Running NCD services: clinics, medicines, registers and quality

Good NCD care is mostly organisation. The clinical protocols for hypertension, diabetes, asthma and COPD are short; what fails is the system around them: medicines run out, patients are not followed up, nobody knows how many people are controlled. This course is about that system. It follows WHO PEN (2020), the HEARTS technical package (2018) and the WHO guidance on integrating NCD care with HIV and TB services (2023).

The WHO PEN steps for bringing NCD care into primary care

1. Engage stakeholders: the district team, facility staff, community leaders, private providers, people living with NCDs.
2. Assess the current situation: governance, financing, medicines and technologies, workforce, information systems and how services are organised now. Do a facility assessment.
3. Develop a service delivery package adapted to local needs, with protocols and referral criteria.
4. Build capacity: train staff to assess, diagnose, manage and refer, and to record data.
5. Monitor and evaluate: choose indicators and a monitoring process; the second level visits first-level facilities at least once every three months.
6. Review and plan to scale up from demonstration sites to the whole district or country.

Source: WHO PEN, 2020, section 3 (Adapting WHO PEN).

The facility assessment (WHO PEN annex 4.1)

Choosing a service model

WHO PEN asks whether NCD care will be given in the general outpatient clinic (patients see any available provider) or in a disease-specific clinic. Both can work. Things to decide:

• Daily or set days? A weekly NCD day concentrates staff and supplies but can be hard for people who work. Integrated daily care is more flexible but needs every clinician to know the protocol.
• One stop for several conditions. People with hypertension often have diabetes, HIV or depression. One visit, one record and one refill date for all of them saves time and money (lesson 7).
• Where each task happens: a vital signs station for weight and blood pressure, a consulting room, a dispensary, a place for group education.
• Who does what: agree the team roles before you start (lesson 4).

Map the patient pathway

Draw the steps a patient takes: registration, vital signs, consultation, tests, dispensing, next appointment. HEARTS gives an example patient-flow pathway. Walk it yourself and time it. Long waits and many queues are a common reason that people stop coming.

The minimum package to start

Source: WHO PEN, 2020; HEARTS technical package: implementation guide, 2018.

A stock-out of one medicine can undo a whole programme: patients lose confidence, stop coming and become uncontrolled. The HEARTS module on access to essential medicines and technology (2018) covers the four steps of the supply chain: quantification, procurement, storage and distribution. The health centre's part is mainly quantification (how much to order) and storage.

The core lists

Use your national essential medicines list as the starting point. HEARTS advises that the facility develops its own list from it, with generic name, dosage form, strength, basic unit and pack size for each item.

Essential technologies (WHO PEN annex 4.3)

• Thermometer, stethoscope, validated BP device (automated digital reading preferred for non-physician staff), tape measure, weighing scale.
• Peak flow meter with disposable mouthpieces; spacers.
• Glucometer and test strips; 10 g monofilament; urine protein and ketone strips.
• When resources allow: nebuliser, pulse oximeter, cholesterol assay, serum creatinine, urine microalbumin strips, ECG (if staff can interpret it).
• Tools: CVD risk charts, protocols and flow charts with referral criteria, patient record, register, audit tools.

The WHO list of priority medical devices for cardiovascular disease and diabetes (2021) gives more detail by level of care and technical specifications.

How much to order: the HEARTS method

1. List the products with pack sizes.
2. Know your supply interval: how often deliveries come or you collect them. HEARTS recommends monthly in most cases.
3. Work out the reorder factor: supply interval in months multiplied by 2. Monthly delivery gives a factor of 2; every 3 months gives 6; every 6 months gives 12. This covers use until the next delivery plus a buffer.
4. For a new service: estimate monthly need from the number of patients and the protocol, round up to whole packs, then multiply by the reorder factor.
5. Once the service is running: order to a maximum stock level based on past consumption.

• After about six months, compare actual monthly consumption from the stock cards with your estimates, and find the reason for any large difference (HEARTS).
• Order as often as you can: forecasting two or three months ahead is less accurate than one month, and early stock-outs lose patients' trust (HEARTS).
• Watch slow-moving items so they do not expire; rotate stock (HEARTS).
• Remember consumables: strips, lancets, mouthpieces, reagents and gloves need forecasting too.

Storage

• A secure, lockable, cool, dry and well-organised store, with stock cards or a stock register for every item (HEARTS).
• Insulin needs refrigeration; check and record the fridge temperature, and have the log reviewed regularly (HEARTS).
• Store glucose and urine test strips as the maker instructs; an error code on the meter means checking the meter and strips before testing more patients (HEARTS).
• Keep medicines that look alike apart, and label clearly (HEARTS).

Measure availability

HEARTS uses one simple indicator: the proportion of facilities reporting no stock-out of core CVD and diabetes medicines in the last quarter. The target is no stock-out. Record the number of days each item was out of stock; it is the evidence you need to get the supply chain fixed.

