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Chronic noncommunicable Disease Management Program

In order to form joint responsibility for health with the involvement of the person himself/herself and the management of chronic noncommunicable disease aimed at reducing morbidity, complications and mortality of the population, within the framework of the State Program for the Development of Healthcare “Densaulyk” for 2016-2019, the Ministry of Health of the Republic of Kazakhstan is working to strengthen primary health care with the introduction of disease management programs based on evidence-based medicine.

The introduction of the DMP is dictated by the need for serious transformations in the prevention and control of chronic noncommunicable diseases, in increasing the joint responsibility of patients for their health, improving the interaction of medical personnel and the use of all available resources aimed at preventing possible complications or aggravation of conditions.

DMP is a program aimed at reducing healthcare costs and improving the quality of life of people with chronic diseases by preventing or minimizing the consequences of the disease through integrated care.

At the same time, DMP is a system of coordinated medical interventions and communications for groups of patients with conditions where self–help/self-management efforts can be made. Such a program enables individuals, together with other health care providers, to manage their disease and prevent complications.

International experience and various approaches in the implementation of the DMP were discussed at the level of the Ministry of Health of the Republic of Kazakhstan with international consultants. It was decided to develop and implement a disease management program based on evidence-based medicine, increase public awareness of health issues and joint responsibility for the health of citizens between the state, employees and citizens themselves to address approaches to social modernization and further strengthen health reforms.

5 chronic noncommunicable diseases management programs are being implemented in the activities of the Presidential Hospital: 1. diabetes mellitus (DM), 2. coronary heart disease (CHD), 3. arterial hypertension (AH), 4. bronchial asthma (BA), 5. chronic obstructive pulmonary disease (COPD).

Disease management programs as a new form of prevention and community outreach

“We must seriously take up prevention and improve the quality of primary health care. With well-organized preventive work, diseases can be prevented at an early stage. Therefore, it is necessary to introduce a set of national health monitoring programs for target population groups in Kazakhstan”.

(Message of the President of the Republic of Kazakhstan - Leader of the Nation N.A.Nazarbayev to the people of Kazakhstan “Strategy “Kazakhstan 2050” - a new political course of the established state”)

In his annual message to the People of Kazakhstan, the President designated primary health care (hereinafter referred to as PHC) as the main priority in healthcare. In the Message of the President of the Republic of Kazakhstan – “Strategy “Kazakhstan 2050” - a new political course of the established state”, the Leader of the Nation also reflects the importance of directions in improving medical care at the primary level.

In 2013, the Ministry of Health of the Republic of Kazakhstan launched a project for the implementation of disease management programs (hereinafter referred to as the DMP).

Within the framework of this project, work has begun in two pilot regions (Pavlodar and North Kazakhstan regions) on three diseases: diabetes mellitus, arterial hypertension, and chronic heart failure. (Order of the Ministry of Health of the Republic of Kazakhstan dated April 01, 2013 “On the implementation of the chronic noncommunicable Diseases Management Program for in pilot regions” #211). One of the significant conditions for the effectiveness of the disease management program is to support the interaction between the doctor and the patient in order to jointly plan an individual disease management strategy.

Now, only a few are familiar with this kind of programs, where self-management and self-help are the key conditions. So what exactly is a DMP?

Let’s begin with, that the DMP includes the management of chronic noncommunicable diseases, (hereinafter referred to as CNCD). Today, CNCD remains one of the most urgent problems of modern healthcare, being the leading causes of high premature mortality and disability of the population of developed countries. Their development is explained by the impact of many risk factors, the main of which are gender, age, smoking, hypertension, overweight, elevated blood sugar, alcohol abuse, low physical activity (R.C.Brownson, 1998). According to many epidemiological studies, the role of the above factors in the development of cardiovascular and other chronic noncommunicable diseases is proven and indisputable (R.G.Oganov, 2007).

Accordingly, the prevention of risk factors for the development and progression of CNCD is an important area of work of medical professionals, especially at the PHC level. According to the WHO European Region, CNCD are the main cause of mortality, morbidity and disability worldwide, including in the Republic of Kazakhstan. This circumstance makes the problem of the CNCD especially relevant for Kazakhstan.

CNCD is a number of chronic diseases, including cardiovascular diseases (CVD), oncological, chronic respiratory diseases, mental disorders, diabetes.

