a uniform policy. The prevention measures and actions are always underpinned by a policy instrument, which encourages and enforces behavior shift in individuals or organizations. The main aim of the healthy workplace policy is to create a supportive environment that makes health choices possible for all employees. It is important to consult and engage stakeholders- employers and employees, in the development and implementation of policies to ensure feasibility, commitment and sustainability. Strong and sustained leadership of top management is crucial to tackle the diabetes burden in the PSEs.

2 Implement primary prevention programs. Health promotion, employee education and interventions tailored to high risk groups should be pivotal to any

primary prevention program at workplace. The workplace is an appropriate setting for health promotion, because of the significant proportion of time spent at work by the large majority of the population, and it also offers an opportunity to utilize peer pressure to encourage employees to make desirable alterations to their health habits.

3 Form partnerships and collaborations. There is a strong case for the PSEs to engage and partner with other stakeholders – government programs, hospitals, NGOs etc, to influence the social and environmental factors that determine the burden of chronic diseases. The need to promote and develop multi-stakeholder partnerships and approaches that make the best use of resources and strengthen a holistic approach to healthy lifestyles is important. Integrating with the screening system of the NPCDCS program and making diabetes medicines available at an affordable cost for the PSE employees and their dependents will reduce the huge morbidity and early mortality from diabetic complications.

4 Improve the health care infrastructure. Necessary adjustments in the infrastructure of health care are required to improve the quality of diabetes care services. Infrastructure in health care can include professional education, data systems, financing and delivery systems, research, and patient education resources, among others. The most critical amongst all is the education of the health workforce. A skilled and multidisciplinary workforce is

73

fundamental to the provision of effective diabetes management services. In addition to clinical skills, service providers require a range of skills including communication, collaboration, advocacy, planning, management and evaluation. It is vital to collaborate with medical colleges, training institutes and professional associations for providing Continuous Medical Education (CME) to the healthcare providers in PSEs. This would be an effective way of bringing new knowledge about diabetes and chronic illness into practice.

5 Strengthen the monitoring and evaluation (M&E) systems. M&E of diabetes and its complications in PSEs is critical in order to timely recognize the disease, identify high-risk groups, revise/formulate health care policy, make informed decisions and evaluate progress in disease

prevention and control. A more integrated approach to collecting data using robust information technology would improve the ability to track progress and monitor performance.

Translating evidence into practice to curb the diabetic epidemic in PSEs requires fundamen-tal shifts in policies and health systems. The greatest impact can be achieved by creating healthy policies in PSEs that promote diabetes prevention and control and reorienting health systems to address the needs of people with diabetes. Through a judicious blend of tech-nological innovation, institutional reforms to promote the efficiency and equity of health services for diabetes care and capacity build-ing, to close knowledge-action gaps, PSEs will be able to strengthen diabetes management within their facilities.

The Way Forward

74


Considering the rising burden of non-communicable diseases and existing risk

factors, Government of India initiated the integrated National Program for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). The program attempts to create a wider knowledge base in the community for effective prevention, detection, referral and treatment strategies through convergence with the ongoing interventions and other national programs. While the national program in the country is evolving, policies are being framed and strengthened, private sector investment on diabetes care and management is increasing and a need was felt to hold a high level seminar in India to provide a much needed impetus and direction to diabetes management and care. The purpose of the 1st National NCD Summit 2013 was towards creating a platform at state and national level for strengthening public health strategies for comprehensive diabetes management. The summit was an effort towards a greater objective of making India better prepared to take the challenge of increasing diabetes burden. The summit featured the united efforts of advocacy groups, academia, professional bodies, Government officials and agencies, public and private healthcare providers and healthcare industry partners, who have all come together to contribute to this initiative.

