CASE STUDY
Background
Reducing the burden of non-communicable diseases (NCDs) in low and middle-income countries (LMICs) has become a global priority. NCDs kill 38 million people each year. Almost three quarters of NCD deaths – 28 million – occur in LMICs. 16 million NCD deaths occur before the age of 70; 82% of these ‘premature’ deaths occur in LMICs.[1]
To help address this, we have worked with our partner NGOs and ministries of health in Pakistan, Bangladesh, Uganda and Nigeria to develop a NCD care package and train-the-trainer modules. This case study shares our experiences of adapting and piloting the package in Nigeria, and highlights some of the key considerations for other organisations looking to develop a similar intervention in their own country.
The package explained
The NCD package has been developed for use by generalist clinicians, nurses and educators in health centres and hospital outpatient departments. It draws on our experience with TB and other chronic disease management interventions and follows the identification, diagnosis, patient education and follow-up process. Currently it includes:

• a case management guide
• a lifestyle desk guide
• a treatment record card
• a lifestyle education leaflet
• training modules

Adapting and piloting the materials
From our experience in Nigeria, we have developed a 9-stage ‘how-to’ guide for tailoring the package to a specific country context. This includes advice on using a technical working group (TWG) as a good first step towards adapting the NCD package materials.
The TWG should comprise around 6 members including clinicians, national programme representatives and World Health Organization country office representatives. Bringing the TWG together for a 3 or 4-day workshop is a good idea, although weekly meetings over a few months is also an option if this is not feasible.
The NCD care package process at a glance:

• The guides, modules, cards & education tools provide a package of care for use by non-specialist clinicians.
• They can be adapted by a technical working group (TWG) and further refined through a pilot/train-the-trainer course.
• This enables standardised quality care for screening, treatment, education and follow-up in a health centre or outpatient department.
• Successful implementation depends on integrating NCD care within strong district health systems.

Training the trainers
In Nigeria, we followed the TGW workshop with a 4-day ‘train the trainers’ course led by local facilitators and supported by COMDIS-HSD staff. Each day different groups of general hospital doctors and nurses were trained to use the package. The focus was on role play and interactive learning methods, helping participants develop their consultation and communication skills around common non-communicable diseases such as hypertension, diabetes, asthma and epilepsy.
The course offered another useful opportunity to further refine the materials based on participants’ experience of using them. We suggest that while one facilitator leads the training session, another should observe and capture any feedback or changes.
The key role of the treatment record card
A key part of the NCD package is the treatment record card, adapted and refined through the TWG and pilot course process. At the initial and subsequent consultations, the BP, glucose, changes to drugs, etc are recorded on the card, with a new row filled in at each subsequent consultation.
The cards can be useful in keeping track of patients’ attendance at clinic appointments. Those who have failed to attend can be quickly identified and followed up by phone to discuss any problems and arrange an alternative date.
The treatment record cards are also a valuable source of data for reviewing the quality of care provided.
Implementing the NCD package in your health system:  4 key lessons

1. Implementation requires integrating NCD care within the district health system and all health  facilities. A member of the district health team should take on responsibility for management and supervision of this process and NCD care.
2. Drug and test availability: The guides are adapted to include evidence-based tests and drugs, so it is important to ensure that these are available on the essential drug list and provided through the routine supply system.
3. Trends in cases and outcomes need to be reviewed in routine performance management meetings. Care pathways and up/down referral pathways need to be established.
4. Reporting of the patients registered and their treatment outcomes should be integrated within the health information system.

Find out more:
See our NCD Care Package and guidelines on implementation and scale-up.
Reference:
1: World Health Organization (WHO) Non-communicable diseases factsheet (2015)
This project has been funded by UK aid from the UK government
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