THE NON-COMMUNICABLE DISEASE SYSTEM ASSESSMENT TOOL FOR IDENTIFYING PRIORITIES FOR INVESTMENT Benjamin Chan Simone Wahnschafft Meng Meng Xu The findings, interpretations, and conclusions expressed do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because the World Bank encourages the dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licences, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Attribution Please cite this work as follows: Chan, Benjamin; Wahnschafft, Simone; Xu, Meng Meng. 2024. The Non-Communicable Disease System Assessment Tool for Identifying Priorities for Investment. Washington DC: World Bank. © 2024 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW, Washington, DC 20433 Telephone: +1-202-473-1000 www.worldbank.org All rights reserved. I THE NON-COMMUNICABLE DISEASE SYSTEM ASSESSMENT TOOL FOR IDENTIFYING PRIORITIES FOR INVESTMENT BENJAMIN CHAN SIMONE WAHNSCHAFFT MENG MENG XU MARCH 2024 II Table of Contents Acknowledgements IV Executive Summary 2 1 Introduction: Burden of Non-Communicable Diseases and Investments in Their Management 4 1.1 Growing Burden of Non-Communicable Diseases 4 1.2 Gaps in Management of NCDs 5 1.3 World Bank Projects Supporting Improved NCD Management 7 2 Conceptual Frameworks and Design of the NCD Assessment Tool 12 2.1 Scope of Assessment Tool 12 2.2 Conceptual Framework for the Assessment Tool 13 2.2.1 WHO Operational Framework for Primary Health Care 13 2.2.2 Chronic Care Model 14 2.3 Development of Best Practices for Strengthening NCD Management 15 2.4 Framework for Reporting Results on NCD Management 21 3 Conducting the Assessment 25 3.1 Gathering Information for the NCD Assessment 25 3.1.1 Preparation for Assessment 25 3.1.2 Desk-Based Review 25 3.1.3 Key Informant Interviews 28 3.1.4 Site Visits 29 3.2 Synthesis and Interpretation of Results 32 3.2.1 Evaluation Metric 32 3.2.2 How to Use the Tool 32 Annex 1 – Technical Details of Best Practices 33 III Acknowledgements The report was written by core authors Benjamin Chan, Simone Wahnschafft and Meng Meng Xu, with contributions from Cameron Feil, Latifat Okara and Bomy Yun. The project was conducted and managed under the guidance of Jaime Bayona Garcia and Renzo Sotomayor. We would like to thank the invaluable input from reviewers Mamka Anyona, Lerly Luo, Jeremy Veillard, Shuo Zhang and Mickey Chopra. Special thanks to copy editor Jane Coutts. Cover photo credits: iStock (GlobalStock, MJ Prototype, Vitapix). We gratefully acknowledge the Access Accelerated Trust Fund for the generous funding support for the study and report. IV List of Figures Figure 1. Leading Causes of Death by Disease Group 5 Figure 2. Number and dollar amount of new World Bank health sector projects with NCD-related activities, 2016-2020 7 Figure 3. Regional distribution of World Bank health sector projects focused on NCDs, 1980-2020 8 Figure 4. World Bank Project Cycle 11 Figure 5. WHO Operational Framework for Primary Health Care 14 Figure 6. Chronic Care Model (CCM) 16 Figure 7. Indicators to Monitor PHC Results for NCD Management Along a Disease Continuum 23 List of Tables Table 1. Leading Causes of Death by Disease Group 9 Table 2. Number and dollar amount of new World Bank health sector projects with NCD-related activities, 2016-2020 18 Table 3. Regional distribution of World Bank health sector projects focused on NCDs, 1980-2020 24 Table 4. World Bank Project Cycle 27 Table 5. WHO Operational Framework for Primary Health Care 30 V LIST OF ABBREVIATIONS BP Blood pressure CCM Chronic Care Model COPD Chronic Obstructive Pulmonary Disease DALY Disability-adjusted Life Year DCP3 Disease Control Priorities 3 EMR Electronic Medical Record IPF Investment Project Financing LDL Low-density Lipoprotein LMIC Low- and Middle-income Country MOH Ministry of Health NCD Non-communicable Diseases PEN Package of essential NCD interventions PforR Program-for-Results PHC Primary Health Care PHCPI Primary Health Care Performance initiative QI Quality improvement SARA Service Availability and Readiness Assessment SDG Sustainable Development Goal SDI Service Delivery Indicators assessment SPA Service Provision Assessment UHC Universal Health Coverage UNICEF United Nations International Children’s Education Fund WHO World Health Organization 1 Executive Summary Non-communicable diseases (NCDs) impose an increasingly heavy health and economic burden on low- and middle-income countries (LMICs). Three of four deaths worldwide are attributed to NCDs, with hypertension affecting more than a third of adults in LMICs. Prevalence of diabetes in Africa has more than doubled from 2000 to 2014. One explanation for these trends is that improved management of infectious diseases over time has led individuals living longer and developing conditions such as cardiovascular disease, diabetes and cancer. Increasing tendencies towards unhealthy diets, decreased physical activity and greater alcohol use are also contributors. In response to these challenges, the UN made one of the Sustainable Development Goals to reduce NCD mortality by one-third by 2030. The World Bank’s investments in NCD management have increased steadily, with the greatest increases occurring in the past decade. The World Bank spent more than $7 billion on NCD-related projects from 1980 to 2020, half of which on projects begun between 2016 and 2020. World Bank NCD- related projects exist in all regions, including Sub-Saharan Africa, and are often structured as Investment Program Financing (IPF) or Program for Results (PforR). It is anticipated that demand from countries for investments into managing NCDs will continue to grow, and World Bank staff will need to respond by helping countries to identify relevant ideas for improving health systems, priorities for investments, and indicators for monitoring and evaluation. A team at the World Bank has developed this “Non-Communicable Disease System Assessment Tool for Identifying Priorities for Investment” (or “NCD System Assessment Tool” for short), to assist task-team leaders (TTLs) in the preparation, monitoring, and/or restructuring of NCD- related projects. Drawing on the WHO’s Operational Framework for Primary Care, the tool examines health system performance across 14 strategic and operational levers which together drive improvement in the delivery of services and health outcomes. The team also used the Chronic Care Model, developed by the McColl Institute in the USA and used by many ministries of health worldwide, to provide more detail in the definition of strong health system performance, focusing on existence of decision supports, delivery system design, health information systems and patient self-management. The tool’s main focus is on preventing and managing NCDs through a primary health care (PHC) approach, but it also examines the availability of some hospital-based NCD services. The tool evaluates health systems against 43 best practices—practical policies, plans, programs or structures—recommended by global consensus panels or proven to be effective in meta- analyses, systematic reviews and Cochrane reviews. These best practices provide detail for the two frameworks described above. The tool looks for evidence of a strategic approach to managing NCDs, such as: strengthening primary health care, a plan with targets and timeframes for improving NCD care; policies on unhealthy behavior such as smoking, alcohol or unhealthy foods; universal health coverage for core drugs, tests and medical procedures; and intersectoral cooperation to address determinants of health. At the operational level, it searches for things such: a multi-disciplinary primary care team; availability of core equipment and supplies, information systems to track clinical data at each encounter and produce reports on quality indicators to providers and planners and a well-defined system of accountability or supervision. At the most granular level, it examines the model of care and workflows in primary care for items such as: clear, consistent procedures for screening, a process to ensure all recommended clinical practices are adopted, timely adjustment of medications, process to bring in patients lost to follow-up; triaging and intensive management of high risk patients; community outreach and home visit services, patient education and self-management supports. To ensure best practices are adopted, the tool also searches for decision support tools, quality improvement teams and examples of successful improvement projects. 2 The tool searches for past measurements of quality indicators and outcomes to inform priorities for investment, and gaps in the ability to measure quality point to areas where investment in health information systems is required. While many countries measure incidence, prevalence and utilization statistics for NCDs, these generally yield little information about health system performance, so the tool looks for data on indicators for the percentage of target populations that receive certain recommended tests and achieve certain desired outcomes. For example, for hypertension, it searches for percentage of adult population screened at the recommended intervals, the percentage of hypertension patients receiving treatment and the percentage attaining control of their disease (blood pressure less than 140/90). The tool also searches for information on long-term complications of NCDs, patient experience, wait times, and variations in these indicators by geography or socioeconomic factors. The tool is intended to do a rapid assessment based on document reviews, key informant interviews and site visits conducted over a brief period. Evaluators examine documents such as health system plans, policies, previous studies or reports on outcomes, past surveys of facilities, patients or health workers. Key informant interviews include people in the ministry of health, professional associations, non-governmental organizations and civil society. Site visits include primary health care facilities in urban and rural sites, regional health offices and hospitals. The end product of the assessment is a list of options for investment. The recommended options focus on areas where a best practice has been adopted only partially or not at all. Ministries of health review the list to decide which of the highlighted areas to prioritize for further investment. As such, the list can be used by the task team leader and client government as they design the new Bank project. 3 1. Introduction: Burden of Non-Communicable Diseases and Investments in Their Management 1.1 Growing Burden of Non-Communicable Diseases Once considered a problem reserved for high-income countries, the burden of non-communicable disease has escalated dramatically in low- and middle-income countries in recent decades. Worldwide, three of every four deaths (74%) are attributable to NCDs (WHO, 2022(a)). The prevalence of diabetes in Africa has more than doubled, from 3.1% in 2000 to 7.8% in 2014 (Atun et al., 2017), while hypertension affects more than a third of all adults in low- and middle-income countries (LMICs) (Bearney et al., 2019). These countries are also deeply affected by premature mortality caused by NCDs; among deaths in LMICs due to cardiovascular disease, 50% were deemed premature (occurring before age 70 years), compared to 20% in high-income countries (HICs) (Frieden and Bloomberg, 2018). Although NCDs were absent from the Millennium Development Goals, these trends have prompted their inclusion in Sustainable Development Goal 3.4, to reduce premature non-communicable disease mortality by one-third by 2030. One reason for the rise in NCDs is the epidemiological transition from infectious diseases to chronic conditions. Worldwide infant mortality rates have decreased by more than half since 1990 (UNICEF, 2015), driven by improved immunization, post-partum care and management of childhood infectious diseases. Preventive measures reduced the incidence of malaria by 28% from 2000 to 2020 (WHO, 2021(a)), while increased availability of anti-retroviral therapy markedly improved HIV survival. The reduction in relative burden of infectious diseases which tend to affect younger persons leads to increased life expectancy and greater likelihood of developing NCDs later in life. As a result of these trends, the number of deaths from infectious diseases such as respiratory infections, diarrhea, malaria, TB and HIV has decreased from 2000 to 2019, while deaths from ischemic heart disease, stroke, chronic obstructive pulmonary disease, diabetes and cirrhosis of the liver have increased (see Figure 1). 4 Figure 1. Leading Causes of Death by Disease Group. Source: WHO, 2020(a) Another contributor to rising prevalence of NCDs is changing health behaviors, including unhealthy diets, physical inactivity, alcohol and tobacco use. Several shifts in low- and middle- income countries are increasing exposure to these risk factors. Marketing of unhealthy foods over the last two decades has contributed to an almost two-fold increase in consumption of ultra-processed foods in middle-income countries, and a doubling of consumption of high-sugar processed beverages in low- and lower-middle-income countries (Global Nutrition Report, 2020). Rapid urbanization and labor-reducing technologies have been associated with decreased work- and household-related physical activity (Boakye et al, 2023) Global per capita alcohol consumption increased from 5.9 to 6.5L per year from 1990 to 2017 (Manthey et al., 2019). In many LMICs, the increased consumption found is believed to have been influenced by increases in income level over time making alcohol more accessible (Manthey et al., 2019). Fortunately, global tobacco use has declined steadily from 25.7% in 2000 to 18.4% in 2020 (WHO, 2019), with declines occurring in all continents, likely due to gradual expansion of anti-tobacco policies. However, high levels of men (31.7%) were still smoking in 2020, compared to 5.2% of females (WHO, 2019). 1.2 Gaps in Management of NCDs To face this rising epidemic of NCDs, it is imperative to slow down its progression at multiple stages, through primary, secondary and tertiary prevention. Primary prevention aims to prevent disease from occurring by improving health behavior or preventive services like immunization. Once the patient develops a disease, secondary prevention aims to control the disease and slow down damage to the body. After damage has occurred, tertiary prevention offers more sophisticated, costly treatments to limit further disability. 