Non-communicable diseases (NCDs) have emerged as the leading cause of death globally. Of 56.9 million global deaths in 2016, 40.5 million, or 71%, were due to non-communicable diseases (NCDs). The four main NCDs are cardiovascular diseases, cancers, diabetes and chronic lung diseases. The burden of these diseases is rising disproportionately among lower income countries and populations. In 2016, over three quarters of NCD deaths — 31.5 million — occurred in low- and middle-income countries with about 46% of deaths occurring before the age of 70 in these countries.

The Chronic Care Model (CCM) is an integrated patient-centred, evidence and population-based comprehensive system which is applied in strategies to organize and improve chronic disease care. These strategies or components are designed to support the development of an informed, proactive patient population and prepared, proactive health care teams. On the provider side, preparation means having the necessary expertise, information, and resources to ensure effective clinical management. It also means having timely access to the necessary equipment, supplies, and medications needed to provide evidence-based care. It prepares health care teams to anticipate patients’ needs, to prevent illnesses and complications through risk factor reduction, and to plan care in a manner that does not depend on acute exacerbations or symptoms as the sole trigger for clinical encounters. It provides patients with the essential elements of self-management support such as needed information, education, motivation, and confidence to act as partners in their care. Self-management encompasses any intervention that enables patients to better manage their health condition(s) on a daily basis. This includes technological interventions–such as smartphone applications, medical device deployment, and tele-monitoring systems as well as non-technological interventions–such as educational materials, in-person training sessions, and social support. The CCM also establishes formal linkages for community engagement which leverage untapped resources and help to support/ ensure healthy and facilitative environments for people living with NCDs.

To address this Velsoft was engaged to develop training modules for health care workers, patient self-management and community support as well as design the implementation of the training programme for the community supports and patients with NCDs.

The two key objectives of the project were to:

1. Develop training modules for self-care of patients, their primary caregivers and volunteers from support groups and the community, for the Chronic Illness Care of Hypertension, Diabetes Mellitus and Cardiovascular Disease.
2. Develop training modules for health care workers (i.e. community health workers, nurses, primary care medical doctors) for the Chronic Illness Care of Hypertension, Diabetes Mellitus and Cardiovascular Disease.

The result is to provide technical assistance in the design and implementation of the Chronic Care Model in participating health services networks. The Chronic Care Model is designed to strengthen the health care system and improve patient health outcomes for persons with chronic diseases by changing the routine delivery of ambulatory care through six interrelated components of health care delivery.  These components namely, health system and organizational support, delivery system design, clinical information system, evidence-based decision support for staff and patients, self-management support and community support are meant to make patient-centered and to deliver evidence-based care.