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Contents
Introduction .................................................................................................................................... 4
Abbreviations .................................................................................................................................. 5
Chapter 1: Why focus on hypertension .......................................................................................... 6
1.1. Reasons to focus on hypertension ....................................................................................... 6
1.2. Government of India’s initiatives on hypertension control ................................................ 8
1.3. Essential components of scalable treatment of hypertension ............................................ 9
Chapter 2: Hypertension diagnosis & treatment using practical treatment procotols ................ 11
2.1. Measurement of blood pressure ....................................................................................... 11
2.1.1. Whose blood pressure should be measured .......................................................... 11
2.1.2. How to measure blood pressure ............................................................................ 11
2.2. Diagnosis of hypertension ................................................................................................. 16
2.3. Treatment of hypertension ................................................................................................ 16
2.3.1. Who should receive hypertension treatment? ...................................................... 16
2.3.2. The goal of hypertension treatment....................................................................... 16
2.3.3. Available medications for treating hypertension ................................................... 16
2.3.4. Use a standardized protocol ................................................................................... 18
2.3.5. Patient education .................................................................................................... 22
2.3.6. Treatment inertia .................................................................................................... 23
2.3.7. Frequently asked questions (FAQs) on hypertension treatment ........................... 23
Chapter 3: Drugs & Technology .................................................................................................... 27
3.1. Regular and uninterrupted availability of medication....................................................... 27
3.1.1. Drug supply chain: .................................................................................................. 27
3.1.2 Key considerations to ensure uninterrupted drug supply under IHCI..................... 29
A. State level: State Programme Managers & drug procurement corporation
officials .................................................................................................................. 29
B. District level: District Programme Managers & Warehouse Pharmacists ........ 30
C. Facility level: Medical Officers/ Pharmacists .................................................... 31
D. Monitoring by programme supervisors............................................................ 32
3.2. BP Measuring devices ........................................................................................................ 35
3.2.1. Types of devices ...................................................................................................... 35
3.2.2. Maintenance and calibration .................................................................................. 36
3.2.3. Validation of blood pressure measuring devices .................................................... 36
3.2.4. How reliable are automated, digital blood pressure measurement devices? ....... 36
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Chapter 4: Task sharing and patient-centred care ....................................................................... 44
4.1 Task sharing .................................................................................................................... 44
4.1.1 Advantages of task sharing ...................................................................................... 44
4.1.2 Requirements to initiate and establish task sharing in a facility ............................. 45
4.1.3 Steps for implementing task sharing ....................................................................... 45
4.1.4 Responsibilities which can be shifted to non-physicians ........................................ 46
4.2 Opportunistic screening and patient flow .......................................................................... 47
4.3 Patient-centred services ..................................................................................................... 48
4.3.1 What are the ways to improve patient-centred services? ...................................... 48
4.3.2 Strategies to establish patient-centred services ..................................................... 49
4.4 Decentralisation to sub-centres/health and wellness centres (HWC) ............................... 49
4.4.1 Strategies for decentralisation................................................................................. 50
4.4.2 Patient flow under decentralisation ........................................................................ 51
4.4.3 Format for line list register at the sub-centre ......................................................... 51
4.5 Health and Wellness Centre (HWC) .................................................................................... 52
4.5.1 Implementing IHCI in HWCs ..................................................................................... 52
4.5.2 Services to be provided in HWCs under IHCI ........................................................... 53
4.5.3 Roles of various field staff under the program ........................................................ 53
4.6 Lost to follow up – prevention, identification, and retrieval.............................................. 54
4.6.1 Prevention of Loss to follow up ............................................................................... 55
4.6.2 Identifying ‘missed visits’ ......................................................................................... 58
4.6.3 Retrieval of patients who missed follow up visits ................................................... 60
Chapter 5: Information systems - monitoring indicators and reporting tools ............................. 63
5.1 Core indicators .................................................................................................................... 63
5.1.1 Quarterly indicator – 3 to 6 monthly hypertension control rates ........................... 63
5.1.2 Annual Indicator....................................................................................................... 66
5.1.3 Hypertension Registration Rate ............................................................................... 71
5.2 Paper-based reporting tools ............................................................................................... 72
5.2.1 Patient BP Passport .................................................................................................. 72
5.2.3 Hypertension treatment card .................................................................................. 74
5.3 Digital systems .................................................................................................................. 110
5.4 Facility reports .................................................................................................................. 113
5.4.1 Facility quarterly report ......................................................................................... 116
5.4.2 Facility annual report ............................................................................................. 116
5.5 Monitoring cycle ............................................................................................................... 117
Answer key for Monitoring Indicators and Reporting tools ................................................... 118

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Chapter 6: Supportive supervision ............................................................................................. 125
6.1 Purpose of supervision ..................................................................................................... 125
6.2 Approaches to supervision ............................................................................................... 125
6.3 Steps of supervision .......................................................................................................... 127
6.3.1 Step 1: Planning supervisory visits ......................................................................... 127
6.3.2 Step 2: Conducting supportive supervision visits .................................................. 131
6.3.3 Step 3: Follow-up activities .................................................................................... 139

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Introduction
India is facing the rising burden of non-communicable diseases (NCDs) in general and
hypertension in specific. The National Programme for Prevention and Control of Cancer,
Diabetes, Cardiovascular diseases and Stroke (NPCDCS) has given due recognition to this and
has set a goal of 25% reduction in mortality due to non-communicable diseases by 2025.
NPCDCS has initiated a population-based screening program (PBS) for hypertension, diabetes,
and cancers of the breast, cervix and oral cavity. India Hypertension Control Initiative (IHCI), a
multi-partner initiative, complements this screening program by strengthening the
management of hypertension in primary health care settings. It aims to accelerate progress
towards the Government of India's NCD target by supplementing and intensifying evidence-
based strategies towards strengthening the building blocks of hypertension management and
control. IHCI partners include the Ministry of Health & Family Welfare, Government of India,
State Governments, Indian Council of Medical Research (ICMR) and World Health Organization
(WHO) India. Resolve to Save Lives, an initiative of Vital Strategies, is a technical partner.

IHCI was launched in November 2017 and is currently operational across 26 districts in Punjab,
Kerala, Madhya Pradesh, Telangana, and Maharashtra. The phase-2 of the project was
launched in July 2019 and will cover a total of 100 districts across all Indian States.

The major aim of this module is to build competencies of health professionals at the primary
health care level to treat hypertension as per the standard state-specific treatment protocol
using a patient-centric approach. This module also aims to build capacity for strengthening
drug logistic systems at the district and health facility levels. Additionally, this module provides
strategies and guiding principles for information systems, monitoring and supervision of the
hypertension control program.

This module has strived to avoid duplication of the existing modules of various cadres of health
workers. It should be considered a supplement to the existing training materials for different
cadres of health care providers under the NPCDCS.

States can use these modules for team-based training at the primary health care level such that
all members are aware of the entire team’s roles to ensure the best outcomes for the patient
as well as for control of hypertension in their areas.

This module has been jointly prepared by all partners of the India Hypertension Control
Initiative.

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Abbreviations
ASHA Accredited Social Health Activist
AIDS Acquired Immunodeficiency Syndrome
ACEI angiotensin-converting enzyme inhibitor
ARB angiotensin receptor blocker
App application
ANM auxiliary nurse midwife
BP blood pressure
CCB calcium channel blocker
CHEP Canada Hypertension Education Project
CCU cardiac care unit
CVDs cardiovascular diseases
CKD chronic kidney disease
CHC community health centre
DBP diastolic blood pressure
DH district hospital
DLHS District Level Health Survey
DDC drug dispensing counter
EDL Essential Drug List
ELM Essential List of Medicine
FDC fixed dose combination
FAQ frequently asked questions
GoI Government of India
HWC Health and Wellness Centre
HTN Hypertension
ID identification details
IHCI India Hypertension Control Initiative
LFU loss to follow up
LMIC Low- and Middle-income countries
MLHP mid-level health provider
MoHFW Ministry of Health and Family Welfare
NLEM National Essential List of Medicine
NFHS National Family Health Survey
NHM National Health Mission
National Programme for Prevention and Control of
NPCDCS
Cancer, Diabetes, Cardiovascular diseases and Stroke
NCDs non-communicable diseases
OPD outpatient department
PHC primary health centre
Q Quarter
RAS Renin-Angiotensin System
RKS Rogi Kalyan Samithi
SMS short messaging system
SC sub-centre
SBP systolic blood pressure
TB Tuberculosis

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Chapter 1: Why focus on hypertension
Expected competency on completion of session: Ability to convey to patients, health care workers, and
leaders the importance of treatment and control of hypertension.
Audience: Health care providers and facility managers.
In this session, you will learn about:
• Burden of cardiovascular disease and hypertension- global and Indian scenario
• Reasons to focus on hypertension
• Essential components of a scalable hypertension program

1.1. Reasons to focus on hypertension

a. Hypertension is the number one cause of mortality and morbidity: Cardiovascular diseases
(CVDs), which include heart attacks and stroke, are the most common cause of mortality
and morbidity across the world and are responsible for one-third of total deaths in India.
While the deaths due to CVDs are decreasing in rich countries, they are increasing in low-
and middle-income countries (LMICs).

Uncontrolled blood pressure is one of the main risk factors for CVD and is estimated to be
responsible for more than 10 million deaths per year, which is more than all infectious
diseases combined (figure 1). Hypertension contributes to an estimated 1.6 million deaths
annually in India, due to ischemic heart disease and stroke.1
Figure 1: High blood pressure is the world’s leading killer 2

Global deaths per year (million)

10.5

3.2
1.9 1.6 1.3 0.6
High blood Acute Diarrheal AIDS TB Malaria
pressure Respiratory diseases
infection

b. Large burden of hypertension - both globally and in India: An estimated 1.4 billion people
worldwide have high blood pressure, but just 1 in 7 people have it under control.
With one in four adults detected with high blood pressure (DLHS 4 ≥18 years), it is
estimated that there are more than 20 crore adults with hypertension in India. However,

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 less than half of them are aware of their hypertension status and less than one-tenth of all
people with hypertension have their blood pressure under control (NFHS 4, 15-49 years).3

Repeated cross-sectional surveys have shown that the prevalence of hypertension has
almost doubled in the past 20 years, with narrowing of the rural and urban gap. While the
number of people with hypertension has increased over the years, the rates of blood
pressure control have remained low.4

c. Hypertension control can save most lives: Hypertension is the number one cause of death.
Improving blood pressure treatment will:
• Save maximum lives by preventing fatal heart attacks and strokes;
• Reduce disability, by preventing non-fatal heart attacks and strokes, and preventing
dialysis;
• Reduce medical costs spent on caring for patients who are having heart attacks and
strokes, and for the rehabilitation and nursing care needed in the aftermath of a
stroke or heart attack;
• Improve productivity by reducing the number of people who are disabled by CVDs
and are unable to work and who may require long-term nursing care.
Treatment of hypertension among adults in primary care can save more lives than any
other primary care program. Deaths due to hypertension are largely preventable. In
comparison to other evidence-based interventions for non-communicable diseases,
control of hypertension has the largest potential to save lives (figure 2).5
It is estimated that increasing coverage of antihypertensive medications to 70% of people
with raised blood pressure alone can delay 39.4 million deaths globally over 25 years.6
Figure 2: Hypertension control is key to reducing CVD deaths
High
Hypertension cholesterol High sodium Air pollution Tobacco Overweight
0
Percentage of CVD deaths

-10
eliminated

-20

-30

-40

-50 Risk factors not mutually exclusive.

Source: Institute for Health Metrics and Evaluation, 2015 data.
-60

d. Hypertension control is simple, affordable and essential

• Easy to diagnose: Hypertension is easy to diagnose and requires only a well-functioning
BP measuring device.
• Simple: Treatment of hypertension need not be complicated. Practical, precise, and
simplified protocols such as those adopted by the India Hypertension Control Initiative
(IHCI) are based on evidence generated from thousands of clinical trials over several
decades. The protocol medications are safe and effective in lowering blood pressure
and preventing CVDs.

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 • Affordable: The medicines to treat hypertension are inexpensive and available in
generic form. Patients in all countries have access to the same medications, which are
safe and effective. Further, the bulk purchase of medications for a single standard
protocol-based treatment will reduce the cost further.
• Essential: Just as we give vaccines to children to prevent the development of illnesses
against which we are vaccinating, we treat people with hypertension because there is,
at present, no way to predict which patients will have a heart attack or stroke or other
complications. And although many heart attacks and strokes occur among older people,
death or disability from CVDs at a younger age is particularly tragic and preventable.

e. Hypertension control program can be easily integrated in primary health systems: More
than 90% of hypertension cases can be managed by a primary care physician. The use of
practical protocols and effective generic medications further simplify hypertension
management. Further, most tasks related to hypertension management can be carried out
by non-physicians – nurse, pharmacist, auxiliary nurse midwife (ANM). These tasks include
and are not limited to blood pressure measurement, refilling medication for patients with
controlled blood pressure, sending reminders to patients for follow up and recording and
reporting.
A well-functioning hypertension control program can impart discipline in management of
non-communicable diseases (NCDs) in the primary health care system, thus increasing the
system’s confidence in managing NCDs.
f. International experiences suggest high hypertension control rates are achievable: In the
early 1990s, hypertension control rates in Canada were low. The Canada Hypertension
Education Project (CHEP) identified the gaps in awareness, treatment, and control of
hypertension and focused on linking every individual to a primary health care system for
screening, treatment and follow up of high blood pressure. As a result, the population-level
control of hypertension improved from 13% in 1985-92 to 68% in 2012-13.7 CHEP also
demonstrated a reduction in rates of stroke, myocardial infarction, and cardiac failure.
Thailand used a team-based approach to the management of hypertension in primary
health care. Subsequent surveys showed significant improvements in hypertension control
rates. From 2004 to 2014, the hypertension control rates increased by more three-folds
(8.6% to 29.7%).8,9

1.2. Government of India’s initiatives on hypertension control

The Government of India (GOI) has adopted a National Action Plan for the prevention and
control of non-communicable diseases with specific targets to be achieved by 2025. These
targets include:
• 25% relative reduction in overall mortality from cardiovascular diseases,
• 30% relative reduction in mean population intake of salt/sodium, and
• 25% relative reduction in the prevalence of raised blood pressure.
In order to achieve a 25% relative reduction in the prevalence of raised blood pressure by 2025,
approximately 4.5 crore additional people with hypertension will need to have their blood
pressure effectively treated.

The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular
Diseases and Stroke (NPCDCS) was launched in 2010 to address the rising burden of non-

8
communicable diseases in India. Under NPCDCS, a population-based screening program (PBS)
has been initiated - for hypertension, diabetes, and cancers of breast, cervix and oral cavity.
The India Hypertension Control Initiative (IHCI), a multi-partner initiative, complements this
screening program by strengthening the management of hypertension in primary health care
settings. IHCI provides a continuum of care to those diagnosed with hypertension during
screening, by ensuring treatment, control, and documentation.

1.3. Essential components of scalable treatment of

hypertension

Most patients with hypertension can be successfully managed by ensuring provision of five key
components of care:

These 5 components are based on the Global Hearts Initiative and complement the NPCDCS.
The Global Hearts Initiative comprises five technical packages that provide a set of evidence-
based interventions that, when used together, can potentially have a major impact on
improving global heart health: (1) HEARTS for the treatment of hypertension in primary care
services, (2) MPOWER for the reduction in tobacco use, (3) SHAKE for reduction in population
salt consumption, (4) REPLACE action package to eliminate industrially-produced trans fats
from the global food supply, and (5) Active technical package for increasing physical activity.

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 Key Messages
• More than 20 crore Indians have hypertension
• Less than half of those with raised blood pressure in India are aware of their status
• Less than one-tenth people with hypertension in India have their blood pressure under
control.

Exercise 1: Estimate the number of persons with hypertension in your state/district

To do this exercise, we need information on (1) adult population of the state/district

and (2) hypertension prevalence rate
(1) Adult Population of the state/district:
• Use the most recent census data for your state or district. Age disaggregated data for a
district from 2011 census are available at http://www.censusindia.gov.in/2011census/C-
series/C-13.html
• Get the total adults aged ≥ 30 years in the state/district
(2) Prevalence of hypertension: Use the most recent, comprehensive, population-level estimate
of hypertension of the state/district.
• District Level Household Survey 4 (DLHS-4) conducting during 2012-13 provides
hypertension prevalence estimates for states and most districts and can be accessed at
http://rchiips.org/DLHS-4.html
• If your district prevalence is missing, assume the average rate of the state and if the state
value is missing, use the national average (25%)
• If there is a more recent and reliable regional data available, please use that information
Calculate the total number of adults with hypertension:
Multiply the adult population (aged ≥30 years) & hypertension prevalence

References
1. Gupta R, Indian Heart J. 2018;70(4):565–572. doi: 10.1016/j.ihj.2018.02.003
2. GBD 2016, Lancet. 2017; 390:1345–1422
3. Prenissl J, PLoS Med. 2019 May 3;16(5):e1002801.
4. Roy et al. BMJ Open. 2017; 7(7): e015639.
5. Institute for Health Metrics and Evaluation, 2015 data.
6. Kontis Circulation. 2019; 140:00–00. DOI: 0.1161/CIRCULATIONAHA.118.038160
7. Canadian Heart Health Surveys (CHHS) -1985-92 & Canadian Health Measures Survey (CHMS) -2012-13
8. Wichai A Journal of Hypertension.2012; 80(9):1734–1742
9. Thailand National Health Examination Survey 2014.

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Chapter 2: Hypertension diagnosis & treatment using
practical treatment procotols
Expected competency on completion of session:
• Ability to correctly measure blood pressure and diagnose hypertension.
• Ability to treat hypertension patients using a standardized protocol, follow up for adherence to
treatment and manage associated co-morbidities to achieve target blood pressure control.
Audience: Healthcare providers, facility managers, supervisors
In this session you will learn about:
• Whose blood pressure should be measured?
• How to measure blood pressure?
• Diagnosis of hypertension
• Who should receive treatment?
• Medications used for treating hypertension (class, dose, side effects)
• Treatment goal for hypertension
• Standardized protocol adopted by the state
• Ensuring adherence to medication
• Lifestyle advices

2.1. Measurement of blood pressure

2.1.1. Whose blood pressure should be measured
Population-based screening: Under the population-based screening (PBS) program of NPCDCS,
all adults in the population ≥30 years are to be screened for hypertension at least once every
year.
Opportunistic screening at health facilities: High blood pressure can occur in young adults.
About 12% of adults between 18-30 years have hypertension.1 Therefore, it is recommended
that all the adults aged ≥ 18 years visiting a health facility should undergo blood pressure
measurement.
Most people with raised blood pressure have no symptoms and measurement of blood
pressure is the only way to identify persons with high blood pressure. Therefore, it is important
to measure the blood pressure of all adults attending out-patient clinics irrespective of their
symptoms. Accurate measurement and recording of BP are essential for diagnosis and
management of hypertension. Strategies to improve opportunistic screening at public health
facilities are detailed in chapter 4.

Measure blood pressure of all adults ≥ 18 years visiting the outpatient clinic.

2.1.2. How to measure blood pressure

Preparation of the patient
• The patient should avoid tea/coffee, exercise, and tobacco use for at least 30 min before
measurement.
• The patient should have rested for at least 5 minutes before measurement.
• Ensure s/he has emptied his/her bladder.
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• When taking blood pressure, the patient should be seated, with back supported and both
feet resting on the ground.
• The patient should not speak while blood pressure is being measured.
Choosing the cuff: The ideal cuff bladder length Arm Recommended cuff
and width are ≥80 percent and ≥40 percent of the circumference size
patient's arm circumference, respectively. (cm) (width x length in cm)
22-26 12x22 (small)
Applying the cuff
27-34 16x30 (medium)
• Explain the procedure to the patient. 35-44 16x36 (large)
• If the patient is wearing a thick-sleeved 45-52 45x52 (extra-large)
garment, ask the patient to uncover the arm
by either removing the top garment or rolling up the sleeve. If the cuff is tied over the
clothing, ensure that it is tied snugly and evenly.
• The patient’s arm should be supported on the table
and relaxed.
• Make sure the arm cuff is properly deflated (air is
out) before placing it around the patient’s upper
arm.
• Wrap the cuff comfortably or snugly above the
elbow, about 2 cm (or 2 finger breadths) from the
elbow and secure the Velcro tape.
• Keep the cuff at the heart level during measurement.