5 A strong health care system emphasizing primary care can ensure these three levels of prevention are available. Policy interventions like taxation and restrictions on marketing are important tools to discourage use of smoking, alcohol and unhealthy foods, but primary health care (PHC) also has a role, through counselling individuals on healthy lifestyles. The role of PHC is critical for secondary prevention, first by ensuring timely identification of patients with disease (i.e., screening) and, once patients are diagnosed, by prescribing medication and other treatments and monitoring and offering counselling on living with their disease. Primary care’s role in tertiary prevention lies in identifying complications and making appropriate referrals for specialized services delivered by specialists or in hospital. However, it is far more beneficial to the patient and health system to manage diseases before they require tertiary prevention. A strong health care system should also have adequate infrastructure and capacity, which is geared to non-communicable disease management. At the core of a strong PHC system is universal coverage for basic health services, adequate infrastructure, such as reasonably equipped clinics in good physical condition, human resources including doctors, nurses and other health professionals, a reliable supply chain for drugs and supplies, responsible governance and management and dependable health information systems. These elements need to be tailored to include NCD management. Equipment specific to NCDs is needed, such as blood pressure monitors and lab analyzers for blood sugar or cholesterol. Essential drug lists need to include medications for hypertension, diabetes and other chronic conditions. Health systems also need well-trained staff who understand NCD practice guidelines, and interdisciplinary teams with counsellors trained on diet, healthy lifestyle, mental health and living with a disease. Health information systems need to capture data on NCDs, calculate NCD indicators and provide decision support. Providers need to be held accountable for following best practices for safe, equitable and effective NCD management. Unfortunately, there are wide gaps in screening, treatment and control of NCDs, leading to major complications for many patients. In a meta-analysis of population surveys in 44 low- and middle-income countries, prevalence of hypertension among adults was 17.5% based on blood pressure measurements in the sample. Of that group, 73.6% had been screened (blood pressure taken previously), 39.2% were diagnosed with hypertension, 29.9% received treatment, and 10.3% had achieved blood pressure control (Geldsetzer et al., 2019). Results were worst in sub-Saharan Africa. Similarly, in one population survey in South Africa, 10.1% of the adult population was found to have diabetes based on abnormal blood tests or history (Stokes et al., 2017). However, among these individuals, 45.4% had never been screened, 14.7% were screened but undiagnosed, 2.3% were diagnosed but untreated, 18.1% were treated but uncontrolled. Overall, only 20% achieved control of their blood sugar with proper treatment. As a result of these care gaps, complication rates from NCDs are rising rapidly. From 1990 to 2019, the incidence of stroke increased by 70%, and deaths from stroke by 43%, with the bulk of the global stroke burden residing in LMICs. Diabetic retinopathy, the leading cause of blindness among working age adults, now affects 103 million people worldwide and is projected to increase by 55% globally by 2045, with the largest increase anticipated in the Pacific, Middle East and North African regions. Furthermore, there are major gaps in the infrastructure and capacity of health systems needed to manage NCDs well. A 2019 WHO country survey on capacity to manage NCDs noted that 52% of countries lacked national guidelines for all four major NCDs, over a third of countries lacked national programs for breast and cervical cancer, and 47% of countries reported that they could not ensure that basic technologies for NCD management (measurement of height, weight, blood glucose, blood pressure and cholesterol) were generally available in primary health facilities (WHO, 2020(b)). One review of capacity at first-referral level hospitals in eight low-income countries found widespread gaps in basic drugs, equipment and supplies to treat NCD complications like diabetic ketoacidosis and hypertensive crisis (Gupta et al., 2020). Deficient clinical skills in providers are also widespread. In facility surveys using clinical vignettes 6 to test provider knowledge in nine sub-Saharan African countries, only 50% of providers could correctly diagnose diabetes and only 57% could prescribe the appropriate treatment (Gatti et al., 2021). These factors combined lead to overall poor quality of care. The evidence-based services found in clinical practice guidelines for NCDs are implemented less than half the time in LMICs (Kruk et al., 2018). 1.3 World Bank Projects Supporting Improved NCD Management Management of non-communicable diseases, particularly in primary care, is an increasingly common theme in World Bank health-system strengthening projects. Between 2016 and 2020 there was a sharp increase in investment to address NCDs in projects, with an average of $135 million USD per year in new loan commitments dedicated to strengthening non-communicable disease prevention and or management (see Figure 2). About half (48%) of projects in the World Bank health sector portfolio approved from 1980 to 2020 with NCD-related activities were approved in 2016 or later. The bulk of these projects were in middle-income countries in Eastern and Central Europe, Southeast Asia and Latin America and the Caribbean (see Figure 3). More recently, project financing has expanded to lower-income countries. In fiscal years 2021 and 2022, the World Bank approved 40 health, nutrition and population projects, 19 (48%) of which included NCD-related activities. Seven of them (36%) were in the Sub-Saharan Africa Region (Villar Uribe et al., 2022). Figure 2. Number and dollar amount of new World Bank health sector projects with NCD-related activities, 2016-2020. Source: derived by authors from World Bank Operations Portal. 7 Figure 3. Number and dollar amount of new World Bank health sector projects with NCD-related activities, 2016-2020. Source: derived by authors from World Bank Operations Portal. These World Bank non-communicable disease projects address a wide range of topics including health promotion, screening and treatment, using different lending instruments. Table 1 lists recent examples of World Bank NCD projects. The most common conditions examined include diabetes, hypertension and cancer screening. Many projects are structured as a Program-for-Results (PforR) where disbursements of funds are linked to governments’ achievements in implementing anti-tobacco regulations, health promotion, persons screened and diagnosed for disease, or treated according to guidelines and attaining control of their disease (e.g. blood pressure or blood sugar). Other projects use the Investment Project Financing (IPF) approach, to finance specific activities such as including NCD-related drugs or tests in universal health coverage or establishing clinical practice guidelines or training programs for providers. Often, specific NCD-related components are embedded in the program development objectives and key performance indicators of a project (see Box 1 for an example). Box 1. Example of NCD-related project development objective (PDO) and key performance indicators (KPIs) drawn from a World Bank project. Protecting Vulnerable People Against Non-communicable Diseases Project (P133193) Project Development Objective To contribute to: (i) improving the readiness of public health facilities to deliver higher quality NCD-services for vulnerable population groups and expanding the scope of selected services; and (ii) protecting vulnerable population groups against prevalent NCD risk factors. Indicators • Percentage of eligible women aged 25-64 with at least one cervical cancer screening visit according to defined protocols. • Percentage of eligible population with hypertension under treatment. • Percentage of eligible adults with hypertension diagnosed in regions with the poorest health outcomes 8 Table 1. Examples of Recent World Bank NCD Projects NUMBER TITLE COUNTRY TYPE STATUS NCD TOPIC Primary Health Care Active P173168 Ghana PforR Disbursements linked to hypertension screening. Investment Program (2022-) Disease Prevention and Active Improve screening for hypertension, diabetes, P175023 Armenia IPF Control Project (2021-) cervical cancer. Disbursement based on provision of A1c test PHC Quality Kyrgyz Active for diabetes, drug coverage for diabetes, P167598 PforR Improvement Program Republic (2019-) hypertension, anemia, online NCD training modules, NCD practice guideline development. Health System Active Improve cervical, breast and colon cancer P152799 Strengthening and Türkiye IPF (2016-) screening. Support Project Closed Disbursement based on hypertension patients Moldova Health P144892 Moldova PforR (2014-22) attaining BP control, increased availability of Transformation Project anti-hypertension drugs. Additional Financing Improved health promotion, NCD surveillance, P133187 to Health System Uzbekistan PforR Closed practice guidelines and physician training on Improvement Project NCDs Disbursements linked to cervical cancer Primary Health Care Active screening, screening and follow-up of high P163721 System Strengthening Sri Lanka PforR (2018-) cardiovascular risk patients, provision of mental Project health counselling. Health System Active Performance-based financing for screening and P166783 St. Lucia IPF Strengthening Project (2018-) treatment for hypertension and diabetes. Disbursements linked to treatment to target Strengthening Universal Active P148435 Costa Rica PforR for diabetes and hypertension, colon cancer Health Insurance (2016-) screening. Increase number of PHC facilities providing NCD Protecting Vulnerable Active services, colon cancer screening, school obesity P133193 People Against Non- Argentina IPF (2015-22) programs, regulations on tobacco marketing, Communicable Diseases sodium reduction policies. Active Disbursements linked to diagnosis and P148017 Health Sector Support Morocco PforR (2016-) treatment of diabetes and hypertension. Disbursements linked to treatment of diabetes Active and hypertension according to protocols, and Health System P164382 Samoa PforR (2020- attainment of control of disease; screening for Strengthening Program 2027) cardiovascular disease; participation of children in school health promotion activities. Sub-Saharan Europe and Central South Asia Latin America and Middle East and East Asia and Pacific Africa Asia the Caribbean North Africa PforR: Program for Results. IPF: Investment Project Financing. Source: derived by authors from World Bank Operations Portal. 9 Bank projects generally require intelligence gathering regarding gaps in the system and opportunities for investment, particularly during the initial phases of project preparation but also while projects are in progress. Figure 4 outlines the typical project cycle. During the identification phase, there are discussions with the country on priorities for investment, which are followed by creation of a concept note. Once this is approved then additional details about the project such as scope, duration, interventions, measurement and evaluation framework and cost are developed in a project appraisal document (PAD). Figure 4. World Bank Project Cycle. Source: World Bank. At present, there is limited information available to objectively determine areas for investment for non-communicable disease management. Many countries employ STEPS surveys which interview random samples of the population and take physical measurements and lab tests. A STEPS survey can offer information on the care cascade (a way of looking as care as connected steps that cover a client’s needs from the beginning). It can show the true prevalence of disease, the rate of under- diagnosing, under-treatment of those diagnosed and failure to control disease in those being treated. This information contributes mainly to the results section of the Primary Health Care Monitoring and Evaluation framework, not the strategic and operational levels. The WHO NCD Capacity Survey is also a useful source of information across multiple sections of the framework. However, because that survey is based on self-reported data, it might lack the detail needed to validate responses or specify improvement approaches. In particular, the survey has relatively little information on models of care. Many countries have commissioned standardized facility surveys, such as the Service Provision Assessment (SPA), Service Availability and Readiness Assessment (SARA), and Service Delivery Indicators (SDI) assessment. Such surveys can provide information about equipment, facilities, drugs and staffing but lack detail on policy interventions, models of care and national health information capabilities. 10 To address the growing emphasis on non-communicable diseases, this assessment tool has been developed to help the country requesting financing and World Bank task team leaders to objectively identify the greatest system gaps in how a country is managing NCDs. This in turn will provide an evidence base to determine what the priorities for investment should be, which then can be incorporated into the design of the Bank project. The tool also allows existing information on NCDs to be pooled in a structured, organized way and can supplement it with more specific questions asked interviews and site visits. The result is a more comprehensive and holistic view of the country’s NCD management. This tool is intended to be applied as part of developing the concept note or the project appraisal document to gather objective information on care gaps and identify priorities and interventions needed. Ultimately the assessment should help ensure barriers to delivering good care have been recognized and considered. Once Bank projects have been launched, barriers to progress may arise. This tool could be used mid-term to identify them and options for changing activities to overcome them. Barriers can be assessed at any time, but the mid-term review brings greater scrutiny and presents a window of opportunity to adjust project activities. This tool, or portions of it, could be applied to help identify some of these barriers and possible activities to emphasize. 11 2. Conceptual Frameworks and Design of the NCD Assessment Tool This section describes how this tool identifies gaps in health-system capacity that could be targeted for investment in a World Bank project. The tool examines health system capacity and infrastructure, work processes and models of care, the policy environment and information systems, and collates existing data on current performance on patient quality measures. 2.1 Scope of Assessment Tool Non-communicable diseases (also known as chronic diseases) are not transmissible between persons. They result from a combination of genetic, physiological, environmental and behavioral factors and tend to be of long duration. Managing these diseases requires regular follow-up to monitor changes in them and adjust treatment accordingly. WHO identifies four major groups of NCDs: cardiovascular, diabetes, respiratory and cancer. Cardiovascular disease includes coronary artery disease, stroke and heart failure. Common respiratory conditions include asthma and chronic obstructive pulmonary disease (COPD). The most common focus of managing them in low- and middle-income countries is screening for hypertension, diabetes and cancer. There are many other NCDs, including: • Mental illness • Conditions affecting other body systems, such as inflammatory bowel disease, cirrhosis of the liver, renal failure • Neurological conditions such as epilepsy and arthritis • Auto-immune diseases The tool does not go into clinical detail on managing these diseases, but the general principles of good management of chronic conditions should be applicable to all of them. It should be noted that since the advent of antiretroviral therapy, managing HIV resembles treating other chronic diseases. Thus, while HIV is technically not an NCD, improving NCD management should have crossover benefits those patients as well. The tool also looks at managing the risk factors that lead to NCDs: tobacco and alcohol use, poor diet and physical inactivity. These can all lead to developing a non-communicable disease and contribute to the complications of them. This tool examines how NCDs are managed in primary, secondary and tertiary care, emphasizing the first two. Most of the tool’s criteria examine actions to reduce risk factors, screen patients and manage their condition well with drugs, monitoring, lab tests and counselling. Because the best approach to reducing the burden of NCDs is prevention, most of the assessment activities focus on primary care. However, a smaller portion of the tool examines tertiary prevention and hospital services to manage complications. 12 2.2 Conceptual Framework for the Assessment Tool The toolkit is designed to identify examples of excellence in non-communicable disease care in different domains of the health system, using the conceptual frameworks listed below. 