Keralam to focus on continuity of care in NCD management

Hridayaragam initiative is so envisaged that the health system will track these individuals, book appointments for higher referrals for them and ensure that they get appropriate and timely care.

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The Health department is all set to launch a new initiative to tackle the increasing morbidities and complications resulting from non-communicable diseases (NCDs) in Keralam by ensuring a care continuum and seeing to it that people are not lost to follow up.Keralam went through a rapid epidemiological transition ahead of the rest of India because of an ageing population, coupled with rapid urbanisation, sedentary habits, high levels of stress and a dietary habit which was overwhelmingly carbohydrate-based, with very low consumption of fruits and vegetables.It was not until the mid-to-late 1990s that Keralam recognised that achieving high life expectancy and excellent health indicators as that of developed nations came with a price.It was the renowned public health activist, the late C.R. Soman who first spoke about the lifestyle disease epidemic that awaited the State. By early 2000s, Keralam recognised the gravity of the warnings and started building the infrastructure to manage NCDs.LimitationsOver the years, the State has built up an extensive health infrastructure to tackle NCDs from primary care upwards. However, none of the NCD control programmes implemented in Keralam has so far been able to go beyond population-level screening and detection.Today roughly one in every four adults in the State has diabetes, and about one in three has high blood pressure and these numbers are only growing. The health system has not been able to do much about primary prevention, improving treatment adherence or improving the control and management of multiple chronic conditions.Plugging the gapThe new Hridayaragam initiative is important because it explicitly positions continuity of care as part of the NCD response, a major gap that the system has failed to tackle efficiently till date, Health department, reckons"This is a community-oriented health initiative which places primary care facilities at the heart of coordinated care for NCDs. It intends to go beyond screening so that the population is risk-stratified. Preventive health campaigns will focus on those in the mild risk strata whereas those in the moderate and high risk categories will be linked to regular specialist consultation, diagnostics and treatment by the health system.The programme is so envisaged that the health system will track these individuals, book appointments for higher referrals for them and ensure that they get appropriate and timely care,’ a senior Health official said.A defining feature of the campaign is its "care coordination" approach, designed to ensure that every patient reaches the right doctor at the right facility at the right time without being sent from one hospital to another or being lost track of along the way.Health diaryEvery newly diagnosed person is registered and given an individual health diary and placed on a structured follow-up schedule covering treatment adherence, lifestyle modification and complication prevention.Patients will be navigated through the referral pathway in a structured manner so that appropriate level of treatment is given at the right time, without shunting everyone to tertiary care centresThis will be done by bringing together all digital resources in the health system so that diagnosis, treatment and follow up data are recorded through the eHealth Hospital Management System. The health diary of patients will be maintained physically and digitally and it will be accessible to the patient as well as the health systemThe digital system will automatically identify high risk individuals who have not yet been screened, link them with the concerned health workers, track missed appointments, and identify persons requiring follow up.The campaign has will be launched on a pilot mode in three Legislative Assembly constituencies to represent the urban community (Vattiyurkavu constituency in Thiruvananthapuram), Idukki constituency (rural), and Nilambur constituency in Malappuram, which is semi-rural/urban).The Health department hopes that the pilot study will generate generate robust implementation evidence so that the programme can be further refined before it is scaled up across the State. Published - September 07, 2026 08:40 pm IST