Integrated disease management programme

Comprehensive integrated care, self-care, patient support and education, training for healthcare workers to improve the quality of care

This team works to facilitate and support the strengthening of the capacity and competencies of the health system for the integrated management of chronic noncommunicable diseases (CNCDs) and their risk factors. The team follows the Chronic Care Model, as described below. .

The Chronic Care Passport is a patient-held card used by patients with CNCDs such as diabetes, hypertension and chronic obstructive pulmonary disease.

  • Passport to healthy lifestyle
  • Chronic Care Passport
  • Chronic care passport for professionals
  • Healthy Living for Patients
  • Innovative Care for Chronic Condition