2.2.1 WHO Operational Framework for Primary Health Care Given the strong role of PHC in primary and secondary prevention of NCDs, we used the WHO’s Operational Framework for Primary Health Care as a conceptual framework for this assessment tool. The framework (Figure 5) lists 14 strategic and operational levers which define a high-performing health system and the results it intends to achieve (UNICEF, 2020). Its purpose is to guide health system leaders through the steps needed to transform a vision for strong primary care into implementation and success. The strategic levers in the framework are high-level policy or governance actions which a ministry of health or oversight body can implement. They include robust universal health coverage, clear plans, an accountability structure that links the ministry’s expectations to middle management structures and front-line providers, funding, and policies for discouraging unhealthy behavior. The framework’s operational levers identify structures and activities needed in the health system that managers and front-line providers can act on. They include issues such as human resources, facilities, equipment and supply chains. Models of care describe how to organize these resources into a system to deliver care. Measurement systems are needed to monitor how well the system is functioning. The framework’s results describe indicators which measure the overall performance of the system. The last part of the framework identifies results that have succeeded from the perspective of patient and population health. Figure 5. WHO Operational Framework for Primary Health Care (PHC). Source: UNICEF (2020). 13 2.2.2 Chronic Care Model The “Chronic Care Model,” widely used in many countries, is also used as an additional conceptual model in the assessment tool, to provide richer detail, particularly in the area of models of care in the Primary Health Care Monitoring and Evaluation (PHCME) framework. The Chronic Care Model (Wagner, 1998) was developed at the MacColl Institute by researchers led by Dr. Ed Wagner. They found even in health systems with plentiful resources and highly skilled staff, care for NCDs can be poor. Other studies have found best practice adoption rates of only 50% in the USA. The MacColl group discovered that models of care where best practices were organized and tailored for the chronic nature of NCDs had the best outcomes (Wagner, 1996). The Chronic Care Model emphasizes the need for a well-organized approach to delivering services, decision supports, clinical information systems, self-management support for patients and community-focused resources and policies. “Well-organized approach” means patients who need NCD care are evaluated in a structured way that aligns all best-practice care delivered by different members of the team with activities to ensure the patient is seen on a regular schedule. This is not the status quo authors of the model observed, where NCD services were done in random order if the doctor happened to remember, often added to a list of other complaints with no systematic follow-up. Information systems allow providers to monitor whether key evidence-based best practices are being used and provide feedback on whether care is done according to quality indicators. Decision supports are important for following increasingly complex practice guidelines. Simple tools such as reminders, checklists or algorithms can help remind providers of what to do and when. Good delivery system design gives providers and health systems efficient, standardized processes to ensure patients receive all the care they need on schedule. Self-management support means patients get help managing their condition well, which may include setting and achieving goals to improve lifestyle, or even adjusting their own medications and treatments. Community resources and policies include group or population-level interventions to encourage patients to adopt healthy lifestyles and become more engaged in managing their health. There is extensive evidence of the effectiveness of the Chronic Care Model. Meta-analyses and systematic reviews have found improved outcomes in diabetes (Stellefson et al., 2013; Baptista et al., 2016), hypertension (Davy et al., 2015), COPD (Adams et al., 2007), mental health conditions (Miller et al., 2013), HIV (Pasricha et al., 2013), and childhood obesity (Jacobson and Gance-Cleveland, 2011). 14 Figure 6. Chronic Care Model (CCM). Source: the MacColl Institute. 2.3 Development of Best Practices for Strengthening NCD Management Using this conceptual framework, we developed a list of 43 best practices for strengthening NCD management, divided into the 14 components of the PHCME framework. These 43 best practices cover key activities a country’s health system should adopt in order to achieve excellence in each of the 14 components. See Table 2 for a list and brief description of these best practices and Annex 1 for more details. Specific questions used for evaluation in the field can be found on a separate electronic data collection tool, released as a companion tool to this document. The best practices were developed through a review of consensus documents and guidelines from the WHO, World Bank and other organizations as well as systematic reviews, Cochrane reviews and meta-analyses. Descriptions of the evidence behind each best practice are found in Annex 1. To determine which clinical interventions would be cost-effective for low- and middle-income countries based on cost-effectiveness, the assessment tool use the WHO’s Tackling NCDs: Best buys analysis and other reference documents (Box 3). The best buys analysis identifies clinical interventions such as diagnostic tests, drugs, procedures and medical devices, surgeries, counselling and other treatments for NCD patients that are appropriate even in low-income countries. To be a best buy, an intervention must have a cost-effectiveness ratio of less than $100 per disability-adjusted life year (DALY) saved (WHO, 2017). The Best buy analysis also lists interventions with a higher cost-effectiveness ratio, suggesting these could be considered by low-income countries and are likely affordable in middle- income countries. 15 The WHO-PEN document (WHO, 2020(c)) outlines interventions appropriate for all countries and generally mirrors the Best buys document as well as clinical best practices in the WHO HEARTS Technical Package for Cardiovascular Disease Management in Primary Care (WHO, 2018(a)). PEN also includes a proposed list of equipment, drugs and supplies required to implement these services. PEN-Plus (WHO, 2022(b)) is an extension of PEN, listing additional tests, drugs and other services appropriate in LMICs, citing as proof that three sub-Saharan countries have already adopted these interventions. DCP-3 contains a list of recommended clinical interventions encompassing the above, as well as higher cost specialty interventions (Prabhakaran et al., 2017). Box 2. Guidance Documents for Identifying Clinical Interventions Appropriate in Low- and Middle-Income Countries • Tackling NCDs: “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. World Health Organization, 2017 • Appendix 3 of the WHO Global Action Plan for Prevention and Control of NCDs, 2013-2020 • WHO Package of Essential Non-Communicable Disease Services (PEN) and PEN-PLUS • WHO HEARTS Technical Package for Cardiovascular Disease Management in Primary Care • World Bank Disease Control Priorities 3rd Edition (DCP3) For interventions that describe a model of care, both research and reviews used for the Chronic Care Model and more recent evidence reviews were used. Models of care interventions include: • Methods for improving delivery of care such as recall and reminder systems for appointments; • Standard process for follow-up visits; • Self-management; and • Case management or intensive follow-up for high-risk patients. The more recent studies are consistent with earlier studies from the 1990s when the Chronic Care Model was developed. For system-level, cross-cutting best practices, the tool references WHO consensus documents and universal calls to action. Certain best practices (such as having a national plan, intersectoral action, universal health coverage, adequate human resources, facilities and equipment, and PHC research networks) are essential infrastructure for managing all NCDs. It is not necessary to run clinical trials to demonstrate their effectiveness, but the tool identifies WHO consensus documents advocating for investment in these areas. 16 Table 2. List of Best Practices for NCD Management in PHC LEVER IN WHO OPERATIONAL BEST PRACTICES FOR BRIEF DESCRIPTION FRAMEWORK FOR PHC NCD MANAGEMENT L1. Political National NCD There is a national strategy or plan for NCDs with time-bound targets, commitment BP1.1 strategy / plan with targets, indicators, actions, defined roles and monitoring of progress. and activities, timelines. leadership BP2.1 Universal health coverage for There is universal health coverage for NCD services in primary and specialty NCDs. care, with elimination of financial barriers to access. BP2.2 Accountability Accountability mechanisms exist with expectations for quality and L2. mechanisms. consequences if not met. Mechanism may be managerial or supervisory; Governance financial (incentives); contractual; community-based. and policy S frameworks R BP2.3 Tobacco policies. There are tobacco taxes, indoor smoking bans, standardized packaging or graphic warnings; and advertising bans. E V BP2.4 Alcohol policies. There are alcohol excise taxes; advertising or marketing bans; and restrictions E on physical availability of alcohol. L BP2.5 Unhealthy food policies (sugar, C There are policies on unhealthy foods, including taxes, front-of-package salt, trans-fatty acids) labeling, limits or bans on content, and restrictions on unhealthy foods in I schools and hospitals. G L3. E Funding, BP3.1 Dedicated funding for NCDs. There are sufficient funds budgeted by the government for NCD-related T resource services. Revenues from taxes on unhealthy substances may be reinvested in A allocation health promotion. R T BP4.1 Multisectoral planning beyond There is a planning body including sectors outside of health that considers L4. health. policies and activities to promote prevention and treatment of NCDs. S Engagement of communities BP4.2 Stakeholder engagement in Stakeholders, including civil society groups, non-governmental organizations, and planning and execution. professional associations, patient advocacy groups, private sector and stakeholders donors have a role in planning and execution of activities to improve NCD management. BP4.3 Healthy lifestyle public There is a community-wide public education and awareness campaign for awareness campaigns. healthy lifestyle and behavior change, using print, radio, TV, social media, community events and engages community organizations. LEGEND FOR COMPONENTS OF CHRONIC CARE MODEL DELIVERY SYSTEM SELF-MANAGEMENT DECISION SUPPORT CLINICAL INFORMATION COMMUNITY RESOURCES DESIGN SYSTEMS AND POLICIES Source: authors 17 Table 2. List of Best Practices for NCD Management in PHC (continued) LEVER IN WHO OPERATIONAL BEST PRACTICES FOR BRIEF DESCRIPTION FRAMEWORK FOR PHC NCD MANAGEMENT BP5.1 NCDs managed at PHC level. Most NCD services for screening, treatment, counselling are provided at the PHC level. Referrals and coordination with PHC can access specialty NCD services, through referrals, outreach clinics BP5.2 specialists. or shared care models. There is reliable communication between PHC and specialists and specialist gatekeeping. BP5.3 Structured NCD screening There is a structured, consistent screening process using a mix of evidence- S program. based interventions (opportunistic, reminder, mail-in, outreach, incentives). R BP5.4 Appointment scheduling system. Patient visits are scheduled conveniently for patients with little or no waits and E sufficient time reserved for complete NCD follow-up. V E L5. BP5.5 Recall process for patient There is a standard recall system to track patients due or overdue for follow- L Models follow-up. up and remind them to return. of Care BP5.6 Standardized, efficient process Visits for NCD care are carefully planned to ensure all recommended practices L for each visit. are implemented, in a convenient manner for patients. A BP5.7 Intensive management of High-risk patients with poor control of their disease are identified and seen N high-risk patients. more frequently or provided with case management. O BP5.8 Services delivered to PHC staff visit households to provide NCD services for disabled, marginalized I households. or remote populations. Patients may also be served with home monitoring T technologies. A There are patient education programs on living with NCDs and having a R BP5.9 Patient education programs. healthy lifestyle for individuals or groups, using multiple formats, geared for low E literacy. P BP5.10 Patient self-management Patient self-management support programs are offered by certified staff to O program. coach patients on managing their condition and developing confidence to make life changes. Programs link patients with non-professional peers who have experience BP5.11 Peer support programs. living with disease and offer on-going self-management support and encouragement. LEGEND FOR COMPONENTS OF CHRONIC CARE MODEL DELIVERY SYSTEM SELF-MANAGEMENT DECISION SUPPORT CLINICAL INFORMATION COMMUNITY RESOURCES DESIGN SYSTEMS AND POLICIES Source: authors 18 Table 2. List of Best Practices for NCD Management in PHC (continued) LEVER IN WHO OPERATIONAL BEST PRACTICES FOR BRIEF DESCRIPTION FRAMEWORK FOR PHC NCD MANAGEMENT L6. BP6.1 Adequate supply and mix of The supply of health professionals is comparable to peer countries; PHC Primary skilled health professionals. team has staff with varied skills (e.g. health education, foot care, mental healthcare health); staff are licensed. workforce BP6.2 Advanced models for There are advanced models for maintaining staff skills for managing maintaining competence. NCDs (e.g. continuing education courses, mandatory recertification, problem-based or case-based learning). S BP6.3 Advanced task-shifting. Tasks such as drug management, foot care and counselling are R delegated to non-physician providers. E BP7.1 Availability of PHC facilities NCD services are provided in facilities which are conveniently located for V providing NCD care. patients. L7. E Physical BP7.2 Equipment for NCD services at PHC facilities have equipment required for managing common NCDs, as L infrastructure PHC level available. recommended in WHO guidelines. BP7.3 Equipment for specialty NCD Hospitals and specialty facilities have equipment for managing L services available. complications or complex stages of NCDs, such as heart attacks, A strokes, cancer treatment or kidney failure. N L8. BP8.1 Essential medicines for NCDs Drugs for diabetes, hypertension and other NCDs are covered by the O Medicines and available. defined benefits package of UHC and are in stock. other health I products BP8.2 Essential diagnostic tests Essential NCD services are available at the primary care level. T available. A BP8.3 Strong supply chain Measures are in place for effective management of the supply chain for R management. medicines and other health products. E L9. BP9.1 See BP 4.2 above on (Engagement with private sector partners is included in BP4.2 on P Engagement stakeholder engagement. stakeholder engagement.) O with private sector providers L10. BP10.1 Stable, predictable funding to Clinics and providers receive stable, predictable funding. Purchasing and PHC sites. payment LEGEND FOR COMPONENTS OF CHRONIC CARE MODEL DELIVERY SYSTEM SELF-MANAGEMENT DECISION SUPPORT CLINICAL INFORMATION COMMUNITY RESOURCES DESIGN SYSTEMS AND POLICIES Source: authors 19 Table 2. List of Best Practices for NCD Management in PHC (continued) LEVER IN WHO OPERATIONAL BEST PRACTICES