The programme was organized in two stages. It was a 2 Day “National NCD summit” in Delhi, preceded by state roundtables in selected 5 state capitals and the development of a National White Paper to identify and assess the strengths, gaps, opportunities and best practices pertaining to policies for managing Diabetes in India. This White Paper was an outcome of a series of 5 state round-table discussions and scores of in-

depth interviews with several stakeholders from within and outside the Government, working on Diabetes management.

The research and the White Paper clearly demonstrated that each state has its own strengths, weaknesses and priorities. Over the last two years, Diabetes management interventions under NPCDCS have reached more than 17.6 million patients, but with the incidence still going up, it is essential to scale up the effective interventions. The round-table discussions and analysis of qualitative information was conducted in line with the strategic framework of NPCDCS and classified under the following five broad areas:

1. Prevention2. Early detection (and screening)3. Treatment4. Training and Capacity Development5. Monitoring, Surveillance and Evaluation

Key Programme OutcomesCollaborative initiative aims at comple-menting the initiatives taken by the state and the Government of India initiatives for strengthening the Diabetes component of the NCD programme and specific key outcomes were as follows:

• Sensitization and capacity building of all state nodal officers across states on high level policy around NCDs.

• Learning of best Practices from National and international initiatives for shaping and strengthening the National initiatives in India.

• Exploring PPP opportunities and involvement of industries to complement the NCPCDCS initiatives based on the outcomes of the NCD summit.

Please visit www.nationalncdsummit.in to learn more about this initiative.

Brief on National NCD Summit, 2013 and the 1st national Whitepaper on NCD

75

References

1. Diabetes Atlas IDF 2013.

2. Albala B-. Diabetes, fasting glucose levels, and risk of ischemic stroke and vascular events: findings from the Northern Manhattan Study (NOMAS). Diabetes Care 2008;31:1132 - 7.

3. al IAe. Incidence of lower-limb amputations in the diabetic compared to the non-diabetic population. Findings from nationwide insurance data, Germany, 2005-2007. . Experimental and Clinical Endocrinology & Diabetes, 2009;117:500 - 4.

4. S R. Global data on visual impairment in the year 2002. Bulletin of the World Health Organization 2004;82.

5. CY J, MB M. Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Medicine 2008;5:e152.

6. V M, S S, Saboo B. Current glycemic status and diabetes related complications among type 2 diabetes patients in India: data from the A1chieve study. . J Assoc Physician India 2013;61:12 - 5.

7. Mohan V. Prevalence of coronary artery disease and its relationship to lipids in a selected population in South India: The Chennai Urban Population Study J Am Coll Cardol 2001;38:682 - 7.

8. The Silent Epidemic – An economic study of diabetes in developed and developing countries. 2007.

9. S V. Economic Implication of Chronic Disease in India - a fact sheet: South Asia Network for Chronic Disease; 2009.

10. Taylor DW. The burden of Non Communicable Disease in India: Cameroon Institute; 2010.

11. Shetty P. India’s Diabetes time Bomb, Outlook Diabetes. Nature 2012;485.

12. The Growing Danger of Non-Communicable Diseases: Acting Now to Reverse Course. : The World Bank Human Development Network; 2011.

13. Frank H. Globalization of diabetes: The role of diet, lifestyle, and genes. Diabetes Care 2011;34.

14. NFHS - III: IIPS & Macro International 2007.

15. Mohan V SC, Deepa R. . Glucose intolerance (diabetes and IGT) in a selected south Indian population with special reference to family history, obesity and life style factors - The Chennai Urban Population Study (CUPS 14). J Assoc Physician India 2003;51:771 - 7.

16. P P. Prevalence and risk factors of diabetes among bank employees of Meerut district. Indian Indian J Pre Soc Med 2009;40.

17. al RAe. High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. . Diabetologia 2001;44:1094 - 101.

