Democratic Socialist Republic of Sri Lanka Ministry of Health PROJECT ON HEALTH PROMOTION AND PREVENTIVE CARE MEASURES OF CHRONIC NCDS FINAL REPORT MARCH 2013 JAPAN INTERNATIONAL COOPERATION AGENCY (JICA) GLOBAL LINK MANAGEMENT, INC. SL JR 13-002 The following foreign exchange rates are applied in the study (as of February 2013) USD 1 = 91.04 JPY LKR 1 = 0.72 JPY Location Map Abbreviations AMO Assistant Medical Officer BH Base Hospital BHA, BHB Base Hospital type A, Base Hospital type B BMI Body Mass Index CD Central Dispensary CI Confidence Interval CVD Cardio-vascular diseases DDG/DS Deputy Director General, Dental Services DDG/ET&R Deputy Director General, Education, Training & Research DDG/F Deputy Director General, Finance DDG/LS Deputy Director General, Laboratory Services DDG/MS Deputy Director General, Medical Services DDG/P Deputy Director General, Planning DDG/PHS Deputy Director General, Public Health Services DG Director General DGH District General Hospital DH District Hospital DM Diabetes Mellitus ECG Electrocardiograph ECU Emergency Care Unit ET&R Education, Training and Research FBG Fasting Blood Glucose FY Fiscal Year GH General Hospital GoSL Government of Sri Lanka GPT(ALT) Glutamic Pyruvic Transaminase HC Health Check-up (subgroup) HDL High Density Lipoproteins HEB Health Education Bureau HEO Health Education Officer HI Health Information (subgroup) HLC Healthy Lifestyle Centre(s) HMP Health Master Plan HR Hazard Ratio HT Hypertension HP Health Promotion (subgroup) HRH Human Resources for Health HSDP Health Sector Development Programme ICB International Competitive Bidding ICU Intensive Care Unit IEC Information, Education and Communication IDA International Development Association IFG Impaired Fasting Glycaemia IHD Ischaemic Heart Disease IMMR Indoor Mortality and Morbidity Return JCC Joint Coordinating Committee JICA Japan International Cooperation Agency JPY Japanese Yen LDL Lipid Density Lipoproteins MCH Maternal and Child Health MET Metabolic equivalent for Task MI Myocardial Infarction MLT Medical Laboratory Technologist MO Medical Officer MoH Ministry of Health MOH Medical Officer of Health, or Medical Office of Health NABNCD National Advisory Body for NCDs N/A Not Available NAFLD Non Alcoholic Fatty Liver Disease NC North Central Province NCD Non-Communicable Diseases NHSL National Hospital of Sri Lanka NO Nursing Officer NPP NCD Prevention Project NW North Western Province OPD Outpatient Department OR Odds Ratio p Probability value PEN Package of Essential NCD interventions for primary health care in low-resource settings PDHS Provincial Director of Health Services PDM Project Design Matrix PGH Provincial General Hospital PGIM Post Graduate Institute for Medicine PH Provincial Hospital PHI Public Health Inspector PHM Public Health Midwife PMCU Primary Medical Care Units PPA Programme Planning Assistant PU Peripheral Unit PY Person Years RDHS Regional Director of Health Services RH Rural Hospital RHS Ragama Health Study RMO Registered Medical Officer Rs Sri Lankan Rupees SD Standard Deviation SLDCS Sri Lanka Diabetes and Cardiovascular Study STEPS STEPwise approach to surveillance TAG Triacylglycerol TH Teaching Hospital TOT Training of Trainers ToR Terms of Reference TWG Technical Working Group USD United States Dollars VP Visiting Physician WB World Bank WHO World Health Organization Table of Contents CHAPTER 1 INTRODUCTION .................................................................................... 1 1.1 NCD Situation in Sri Lanka ............................................................................................................. 1 1.2 Challenges of the Ministry of Health (MoH) ................................................................................... 2 1.2.1 Formulation of the NCD policy ............................................................................................. 2 1.2.2 Implementation of NCD policy and programmes .................................................................. 3 1.2.3 Risk factor surveillance .......................................................................................................... 4 1.2.4 Mapping NCD-related research ............................................................................................. 4 1.2.5 Multi-sectorial coordination .................................................................................................. 5 1.3 International Trends and NCD Prevention Partners in Sri Lanka ................................................. 6 1.3.1 International trends on NCD prevention ............................................................................... 6 1.3.2 NCD prevention partners in Sri Lanka ................................................................................. 7 1.4 NCD Prevention Project (NPP) ........................................................................................................ 9 1.4.1 Background ............................................................................................................................ 9 1.4.2 Project components .............................................................................................................. 10 1.4.3 Implementation structure ..................................................................................................... 11 CHAPTER 2 NCD Risk Factors .................................................................................. 14 2.1 Introduction ..................................................................................................................................... 14 2.2 Background Information about Ragama Health Study (RHS) ..................................................... 14 2.2.1 Purpose of the RHS .............................................................................................................. 14 2.2.2 RHS study setting ................................................................................................................. 14 2.2.3 RHS population .................................................................................................................... 15 2.2.4 RHS examination items ........................................................................................................ 15 2.2.5 RHS ethical aspect ................................................................................................................ 15 2.3 Methodology of Follow-up Risk Factor Survey ............................................................................. 16 2.3.1 Design ................................................................................................................................... 16 2.3.2 Variables for the follow-up studies ...................................................................................... 16 2.3.3 Statistical methods ................................................................................................................ 17 2.4 Analysis of the Baseline Data ......................................................................................................... 17 2.5 Results of the Follow-up Study ....................................................................................................... 19 2.5.1 Participants ........................................................................................................................... 19 2.5.2 Outcome data ........................................................................................................................ 20 2.6 Discussion ........................................................................................................................................ 26 2.6.1 Prevalence of NCDs ............................................................................................................. 26 2.6.2 Risk factors ........................................................................................................................... 26 2.7 Recommendations ........................................................................................................................... 27 2.8 Limitations ....................................................................................................................................... 28 CHAPTER 3 NPP models for NCD prevention ........................................................... 29 3.1 Screening Model .............................................................................................................................. 29 3.1.1 Development structure and system ....................................................................................... 29 3.1.2 A transition of screening models .......................................................................................... 30 3.1.3 Information system ............................................................................................................... 36 3.1.4 Treatment strategies ............................................................................................................. 37 3.1.5 Referral and back-referral ................................................................................................... 38 3.2 Result of Feasibility Test in Pilot Areas ......................................................................................... 38 3.2.1 Main results in Kurunegala ................................................................................................. 38 3.2.2 Main results in Polonnaruwa .............................................................................................