FOR BRIEF DESCRIPTION FRAMEWORK FOR PHC NCD MANAGEMENT L11. Digital BP11.1 Basic computer and internet. Clinics have access to basic technologies, including computers, internet technologies service and personnel with basic computer literacy. Clinics use computers for documentation, archiving and retrieval of BP11.2 Electronic medical record information, accessing results and reports, prescribing, referrals, decision support, shared care. BP12.1 Practice guidelines for NCDs exist. There are current practice guidelines for major NCDs and lifestyle S education, which follow international standards on evaluating evidence R and are tailored to the country’s resources. E L12. Systems for BP12.2 Standards and inspection for Standards exist for equipment, supplies, infrastructure and workplace V improving the equipment, facilities. policies, with a basic quality assurance/inspection program to ensure E quality of care standards are met. L BP12.3 Decision support tools for NCD. Decision support tools for NCD management (protocols, flowsheets, algorithms etc.) remind providers of what actions to take and are widely L used. A BP12.4 Quality improvement (QI) teams, PHC facilities have QI teams, training, mentorship and quality leaders. N QI training, demonstrated Some teams can show improvements and use of QI tools. improvements O I L13. PHC BP13.1 Network for NCD research NCD researchers are publishing studies on topics of interest to policy T - oriented makers and providers, and are supported by long-term funding, training research and mentorship. A R BP14.1 NCD surveillance data exists (tracking Data are available on incidence and prevalence of different NCDs. incidence, prevalence, mortality) Cause-specific mortality data is reliable. E P L14. Monitoring BP14.2 Person-oriented charting within Each patient has a chart containing all their data kept at their primary and Evaluation PHC health care site. O BP14.3 Centralized NCD registries Centralized, standardized, population-based registries exist for key NCDs (e.g. cancer, diabetes, hypertension) and contain clinical data from each encounter. BP14.4 Reporting on quality indicators Quality indicators for NCDs are reported in a timely fashion at multiple levels (facility, regional, national), over time, by facility. Reports are used widely for decision-making. LEGEND FOR COMPONENTS OF CHRONIC CARE MODEL DELIVERY SYSTEM SELF-MANAGEMENT DECISION SUPPORT CLINICAL INFORMATION COMMUNITY RESOURCES DESIGN SYSTEMS AND POLICIES Source: authors 20 2.4 Framework for Reporting Results on NCD Management A key component of the Operational Framework for Primary Health Care is gathering results on improved health of NCD patients, which are generated by the 14 strategic levers. Interventions based on these levers are intended to improve: • access, use and quality; • participation, health literacy and care seeking; and • determinants of health. Information revealed about weaknesses in these areas can be used by policymakers to strengthen investment requests to ministries of health and finance and external funders. This assessment tool comprises a mixed list of “ideal” indicators, which cover several non- communicable diseases and different stages of illness. They incorporate a variety of dimensions of quality and measures for examining both processes and outcomes. Information on different NCDs at different stages of illness will provide a comprehensive view of NCD care. The dimensions of quality include being safe, effective, people-centered, accessible, equitable, efficient and integrated (see Box 3) (WHO, 2018(b)). Process measures capture whether a best practice intervention has been implemented, while outcomes describe the results or health benefits for patients. Figure 7 describes how this list can be conceptualized, and Table 3 gives concrete examples of the recommended indicators. Countries may vary in how they define these indicators and may add additional ones for adaptation to local circumstances. Box 3. Dimensions of Quality Effective: evidence-based health care is provided to those who need it. Equitable: the same quality of care is received by all persons. Accessible: care is easy to obtain, affordable and timely. Person-centered: care is responsive to individual preferences, needs and values. Safe: care provided does not harm patient. Efficient: maximizing the benefit of available resources and avoiding waste. Integrated: patient transitions smoothly between different locations and stages of care 21 Figure 7. Indicators to Monitor PHC Results for NCD Management Along a Disease Continuum Source: authors Because in many cases data may be unavailable or hard to find, people using the assessment tool should scan multiple sources to find information for their work, including: • routine data collection systems; • population surveys; • health facility surveys; and • data reported to the WHO. The tool can also draw on ad hoc research studies which offer only a one-time, small sample calculation of a particular indicator. (Further details on data sources are found in the next section.) Recording where data are missing can help identify priorities for investing in data collection. If there is no data on patient experience, for example, the tool will highlight that, potentially encouraging investment in regular surveying. 22 Table 3. Primary Health Care Result Indicators for NCD Management PHCME INDICATOR INDICATOR BEST PRACTICES FOR STAGE OF TYPE DIMENSION RESULTS GROUP SUB-GROUP NCD MANAGEMENT DISEASE DISEASE OF QUALITY R1.1 R1.1A Screening % of adults screened for CVD Diagnosis P Effective Screening for hypertension or hypertension and or cardiovascular Processes cardiovascular risk risk R1.1B Diabetes % of adults screened for diabetes Diabetes Diagnosis P Effective screening R1.1C Cancer % of eligible women screened: screening - for breast cancer in last 2 yrs R 1 I M P R O V E D A C C E S S , U T I L I Z AT I O N A N D Q U A L I T Y - for cervical cancer in last 3 yrs Cancer Diagnosis P Effective % of eligible adults screened for colon cancer in last 5 yrs R1.2 R1.2A Cancer % of breast, cervical, colon Cancer Diagnosis O Effective, Screening screening outcomes cancers presenting at early stage Safe Outcomes R1.3A Hypertension % of HTN patients on appropriate CVD Treatment P Effective treatment treatment R1.3 Treatment R1.3B Diabetes % of diabetes patients: Processes treatment - on appropriate treatment Diabetes Treatment P Effective - get special exams (eye, foot) every 6-12 months R1.4A Hypertension % of HTN patients with CVD Treatment O Effective outcomes BP<140/90 % of diabetes patients: Diabetes Treatment O Effective R1.4B Diabetes - With A1c <7 outcomes - With LDL < 2.0 - With BP < 130/80 R1.4 Treatment R1.4C Cancer Five-year survival rates for breast, Cancer Treatment O Effective Outcomes outcomes cervical, colon cancer R1.4D Long-term Incidence rates of: CVD, complications of CVD, - Stroke, acute myocardial Diabetes Treatment O Effective diabetes infarction, end-stage renal failure, diabetic retinopathy, diabetic lower limb amputations R1.4E Premature Mortality rate from NCDs occurring mortality from NCDs between ages 30-70, or Person Years All NCDs All stages O Effective of Life Lost from NCDs LEGEND: P = process, O = outcome Source: authors 23 Table 3. Primary Health Care Result Indicators for NCD Management (continued) PHCME INDICATOR INDICATOR BEST PRACTICES FOR STAGE OF TYPE DIMENSION RESULTS GROUP SUB-GROUP NCD MANAGEMENT DISEASE DISEASE OF QUALITY R1.5 Equity R1.5A Equity Gap in Difference in premature mortality premature deaths (or other indicators) between: All NCDs All stages O Equity from NCDs (or other - Urban & rural indicators) - Top & bottom income quintile - Lowest & highest education level % of patients with PHC provider R1.6 Access R1.6A Access to NCD % of patients reporting cost barriers All NCDs All stages O Access care % of patients reporting location barriers % of patients discharged from R1.7 R1.7A Readmission hospital who return within 30 days; Integrated rates calculate for: All NCDs Treatment P, O Integrated, - COPD Efficient - Congestive heart failure - Acute myocardial infarction HEALTH LITERACY & CARE SEEKING R2.1 R2.1A Hypertension % of hypertension patients followed CVD Treatment P Effective R2 IMPROVED PARTICIPATION, Follow-up follow-up up every 3 months R2.1B Diabetes % of diabetes patients with follow- follow-up up, A1c every 3-6 months Diabetes Treatment P Effective % overall satisfaction with care R2.2 Patient R2.2A Patient % satisfied with communication Person- experience experience with NCD % informed of diagnosis All NCDs Treatment O centered- care % receiving courteous care ness % reporting involvement in decisions R3.1 R3.1A Lifestyle % of population receiving lifestyle All NCDs Prevention P Effective Counselling counselling counselling R3 IMPROVED DETERMINANTS OF HEALTH R3.2A Risk factor % of adults who: prevalence - smoke - have excessive alcohol intake All NCDs Prevention O Effective - have poor diet R3.2 - are physically inactive Prevalence of risk factors R3.2B Hypertension % of adults with hypertension CVD Prevention O Effective and NCDs prevalence R3.2C Diabetes % of adults with diabetes Diabetes Prevention O Effective prevalence LEGEND: P = process, O = outcome Source: authors. 24 3. Conducting the Assessment 3.1 Gathering Information for the NCD Assessment 3.1.1 Preparation for Assessment This tool is designed to do rapid assessments, suitable for the timeframe of a typical World Bank project preparation cycle. Tests of the tool in three countries suggest that approximately 12 person- weeks of time is required to conduct the analysis, or six weeks for a two-person team. Approximately two weeks should be set aside for site visits and interviews, with the rest reserved for reviewing documents before the visits, synthesizing and presenting results from them on return and writing reports. Schedulers using these guidelines should be aware time and human resources required for an assessment will vary by the size and complexity of the country. The composition of the assessment team may vary, but the tool is designed for two-person teams where at least one member has clinical experience. It is strongly recommended that at least one member of the team have a clinical background in primary health care given that the assessment involves examining workflows for clinical decision-making and coordination of care. The team should plan for two full-time equivalent (FTE) weeks of preparation, two weeks of mission time in-country, and two weeks post-mission to analyze the findings, write reports, and disseminate recommendations. Estimate of time commitment might be higher or lower depending on the complexity of the country and experience level of the consultants. Key individuals in the host country and the World Bank country office should be identified at the outset and clear roles and responsibilities for each defined. This includes identifying a primary contact in the ministry of health who is responsible for identifying key informants, documents and facilitating site visits. At the World Bank country office, task team leaders in the and the individual responsible for logistics such as scheduling and in-country travel must be chosen. Initial discussions with the host country should clarify the assessment’s scope. The tool is designed to measure all strategic and operational issues of a health care system. Tests of the tool, however, suggest ministries of health may request some best practices not be evaluated because they are not a priority or have already been addressed. Countries may also ask for more detailed analysis of some levers or best practices. 3.1.2 Desk-Based Review The assessment can start with a desk-based review, beginning with the WHO NCD Country Capacity Survey. Last completed in 2019 by 194 countries, the survey holds detailed information on strengths and gaps in basic health system capacity for managing NCDs. However, country-level survey responses are not publicly available, so the assessment team must coordinate with the country’s contact for the country capacity survey to get the country’s most recent survey results. If they are not available, more aggregated results of the survey, listed, by country are available on the WHO’s Global Health Observatory website. (See Table 4 for a list of other data sources). 25 Table 4. Resources for Desk-Based Review for Assessment RESOURCE DESCRIPTION WHO NCD Country Capacity Survey Conducted by 194 countries in 2019, assesses national capacity for NCD management in four modules: (1) Public Health Infrastructure, Partnerships and Multisectoral Collaboration for NCDs and their Risk (request individual country survey results Factors; (2) Status of NCD-Relevant Policies, Strategies and Action Plans; (3) Health Information from WHO country office or the responsible Ministry of Health official) Systems, Monitoring, Surveillance, and Surveys for NCDs and their Risk Factors; and (4) Capacity for NCDs Early Detection, Treatment, and Care within the Health System. WHO Global Health Observatory, NCD National Capacity This website contains information on indicators based on the WHO NCD Country Capacity survey, broken down by country. Can be used if the more detailed document above is not available. https://www.who.int/teams/ncds/ surveillance/monitoring-capacity/ncdccs WHO NCD Global Progress Monitor The WHO global progress monitor (2020 version) has data on 19 indicators for global action for NCDs www.who.int/publications/i/item/ncd- across 194 countries. progress-monitor-2020 WHO NCD Document Repository A repository of documents on NCD targets, policies and guidelines submitted to WHO for the NCD https://extranet.who.int/ncdccs/ Country Capacity Survey. documents/ Global Essential Medicines List A centralized repository with information on essential medicines lists for 137 countries. https://essentialmeds.org/ PHCPI Core Indicators Using globally comparable data, these indicators can be used to quickly assess a country’s PHC performance and make informative comparisons. Several of the indicators apply to NCD management improvingphc.org and are used in the PHCPI quick scan assessment phase. WHO Planning Cycle Repository A repository of national health strategies and/or plans from different countries available on the WHO https://extranet.who.int/ extranet. countryplanningcycles/planning-cycle/ STEPS survey (WHO) This survey asks a random sample of adults about past history of diabetes, hypertension, https://www.who.int/teams/ cholesterolemia or heart disease, and risk factors (smoking, alcohol, diet, exercise). It also collects noncommunicable-diseases/surveillance/ physical measurements (e.g. weight, height, BMI, waist circumference, BP) and lab samples (e.g. FBG, systems-tools/steps/manuals cholesterol). Demographic Health Surveys Most countries have these, often including data on NCD risk factors and access to care. Data is often disaggregated by information needed to assess equity: gender, rural/urban and income strata. (request from individual country) SARA, SDI, SPA facility surveys * https://www.who.int/data/data-collection- These examine health facility resources such as infrastructure, availability of staff and drugs. tools/service-availability-and-readiness- assessment-(sara)/service-availability-and- readiness-assessment-(sara)-related-li National health accounts https://www.who.int/health-topics/health- accounts#tab=tab_1 For information on country financing of disease areas including NCDs Health account production tool https://www.who.int/publications/i/ item/9789240065550 PHCPI = Primary Health Care Performance initiative. * SARA: Service Availability and Readiness Assessment; SDI: Service Delivery Indicators; SPA: Service Provision Assessment. Source: authors. 