Non-communicable diseases (NCDs) are long lasting illnesses caused by multiple factors which include genetic, physiological, environmental, and behavioral factors. (1)The foremost NCDs are Diabetes mellitus, cardiovascular diseases, malignancies, and chronic respiratory diseases. Every year, 41 million people die due to NCDs, which account for74% of all deaths worldwide and 17 million premature deaths were due to NCDs, among these 86 percent of deaths were belongs to low- and middle-income countries (LMICs). (1) The main prevalent NCD is cardiovascular disease, which accounts for 17.9 million deaths per year, next to that are cancer (9.3million), respiratory disorders (4.1 million), and diabetes (2.0 million). Among all premature NCD deaths, 80 percent are due to these 4categories of diseases. India is experiencing a rapid health transition with the increasing burden of NCDs which is more than communicable diseases. (2) In India, as per the 2016 statistics, NCDs account for 62% of deaths and 55% of disability-adjusted life years(7).As per the NFHS-5 in India, the prevalence of Diabetes Mellitus in Men and women is15.6% and 13.5 respectively and the prevalence of Hypertension in Men and women is 24.0% and 21.3% respectively.(3) In Andhra Pradesh the prevalence of Diabetes mellitus in men and women is 21.8% and 19.5% respectively, and the prevalence of Hypertension in Men and women is 29.0% and 25.3% respectively.(4) In the Sustainable Development Goals (SDGs) NCDs were included in health goal number 3, i.e., ensure healthy lives and promote the well-being of all at all ages. Of this, target 3.4 is to reduce by one-third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. (2)The NCDs are at the top of all causes of mortality, so there is a necessity to work on the agenda of global health, i.e., SDGs for NCDs, acceptable to both developing and developed countries.(3)The 2030 Agenda for Sustainable development recognizes NCDs as a significant challenge. For NCDs excessive intake of tobacco and alcohol, inadequate physical activity and unhealthy diets are the main risk factors. All these can be modifiable, so that the morbidity and mortality due to NCDs can be reduced .To achieve this reduction an intensive and integrated action at the country level is required.(1) In 2013-2020 WHO developed a Global action plan for the prevention and control of NCDs to support the countries, which consists of nine global targets that have the most remarkable effect on NCD mortality.(4)These targets focus on the prevention and control of NCDs. In 2010 Government of India launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) for the prevention and control of major NCDs by focusing on strengthening infrastructure, development of human resources, health promotion, early diagnosis, management and referral. For the implementation of this programme, establishment of NCD Cells at National, State and District levels and NCD Clinics at District and CHC levels, to provide services for early diagnosis, treatment and follow-up for common NCDs. It provides free diagnostic facilities and drugs for patients attending the NCD clinics. (5) Cardiac Care Units (CCUs) were also set up in identified districts for providing facilities for emergency Cardiac Care. Day Care Centres in the identified districts were setup to provide facilities for Cancer care. The programme was implemented in the country in a phased manner. From 2010 to 2012, the programme was introduced in 21 States in 100 districts. After assessing the implementation of first phase some changes were done in order to strengthen the programme. (5) By March2017, this programme is aimed to be implemented in the entire country. All 36 States/UTs were covered in the programme as on March 2016. Around 298 District NCD Cells and 293 District NCD Clinics were established in the country. Also, there are 103 functional Cardiac Care Units for emergency cardiac care and 64 Day-Care Centres for Cancer care at the District levels in the country.(6)The programmes like National Tobacco Control Programme(NTCP),National Programme for Health care of Elderly(NPHCE),National Programme for prevention and control of fluorosis (NPPCF) National Oral Health programme (NOHP),National Mental Health programme(NMHP),National programme for palliative care(NPPC),National programme for prevention and control of Deafness(NPPCD) were integrated into NPCDCS. In 2021 Non alcoholic Fatty liver diseases (NAFLD) was also integrated into NPCDCS. In Andhra Pradesh NPCDCS Programme was launched in 2010-12 i.e., in the first phase. In Ananthapuramu district programme was launched in 2016. However the programme is running in India for more than ten years it still faces many problems in the implementation of NCD-related health services in primary care .(6) As the sub centres are close to the community, activities conducted at the Sub centre are very important for the implementation of the programme. The present study was undertaken to assess the extent of implementation and enumerate the challenges faced by healthcare providers at the sub centre level. Aims and Objectives 1. To assess the implementation of NPCDCS programme at Sub centre level 2. To enumerate challenges faced by health care providers at sub centre level.

