A Model of Cost and Time-Effective Disease Screening for

Non-Communicable Diseases in India

Nibras K. Thodika

, Srujan Janagam

, Smitha Thomas Kaniyampady

, Arkalgud Ramaprasad

1,3 b

Anupama Shetty

and Chetan Singai

1,4 c

Ramaiah Public Policy Center, Bengaluru, India

Narayana Health, Bengaluru, India

University of Illinois, Chicago, U.S.A.

Ramaiah University of Applied Sciences, Bengaluru, India

{srujan.janagam, smithathomas.kaniyampady, anupama.s.dr}@narayanahealth.org

Keywords: Non-Communicable Disease Screening, Mobile Health Technologies, Point-of-Care Technologies.

Abstract: Background: India has the largest burden of the NCDs globally. Screening and identification of clusters with

the common risk factors are crucial for early detection, prevention, and control at both individual and

population levels. Objective: This study documents a model of cost and time-effective disease screening for

NCDs. The model uses a combination of mobile health clinics-based point-of-care diagnostic technologies.

The model, for its easy-to-use, cost and time effective operation, should be scalable as a tool for community-

based disease screening and population level NCD surveillance. Method: The study documents the materials

and processes of NCD screening camps conducted in Bangalore, India. A time and motion study analysis and

cost analysis were undertaken to establish the time and cost effectiveness. Results & Discussion: The Study

found out a baseline time and cost components for a camp based NCD screening strategy using the mHealth

tools and mobile health facilities. This reinforces the potentials of integration of the NCD screening into the

public primary health care centres for effective scaling up and achievement of surveillance as well as

monitoring and evaluation of the NCD prevention and control programs in the country.

1 INTRODUCTION

This paper presents a model for population-based

screening for non-communicable diseases (NCD) in

India based on a combination of mobile health

clinics-based point-of-care diagnostic technologies

and mHealth applications. It describes the context of

NCD in India, the technology used in screening

camps, the data from the camps, a framework to

conceptualize the application, and conclusion about

generalizing the model.

1.1 Non-Communicable Disease

Burden and Response in India

The demographic transition in the low- and middle-

income countries has been accompanied by

https://orcid.org/0000-0001-9115-6382

https://orcid.org/0000-0003-1551-6854

https://orcid.org/0000-0002-7037-6033

increasing health risks in the form of NCD burden

(OMS, 2011; Shah & Mathur, 2010). Majority of the

low and middle-income countries have devoted

considerable attention to communicable diseases as

against NCDs. This is increasing the burden on their

health care systems and ultimately on the quality of

life in these countries (Kroll et al., 2015). India has

the largest burden of NCDs globally (Menon et al.,

2014). The disease burden is expected to worsen due

to the rapid urbanization, accompanying lifestyle

changes, and inadequacy in health system

preparedness (Prakash Upadhyay, 2012). The disease

burden in the country also poses the need for scalable

and affordable methods for NCD prevention and

control that can be expanded into the remote and rural

parts of the country. The National Programme for

Prevention and Control of Cancer, Diabetes,

Cardiovascular Diseases and Stroke (NPCDCS) was

312

Thodika, N., Janagam, S., Kaniyampady, S., Ramaprasad, A., Shetty, A. and Singai, C.

A Model of Cost and Time-Effective Disease Screening for Non-Communicable Diseases in India.

DOI: 10.5220/0010202103120319

In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 312-319

ISBN: 978-989-758-490-9

launched by the government to combat the risk

through strategies such as surveillance, early

diagnosis, and universal availability of treatment at

primary, secondary and tertiary levels of health

facilities (Ministry of Health and Family Welfare,

Government of India, 2017). Population-based

screening as part of comprehensive primary health

care has been recommended for the strategic

management of the disease. However, in contexts

such as India, it has been difficult to implement such

measures in a sustainable way.

1.2 Prevention and Control of NCDs

through Surveillance

NCDs have multiple causes, the combined effects

from which lead to a disease rate in the population.