18. Karen Siegel KMVNaSK. Finding A Policy Solution To India’s Diabetes Epidemic. . Health Affairs 2008;4:1077 - 90.

19. Ghouse S. An Overview of Central Public Sector Enterprises in India.

20. Overview of the Central Public Sector Enterprises in India.

76


Abbreviations

AIDS Acquired Immunodeficiency Syndrome

BCC Behavior Change Communication

BHEL Bharat Heavy Electricals Limited

BMI Body Mass Index

CBO Community Based Organization

CII Confederation of Indian Industries

CME Continuing Medical Education

CNE Continuing Neonatal Education

DPE Department of Public Enterprises

ECG Electrocardiography

ESRD End Stage Renal Disease

FSSI Food Safety and Standards Authority of India

GDM Gestational Diabetes Mellitus

GDMO General Medical Duty Officer

GDP Gross Domestic Product

HbA1C Glycosylated Haemoglobin

HIV Human Immunodeficiency Virus

HMIS Hospital Management Information System

ICMR Indian Council of Medical Research

ICT Information and Communication Technologies

IDF International Diabetes Federation

IEC Information Education and Communication

IOCL Indian Oil Corporation Limited

IiPM Indian Oil Institute of Petroleum Management

IT Information Technology

LFT Liver Function Test

MCH Maternal and Child Health

MDG Millennium Development Goals

M&E Monitoring and Evaluation

MoHFW Ministry of Health and Family Welfare

NCD Non-Communicable Disease

NGO Non Governmental Organization

NLC Neyveli Lignite Corporation Ltd.

NPCDCS National Program on Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke

NRHM National Rural Health Mission

NTPC National Thermal Power Corporation

OGTT Oral Glucose Tolerance Test

OHSAS Occupational Health & Safety Advisory Services

PFA Prevention of Food Adulteration

PME Periodic Medical Examination

PSE Public Sector Enterprise

PVD Peripheral Vascular Disease

SAIL Steel Authority of India Ltd.

SECL South Eastern Coalfields Ltd.

SMBG Self Blood Glucose Monitoring

TB Tuberculosis

TMT Tread Mill Test

TNA Training Needs Assessment

TPM Total Preventive Maintenance

USD United States Dollar

77

We would like to acknowledge the special contribution of the Advisory

group members especially Dr. A K Goyal (Chief Medical Services, ONGC), Dr. Damodar Bachani (Deputy Commissioner, MOHFW), Dr. Mitra Rey (CIL), Dr. Sandeep Sharma (Senior Manager & Additional Chief Medical Officer, IOCL), Dr. S K Gupta (Director, SAIL), Dr. Chandra Tripathi (Chief Medical Officer, GAIL), Dr.Manu Saksena (Medical Superitendant,BHEL), Dr. PC Rai (Chief Medical Officer, NTPCL), Dr. Sengupta (Senior Advisor, CII), Indranil Bhattacharya (Medical Advisor, Eli Lilly And Company) for providing valuable technical oversight and guidance for preparing this white-paper.

We sincerely recognize and appreciate the efforts of the IMS Health Information and Consulting Services India Pvt. Ltd. team, as the knowledge partner, for collating and compiling the body of evidence and data from all the state round tables, questionnaire survey and key informant interviews in form of this whitepaper.

Acknowledgements

We would like to thank the PSEs from the state of Raipur, Kolkata, Bangalore, Hyderabad and Mumbai for participating in the state round tables and contributing to this work. It would not have been possible to draft this white-paper without the active involvement of the state counterparts and the participants of the roundtable discussions including the Government officials from Ministry of Health and Family Welfare as well as from the Department of Public Enterprises (DPE) State Departments of Health, Nodal Officers for NCD and research & academic institutes. We would like to express our gratitude towards all the participants of the round table discussions for their valuable inputs and support.