Source: HEARTS technical package: access to essential medicines and technology, 2018; HEARTS: systems for monitoring, 2018; WHO PEN, 2020; WHO Model List of Essential Medicines, 24th list, 2025; WHO list of priority medical devices for management of cardiovascular diseases and diabetes, 2021.

A register turns individual care into a programme. It tells you how many people are on treatment, how many are controlled, how many have been lost, and whether things are getting better. HEARTS: systems for monitoring (2018) gives a small set of standard indicators and the tools to collect them, designed to work on paper in any setting.

Three tools

HEARTS describes three ways to keep records: paper only; a hybrid with a paper or electronic longitudinal register; and full electronic records. Start with what you can sustain. Give every patient a unique ID number and write it on the card, the register and the patient-held booklet.

The core facility indicator

The HEARTS facility indicator is six-monthly control of blood pressure among people treated for hypertension. It is a cohort measure: it follows a defined group of patients, all registered in the same quarter, and asks how many are controlled six months later.

The other HEARTS indicators

For diabetes, WHO PEN (annex 4.5) suggests: the number of patients (and new patients) treated, reported monthly; the control rate among people treated, every 6 months (HbA1c under 7.0%, or fasting plasma glucose under 7.0 mmol/L (126 mg/dL), at the last visit in the last 6 months); and new complications each year (foot, kidney, eye, nerve and cardiovascular).

Good data habits

• Record the BP at every visit, on the card and in the register's quarterly column.
• Write the next appointment date on the card and in the appointment book before the patient leaves.
• Mark transfers out, deaths and losses to follow-up when you learn of them.
• Each quarter, review a sample of 5 to 10 records with the HEARTS clinical audit tool: are the card and register consistent, and was the protocol followed? (lesson 6)
• Fewer, well-collected indicators are better than many that are incomplete or never used (HEARTS).

Source: HEARTS technical package: systems for monitoring, 2018; WHO PEN, 2020, annex 4.5.

There are not enough doctors to treat everyone with an NCD. HEARTS: team-based care (2018) describes two approaches, often combined. Task shifting moves clinical and non-clinical tasks from one type of health worker to another (for example from medical officers to clinical officers and nurses). Team-based care shares the work among members of a team, each with a clear role. Strong evidence shows team-based care improves blood pressure control cost-effectively.

What it achieves (HEARTS)

• More access: more hours of care and shorter waits.
• Better follow-up and adherence; better BP control and outcomes.
• Better patient knowledge and quality of life; saves time for patients and staff.
• Higher satisfaction for patients and clinicians.

What gets in the way (HEARTS)

Rapid staff turnover, skills that fade without practice, patients who prefer to see a doctor, doctors' reactions, and laws and policies that limit who can prescribe.

Requirements for safe task-sharing (HEARTS)

• Consult and coordinate with the physician.
• Train health workers in their new skills.
• Enable more health workers to prescribe or refill, as national rules allow.
• Define each role and responsibility clearly.
• Arrange close supervision, mentoring and support.
• Hold regular team meetings to discuss patients and problems.
• Measure processes and outcomes.

Who can do what

WHO PEN notes that in facilities with only non-physician health workers, most core NCD medicines are used to refill prescriptions issued by physicians at a higher level. WHO PEN also asks which staff cadres have authority to prescribe or authorise refills: find out your national rules before you design the team.

A team in practice (HEARTS country example)

In one country example in HEARTS, a doctor makes the diagnosis and adjusts treatment for people not at target; a nurse sees controlled patients; a senior nurse runs the service and prescribes continuing medicine without changing the drug or dose; a pharmacist checks adherence; a data clerk enters BP and treatment into the registry, phones patients who miss appointments and prints the next day's list. Controlled patients are moved to a nurse-run facility nearer home, where the nurse refills medicines and adjusts doses after talking with the doctor by phone.

The six HEARTS implementation steps

1. Engage the team, with a leader who has enough authority.
2. Decide the team's composition: who could learn a new role?
3. Design workflows for the new model of care.
4. Improve communication within the team and with patients.
5. Introduce changes gradually.
6. Keep improving the model.

Use a task reassignment table: for each task, who does it now, who would do it in a perfect world, and what training they need.

Source: HEARTS technical package: team-based care, 2018; HEARTS: implementation guide, 2018; WHO PEN, 2020.

Long-term conditions need long-term contact. Most of the benefit of treatment is lost when people stop coming, run out of medicines or take them irregularly. This lesson is about the systems that keep people in care.

How often to see people

An appointment system that shows who is missing

• Give a date, not 'come back in a month'. Write it on the patient-held card, the treatment card (HEARTS has a 'date of next visit' field) and the appointment book or register.
• At the end of each clinic day, list everyone due that day who did not come.
• Agree a local rule for when a missed appointment becomes a 'defaulter' to trace (for example, not seen within a set number of days of the due date), and when someone is recorded as lost to follow-up in the register.
• Record every outcome of tracing: returned, transferred, moved, died, refused, not found.