Taking a blood pressure measurement

a. Using a digital blood pressure device
• Turn the monitor on from the on/off button.
• Ask the individual to stay still, breathing normally, without talking or laughing.
• Press the START/STOP button to begin the measurement.
• The BP cuff will automatically start to inflate. This might be uncomfortable for some.
Reassure the patient that the discomfort is temporary.
• The cuff will slowly deflate to take the measurement.
• When the reading is complete, the systolic (SBP) and diastolic blood pressure (DBP)
readings and pulse rate will appear on the screen.
• Note the BP readings exactly as seen in
the device in the patient record. Please
do not round off.
• If the monitor/machine does not record
the reading, re-position the cuff and try
again after 1-2 minutes and repeat the
above-mentioned steps.
• Turn the machine off and remove the
cuff.

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b. Using a manual instrument
• The cuff has a bulb at one end of the tube that you will
squeeze to inflate the cuff.
• Apply the cuff on the individual’s arm and place your
stethoscope where you will be able to hear the sounds of
blood flowing. The place is where you can feel the pulse.
You can find the place by placing your index and middle
fingers of one hand in the crease of a relaxed elbow.
• Put your stethoscope on and hold the head of the
stethoscope in place.
• Screw the valve tight and inflate the cuff to 200 mmHg.
Keep holding the stethoscope at the right spot.
• Slowly let the air out of the cuff while listening for the sounds of blood flowing. Keep a rate
of deflation 2−3 mmHg per second (equals one line on the dial every second).
• When you start letting the air out, you should not hear any distinct sounds at first. You will
then hear a thump, which will be followed by several other similar thumping sounds. The
number on the dial when you heard the first thump is the patient’s systolic blood pressure.
The thumping sounds will eventually stop. The number on the dial when you heard the last
sound is the patient’s diastolic pressure.

Additional blood pressure readings

Although many guidelines recommend measuring multiple blood pressures at each visit, this
may not be practical in a primary care setting.2 These guidelines also frequently recommend
discarding certain results and averaging others, a complex computational task that may be
difficult, if not impossible, to do consistently and accurately in busy clinics and primary care
health delivery systems.
A practical approach:
1. If the first blood pressure (BP) is <140/90 mmHg, then no other blood pressure
measurement is needed during that encounter.
• There is a 95% chance that second BP will be lower than the first, so if the first BP is
<140/90 mmHg, the mean blood pressure would be <140/90 mmHg.3

2. If the first BP is >140/90 mmHg, perform a second BP and use the second reading as the
recorded BP for the encounter.
• Averaging the two measurements to determine mean BP in a busy primary care setting is a
time-consuming exercise and is potentially prone to errors.
• The second BP is likely closer to the actual average than the first because the first BP
measurement in a series is usually the highest. Subsequent repeated measurements have a
tendency to be closer to the actual BP.

3. If there is a large difference between the first and second reading (>5 mmHg), it is
reasonable to do a third measurement and use the third BP as the recorded BP.
• A third BP is often much closer to the second BP than to the first BP, moving the mean
closer to the second and third BP measurements.

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Table 1: Common errors during BP measurement and their impact on measured BP 4,5,6
Error in Measurement Variation in BP (mmHg)

Unsupported back/feet 6

Unsupported arm 10

Wrapping the cuff over 5-50

clothing

Incorrect cuff size 2-10

Sitting with crossed legs 2-8

Talking 10
Full bladder 10

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BP Measurement Checklist Poster

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2.2. Diagnosis of hypertension
• Hypertension diagnosis is established if the systolic blood pressure ≥140 mmHg and/or
diastolic blood pressure ≥90 mmHg, on two different days.
• However, if the blood pressure is ≥160 mmHg or ≥100 mmHg at the first reading, second
reading should be taken on the same day to establish the diagnosis.
• If the patient has other symptoms requiring immediate treatment in addition to high blood
pressure, the diagnosis and treatment of hypertension are at the discretion of the medical
officer.
• If the patient had the blood pressure measurement done during the screening program at
the community level, then the BP reading during clinic visit can be considered as the second
reading.
• If only the systolic, or only the diastolic blood pressure is raised, manage according to the
higher number.

Key Messages
◼ Measure blood pressure of all adults visiting the out-patient clinic.
◼ Diagnosis of hypertension is made if the systolic blood pressure ≥140 mmHg and/or
diastolic blood pressure ≥90 mmHg, on two visits on different days.

Exercise 2: Practice measuring blood pressure

2.3. Treatment of hypertension

2.3.1. Who should receive hypertension treatment?
Hypertension treatment is indicated for all adults diagnosed with hypertension as defined in
the previous section (SBP ≥140 mmHg and/or DBP ≥90 mmHg, on two different days). Patients
with SBP ≥160 mmHg or DBP ≥100 mmHg may be indicated for immediate treatment.

2.3.2. The goal of hypertension treatment

The goal of hypertension treatment is to keep blood pressure under control. BP is considered
under control when the systolic blood pressure is <140 mmHg AND diastolic blood pressure is
<90 mmHg.

2.3.3. Available medications for treating hypertension

Three main classes of medications are recommended for the first-line treatment of
hypertension - calcium channel blockers, renin-angiotensin system (RAS) inhibitors
(Angiotensin receptor blockers and Angiotensin-converting enzyme inhibitors), and
thiazide/thiazide-like diuretics. Amlodipine, telmisartan, and chlorthalidone are the
medications of choice in the standardized treatment protocols being followed in most States.

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 Other medications can be added as substitutes and in special cases. The various medications
used for the treatment of hypertension are mentioned below:

Table 2: Common medications used in the management of hypertension

Class Medication Starting Intensification Important notes
dose dose
Calcium Amlodipine 5 mg 10 mg o Doesn’t require any metabolic monitoring.
channel Therefore, a good first choice for primary
blocker health centers
o Can be given to women in childbearing age
who may become pregnant
Ankle oedema ~10% cases (particularly at 10 mg
dose and absence of ACEI/ARB)
Angiotensin Telmisartan 40 mg 80 mg o Should not be given to women who are or
receptor may become pregnant
blocker o Benefits some patients with kidney disease,
(ARB) prior heart attack, and low ejection fraction
o Addition of ARB to CCB reduces the
incidence of ankle oedema
Losartan 50 mg 100 mg o ARB and ACE-I should not be combined
together
Risk of hyperkalemia especially if the patient has
CKD – consider checking serum creatinine and
potassium before initiating treatment and
thereafter at least once a year.
Angiotensin Enalapril 5 mg 10 mg o Should not be given to women who are or
converting may become pregnant
enzyme o Benefits some patients with kidney disease,
(ACE) prior heart attack, and low ejection fraction
inhibitor o Addition of ACE inhibitors to CCB reduces
the incidence of ankle oedema
o Can cause persistent cough ~ 10% cases
o ARB and ACE-I should not be combined
together
Risk of hyperkalemia especially if patient has CKD
– consider checking serum creatinine and
potassium before initiating treatment and
thereafter at least once a year
Thiazide or Hydrochlorothiazide 25 mg 50 mg o Should not be given to women who are or
thiazide-like may become pregnant
diuretics o Risk of hypokalemia – consider checking
serum creatinine and potassium before
Chlorthalidone 12.5 mg 25 mg initiating treatment and thereafter at least
once a year.
Using along with ACE Inhibitor/ARB will reduce
the risk of hypokalemia
Beta-Blocker Atenolol 50 mg 100 mg o Not the first choice of drug for the
treatment of hypertension
o Recommended to be added to initial
treatment of patients with a history of a
heart attack within the last 3 years or atrial
fibrillation or heart failure
Should not be stopped abruptly as withdrawal
may worsen symptoms of angina. Should be
tapered over 5-10 days.

17
In addition to above anti-hypertensive medications, below medicines can be used in specific
cases:
o Low dose aspirin: 75 mg aspirin once a day is recommended to be given to patients with a
history of heart attack or stroke.
o Statins: Atorvastatin 10 mg is recommended in patients with a history of heart attack or
stroke. Should not be given to women who are or may become pregnant.

Fixed-dose combinations
A high proportion of people with hypertension require two or more drugs to achieve BP
control. Fixed-dose combinations (FDC) medication includes two or more classes of anti-
hypertensives in a single pill. FDC initial treatment compared to initial single drug treatment
provides:
• Reduced number of pills resulting in less burden on the patient
• Improved adherence to therapy
• Greater and more rapid blood pressure reduction
• Reduced CVD in observational data
• Drug combinations with single drugs in clinical practice are often suboptimal
Potential disadvantages of FDCs include a lesser ability to individualize drug titration and to
identify adverse drug effects. In addition, there must be no contraindication for both drug
components.

In July 2019, the World Health Organization included four FDCs for hypertension management
in its Essential medical list (EML)7.
Table 3: Fixed-dose combinations of antihypertensive drugs in WHO’s essential medicines list 7
Classes Combination drugs Doses
ACEI+ CCB lisinopril + 10 mg + 5 mg; 20 mg + 5 mg;
amlodipine 20 mg + 10 mg
ACE+ thiazide lisinopril + 10 mg + 12.5 mg;
diuretic hydrochlorothiazide 20 mg + 12.5 mg; 20 mg + 25 mg
ARB+CCB telmisartan + amlodipine 40 mg + 5 mg; 80 mg + 5 mg;
80 mg + 10 mg
ARB+ thiazide telmisartan + 40 mg + 12.5 mg; 80 mg + 12.5 mg;
diuretic hydrochlorothiazide 80 mg + 25 mg

2.3.4. Use a standardized protocol

The ability to rigorously follow a standardized hypertension protocol is an important step to
achieve a target BP control. The standardized protocol defines short specific steps to achieve
treatment goals and is different from clinical guidelines provided by professional bodies. Table
4 provides the differences between a standardized protocol and clinical guidelines.

18
Table 4: Differences between protocol and guidelines
Protocol Guidelines
Scope Specific for a local setting Summary of evidence-based
(district/state/hospital) practices issued by professional
bodies
Complexity Low High
Length One page 50-500 page
Specificity High- specific information such as Low- Drug classes and many drug
Drug name and dose options
Dose Dose titration with specific drug and Overall titration approach
dose
Use in Easy to understand and implement at Better understood by experts
primary care primary care level
Public health Easy to implement at scale Challenging to implement at scale
context

Benefits of using standardized, evidence-based protocols:

• Reduces unwarranted clinical variability and inappropriate therapeutic inertia
• Enables the health care team to advance patients safely and efficiently along the treatment
pathway
• Sends a strong signal to clinical staff that hypertension control is a priority
• Results in a more efficient and cost-effective selection of medications and treatment
approaches
• Facilitates logistics, training, supervision, evaluation, and overall program implementation
and increases the impact of treatment programs
• Can potentially be incorporated into electronic health records through clinical decision
support tools, registry functions, and measurement to facilitate quality improvement.
Common strategies used for escalation of antihypertensive drugs 13
• Start with one drug, titrate to the maximum dose, and then add a second drug
• Start with one drug and then add a second drug before achieving the maximum dose of the
initial drug
• Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination
This module provides two commonly used protocols in India (see page no 20 & 21) and the
protocol of your state may be slightly different. However, the goals and principles of the
standardized protocol remain the same.
Please note that:
• Medical Officers should follow the state-specific standardized protocols.
• It is important to be familiar with the side effects of the different protocol medications in
order to make an informed decision and be able to recognize them on follow up.
• In any protocol, the health care provider must consider the treatment targets and be
familiar with the medications.

The goal of the hypertension treatment is to reach

systolic BP <140 AND diastolic BP <90 mmHg.

19
Standardized treatment protocol- AATTCC

20
Standardized treatment protocol -ATTACC

21
2.3.5. Patient education
Adherence to medication
To promote adherence to medication, the IHCI has adopted the following strategies:
1) Standardized protocol
2) Uninterrupted drug supply
3) Free drugs
4) Once a day schedule for drug intake
Additionally, patients should be counselled on the following:
• Education- Explain
o The diagnosis and the need for life-long medication;
o Difference between medicines for long-term control (as in hypertension) and medicines
for quick relief (such as for headaches);
o The damage to target organs if blood pressure is uncontrolled (i.e. the possibility of
stroke, heart attack, or kidney failure);
o How to take medications at home. Show the patient the appropriate dose;
o Medication should be consumed every day at a fixed time when the patient can
remember
o The importance of
▪ Keeping enough supply of medications at home till the next visit to the health
facility;
▪ Taking the medicines regularly as advised, even if there are no symptoms;
o Potential adverse effects of the medications and what to do
Most importantly check the patient’s understanding before the patient leaves the
health centre

• Reminders:
o Encourage patients to use medication reminders, such as alarms and smartphone
applications;
o Implement patient reminder systems (e.g., e-mail, phone calls, text messages), where
possible, to ensure patients adhere to their medication regimen.
A physician can help to increase a patient’s compliance with treatment by:
• Motivation:
o Good patient-health care provider relationship;
o Positive feedback: praise adherence through positive feedback and encouragement.

Lifestyle management
Treatment of hypertension must be accompanied by healthy lifestyle choices. This will
complement the treatment and address various aspects of healthy choices that aim for overall
health improvement. Practical advice is as follows:
• Advise all patients against tobacco use and alcohol intake.
• Suggest ways to increase their physical activity, to improve overall health and weight
control.

22
 • Adopt a healthy diet – reduce salt intake (less than 5 g salt per day including salt in
processed foods, and salt added while cooking or eating), use healthy oils, increase fruit
and vegetable intake, limit red meat, prefer fish and foods rich in omega-3 fatty acids, limit
consumption of fried foods, processed foods and foods high in saturated fat, and avoid
added sugar.

Table 5: Effect of changes in lifestyle on systolic blood pressure 8

Lifestyle Dose Approximate Reduction in SBP
changes Hypertension Normotension
Weight loss -1 mm Hg for every 1 kg loss -5 mm Hg -2/3 mm Hg
Healthy diet Rich in fruits vegetables, -11 mm Hg -3 mm Hg
(DASH diet) whole grains, and low-fat
dairy products
Reduced saturated and trans
fat
Sodium reduction <1500 mg/d is optimal goal -5/6 mm Hg -2/3 mm Hg

Increased 3,500-5000 mg/d, preferably -4/5 mm Hg -2 mm Hg

Potassium through dietary sources

2.3.6. Treatment inertia

Treatment inertia is defined as a failure to increase the dose of medication or add another
medication when a patient’s blood pressure is not under control. The potential reasons and
solutions are provided below.
a. The doctor may not notice the high BP recording due to busy crowded clinics
• A nurse or other staff may highlight the raised BP reading for the doctor
(using colour pen/highlighter or symbol)
b. BP readings are borderline high
• Discussed in the FAQs (page 26)
c. The doctor suspects that the patient might have missed medications
• The nurse should ask detailed history to understand the patient’s adherence.
How to address missed medications is discussed in FAQs (page 26-27)
d. A patient might have reported adverse effects
• Change medications to a different class
It is difficult for a clinician to make a decision with one high BP reading. A well-maintained
record (paper/electronic) with multiple BP readings can help the clinician understand the trend
of blood pressure and make an informed decision.

2.3.7. Frequently asked questions (FAQs) on hypertension treatment

i. How to manage patients with borderline high blood pressure?
Anti-hypertensive medication should be escalated to the next step in the protocol if blood
pressure is equal or slightly higher than systolic 140 mmHg or diastolic 90 mmHg. Evidence
suggests that cardiovascular risk increases with every mmHg rise in blood pressures beyond
SBP 115 mmHg and DBP 75 mmHg. 9

23
 A clinical trial that aimed to compare intensive blood pressure control (SBP <120 mmHg;
intensive group) and standard control (SBP<140 mmHg; standard group) showed that the
intensive group had 27% lesser cardiovascular events compared to the standard group. 10
Additionally, treatment adverse effects were similar between both groups. Though some
specific adverse events (hypotension, electrolyte abnormality, acute kidney injury)11 were
higher in the intensive treatment group, most were mild transient events; contrast this with
mortality or lifetime disability from a major stroke or heart attack.

ii. How should medications be managed when a patient on medications has lower than
normal blood pressure?
If the systolic BP is below 110 mmHg: For asymptomatic patients, discontinue one medication
(usually the last medication prescribed)
If systolic BP is below 90mmHg & asymptomatic:
• Stop all antihypertensive drugs until blood pressure is re-assessed (ideally within the
next seven days).
• Evaluate the causes of low blood pressure - side effects from other medications,
dehydration, acute inflammatory conditions, or measurement error.
• Request the patient to return for repeat blood pressure measurement
If systolic BP is below 90mmHg & symptomatic: Significant symptomatic reductions in blood
pressure require immediate individualized assessment and management.

iii. How to treat a patient who is already on non-protocol drugs?

If a patient is on non-protocol drugs
▪ BP is <140/90:continue to use the same medication(s).
▪ BP is ≥ 140/90: move to/add on protocol medicines.
▪ Non-protocol drug is not available at facilities: replace with protocol medicines
Most patients who are on treatment in public health facilities in India are likely to be on β
blockers, specifically atenolol. β blockers are no longer recommended as the primary treatment
of hypertension.

If a patient has controlled blood pressure using β blockers, the same can be continued.
However, if the BP is uncontrolled, s/he should be started on protocol drugs and β blockers
should be tapered off. Please note that β blockers should not be stopped suddenly. This is
because a sudden withdrawal of β blockers may exaggerate symptoms of coronary artery
disease. Therefore, it is recommended that the β blocker should be tapered over 5-10 days. For
example, for a patient currently taking Atenolol 50 mg 1 tab daily, prescribe Atenolol 50 mg ½
tab daily along with amlodipine 5 mg once daily. After one week, stop Atenolol and continue
Amlodipine.

iv. What is the best practice for managing treatment interruption/missed medication doses?
"Doctor, I usually take my high blood pressure medicine every day—but not today!" This
patient story is familiar to health care workers who manage blood pressure all over the world.
The only solution to the missed medication dose scenario is to instruct the patient to take their
medications and repeat the blood pressure measurement while on the medication, for
example, one week later. Health care workers should not guess what the treated blood
pressure would be, as individual patients respond differently to antihypertensive medications.

v. Is it better to take antihypertensive medications in the morning or evening?

24
 The general advice is to take when patient is most likely to remember. Some programs
recommend after brushing teeth in the morning. There is insufficient evidence to suggest that
taking at any particular time is better – other than at the time when patient is most likely to
remember it. It is important to take medication at the same time every day!

vi. How should amlodipine induced ankle oedema be managed?

Treatment of ankle oedema will depend on its severity and other patient factors. Mild oedema
which is not troublesome to the patient does not require specific treatment. Whilst ankle
oedema associated with amlodipine is rarely clinically serious, it may significantly reduce
patient adherence. It is usually refractory to diuretic treatment as it is due to changes in
capillary pressure leading to leakage into surrounding tissues, rather than due to water
retention. Treatment strategies include:
• Non-pharmacological interventions: Elevation of legs when in a prone position, or
graduated compression stockings may help in mild cases
• Reduce dose: For example, if on 10 mg amlodipine, reduce the dose to 5 mg.
• Add ACEI or ARB: Studies have shown that adding an ACEI or ARB to amlodipine reduces the
incidence of ankle oedema. This may be due to the dilatation of venous vessels, which may
then lead to a reduction in capillary hypertension and therefore leakage of fluid into the
surrounding tissues.
• Discontinue & switch to other medications: If the above three options fail, discontinue
amlodipine and switch to an antihypertensive from another class of drugs.

vii. If a medication in the protocol is not available, can another medication from the same
drug class be substituted? (E.g. substitute Telmisartan by Losartan or Chlorthalidone by
Hydrochlorothiazide)
Absolutely. In general, all antihypertensive medications lower blood pressure effectively. Most
guideline development groups do not distinguish amongst specific drugs in a particular class
based on drug efficacy.12 Use the equivalent doses of the alternative drugs as provided in table
2. However, please note that the uninterrupted availability of protocol medications is the key
strategy of IHCI. The program expects a seamless supply of protocol medications by improving
drug forecasting and supply logistics (ref chapter 3). Therefore, it is expected that the need for
substitution is required less frequently.