Estimates from habit and risk factors are needed to

plan public health interventions and clinical

programmes (Kontis et al., 2014). It has been

identified that interventions to prevent and treat

NCDs at the earlier stages are cost-effective (Ministry

of Health and Family Welfare, Government of India,

2017). Integrating the NCD screening and diagnosis

at existing primary healthcare centres has been

suggested (World Health Organization, 2010).

However, operational issues persist in terms of

implementing population-level screening, especially

in resource-limited settings (Deepa et al., 2011). This

requires scalable and cost-effective models of

population-based screening of NCDs in various

regions in the country with divergent ground-realities.

Screening and identification of clusters with common

risk factors are crucial for early detection, prevention,

and control at both individual and population levels

(Ahmed et al., 2009) to reduce morbidity and

mortality. Innovative methods using cutting-edge

technologies to enhance screening capabilities have

been on the rise. They include non-laboratory-based

diagnostics, point-of-care technologies, mobile health

clinics. and mHealth applications in the pursuit of

achieving access and scale-ups (Bertoncello et al.,

2020; Gaziano et al., 2008; Malcolm et al., 2019;

Pandya Ankur et al., 2014). Apart from their

screening capabilities, the methods are considered

effective vehicles for information and awareness-

raising strategies as well (Bertoncello et al., 2020).

However, challenges persist on the field in terms of

their cost-effectiveness and broadening access to

them. This demands scalable methods that consider

issues of cost-effectiveness, access, and scalability

(Subramanian et al., 2018) and can be

institutionalized as part of the public health care

systems.

1.3 Objective

This study documents a camp-based population

screening model tested for NCD surveillance in India.

The model is a combination of mobile health clinics-

based point-of-care diagnostic technologies and

mHealth applications. The model ensures cost

effective NCD screening. For its easy-to-use, cost and

time effective operation, the model should be scalable

as a tool for community-based disease screening and

population level NCD surveillance using community

health resources. Integrating this into the public

health care systems should provide individual and

population level insights on NCD risk factors on a

routine basis at primary care centres. In this respect,

the study will set the baselines regarding the

materials, tools, and human and financial resources

incurred for the same. It will also compare them with

the existing standards available and contribute to

improving the existing NCD prevention and control

strategies.

2 METHODS AND MATERIALS

The study will describe the method and materials

utilized during the population-based NCD screening

camps conducted in Bengaluru, India. Using the time

and cost related data from the mobile health camps, it

will undertake time and motion study and cost

effectiveness analysis to understand and analyse the

uniqueness of the model, explore the scope for future

improvements, and provide learning for existing

practices.

2.1 NCD Screening Camps

The NCD screening camps were conducted in the city

of Bengaluru, Karnataka, India as part of the

Harnessing Oncological Preventive and Early

detection services (HOPE) program. The HOPE

program, as a population-based opportunistic

screening program for underserved populations,

aspires to improve awareness of oral and breast

cancer, initiating early detection through appropriate

technologies, and creating a continuum of follow-up,

further investigations, and curative services for

relevant cases. The program recognises the need for

lifestyle modification and behaviour change to

manage NCDs. It therefore focuses on creating and

spreading awareness about oral cancer, breast cancer,

and other NCDs amongst the general population.

Taking into consideration the shortage of health care

human resource in the country, all the devices and

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313

software taken on are simple. The screening is

conducted by a trained staff who do not necessarily

have to be from a medical/paramedical background.

The staff are trained on use of point-of-care devices,

mHealth technologies, interpretation of results, and

basic counselling of respondents.

The program aims to reach semi-urban and rural

populations as well as low income groups who would

not have access to routine screening and diagnosis for

NCDs. This is achieved through a screening

procedure that includes NCD screening (blood

pressure, SPo2, blood sugar, body mass index,

Haemoglobin, and vision testing), along with the

one-on-one counselling at the end of the screening

process, as well as scheduled periodic follow-up with

identified high-risk cases. A mobile Mammography

Bus is part of the screening camps conducted across

urban and rural regions in the state of Karnataka,

India (including Bengaluru). It makes use of software

applications with integrated medical devices,

available on offline basis to enable capture of clinical

data, data management, remote monitoring, and

evaluation of data. Using systematic documentation,

training, and special referral protocols, dedicated

follow up of cases is done by a separate team that

helps track cases across locations. In the long run, it

aims at training frontline healthcare workers from the

public sector. Also, creating awareness of risk factors

is emphasised in all the screening camps. Apart from

screening camps, the awareness sessions are also

conducted in schools and colleges. It has been

conducted in various settings such as factories,

educational institutions, and community living

spaces.