26 Next, the evaluation team should examine other standardized sources such as facility surveys, patient surveys (e.g. STEPS), WHO websites and WHO document repositories. Patient surveys are useful for gathering data for the results section and on barriers to access. Facility surveys offer information on health system infrastructure. WHO also has a repository of documents related to the NCD capacity survey. It may contain information such as national plans and practice guidelines, but not necessarily everything of potential interest. Next, the assessment team should review other data sources and publications unique to the country, obtained from both the WHO NCD Documents Repository and the country’s government. Documents include the following: • national strategic plans specifically for NCDs • national health statistics • national reports on vital statistics • ata on human resources (e.g., number of doctors, nurses, etc.) • government policies on tobacco, alcohol, healthy diet and exercise • list of government-approved quality indicators • reports, plans or strategies regarding health information infrastructure • patient experience surveys • population health surveys (e.g., of the general population, youth, or other target group) When countries complete the NCD Country Assessment Survey, the WHO invites them to submit their supporting documents to its repository of NCD-related documents. If a country did not submit all documents on the list, the ministry of health will have to be asked for them. 27 3.1.3 Key Informant Interviews The assessment team should interview key ministry of health employees involved in NCDs, and also people outside the ministry to get perspectives from providers, patients, donor organizations and academia. People who should be interviewed include: Ministry of health personnel, responsible for: • High-level leadership (such as deputy minister, director general, vice-minister) • Strategy or planning • Primary care • Health information • Information technology • Statistics or health analytics • NCD management • Health promotion (tobacco, alcohol, diet, exercise) • Human resources • Quality department or agency Experts outside the ministry of health, such as: • NCD patient advocacy groups • Clinical experts or academics • International organizations • Civil society • Professional organizations • Private sector providers (contingent on scope of assessment) Non-health sector ministries, such as: • Health insurance funds • Ministry of social protection (managing social health insurance) • Ministry of finance • Ministry of trade (for excise tax of imported food) • Ministry of agriculture (for healthy food) Note that job titles for these positions vary from one country to another. 28 3.1.4 Site Visits Site visits are an essential part of assessing NCD capacities. It is essential to visit a wide variety of primary care facilities to understand NCD care in a mix of rural and urban settings, at different clinical levels and in diverse practices (e.g., nursing stations, multidisciplinary practices, private vs public clinics, community centers, etc.). Another factor to consider is the population served; facilities targeting different patient demographics covering a variety of cultural, religious, social and economic backgrounds should be visited. As well, hospitals of different sizes, and levels of care should be visited to document what services they offer. Table 5. List of Data Information Sources for Each Best Practice WHO NCD Best Practices for NCD Country Capacity Documents Key Informants / Site Visits Management Survey BP1.1 National NCD plans, QII.1-9 National health plan or strategy (look for Senior MOH (e.g. deputy minister or equivalent); targets and timeframes NCD section), or National NCD plan Planning department BP2.1 Universal health coverage Policy documents on UHC Senior MOH (e.g. deputy minister); for NCDs Defined benefits package Focal point for UHC Essential medications list BP2.2 Accountability Accountability agreements for health Senior MOH (e.g. deputy minister); mechanisms facilities Regional or district health managers Description of performance-based Focal point for performance-based funding funding arrangements arrangements Templates for supervision visits to health facilities BP2.3 Tobacco legislation, list of excise taxes Examples of packaging, warnings Anti-tobacco policies QI.3, QII.16 UNtobaccocontrol.org (questionnaires Dept of health promotion or public health submitted by countries to WHO) BP2.4 Anti-alcohol policies QI.3, QII.10 Alcohol legislation, list of excise taxes Dept of health promotion or public health Examples of warning labels BP2.5 Policies to reduce sugar, QI.3, Sugar/salt/fat legislation, list of excise Dept of health promotion salt, fat intake QII.11,14, taxes 15,19-23 Examples of food labelling BP3.1 Dedicated funding for QI.2 Budgets for UHC or NCD care Focal point for UHC NCDs MOH – Budgeting office or ministry of finance BP4.1 Multisectoral planning QI.4 Intersectoral committee terms of Senior MOH (e.g. deputy minister); beyond health reference Intersectoral committee chair BP4.2 Stakeholder engagement Civil society, NGOs, professional associations, patient advocacy groups, private sector representative BP4.3 Healthy lifestyle public Q24-27 Health promotion posters, ads, materials Dept of health promotion awareness campaigns for distribution MOH = Ministry of Health. PHC = primary health care. UHC = universal health coverage. Source: authors. 29 Table 5. List of Data Information Sources for Each Best Practice (continued) WHO NCD Best Practices for NCD Country Capacity Documents Key Informants / Site Visits Management Survey BP5.1 NCDs managed at PHC level Department of primary care; chief medical, nursing officers responsible for PHC BP5.2 Referrals and coordination QIV.4 Site visits with specialists Department of primary care; chief medical, nursing BP5.3 Structured NCD screening QIV.3, officers responsible for PHC program QIV.11 Department of health promotion Site visits BP5.4 Appointment scheduling system BP5.5 Recall process for patient follow-up BP5.6 Standardized, efficient Department of primary care; chief medical, nursing process for each visit officers responsible for PHC Site visits BP5.7 Intensive or case management of difficult cases BP5.8 Services delivered to households BP5.9 Basic patient education Standard patient education materials programs Department of primary care; chief medical, nursing BP5.10 Advanced patient self- Self-management training guides officers responsible for PHC management program Department of health promotion Site visits BP5.11 Peer support programs and group visits BP6.1 Adequate supply and The supply of health professionals is of mix of skilled health comparable to peer countries; PHC team professionals has staff with varied skills (e.g. health Ministry, health human resources department education, foot care, mental health); staff are licensed BP6.3 Advanced models for Ministry, health human resources department maintaining competence BP6.4 Advanced task-shifting Ministry, health human resources department BP7.1 Equipment in primary care QIV.2 Facility standards NCD services BP7.2 Equipment for specialty NCD QIV.7,8,12 Hospital site visits services BP7.3 Equitable distribution of PHC MOH, PHC department facilities MOH = Ministry of Health. PHC = primary health care. UHC = universal health coverage. Source: authors. 30 Table 5. List of Data Information Sources for Each Best Practice (continued) WHO NCD Best Practices for NCD Country Capacity Documents Key Informants / Site Visits Management Survey BP8.1 Essential medicines for QIV.6 Essential medicines list MOH, PHC department NCDs available Site visits BP8.2 Essential diagnostic tests Essential benefits package MOH, PHC department available. Site visits MOH, PHC department BP8.3 Strong supply chain Site visits management Central stores for supply, or procurement office BP10.1 Stable, predictable funding MOH – budgeting office or ministry of finance to PHC sites BP11.1 Basic computer and Site visits internet BP11.2 Electronic medical record Health information strategy documents Site visits or reports BP12.1 Practice guidelines for QIV.1 Practice guidelines for major conditions MOH, PHC department NCDs exist (e.g. hypertension, diabetes, cardiovascular Representative of organization publishing disease, COPD, asthma, cancer screening) guidelines BP12.2 Standards and inspection Facility standards MOH, PHC department for equipment, facilities BP12.3 Decision support tools for Examples of decision support tools MOH, PHC department NCD (flowsheets, algorithms) Site visits Quality improvement National quality strategy MOH, PHC department BP12.4 (QI) teams, QI training, Documentation on past national quality MOH, quality department demonstrated campaigns Chief medical, nursing officers responsible for improvements PHC Site Visits BP13.5 Network for NCD research QII.17,18 Researchers BP14.1 NCD surveillance data QIII.1-2 Vital stats data MOH, health information exists (incidence, Surveillance data MOH, vital statistics prevalence, mortality) BP14.2 Person-oriented charting Blank patient charting templates within PHC MOH, health information MOH, PHC department BP14.3 Centralized NCD registries QIII.3-5 National quality indicator lists Site visits NCD registry specifications BP14.4 Reporting on quality Quality indicator reports indicators MOH = Ministry of Health. PHC = primary health care. UHC = universal health coverage. Source: authors. 31 3.2 Synthesis and Interpretation of Results 3.2.1 Evaluation Metric The tool uses a series of assessment questions to help determine to what extent a best practice has been implemented. Answers to these questions can be drawn from any combination document reviews, interviews or site visits. The full list of questions is found in the data collection tool released concurrently with this publication. Each best practice is scored as: 1) mostly implemented, 2) partially implemented, or 3) not implemented or at early stage. We elected to use a qualitative grading system instead of numeric score. This way, results are reported as narratives describing what has been accomplished in the country and which elements of the best practice are missing. This is to keep the focus on providing guidance on steps to be taken to strengthen the best practice. 3.2.2 How to Use the Tool This tool can be used in its entirety, or for a focused analysis on certain parts of the health system. It is designed to identify potential gaps in NCD management in all parts of the health care system. In practice, a ministry of health or task team leader may decide certain areas of the system do not need further evaluation. This may occur because the country feels the area’s operations are working well or because there are already plans and projects underway to address gaps. This tool can help identify priorities; a future guidance document will provide further suggestions on project design and implementation tips. This tool is designed to identify weaknesses in NCD care and areas for improvement and will be particularly useful when a country declares a strong interest in strengthening its NCD management and needs practical advice on what to do. This tool can also be used by task team leaders to determine priorities for investment in a new World Bank project. However, those projects need more detail, such as the amount and type of resources needed, a time frame with milestones, barriers to be addressed and a measurement and evaluation framework. A publication to address developing NCD projects with the World Bank is planned for later in this series. While designed for World Bank projects, this tool can be used by governments and other organizations to set priorities for their own projects. Ideally, this type of analysis should be conducted in concert with other funding agencies with health ministries in the lead to provide is a unified set of priorities determined by government. This mirrors the approach used by the Global Financing Facility. 32 ANNEX 1 – Technical Details of Best Practices Lever 1. Political Commitment and Leadership BP1.1 National non-communicable disease strategy / plan, targets, activities, timelines Description: This best practice examines whether the country has a plan or strategy for improving NCD services, whether it’s a stand-alone plan for NCDs or a national plan with an NCD component. It evaluates the plan according to several desired characteristics: • It has NCD quality indicators to monitor progress, with numeric targets and a time frame for completion; • It is currently in force; • It contains key actions with timelines; and • It defines the roles and responsibilities of different actors. Rationale: the WHO’s Handbook for National Quality Policy and Strategy recommends setting goals that are “clear and meet a particular need, and should also be time bound, with a means to assess progress and achievement.” A clear, ambitious goal can rally providers around a common objective and draw attention to important tasks for achieving the goal. This recommendation is consistent with decades of psychology research showing organizations and individuals achieve better results when they set specific goals (Locke & Lathan, 2002). Lever 2. Governance and Policy Frameworks BP2.1 Universal health coverage for non-communicable diseases Description: According to the WHO, “universal health coverage (UHC) means that everyone receives quality health services, when and where they need them, without incurring financial hardship” (WHO, 2021(b)). Some countries have public health insurance plan for all, while others offer coverage only for certain groups (e.g. low-income, elderly) and mandate other forms of insurance (e.g. private or employer- based plans) for others. There is typically a defined benefits package of services provided free or at low cost. The assessment tool analyzes what the defined package contains to determine if core NCD services are included, such as: • Assessments by physicians, specialists and other health professionals • NCD drugs (e.g. for hypertension, diabetes, hypercholesterolemia, respiratory conditions) • NCD-related diagnostic tests (e.g. A1c for diabetes, cholesterol and general hematology and biochemistry) • Counselling for lifestyle management 33 The tool also examines selected hospital-based services for NCD complications, such chemotherapy, radiation and diagnostic imaging for staging cancer; laser treatment for diabetic retinopathy; dialysis for diabetic nephropathy and stroke for acute myocardial infarction and stroke. We recognize that in some low-income countries, some specialized services may be beyond what the country can afford. The tool also examines out- of-pocket expenses associated with the defined benefits package, and eligibility criteria, to evaluate the degree of protection from financial hardship for the most vulnerable. Rationale: Nations of the world declared universal health care a common objective of the 2030 Sustainable Development Goals (SDG) in 2015. Progress towards SDG 3.8 — Achieving UHC is monitored by two indicators: SDG indicator 3.8.1 on the coverage of essential health services, and SDG indicator 3.8.2 on catastrophic health spending. To monitor indicator 3.8.1, the WHO has constructed a UHC service coverage index based on 14 indicators covering a broad range of diseases, which includes NCDs. However, only three high-level indicators are used: hypertension prevalence, tobacco use and mean fasting blood glucose as a proxy for managing diabetes. To provide a more comprehensive view of UHC, this tool examines whether the basket of NCD services (described in WHO’s Tackling NCDs: “Best buys” document), are provided free or at low cost. BP2.2 Accountability mechanisms Description: This best practice examines accountability mechanisms for promoting high quality NCD services. Accountability means that expectations of performance for a provider or group have been defined, and consequences or actions follow if expectations are not met. Consequences include increased scrutiny, reporting requirements or financial penalties. There are many methods of achieving accountability, including: • Managerial or supervisory accountability, where PHC facilities report to a higher level regarding their performance. One approach is supportive supervision where, if results are poor, the facility receives greater scrutiny but also advice or mentorship to improve results; • Financial accountability, where pay-for-performance or results-based payment programs provide additional remuneration for good quality care, or penalties for poor quality; • Contractual accountability, where health care providers are contracted by a purchaser to provide services and getting the contract is based in part on quality results; • Patient choice accountability, where patients choose providers based on quality of care; and • Community accountability, where PHC facilities report to community representatives or committees to hear concerns. A country does not need to use all methods, as long as it has at least one mechanism which works well. Each method should set clear expectations for quality of NCD services and have meaningful consequences for poor quality. Rationale: While the need for accountability is broadly accepted, mechanisms vary widely and even within them there are variations in design and execution. There is no compelling evidence showing one method is being better than another but there is some evidence of encouraging accountability. A meta-analysis of supportive supervision found it helped improve job satisfaction and worker motivation but had mixed results of improving outcomes (Bailey et al., 2016). Extensive studies suggest financial incentives lead to inconsistent improvements in quality that are modest at best (James, 2012). They may be more useful in conjunction with other mechanisms. One meta-analysis of community accountability suggests some modest improvements in clinical quality and reduction in corruption, while another review (Molyneux et al., 2012) concludes success depends on training and support of the community members. 