Study Design: Facility based Cross-Sectional Study Study Area: Ananthapuramu district belongs to the Rayalaseema locality of Andhra Pradesh. It is one of the driest places in South India, covering area of 10,205 km2. The Public health System of Ananthapuramu district Compasses 586 Sub centers, 88 PHCs, 44 UPHCs, 15CHCs,2 Area hospital, 1Districthospital, 1 Teaching hospital, 1 Cancer hospital, catering services to the Public under 3 different administrations (i.e. DM and HO, DCHS and Medical Education). Under NPCDCS programme there are 1NCD cell, 18NCD clinics, 1Cardiac care unit are present. In Ananthapuramu there are 5 revenue divisions, under which 88 PHCs are Present. TABLE1: NUMBER OF PHCS UNDER REVENUE DIVISIONS S.no Name of Revenue division Number of PHCs 1 Ananthapuramu 28 2 Dharmavaram 10 3 Kalyandurg 15 4 Kadiri 15 5 Penukonda 20 Total 5 Revenue divisions 88 PHCs TABLE 2: LIST OF SUB CENTRES UNDER SELECTED PHCS S.no Name of PHC Name of Sub Centre 1 Atmakur AtmakurB.YaleruThopuduparthyThalupurMuttalaP.Yaleru Sanapa 2 BukkarayaSamudram BukkarayaSamudramSiddarampuramS.KondapuramVadiyampetaR.Kothuru Janthuluru 3 Rapthadu RapthaduM.B.PalliG.R.Palli Marur BukkacherlaBommeparthi 4 Bathalapalli BathalapalliMalayavanthamMustoorApparacheruvuRamapuramDampetlaObulapuram N.B.Palli 5 Beluguppa BeluguppaVenkatadripalliGangavaramRamasagaramAnkampalli Kaluvapalli 6 Muddinayanapalli MuddinayanapalliEastkodupalliMudigalluManirevuMangalakunta Golla Narayanapuram Kuralapalli Duradakunta Chapiri Mallikarjunapalli 7 Bukkapatnam BukkapatnamBuchaiagaripalliDhupampalli Narasimpalli 8 Nallacheruvu NallacheruvuGorantlavaripalliPanthalacheruvuYarramguntapalliChinnayalmpalliTavalammarri Mallireddypalli K.Pulakunta 9 Gorantla Gorantla BudiliG.G.Palli Singireddypalli PalasamudramMandalapalli Mallapalli R.C.Palli 10 Chilamathur Chilamathur DemakethapalliMaravakothapalli Veerapuram Tekulodu Kodur Kodikonda Kambalapalli Chagaleru Somagatta Total 10 75 Study Tools: A pre tested questionnaire for data collection at the Sub centres was prepared by using NPCDCS guidelines(5) for Sub centres and an article by Anand et al,(24) and then it was modified to the present study settings to include the following data: Section1: 1. Health facilities which are fully functional a. Health facilities with trained human resource b. Health facilities with functional equipment c. Health facilities with stock-out of IEC materials/ consumables Section 2: 1) Activities include: a) Training sessions b) IEC materials display c) NCD screening camps. d) Health awareness camps Section 3: 1) Total Number of Cases of hypertension surveyed up to my study period. 2) Total number of Cases of Diabetes Mellitus surveyed up to my study period. 3) Total number of cases having both Hypertension and Diabetes Mellitus surveyed up to my study period. Section 4: A Pre validated Questionnaire was used to collect the data about challenges of Heath care providers at sub centre level. Study Variable: Data related to Sub centres like Medicines, Equipment, Diagnostics, Health Promotional Activities, Screening camps and Challenges faced by Health care workers at Sub centre level. Ethical Clearance: Ethical clearance was obtained from the Institutional Ethics Committee, Government Medical College, Ananthapuramu, prior to the start of the study. Project number: 13/2020 Data Collection: Data Analysis: Data thus Collected was entered into Microsoft Excel sheets version 2010 and analyzed. All the descriptive data was presented in frequencies, Percentages, bar diagrams and Pie Charts.

