Urban Health – Non-Communicable Diseases Project


Urban Lalitpur is relatively new – with the city growing by a third in the previous decade (2001-2011).  The HBM hospital has pioneered various rural community health and development programmes over the past forty years – but has not reached out to the urban population of Lalitpur so far.

We propose a “Healthy Lalitpur” approach to building community level screening and health promotion among specific targeted neighbourhoods with a special focus on addressing non-communicable diseases such as diabetes, hypertension while integrating practical palliative care services.


  1. High touch – High tech
  • Targeted neighborhoods (10,000 population to start with) covered by volunteer enumerators – basic database set up
  • Volunteer Health visitors recruited
  • Basic skills training of health visitors done and volunteer management and retention equipping done for HBM supervisory staff
  • Specific home-visit plans developed and implemented with maximum ‘human touch’ components to see results-based changes in families
  • Dynamic tablet-based HMS helps health visitors optimize field visits and communicate with families about upcoming activities

  1. Continuum of care approach
  • Screening of high risk life-styles – and targeted behavior modification
  • Screening for detection of existing NCDs
  • Treatment and follow up of NCDs
  • Leveraging HBM hospital facilities such as Diabetes clinic, Laboratory, Palliative care mobile team and ward, In patient back up
  • Dove-tailing with government National Health Mission NCD outreach approaches

  1. Outcomes focussed
  • Tracking of individuals with NCD risks / existing NCDs to see concrete changes in reducing risk factors, increase health-care use, monitor medication adherence and show positive health outcomes
  • Developing dynamic geo-spatial intelligence system to help guide health visitors maximize field visits (in collaboration with Low Cost Effective Care unit of CMC Vellore) which can be shared with other urban health outreaches

For more details please contact:

Dr. Sheba Eicher, Medical Superintendent, HBM Hospital, Civil Lines, Lalitpur UP 284403    9323712065    Sheba.Eicher@eha-health.org   Lalitpur@eha-health.org