34 BP2.3-2.5: Tobacco policies, alcohol policies, unhealthy food policies (sugar, salt, trans-fatty acids) Description: There are several approaches backed by research to reduce unhealthy behavior such as smoking or excessive alcohol, sugar, salt or fat intake, including: • Taxing sales • Marketing, packaging or labelling restrictions • Restricting where the unhealthy substance can be sold or used. The assessment tool examines the extent to which these approaches have been implemented, which generally requires both legislation and enforcement. Other actions for encouraging healthy lifestyles include mass media campaigns and treatment or counselling for individual patients; more on these below. Rationale: The evidence supporting these interventions is well-established in the scientific literature through Cochrane reviews (McNeill et al., 2017), meta-analyses and consensus panels. The research has been used in several WHO documents, including Framework Convention on Tobacco Control (WHO, 2003), Global Strategy to Reduce Harmful Use of Alcohol (WHO, 2010(a)), and Recommendations on Marketing of Foods and Non-Alcoholic Beverages (WHO, 2010(b)). The WHO Best buys analysis identifies interventions that have the most favorable cost-effectiveness for LMICs, costing of <=$100 per disability adjusted life year averted. These include, for tobacco: taxes, plain packaging with graphic warnings, advertising bans and eliminating smoking in indoor or public places. For alcohol: taxes, banning advertising and restricting availability (e.g., reduced hours of sale). For unhealthy diets, front-of pack labelling, reducing salt intake in public institutions (e.g., hospitals, schools) and regulating limits on amounts of salt in food. Taxes on sugar-sweetened beverages and legislated bans on industrial trans-fats were rated as effective but had a cost-effectiveness ratio > $100 per DALY averted. Additional details on designing anti-tobacco policies were derived from the WHO technical manual on tobacco tax policy and administration, which gives recommendations on the amount of the tax, method of valuation and enforcement mechanisms (WHO, 2021(c)). Lever 3. Funding and Resource Allocation BP3.1 Dedicated funding for non-communicable diseases Description: Non-communicable disease care must be adequately funded to be effective. This best practice looks for budgeting that accounts for the number of people using the service and its cost per unit of service. For example, if a health system offers free A1c tests to diabetes patients but does not allocate sufficient funds, supplies may run out and patients either have to wait till the next fiscal year or pay for the test privately. This best practice also examines whether revenues derived from taxes on unhealthy behavior (such as consuming tobacco, alcohol and unhealthy food) are earmarked at least in part for health promotion programs. 35 Rationale: Preventing and managing NCDs reduces human suffering and helps reduce demands on the health system but must be well funded to succeed. The WHO’s UHC Service Package Delivery and Implementation (SPDI) tool encourages countries to conduct micro-level planning for each individual service they intend to offer, to the level of details of specific drugs and lab tests. The tool helps the country estimate human resources and material costs needed, which could be used by governments for budget cost projections. Directing taxes on unhealthy behavior toward health promotion activities is not a requirement; as long as health promotion is well funded, the source of the funds does not matter. However, if health promotion is relatively underfunded, dedicating taxes on unhealthy behavior in health promotion could help solve the problem (Nugent et al., 2018). Lever 4. Engaging Communities and Stakeholders BP4.1 Multisectoral planning beyond health Description: Overall health and health behavior are heavily influenced by the environment in which an individual lives and therefore health-promoting public policy best practices are essential to NCD prevention efforts. Different aspects of the environment (e.g. neighborhoods, public transit, workplaces, schools) are controlled by organizations and ministries beyond of health care. Integrating NCD-related health promotion throughout the community requires a multisectoral mechanism to coordinate activities such as: • Creating adequate parks and pathways to encourage physical activity (walking, cycling) • Requiring grocery stores within walking distance of residential areas (urban planning) • Mandating occupational health and fitness programs (employment or industry) • Restricting smoking and access to unhealthy food in workplaces, public buildings and schools • Subsidizing healthy food (finance) • Controlling air pollution for respiratory health (environment) Rationale: The WHO’s Healthy Cities initiative calls on governments to improve health in urban areas through actions such as creating physical environments that support health and healthy choices (WHO, 2020(d)). Similarly, the WHO’s Health in All Policies (HiAP) initiative advocates for policies in environment, education, agriculture, finance, taxation and economic development to promote overall health and equity (WHO, 2014). 36 BP4.2 Stakeholder engagement in planning and execution Description: Stakeholders in the battle against NCDs may include professional organizations, civil society groups, non-governmental organizations, patient advocacy groups and international funders. The private sector may also be a key party, especially in countries which rely on mandatory private or employer-based insurance to help achieve universal coverage. This best practice examines the extent to which these stakeholders have been involved in developing strategies and plans for NCD management and play a role in the execution of the plan or delivery of services. Rationale: Stakeholder engagement is one of the eight tenets of the WHO’s National Planning and Quality Strategy guidelines (WHO, 2018(c)). Involving stakeholders increases buy-in to necessary changes to the system and takes advantage of the networks of influence or external sources of funding of these organizations. BP4.3 Healthy lifestyle public awareness campaigns Description: This best practice examines the nature and effectiveness of community-wide public education and awareness campaigns for healthy lifestyle and behavior change. These can cover any topic (smoking, alcohol, unhealthy diet or physical inactivity). Different communication methods may be used, including mass media, social media, special events or outreach activities (e.g. visits to workplace, schools, places of worship, community centers, etc.). Celebrities or respected individuals may be recruited to help deliver key messages. The country may also consider using short-term financial incentives to encourage participation. Rationale: WHO’s Tackling NCDs: Best buys says public awareness campaigns have a cost-effectiveness ratio of < $100 per DALY averted. Evidence consistently shows public awareness campaigns are effective in improving health behavior but the impact is small: one meta-analysis of 51 well-designed studies identified a modest mean effect size of r=0.05, with newspapers and brochures having greater impact (Anker et al., 2016). However, a small effect across an entire population does translate to large numbers of persons affected. 37 Lever 5. Models of Care BP5.1 Non-communicable diseases managed in primary health care Description: Most people get their care in primary health centers, which makes providing NCD care an important role for PHC. This item examines whether screening, diagnosis and treatment are typically done in PHC, by specialists or in outpatient hospital clinics. It also asks whether vertical NCD programs exist (that is, those that focus on a single condition), or if they are integrated as part of primary care. It looks for a gatekeeping system where specialists are seen only through referral from PHC. In addition, this item examines whether patients are assigned to a specific primary care provider or team (“empanelment”) to ensure continuity of care. Insulin management and cervical cancer screening are used to verify the findings. Rationale: The WHO Package of Essential Non-communicable (PEN) Disease Interventions recommends a core set of clinical interventions that should be provided specifically in PHC (WHO, 2020(c)). These include cardiovascular risk assessment, management of hypertension, diabetes, asthma and COPD, early cancer diagnosis, healthy lifestyle counselling self-care and palliative care. One meta-analysis of 21 studies shows gatekeeping is associated with better prevention care and lower health costs, but also lower patient satisfaction (Sripa et al, 2019), so patient expectations will have to be managed work done to increase trust in primary health care in the community. BP5.2. Referral and coordination with specialists Description: Patients do better when their care providers work together and coordinate their treatments. This item examines relationships between PHC doctors and specialists and different models of interaction. It asks if doctors and specialists routinely exchange correspondence (i.e. referral requests with clinical information from PHC and consultation notes from the specialist). It also looks at more advanced interaction, where specialists visit remote PHC facilities, or jointly manage patients and provide mentorship and education to PHC staff. Rationale: Poor communication between providers can lead to patient safety risks, patient dissatisfaction, discontinuity of care and wasted physician time (Vermeir et al., 2015). Studies demonstrate this is a significant problem, even in high-income countries (van der Kam et al., 1998). A Cochrane review of specialist outreach clinics (Gruen et al., 2004), concluded models of care where specialists provided usual services in remote settings improved access but not quality of care. However, more complex models where the visiting specialist also offered collaboration with primary care or education was associated with better health outcomes, adherence to guidelines and lower hospitalization. The disadvantage is that it costs more. 38 BP5.3: Structured NCD screening program Description: This best practice examines whether the country has a systematic approach to screening or a national strategy, instead of ad hoc administration and looks at approaches used for population screening for NCDs, such as: • Opportunistic screening, where individuals visiting PHC for any reason are offered screening; • Reminder systems, contacting patients when they are due for screening; • Mail campaigns for colorectal screening where kits are mailed out and patients mail back stool samples; • Outreach, where PHC providers visit community centers, malls, workplaces, schools or individual households; and • Short-term incentives, such as cash, gifts or lotteries to encourage participation. Any combination of these programs may be attempted. The target population may be all persons eligible for screening or those at higher risk for disease. Rationale: Screening allows earlier detection of disease and in turn, more time to prevent or treat it, saving the individual suffering and reducing health-care costs. There are many examples of highly successful efforts to increase the proportion of people screened for disease, including Malawi’s “Screening for Health and Referral in the Facility;” mail-in campaigns for colorectal screening (Kachimanga et al., 2017). which have a very favorable cost-effectiveness ratio (Wheeler et al., 2020). One meta-analysis of sending screening reminders by mail or other means estimated a 50% increase in mammography use (Wagner, 1998). Incentives to patients can be effective in increasing screening rates, but are useful mainly for short-term interventions (Giles et al., 2014). BP5.4 Appointment scheduling Description: This item examines whether best practices for booking appointments are used in primary care facilities. When booking, patients should be able to: use convenient means, choose a specific time and day, get same-day service for urgent concerns, come after hours or on weekends if necessary and avoid long waits to get an appointment or when they arrive for it. It should also be easy to book dedicated follow-up visits for NCDs, long enough to offer all essential care. Facilities can achieve good care either through dedicated, scheduled NCD clinic days or by flagging visits for NCD care to ensure there is sufficient time complete care protocols. Rationale: Efficient and rapid access to care makes it more likely patients will attend appointments and get the help they need to manage their condition. The common practice in some countries is to tell patients to return for follow-up on a certain day without a set time, which leads to long, unpredictable waits, discouraging patients from coming back. Research done for the Chronic Care Model found having dedicated appointments for non-communicable diseases improved the quality of care. In the past, PHC care focused on acute, episodic care, with NCDs treated as an item on a list of complaints and managed haphazardly. Best performing sites had a structured, protocol-driven approach where best practices were systematically carried out (Wagner, 1996) 39 BP5.5 Recall process for patient follow-up Description: Patients with chronic NCDs require regular follow up so the progression of their disease can be monitored and treatment adjusted. Patients, however, may forget to book a return visit, fail to go, or skip it because it does not seem important. The result is often serious complication later on. This best practice examines whether health facilities have a reliable system for providing appointment reminders, identifying patients who missed follow up and multiple ways of contacting the patient (phone, text, email, letter, postcard, home visit). All this would ideally