Strengthening Community-based Noncommunicable Disease Follow-ups: Addressing Gaps in Implementation

Dear Editor, The increasing burden of Noncommunicable Diseases (NCDs) such as diabetes, hypertension, cardiovascular diseases, and cancer in India has led to a greater focus on early detection and preventive care. Recognizing this, the National Health Mission has taken proactive steps to strengthen community-based screening and follow-up through Accredited Social Health Activists (ASHAs). Under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS), the Government of India has introduced financial incentives to promote ASHA engagement in NCD-related activities at the grassroots level. As per the NPCDCS 2024–26 guidelines, ASHAs are entitled to receive Rs. 10 for completing Community-Based Assessment Checklist (CBAC) forms for all individuals aged 30 years and above – a one-time activity during enumeration. In addition, Rs. 50 is to be provided annually for two follow-up visits per patient diagnosed with hypertension, diabetes, or one of the three common cancers, for treatment initiation and ensuring compliance.[1] These incentives are designed to improve early identification, timely treatment, and consistent follow-up of NCD cases through community health workers. Despite these policy measures, India’s goal to provide standard care to 75 million people with hypertension and diabetes by 2025 remains unmet.[2] Field observations from various districts highlight several implementation challenges. While enumeration and initial screening have commenced in some areas, follow-up activities by ASHAs are yet to begin in many communities. This critical gap undermines the continuity of care and increases the risk of complications due to untreated or poorly managed NCDs. One key concern is the incomplete filling of CBAC forms. In many instances, ASHAs deprioritize this activity due to competing responsibilities, or they fill out forms without actually conducting thorough screenings. Postidentification, patients are expected to be linked to treatment and followed up at least twice a year. However, on-ground interactions reveal that follow-ups are not being conducted consistently. Most ASHAs and even their supervisors are unaware of the follow-up incentive provision under NPCDCS, resulting in minimal engagement in this crucial step. Lack of awareness about these incentives, coupled with the burden of multiple tasks, limits ASHAs’ ability to conduct meaningful follow-up. This has led to cases of treatment discontinuation and poor health outcomes. Since follow-up plays a vital role in ensuring regular treatment adherence and reducing complications, its absence creates a serious gap in NCD program implementation. The government’s initiative to incentivize ASHAs for NCD follow-up is timely and commendable. However, actual disbursement of payments and awareness at the grassroots level must be ensured to translate policy into practice. Periodic refresher trainings focusing on NCD protocols, simplified reporting formats, supportive supervision, and timely recognition of ASHAs’ work can significantly improve their involvement. Furthermore, community-level engagement campaigns could enhance awareness and encourage participation in screening and follow-up services.[3] Addressing these operational challenges is critical for achieving India’s NCD targets. Strengthening the role of ASHAs through timely incentives, training, and supportive supervision can bridge the gap between identification and continuity of care. This will ultimately improve the outcomes for patients living with NCDs, especially in underserved and rural communities. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.