1. Demographic distribution Table 4: DISTRIBUTION OF SUB CENTRES ACCORDING TO REVENUE DIVISIONS s.no Revenue division Sub centres Percentage 1 Ananthapuramu 13 17% 2 Dharmavaram 15 20% 3 Kalyandurg 17 23% 4 Kadiri 12 16% 5 Penukonda 18 24% Total 75 100% TABLE5: POPULATION DISTRIBUTION OF SUB CENTRES IN SELECTED PHCS S.no Population Number Percentage 1 <5000 37 49.30% 2 5000-10000 37 49.30% 3 >10000 1 1.40% The sub centres of selected 10 PHCs covered a population of 394892, with each sub centre covering a mean population of 5265.2(range: 2970-13816).Out of 75 sub centres, 37(49.3%) sub centres were covering a population in the range of 5,000-10,000 and sub centres covering a population of less than5000 are 37(49.3%) and only one (1.4%) sub centre covering a population of more than10,000. TABLE6: Age wise distribution of population Age population Percentage <30years 1,86,562 47% >30years 2,08,330 53% Total 3,94,892 100% In the study population 53% were belongs to the age group of <30 years and remaining 47% were belongs to the age group of >30 years. TABLE 7: Gender wise distribution of study population Gender Population Percentage Male 2,00,717 51% Female 1,94,175 49% Total 3,94,892 100% 2. Input assessment: A. Human resources: TABLE8: Staff availability in total sub centres as per NPCDCS guidelines Staff Availability Number Percentage Sanctioned as per the requirement 150 100.00% Filled in position 140 93.33% Vacant 10 6.67% TABLE 9: Sub centres with Staff availability as per NPCDCS guidelines Staff availability Sub centres Percentage All filled 65 86.67% Partially filled 10 13.33% Total 75 100.00% B. Infrastructure: TABLE 10: Distribution of Sub centres withNCD register Maintenance NCD Register Subcentres Percentage Maintained 60 80.00% Not maintained 15 20.00% Total 75 100.00% TABLE 11: Distribution of Sub centres with availability of Glucometer Glucometer Subcentre Percentage Present& Functional 68 90.67% Present & Not Functional 7 9.33% Absent 0 0 Total 75 100.00% TABLE 12: Distribution of Sub centres with Supply of glucometer strips Supply of Strips Sub centres Percentage Regular 6 8% Not Regular 69 92% Total 75 100% TABLE 13: Distribution of Sub centres with availability of Sphygmomanometer Sphygmomanometer Sub centres Percentage Present& Functional 73 97.33% Present& not Functional 2 2.67% Absent 0 0 Total 75 100.00% TABLE 14: Distribution of Sub centres with availability of Weighing Machine Weighing Machine Sub centres Percentage Present& Functional 68 90.67% Present & not Functional 7 9.33% Absent 0 0 Total 75 100.00% Weighing machine is used to measure bodyweight there by Body Mass Index(BMI).Although we have seen weighing machine in all the sub centres, only 68(90.67%) were functional and in remaining 7(9.33%) sub centres weighing machine was not functional. Measuring tape was available in all sub centres of selected PHCs. TABLE 15: Distribution of Sub centres with availability of Stethoscope Stethoscope Sub centres Percentage Present& Functional 66 88% Present& not Functional 9 12% Absent 0 0 Total 75 100% Out of 75 sub-centres 66(88%) were having functional stethoscope and in remaining 9 (12%) sub centres stethoscope was not functional. TABLE16: DISTRIBUTION OF SUB CENTRES WITH SUPPLY OF ESSENTIAL MEDICINES FOR NCDs Essential medicines for NCDs Subcentres Percentage Regular 4 5% Irregular 71 95% Total 75 100% Out of 75 sub centres, only 4(5%) had regular supply of essential medicines for NCDs and the remaining 74(95%) had irregular supply. C. Health education: TABLE17: Distribution of Sub centres with supply of IEC Material IEC Material Subcentres Percentage Present 61 81.33% Absent 14 18.67% Total 75 100 IEC material displaying dietary patterns, self care, importance of regular checkups, adherence to drugs, risk of complications, management of hypoglycemia and need for cessation of smoking and alcohol consumption should be displayed in and around every sub centre. Out of 75 sub centres, IEC material was present in 61(81.33%) sub centres and in remaining 14(18.67%) it was absent. 