78


Lilly is a global healthcare leader that unites caring with discovery to make life better for

people around the world. We were founded more than a century ago by a man committed to creating high-quality medicines that meet real needs, and today we remain true to that mission in all our work. Across the globe, Lilly employees work to discover and bring life-changing medicines to those who need them, improve the understanding and management of disease, and give back to communities through philanthropy and volunteerism. To learn more about Lilly, please visit us at www.lilly.com

79

IMS Health is a leading worldwide provider of information, technology, and

services dedicated to making healthcare perform better. With a global technology infrastructure and unique combination of real-world evidence, advanced analytics and proprietary software platforms, IMS Health connects knowledge across all aspects of healthcare to help clients improve patient outcomes and operate more efficiently. The company’s expert resources draw on data from nearly 100,000 suppliers, and on insights from 39 billion healthcare transactions processed annually, to serve more than 5,000 healthcare clients globally. Customers include pharmaceutical, medical device and consumer health manufacturers and distributors, providers, payers, government agencies, policymakers, researchers and the financial community. Additional information is available at www.imshealth.com.

80


corporate citizenship programmes. Partnerships with civil society organizations carry forward corporate initiatives for integrated and inclusive development across diverse domains including affirmative action, healthcare, education, livelihood, diversity management, skill development, empowerment of women, and water, to name a few.

The CII theme of ‘Accelerating Growth, Creating Employment’ for 2014-15 aims to strengthen a growth process that meets the aspirations of today’s India. During the year, CII will specially focus on economic growth, education, skill development, manufacturing, investments, ease of doing business, export competitiveness, legal and regulatory architecture, labour law reforms and entrepreneurship as growth enablers.

With 64 offices, including 9 Centres of Excellence, in India, and 7 overseas offices in Australia, China, Egypt, France, Singapore, UK, and USA, as well as institutional partnerships with 312 counterpart organizations in 106 countries, CII serves as a reference point for Indian industry and the international business community.

The Confederation of Indian Industry (CII) works to create and sustain an

environment conducive to the development of India, partnering industry, Government, and civil society, through advisory and consultative processes.

CII is a non-government, not-for-profit, industry-led and industry-managed organ-ization, playing a proactive role in India’s development process. Founded in 1895, India’s premier business association has over 7200 members, from the private as well as public sectors, including SMEs and MNCs, and an indirect membership of over 100,000 enterprises from around 242 national and regional sectoral industry bodies.

CII charts change by working closely with Government on policy issues, interfacing with thought leaders, and enhancing efficiency, competitiveness and business opportunities for industry through a range of specialized services and strategic global linkages. It also provides a platform for consensus-building and networking on key issues.

Extending its agenda beyond business, CII assists industry to identify and execute

2nd National White Paper




KNOWLEDGE PARTNER



Eli Lilly and Company Disclaimer “This National NCD Summit is funded by Eli Lilly and Company (India). The content has been generated in public interest and for the well-being of the society. Lilly was not involved in the creation of this content and the views expressed are participants own independent views. This shall in no way be considered a substitute to any personalized advice of HCPs on the disease state of an individual. Lilly makes no representations or warranties of any kind express or implied in relation to the content and the views posted thereon and shall not be bear any liabilities that may arise out of the use or misuse of this information” CII Disclaimer No part of this publication may be reproduced, stored in, or introduced into a retrieval system, or transmitted in any form or by any means (electronic, mechanical,photocopying, recording or otherwise), in part or full in any manner whatsoever, or translated into any language, without the prior written permission of the copyright owner. CII has made every effort to ensure the accuracy of the information and material presented in this document. Nonetheless, all information, estimates and opinions contained in this publication are subject to change without notice, and do not constitute professional advice in any manner. Neither CII nor any of its office bearers or analysts or employees accept or assume any responsibility or liability in respect of the information provided herein. However, any discrepancy, error, etc. found in this publication may please be brought to the notice of CII for appropriate correction.

Published by Confederation of Indian Industry (CII), The Mantosh Sondhi Centre; 23, Institutional Area, Lodi Road, New Delhi 110003, India, Tel: +91-11-24629994-7, Fax: +91-11-24626149; Email: [email protected]; Web: www.cii.in

management and care of diabetes in public sector...

Documents