Abstract
One of the leading risk factors for the development of DCS is hypertension, which is a global public health problem and causes the burden of heart disease, stroke and kidney failure, as well as contributes to premature death and disability, and therefore remains relevant in particular for the population of low-and middle-income countries and weak health systems. In Kazakhstan, in accordance with the State program for health development «Densaulyk» for 2016-2019 of the Republic of Kazakhstan, as part of the modernization and priority development of PHC, a gradual transition from dispensary to management of major chronic diseases at the outpatient level has been implemented through the introduction of a disease management program (DMP), which includes the fight against behavioral risk factors in patients covered by dynamic monitoring, achieving full interaction between patients and medical workers, developing self-management skills in patients. Work continued on the implementation of integrated disease management programs based on diagnostic and treatment protocols at all levels and monitoring with the Central coordinating role of PHC workers. When fully implemented in clinical practice, DMP allows optimizing the interaction between medical professionals and patients on joint planning of disease management strategies, patient training and further involvement in the treatment process, evaluating its results, solving psychological and economic problems, and self-management in order to further develop measures to improve the quality of life.
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