References
1. Zafar KS, International Journal of Research in Medical Sciences, 2017 Vol 5; no. 11
2. Whelton PK. AHA Clinical Practice Guidelines. 2018 Jun;71(6):1269-1324.
3. Handler J. The Journal of Clinical Hypertension. 2012;14(11):751-759.
4. AHA 2018; https://targetbp.org/tools_downloads/mbp/
5. Pickering. Circulation. 2005;111: 697-716.
6. Handler J. The Permanente Journal/Summer 2009/Volume 13 No. 3 51
7. World Health Organization Model List of Essential Medicines, 21st List, 2019. Geneva: World Health
Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.
8. J Am Coll Cardiol. Sep 2017, 23976; DOI: 10.1016/j.jacc.2017.07.745))
9. Prospective Studies Collaboration Lancet 2002; 360:1903-1913.
10. Sprint Research Group N Engl J Med 2015; 373:2103-2116
11. Rocco American Journal of Kidney Diseases. 2018; 71:352-361

25
12. National Institute for Health and Clinical Excellence (NICE). Hypertension in adults: diagnosis and
management.2011.
13. JNC 8 guidelines. JAMA. 2014;311(5):507-520.

26
Chapter 3: Drugs & Technology
Expected competency on completion of session:
• Understand medication supply chain and facility-level drug stock goals.
• Understand various types of BP devices and advantages of digital devices in public health

Audience: Program managers, health care providers, facility pharmacists

In this session, you will learn about:

• Basics of drug supply chain
• Measures to ensure continued availability medication at the health facility
• Monitoring drug availability
• Types of BP monitors
• Advantages of digital BP devices

3.1. Regular and uninterrupted availability of medication

Ensuring access to an uninterrupted supply of medications to people with hypertension is one
of the key components of IHCI.

Stockouts inadequacy/shortage of drugs:

• Increases the risk of lack of adherence to treatment & loss to follow up
• Damages the credibility of the health care system/program.

Appropriate forecasting, procurement, stocking, and equitable distribution can ensure

uninterrupted availability of medications. In this section, we describe basic principles of drug
logistics management and focus on specific activities to be carried out at the level of health
facilities to ensure adequate availability of medications.

3.1.1. Drug supply chain: The drug supply chain cycle in the public health care system
begins with the selection of drugs and ends with dispensing to patients. A typical supply chain
can be outlined as below:

Dispensing
Selection of Storage and
Forecasting Procurement to the
drugs distribution
patient

A. Selection of drugs: The first step in the drug supply chain is the selection of drugs that
need to be procured. Generally, the drugs included in the National List of Essential Medicines
(NLEM) or the State Essential Drug List (EDL) would be selected.

27
ESSENTIAL LIST OF MEDICINES (ELM) is a limited list of carefully selected medicines that
satisfy the health care needs of the majority of a population. The concept of ELM was
introduced by WHO in 1975 and ELM has been shown to improve the quality and cost-
effectiveness of health care delivery when combined with proper procurement policies and
good prescribing practices.
The National List of Essential Medicine (NLEM) is revised on a regular basis. Additionally, the
States also have their own Essential Drug Lists based on states’ disease burden. Typically, the
drugs that are in the essential list would be in the State’s procurement and supply chain plan.

B. Forecasting: Forecasting is the process of determining the quantity of medication to be

required in a set timeframe (typically annually). It is the most important step in ensuring
adequate drug availability. Commonly used methods of forecasting are (1) Consumption-based
and (2) Morbidity-based.
B.1. The consumption-based method uses data of past consumption of individual medicines or
products to project future needs. This method assumes that the previous supply was adequate
and uninterrupted. Therefore, the consumption-based method can significantly underestimate
the drug requirement if there were drug shortages or stock-outs in the previous year. Further,
this method cannot account for changes in disease burden, treatment-seeking behaviours, and
treatment protocols. This method cannot be used when a new drug is introduced as there is no
data on past consumption. Typically, most states use the consumption method for forecasting
annual drug requirements for various disease control programs.
B.2. The morbidity-based method estimates the need for specific medicines or products, based
on the frequency of disease (using surveillance and demographic data), expected burden at the
health facilities (using service delivery data), and standard treatment guidelines. This method is
recommended for an evolving program such as IHCI.

The morbidity-based method is complex, time-consuming and uses several assumptions at the
beginning of a program that need to be validated with programmatic data after large scale
implementation of the program and revised accordingly.

Table 1: Comparison of consumption & morbidity-based methods of forecasting

Method Strength Limitation

Consumption- Reliable when Is not useful when
based method • A drug is been used regularly in • A new drug is introduced
the past • Changes in disease burden,
• No major changes expected in treatment-seeking, and
demand, such as an increase in protocols of treatment
the number of cases or changes in • Major drug shortages or stock-
the treatment protocol outs in the previous year
• No major shortages or stock-outs
in the previous year

28
 Morbidity- Used when Is not useful when
based method • A new drug is introduced • Prevalence/morbidity data is
• Anticipated changes in disease not available or outdated.
burden, treatment-seeking • No standard treatment
behavior, and protocols of guidelines
treatment May not be needed if the program
• Major drug shortages or stock- is stabilized
outs in the previous year
• Reliable sources of information on
morbidity pattern are available

Procurement: The majority of the public procurements are done through a tender process. The
procurement of drugs under the public health system in the state can either be centralised
(State level)or decentralised (District level). Additionally, there usually is provision for need-
based emergency procurement at the district/health facility level (the proportion varies from
state to state). Apart from State/NHM funds, health facilities also have their local funds such as
Rogi Kalyan Samiti (RKS) funds using which drugs can be procured as a stop-gap measure in
case there is a disruption in supplies.
Storage and Distribution: Drugs procured from suppliers/manufacturers are generally received
and stored at regional or district-level warehouses. Supplies to health facilities are made from
warehouses at a predefined frequency. The frequency of distribution and mode of last-mile
delivery of drugs from the regional/ district stores to health facility stores varies between
states.
Some states/districts supply directly to health facilities from the warehouses while in other
states/districts, supplies are sent to block health facilities and thereafter distributed to all
facilities in the block.

3.1.2 Key considerations to ensure uninterrupted drug supply under IHCI

A. State level: State Programme Managers & drug procurement
corporation officials
a. Essential Drug List: Under IHCI, each state has adopted a specific treatment protocol for the
management of hypertension. The treatment protocols generally consist of three classes of
drugs: calcium channel blockers (Amlodipine), angiotensin receptor blockers or ACE
inhibitors (Telmisartan or Enalapril), and thiazide or thiazide-like diuretics (Chlorthalidone
or Hydrochlorothiazide). It is important to ensure that all the recommended treatment
protocol drugs are:
• Included in the essential drug list (EDL) of the state.
• In the list of medicines to be procured for all levels of healthcare, i.e. primary,
secondary & tertiary.

29
 b. Annual forecasting of the drugs at the state: Under IHCI, the recommended hypertension
treatment protocol may be different from the previous drug prescription patterns. In
addition, with increasing registrations of patients (both through population-based screening
and opportunistic screening) and strategies to ensure their return to care, it is expected
that there would be a steady increase in the use of the protocol drugs.

Therefore, the consumption-based method is not suitable for drug forecasting and
morbidity-based method should be used. When the program reaches saturation of patient
registration and uninterrupted availability of the drugs has been ensured for 2-3 years, then
the consumption-based method may be used for future forecasting.

Based on the best available assumptions, tools are available for estimating drug requirements
for both AATTCC and ATTACC Protocols. The officials may reach out to the IHCI officers at WHO
and/or ICMR to receive the customised tools. Further, IHCI will provide technical support to
states in the adoption of the tools to the states.

c. State Procurements:
• Rate contracts (fixed rate with flexibility on quantity to be procured within the duration of
the contract) should be preferred over quantity contract (fixed quantity procurement
under a contract) as it allows flexibility of periodic procurement and quantity correction
based on actual consumption.
• A multi-year rate contract is useful in cutting down tender processes every year, enhancing
supplier’s confidence in the system and attaining price stability.
• Rate contract with multiple suppliers helps to have an alternate supply source in case of
supply failure/noncompliance by a particular supplier.
• Periodic/scheduled procurement (bi-monthly/quarterly procurement based on inventory
level) or procurement with scheduled supply should be preferred over one-time
procurement.
• It is very important to have rate contracts in continuity. Tenders must be initiated well in
advance. A practical suggestion would be at least 4 months prior to the expiry of existing
rate contracts (typically it takes about 4 months for the procurement process).

B. District level: District Programme Managers & Warehouse

Pharmacists
a. Drug stock goals
• Combined stock available at the facilities plus warehouse should meet at least 6 month’s
requirements (This includes the buffer/safety stock to cater to supply delays or an
unexpected surge in drug uptake).
• If the stock is lower than 6 months requirement, then supply should be sought from the
vendor (for decentralized procurement) or Follow up with the state procurement agency.
(For centralized procurement)
• At any point in time, health facilities in the district should have 2-3 months stock of
medicines
30
• No health facility should have less than the one-month stock of any protocol drug at any
time.

Note:
o The stock levels are expressed as ‘months of stock’ which indicates how long the drugs will
last. For example, 2 months of stock means the stock will last for another two months.
o 6 months requirement is recommended considering a minimum 2-3 month’s stock at the
field level, typical lead time (time taken between the purchase order placed and goods
received) which is about 60 days and quarantine time (time lag for getting quality clearance
of the received drugs) of 15-20 days. If orders are not placed in time, then these supplying
stores can run out of stock, disrupting the supply chain.

b. Storage and Distribution: Ensuring adequate availability of the drug at each service delivery
point is more important than overall availability at the district/state level. To estimate the
requirements at each health facility, a ready reckoner (Annexure C & D ) may be used.

Overstocking at some health facilities and stockout/ shortage at others are often seen in
public health settings due to disproportionate requisition by a health facility or allocation by
warehouses. The distribution of medications usually follows one of the following systems:

o Requisition system (Pull system): Person receiving the supplies calculates the required
quantity. (May use ready reckoners in Annexure C & D)
o Allocation system (Push system): Person supplying calculates the required quantity. (May
use ready reckoners in Annexure C & D)

Drug distribution to health facilities should be based on patient load (total patients
registered) and stock already available at the health facilities. It can be either through the
“Pull” or “Push” system

C. Facility level: Medical Officers/ Pharmacists

a. Drug stock goals at a health care facility: At any point in time, health care facility should
have stock in the range of 2-3 months stock
Facilities should avoid having less than the one-month stock of any protocol drug at any
time.
Note: The stock levels are expressed as ‘months of stock’ which indicates how long the drugs
will last. For example- 2 months of stock means the stock will last for another two months.
b. Inventory management at the health facility level: Maintaining optimal levels of drugs at a
health facility ensures continuity of treatment of all patients and reduces wastages.
• A typical health facility that receives a once a month supplyshould maintain 2-3 months
stock. (If the facility receives the supply with longer gaps (e.g. 2 to 3 months) then it
should use the Min-Max inventory levels (Annexure E ).
31
 • At the beginning of the program, ensure a 3-month stock.
• Refilling quantity should be decided considering max-inventory level based on the
frequency of the supply. If the stock requirement is dynamic based on patient load,
ready reckoner (Annexure C& D) may be used to estimate the stock.
• To calculate indent, subtract the current stock from the 3- month stock requirement (If
drug supply is monthly). For other supply which is longer than a month subtract from
the maximum requirement as in Min-Max calculation (See Annexure E)

c. Dispensing of drugs: As per the treatment protocol, patients are called for treatment
follow-up after one month. Therefore the drug should be prescribed and dispensed for at
least 30 days. Dispensing should be done with a clear message on the importance of regular
medication and the consequences of non-adherence.

d. Maintenance of records: In many states, in addition to supply from states, the health facilities
receive drugs from other local resources such as Panchayat funds or untied funds or
donations. Health facilities should maintain records of receipt and issue of all drug stocks,
irrespective of the source, preferably in a single stock ledger. Health facilities should regularly
update the records and report the actual status in the quarterly/monthly reports.

The following records are usually maintained:

• Drug store records
o Stock Ledger: “Stock ledgers ” should reflect both stock in hand and transaction
history (receipt & issue).
o Logistics Management Information System (LMIS): Presently, almost all states are
using IT-enabled drug supply chain management systems in all transactions related
to the receipt and the issue of stock should be updated.
• Drug dispensing counter records
We suggest including two recording systems at the DDC

o Daily Consumption record at Drug Dispensing Counter (DDC) (See Annexure A)

o Patient wise service uptake at drug distribution counter (Annexure B).

D. Monitoring by programme supervisors

i. Point of assessment:
• All the health facilities - Main stores and drug distribution counters (DDC)
• District level/regional level stores

ii. Source of data:

• Stock ledger: In general, facility-, district- and regional- stores maintain a “stock ledger”
which reflects both stock in hand and transaction history (receipt & issue).

32
 • Physical stock verification: Stock ledgers may not be updated regularly. Therefore, stock
verification from ledgers/stock registers should be supplemented by the physical counting
of available stock.
• Logistics Management Information System (LMIS): Presently, almost all states are using IT-
enabled drug supply chain management systems in which information on drug availability at
any health facility/store can be obtained from the website. Therefore, is the most
convenient source of data. However, LMIS may not be updated regularly, specifically at the
health facility level. Therefore, LMIS data may be outdated and not useful.
Table 2: Monitoring of drug information at health facilities

Particulars Point of Datapoint Source Tool/ method Utility

assessment document to be used
Stock adequacy Health facility- Stock on hand Stock ledger Ready Monitoring and
main store and and Physical reckoner maintaining inventory level
DDC count (Annexure C &
D)
The longevity Health facility- Stock on hand Stock ledger Described Make a decision on
of the available main store and and Physical below c procurement, indent or re-
stock DDC count distribution
Patients
registered Facility register
Consumption Health facility Opening Stock ledger Correlate drug Monitor program
pattern level: DDC balance, Consumption consumption performance and
receipt, closing record and patient dispensing pattern
balance for registration d
each drug for a Supplementary
specific period information on follow up
Facility register and default
Patients
registered

Notes:

a. Stock data should be collected and documented as a number of tablets (not strips or packs).
b. The ready reckoner tool (Annexure C & D) can be used by supervisors for assessing stock
adequacy at a health facility at any point of time. This can also be used by health facility
pharmacist for routine stock level monitoring and as a guiding document for placing monthly
indent to the district/regional store from which the health facility gets medicines.
c. The longevity of available stock: Stock on hand data should be assessed in terms of “how
long the stock would last” and not just in numeric quantities. A ready reckoner (Annexure C
& D) provides the estimated quantity required for 90 days using AATTCC and ATTACC
protocols. A practical tip based on the current assumption to calculate the stock levels in
days are calculated as below:
AATTCC ATTACC
Amlodipine 5 mg Stock/(N*1.4) Stock/(N*1.12)
Telmisartan 40 mg Stock/(N*0.37) Stock/(N*0.65)
Chlorthalidone 12.5 mg Stock/(N*0.06) Stock/(N*0.06)
*N= number of patients registered

33
 To have a quick and realistic assessment of drug availability status, it should be ensured
that all transactions related to drug receipt and issue at all levels should be updated in the
software system (if available) or in the physical registers/ledgers.

d. Consider a health facility with 130 registered patients following the AATTCC treatment
protocol. In the month of assessment, 100 patients were followed up in the clinic. We
expect that approximately 4200 Amlodipine 5mg tablets would have been dispensed. A
significant discrepancy in the number of patients treated and the drug dispensing (in this
example let us say <3000 or >6000) may prompt the supervisor to examine the following:
• Significantly fewer drugs dispensed
o Less than 30 days medication dispensed
o Drug stockout
o Patients card were wrongly updated
• Significantly more drugs dispensed.
o Treatment cards are not updated
o Many unregistered patients are being treated

Exercise 1 - Estimation of Min-Max level and quantity of the drug to be issued to a

health facility

Problem 1: CHC Rampur has 420 hypertension patients registered. The protocol followed in the
CHC is AATTCC. The CHC collects drugs from district drug warehouse each month. The current
availability of stocks at CHC is as follows. Please suggest the action to be taken by the health
facility pharmacist:
1. Amlodipine 5 mg – 18,000 tablets
2. Telmisartan 40 mg – 15,000 tablets
3. Chlorthalidone 12.5 mg – 12,000 tablets

Problem 2: PHC Madhuban has 170 hypertension patients registered. The protocol followed in
the PHC is ATTACC. The PHC collects drugs from the district drug warehouse once in two
months. The current availability of stocks at PHC is as follows. Please suggest the action to be
taken by the health facility pharmacist:
1. Amlodipine 5 mg – 80,000 tablets
2. Amlodipine 10 mg – 5000 tablets
3. Telmisartan 40 mg – 7000 tablets
4. Chlorthalidone 12.5 mg – 6000 tablets

34
3.2. BP Measuring devices
Several barriers to accurate and affordable blood pressure measurement, particularly in low-
and middle-income countries include: 1
• Absence of accurate, easily obtainable, inexpensive devices for BP measurement;
• Frequent marketing of non-validated BP measuring devices;
• The relatively high cost of BP devices given the limited resources available;
• Limited awareness of the problems associated with conventional BP measurement
techniques;
• A general lack of trained manpower and limited training of personnel.
To fulfil the requirements related to BP measurement in low resource settings, a BP measuring
device should, therefore, be affordable and simple to use, but at the same time be accurate
and robust so that it can be easily used for repeated blood pressure measurements.

3.2.1. Types of devices

There are three types of commonly used devices: mercury sphygmomanometers, aneroid
manometers, and digital (semiautomatic and fully automatic) devices. In a 2005 policy paper,
the WHO noted that “of all the mercury instruments used in health care, the largest amount of
mercury is used in mercury sphygmomanometers (80-100 g/unit).”2as a signatory to the
Minamata Convention, India is committed to phasing out of mercury devices.
1) Mercury sphygmomanometer
• The gold standard of BP devices- most accurate when used correctly
• Relies on auscultatory technique
• Inexpensive and most commonly used instrument in the Indian Public Health System.
• The government of India is committed to phasing out the use of mercury devices.
• Prone to observer bias and terminal digit preference

2) Aneroid sphygmomanometer
• Uses a bellow and lever system, which is affected by everyday wear and tear, leading to
false BP readings
• Needs regular calibration (at least every 6 months)
• Prone to observer bias and terminal digit preference

3) Digital device
• When used correctly, automated, digital blood pressure measurement devices are
highly reliable and preferable to manual blood pressure devices.3
o Specifically, in busy clinics and when the measurement is done by non-
physicians
• Simplifies the measurement process
o Eliminates errors related to hearing deficits, parallax, incorrect initial inflation
pressure and rapid deflation
o Enables multiple measurements to be taken sequentially
o Eliminates the subjectivity of measurement by reducing observer errors and
terminal digit preference

35
 Table 4: Comparison of commonly used BP measuring devices.
Parameter Mercury Aneroid Digital
Accuracy Considered the Mechanical shocks may lead to Highly reliable
“gold incorrect readings when the
standard” Needs calibration at least every 6 validated
months instrument is
used correctly
Observers skills & High High Low
expertise
Terminal digit Yes Yes No
preference
Observer bias Yes Yes No
Use by field workers Difficult Difficult Simple
Health & Yes No No
environmental effects
Availability in the No Yes Yes
near future

3.2.2. Maintenance and calibration

All blood pressure measuring equipment should be regularly checked and calibrated in
accordance with the manufacturer’s instructions. BP cuff and tubing should be regularly
inspected and replaced as necessary. Excessive air leakage from damaged cuffs, tubing and
tubing connectors may reduce the accuracy of BP readings.

