Health service planning requires a solid understanding of baseline disease burden and the local availability of staff, space, medications, and equipment. Baseline assessment tools will provide foundational knowledge surrounding epidemiology and service readiness at the district level.
Baseline disease burden
In the early years of NCD service decentralization, levels of coverage may be so low that population prevalence is largely irrelevant for the organization of treatment services. In this scenario, the most important information may be the mix of patients that are hospitalized with NCDs or that are presenting unscheduled to outpatient departments.
Population prevalence becomes more important for decisions regarding preventive interventions or screening programs, and as the level of treatment coverage increases.
Local clinical facility data
First-Level/District hospital registries
Information regarding the pattern of admissions at district hospitals can be extremely useful in planning during the early stages of an NCD program. Many hospitals already keep registers with data on diagnosis at admission and discharge, age, sex, home address, and length of stay, which may or may not be reported through central health management information systems (HMIS). This data can helpful to anticipate numbers of patients with severe conditions that can be connected to outpatient chronic care. Registers can help identify locally important causes of morbidity and death, such as sickle-cell disease. Additionally, these registers can be monitored to track anticipated reductions in admissions and hospitalization time for NCDs as outpatient services expand.
Population health data
In many settings, there will be limited information about death and morbidity due to NCDs at a population level. In many countries, there will be data on cause-of-death through verbal autopsy at sentinel sites or through national sample surveys. However, verbal autopsy approaches are very limited in their ability to distinguish reliably among many specific causes of death, and are probably most useful to reaffirm that NCDs are an important cause of morbidity and mortality broadly speaking. The most commonly available data regarding morbidity often comes from disease-specific health examination surveys, such as blindness, epilepsy, rheumatic heart disease, and injuries. These data are often sporadic. More commonly, data is available regarding metabolic and behavioral risk factors such as hypertension, adult-onset hyperglycemia, and tobacco use.
The Global Burden of Disease study provides comprehensive modeled estimates for mortality, prevalence, and incidence by 5-year age group for a fairly comprehensive set of NCDs. There are still gaps however, especially for less prevalent diseases like type 1 diabetes.
Population estimate information can be helpful in decisions regarding the cost-effectiveness of screening programs, relatively broad preventive measures and policies, such as penicillin for sore throats, may often be of limited use for early planning of treatment services for severe NCDs. As time goes on, population denominators can be helpful in monitoring levels of service coverage.
Table 1 - Local data sources for population prevalence of NCDs and risk factors
Global Burden of Disease (GBD) study
Global Burden of Disease (GBD) led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, provides annually updated estimates of cause and age-specific deaths, incidence, and prevalence at national level, as well as increasingly at the sub-national level. In many countries, local data supporting these estimates are very limited. Data estimates are produced largely based on the epidemiology of neighboring countries where data is available and are adjusted for local variables. These estimates represent the best possible synthesis of the available research.
WHO STEPwise Approach to NCD Risk Factor Surveillance (STEPS)
WHO STEPS tools provide guidance and materials to identify the prevalence of select NCDs and their associated risk factors. The three “steps” include community-based data collection for behavioral history, physical measurements, and biochemical measurements.
While many low and middle income countries (LMICs) have successfully conducted the survey, there are some important limitations to the tool. The tool focuses on common risk factors for NCDs in adults, rather than severe NCDs at all age groups. The core interview questions and measurements are limited to tobacco and alcohol use, diet, physical activity, overweight, blood pressure, blood glucose and lipids, and urine sodium/creatinine. For women, there is an additional question regarding a history of cervical cancer screening.
There are also optional modules focused on:
- More extensive cervical cancer screening history
- Oral health
- Tobacco policy
- Violence and injury
IDF Diabetes Atlas
Published by the International Diabetes Federation (IDF), the Diabetes Atlas provides country-level estimates for prevalence, mortality and expenditures of diabetes in low- and middle-income countries. Projections to the year 2040 are also provided.
The International Study of Asthma and Allergies in Childhood (ISAAC)
ISAAC is a collaborative research program that investigated trends in asthma, rhinoconjunctivitis, and eczema from 1991 – 2012 across 105 countries and is inclusive of over two million children. The database focuses on prevalence as well as potential causes of the diseases.
Local school surveys
Many LMICs have collected or published isolated school-based surveys of rheumatic heart disease. Such data can provide relevant estimates to a local catchment area in a similar setting.
Baseline facility assessment
Comprehensive NCD care is required in order for facilities to be prepared to provide services for severe chronic NCDs. In order to achieve this, facilities must have essential support services that are readily accessible and equipped.
- Radiology: A plain film radiography machine and a radiology technician are essential to monitor for complications and assess the differential diagnosis surrounding NCDs, especially chronic respiratory disease. Ultrasound is also key for diagnosis and management of heart failure as well as a variety of other NCDs, such as thrombosis.
- Laboratory: Several essential tests, including creatinine, electrolytes, and glucose are needed for proper diagnosis and management. Trained laboratory technicians are also critical.
- Pharmacy: In addition to an adequate supply chain of essential NCD medicines, the pharmacy will need dedicated space for NCD drug storage, including a refrigerator or other reliable cooling means for insulin.
- Social work: Protocol-based support for vulnerable NCD populations, such as Type I diabetes and rheumatic heart disease patients, will need to be incorporated into social work responsibilities. Given the need for life-long adherence,
Baseline and continuous monitoring of facility operations
A facility-level operations assessment tool guides the monitoring of operational capacity across multiple sectors of the local NCD delivery system. This tool includes essential staff, clinic space, equipment, medications, and other resources. Assessment of a facility should occur at baseline and then repeated at least annually to monitor operational quality of the NCD clinic as implementation progresses. Note that the medication list in this tool may go beyond what is considered essential for a given context, but the routine documentation of availability for “non-essential” items is still of value.