One of the main directions of prevention is also medical examination. The effectiveness of dispensary for diseases remains one of the important problems of modern healthcare today. Judging by the facts given above: about the problems and shortcomings of the preventive service in Kazakhstan, we can say that medical examination, especially in the form in which it is currently carried out, is ineffective. In this regard, it is necessary to look for new forms of prevention and work with the population with chronic noncommunicable diseases. One of these forms are DMP.

According to the definition of the American Disease Management Association (DMAA), Disease Management is a system of coordinated interventions and communications in order to protect the health of the population with conditions in which the patient’s own efforts to protect health are essential.

Disease management is provided by the following components:

1) process of identifying groups of patients that need disease management;

2) organization of assistance in the process of disease management based on reliably measured data of the patient’s current condition;

3) model of practical cooperation of the patient with doctors and other medical service providers (nursing staff /patient care managers/, clinical pharmacologists, social workers, volunteers);

4) teaching the patient for health self-management (may include primary prevention, behavior modification programs, compliance monitoring);

5) current and final analysis, evaluation and planning;

6) regular feedback (may include in-depth conversations with the patient, doctor and support services in order to correct the “health plan”).

The process of DMP implementation includes the following stages:

1) Identification of patients.

One of the main tasks of PHC workers will be to identify patients with pathologies that are selected as part of the pilot.

2) Questionnaire and invitation to participate in the DMP.

The questionnaire consists of several questions, the main purpose here will be to obtain information about the patient’s data and how familiar he is with the DMP, whether he/she wants to participate in this program. In the invitation to participate in the DMP, he/she shall once again explain the advantages of his/her participation in the Program, what the patient is entitled to within the DMP, as well as his/her duties. After that, the contract is concluded.

3) Patient training.

At this stage, the health schools of PHC organizations will be involved.

4) Organization of contact with the primary care physician.

Here the doctor will be assigned a certain list of duties: what he/she shall control within the framework of patient management.

5) Organization of the multidisciplinary group work.

The approximate composition of the group: general practitioner/GP, cardiologist, endocrinologist, dietitian or trained nursing staff, specialist of the HLS, nurse for counseling and training patients, social worker, etc. The list of responsibilities of the group members includes training, medical care and treatment, development of internal rules, holding events and monitoring.

The purpose of the monitoring will be to assess the effectiveness of the DMP in comparison with traditional treatment, as well as to determine the level of satisfaction with the programs.

DMP were successfully used in a number of countries: Finland, where the world’s highest mortality rate from coronary heart disease was registered (1971). 1972-1977 pilot implementation of DMP was introduced;

- Holland. 2000 - diabetes mellitus;

- Germany. 2001 - pilot implementation of programs on type 2 diabetes mellitus, lung cancer and coronary heart disease. 2003 - breast cancer program;

- Canada. 2003 - CHF, COPD, diabetes mellitus.

In 2017, 4 city polyclinics of Pavlodar and 3 city polyclinics of Petropavlovsk took part in the pilot for the DMP introduction in the Republic of Kazakhstan. The pilot implementation of DMP includes the following chronic noncommunicable diseases: diabetes mellitus, arterial hypertension and chronic heart failure.

In the context of the regions, the distribution of DMP was carried out as follows:


city polyclinic #1 – diabetes mellitus;

city polyclinic # 2 - chronic heart failure, arterial hypertension;

city polyclinic # 4 - diabetes mellitus;

city polyclinic # 5 – arterial hypertension.


city polyclinic #1 - diabetes mellitus;

city polyclinic # 2 - chronic heart failure;

city polyclinic # 3 – arterial hypertension.

Multidisciplinary teams for the DMP implementation were created in each polyclinic, and regional coordinators for the implementation of DMP in each pilot region were identified.

The Department for improvement of Primary Health Care of the Center for Healthcare Standardization of the Republican Center for Health Development carries out the DMP implementation in pilot regions. The implementation work is carried out with the support of the Canadian Society for International health consulting company. The coordinating body is the Department of Organization of Medical Care of the Ministry of Health of the Republic of Kazakhstan.

Thus, a change in behavior, adherence to the therapeutic and preventive advice of the medical team, control and self-control of the disease can lead to a significant improvement in the health indicators of the region at the same time, without requiring large economic investments, such as heart transplantation, and other invasive methods of treatment that medical workers are forced to resort to in cases of unmanageable disease. The introduction of disease management programs contributes to better indicators, but requires efforts not only of the patient, but also of the entire healthcare system.

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