3.2.3. Validation of blood pressure measuring devices

Accuracy is of prime importance when selecting a blood pressure measuring device. Thus,
regardless of the type of device used, standardized validation procedures are essential.
International protocols for blood pressure measuring device validation have been released by
several organizations. 4

3.2.4. How reliable are automated, digital blood pressure measurement

devices?
There is a general mistrust of digital BP devices among health professionals. This is because
most BP devices available in the market are not validated and do not meet the prescribed
global standards. A study found that of the 500 automatic BP devices available, less than 10%
were independently validated.1,5 One important accuracy requirement is that the devices
produce blood pressure measurements that are within 5±8 mmHg of an auscultatory reference
standard (which is meticulously performed, standardized, simultaneous, blinded two-observer
auscultation performed using a sphygmomanometer known to be accurate). It is important to
use an automated device that has passed at least one of these standards and tested by an
independent authority.

Another important factor to be considered in the use of automated devices is durability. Many
devices available in the market are for home use and not for office use where BP is measured in
larger volume. Therefore, for health facilities, professional models are recommended. Various

36
levels of professional models are available based on clinic patient volume- low volume, medium
volume, and high volume, including arm-in BP instruments.
Annexure- F provides the specification for quality professional BP devices that can be used for
tender purposes.

References
1. World Health Organization. Affordable Technology: Blood Pressure Measuring Devices for Low
Resource settings
2. World Health Organization (2005). Mercury in Health Care.
3. Padwal R, Campbell NRC, Schutte AE, et al. Optimizing Observer Performance of Clinic Blood
Pressure Measurement: A Position Statement from the Lancet Commission on Hypertension
Group. J Hypertension In press.
4. Stergiou GS, Alpert B, Mike S, et al. A Universal Standard for the Validation of Blood Pressure
Measuring Devices. Hypertension. 2018;71(3):368-374. doi:10.1161/hypertensionaha.117.10237.
5. World Health Organization. Integrated Management of Cardiovascular Risk. Report of WHO
meeting. Geneva 2002.
6. http://supplychainhandbook.jsi.com/wpcontent/uploads/2017/02/JSI_Supply_Chain_Manager%27s_H
andbook_Final-1.pdf

37
Annexure A: Daily Consumption record at Drug Dispensing Counter (DDC)
Notes:
Month:
Total Losses /
Closing
Sl Opening Receipt during Date wise consumption consumption of expired (if
Drug name balance
no balance month the month any)
1 2 3 4 5 6 .. .. 31
1 Amlodipine 5 mg 200 2000+3000+2000 270 180 300 10 150 210 240 1200
2 Amlodipine 10 mg
3 Telmisartan 40 mg
4 Telmisartan 80 mg
5 Losartan 25 mg
6 Losartan 50 mg
Hydrochlorothiazide 25
7 mg
8 Chlorthalidone 6.25 mg
9 Chlorthalidone 12.5mg
• Opening balance: Enter the drug availability, at the drug dispensing counter on the first day of the month. For example, if the DDC has 200 tablets
of Amlodipine 5mg on 1st September, enter ‘200’ in the opening balance.
• Receipt during the month: Enter the number of drugs received during the month. For example, in the month of September if DDC received the
following amount of amlodipine 5 mg
1st September – 2000
12th September – 3000
25th September – 2000
Enter this as 2000+3000+2000
• In date wise consumption- enter the total quantity of drugs issued by end of each day
• Closing balance- count the stock available on the last day of the month and enter. Note: this would be the opening balance for the next month.

38
Annexure B: IHCI patient tracking Matrix: drug dispensing counter (DDC)
Name of the facility:
Sl. No. Redg No. Apr-19 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

1
2
3
4
5
6
7
…
…
N
Notes:
• When a registered patient receives drugs (ALL PRESCRIBED IHCI DRUGS) at a DDC, the pharmacist can put a ‘√’ against the registered number for
the relevant month.
• If one or more prescribed drugs are not available or not dispensed, then put an ‘X’
• If a patient did not come to the clinic in a particular month, keep the cell ‘blank’
• If an unregistered patient comes to dispensing counter, (s)he can be guided to get registered.

39
Annexure C: Drug requirement: Ready Reckoner AATTCC protocol
Three month drug requirements Three month drug requirements
No. of patients No. of patients
registered (Up-to) Amlodipine Telmisartan Chlorthalidone registered (Up-to) Amlodipine Telmisartan Chlorthalidone
5 mg 40 mg 12.5 mg 5 mg 40 mg 12.5 mg
20 2520 660 120 520 65520 17160 3120
40 5040 1320 240 540 68040 17820 3240
60 7560 1980 360 560 70560 18480 3360
80 10080 2640 480 580 73080 19140 3480
100 12600 3300 600 600 75600 19800 3600
120 15120 3960 720 620 78120 20460 3720
140 17640 4620 840 640 80640 21120 3840
160 20160 5280 960 660 83160 21780 3960
180 22680 5940 1080 680 85680 22440 4080
200 25200 6600 1200 700 88200 23100 4200
220 27720 7260 1320 720 90720 23760 4320
240 30240 7920 1440 740 93240 24420 4440
260 32760 8580 1560 760 95760 25080 4560
280 35280 9240 1680 780 98280 25740 4680
300 37800 9900 1800 800 100800 26400 4800
320 40320 10560 1920 820 103320 27060 4920
340 42840 11220 2040 840 105840 27720 5040
360 45360 11880 2160 860 108360 28380 5160
380 47880 12540 2280 880 110880 29040 5280
400 50400 13200 2400 900 113400 29700 5400
420 52920 13860 2520 920 115920 30360 5520
440 55440 14520 2640 940 118440 31020 5640
460 57960 15180 2760 960 120960 31680 5760
480 60480 15840 2880 980 123480 32340 5880
500 63000 16500 3000 1000 126000 33000 6000
Example: For a health facility with 210 patients registered, adequate stock for 3 months would be 27720 tablets of Amlodipine 5 mg, 7260 tablets of Telmisartan 40
mg & 1320 tablet of Chlorthalidone 12.5 mg

Note: If there are multiple strengths of the same medication is available, convert to the base strength mentioned in the table.

40
Annexure D: Drug requirement: Ready Reckoner ATTACC protocol
Three month drug requirements Three month drug requirements
No. of patient No. of patient
Amlodipine Telmisartan Chlorthalidone Telmisartan 40 Chlorthalidone
registered (Up-to) registered (Up-to) Amlodipine 5 mg
5 mg 40 mg 12.5 mg mg 12.5 mg
20 2040 1200 120 520 53040 31200 3120
40 4080 2400 240 540 55080 32400 3240
60 6120 3600 360 560 57120 33600 3360
80 8160 4800 480 580 59160 34800 3480
100 10200 6000 600 600 61200 36000 3600
120 12240 7200 720 620 63240 37200 3720
140 14280 8400 840 640 65280 38400 3840
160 16320 9600 960 660 67320 39600 3960
180 18360 10800 1080 680 69360 40800 4080
200 20400 12000 1200 700 71400 42000 4200
220 22440 13200 1320 720 73440 43200 4320
240 24480 14400 1440 740 75480 44400 4440
260 26520 15600 1560 760 77520 45600 4560
280 28560 16800 1680 780 79560 46800 4680
300 30600 18000 1800 800 81600 48000 4800
320 32640 19200 1920 820 83640 49200 4920
340 34680 20400 2040 840 85680 50400 5040
360 36720 21600 2160 860 87720 51600 5160
380 38760 22800 2280 880 89760 52800 5280
400 40800 24000 2400 900 91800 54000 5400
420 42840 25200 2520 920 93840 55200 5520
440 44880 26400 2640 940 95880 56400 5640
460 46920 27600 2760 960 97920 57600 5760
480 48960 28800 2880 980 99960 58800 5880
500 51000 30000 3000 1000 102000 60000 6000
Example: For a health facility with 210 patients registered, adequate stock for 3 months would be 22440 tablets of Amlodipine 5 mg, 13200 tablets of Telmisartan
40 mg & 1320 tablets of Chlorthalidone 6.25 mg;
Note: In case there are multiple strengths of the same medication is available, convert it to the base strength mentioned in the table.

41
Annexure E: Min-Max inventory levels

Min-Max inventory levels stand for the minimum and maximum level of the stock to be maintained at a
health facility.

• The minimum stock level is the level of stock at

Min stock level = Quantity required for
which actions to replenish drugs must be ensured.
replenishment period + buffer/safety stock
• Buffer stock is the quantity of stock that should be
maintained in case there is a disruption or delay in Maximum stock level = 2 X quantity required
the regular frequency of supply and is typically kept for replenishment period + buffer stock.
at one month's stock.
• Under normal circumstances, a facility should not have stock above the maximum stock level.

The decision for minimum and maximum level is dependent upon how frequently the health facility
receives the drug stock.

Table: Recommended Min and Max stock based on frequency of supply

Frequency of supply Buffer stock Minimum stock Maximum stock

Monthly 1 month 2 month 3 month
Two monthly 1 month 3 month 5 months
Quarterly 1 month 4 month 7 months

Calculating indent = Max stock quantity level – stock in hand

42
Annexure F: Specification for quality digital BP instruments

1. Designed for professional use in hospital settings (personal homebased use models not to be
included).
2. Model(s) meets at least 1 of 3 global standards#
i. Association for the Advancement of Medical Instrumentation (AAMI)/ American National
Standards Institute (ANSI) / International Organization for Standardization (ISO)
ii. British Hypertension Society (BHS)
iii. European Society of Hypertension International Protocol (ESH-IP)
3. Device must have the validation as per international standards and the publication of the
device validation should be available.
4. Pressure measurement range should be 60 to 290 mm Hg systolic, and 40 to 200mm Hg diastolic
5. Pressure display accuracy of +/- 3 to 5 mm Hg
6. Measurement method: oscillometric measurement
7. Cuff Size: At least two cuff sizes (minimum two cuffs to be supplied for each machine)
8. Operable in both battery and electrical outlet (input range 100-240V and output voltage DC 6V) and
150-200 measurements when fully charged
9. Availability of replacement cuff/sleeve
10. Built-in surge protection to prevent damage to instrument in case of power surge.
11. Service centres available within the state
12. Devices should include a temperature-stabilizing system, which allows for use in extreme
weather conditions.
13. Minimum of three years warranty including all spares and re-calibration
14. Rate of inflation/deflation to be specified by vendor
15. Low Battery indicator and error indicators
16. Carrying case/bag to be provided

43
Chapter 4: Task sharing and patient-centred care
Expected competency on completion of session:
• Understanding how task sharing and Patient centred approaches can be used to provide
comprehensive hypertension management in public health systems
• Processes of decentralized care
Audience: Program managers, medical officers, non-physicians (staff nurse, ANMs and others)
In this session, you will learn about:
• Implementing team-based care & patient-centred services
• Improving patient flow in clinics
• Decentralization to subcentres and health and wellness centres

4.1 Task sharing

Strategic redistribution of tasks among various health care workers within the public health clinics can
enhance the efficiency of care. Some examples of task sharing in hypertension management are:

• Diagnosis of hypertension by a medical officer

• Blood pressure measurement by a staff nurse instead of a medical officer
• Drug refill by a staff nurse or ANM when BP is under control instead of a medical officer
• Dispensing of NCD drugs by staff nurses at the NCD clinic/corner, instead of a pharmacist
• The entry of patient details in treatment cards by a counsellor instead of a staff nurse

Team-based care Task shifting

• Strategic redistribution of work among • Reassignment of clinical and non-clinical tasks

members of a practice team from one level or type of health worker to
another while maintaining quality
• All the members play an integral role in
providing patient care • Health services can be provided more efficiently

• Deliver better services and care • Increases the accessibility of services to the
patients and increases adherence

Task Sharing

4.1.1 Advantages of task sharing

• Expanded access to care
• Provision of better support to patients

44
• Improved patient awareness
• Improved adherence to medications
• Improved follow up visits and BP control
• Time-saving and cost-efficient
• Enhanced patient and health staff satisfaction

4.1.2 Requirements to initiate and establish task sharing in a facility

• Identification of potential staff by Medical officer
• Training of health staff on tasks such as BP measurement and dispensing of medications
• Enable existing health staff cadres such as supervisors, entry operators to enter patient details in
treatment cards or Simple app
• Clearly define roles and responsibilities for each cadre of health staff
• Ability to monitor the process regularly and take feedback for further improvement

4.1.3 Steps for implementing task sharing

1. Engage the team: At the health facility, bring together a team of health staff of various cadres such
as regular and/or NCD staff nurses, supervisors, pharmacists, counsellors, lab technicians, and non-
clinical staff such as attenders. The team should be guided and managed by a physician/medical
officer.
2. Determine the team composition: Determine the model of care which needs to be set up
depending on the level of health facility (PHC/CHC/DH) and patient load. Identify which cadre of
health staff need to be trained on new skills in order to establish streamlined patient flow. The
members of the team must be motivated enough to carry out the newly designated tasks.
3. Design workflows to reflect the new model of care: Based on the composition of the new team
and newly designated roles and responsibilities, determine the new workflow pattern or patient flow.
Plan the workflow so that the members of the team are comfortable in doing the allocated tasks and
the process is saving time while preserving quality.
E.g.: When a patient’s BP is under control, the staff nurse dispenses the same drugs to the patient and
sends the patient directly to the pharmacist, instead of the patient going to the Medical officer.
4. Increase communication among the team members and with patients: Organise weekly meetings
with the team to see their progress and modify the flow based on feedback. The team leader, typically
a medical officer should keep the communication open with the team members. Make patients aware
of the new roles of the health staff using wall posters/signs.
Examples:
a. BP will be measured by a staff nurse after issuing OP slip
b. Hypertension and diabetes medicines will be dispensed by a pharmacist

5. Use a gradual approach to implement the model: Give time for the team members to get adapted
to the new workflow and their new roles. This might take weeks or months.

45
 E.g.: A supervisor at the facility might take time to get used to entering patient details in the treatment
cards or entering data online.
6. Optimize the workflow: After receiving feedback and observing the new workflow, optimize it so
that the patient needs to visit fewer counters. This saves time and increases efficiency.
E.g.: A patient with controlled blood pressure meets only a staff nurse and a pharmacist and, in some
cases, just a staff nurse (if the nurse can dispense drugs)

4.1.4 Responsibilities which can be shifted to non-physicians

Certain functions or skills can be shifted from physicians to other health staff such as staff nurses,
supervisors, pharmacists, etc. They are:

• History taking
• Blood pressure measurement
• Continuing medication to those patients with controlled BP
• Providing lifestyle management advice
• Advice on adherence to medication
Table 1: Example team member and roles matrix for hypertension management

Nurse/
Task Doctor Community Pharmacist Counsellor Community HW
Health officer

Patient history ✓ ✓

Diagnosis ✓

Evaluation for secondary causes,

other risk factors & organ ✓
damage

Identify barriers to adherence ✓ ✓ ✓ ✓

BP measurement ✓ ✓ ✓

Lifestyle counselling ✓ ✓ ✓ ✓

Refill medications ✓ ✓ ✓

Titrate medications ✓

Patient follow-up ✓ ✓ ✓

Refer to higher centre ✓ ✓

Data entry ✓ ✓ ✓ ✓

46
4.2 Opportunistic screening and patient flow
As discussed in chapter 2, all adults aged ≥ 18 years should be screened for hypertension at health
care facilities. To ensure that every patient's BP is measured, the following measures can be
undertaken:

a. Structural
• Putting up of notice boards stating that “All adults should check their blood pressure” and
providing directions to the place of measurement.
• Setting-up an NCD pre-check area before the examination by the doctor and establishing
proper patient flow.

b. Manpower-related
• Dedicated/ designated NCD staff nurses and counsellors for blood pressure measurement and
recordings.
• Engaging available staffs in the clinic – PHC ANM, health supervisor, educator, pharmacist,
dressers, nursing students, etc.

c. Logistic
• Ensuring availability of professional digital BP monitors.
• Regular refresher training of staff in BP measurement.
• Documentation of BP measurement for all adults in OPD registers.

d. Administrative
• Gradual scale-up in facilities: start in few facilities; once established, use the lessons learnt in
other facilities.
• District/State official should issue guidelines/orders on opportunistic screening.
• Discussing issue of opportunistic screening and registrations at the review meetings.

e. Supportive supervision: During supportive supervision, a supervisor can

• Identify a paramedical staff who can be trained and engaged for BP measurement
• Assess gaps in opportunistic screening (e.g. compare the OPD attendance and number
screened)
Once a patient has been diagnosed with ‘hypertension’ and started on treatment by the medical
officer, facility staff nurse (or another person designated for the job) should document details in
treatment cards or the Simple app and facility hypertension register. A patient ID card/BP passport
should be is issued to the patient.

47
 Suggested Patient flow for opportunistic screening in clinic

4.3 Patient-centred services

The success of any program depends on how effective it is in reaching the patients and the community.
That is why developing a patient-centric approach is crucial in ensuring the long-term sustainability of
the program.

A patient-centred approach is “providing care that considers the patient’s needs, values, preferences
and ensures accessibility of quality services.”

Services under any program must be

Affordable

Accessible

Acceptable

4.3.1 What are the ways to improve patient-centred services?

• Reduce and preferably eliminate the cost for medications and medical visits;
• Increasing patient convenience of visits and medication refills (e.g. refills for at least 30 days and when
possible for 90 days);
• Use of once-daily treatment regimens to increase treatment adherence and make the patient feel
comfortable taking the medicines;

48
• Improving access to blood pressure measurements and possibly medication refills at HWC and SC;
• Provide lifestyle advice and adherence counselling.

4.3.2 Strategies to establish patient-centred services

• Decentralized care: moving care closer to the patient’s home (from district hospitals to PHCs; From
PHCs to sub-centre/health and wellness centers);
• Home-based BP check-up and drug refills to bedridden patients and elderly patients;
• Awareness generation in the community about the importance of hypertension and its regular
treatment - through ANMs and ASHAs in local meetings and gatherings;
• Form patient support groups for mutual motivation;
• Public education to increase awareness of the importance of blood pressure control.

4.4 Decentralisation to sub-centres/health and wellness centres (HWC)

Patient-centred services can only be made possible if the services under the program are decentralised
to make them available at the sub-centre/health and wellness centre level.