The list of activities undertaken during the camps

are as follows in their respective order:

Registration/Consent form filling, height and weight

measurement, MAC/Hip/Waist measurement, Pulse-

Oximeter reading, six-lead ECG, Blood pressure, HB

and blood sugar test, vision test, and explanation of

results with reference scale to the beneficiary.

The data collected using the model are

demographic, medical history, community risk

assessment, physical and behavioural risk factors,

habit history and physical measurements following

the WHO STEP guidelines(NCDs | STEPS Manual,

2002.).

2.2 Materials and Resources

The device kit being used by the trained staff (Figure

1) includes the following devices:

• 6 lead ECG: Used to collect the 15 secs ECG

record which is then interpreted using the

Artificial Intelligence tools based on the

Glasgow algorithm

• Digital BP Device: Used to collect Blood

pressure reading. It operates on

oscillometric method with options for

manual reading as well

• Glucometer: Used for measuring blood

glucose level, either random or fasting. A

single drop of blood needs to be drawn from

the individual by means of a small prick on

their finger

• Haemoglobinometer: used to measure the

hemoglobin level, also measured from a

drop of blood

• Digital stadiometer: used to measure height

• Digital weighing scale: used to measure

weight

• Tablet loaded with NCD screening software

application: for data entry purposes and inference

of results.

Figure 1: Device kit used for Screening.

All devices in the kit have been approved by

standards control bodies. The methodology of

operating the device and interpreting results is

straightforward and undemanding. The output from

the software application is colour-coded enabling the

healthcare worker to easily make an inference.

The data collected through the application can be

broadly classified into the following groups:

1. Socio-demographic details: for following up

and monitoring the program

2. Past Medical History: to identify newly

detected cases, understand management of

existing cases

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3. Community based risk assessment: risk

profiling is conducted in line with the

protocol adopted by the National Health

Mission

4. Habit History: behavioural aspects and risk

factors known to directly impact onset of

NCDs

5. Vital Parameters: to understand the current

health status of the beneficiary

More than sixty-five variables are collected. The

number of variables is higher for women as breast and

cervical cancer screening are also done.

The screening process involves history taking,

risk assessment, performing tests and counselling

based on the results. The data collected using a

mobile application are stored in a local mobile

database. When the internet is available this local

database is pushed to the server database using

application interfaces. The data is populated from the

server database to the dashboard using the Angular

and Java programming languages.

Taking into consideration the large number of data

variables collected and tests performed, it is

necessary to optimise the process workflow to ensure

that quantity was increased without denting the

quality. A time and motion study was undertaken for

this purpose.

2.3 Time and Motion Analysis

The time and motion study intends to set a baseline

that can be used for future application of the presented

model on a larger scale. The analysis used data from

the screening camps conducted in 3 NCD mobile

camps conducted in Bengaluru, India. Data from the

screening of a total of 70 individuals are considered.

The data was recorded by observing the time taken

for each designated activity individually. The

activities are scheduled according to the order of data

to be entered in the mobile application being used for

documentation. The study analysed two person-

device kits combinations. (i) 2 resource persons and 2

kits, as well as (ii) 3 resource persons and 2 kits. The

process chart along with observed timings using the

second combination has been illustrated in Figure 2.

The differences in the outcomes are explained in the

results of time and motion analysis.

Figure 2: Time and Motion Study Results.

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2.4 Cost Analysis

The overall cost incurred for the screening program

was recorded. The average screening cost was

derived using the average number of screening that

could be done in a month, considering the time

observed in the study. Costs incurred for human

resources payments and other consumable resources

have been factored for calculating total costs.

