Patient and programme monitoring
Patient and programme monitoring involves the systematic collection, management, analysis and use of healthcare service delivery data at the facility level to support strategic decision-making at facility, regional and national levels. The insights generated from the data can be used to improve care quality and health outcomes, optimize operational efficiency, inform policy formulation, as well as accelerate progress towards national and global goals.
Clinical management of people with noncommunicable diseases (NCDs) and ensuring high quality service delivery can be challenging as it generally requires maintenance of reliable, longitudinal, case-based, patient data at the granularity of the facility level. Additionally, routine collection and compilation of data on resource inputs (such as pharmacy stock, staffing), processes (such as clinic scheduling and volume), treatment outcomes (such as blood pressure control, death) helps monitor programme performance, inform actions to improve performance gaps and operational efficiency. Parsimonious selection of indicators and data elements that are most informative, and electronic capture of patient medical records linked with programme data that digitally feeds into health facility information systems can reduce the burden of data collection, aggregation and analysis and improve data quality and use.
To aid with selection of standardised, informative indicators, WHO provides a suite of NCD monitoring norms and frameworks that have been developed through comprehensive process of literature review and consultation with multidisciplinary experts. WHO additionally provides digital tools for facility-based data collection, aligned with WHO norms, and which countries can customize based on national priorities, information needs and capabilities.
Resources
NCD facility-based monitoring norms and frameworks (Primary care)
WHO's Noncommunicable disease facility-based monitoring guidance: framework, indicators and application
WHO has developed the Noncommunicable disease facility-based monitoring guidance for NCD patient and programme monitoring, including a framework and parsimonious set of relevant, valid, and feasible standardized indicators to guide recording and reporting of health services data at the primary care level. Countries can use this framework to strengthen monitoring for NCDs by leveraging existing national health information systems, particularly routine health facility reporting systems and health facility survey systems.
Noncommunicable disease facility-based monitoring guidance
NCD facility-based monitoring norms and frameworks (Secondary and Tertiary care)
WHO is developing facility-based monitoring guidance for secondary and tertiary care settings, for a variety of NCDs. Facility-based monitoring in hospital and specialized care facilities provides essential information on the quality, effectiveness, and equity of health services beyond the primary care level. While primary care data capture prevention, diagnosis, and routine management, secondary and tertiary care data reflect the health system’s capacity to manage complex cases, complications, and advanced treatments such as chemotherapy and radiotherapy to treat cancer, dialysis for renal failure, and specialised surgical procedures. Monitoring at these levels helps assess referral pathways, identify gaps in continuity of care, uncover personnel needs, evaluate outcomes of inpatient and specialized services, and track the use of advanced diagnostics and medicines. Integrating hospital with primary care information systems strengthens the overall NCD surveillance and insights generated therefrom, enriching decision-making and fostering accountability for high quality services across the full continuum of the health system.
NCD facility-based monitoring digital tools and supporting publications
WHO has developed a suite of harmonized digital solutions aligned with WHO norms and standards, which are designed to help Member States improve data quality, streamline reporting, and turn routine data into actionable insights for decision-making at the facility level. These integrated digital solutions for NCDs include: WHO NCD DHIS2, WHO NCD e-Registry, CVD Risk Scoring application programming interface (API), and WHO NCD Dashboard.
Toolkit for the analysis and use of facility-based data on noncommunicable diseases
WHO has published an accompanying four-module toolkit entitled Toolkit for the analysis and use of facility-based data on noncommunicable diseases. This toolkit will facilitate implementation of the digital solutions and support stakeholders at different levels of the health system in the systematic collection of individual-level data that can be used to generate facility-level dashboards and inform strategic decision-making.
Module 1: Surveillance tools and methodologies in primary care settings
The guide contains practical tools and methodologies for evaluating the detection, diagnosis, and treatment of NCDs such as cardiovascular diseases (CVDs), diabetes, and chronic respiratory diseases (CRDs), as well as the early diagnosis of cancers and cervical cancer screening at facility level (as outlined in WHO’s Noncommunicable disease facility-based monitoring guidance: framework, indicators and applications.
Toolkit for the analysis and use of facility-based data on noncommunicable diseases:...
Module 2: Companion training exercises
These exercises offer programme managers in health facilities and at national offices the opportunity to practice the analysis and manual calculation of NCD core indicators for routine reporting and programme improvement. Manual calculation provides insight into what happens on the back-end of automated indicator calculations, and is also useful in paper-based settings.
Toolkit for the analysis and use of facility-based data on noncommunicable diseases:...
Module 3. WHO District Health Information System 2 (DHIS2) user manual
The WHO NCD DHIS2 package offers a standardized digital platform for collecting, managing, and analysing NCD data at health facility level. Aligned with WHO’s NCD facility-based monitoring guidance, the package incorporates recommended indicators and supports countries in establishing robust and harmonized health information systems for facility-based NCD surveillance. This manual provides operational guidance for effective deployment, configuration, and use of the WHO NCD DHIS2 in diverse contexts. Designed for health information system administrators, programme managers, health-care providers and data analysts, the manual includes step-by-step instructions for installation and configuration, accurate entry of aggregated and individual-level data, and interpretation of reports and indicators. Source code and the latest release of the package can be found on GitHub at https://github.com/WorldHealthOrganization/NCD-DHIS2/.
Toolkit for the analysis and use of facility-based data on noncommunicable diseases:...
Module 4. WHO E-Registry user manual
The WHO NCD E-Registry package delivers a holistic and unified approach to managing and monitoring NCDs at the facility level. By offering a seamless, end-to-end framework, the NCD E-Registry facilitates comprehensive disease management along the continuum of care, from patient registration to clinical evaluation, diagnosis, treatment, and follow-up care. This manual provides detailed instructions on effective configuration and use of the WHO NCD E-Registry, including data entry and accessing automatically calculated core indicators. Source code and the latest release of the package can be found on GitHub at https://github.com/WorldHealthOrganization/NCD-E-Registry.