When services like BP measurement and drug refills are available only at the level of PHC/CHC/DH,
patients may find it difficult to visit the facility every month due to various reasons:

• Distance between the patient’s home and facility

• Lack of adequate transport facilities
• Out-of-pocket expenditure on transport by the patient
• Inability to travel – elderly/disabled/bedridden patients

Most patients come from rural areas with difficult access to PHC/CHC/DH and
hence will find the services more acceptable if they are made available nearer
to them

Decentralisation is “BP check-up and drug refills at the sub-centre level/HWC level”

Principle of comprehensive primary health care: Time to care < 30 mins

49
4.4.1 Strategies for decentralisation

•Sub- •Home visits by

centre/ANM ASHAs

Increased
Accessible
awareness of
place for BP
importance of
measurement
BP control

Convenient
Cost medical visits
reduction/e for medication
refills
•Mobile medical •HWCs/MLHPs
units

Experience from Telangana: Decentralisation was initiated as a pilot in select facilities in IHCI districts of
Telangana. The following strategies were adopted:

• Training of ANMs on IHCI components and BP measurement by CVHO and STS

• Orientation of ASHAs on components of IHCI
• Ensuring functional BP apparatus at all sub-centres
• Copies of original treatment cards given to ANMs to maintain at sub-centre
• Drugs supplied to sub-centres from the PHCs based on number of patients registered in those
sub-centres
• Details of patients’ visits entered in the copy of treatment card or in the register maintained by
ANM during the follow-up visits
• ANM refills drugs for patients with controlled BP, while patients with uncontrolled BP are referred
to PHC
• Data of follow up visits in the copies of cards transferred to the original cards at the PHC during
monthly meetings
• Defaulters identified by ANM at the end of the month and information of those patients given to
respective ASHAs for tracking and retrieval through home visits

50
 4.4.2 Patient flow under decentralisation

Patient comes to SC/HWC for

continuation of treatment

ANM measures BP and asks for any

complaints
BP not under BP under
control control

• Refers patient to Medical officer • Refills medications

• Enters details in treatment card • Reinforce treatment adherence
• Entry in patient card
• Gives date for next visit

4.4.3 Format for line list register at the sub-centre

The response to decentralization in Telangana is highly encouraging. For example, in Telangana, the
follow-up and BP control rates were 77% vs.47% and 53% vs. 35% in decentralized and not-decentralized
PHCs, respectively. This is because patients find it convenient to do a follow up at the subcentres as there is
less travel and wait time. Further, the follow-up rates in decentralised villages were significantly higher
than the district averages. (See figure below).

51
 Follow up rates (%)
100 92 93
90 86
80 73
68 67
70
60
50
40
30
20
10
0
District 1 District 2 District 3

PHC with SC follow up District average

Decentralization of hypertension care to HWCs and subcentres is likely to enhance detection and control of
hypertension and helps to achieve the National Action Plan goal of a 25% reduction in high blood pressure.

4.5 Health and Wellness Centre (HWC)

Transforming existing sub-centres and primary health centres into health and wellness centres will
ensure universal access to an expanded range of comprehensive hypertension management services,
including prevention of risk factors, promotion of healthy lifestyles, effective hypertension
treatment, and rehabilitative care.

A team-based approach by mid-level healthcare provider (MLHP) and auxiliary nurse midwife (ANM)
in HWCs can enable the delivery of high-quality care through a commensurate expansion in improved
delivery of medicines and availability of diagnostics, use of standard treatment protocols and
advanced technologies, including IT systems like Simple app.

4.5.1 Implementing IHCI in HWCs

1. Manpower:- MLHP is additional manpower in HWCs supporting already existing ANMs and ASHAs in
sub-centres.
2. Capacity building: Training of staff on comprehensive hypertension management and control.
3. Logistics and drugs: All HCWs would be equipped with a professional digital sphygmomanometer,
treatment cards, hypertension line list and follow up registers and adequate stock of all anti-
hypertensive drugs as specified under the state hypertension treatment protocol.
4. IEC: Posters on the method of blood pressure measurement along with hypertension diagnosis and
treatment protocols. Health education materials on lifestyle modifications.

52
 5. Recording and reporting: Manually done through individual treatment card and hypertension
register or through electronically-maintained data through the GOI CPHC NCD solution or the Simple
app.
6. Health promotion and counselling: Counselling on lifestyle modifications and treatment adherence.

4.5.2 Services to be provided in HWCs under IHCI

1. Opportunistic screening: Early detection using professional Sphygmomanometer and linking with
population-based screening. All suspected cases identified at HWCs would be confirmed by a medical
officer at PHC or higher centre.
2. Registration :Confirmed cases would be registered at HWCs by issuing the treatment card or in the
Simple app.
3. Standard treatment protocol: Equitable distribution of free and quality drugs as per the established
state-specific standard treatment protocol. Treatment provided at HWCs to hypertensives whose
blood pressure is under control. However, confirmation and initiation of treatment would be done
only by the medical officer at PHC or higher centres.
4. Referral services: for patients with uncontrolled BP or complications. In addition, suspected cases
whose diagnosis need to be confirmed or treatment initiated will be referred to a PHC or higher
centres.
5. Follow up: Tracking and follow up of each patient every month through individual treatment card
ensuring the continuum of care. ASHA incentives would be tagged with home visits and follow up of
treatment compliance.
6. Linkage with mobile medical units (MMUs):ANM/MLHP attending the MMUs would ensure the
linkages of services
7. Recording and reporting – HWCs will maintain individual treatment cards and hypertension register
for tracking of treatment compliance and retrieval of defaulters. Monthly registration and quarterly
and annual reports are sent to PHC.
8. Health promotion and community mobilisation – Provision of regular advice on adopting a healthy
lifestyle and avoiding modifiable risk factors along with training on yoga and meditation.

4.5.3 Roles of various field staff under the program

Staff Cadre Roles
Compile village level line list of hypertensives
Mobilise patients for registration

Maintain a copy of treatment cards or the follow-up register

Measure BP of patients and give drug refills during follow up visits
Enter details of follow up visits in treatment cards or follow up register
ANM
Give appointment for next follow up visit
Refer to medical officer if BP is not under control or if any complications are present
53
 Receive and maintain antihypertensive drugs from PHC pharmacist
Send monthly report of follow-ups and missed cases to PHC staff nurse

Share list of defaulters with ASHAs for home visits

Organise awareness activities related to NCDs during village level meetings

Coordinate with local public representatives in awareness activities

Screening for hypertension in the community and referral of suspected cases to PHC
Registration of confirmed cases under IHCI and issue treatment card and patient ID card
Monthly drug refills to patients with BP under control
Refer patients with uncontrolled BP or complications to Medical officer
MLHP/CHO
Tracking of follow up visits with defaulter identification and retrieval

Follow up of patients receiving drugs at Mobile medical units

Maintain treatment cards and send regular reports such as Quarterly and Annual reports

Health education to patients on lifestyle modifications

ASHA Maintain a line list of hypertensives of their village

Mobilise patients for registration
Collect a list of defaulters from ANM
Make home visits to defaulters and counsel to come for follow up
Counselling patients on treatment adherence
Patient education about complications and danger signs

4.6 Lost to follow up – prevention, identification, and retrieval

For the success of IHCI, it is crucial for the program to ensure that people with hypertension
registered with IHCI are regularly followed up at the health facilities for monitoring of blood
pressure and refilling of medication.
For programmatic reporting, IHCI defines ‘lost to follow up’ as those individuals who did not return
to care for 12 months. “Missed visit” is defined as those individuals who did not return to care at
least once in a quarter following 3-6 months of registration. In this section, we describe the
strategies for prevention, identification, and retrieval of patients.

Based on the experiences of IHCI phase 1, the following factors that can affect lost to follow up
have been identified:

54
1. Health system factors
• Drug stock-outs: patients lose trust with the system
• Non- or irregular availability of service providers
• Unfriendly staff
• Longer distance to health facilities or higher cost of travel
• Lack of patient education on importance of adherence and follow up
• Drug side effects

2. Patient factors
• Lack of awareness - asymptomatic condition; lack of perceived importance of regular
treatment
• Elderly patients and bedridden patients
• Preference for private sector/informal providers

In addition, the following factors hinder retrieval of patients back into the system:
• Large registrations in higher-level health facilities, such as district hospitals, where
o The clinic is not linked to community-level staff to retrieve patients
o Registered patients may be from far-off places
• Poor documentation of patient contact details
• Lack of telephone facilities in clinics and nurses’ concerns relating to the usage of personal
phones for making patient calls.

4.6.1 Prevention of Loss to follow up

The focus should be on good quality implementation of IHCI strategies to prevent or reduce patient
loss to follow up.
1. Availability of drugs and service providers
i. Patients lose trust in the clinic/system if drugs and providers are frequently unavailable
during their visit.
ii. Ensuring uninterrupted medication through improved drug logistic systems would
reduce the issue of shortage of drugs.
iii. If there is a deficiency in human resources, a stop-gap arrangement should be made to
ensure no interruption in services. For example, if there is no medical doctor at PHC, a
medical doctor from neighboring PHC or CHC may be deputed to visit the PHC on a fixed
day of the week. (This is being practiced in Punjab and Madhya Pradesh)
iv. Patient BP monitoring and continuation of medications can be carried out by other
trained staff in the clinic- staff nurse, health supervisor, ANM or pharmacist.
2. Decentralization – Patients are more likely to come regularly for follow up if the clinics are
closer to their home. This can be ensured at two levels.

55
 i. Patients detected with hypertension at higher facilities (district hospitals & CHCs) -
Register and initiate the treatment. Thereafter, facilitated ‘transferring out’ to a PHC
closest to their place of stay. This has been piloted in Telangana with reasonable success.
ii. Patients registered at PHCs, should be encouraged to follow up for medications and BP
monitoring services at a sub-centre/HWC near their residence.

In parallel, ensure
• Availability of medications at the HWC/SC
• Systems for sharing of patient information between HWC/SC and PHC/CHC where the
patient is registered
In Telangana, this is been tried in a few PHCs where sub-centres were provided with IHCI
medications from the PHC and a copy of the treatment card. In these PHCs, programmatic data
showed that the follow up was higher than the district average.

3. Patient counselling and education

a. Counsel/educate patient during registration about the importance of regular treatment and
follow up visits
b. Staff who can counsel at various levels
i. Staff nurse
ii. Counsellor
iii. Pharmacist
iv. MLHP/ANM
c. Patients must be educated on
i. Importance of regular treatment and BP monitoring
ii. Risk of stroke, heart attack, kidney failure if BP not controlled
iii. Availability of services
iv. Patients must come at least 3-4 days before the medicines are going to be finished

4. Documentation of patients’ details

• Documentation of patient contact details in the treatment card is essential to retrieve the
patient who missed visits. The details which must be documented are:
i. Full name
ii. Full address with landmark (PHC area, sub-centre, and village)
iii. Patient’s phone number
iv. Phone number of relatives or neighbors if the patient does not have his/her own
phone
5. Documentation of every visit: It is important to ensure all visits of a patient are documented
and the blood pressure recorded. Lack of documentation will lead to an incorrect marking of
‘missed visit’.

• A good patient flow within a health facility will improve the documentation.
56
• The entry of patient’s BP in OPD register cab be an effective way to ensure patients aren’t
missed
• Local measures may be undertaken. For example (Stamping of outpatient card). In higher
health facilities such as district hospitals, the recording, and reporting are maintained at the
NCD clinic. However, registered patients may visit other doctors in the facility to receive
treatment for hypertension. These patients will be noted as missed follow up as they did not
visit the NCD clinic, though they had followed up at the same facility (false negative reporting).
To address this issue, District Hospital Ratlam has started using an NCD clinic stamp on out-
patient cards. The pharmacist of the clinic has been instructed that the medication for
hypertension is provided only to those patients whose cards have the NCD clinic stamp. If the
stamp is missing, patients are requested to visit the NCD clinic where their visit is noted.

Practice of NCD clinic stamp at DH Ratlam, Madhya Pradesh

6. Patient-centred care
i. Simple prescriptions: patients should get medication for a minimum of 30 days. If BP is
under control and adequate drugs are available, medication may be provided for 90 days.
If available, preferably provide fixed-dose combination medication.
ii. Less wait time: patients are unlikely to visit clinics regularly if the wait time is long and if
they must go to multiple counters. Minimal documentation and single window clearance
may encourage patients to make a quick visit to the clinic.
7. Friendly staff that make patients comfortable ensures that patients will want to come
regularly for visits.
Patient reminders
i. Some facilities in Telangana telephonically contact patients before the due date to
remind them of their impending visit. However, this may not be feasible in busy clinics.
ii. Short Message System (SMS): An automated reminder message (text message or
WhatsApp message) before the due date may be tested for its effectiveness in improving
follow up.

57
 4.6.2 Identifying ‘missed visits’

A. Paper-based reporting

1. Two stack system (see chapter 5 for more details)

• Commonly followed system for quick identification patients who missed a visit by the end of the
month
• Requires two shelves
• On the first day of each month, all cards should be in the shelf 1.
• As patients come for treatment during the month, the card is taken from shelf 1, updated and
placed at corresponding numbers in shelf II.
• On the last day of the month, review leftover cards on shelf 1. These are patients who did not
visit the health facility during the month.
• Once in three months, a list of patients who did not come for follow up should be prepared,
ideally sub-centre wise and shared with the respective ANM/ASHA for follow up.

Example of two stack system of storage

Pre-printed patient registered numbers

• Some PHCs in Kerala has a large number of registered patients (up to 2000) and also have only
one or two days of NCD clinic in a week. This has resulted in very busy clinics wherein
maintaining two stack system is difficult. Some clinics in Thrissur have designed a system of pre-

printed patient registration numbers

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 • At the beginning of the month, all IHCI registered patient ID numbers are printed on a sheet of
paper. When a patient visits the facility his/her registration number is struck off.
• At the end of the month, all the numbers that are not struck out are the defaulters

Defaulter Identification: HT/HD

Name of Institution: Name of the Nodal Person of institution:
Month & Year: Total no: of defaulters identified in the month:

0001 0041 0081 0121 0161 0201 0241 0281 0321 0361
0002 0042 0082 0122 0162 0202 0242 0282 0322 0362
0003 0043 0083 0123 0163 0203 0243 0283 0323 0363
0004 0044 0084 0124 0164 0204 0244 0284 0324 0364
0005 0045 0085 0125 0165 0205 0245 0285 0325 0365
0006 0046 0086 0126 0166 0206 0246 0286 0326 0366
0007 0047 0087 0127 0167 0207 0247 0287 0327 0367
0008 0048 0088 0128 0168 0208 0248 0288 0328 0368
0009 0049 0089 0129 0169 0209 0249 0289 0329 0369
0010 0050 0090 0130 0170 0210 0250 0290 0330 0370
0011 0051 0091 0131 0171 0211 0251 0291 0331 0371
0012 0052 0092 0132 0172 0212 0252 0292 0332 0372
0013 0053 0093 0133 0173 0213 0253 0293 0333 0373
0014 0054 0094 0134 0174 0214 0254 0294 0334 0374
0015 0055 0095 0135 0175 0215 0255 0295 0335 0375

2. Line list of missed visits

• At the end of every month, based on various systems mentioned above, staff nurse identifies
patients who missed their visits.
• List of patients who did not visit in the last three months are made and the patients contacted and
reminded for follow up.
• Once every 3 months, coinciding with the quarterly report, a list of patients with missed visits who
did not return to care for the last 3 months is made sub-centre-wise and shared with ANMs and
ASHAs for further tracking and retrieval.

3. Follow up register
• Many facilities (specifically those with high registration) maintain separate follow up register.
Patients’ contact details are entered registration number-wise and month-wise columns are
provided for marking follow up over the subsequent 12 months. In the monthly column, the date of
the visit is noted when the patient visits.
Advantages:
a. All contact and follow-up details of the patient are in one place
59
 b. Helps identify patients who miss visits
c. Facilitates preparation of facility monthly report
d. Allows identification of not just those who defaulted in the previous month but also patients
who have defaulted for a longer duration
e. Provides pattern of defaulters at a glance

B. Digital reporting

1. Overdue list from Simple App

The Simple app automatically generates the overdue list of patients who have missed visits after 30
days of the previous visit. This is accessed at the ‘overdue’ tab of the app. The list is also organised in
order of priority (patients with BP≥160/100 and longer duration of ‘no follow up’) along with phone
numbers for the ease of health facility nurse. The Simple app in mobile phones also has an overdue list
from where staff can directly make calls to patients. The calling number is masked to ensure the privacy
of the health staff phone number.
The overdue list may also be downloaded by the supervisors from the Simple app dashboard. The list
can be downloaded at the end of every quarter.
Example of an overdue list from the SIMPLE app

4.6.3 Retrieval of patients who missed follow up visits

60
 A. Retrieval strategies

1. Telephonic contact:
o Practiced in most facilities. Patient should be contacted over the phone if he/she did not
return for the visit. The first attempt to connect with patients is telephonic contact
irrespective of paper or digital record system. The call is usually done by health facility
nurse. A list of patients who missed visit in the previous 3 months can be prepared for
making calls.
o The phone calls that are made through the Simple app allows masking of the caller's phone
number. The outcome of the call made to patient should be documented.

Missed visits patients identified through two stack system or

follow up register or Simple app overdue list

Staff nurses contact patient through phone call and counsel

them to come for follow up

Response of the patient is noted down in the treatment card

for future follow up and documentation

Details of non-responsive patients are shared with concerned

ANMs and ASHAs for home visits

2. Home visits by ANM/ASHAs:

• Under the NPCDCS program there is a provision for incentives to ASHAs for ensuring follow up
of patients with hypertension and diabetes. This provision should be leveraged for the retrieval
of patients.
• At PHC level
o Staff nurses prepare sub-centre-wise list of patients who missed visits and hand it over to
the ANMs during the monthly meetings.
o The ANMs return the list with their comments (after home contacts by ASHA workers)-
whether the patient agreed to return, could not be contacted, had taken medicine from
private providers, or other reasons.
o This system is currently used in many facilities in Telangana
• At the level of district hospital or CHC
o It is challenging to retrieve the patients due to the lack of community health workers at the
higher-level facilities.

61
 o The list of patients who missed visits can be prepared according to the PHC area (based on
the name of the village). This strategy is being tried in many facilities in Telangana. The list is
shared with respective PHC NCD nurse through WhatsApp
o PHC NCD nurse attempts retrieval through ANMs
3. Short Message System (SMS): The Simple app automatically sends reminder text messages
requesting patients to return if they have missed their visit by 3 days.

4. Patient support groups: can be tried in remote areas such as tribal areas and closely-knit
communities
• Local support groups can be formed by ASHAs, consisting of local influencers like elected
representatives, teachers, local volunteers, village elders, etc.
• The group can be educated about the patients with hypertension in their community and the
importance of their regular follow up.
• The group can speak to these patients with the objective of “pushing” them for follow up visits.

5. Phone calls by supervisors

• During supportive supervision visits, supervisors such as medical officers/district program
officers/CVHO/STS can identify missed visits especially of patients with BP ≥ 160/100 mm of Hg
and call them for retrieval.
• In the process, the staff nurse is also trained and motivated.
• For non – responsive cases, concerned ANMs/ASHAs are to be contacted.

6. District/block level monthly reviews

• Regular monthly reviews at the district/block level, along with NPCDCS should be carried out.
• This will help in generating problem-specific discussions and identification of solutions that may
require administrative support.

B. Effectiveness of retrieval strategies

As of now, the effectiveness of each of the retrieval strategy is unknown.
• Operational research in the sentinel sites under IHCI is being conducted and the results of this
research are expected to provide significant insights. Initial data suggests that nearly half of the
patients who were contacted returned to the health facility.
• Analysis of data from the simple app may provide important insights on:
- The pattern of loss to follow up
- Effectiveness of SMS and phone calls in the retrieval of patients
• CVHOs and supervisors should also make efforts to document effectiveness in a few health
facilities in their districts.

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Chapter 5: Information systems - monitoring indicators and
reporting tools

Expected competency on completion of session: Ability to correctly maintain primary/secondary health

care-level recording and reporting tools
Audience: Medical officers; facility staff nurses; district and state supervisors
In this session:
• Understand the core Indicators for monitoring using facility reports: Quarterly & Annual
• Information system
o Paper-based - Patient BP passport with QR code; hypertension treatment card & facility
hypertension register
o Digital systems - Simple App
• How to do facility reports - Quarterly and Annual

An information system that will enable cohort-based monitoring is one of the core strategies of IHCI.
This chapter will provide an overview of monitoring indicators and reporting tools for the paper-based
system and an android based Simple app.