3 RESULTS

3.1 Time and Motion

The results of the time and motion study are

illustrated in Table 1. It details the activity-wise

duration for screening process, parallel activities if

any, and the number of personnel involved at each

step. The total duration of each screening activity was

found to be 430 seconds. When the tolerance time of

45 seconds is added the total screening, time is 475

seconds i.e. 8 minutes approximately. This is

including the vision screening, without which the

duration taken was 5 minutes 56 seconds for one

screening using one kit. 10 screenings can be done

using one kit; hence two kits can do up to 20

screening in the specified time frame. The results

were achieved when 3 personnel were involved in the

screening. When compared with the combination of

two kits and two personnel, the results also showed

that optimal time utilization was achieved when 3

personnel and 2 kits were used for the screening.

Thus, the latter combination is considered for further

analysis.

3.2 Cost

The NCD screening model is a minimalistic, low

resource model. The operational expenditure of the

model comes down to the human resource cost of the

team (Rs. 48000/Month and Rs.16/screening) and the

consumables required for conducting the tests

(Rs.34/screening) namely, cotton swabs, needles for

pricking, blood glucose and haemoglobin testing

strips to mention a few. This model relies on other

stakeholders, such as the community partner or

organising partner, to bear the cost of transport.

Therefore, the latter costs have not been factored.

The optimal performance of a team of 3 members

would be to conduct 20 camps a month screening at

least 150 people at each camp. The cost for screening

per person would be Rs. 50 (0.68 USD). This includes

follow up of high-risk cases at least 3 times.

Table 1: Results of Time and Motion Study Personnel-Wise.

Session Sl. No Activity Duration Parallel Activity Personnel In

Wor

Step-1 Registration/Consent for

40sec

Step-2 Hei

ht and Wei

Measuremen

18sec

Step-3 MAC/Hip/Waist Measuremen

25sec

Total Time For 1

staff 1 min 23sec

Step-4 Pulse Oximete

10 secs

Step-5 Easy ECG 52 secs Details to be

updated in Tablet

(1-min)

Step-6 Blood pressure apparatus 40 secs

Total time for 2

staff 1 min 42 sec

Step-7 HB and Blood Suga

1 min 20 sec

(80 sec)

Details updated

in Tablet

(30sec)

Step-8 Vision test (If done) 2 mins

Step-9 Print Results + Explanation

with reference scale

45 secs

Total time for 3

Staff 4 min

Total Duration

430 Seconds (7

Minutes 16

seconds)

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4 DISCUSSION

This study documents a camp-based population

screening strategy for NCD risk factors. The cost,

time, and human resource factors involved in the

model were documented and analysed. These factors

are critical for wide-scale operational feasibility of

the disease screening and thus have implications in

addressing the disease surveillance for NCDs in the

country.

The study documents a baseline for the resource

requirements for the population-level NCD screening

for risk factor assessment. It identifies its uniqueness

in terms of non-requirement of the medical

professionals for screening. Trained community

workers or volunteers can contribute to the human

resource requirements in the model which throws

open possibilities of operationalizing routine

screening in resource constrained conditions. This is

achieved through the utilization of a combination of

point-of-care and mHealth technologies woven

together into an efficient process.

While the study could not compare the cost with

existing standards in the Indian context due to the

non-availability of data (apart from Amarchand et al.

2015 which identified below 1 USD per-screening

without collecting blood pressure and sugar levels), it

provides a baseline for research and

operationalization of the screening activities on

similar lines. The study found out the costs for human

resources and consumables are below 1 USD.

International comparisons are consumer side

payments which has been documented as 4 USD in

Kenya (Subramanian et al., 2018) and as 3.95 USD

per person identified when an all-inclusive NCD

screening was integrated into existing HIV screening

in South Africa (Golovaty et al., 2018).

The cost analysis in the study only considered the

human resources and other consumable costs only

since the other costs for the presented model were

provided by the community. The study thus, was not

able to account for the other costs, especially

infrastructure and other fixed costs. However, the

model presented collects a lot of important data

including the blood pressure, blood glucose level and

ECG etc. and should provide a solid baseline for

wide-scale operationalization.

Also, the time taken for the disease diagnosis and

screening has a significant impact on the behavioural

trends of the patient population especially in the

context of low- and middle-income countries such as

India. Time taken for Out-Patient Department (OPD)

and their impact on the health seeking behaviour has

been studied. It was found out that the longer waiting

time and affordability significantly impact the health

seeking behaviour among the target population.

