Guide de Prévention Primaire et de Prise en Charge des Maladies Chroniques Non Transmissibles et de leurs Facteurs de Risque

Objectives

The guide provides an integrated primary-health-care framework for preventing, screening and managing chronic non-communicable diseases (NCDs) in Madagascar, aiming to reduce premature illness, deaths, complications, household impoverishment and productivity losses associated with chronic conditions.[1][2][3]It covers cardiovascular and cerebrovascular disease, diabetes, obesity, chronic respiratory disease and cancers, while recognising their shared and modifiable risk factors.[4][2][3]

• Prevent behavioural, environmental, socioeconomic and metabolic risks, particularly tobacco use, harmful alcohol consumption, unhealthy diets, physical inactivity, pollution, hypertension, diabetes, overweight, obesity and dyslipidaemia.[2][5][6][7]
• Promote population-wide prevention, including among children, while recognising non-modifiable risks such as age, sex and family history.[3][5]
• Increase awareness, early detection and early management through health education, risk-factor screening, systematic measurement of clinical parameters and biological testing.[1][8][9]
• Prevent hypertension through healthier diets, lower salt and alcohol intake, tobacco reduction, physical activity, weight management and stress reduction, while providing lifelong treatment and complication prevention for diagnosed patients.[10][11][12]
• Reduce diabetes-related morbidity and mortality, improve quality of life and prevent metabolic and degenerative complications through glycaemic control, lifestyle support, treatment and screening for complications.[13][14][15]
• Address obesity as a chronic progressive condition through weight management, management of complications and improved quality of life.[16][17]
• Reduce chronic respiratory disease through early recognition of chronic cough, asthma and chronic obstructive pulmonary disease, reduction of tobacco and household-pollution exposure, symptom control and exacerbation prevention.[18][19][20]
• Support early cancer recognition, referral, pain control and palliative care, with quality of life prioritised when illness threatens survival.[21][22][23]

Implementation

Implementation centres on routine primary care in basic health centres, delivered by health workers and supported by community health workers, referral facilities and specialist services.[1][3][24][25]The guide combines health promotion, individual counselling, clinical screening, risk assessment, treatment, follow-up and referral, using an integrated response because major NCDs share risk factors and require related interventions across health-system levels.[3][26][27]

• Deliver health education through waiting-room discussions, individual counselling, practical demonstrations, posters, leaflets, audio-visual materials and locally available communication channels.[28][26][24]
• Apply the BIPER consultation sequence through a respectful confidential welcome, directed history-taking, systematic measurement, overall risk assessment and advice, followed by an agreed next appointment.[26][25]
• Assess behavioural risks, family history, living and working conditions, harmful habits and diet; measure vital signs, weight, height, body mass index, blood pressure and, where appropriate, waist circumference and biological parameters.[25][9]
• Screen adults for hypertension during consultations and undertake more frequent checks for people with additional risk factors; use blood-glucose and lipid testing for people with symptoms or relevant cardiovascular risks.[9][27]
• Provide dietary, physical-activity and behaviour-change counselling that offers practical, culturally appropriate alternatives rather than simple prohibitions.[29][24]
• Strengthen tobacco and alcohol risk reduction through counselling, behaviour-change support, enforcement of relevant legislation, community engagement and referral for specialised support where needed.[7][30]
• Mobilise community health workers to inform communities, identify risky behaviours, encourage healthy diets and activity, refer exposed people, and work under health-worker training, support and supervision.[24][25]
• Manage chronic conditions at the appropriate level of care, including lifestyle measures, medicines, therapeutic education, adherence support and routine review; refer emergencies, severe disease, diagnostic uncertainty or cases requiring specialist investigation.[11][12][14][15]
• Provide urgent referral and initial stabilisation for hypertensive emergencies, suspected stroke, severe asthma, diabetic emergencies and serious respiratory or cancer presentations.[31][32][33][34][22]
• Equip basic health centres for screening and emergency support with blood-pressure and blood-glucose devices, glucose-testing supplies, infusion equipment, catheters, intravenous fluids and selected medicines; the source identifies these resources but does not specify costs or allocations.[35][32][36]
• Coordinate care through health centres, hospitals, referral centres, specialist departments and cancer centres; contributors include Ministry of Public Health entities, regional health services, specialist hospitals, the Association Malgache pour le Développement et l’Amélioration du Diabète, the World Health Organization and PIVOT.[21][22][37]