5.1 Core indicators

There are two health facility-level indicators calculated from the ‘facility quarterly reports’ and ‘facility
annual report’. (These reports are discussed in later part of the chapter)

5.1.1 Quarterly indicator – 3 to 6 monthly hypertension control rates

➢ Percent of patients starting treatment during a quarter (cohort) who achieve BP control
(<140/90) 3 - 6 months after the start of treatment

Number of patients with controlled BP (<140/90) during the last clinical visit who started
hypertension treatment 3 – 6 months earlier (A2)
---------------------------------------------------------------------------------------------------------- X 100
Total number of patients who started hypertension treatment 3 – 6 months earlier (A1)

• Tracer indicator for the quality of the program

• It is a measure of the effectiveness of treatment among patients
• Identify health facilities with lower performance and support them early with the required
interventions
• Indicator can be measured for each treating health facility once every quarter

63
 Understanding the patient cohorts for the quarterly report
• Cohort is defined by the quarter of registration

• BP control of each cohort is assessed 3- 6 months after the start of medication

3 - 6 months’ cohort for quarterly indicator

BP control of cohort registered in January to March

64
BP control of cohort registered in April to June

BP control of cohort registered in July to September

65
BP control of cohort registered in October to December

5.1.2 Annual Indicator

➢ Percentage of patients with hypertension who have controlled BP in a defined geographical

area (reported annually):
Number of patients with controlled BP (<140/90) during quarter 1 of the next
year (if the patient made more than one visit in the quarter, use most recent
reading) (B2)
----------------------------------------------------------------------------------------- X 100
Estimated number of people with hypertension in the catchment
population/geographical area (district/state/province level) (B1)

• The numerator will include all patients with blood pressure under control during the recent
visit between January 1 to March 31 irrespective of year of registration. It will also include
patients who got registered in previous years.
• Indicator of impact: coverage and quality of the programme
• Estimates coverage of patients with controlled hypertension in an area
• The aim is to increase the number of people with controlled BP to increase the impact of
the programme
66
 • Measured for a district or a State
• The denominator is derived from the estimated prevalence for a District/State
• Measured once in a year in April month each year

For Annual indicator – hypertension control coverage rate for one year

Date of reporting – 15th April of every year

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Ready reckoner to determine the quarter for which the quarterly report is to be prepared

Month in which quarterly Quarter for assessing if BP is under Quarter in which patients registered
report prepared control (Yes/No) (A2) for HTN Treatment (A1)

July, 2019 April – June, 2019 January – March, 2019

October, 2019 July – September, 2019 April – June, 2019

January, 2020 October – December, 2019 July – September, 2019

April, 2020 January – March , 2020 October – December, 2019

July, 2020 April – June , 2020 January – March, 2020

October, 2020 July – September , 2020 April – June, 2020

January, 2021 October- December , 2020 July – September, 2020

April, 2021 January – March , 2021 October- December, 2020

July, 2021 April – June , 2021 January – March, 2021

October, 2021 July – September , 2021 April – June, 2021

January, 2022 October – December , 2021 July – September, 2021

April, 2022 January – March, 2022 October- December, 2021

July, 2022 April – June , 2022 January – March, 2022

October, 2022 July – September , 2022 April – June , 2022

January, 2023 October – December , 2022 July – September , 2022

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 Exercise 1

Please complete the following table:

On the given date of reporting, On the given date of reporting, you

Date of you will consider the will consider the BP measurement of
reporting denominator as the number of patients in Column 2 in ______
patients registered in ______ Quarter/year
Quarter/Year
Quarterly report
15 April 2019
15 April 2020
15 July 2019
15 January 2020
15 October 2019
Annual report
15 April 2019
15 April 2020

Interpretation of core monitoring indicators

Exercise 2:

Examine figure 1 and 2 and answer the following questions:

1. Which indicator does the figure depict?

2. How do you interpret this graph?
3. What is the difference in the control rate between the two states?
4. What is the difference in the uncontrolled rate between two states and possible reasons?
5. What is the difference in the proportion of patients who missed visits between two states and
possible reasons?

69
 Fig 1: Hypertension status in Q1 of 2019 among
patients registered in 5 districts of X state in 2018

100%

80%

60%

40%

20%

0%
A (N=785) B (N=1322) C (N=1640) D (N=341) E (N=260) Overall
(N=26146)

BP control (%) Uncontrolled (%) Missed Visit (%)

Fig 2: Hypertension status in Q1 of 2019 among

patients registered in 4 districts of Y state in 2018
100%

80%
In percentage

60%

40%

20%

0%
M (N=36239) N (N=40489) O (N=35241) P (N=9460) Overall
Districts

BP control (%) Uncontrolled (%) Missed Visit (%)

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 Exercise 3: Calculate the annual indicator with the information given below:

As per the Annual Health Survey, the prevalence of hypertension in district X of ABC state
is 26.5%. The projected population for 2019, of adults above 18 years of age is 1,78,9695.
The number of patients with BP less than 140/90 in January 2019 is 655. Calculate estimated
hypertension for the given population and annual hypertension control rate.

5.1.3 Hypertension Registration Rate

➢ Hypertension registration rate:

Total number of patients with hypertension registered at district/state under
IHCI
----------------------------------------------------------------------------------------- X 100
Estimated number of people with hypertension in district/state

This is an important process indicator of the IHCI program. This indicator is used
to evaluate the coverage of the program.

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5.2 Paper-based reporting tools
5.2.1 Patient BP Passport
When a patient is registered at the health facility for treatment of hypertension, the patient is
issued a ‘BP passport’ which is retained by the patient and will be brought back by each patient
during the follow-up visits. It has information on patient identification with patient treatment
number and QR code’ which is pre-printed on the passport and allotted to the patient by the health
facility.

In facilities with the Simple app reporting system

The patient treatment number and QR code will be used to register and retrieve the patient details
in the Simple app.

In facilities with paper-based reporting system

In addition to patient treatment number and QR code, the patient ID number generated in a sequential
manner starting from 00001 for each health facility. The same patient treatment number will be
written in facility register as well as on the BP passport for easy storage and retrieval of treatment card
as shown below.

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On the day of the visit, the health care worker who attends the patient gives the date of the next
visit. This is written on Page 1 of the BP passport. The BP value and drugs prescribed on the day of
follow up is written on Page 2. The patient is advised to bring the BP passport every time he/she visits
the health facility for follow up.

73
Purpose of the BP passport:
• Helps to retrieve the patient details in the Simple app or treatment card using the patient
treatment number, ID number and QR code displayed in the BP passport.
• It also has a snapshot of the medications the patient is on – serves as a treatment record for the
patient.

5.2.3 Hypertension treatment card

A new ‘hypertension treatment card’ is made for each individual patient registered for the
treatment of hypertension. These patients can be:
o newly diagnosed with hypertension and starting treatment; or,
o already on treatment at the facility or elsewhere for hypertension and wish to get/continue
treatment at the health facility.
(Please note that one card is issued for one patient)

The treatment card of each patient captures information on:

1. Patient identification details
2. Prior medical history
3. Hypertension medication
4. Blood pressure values at registration and follow-up visits
5. Follow up of missed visit
6. Patient treatment outcomes: lost to follow up, transferred out, moved to a private
practitioner, died
7. Additional information: laboratory investigations, previous medications, etc

The upper part of the front of the card is to be completed only during the first visit capturing
information on patient identification details, and medical history. The lower side of the front of
the card and reverse of the card is used for tracking medication and blood pressure values at
registration and follow-up visits. In case the patient misses a follow-up visit for 3 months
continuously, an attempt should be made by assigned staff to contact the patient either
through phone or home visit. The date of contact and responses to retrieval efforts such as no
response to the phone call, unable to locate the address, agreed to return or other reasons are
captured at the lower side of the card.
If the patient is transferred to other health facilities (private or government) or lost to follow up
(did not come for follow up for 12 months continuously) or died (confirmed by a relative) is
captured on the second page of the card. Additional notes may be recorded on the reverse
relating to patient’s laboratory investigations and previous medication history, medication side
effects, missed medication history etc.

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75
76
On initial registration and each follow-up visit, non-physician staff enters the date of visit, blood pressure,
and treatment dose. During a follow-up visit, if the patient’s BP is under control (i.e. systolic <140 and
diastolic <90), then non-physician staff dispenses the next month's supply of medication and enters the
information in the treatment card. However, if BP is not under control, then the patient is referred/sent to
the doctor for up-titration of medication as per protocol and patient’s clinical assessment.

If a medicine prescribed by the doctor is not listed in the treatment card, the name of that medication
should be added in the blank rows provided for the same.

Purpose of the hypertension treatment card:

1. At individual patient level: This helps to track patient’s treatment and blood pressure with an
objective to keep it below 140/90 mmHg. The card provides information that is needed for
individual patient management: the date of the previous visit, due date of follow up, BP control
status, regularity of patient visits, and longitudinal data of patient’s medications and BP.
2. At the program level: It will be used to assess the overall impact of the program. The information
will be used to
a. Update facility hypertension register
b. Prepare quarterly and annual facility reports
c. Facilitate supervision
d. Facilitate digitalization
e. Support operations research

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 Exercise 4: How to complete the hypertension treatment card.
Review the patient details and complete the blank treatment card given on the next page.
Please refer to this completed treatment card for future exercises.

Case study 1
Patient name – Rohan Sharma
Age/Sex –34/M
Health Facility - SA Nagar PHC
On 1.1.19, he visits the PHC for the first time to get his blood pressure checked, BP – 146/96 mmHg.
The medical officer advises the patient on salt reduction in diet and to review after one month.
On 6.2.19 -the patient returns, the BP was found to be 150/96 mmHg. The medical officer decides to
start treatment for this patient. The treatment card was issued.
Address - No 121, Nethaji colony, Thambaram west, Kancheepuram district 600044
Neighhbour’s phone number – 981856XXXX. The nearest subcentre to the PHC is Kundrathur.
Rohan’s history: Smoker from the age of 17 until 3 years back and an occasional alcoholic. There was
no other significant history in the past and in the family.
On examination: Height – 167 cm and weight – 60 kg
Treatment – T. Amlodipine 5 mg per day. The patient collects the prescribed drugs from the pharmacy
for 30 days. The patient was asked to come back for a review after one month.
The staff nurse entered the details of the treatment card into the facility hypertension register and
assigned patient ID number – 00001.
Following this, the patient’s visits are as follows.
4.3.19 - BP - 150/85 mmHg. The doctor adds T. Telmisartan 40 mg per day.
5.4.19 - BP - 130/ 80 mmHg. Advised to continue the same drugs.
5.5.19 - BP - 124/80 mmHg. Advised to continue the same drugs.
4.6.19 - BP - 120/80 mmHg. Advised to continue the same drugs.
5.7.19 – BP - 125/76 mmHg. Advised to continue the same drugs.
3.8.19 – BP - 130/80 mmHg. Advised to continue the same drugs.

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 Exercise 5: Case study 2
Review the patient details and the completed treatment card. Spot mistakes on the card.
Name – Radha Srinivasan, Age/Sex – 56/F
Health Facility – SA Nagar PHC
Patients history - a known case of hypertension for the past 6 months and is on treatment as given by
another health facility. On reviewing her prescription reports, she is under T. Amlodipine 5 mg daily.
However, her BP was not under control.
BP – 131/99 mm Hg.
The medical officer decides to modify her management as per protocol.
Date of registration: 8.1.19
• Patient ID treatment number: 00002
• Address: No 6, CLC works lane, Thambaram, Kancheepuram district: Pin code: 600044.
• Phone number: Not available
• Alternate number: 98976***** (spouse number)
Nearest subcentre - Kundrathur
Relevant history - she chews tobacco, is not an alcoholic and her elder brother had died due to heart
attack a year back.
On examination, height – 157 cm and weight – 76 kg. The medical officer prescribes the following
medicines. T. Amlodipine 5 mg daily along with T. Telmisartan 40 mg OD. The patient is advised to
review after one month. The lab results are as follows as on 4.2.19
• Total cholesterol: 167
• Random blood sugar: 140 mg/dl
• Urine albumin: Nil
• Serum creatinine: 0.7 mg
4.2.19, BP - 129/81 mmHg, advised continuing the same
2.3.19 – BP- 117/73 mmHg, advised continuing the same
2.4.19 - BP - 120/72 mmHg, advised continuing the same
12.5.19 – BP - 124/76 mmHg, advised continuing the same
The patient did not return for treatment in June. On the 1stJuly, the nurse called the patient and the
patient said she was feeling fine and so there was no need to continue treatment.
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83
Storage of treatment cards and retrieval of missed visit/lost to follow up in
facilities with the paper-based reporting system

Cards should be stored systematically to facilitate retrieval during the follow-up visit. They will be
needed for recording treatment and progress during follow-up visits and updating facility
hypertension registers. There should be appropriate and safe storage space and tools available
such as two columns of shelves as depicted in the schematic picture below. Arrange cards
sequentially, by patient ID number to:

• Help to retrieve cards easily during the patient visit

• Identify which patients have missed follow up visits in the previous month so that they can be
called and reminded for follow-up for the collection of drugs.
• Identify which patients have been lost to follow up i.e. those patients who have not received
care in the health centre for four continuous quarters (1 year). This applies only to patients who
were registered in the first quarter of the calendar year or previous years as given in the example
below. For the patients who got registered in subsequent quarters, the loss to follow up will be
taken into count in the subsequent annual report. For example, for a patient who got registered
in Jan 2019, if he didn’t come for follow up any time until March 2020, he will be considered as
lost to follow up in the annual report of April 2020. For a patient who got registered in April
2019, and did not come for follow up until March 2020, he cannot be considered as lost to follow
up in the annual report of April 2020.

Management of hypertension treatment cards:

• On the first day of each month, all cards should be in shelf/rack I.

• As patients come for treatment during the month, record BP and medicines prescribed and
move cards to corresponding numbers in shelf/rack II.
• On the last day of the month, review leftover cards on shelf I. These are patients who did not
visit the health facility during the month. If the patient has not visited continuously for a total of
three months, move the card to the box labelled “missed visit”. For such patients, make an
attempt to call each one and counsel to remind them to come for treatment as soon as possible.
If the patient doesn’t return, visit or have a community worker (ASHA, ANM) visit if possible, to
motivate patients to return. If not visited for 12 months, move the card to the box labelled –
“lost to follow up”.
• If patient reports seeking care at another public or private facility, move the card to
‘’transferred’’ (confirming with the other facility if possible); note the name of the facility.
• If a patient has died, as confirmed by the patient’s relative, the card should be moved into a
box labelled – “died”.
• At the end of each month, move the rest of the cards back to shelf I and repeat the process for
every month.
• At the end of each year, call every patient in the lost to follow up box and try to retrieve them
to treatment.

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How to store treatment cards in the health facility:

Shelf I: Arrange Shelf II: Move the End of quarter

cards by patient ID treatment card to next 1. Count cards in each shelf
number at the start shelf after giving 2. Leftover cards in shelf I at the end of 3
of the month/ treatment and making months means these patients have
quarter the entry on the card. missed their follow up visit and have not
collected medicines. Call up to remind
these patients to visit health facility for
follow up.
3. If patients have missed visit for 1 year,
1-100
1-100 move the card to Shelf III.
4. If patient has been transferred to other
101- facility or private sector, mention name
101-200 and move card to Shelf III.
101- 200300 5. If the patient has died, mention date of
200200 201- death in the follow-up section of
201-300 treatment card and move the card to
300
Shelf III.
301-
400
301-400
Shelf III
401-
500
401-500
501-
600
501-600
601-600
601-600
601-
700

Note: In smaller facilities, like sub-centres, with fewer patients, hypertension cards can be kept in a
tray instead of cabinets, which are more suitable for larger facilities with a larger number of cards.

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5.2.3 Facility hypertension register
Each facility maintains a ‘facility hypertension register’ which has line listing of all patients on blood
pressure treatment in that health facility. Each health facility designates a staff member who will
be responsible for maintaining this register. This register is maintained at the health facility level
by the data assistant/dedicated NCD staff nurse/health worker designated for this task. It is:
• updated with new patients registered
o at the time of issuing the treatment card or entering in the Simple app
• updated for BP control status and other outcomes of registered patients in districts not using
the Simple app
o every quarter, and
o at the end of the year
This register helps to:
• Determine the percentage of patients at the facility whose BP was under control after 3 to 6
months of registration.
o Indicates the quality of services provided by the health facility
• Determine annual blood pressure control rates i.e. the percentage of patients whose BP was
under control during the January-March quarter every year.
o Indicates coverage of hypertension services in the given community
• Aids in the preparation of the quarterly and annual facility reports.

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Facility hypertension register – Non-Simple app
districts simple app

Entered immediately after

starting the treatment card

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Entered later

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At the end of quarter and year, enter the summary information given as perforated sheet in the
register on the total number of patients registered, on how many of them achieved BP control at 3 to
6 months after treatment initiation and during annual follow up.

IHCI Quarterly Report

Name of Health facility: ________________ Name of district: _____________

Name of State: ______________

Date of reporting: day, month/Year ___________

Summary report for Quarter: ……................................ Year……………….

Quarterly Outcome
Total Registered
BP Controlled BP Uncontrolled Missed Visit

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 IHCI Annual Report

Name of Health facility: ________________ Name of district: _____________

Name of State: ______________

Date of reporting: day, month/Year ___________

Annual Summary Report for the year……………………………………….

Total Annual Outcome

Registered BP BP Missed Lost to Transferred Shifted to Died
Controlled Uncontrolled Visit Follow Up to other Govt Private

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How to fill out the facility hypertension register

In the non-Simple app districts:

• Information of patients with hypertension, for whom treatment card has been issued, should be
recorded sequentially in the facility hypertension register with the patient ID number.
• At the time of issuing the treatment card, information of patients newly registered should be
entered in the register. The left six columns of the register are entered using the information on
the first page of the hypertension treatment cards. The information on the nearest sub-centre
has to be additionally entered in the register.
• Right columns of the register are for recording BP control status of patients at 3 to 6 months after
the start of treatment (for quarterly facility report) and during Q1 (January-March) every year (for
annual facility report). In case of other outcomes, such as missed visit, lost to follow up (LFU),
taking treatment from the private sector, transfer to other government hospital, and death, the
entry should be made in the register in the given respective column.

Reporting BP control status of registered patients in the facility hypertension register

The treatment outcome (in terms of BP control status) of each patient registered for anti-
hypertensive treatment is assessed 3 to 6 months after the start of treatment. For example, if a
patient is registered for treatment in Q1, his BP control status will be determined in Q2. The same
will be reported in the first month of Q3.

For each patient, a 3 -6 monthly treatment outcome will be assessed and entered only once in the
facility hypertension register. Steps are as follows:
1. Step 1 - Ascertain the quarter of registration: In the first week of every quarter, determine a
quarter of registration of patients whose 3 to 6 monthly treatment outcomes will be reported in
the current quarter. For example: As seen in the table, if the report is being prepared in the first
week of July 2019, patients registered during January-March 2019 will get reported in the
facility hypertension register for their BP control status.

2. Step 2 - Establish the cohort through patient identification numbers: From the facility
hypertension register, identify patient identification numbers of patients registered for
treatment during the quarter ascertained in step 1. For example, patients with IDs from 0201 –
0274 were registered during quarter 1 of 2019 (Jan-Mar 2019).

3. Step 3 - Retrieve treatment cards of patients with ID numbers determined in step 2 (as in the
example, ID numbers 0201-0274).

4. Step 4 - Ascertain the quarter in which the BP status of these patients will be assessed. For
example, in this case, the quarter for assessing BP status is April to June 2019.