3. Process indicators: TABLE18: Distribution of Sub centres with display of IEC material IEC Display Subcentres Percentage Displayed 61 81.33% Not displayed 14 18.67% Total 75 100.00% In the assessment we have seen majority of sub centres 61(81.33%) were displayed IEC material in the form of posters and 14 (18.67%) were not displayed. NCD survey being conducted where HCPs at sub centre level visits households to collect information regarding NCDs and creating awareness in the public. This is the only method of giving awareness to the public followed by all HCPs in all the sub centres. No screening and awareness camps were conducted in any of the sub centres. 4. Output indicators: TABLE19:PrevalenceofNCDsinstudypopulation Disease Number(n=1,86,562) Percentage HTN 9480 10.07% DM 8509 9.10% HTNwithDM 987 1.05% Cancer 138 0.07% TABLE20: Prevalence of NCDs in association with gender Name of the disease Number of cases M(n=95,039) F(n=91,523) Hypertension 5016(5.20%) 4464(4.87%) Diabetes Mellitus 4484(4.71%) 4025(4.39%) HTN with DM 591(0.62%) 396(0.43%) Prevalence of Hypertension among men and women were 5.20% and 4.87% respectively, Diabetes mellitus among men and women were 4.71% and 4.39% respectively and Hypertension with diabetes mellitus among men and women were 0.62% and 0.43% respectively. 5. Challenges faced by HealthCare Providers (HCPs) at sub centre level: TABLE21: Distribution of Healthcare providers with training status in conducting NCD camps Training Number Percentage Trained 89 72% Un trained 35 28% Total 124 100% Out of 124HCPs, 89(72%) were trained in conducting NCD camps and remaining 35(28%) were not taken any training. All the HCPs (124) were able to measure blood pressure and Random Blood Sugar (RBS). TABLE22: Distribution of Healthcare providers with Knowledge of pap smear collection Pap smear procedure Number Percentage Aware 6 5% Unaware 118 95% Total 124 100 Out of 124 HCPs, only 6(5%) were aware of procedure of Pap smear collection and remaining 118(95%) were not aware about that. TABLE23: Distribution of Health care providers with supply of Essential medicines Supply of Essential medicines Number Percentage Regular 14 11% Irregular 110 89% Total 124 100% Regarding supply of Essential medicines, majority 110(89%) were not getting regular supply of Essential medicines remaining 14(11%) were getting regular supply of medicines. TABLE24: Distribution of Healthcare providers with frequency of supply of glucometer strips Supply of strips Number Percentage Regular 9 7% Irregular 115 93% Total 124 100% Out of 124 HCPs only 9(7%) were getting the supply of strips and remaining 115(93%) were not getting strips regularly. TABLE25: Distribution of Healthcare providers view on patient’s treatment adherence Treatment Adherence Number Percentage Adhered 84 67.99% Partially Adhered 12 9.6% Not adhered 28 22.5% Total 124 100% Around, 84 healthcare providers (67.9%) said patients had good adherence, 12 HCPs (9.6%) said patients were partially adhered to treatment and 28 (22.5%) said patients were not adhered to treatment TABLE26: Attitude of Healthcare providers towards NCD camps NCD camps Number Percentage Overburdened 117 94% Not Overburdened 7 6% Total 124 100% Out of 124 HCPs, 117(94%) felt overburdened due to NCD camps and, remaining7 (6%) felt comfortable in conducting NCD camps. TABLE27: Distribution of Health care providers with training status on usage of NCD-CD app Training status on usage of NCD-CD App Number Percentage Trained 110 89% Un trained 14 11% Total 124 100% TABLE28: Attitude of Health care providers regarding work beyond schedule time Work beyond schedule time Number Percentage Problematic 117 94% Not problematic 7 6% Total 124 100% Majority of HCPs 117(94%) said that, they felt working beyond scheduled time was problematic and remaining 7(6%) felt it’s not a problem. TABLE29: Attitude of Health providers regarding biometry thrice a day Attitude regarding biometry Number Percentage Problematic 114 92% Not problematic 10 8% Total 124 100% Out of 124 HCPs, majority of HCPs 114(92%) felt problematic to keep biometry thrice a day and remaining 10 (8%) did not felt any problem due to this. All the HCPS are facing technical challenges while using NCD-CD app due to poor internet signals in the field, which is a major problem. HCPs did not get any incentives for the conduction of NCD camps.

