Hospitals and Primary Health Centers (PHCs) need to bridge the gaps of health service delivery in regard to Non-communicable diseses (NCDs) such as hypertension,  diabetes, Chronic Respirstory Diseases (CRDs) and others, in their catchment population as well as the health status of an individual.

Seven R’s action model

Bhutan was one of the first countries globally to adopt the WHO Package of Essential Non-communicable disease (PEN) interventions programme and scaled it up nationwide in 2013-2014. A PEN clinical audit conducted in 2016 indicated several shortfalls in care practices for hypertension, diabetes and other chronic diseases. There was little follow up by the facility, medicine refills were not monitored carefully, leaving patients to manage alone often with poor result. Patients with chronic illness such as stroke and cancer  as well as others needing palliative care (home-bound and terminally ill individuals) were not reached. 

To address this MoH with support from WHO introduced people-centred care in four districts of Punakha, Tsirang, Wangdue and Zhemgang. These districts transformed the service delivery for NCD patients by using seven strategic actions of care known as the SEVEN R’s. 

• Robust team
• Recall and reminder
• Refill
• Responsive referrals
• Reach out services
• Reliable supply
• Real time mentoring and supportive supervision

This module will discuss the 7R’s components of PEN-HEARTS (SCC)  in detail.

You will also learn about task-sharing/shifting among teams of personnel with different backgrounds such as community health workers, nurses, physicians, dentists, nutritionists, pharmacists and others in delivering efficient and effective care. We will provide real examples of people-centred  services in piloted districts (Punakha, Tsirang, Zhemgang and Wangdue) that have succeeded in improving NCD control.

Module I is divided into four sessions:

• Section I: Robust Team Building
• Section II: Refill, Recall and Reach out
• Section III: Responsive referral
• Section IV: Real-time mentoring and supervision

Objectives

At the end of this module, learners will be able to 

1. Build teamwork for provision of PEN HEARTS services in your health facilities
2. Improve clinic workflow
3. Use of protocol based NCD management to standardize practice and care
4. Ensure continuity of care through people centered referral and follow-up care
5. Train and ensure the facility is running smoothly
6. Institute good governance and accountability for health services by developing a good patient monitoring system