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5. Step 5 - Now, go through the follow-up sheet of each patient card, and review the BP recorded
during the last visit of the patient during the quarter assessed in step 4. For example, from April
to June in our case. Please note that:
• If the patient visited in April, May and June, use the BP reading of June.
• If the patient visited in April and May, use the BP reading of May.
• If the patient visited in April, use the BP reading of April
• If no entry is made in the quarter, mark it as missed visit

6. Step 6 - Report BP control status of the patient in ‘facility hypertension register’ in

quarterly/annual report column using BP record of the patient as seen from his/her ‘treatment
card’ during step 5.
• Write ‘Yes’ if BP <140 and <90
• Write ‘No’ if BP ≥140 and/or ≥90
• Other outcomes include:
• Missed visit (MV): Patient did not have any visit during the quarter (3 months
continuously) of BP assessment or BP was not measured or BP recording was not
documented
• Lost to follow up (LFU): No visit in the previous 12 months and treatment status not
known
• Transfer to private sector (Pvt): Contacted and taking treatment in the private sector
(mention name of doctor if known)
• Transfer to other governmentfacility (TO):Transferred to another government
facility/patient opted to take treatment in another government facility (mention
name of the facility if known)
• Death: Mention date of death if known

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Facility hypertension register in simple app districts

Entered immediately or soon after

registering the patient

93
Entered later

94
In Simple app districts:
Since the BP status (control/uncontrol) of the patients can be obtained from the Simple app dashboard,
information on outcome status is captured along with entry on whether entered in the Simple app and
basic demographic details of patients as discussed earlier.

Exercise 6: Complete facility hypertension register

The facility hypertension register form and 6 treatment cards - (a, b, c, d, e & f) are
given below.

Calculate the following based on the information given in the cards.

1. Quarterly BP status report to be prepared in the month of October 2019

2. Annual report for the year April 2020

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96
97
98
99
100
101
102
103
104
105
106
107
For exercsie 6 – Facility Hypertension Register

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5.3 Digital systems
The use of mobile phones and wireless technologies has grown exponentially across the globe
in recent times. Digital technologies in the management of hypertension can ensure:

Efficient and high-quality care

• Efficient communication and use of information across health care providers

• Provision of timely and secure access to longitudinal clinical data that can help prevent
NCDs and improve the delivery of care

Simple app

Simple is an android app that helps health care workers manage the recording of blood
pressure measurements and medications. A web-based Simple dashboard gives health system
managers the feedback they need to improve BP control across their facilities.
The Simple app system consists of the following recording and reporting tools that are
maintained and utilized at health facilities implementing the India Hypertension Control
Initiative:
• Simple android app for data entry
• BP passport with QR code for patient identification
• Simple web-based dashboard for monitoring
Simple android app for data entry: Healthcare workers enter BP values and BP medications at
each patient’s visit. Finding patients takes only 3-4 seconds with a scannable patient ID system.

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BP passport for patient identification: The BP
passport is a patient ID card in which blood
pressure and medicines can be recorded during
every visit. The BP passport card also has a QR
code which will help to quickly look up a patient
in the Simple app in subsequent visits. Every
patient registered will get a BP passport. When a
patient forgets or loses their BP Passport, a new
one can be issued easily.

Simple web-based dashboard for monitoring:

Facility administrators, district, and State officials
can monitor the performance of facilities in near
real time through a secure web-based
dashboard. They can track registration rates,
follow-up and BP control rates of all registered
patients with hypertension across all facilities in
the district or state. They can also track the
number of calls made through the app by healthcare workers to patients who are at default risk
or lost to follow up.

Advantages of the Simple app

• Fits in workflows: Simple is fast and fits into most workflows, so healthcare workers spend
more time with patients and less time doing data entry.

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• Easy to learn: Healthcare workers can learn Simple in the field in less than an hour.
• Works on any Android device: Simple works on any modern Android phone or tablet,
version 5 or above.
• Offline performance: Simple works in offline mode as well. Data is synced whenever the
user’s internet is active.
• Interoperable with other systems: HL7 FIHR compatible messaging and APIs make the
Simple app interoperable with many health systems.
• Secure: Patient data is encrypted on the device and is aligned with top industry-standard
security.
• Free and truly open source: Simple’s codebase is freely available and open source.

Pilot in India
Simple was deployed in Oct 2018 in Punjab and thereafter in Maharashtra under the India
Hypertension Control Initiative. Simple has had strong uptake in public health facilities in these
two states. Healthcare workers appreciate that Simple is easy to learn, simple to use, and takes
up very little data. In a recent survey, nurses and doctors gave Simple a 4.5/5-star rating.

More details on the Simple app can be found at https://www.simple.org/

Other digital systems

The public health system in India has several digital recording and reporting systems for NCDs -
either in use or currently under development. Broadly these systems are used at two levels.
• Community-level – for creating family records and population-based screening
• Health facility level – for clinical data records

The Ministry of Health and Family Health Welfare has partnered with DELL and TATA Trust to
create Comprehensive Primary Health Care – IT solutions. Further, many states have their own
digital systems for clinical data records. Irrespective of the software used for NCD clinical
records, if the longitudinal records of patient blood pressure are available, IHCI dashboards can
be generated for monitoring.

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5.4 Facility reports
The medical officer will be responsible for timely submitting quarterly and annual reports.
Reports will be prepared by the data entry operator/designated health staff. Based on these
reports the core indicators are calculated.

The facility report comprises of the following variables:

S. No Serial number of health facilities, district wise

District District name
Block Name of block to which the health facility belongs to wherever
applicable
Facility type Either PHC/CHC/GH
Health Facility name Full name of health facility
Q1_R Number of patients registered in quarter 1
Q1_C_n Number of patients under control in quarter 1
Q1_UC_n Number of patients not under control in quarter 1
Q1_MV_n Number of patients missed visit in quarter 1
Q2_R Number of patients registered in quarter 2
Q2_C_n Number of patients under control in quarter 2
Q2_UC_n Number of patients not under control in quarter 2
Q2_MV_n Number of patients missed visit in quarter 2
Q3_R Number of patients registered in quarter 3
Q3_C_n Number of patients under control in quarter 3
Q3_UC_n Number of patients not under control in quarter 3
Q3_MV_n Number of patients missed visit in quarter 3
Q4_R Number of patients registered in quarter 4
Q4_C_n Number of patients under control in quarter 4
Q4_UC_n Number of patients not under control in quarter 4
Q4_MV_n Number of patients missed visit in quarter 4
ANN_R Number of patients registered in health facility
ANN_C_n Number of patients under control in first quarter of subsequent year
ANN_UC_n Number of patients not under control in first quarter of subsequent
year
ANN_MV_n Number of patients missed visit in first quarter of subsequent year
ANN_LFU_n Number of lost to follow up for 12 months continuously
ANN_PVT_n Number of patients taking treatment in private sector
ANN_TO_n Number of patients transferred to other gvt. facility for treatment
ANN_DTH_n Number of deaths

Registered: Total hypertensive patients registered in the health facility under IHCI
BP Controlled: Systolic blood pressure <140 and diastolic blood pressure <90 during last visit of
quarter

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BP Uncontrolled: Systolic blood pressure ≥140 or Diastolic blood pressure ≥90
Missed visit (MV): If the patient did not visit for follow up for 3 months consecutively or blood
pressure not measured or blood pressure not documented
Loss to follow up (LFU): If the patient did not visit for 12 months continuously and treatment
status not known
Transfer to Private (TFRPVT): Taking treatment in the private sector
Transfer to the government (TO): Transferred to other government facilities for treatment or
patient opted to take treatment from the government facility
Death (DTH): Death of registered patient

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Sample facility report – Quarter

Health
Q1_C_ Q1_UC_ Q1_M Q2_ Q2_C_ Q2_UC_ Q2_M Q3_ Q3_C_ Q3_UC_ Q3_M Q4_ Q4_C_ Q4_UC_ Q4_M
S.No Facility Q1_R
n n V_n R n n V_n R n n V_n R n n V_n
name

Report for quarter 1 (A)

Report for quarter 3 (A)

Report for quarter 2 (A) Report for quarter 4 (A)

Sample facility report – Annual

Health Facility ANN_MV_n ANN_PVT_n ANN_T0_n ANN_DTH_n

S.No ANN_R ANN_C_n ANN_UC_n ANN_LFU_n
name

Report for annual (B)

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 Section A of facility report is submitted by 15th of first month of every quarter as ‘facility quarterly
report’. On 15th April every year, Section B is also submitted as ‘facility annual report’.

5.4.1 Facility quarterly report

Data to fill ‘facility quarterly report’ is compiled from the ‘facility hypertension register’. Data reported
in this form helps to calculate a 3 to 6-month BP control rate in patients getting treatment at this
facility.

How to compile facility quarterly report:

The facility quarterly report is prepared and submitted preferably in the first week or the latest by the
15th of the first month of every quarter. Let us understand how to complete this report by using an
example:
• To enter a form with a reporting date of 15 July 2019:
o Reporting quarter to assess BP status would be Quarter 2 of 2019, i.e. 1 April to 30 June
o Registration quarter would be Quarter 1 of 2019, i.e. 1 January to 31 March

Determine A1: Count all patients who were registered between these two dates and fill A1.

Determine A2: Out of A1, count how many patient’s BP control statuses have been documented
as ‘Yes’ in the column titled as ‘Quarterly HTN status’. As discussed earlier this column corresponds to
patients with BP reading <140/90 in Reporting Quarter (1 April to 30 June) in their treatment cards. Fill
the count in A2.

5.4.2 Facility annual report

Section B of the facility report constitutes the facility annual report

• Submitted on 15th April every year

• Determining B2 (number of patients at the facility who have their BP in control during the first
quarter of the year):
o By summing up ‘Yes’ in the column ‘Annual HTN outcome’ of the corresponding year.
o This can be done by writing the total of each page in page summary at the bottom of each
page, and
o Then sum up the page total for all patients registered before 1st Jan of the current year

• Determining B1 (estimated number of patients with hypertension in the area):

o This will be calculated for the district level and above
o This will be based on the recent most survey result

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Purpose of facility report
• Assessing success rate in bringing hypertension under control among registered patients: at 3
to 6 months after treatment initiation and annually during Q1
• Sharing the results of reports with health workers can help them understand how their efforts
have improved the control rate.
• Helps the supervisor understand areas that need additional support

5.5 Monitoring cycle

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Answer key for Monitoring Indicators and Reporting tools
Exercise 1: Determining the Quarter: Complete the following table

On the given date of reporting, you will consider On the given date of reporting,
Date of Reporting the denominator as the number of patients you will consider the BP
registered in ______ Quarter measurement of patients in
Column 2 in ______ Quarter
15 April 2019 October- December, 2018 January – March , 2019

15 April 2020 October- December, 2019 January – March , 2020

15 July 2019 January– March, 2019 April– June, 2019

15 January 2020 July – September, 2019 October- December, 2019
15 October 2019 April – June, 2019 July – September , 2019
Annual report Denominator Numerator
15 April 2019 Estimated number of people with hypertension in January – March 2019
the catchment population/geographical area
(district/state/province level)
15 April 2020 Estimated number of people with hypertension in January – March 2020
the catchment population/geographical area
(district/state/province level)
Note: For annual report:

• The numerator will include all patients with blood pressure under control during the recent
visit between January 1 to March 31 irrespective of year of registration. It will also include
patients who got registered in previous years.
• The denominator is derived from the estimated prevalence for a District/State

Interpretation of Core indicators of Monitoring

Exercise 2: Examine figure 1 and 2 and answer the following questions

6. Which indicator does the figure depict?

Annual Indicator
7. How do you interpret this graph?
8. What is the difference in control rate between two states?
9. What is the difference in uncontrolled rate between two states and possible reasons?
10. What is the difference in proportion of patients who missed visits between two states and
possible reasons?

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Note: Have an overall discussion of how the graph is presented. Compare the control rate,
uncontrolled rate, missed visits between states X and Y and discuss possible reasons for the
difference.

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Exercise 3: Calculate annual indicator with the information given below:

As per the Annual Health Survey, the prevalence of hypertension in district X of ABC state is 26.5%.
The projected population for 2019, of adults above 18 years of age is 1,78,9695. The number of
patients with BP less than 140/90 in January 2019 is 655. Calculate estimated hypertension for the
given population and annual hypertension control rate.

Total >18 years’ population: 1,78,9695

Total expected HTN cases: 4,74,269

Annual HTN control rate: 655 / 4,74,269 *100 = 0.1

120
Exercise 4: How to complete hypertension treatment card

121
Exercise 5: Spot mistakes on card

122
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Exercise 6: Complete facility hypertension register

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Chapter 6: Supportive supervision
Expected competency on completion of session: Ability to conduct supervisory visits and provide
constructive feedback to sub-centre/PHC/CHC/District Hospital staff.
Audience: Supervisors of the block, district, state, and national level
In this session you will learn about:
• Supervision visits schedule preparation
• Supportive supervision checklist
• Interpersonal communication

Good supervision is the process of helping staff improve their own performance continuously.

6.1 Purpose of supervision

Effective management of hypertension requires the cooperation of several health care providers in
peripheral health facilities. As a supervisor, you will be responsible for ensuring that screening,
diagnosis, treatment, and monitoring of patients with hypertension are undertaken as per guidelines.
Supervisory visits to health units give you the opportunity to assess the performance and provide
technical advice and guidance so that the staff can provide better services.

• Good supervision is the process of helping staff improve their performance.

• Supervision is an opportunity to improve staff knowledge and skills.
• Supervisory visits are an opportunity to jointly address the problem and explore solutions. The
supervisory visit gives you the opportunity to see and better understand the problems which
staffs face, especially at peripheral health facilities.
• During these visits, you can
o Observe and reinforce good practices.
o Identify and correct inadequate performance before it becomes a major problem.
• Supervisory visits also give staff the opportunity to talk with you.
• Regular supervisory visits place an emphasis on helping the staff identify and solve problems,
instead of finding fault. This will create a good working relationship between you and the staff of
the district.

6.2 Approaches to supervision

Traditionally, public health programs have used an authoritarian inspection or control approach to
supervision. This approach is based on the thinking that health staff are unmotivated and need
strong control to perform correctly. It has been shown that a supportive approach, where supervisors
and health staff work together to solve problems and improve performance, delivers improved
results.

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Supportive supervision explores if workers are aware of the program priorities and problems and
recognize the fact that workers already know how well-placed they are to achieve those priorities.
Supportive supervision helps local workers understand their programmatic data, interpret it in their
local context and identify programmatic gaps. The hallmark is to listen and to acknowledge all
positive points. Supportive supervision leads to a dialogue that jointly explores problems, sets
priorities and formulates solutions.

Supportive supervision explores if workers are aware of the program priorities and problems and
recognize the fact that workers already know how well-placed they are to achieve those priorities.
Supportive supervision helps local workers understand their programmatic data, interpret it in their
local context and identify programmatic gaps. The hallmark is to listen and to acknowledge all
positive points. Supportive supervision leads to a dialogue that jointly explores problems, sets
priorities and formulates solutions.

Supportive supervision is about helping to make things work, rather than checking to see what is wrong.

“They should smile when they see you walking over the hill to visit”

• Effective supervisors are welcomed by the staff they supervise

• Frank feedback doesn’t mean hostile feedback

• Joint problem-solving shows that the supervisor and the staff person are
on the same team

• Optimism is key: “Irrational optimism is a prerequisite for success!”

126
 6.3 Steps of supervision
Step 1: Planning regular supervisory visits

• Where: using data to decide priority supervision sites

• When: schedule supervision visits using a work plan
• What: decide what to focus on during supervision

Step 2: Conducting supportive supervision visits

• Observation
• Use of data
• Problem solving
• On the job training
• Recording observations and feedback

Step 3: Follow-up

• Follow up on agreed actions by supervisors and supervised staff

• Regular data analysis
• Feedback to all stakeholders

6.3.1 Step 1: Planning supervisory visits

• Where to conduct the visits:

o In general, each health facility should be visited at least once in a quarter.
o If there are more health facilities, then prioritize your visits based on the following criteria:
▪ Low / Decreasing blood pressure control rate
▪ Low / Decreasing registrations
▪ Follow-up of key issues identified during the last visit
▪ Did not visit even once in the last quarter
▪ Delayed / Incomplete / Inaccurate reporting in the last quarter
▪ New staff who may need training

• When to schedule supervisory visits:

o Plan your 3-month calendar using approximately 70 working days per quarter.

127
 o Ensure other planned works such as block, district, state or national level review meetings,
training of new staff, preparation of reports or other planned work are included.
o The schedule should be feasible and practical, considering the distance, transportation
difficulties, or constraints due to weather and travel conditions.
o Try not to rush your visit. Plan to spend enough time at each health facility so that you can
do a good job of supervising.
o The health staff under supervision should be informed of the schedule.
o Consider other planned activities of health staff being supervised, such as weekly/monthly
meetings and special activities (e.g., outreach clinics, market days, etc).

• What to focus on:

o Prepare a summary of the review of previous supervision reports, or data analysis, to
identify what to focus on during supportive supervision visits. An example is provided
below:

Name 3-6-month Last quarter supervision Additional remarks Focus of the planned
of control rate visit visit
facility
A 25% Patient treatment had New staff had been Training on the
not been escalated recruited treatment protocol
according to the protocol
B 80% There was an Patient records and Verify data. Provide on-
inconsistency between registers were not the-job training
reported data and facility updated
hypertension register
data
C - Missing report of some Hypertension Provide support to
patients treatment cards out- print the treatment
of-stock cards
D 30% Stock out of core drugs Sufficient drugs had Training on drug
had been reported not been indented inventory projections
and indenting

Remember: Always keep the concerned officials informed about the visit well in advance. Involve the health facility
in charge during the visit. Share a summary of findings and recommendations at the end of your visit. Written
feedback will help you in the follow-up of key issues for subsequent visits. A summary of your key observations
should be shared with all concerned officials at the institution/block/ district level on a regular basis.

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 Exercise 1. Supportive supervision planning
There are 150 SCs, 40 PHCs and 10 CHCs in a district. Plan your visits for the first quarter of 2020
(January to March) and mark your visits on the calendar. All facilities had a BP control rate of <50% in
the last quarter. In addition, PHC Khera had drug stock-outs while PHC Sundal has only one doctor
who has been on sick leave for the last 3 months. Note that you are busy during the first week of the quarter to
prepare various reports. There is a district-level review meeting on the last Monday of every month and a state-level
review every other month.

129
 January 2018
S M T W T F S Notes:
u 1
o 2
u 3
e 4
h 5
r 6
a
n n e d u i t
7 8 9 1 1 1 1
0 1 2 3

1 1 1 1 1 1 2
4 5 6 7 8 9 0

2 2 2 2 2 2 2
1 2 3 4 5 6 7

2 2 3 3
8 9 0 1

February 2018
S M T W T F S Notes:
u o u e 1
h 2
r 3
a
n n e d u i t
4 5 6 7 8 9 1
0

1 1 1 1 1 1 1
1 2 3 4 5 6 7

1 1 2 2 2 2 2
8 9 0 1 2 3 4

2 2 2 2
5 6 7 8

March 2018
S M T W T F SNotes:
1 2 3
u o u e h r a
n n e d u i t
4 5 6 7 8 9 1
0

1 1 1 1 1 1 1
1 2 3 4 5 6 7

1 1 2 2 2 2 2
8 9 0 1 2 3 4

2 2 2 2 2 3 3
5 6 7 8 9 0 1

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6.3.2 Step 2: Conducting supportive supervision visits

A simple supervision checklist facilitates systematic data collection on input, process,

output and outcome indicators at the health facility. It enables a comparison of indicators
among facilities of same level, thereby, allowing supervisors to identify good and replicable
practices. The checklist can help to identify key problems and discuss possible solutions to
address these problems.

Most importantly, supervisors should fix problems and address urgent issues during the
visit. For example, if a supervisor finds a treatment card of the patient whose last recorded
BP is 180/110 and hadn’t turned up for treatment this month, then the supervisor should
immediately call the patient.

Please refer to a supportive supervision (SS) checklist and a checklist for facilities using
Simple App. SS is organized with the following sections:
1. Screening and BP measurement
2. Treatment outcome
3. Patient recording and reporting system
4. Identification and tracking of missed patient
5. Pharmacy
6. Laboratory facilities
7. Telephone calls by STS

Supervisory visits improve performance

• Supervision contributes to the clinical and monitoring quality

• The most efficient system will vary in different types of facility

• A role of the supervisor is to transfer successful experiences

• As a result, staff should be able to self evaluate their achievements

• A major and very common problem for supervisors is lack of time:

- To travel to multiple facilities and arrive at opportune hours

- To cover multiple patient paths and clinical areas in large facilities

- To balance observation/advice and direct clinical involvement

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 India Hypertension Control Initiative (IHCI)
Supportive Supervision Checklist
Simple App / non-Simple App facility

District name: Name of supervisor:

Facility type & name: DH/ AH/ SDH/ RH / CHC / PHC/ UPHC /SC ………………………………….