Lower waiting times at OPDs for instance, results in

higher satisfaction rate among patients (Aswar et al.,

2014). The time motion study results provided show

the very little time required for the screening.

Monitoring and evaluation of the NCD

interventions are crucial for learning and

improvement. Evolving sustainable systems for

surveillance aligned to the national health programs

is one of the way forward (Krishnan et al., 2011). In

this context, integrated disease surveillance has

become crucial in deciding and planning strategies for

NCDs especially in the wake of Covid-19 (Mathur &

Rangamani, 2020) which has exacerbated the

vulnerabilities due to NCD risk factors (Gopalan &

Misra, 2020). The need for implementation and

operational research on the disease screening has

become ever more critical.

Figure 3: Ontological framework of the NCD screening model.

Functions Data Setting Instruments Resources Outcome

Identification Determinants Individual Questionnaire Tools/Devices Efficient

Collection Socio‐Economic Household ClinicalExamination mHealth Affordable

Curation Income Community BiochemicalTests ImagingTechnology Effective

Analysis Urban/Rural Institutional GIS Accessible

Interpretation Demographic Services

Application Age EHR

Feedback Gender SMS

Literacy SocialMedia

RiskFactors Models

Physical HealthCareCenter

Behavioral MobileHealthClinics

Biochemical PointofCare

HumanResources

CommunityHealthWorkers

Volunteers

[informationfrom

]

[of]

[NCDSurveillance]

[using]

[for]

[settingthrough]

A Model of Cost and Time-Effective Disease Screening for Non-Communicable Diseases in India

317

As such, the documented model along with its

baseline figures regarding the operational details

could be useful for the integration of the monitoring

and evaluation of NCD programs with the primary,

secondary, and tertiary health care centres especially

in the rural areas. It has been found that integrating

the NCD screening and awareness components into

the existing primary health care system is the way

forward for its cost-effectiveness (Amarchand et al.,

2015). The WHO PEN recommends using the

technology supported solutions for scaling up of

disease screening for risk factors using person-

oriented risk factor screening(World Health

Organization, 2010).

Modelling future disease trends is a useful tool for

policymakers so that they can allocate resources

effectively and implement policies to prevent NCDs.

Future research will allow real policy interventions to

be tested; however, better surveillance data on NCDs

and their risk factors are essential for research and

policy (Webber et al., 2014). The screening process

facilitates collection of data that can be deployed for

modelling and risk prediction.



We frame the overall assessment of the model

presented by the paper in the form of an ontological

framework in Figure 3. It lists the dimensions and

elements of the aspired NCD screening strategy. The

assessed model undertakes functions of collection,

interpretation, application, and feedback on a real-

time basis and collects data pertaining to all elements

in the Data dimension of the framework which is

based on the WHO STEP Manual. In terms of Setting,

while the model was tested in institutional settings it

can be scaled up into other settings as well. It used all

the instruments listed including questionnaires,

clinical examination and biochemical tests using

mHealth devices, Point-Of-Care Technologies. While

the model has proved to be efficient and affordable in

terms of time and cost, other aspects of the outcomes

needs to be further researched.

While the lack of extensive comparative analysis

and the resulting inability to provide uniform

baselines are limitations, the study provides insights

into the operational issues of NCD risk factor

surveillance. It adds evidence regarding the scope for

integrating screening into the existing public health

system for routine and informed decision making.

5 CONCLUSIONS

This paper systematically documents the NCD

screening process followed by a population-based

screening program. It sets an operational baseline in

terms of the cost and time for the camp-based

population NCD screening. The process was analysed

for their uniqueness in terms of time and cost

effectiveness in the context of their scalability and

applicability for large scale NCD surveillance in low-

and middle-income countries. The analysis and

discussion have been framed in the form of an

ontology which illustrates the existing and future

potentials of the surveillance models in the NCD

scenario.

ACKNOWLEDGEMENTS

Authors acknowledge the contribution of Mr.

Harikrishnan S in the undertaking of the time and

motion study used in this paper.

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