The present study was done in75 sub centres of selected 10PHCs, from 5 revenue divisions of Ananthapuramu district. In this study the 75 sub centre of selected PHCs covered an average population of 5265, which was slightly more than the population required according to the revised IPHS guidelines of 2012, where the ideal population for a sub centre was 5000. (11) In the study done by Kashyap et al,(8) the mean population covered by the sub centre was 6909 which is more than the present study. In the present study out of 75 sub centres majority(98.6%) of sub centre covered population below 10,000 and in only one sub centre(1.4%) the population was more than 10,000,which is lower to the study conducted by Kashyap et al,(8) where the sub centres covered population more than 10,000 was 5.6%. The input indicators in the current study showed 93.3% of the sanctioned posts were filled at the sub centre level as per NPCDCS guidelines. These findings are higher than the study done by Lwin et al, (9) in Myanmar which showed that 64% of the sanctioned posts were filled. The study done by Kantinath et al, (10) in Udipi district, Karnataka explained that so many vacant posts were present and this is the important missing link in the implementation of the program. The Isfahan Healthy Heart Program, Iran’’ done by Katayoun Rabiei et al,(11) done in 2009 showed that shortage of human resources acted as barriers for the implementation of the programme. In the present study NCD register was maintained in only 80% of the sub centres which is lower when compared to the study done by Kashyap VH et al, (8) at Belagavi taluka, Karnataka where there was 100% maintenance of NCD register was present. The study done by Pratik Jasani et al, (12) at surendranagar district, Gujarat, showed that 100%maintainance of registers. In the current study glucometer is present in all(100%) of sub centres, out of which 90.67% were functional, which is similar to the study done by Kashyap VH et al,(8)& Pratik Jasani et al,(12) where there was availability of glucometer is 100%,but they did not mention about whether all those were functional or not. In the present study regular supply of glucometer strips was only 8% which is very low than the study conducted by Kashyap VH et al, (8) where it was 100% and the study conducted by Sadhana Meena et al, (13) in rural jaipur, Rajasthan in 2019 where it was 25%. In the present study sphygmomanometer was present in all (100%) sub centres but it was functional only in 73 sub centres (97.3%), which is higher to study conducted by Sadhana meena et al, (13) in rural Jaipur, Rajasthan, where in 2 sub centres (25%) sphygmomanometer was not functional. The study conducted by Kashyap VH et al, (8) the availability of sphygmomanometer was 100% which is similar to the present study. In the current study weighing machine was present in all (100%) sub centres but functional in 68 sub centres (90.6%) which is higher when compared to study done by Kashyap VH et al,(28) where the availability is only 94% of sub centres. In the present study in all (100%) sub centres stethoscope was available but functional only in 88% of sub centres when compared to the study done by Kashyap VH et al, (8) where the availability was only 94%.The availability of materials, medicines & equipment in a study done by Pratik Jasani et al, (12) was only 20%. In the current study referral slips were not available in all the sub centres, which is similar to the study done by Sadhana meena et al, (13). In the study conducted by Kashyap VH et al,(8) the availability of referral slips was 19.4%, which is higher when compared to the present study. Process assessment: In the present study IEC material was present and displayed in 81.3% of sub centres, which is slightly lower to the study done by Kashyap VH et al, (8) where it was 83% and it is higher than the study conducted by Pratik Jasani et al,(12) where it was only 30%. In this study no screening camps and awareness camps were conducted due to Covid pandemic, which is similar to the study done by Sadhana Meena et al, (20) where there was no conduction of screening and awareness camps because of covid pandemic. During the study period only NCD survey was conducted using NCD-CD app and during that survey when they went to households, HCPs were giving awareness about NCDs. Conduction of screening camps was 20% in a study done by Pratik Jasani et al.