Name of medical officer in charge:

Designation:
Last month total OP cases: ………………………. CVHO/STS/Both/
Others
Number of HTN patients registered till date:

Last month registration: reported …………… actual …… Date:

Is the HTN treatment protocol displayed on the wall or desk? □ Yes □ No

Is the BP measurement checklist displayed? □ Yes □ No

1 Screening and BP measurement

1.1 Number of staff nurse: NCD nurse posted

under NPCDCS
…………
Nurse designated to
do NCD work………….

1.2 Number of Medical officers: ………………

1.3 Number of functional BP instrument/s in the facility (Digital/Aneroid/Mercury/LED) ___D, ___ A, ___M,
___L

1.4 Who does BP measurement in the facility? (Multiple choices) NCD SN / SN /ANM/
Others
(specify………………….)
NA

1.5 How many days in a week, opportunistic screening is done at the facility? (No. of days)
1.6 In previous 3 working days

a) No of adults whose BP was measured ……….

b) Total no of adult outpatients ……….

NA

1.7 Observe BP measurement for at least one patient. If there is no patient, get your own BP
checked Y N
a. If staff is tying the cuff properly Y N
b. Patient’s sitting position is correct

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 c. BP apparatus position is correct Y N

1.8 Are all adults with BP ≥140/90 referred to the medical officer for management? Y N NA

2 Treatment outcome

Review all treatment cards registered two months before. In case of fewer than 25 registrations in that one month, then previous
months’ cards to be reviewed till 25 cards are reviewed.

2.1 Number of cards reviewed

Assess the treatment outcome for each card. (Use a tally mark to count only one treatment outcome per card)
a. Number with BP b. Number with BP c. Number with BP d. Number for whom e. Number who did not
controlled (<140 and uncontrolled (>140 or uncontrolled (>140 or BP / treatment not visit the facility for
<90) at last visit >90) and treatment >90) and treatment not documented at last previous two months
intensified at last visit intensified at last visit visit (missed visit)

3 Patient recording and reporting system

3.1 Was the facility hypertension register up to date till last week Y N
a) Number of blank patient BP passports available at facility
3.2 b) Number of blank treatment cards available at facility (For simple app only (a) to be
kept; For non-simple app both (a) and (b) to be kept)
a) Is there a place to store treatment cards? Y N NA
3.3
b) Is there a two-stack system in place for arranging treatment cards? Y N NA
3.4 Are the cards arranged by serial number to facilitate easy retrieval? Y N NA
4 Identification and tracking of the missed visit

4.1 Identification mechanism for missed patient Two stack system / Follow up register / Simple App / Others
/ None

4.2 Tracking mechanism for missed patients Phone call / IVRS / SMS / ASHA through home visit/Others
/ None

4.3 No. of patients who missed visit in the previous quarter based on available list …………/ list not available

4.4 a. Overdue list shared with ANM / ASHA Y N

b. if, yes date DD/MM/YYYY

4.5 Among patients who missed visit, how many were contacted either through phone call or home visits?
…………

5 Pharmacy

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 Number of days for which HTN medicine is dispensed
5.1 30, 15, 7, other (….) days
by the facility

Is drug stock register maintained and updated

5.2 Y N
regularly

Is stock sufficient for one quarter for registered

5.3 Drug name
patients? (Write Y/N/NA)

I Amlodipine

Ii Telmisartan

Iii Losartan

Iv Enalapril

V Chlorthalidone

Vi Hydrochlorothiazide

Vii Others (specify)__________________

Viii Others (specify)__________________

6 Laboratory facilities

6.1 Is there a functional laboratory at the facility? Y N

If yes to 6.1, please encircle the type of tests offered

to HTN patients
6.2
1. S. Creatinine 2. S. Electrolytes 3. Urine protein 4. Any other ______________

7 Telephone calls (To be done by STS)

7.1 No of phone calls made on the day of visit (At least 10 calls to be made to patients who have missed visits,
loss to follow up patients, high risk patients)
a. Missed visit / loss to follow up patients……………
b. High risk patients …………….
c. Others …………………

7.2 Missed visit/ loss to follow up patients

1 2 3 4 5 6 7 8 9 10

IHCI registration no.

I Current status

If agree to visit/not willing to return,

Ii
treatment status of patient

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 a. If on treatment

b. If not on treatment

(i. Current status: a. Agree to visit b. Not willing to return c. Discontinued/ not willing to take
treatment at all d. unable to contact/no response / wrong number e. Had visited the facility in
the past 60 days (2 months) f. Death)
(ii. If agreed to visit/not willing to return, treatment status of the patient: a. On treatment, b. Not
on treatment)
a. If on treatment, reason: a. Taking Treatment from other Government Hospital b. Taking
Treatment from Private Hospital/Clinic c. Others (Specify)
b. If not on treatment, reason: a. Too long a wait in health facility b. Drugs were not
available c. Drugs are given for a few days only d. Side effects of the drugs given from the
facility e. Given drugs do not work f. Distance from home g. No proper conveyance to
reach h. No one to help to reach health facility i. Too sick to make the trip j. Bedridden k.
The financial burden of transportation cost

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 Checklist for assessment of Simple App
1.1 Who is using the simple app?

a. NCD Staff Nurse Y N

b. NCD counsellor
Y N
c. Doctor
d. Pharmacist Y N
e. Others (Specify……………….)
Y N

Y N

1.2 Are you filling the details directly in the app? Y N

1.3 Do you face any challenges in patient retrieval? Never / Sometimes

1.4 If any challenges faced, specify:

1.5 Are all patients registered? Y N

1.6 If no, reasons Unable to sync/ Technical

errors in the app/
Unsupported device/ High
OP load/ Incorrect patient
flow

1.7 Are all follow-up patients updated in simple app concurrently? Y N

1.8 Is the simple app user satisfied with the application? 1/2/3/4/5

(Likert scale: Not satisfied at all 1 – 5 Very satisfied)

1.9 Do you face any challenges in getting timely support for issues Y N Help not
experienced while using the simple app? required

1.10 If yes, whom do you contact?

1.11 Are you using the overdue list function? Y N

1.12 How frequently do you call patients?

1.13 Never /Sometimes

Does the call masking work?
/Always

1.14 Never /Sometimes

Are you being charged for the calls?
/Always

1.15 Are the patients receiving SMS? All / Few / No

1.16 Are you using the ‘progress’ tab for reviewing status of program in
Y N
your health facility?

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 1.17 Are you using the ‘progress’ tab for preparing reports? Y N

1.18 Do you discuss the facility performance with supervisor? Y N

1.19 How many patients are registered in Simple app? …………

1.20 How many patients are registered in facility hypertension ………. / Registered not
registers? maintained

(Difference should be automatically calculated)

Refer Annex A for instructions on using the supervision checklist.

Use the checklist to conduct supervision visits by

• Observation:
o How staff does their work
o Observe the availability and usage of IHCI related logistics in the health
facility such as BP monitor, protocol poster, BP passports, treatment cards,
and facility hypertension register
o Watch how the patient moves inside the health facility and how services are
organized including BP measurement, counselling, and treatment
o Listen to how they interact with patients
• Interview:
o Speak with various cadres of health staff to understand their roles and assess
their knowledge
o Ask if there is any shortage in IHCI related logistics
o Phone call to patients to understand the quality of service being provided
• Examination:
o Check records and validate data
o Verify blood pressure entries on the treatment card
o Assess treatment outcome using the patient treatment cards
o Check prescriptions on the treatment card to see if treatment is given as per
protocol
o Validate entries on the patient card with the facility hypertension register
versus reports
o Check drug stock status

Always conduct supervision together with the health facility staff. The purpose of
supervision is to help solve problems together.

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 Exercise 2: Collecting information for the supervision checklist

Please review the supervision checklist provided to you by the facilitator.

For each section of the supportive supervision checklist, discuss how best to
collect information.

Effective Communication Tips

Feedback should aim to help the recipients improve their effectiveness and should focus on
developing skills and strengthening areas that need improvement, rather than criticizing or
judging the recipient for inadequacy.

• The provider should suggest some possible alternatives to what the recipient has
been doing.
• Feedback should help the recipient set reasonable goals for changing and
improving performance or behaviour.
Be supportive

• Start on a positive note. Emphasize what really went well, and praise what the
individual or group is doing right.
• See if the recipient is aware of the issues or concerns that the feedback addresses
before stating them directly. If it comes from the recipient himself, he is much less
likely to be defensive, and apt to be more constructive and creative in discussing
alternatives.
• Don't look for expressions of guilt or responsibility, but rather for changes that will
improve the effectiveness of an individual's or organization's efforts.
• Especially if you're dealing with the opposition, or with the targets of advocacy,
assume— or, better yet, identify and describe—common ground and your
common interest in making things better.
• Focus on the specific issue, and don't point fingers.
• Identify the issue or problem as clearly and specifically as possible. Once you've
done that, stick to exploring it. The question is not "Who's to blame?" but "How do
we make this work as well as possible?"
Be honest

• Providing formative feedback, being supportive, and not blaming doesn't mean
‘not being honest’. On the contrary, formative feedback requires honesty, the
dishonesty renders it useless.
• Deal directly with the real problem or issue. Identify it clearly. If you know, explain
how it became a problem, and help the recipient work out strategies for fixing it
now and preventing its recurrence in the future.
• If the issue is a personal one, identify it clearly and help the recipient understand
how to address it.

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 Feedback should be frank, constructive, and practical

• Understand what the actual problems facing staff are – staff are best positioned
to identify these problems

• Be systematic, including meticulous review of records – use and disseminate

practical checklists and job aids

• Help solve problems on the spot whenever possible (e.g., help update records
and establish a mechanism to do so in the future, solve logistic problems when
possible such as provision of forms or protocol copies when needed)

• Model good behavior (e.g., speak with patients and health workers privately and
respectfully; call patients whose BP is dangerously high and who didn’t return for
care before leaving the visit)

• Give realistic, not theoretical, solutions

• Don’t give false praise. Catch people doing the right things and reinforce these.

Ask questions in a friendly manner and you are likely to obtain more useful
information. Always praise good performance.

6.3.2 Step 3: Follow-up activities

Soon after the supervisory visit, share the feedback report with all concerned. The feedback
report is prepared based on the observations/ findings of visit.

Prefill the data in the feedback form based on the available reports : The report includes
data on previous monthly registrations and quarterly BP control rate which a supervisor
needs to fill before visiting facility.

Complete the form after completion of visit: The feedback also includes input and process
indicators and data on adequacy of protocol drugs.

• It is always a good practice to arrive at prioritized recommendations with timelines

with the staff being supervised and add in the feedback report.
• Use the opportunity of supervision to provide on-the-job training and identify
training needs and mention in the feedback form.
Discuss the findings and handover the form: Discuss your findings with health unit
supervisor and appropriate staff. Work with the staff to find possible solutions and mention
it in comments section

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After the visit, a copy of the report stays at the health facility and keep a copy for your files
and sharing it with district officials. Giving and receiving feedback is a sincere attempt to
help the recipient improve his/her performance, behaviour, understanding, relationships, or
interpersonal skills. This is corrective feedback, and all of us need it from time to time.

Supportive supervision does not end with the conducted visit. Follow-up should be done
after the visit to act on issues as agreed with health facility staff, particularly to solve any
urgent issues related to equipment or drug supply.

Establish a system for continuous feedback and improvement

• No program is perfect

• The best programs have information systems that indicate when and where they
are getting off track

• The best supervisors establish, strengthen, and disseminate these information

systems so health workers themselves can track and improve their own
performance

• Demonstrate the value of accurate, timely data in improving performance

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 IHCI Supportive Supervision – Feedback to Health facilities

Name of Block: Name of Institution: Date of visit:

Program started on: Name of Supervisor: Designation:

Six-months Registration Trend Coverage %

Month Total
& Year Registered
Estd.
# Regd. Target
Population

Quarterly Report Analysis

Missed
Quarter/treatment card Total Control Uncont-
visits Remarks
analysis Regd. % rol %
%

Treatment card analysis

Input Process Drug stock for 3 months

Opportunistic Screening
Dedicated Staff Y/N Amlodipine A I S
(None / Few / Majority)
BP measured by health
Functional digital BP Telmisartan /
Y/N staff before consulting Y/N A I S
monitor Losartan
MO
BP Measurement
BP Measurement Chlorthalidone /
Y/N Technique A I S
Checklist Hydrochlorothiazide
C-correct, I-Incorrect
Defaulter Identification
Treatment Protocol Y/N Y/N Enalapril A I S
System
BP Passport / ID cards Defaulter Retrieval
Y/N Y/N A I S
(100 nos.) System
Treatment cards (100 Timely Report
Y/N/NA Y/N A I S
nos.) Submission
Storage facility for Patient Education &
Y/N/NA Y/N Other A I S
Treatment cards Counselling
Facility Hypertension
Y/N Other Other A I S
Register
Y- Yes N- No NA-Not Applicable *A – Adequate; I – Inadequate; S – Stock out

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 Suggestions / Comments
Follow up of previous supervisory visits:

Current supervisory visits:

Signature of Supervisor Signature of Medical Officer

Supervision is not a one-time activity. Periodic follow up is required to ensure the

recommendations are implemented.

• Continue to analyse data to review if there is improvement in performance.

• Communicate regularly with staff to see if recommendations are being followed.
• If needed, conduct a follow-up visit to the facility before the next supervisory visit
to support health staff, reinforcing key messages, and ensuring that urgent
problems identified during the supervisory visit are solved.

Key Messages
• Supervision should be data/evidence based.
• Start feedback with positive points.
• Discuss issues with the health staffs and reach a common understanding of problem
and their solution.
• Leave the health facility with a plan of action on 3-5 key issues with timelines.
• In your next visit, see if the plan of action was followed.

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 Exercise 3: Discussion: What are the possible data you can use to perform evidence-
based supervision?

Exercise 4: Role play on problem solving and feedback

Pick one problem from the summary report in exercise 3, keeping in mind principles of
good communication, provide feedback to the PHC staff.

References:

1. RNTCP M5-10, MOH, India

2. Supportive Supervision, Module 4, WHO/IVB/08.04

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Annex A: How to Use the IHCI Supportive Supervision Checklist

• Use the checklist for every supervisory visit by CVHO, CVH-STS, officials and others who
supervise the IHCI at health facilities
• Before going to the facility: review observations & recommendations of the previous
supervisory visit to the facility, monthly IHCI report and quarterly BP control report of
facility
• Carry printed treatment protocols and BP measurement checklist so that same can be
given to health facilities, if not displayed
• The checklist should capture data and observation pertaining to NCD clinic of facility; if
NCD clinic is not established at facility then data and observation pertaining to the
whole facility should be captured
• Provide continuous on-job training to health care providers

Checklist to be filled through: (1) Observation of processes; (2) Talking with patients; (3)
Reviewing records and reports (4) Discussion with health staff at facility

1. Screening and BP measurement

o Ask about number of staff nurse posted to do exclusive work related to NCD under
NPCDCS or staff nurse designated to do NCD work in addition to other duties
o Ask about number of medical officers posted
o Ask about number of functional BP monitors of different types
o Observe/ask who all do measure BP
o Ask for number of days in a week, opportunistic screening is done; verify the data of
previous 3 days related to opportunistic screening; If data is not available for 3 days
write “NA”
o Observe process of BP measurement for at least one patient for minimum basic
standard; If there is no patient at all, get your own BP checked
o Observe if all adults with BP ≥ 140/90 mm hg are referred to Medical Officer

2. Treatment outcome
o Review treatment cards of all patients registered in a month, two calendar months
before the visit. The outcome of these patients will be assessed in the previous two
months of visit. (e.g., for supervisory visit done from 1st to 30th November 2019,
patients registered in August 2019 is to be reviewed and their outcome is to be
assessed in September and October 2019)

Visit during Review cards of patients Assess outcomes in

registered in
January 2020 October 2019 November and December
2019
February 2020 November 2019 December 2019 and
January 2020

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 March 2020 December 2019 January and February
2020
April 2020 January 2020 February and March 2020
May 2020 February 2020 March and April 2020
June 2020 March 2020 April and May 2020
July 2020 April 2020 May and June 2020
August 2020 May 2020 June and July 2020
September 2020 June 2020 July and August 2020
October 2020 July 2020 August and September
2020
November 2020 August 2020 September and October
2020
December 2020 September 2020 October and November
2020

o If total registered patients in that month are less than 25, then patients registered in
the previous month in the sequence are to be reviewed till 25 cards are verified
o If any patients (whose cards you identify) have missed a visit and last recorded blood
pressure was greater than 180 systolic or greater than 110 diastolic, make efforts to
call patient along with health staff and return patient to care as rapidly as possible
o Patients with BP under control, whether they are on protocol drugs or on any other
drug, they are in 2.1a. However, if a patient’s BP is not under control, it is important
to note, who is being treated per-protocol (count in 2.1b) and who is not treated as
per protocol (count in 2.1c) in the last visit
o If patients’ BP and/or treatment is not documented in treatment card, then count
them in 2.2d
o Patients who did not visit the clinic for two assessment months count them in 2.2e as
a missed visit patient (and NOT to be counted in any other sections)
o Reviewed patients are to be categorized in only one of the five outcomes

3. Patient recording and reporting system

o Cross-check with NPCDCS and pharmacy register to determine if every patient
dispensed medicine for HTN is registered in the program
o Check for number of Blank BP passport, treatment card at facility and ensure
adequate availability

4. Identification and tracking of missed visit patient

o Observe/ Ask for type of identification mechanism for missed visit patients
o Observe/ Ask for tracking mechanism for missed visit patients
o Ask for no. of patients who missed visit in previous quarter
o Ask if, overdue list is being shared with ASHAs/ ANMs. If response is Yes, ask for date
on which last overdue list was shared
o Ask for number of missed visit patients who were contacted either through phone call
or home visit

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5. Pharmacy
o Observe for number of days hypertension medicine is dispensed by facility
o Visit pharmacy, review records and stocks, discuss with the pharmacist
o Examine stock register for stock and expiry of all HTN protocol drugs
o Check if drug stock is enough for next quarter. Guide pharmacist for timely indenting
accordingly

6. Laboratory facilities
o Confirm from laboratory and treatment card that patients are being tested as per
state treatment protocol. Write NA, if state protocol doesn’t require it.

7. Telephone calls (Must be done by STS during supervisory visit)

o Identify patients for phone call with either of this indicator: (1) who have missed visit
in previous quarter/ loss to follow up for more than 12 months (2) who have systolic
BP more than 180 mmhg or diastolic BP more than 110 mmhg (3) for any other
indication like verification of record, overwriting in treatment cards, with borderline
BP control, etc.
o Phone call to patients of missed visit/ loss to follow up must be done till responses are
received from at least 10 patients
o Record IHC registration number, current status and willingness to return of each
patient.

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 How to categorize the treatment outcomes in the supervisory checklist?

Has the patient visited in the previous two calendar months?

No
Yes

Is the patient blood pressure under control (<140/90 mm Hg) in the Categorise to ‘Missed visit (e)
last visit?

Yes No BP/ treatment not recorded

Categorise to ‘Controlled’ (a) Categorise to ‘BP/ treatment not recorded’ (d)

Is the drug regimen prescribed as per the ‘State’s’ Protocol?

Yes No

Categorise to ‘Uncontrolled’ Categorise to ‘Uncontrolled’

and treatment intensified at and treatment NOT intensified
last visit (b) at last visit (c)

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