be by electronic registry (see BP14.3) but manual tracking systems, though time consuming, also work Rationale: The Chronic Care Model includes use of a reliable follow-up system. Authors of the model cited meta-analyses from the 1990s showing interventions such as phone or mail reminders reduced no-show rates (Macharia et al., 1992). More recent reviews confirm their effectiveness (Reda and Makhoul, 2001). and one meta-analysis comparing ways of improving cancer screening and immunization found patient reminders were the fifth-most effective intervention (Stone et al., 2002). The US Agency for Healthcare Research and Quality has published a guide on how to implement both reminder and recall systems, noting that rates of kept appointments increased 120% in response to letters 660% in response to phone calls. BP5.6 Standardized, efficient process for each visit Description: This item examines whether PHC facilities have an orderly, structured, protocol-driven method for assessing patients with NCDs during follow-up encounters. Rationale: Standardized management is one of the principles of the Chronic Care Model’s Delivery System Design (Wagner, 1996). The original research found primary care’s traditional focus on handling acute, episodic complaints resulted in patients with chronic disease being treated the same way. Without protocols to organize care, adoption rates of NCD best practices were typically around 50%. Switching to protocol- driven follow-up care, with a plan in place for implementing each best practice (including which team member does what, and when) delivered more consistent evidence-based care and achieved better results. BP5.7 Intensive management of high-risk patients Description: Providing more intensive management to patients whose disease is poorly controlled disease (e.g. very high blood pressure or blood sugar) can help individuals achieve better control of their condition and reduce their high risk of complications. Poor control may be the result of factors such as lower education or income, mental health disorders, other co-morbidities or inadequate living arrangements. Intensive management can include more frequent visits and medication adjustments, more frequent counselling or self-management support and assistance with accessing other services such as social work or mental health care. These approaches are used in approaches known as case management, care coordination or patient navigation. 40 Rationale: There’s clear evidence intensive management produces better results for patients. One meta- analysis of intensive follow-up or counselling interventions for patients with poor diabetes control found blood sugar levels improved, with the greatest improvements in those who had worse control (Murphy et al., 2017). Evidence-based international guidelines for hypertension recommend more frequent (1 month) follow-up for BP > 140/90 and every 3-6 months if BP is controlled (Whelton et al., 2017). A Cochrane review on case management for severe mental health issues concludes it may reduce hospitalization, keep patients getting care and improve social functioning (Dieterich et al., 2017). A Korean meta-analysis of diabetes case management reported the medication compliance, self-management goal setting, knowledge of disease, mental health scores and blood pressure control were all improved (Joo and Liu, 2019). BP5.8 Services delivered to households Description: Evidence shows house visits can be a best practice and marginalized and disabled patients may benefit from them most. This item determines whether a broad range of NCD services is delivered through household visits. The visits can be done by community health workers, nurses, doctors or other staff depending on what a patient needs. Patients who benefit from home visits include disabled, marginalized or remote residents who are unable to travel. Services may include screening, diagnosis, treatment, counselling or lab services. This item also examines if home telemonitoring is being done. Rationale: There is extensive evidence from meta-analyses and reviews of the effectiveness of using community health workers to deliver basic services such as screening and routine monitoring for diabetes (Palmas et al., 2015). and hypertension (Anand et al., 2019). BP5.9 Patient education programs Description: Patient education is an important part of managing NCDs. Here we look for whether primary health care providers offer patient education on non-communicable disease and looks at the quality of information and how it is shared. Such programs should give patients a range of information on items including: • The nature of their disease • Medications, their purpose and how to take them • Self-monitoring activities (e.g. recording of weight, blood pressure, blood sugar) • Warning signs to watch for • Healthy lifestyle habits (e.g. physical activity, healthy diet, avoidance of tobacco and alcohol). Based on guidelines from the US Agency for Healthcare Research on effective design (AHRQ, 2020), educational materials provided should be in simple language for those with low literacy, use graphics and recommend actions patients should take. Information should be available in a variety of formats (paper-based, on-line, videos, posters) and individual or group sessions. Sessions can include hands-on activities such as having patients practice using glucometer, or taking cooking classes). Another recommended practice is “teach-back” where patients are asked to repeat information given to verify comprehension. Rationale: There are numerous meta-analyses on the impact of patient education interventions (Simonsmeier et al., 2022) that demonstrate their effectiveness in improving COPD (Tan et al., 2012), and diabetes (Ellis et al., 2004) and for increasing physical activity (Conn et al., 2008). As few as three minutes of advice from a physician can increase quit rates (Stead et al., 2013), while intensive education showed little added effectiveness. 41 BP5.10 Patient self-management support Description: Effective NCD care involves the patient as an active participant in day-to-day managing of their symptoms and treatment, and in making lifestyle changes that will promote better health. It goes beyond patient education programs to allow the patient to solve problems, develop care plans, and set goals with realistic time frames. Multiple successes in achieving goals build self-efficacy (having the confidence to make changes in one’s life). Best practice in self-management supports patients as they learn and implement these skills and follows up on whether goals were achieved. There are standardized programs (e.g., Stanford Model) for trainers to develop and teach these skills. Support may be delivered through a variety of models, including individual and group sessions or self-learning modules. Coaching can be done in person, by video or phone and with certified trainers or peers providing support. Rationale: Numerous meta-analyses have demonstrated the benefits of self-management support, such as improved blood pressure and blood sugar control in diabetes and kidney failure (Zimbudzi et al., 2018), improved risk factors for stroke patients (Sakakibara et al., 2017), fewer readmissions for heart failure (Feng et al., 2022), and improved symptoms, functioning and quality of life for severe mental health patients (Lean et al., 2019). BP5.11 Peer support programs Description: Peer support programs use non-professionals to help patients live with their disease. Typically, the support person has personal experience of the disease and may be a volunteer or community health worker. This tool checks whether these programs exist and whether they incorporate key features for success as defined in the scientific literature. In particular, a peer-support person: • Helps the patient apply day-to-day self-management plans to make the multiple, complex behavioral changes typical of NCD management • Provides on-going support over time • Offers emotional support and encouragement • Links the patient to clinical care and community resources. Peer support can take many forms, including phone calls, text messaging, group meetings, home visits, going for walks together and even grocery shopping; activities depend on local context and culture. The program may be particularly appealing to marginalized populations who have not had good experiences with health professionals in the past. Rationale: Numerous meta-analyses have demonstrated effectiveness in peer support programs, while noting the findings are based on low-level evidence because of limitations in how the original studies were done and lack of comparable outcomes and program design. Nonetheless, one meta-analysis of 23 peer support programs for diabetes found an average reduction in A1c was 0.7 (Fisher et al., 2017). Another meta-analysis of 11 programs in low- and middle-income countries also found reductions in A1c, fasting blood sugar and blood pressure (Werfalli et al., 2020). The Peers for Progress program, established in 2006 by the American Academy of Family Physicians Foundation, is a hub for implementing peer programs and provides research grants. Its research defined the four design features above, and also highlights the importance of providing training and on-going supervision of peers, seeking out patients rather than waiting for them to call for support and paying attention to participants’ emotions (Fisher et al., 2015). 42 Lever 6. Health care workforce BP6.1 Supply and mix of skilled health care providers Description: This item considers best practices for supply, mix and skills of providers for non-communicable disease care. It uses published data (e.g. from WHO) on the ratio of doctors, nurses and other professionals to population and to assess whether the country’s workforce, including PHC workers, is comparable to peer countries. It also looks at whether there is a broad range of different health professionals and skill sets in the PHC workforce (e.g. doctors, nurses, nurse practitioners, nurse assistants, community health workers, dieticians, mental health workers, etc.). It also verifies basic standards for competency in licensure. Rationale: Meta-analyses show that measures of quality of care are better for interdisciplinary teams with high degrees of collaboration (Saint-Pierre et al., 2018). BP6.2 Advanced models for maintaining competence Description: This best practice examines the country’s methods for continuing education of staff on NCD management. In traditional didactic teaching, speakers lectured on a topic and invited discussion afterwards. Contemporary teaching focuses on helping learners apply knowledge in practice, rather than just learn facts. Variations of this method include problem-based learning, where the work is done in a group, practice-based learning, meeting in small groups to discuss difficult cases, and simulation training, practising a patient scenario with a mannequin or actor. Some students read and watch information beforehand then spend in-person time on discussions and interactive activities. Regardless of method used, it is important these opportunities are available to all providers. The other dimension to maintaining competence is setting and implementing standards for it. Options include mandating all health providers do a certain number of training hours per year, or recertify every few years through testing of clinical skills. Failing to comply can lead to loss of practice licence or reduced pay or job opportunities. Rationale: One systematic review of 69 high-quality studies comparing interactive teaching methods to didactic lectures concluded interactive methods were associated with significantly more effective outcomes, such as higher post-training test scores, and learner satisfaction and changes in practice (e.g. medication prescribing) (Bluestone J, 2013). Effective training incorporates simulation or case-based learning, opportunities for interaction between instructor and participants, repeated sessions on the same topic and feedback to participants on whether they mastered the material. The study did not find online versus in-person learning made a difference, as long as these design features were present. It is not yet clear whether one interactive method is superior to another. 43 BP6.3 Advanced task-shifting Description: According to the WHO (WHO, 2007), task-shifting is “the rational redistribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly qualified health workers to health workers who have fewer qualifications in order to make more efficient use of the available staff.” Successful task-shifting involves ensuring the rest of the care team trusts the competency of those receiving a task. It is also important to resolve conflicts between provider groups on how tasks are divided. Examples of task-shifting opportunities for NCDs include authorizing nurses or dieticians to make medication and insulin adjustments, shifting automated tasks (e.g. using an electronic blood pressure monitor) or data entry to administrative staff and shifting counselling from doctor or nurse to nurse assistants or lay workers. Rationale: One systematic review of 21 studies confirms that task-shifting of NCD services in primary care can be carried out safely without worsening outcomes, and in some examples improved them (SL Leong, 2021), because it can allow more time to be spent with the patient. Other studies showed community health workers can effectively conduct cardiac risk assessments (Gaziano TA, 2015) and cervical cancer screening (Attipoe-Dorcoo, 2021). National guidelines for nurse-led insulin titration have been established in Ireland (National Clinical Program for Diabetes, 2023). Lever 7. Physical infrastructure BP7.1 Accessibility of primary health care facilities providing NCD care Description: This best practice examines whether NCD services in primary care are accessible to all, including those people in rural areas, members of disadvantaged group (e.g. ethnic minorities, inner city poor, homeless or nomadic populations). It looks at whether there is good regional distribution of PHC facilities to minimize travel, whether remote facilities can deliver non-communicable disease and whether special provisions have been made to open PHC services where disadvantaged groups live or congregate. Rationale: Providing services close to home reduces travel costs and improves convenience for patients. The WHO’s Primary health care monitoring framework and indicators document determines geographical accessibility by measuring the percentage of population living within 5 km (or 1 hour) of a comprehensive primary care facility or provider and 2 hours of an emergency care unit or provider. However, not all health facilities in remote areas are set up to provide NCD services and are expected to refer those patients to larger centers. This creates obvious barriers for some patients with non-communicable diseases. 44 BP7.2 Equipment for NCD services in primary health care Description: This best practice examines the availability of key equipment for managing non-communicable diseases. Ideally, the services provided using this equipment should be covered under universal health insurance. Equipment includes the following: ITEM PEN (Annex 4.3) Thermometer Basic Stethoscope Basic Blood pressure measurement device (manual. automatic) Basic Measurement tape Basic Weighing machine Basic Peak flow meter Basic 10g monofilament Basic Phlebotomy Station Glucometer Basic Tuning fork Advanced Nebulizer Advanced Pulse oximeter Advanced Hematology analyzer Biochemical analyzer (for electrolytes, cholesterol, A1c, renal function, troponin) Advanced ECG Advanced Defibrillator Advanced Retinal camera (fixed location or mobile) to screen for diabetic retinopathy Local venipuncture PEN: WHO Package of Essential NCD Interventions. Additional items not in PEN added by authors. Rationale: Most of the equipment above is derived from the WHO’s Package of Essential NCD Interventions in primary care, which lists basic equipment for all facilities and more advanced services if resources permit. Field observations while we were developing the tool led us to add three items: • Local venipuncture because lack of it can lead to barriers for patients (transportation, cost, convenience) if they have to travel to a laboratory; • Hematology analyzers are essential for managing anemia, cancer and infectious complications of NCDs; • Retinal cameras allow remote screening and potentially artificial-intelligence-based diagnosis of diabetic eye complications (Attiku et al., 2021). 