(12) in the present study health promotional activities were not conducted at the school level which is similar to the findings from a study by Hiromi Kohori- SegawaID et al, (14) in Bhutan. The similarity in findings may be due to both the countries are developing countries and hence the concentration is more on communicable diseases (8) The study conducted by J.S.Thakur et al, (2) at Chandigarh explained that there was a poor focus on health promotional activities when compared to screening camps. Outcome assessment: In the present study >30 years population was 1, 86,562 out of which 9480 were having HTN, the total prevalence of 10.07%, which is high when compared to the study done by Kashyap VH et al, (8) where the prevalence was 4.9%. In the present study the total prevalence of Diabetes Mellitus is 9.10%. which is similar to study done by Kashyap et al,(8) the prevalence of DM was 4.87% which is less when compared to the present study. In the current study the prevalence of DM among men and women was 4.71%&4.39%respectively. According to National Family Health Survey (NFHS)-5: In India the prevalence of DM among men and women was 17.9% &16.9%respectively (8) which is high when compared to the present study, in Andhra Pradesh the prevalence of HTN among men and women was 24.9%&23.2% respectively(9) which is high when compared to the present study, in Ananthapuramu the prevalence of HTN among men & women was 16.8% &14.2% respectively (10) which is high when compared to the present study. The prevalence of HTN& DM in the present study was low when compared to NFHS-5 this could be due to the study was conducted in only one quartile of the year not the entire year. Challenges faced by Health Care Providers (HCPs): In the present study Out of 124HCPs, 89(72%) were trained in conducting NCD camps, which is higher when compared to the study done by Kashyap et al, (8) where only 69.4%ANMs were trained and which is lower when compared to the study done by Lwin et al, (9) in Myanmar which showed that 90% of the appointed staff had been trained in PEN. The low level of trained staff in the present study may be due to the recruitment of the staff on a contract basis. In this district training on conducting NCD camps were given 2 years back only, after that no recurrent training was given. So the staff recruited after that was not trained. Most of the staff was not trained as they may have been recruited recently. Regarding supply of medicines for NCDs, majority 110(89%) were not getting regular supply of medicines NCDs, remaining 14(11%) were getting regular supply of medicines, which is low when compared to the study done by Kashyap et al, (8) where 8 of 36 ANMs (22%) were not getting adequate supply of medicines and they felt that the availability medicines for NCDs at sub centres will improve the follow up care. In the present study at the sub centre level the patients were getting the medicines mostly from the 104 vehicle which visits the every village once in a month. In the present study 94% HCPs felt overburdened due to NCD camps. They felt that due to so many National programs, they are unable to give quality of services which is similar to the study conducted by Kashyap et al,(8)and the study conducted by Marwa Abdel-All et al(32) in which the ASHAs were of the same opinion. The work burden can be reduced by appropriate planning of activities that are done at the PHC and sub centre level. In Andhra Pradesh a new system was introduced in 2020, that is village secretariat, as a part of that volunteers were appointed who belong to that village only. The work of HCPs at the sub centre level can be shared by those volunteers, which can reduce the burden of them. As a part of that community volunteers can give awareness to the public and motivate them to get screened for NCDs. The study also found that Screening is being done using an NCD-CD app which screens the population for both Communicable diseases and non-communicable diseases. Though this is a new approach and helps to screen the entire population, the opportunistic screening of people above the age of thirty years that has