Clinical follow-up is specified for several conditions, including periodic blood-pressure checks, diabetes review, obesity reviews, asthma assessment and observation after emergency treatment.[29][15][38][39]However, the supplied material does not establish a document-wide monitoring and evaluation framework, programme indicators, reporting system, surveillance arrangements, budgets, financing sources, implementation timetable or formal accountability mechanism.[1][3][40][41]

Monitoring & Evaluation

Monitoring is primarily embedded in clinical screening, risk assessment, treatment review and scheduled follow-up rather than in a document-wide performance-management system. The material does not specify a formal monitoring and evaluation framework, programme-level indicator set, reporting schedule, surveillance architecture, audit process or named accountability body.[1][3][40]

• Measure blood pressure routinely from age 18 during consultations, check it at least annually, and increase monitoring for pregnancy, hormonal treatment and people with additional cardiovascular risks.[29][9][10]
• Confirm hypertension through repeated readings over consultations, monitor treatment response against blood-pressure targets, and assess adherence and possible orthostatic hypotension during follow-up.[42][11][43][12]
• Screen for diabetes among symptomatic people and those with relevant risk factors, using blood or urine glucose testing; confirm diagnosis through specified fasting, random glucose, oral glucose-tolerance or glycated-haemoglobin thresholds where available.[9][36]
• Monitor diabetes through capillary glucose measurement, clinical review, annual assessment for complications and glycated haemoglobin every three months where feasible.[44][14][15]
• Assess cardiovascular risk by combining modifiable and non-modifiable risk factors and considering the probability of a fatal cardiovascular event over the following 10 years.[27][45]
• Measure weight, height, body mass index, waist circumference and vital signs systematically to identify obesity, central obesity and associated risk.[25][9][16]
• Maintain continuity of care by setting a subsequent appointment at the end of consultations and using counselling and follow-up to support long-term prevention of vascular and other complications.[26][24]
• Monitor acute conditions at facility level, including two-hour blood-pressure observation for uncomplicated hypertensive surges, hourly vital-sign monitoring where stroke referral is delayed, and observation after acute asthma treatment according to severity.[31][32][39]
• Review asthma through symptoms, vital signs, pulmonary examination, peak expiratory flow where available and validated control questions; schedule review intervals according to asthma severity and treatment response.[34][46][47][20]
• Assess chronic respiratory disease through clinical review, spirometry where feasible and breathlessness classification; review respiratory function annually for chronic cough.[19][48]
• Monitor obesity through regular long-term reviews, including three-monthly follow-up, nutritional assessment, complications and quality-of-life considerations.[17][49][38]
• Supervise community health-worker activities, identify risk factors through community diagnosis and monitor the distribution and use of educational materials, although no standard reporting metrics are defined.[28][25]

Costing & Financing

No explicit monetary costing, budget, financing source, allocation, funding gap, resource-mobilisation plan or economic assumption is provided across the supplied material.[1][14][40]The guide nevertheless identifies substantial service-resource requirements for prevention, screening, referral, emergency care and chronic disease management.[25][35][44]

• Provide health education and communication resources, including audiovisual materials, leaflets, posters, practical demonstration materials and community-health-worker support.[28][24][25]
• Equip basic health centres with blood-pressure and blood-glucose measurement devices, infusion equipment, catheters, intravenous fluids and selected emergency medicines for stroke care.[35][32]
• Supply diabetes-testing equipment and consumables, including glucometers, reagent strips, lancing devices, lancets, gloves and sharps-safety boxes.[36][44]
• Ensure access to medicines and clinical supplies for hypertension, diabetes, asthma, chronic respiratory disease, emergency stabilisation and palliative pain management, although no prices or procurement arrangements are given.[43][14][39][50]
• Support referral capacity to hospitals, specialist services, oncology centres and diagnostic facilities, including spirometry, imaging, laboratory testing and pathology where indicated.[18][21][22][51]
• Recognise that prolonged treatment and care for chronic non-communicable diseases may be costly for households, exhaust resources, contribute to poverty and reduce productivity; no monetary estimate or financial-protection mechanism is specified.[1]