45 BP7.3 Equipment for specialty NCD services Description: Although hospital-based and specialist-level services are not the toolkit’s main focus, they are important for managing NCD complications and for tertiary prevention to limit further damage to body systems. Primary health care has an important role in identifying which patients could benefit from these procedures and ensuring timely referrals. Examples include: CONDITION SERVICES REQUIRED PEN BB1 BB2 DCP3 Percutaneous coronary intervention X X Cardiovascular Cardiac rehabilitation program X Stroke rehabilitation program X Diabetes Photocoagulation for retinopathy X Peritoneal or hemodialysis X Renal failure Kidney transplantation X Pulmonary rehabilitation program X Respiratory Oxygen X Mammography X X Cancer screening Pathology lab X X Colonoscopy suite X X Cancer staging Radiology, ultrasound, bone scan, CT scan X Chemotherapy units X X Cancer treatment Radiation therapy machines X X Surgical oncology program X X PEN: WHO Package of Essential NCD Interventions. BB1: WHO Best Buys with cost-effectiveness ratio of <=$100 per DALY averted. BB2: Items recommended in WHO Best Buys that do not meet the $100 threshold for cost-effectiveness. DCP3: Disease Control Priorities 3 Rationale: These services are listed in either PEN, DCP3, or Best Buys. Low-income countries may wish to focus on items in PEN and Best buys with cost-effectiveness ratio of <=$100 per DALY averted. Items on the other lists may still be considered in low-income countries but as a lower priority; for middle-income countries, all items are appropriate. 46 Lever 8. Medicines and other health products BP8.1 Essential medicines for management of NCDs Description: This table lists essential medications for hypertension, diabetes, respiratory, cancer and other conditions: MEDICATION PEN BB1 BB2 DCP-3 Aspirin X X Diabetes first-line medications (eg metformin, sulfonylureas, insulin) X X X Diabetes second-line medications (thiazolidinediones, DPP-4 inhibitors, in rare SGLT2 inhibitors, GLP-1 agonists) cases Anti-hypertensives (thiazide diuretics, ACE inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers, X X X spironolactone) Other cardiac drugs (furosemide, isosorbide dinitrate, glyceryl trinitrate) X Clopidogrel X Lipid-lowering drugs (statins) X X Adult vaccinations (Hepatitis B vaccination X HPV X Influenza vaccination X X Pneumococcal vaccination for chronic respiratory diseases X Anticoagulants (heparin) X Salbutamol (inhaled) X X X Inhaled steroids X X Prednisolone X X in some Nicotine replacement therapy circumstances Pain medications (paracetamol, ibuprofen, codeine, morphine) X Psychiatric medications (diazepam, promethazine) X Anti-depressant X Infusions (saline, dextrose) X Epinephrine X Chemotherapy drugs X X Thrombolysis X X PEN: WHO Package of Essential NCD Interventions, Annex 4.2. BB1: WHO Best Buys with cost-effectiveness ratio of <=$100 per DALY averted. BB2: Items recommended in WHO Best Buys list that do not meet the $100 threshold for cost-effectiveness. DCP3: Disease Control Priorities 3 47 Rationale: These lists of essential medications are based on expert consensus panels facilitated by either the WHO or World Bank. Some lists designed for countries with certain national income levels. As noted above, the highest priority for low-income countries are those in the PEN and BB1 list. In middle- income countries, all should be available. BP8.2 Supplies for essential diagnostic tests. Description: This table lists essential diagnostic tests: TESTS PEN BB1 BB2 DCP-3 Urinalysis (test strips) Basic X Blood sugar test strip Basic X Complete blood count X Electrolytes X Creatinine X Blood sugar X HbA1c Advanced X Cholesterol Advanced X Lipid profile Advanced X Troponin test strips Advanced Urine microalbuminuria test strips Advanced Pap smear X X HPV testing X X Fecal occult blood X X PEN: WHO Package of Essential NCD Interventions, Annex 4.2. BB1: WHO Best Buys with cost-effectiveness ratio of <=$100 per DALY averted. BB2: Items recommended in WHO Best Buys list that do not meet the $100 threshold for cost-effectiveness. DCP3: Disease Control Priorities 3 Rationale: As noted above, the highest priority for low-income countries are those in the PEN and BB1 list. In middle-income countries, all should be available. 48 Lever 10. Purchasing and payment BP10.1 Predictable funding for PHC sites and providers and efficient procurement Description: This best practice examines whether heath facilities and individual providers are paid reliably and on time. Payment delays can occur because of government revenue shortfalls or cumbersome administrative processes. Delayed salaries may lead to low staff morale and loss of personnel. Late fund transfers to facilities may lead to missing supplies and delayed maintenance or repair of equipment. Rationale: Primary health care organizations need to receive adequate funding on time, or risk failing to meet patient needs. Similarly, not being paid undermines staff commitment to their work will suffer low morale, possibly affecting their work which could compromise patient care. Numerous media reports of inability to pay on time suggest this is a significant problem in some low-income countries (Press Trust of India, 2020). BP10.2 Strong supply-chain management Description: Strong supply chains are necessary to ensure drugs and supplies move smoothly from the supplier to the health facility. This best practice examines whether primary care centers often run out of stock and looks for root causes of these failures. Best practices to avoid supply-chain issues include: • an efficient centralized procurement and purchasing system • analytical capability to forecast demand for drugs and supplies • ability to track and manage inventory in a timely fashion (ideally, electronically) • a good relationship with suppliers • an efficient transportation system to bring drugs from warehouse to PHC site • pull systems to signal when stocks require replenishment Rationale: Running out of supplies can lead to missed or inadequate treatments or tests. Lever 11. Digital technologies BP11.1 Basic computer and internet Description: This item examines whether clinics have access to basic technologies including functioning computers, reliable internet service and personnel with basic computer literacy. Rationale: Basic computers and internet are essential building blocks for record keeping, communicating, on-line training and future digitalization but health facility surveys show many primary care centers in low- and middle-income countries lack them. For example, 45% of facilities in Nepal in 2021 lacked computers and internet (Ministry of Health, Nepal, 2022), as did 31% of public facilities in Senegal in 2019 (Agence Nationale de la Statistique et de la Démographie, 2020), and 42% of facilities in Bangladesh in 2017 (NIPORT, 2020). 49 BP11.2 Electronic medical records Description: Electronic medical records are a building block of good care. This item examines whether PHC sites have electronic medical records (EMRs) and how well they are used. It also explores whether there is a common EMR throughout the country or national standards for different systems, the extent of interoperability with other systems (in labs, hospitals or other PHC sites), and their ability to exchange information (e.g. with specialist, hospital, lab, pharmacy). It also examines whether the system is user- friendly (i.e. easy to navigate with minimal steps for each action) and used for decision support. Rationale: Well-designed EMRs can consolidate patient information, keep all providers up to date, avoid handwriting interpretation errors and make it easier to exchange information Lever 12. Systems for improving the quality of care BP12.1 Practice guidelines for NCDs Description: This item looks at whether primary care organizations have clinical practice guidelines for common NCDs, including diabetes, hypertension, coronary artery disease, heart failure, COPD, asthma, depression and cancer, as well as for reducing risk factors (physical inactivity, poor diet, alcohol, tobacco). It examines whether the guidelines are evidence-based, up-to-date and account for the level of resources available to the country. Rationale: Standardized, effective care requires practice guidelines to define the services to be provided to patients at different stages of their condition. BP12.2 Decision support tools for NCD Description: This item examines whether PHC providers have tools such as flowsheets for chronic disease management; checklists; algorithms for diagnosis, treatment selection or referral; and/or protocols for adjusting medications such as insulin. At the hospital level, the item examines if physicians use similar tools as well as standardized order sets at the time of admission. For health systems with electronic medical records, this item examines whether there are electronic reminders to flag potential drug errors or safety issues, best practices to order or inappropriate orders to avoid. Rationale: Practice guidelines tell providers what activities to do at time of screening, diagnosis and follow-up, but are usually lengthy documents which are cumbersome for physicians to use on a day-to- day basis. Decision support tools help remind providers about what tasks to do in different situations and are one of the core elements of the Chronic Care model. One meta-analysis of 148 studies on these tools found major improvements in providing preventive services, ordering tests and prescribing therapies (odds ratios from 1.42 to 1.72) (Bright et al., 2012). 50 BP12.3 Standards and inspection for equipment, facilities Description: This item checks whether PCH providers have standards for equipment, supplies, infrastructure and workplace policies. It also looks for a quality assurance or inspection program to ensure the standards are followed and a process for ensuring facilities address any gaps. Particular attention is paid to whether the drugs, supplies and equipment listed above are reviewed in the inspections. Rationale: Quality assurance activities are a common component of the inspection and supportive supervision activities in many countries (Bailey et al., 2015) and should include NCD-related infrastructure. BP12.4 Quality improvement teams, training and demonstrated improvements Description: This best practice examines the level of quality improvement (QI) knowledge and skills applied to NCD management. It looks at whether facilities have a designated quality lead, quality committees or teams, and staff with formal QI training. The assessment team requests examples of successful QI projects or “collaboratives” involving multiple sites working on the same quality topic concurrently, and documentation of use of QI tools such as process maps, cause-effect (fishbone) diagrams and plan-do- study-act (PDSA) cycles. Rationale: Having a strong complement of staff trained in QI and leading improvement projects was found to be a key lever of success in a review of several high-performing health systems around the world (Baker et al., 2008). QI collaboratives combined with training have been found to be effective in improving patient outcomes, as noted in a meta-analysis of 29 studies in LMICs (Garcia-Elorrio et al., 2019). There are numerous examples of successful improvement initiatives for managing NCDs, including diabetes (Schouten et al., 2010), hypertension (Chan et al., 2020) and heart failure (Garcia-Elorrio et al., 2019). Lever 13. PHC-oriented research BP13.1 Network for NCD research Description: This item examines the number of research centers and faculty involved in NCD research, and their academic output in terms of both publications and methods and analytical tools for planning and management. It also assesses capacity to undertake common research such as measuring the burden of NCDs; evaluating effectiveness of models of care, programs or policies; determining cost-effectiveness of interventions; designing guidelines and protocols for care delivery; and developing health information systems for monitoring and evaluation. Lastly, it considers training and career development for NCD researchers; development of institutional research capacity; capacity for knowledge transfer to policy-makers; and stability of funding for research. Rationale: In May 2008, the 61st World Health Assembly endorsed the Global Strategy Action Plan for the Prevention and Control of NCDs. Its fourth objective was to “promote research for the prevention and control of NCDs.” This event led to publication of WHO’s Prioritized Research Agenda for NCDs in 2011 (WHO, 2011), which identified key research questions for each main NCD across three thematic areas: identifying causes and measuring magnitude, analyzing problems and developing solutions and applying and evaluating solutions. The agenda also calls for investing in research capacity and knowledge transfer. 51 Lever 14. Monitoring and evaluation BP14.1 Non-communicable disease surveillance data (incidence, prevalence, mortality) Description: This item examines whether the country has a system for monitoring incidence, prevalence and premature mortality rates for NCDs. The reliability and accuracy of these data are also examined. Rationale: These are core indicators for measuring burden of disease. They are recommended in the WHO’s PHC Monitoring Framework and Indicators, indicator 39 (WHO, 2022(c)). BP14.2 Person-oriented charting in primary health care Description: This item examines whether facilities have medical charts for each patient. This does not occur in many countries; instead, patients keep their medical record in a small booklet, and the health facility only records name, date and diagnosis in a log. Rationale: A medical record with clinical data accessible to the health facility allows staff to review the patient’s previous care and use the information when adjusting treatments. Records can also be reviewed in between visits to plan care. Patient records can be audited to assess care quality. keeping individual patient charts is indicator 35 in WHO’s PHC Monitoring Framework and Indicators. BP14.3 Centralized NCD registries Description: This item examines whether primary health care providers have registries for NCDs and the types of information entered. The simplest registry is a list of patients who have been diagnosed with a disease. A sophisticated electronic registry captures clinical information at each visit, which can then be used to generate quality indicators and feedback reports for providers. Rationale: Disease-specific patient registries with detailed clinical information have existed for over 60 years, starting with cancer (Pukkala et al., 2018). The number of diabetes registries worldwide is growing, and a systematic review of 21 studies showed they contain a mix of information from physical measures and lab values to socio-economic status and disease complications. The data from NCD registries can be used for disease surveillance and quality improvement. BP14.4 Reporting on quality indicators Description: This item examines whether there is a list of quality indicators for NCDs and if so, how they are reported. Indicators can be reported at multiple levels including facility, district, regional and national. 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