been put forward in the National Guidelines would have been a much better approach as it is based on the high-risk population screening strategy. Employing high-risk screening strategy would have helped in the better utilization of the resources. In the present study all the HCPS are facing technical challenges while using NCD- CD app due to poor internet signals in the field, which is a major problem. Only 89% of HCPs were trained about the usage of NCD-CD app. The technical problems acted as barriers for the programme implementation which are in accordance with the findings from a systematic review in China by Hongfei Long et al, (16) in 2018 which explained that excessive dependence on technology as a barrier in engaging Community Health Workers in Non-Communicable Disease (NCD) Prevention and Control. The technical problems could have been overcome if the app was pilot tested prior to the introduction in the field and the staff was adequately trained regarding the usage of the app. An Uninterrupted internet connection could have improved the app functioning. Strengths of the study: As per the best of our knowledge the assessment of this programme at the sub centre level has not been done in our state, so this becomes the first study in our state to assess the lacunae in the implementation of NPCDCS programme. This will be helpful to the policy makers to fill the gaps in implementation of the programme. As the study was conducted among grass root level Health Care Providers(HCPs) the practical problems faced at the field level could be assessed, which can be resolved by discussing with higher officials. Limitations: • Incidence of NCDs could not be assessed as NCD camps were not being conducted at sub centre level during the period of study due to Covid 19 pandemic situation in the country. • As the data was based primarily on NCD survey conducted in the first quartile of the year, when it was still ongoing process/when the entire population was not covered, the prevalence of NCDs might have been under estimated. • As the cancer data was not maintained properly, prevalence of cancer was not assessed. • At the sub centre level percent of patients screened, treated and controlled could not be calculated as data was not available at the sub centre level. • This study did not assess the awareness and perceptions of the community towards the programme. • FUTURE IMPLICATIONS: • Further studies are recommended to assess the implementation of NPCDCS programme at various levels of healthcare, which can give the overall view of the programme functioning along with barriers and challenges faced by HCPs at various levels of health care. • Monitoring and evaluation of the program need to be done periodically. • Studies assessing the awareness and perception of the community towards the programme are recommended. • Studies to be done by taking the entire year data which can correctly estimate the prevalence and incidence of NCDs. RECOMMENDATIONS: • Operational guidelines are to be made available at the state level and district level. • Periodical training sessions to be conducted for the health care providers. • IEC materials to be provided at all the health care facilities to create awareness among public. • Availability of medicines for NCDs at the sub centre level to be done, which increases the compliance of patients. • Conduction of screening camps regularly. • Monitoring and evaluation of the program need to be done periodically. • As the cancer prevalence is increasing special focus on cancer screening and creating awareness should be given more priority. • To reduce the burden of HCPs at sub centre level we can involve the volunteers to create awareness among general public and motivate them to get screened for NCDs.

Some of the sub centres were having partially filled HCPs posts, which disturbs the services. Majority of sub centres were having functional equipment. There was no conduction of screening and awareness camps, only survey was being conducted with NCD- CD app. As the training sessions were not conducted periodically, recently recruited staffs were not trained for the conduction of NCD camps. The HCPs were over burdened, so that they were unable to give quality of services.

1.Non communicable diseases [Internet]. Available from: https://www.who.int/newsRoom/fact-sheets/detail/non communicable-diseases [accessed on 30-10-2022]. 2.Thakur JS, Paika R, Singh S. Burden of non communicable diseases and Implementation challenges of National NCD Programmes in India. Medical journal Armed forces India. 2020 Jul 1; 76(3):261-7. 3.Government of India, MOHFW, National Family Health Survey(NFHS-5) 2019-21India fact sheet available from5. http://rchiips.org/nfhs/ NFHS5 Reports/India.pdf.[accessed on 12-11-2022] 4.Government of India, MOHFW, National Family Health Survey (NFHS-5) 2019-21 State fact sheet –Andhra Pradesh available from http://rchiips.org/nfhs/ NFHS5/AP-Fact sheet.pdf[accessed on 12-11-2022] 5.National Programme for prevention & Control of Cancer, Diabetes, Cardiovascular Diseases & stroke (NPCDCS) : National Health Mission Available from: https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=1048&lid=604[accessedOn 30-10-2022] 6.Pati MK, Swaroop N, Kar A, Aggarwal P, Jayanna K, Van Damme W. A narrative review of gaps in the provision of integrated care for non communicable diseases in India. Public Health Reviews. 2020 Dec; 41(1):1-6. 7.Director General of Health Services, Ministry of Health and Family Welfare, Government of India, Indian Public Health Standards (IPHS), Guidelines for Sub Centers; Revised 2012. Available from: http://www.nhm.gov.in/images/pdf/ guidelines/iphs/iphs-revised-guidlines-2012/sub-centers.pdf.[accessed on 12-11-2022] 8.Kashyap VH, Shivaswamy MS. Assessment of implementation of the national programme for the prevention and control of cancer, diabetes, cardiovascular diseases, and stroke at sub centers of Belagavi taluka: A cross-sectional study. Indian Journal of Health Sciences and Biomedical Research (KLEU). 2019 Jan 1; 12(1):21. 9.Aye LL, Tripathy JP, Maung Maung T, Oo MM, Nwe ML, Thu HM, Ko K, Kaung KK. Experiences from the pilot implementation of the Package of Essential Non-communicable Disease Interventions (PEN) in Myanmar, 2017-18: A mixed methods study. PloS one. 2020 Feb 18; 15(2):e0229081. 10.Pattan shetty SM. A study on implementation of national programme for prevention and control of cancer, diabetes, cardiovascular diseases and stroke in Udupi district, Karnataka. International Journal of Community Medicine and Public Health. 2018 Jun; 5(6):2384. 11.Rabiei K, Kelishadi R, Sarrafzadegan N, Abedi HA, Alavi M, Heidari K, et al. Process evaluation of a community-based program for prevention and control of 75 non- communicable disease in a developing country: The Isfahan Healthy Heart Program, Iran. BMC Public Health. 2009 Feb 12;9:57 12.Jasani P, Nimavat J, Joshi J, Jadeja Y, Kartha G. A study on evaluation of non- communicable disease control programme in Surendranagar district. Int J Sci Res. 2015; 4:685-8. 13.Meena S, Rathore M, Gupta A, Kumawat P, Singh A. Assessment of National Program for Prevention and Control of Cancer, Diabetes, CVD and Stroke (NPCDCS): An observational study in rural Jaipur, Rajasthan. Journal of Family Medicine and Primary Care. 2022 Jul 1; 11(7):3667-72. 14.Islam SMS, Purnat TD, Phuong NTA, Mwingira U, Schacht K, Fröschl G. Non‐Communicable Diseases (NCDs) in developing countries: a symposium report. Glob Health. 2014 Dec 11; 10(1):81. 15.Abdel-All M, Abimbola S, Praveen D, Joshi R. What do Accredited Social Health Activists need to provide comprehensive care that incorporates non communicable diseases? Findings from a qualitative study in Andhra Pradesh, India. Hum Resour Health. 2019 Oct 22; 17(1):73.