Tracing

In the HEARTS team-based care examples, a data clerk prints the list of people who missed appointments and phones them to give a new date; in another, pharmacies report people who are not collecting their antihypertensive medicines. Community health workers can visit people without phones. Trace early: a person who has missed one refill is much easier to bring back than someone who has been away for six months.

Why people stop taking medicines

HEARTS lists the factors: availability and cost of medicines, cultural background, other illnesses, age, sex, allergies, personal preferences, and beliefs such as 'if I have no symptoms I am not sick'. Add side effects, the number of tablets, travel costs and waiting times. Ask about each in a non-judgemental way.

What helps (WHO PEN and HEARTS)

• Explain the reason for each medicine, and the difference between medicines for long-term control (for example blood pressure) and for quick relief (for example wheeze).
• Show the dose, say how many times a day, label and package the tablets, and check understanding before the person leaves (WHO PEN).
• Explain that medicines must be taken regularly even without symptoms, and that the person should never let the supply run out (WHO PEN).
• Simplify: once-daily medicines, fixed-dose combinations, aligned refill dates for all conditions.
• Group education can be a cost-effective way to deliver self-care education (WHO PEN self-care).
• Consider bulk (longer) dispensing for stable patients to improve adherence, if your supply allows (HEARTS). HIV programmes already give multi-month refills to stable patients (WHO NCD integration guidance, 2023).
• Agree a self-care plan: home BP or glucose monitoring where affordable, written action plans for asthma and COPD (WHO PEN).

Your blood pressure tablets work only while you take them. You will feel the same whether you take them or not, so take them every day and come before they run out. If anything makes that hard, tell us and we will try to help.

Source: WHO Guideline for the pharmacological treatment of hypertension in adults, 2021; WHO PEN, 2020; HEARTS technical package: team-based care, and access to essential medicines and technology, 2018; WHO Integrating the prevention and control of NCDs in HIV/AIDS, TB and SRH programmes, 2023.

Measuring is only useful if someone acts on the result. HEARTS: systems for monitoring (2018) describes clinical audit as part of continuous quality improvement: compare care with clear standards, then agree strategies to close the gap. WHO PEN (2020) asks for periodic audits of facilities and supervision visits at least every three months.

Choose a few indicators

Clinical audit in one hour

1. Pick 5 to 10 treatment cards at random (for example every tenth card in the box).
2. For each, check against the protocol: BP recorded at each visit? If above target, was treatment increased? Statin given when indicated? Annual urine and foot checks in diabetes? Next appointment date written? Card consistent with the register?
3. Count how many met each standard.
4. Discuss the findings with the team, and use one or two cards as teaching cases.

Source: HEARTS: systems for monitoring, 2018, table 9 and annex (supervision and clinical audit tools).

A simple improvement cycle

1. Measure: what is the current level? (for example control rate 38%)
2. Find the cause: look at the breakdown and the audit. Are people missing visits, or attending but not stepped up, or running out of medicines?
3. Change one thing: choose a change the team can make now (for example a nurse checks every card with BP above target before the patient leaves).
4. Measure again: next month or next quarter. Keep the change if it worked; adapt it if not.

Plot the indicator each month or quarter on a chart on the clinic wall. A line that the whole team can see is more motivating than a number in a report.

Reviewing data at each level (HEARTS)

Source: HEARTS technical package: systems for monitoring, 2018; WHO PEN, 2020.

People living with HIV now live long lives, and many develop hypertension, diabetes, heart disease and some cancers. TB is more common and more dangerous in people with diabetes. WHO's guidance on integrating NCDs into HIV, TB and sexual and reproductive health programmes (2023) argues for moving away from separate disease silos towards integrated, person-centred primary care. It sets out 18 strategic actions in five areas: people and communities, policy and leadership, financing, capacity and infrastructure, and the model of care.

TB and diabetes: what WHO recommends

Why it matters: people with diabetes have about 1.9 times the risk of developing TB (one study found 4.2 times in type 1 diabetes); in 2019 about 15% of people with TB were estimated to have diabetes; and diabetes raises the risk of dying during TB treatment and of relapse (WHO TB handbook, 2024).

HIV and NCDs: practical integration

• Measure blood pressure for every adult at routine visits, and blood glucose in people with risk factors (WHO 2023 integration guidance).
• Screen women living with HIV for cervical cancer from age 25, every 3 to 5 years with HPV testing (every 3 years with VIA), as in the WHO 2021 guideline.
• Ask about tobacco and alcohol, and screen for depression.
• Use existing HIV structures (vital signs station, appointment systems, adherence support, multi-month refills) for NCDs too.

Designing an integrated service

Medicine safety

• Rifampicin, the core TB medicine, interacts with many other medicines: it lowers the concentration of several antiretrovirals, for example (WHO TB handbook, 2024). Check every NCD medicine against the TB and HIV regimens with your national formulary or pharmacist when TB treatment starts and stops.
• Keep one up-to-date medicine list for the person (Medication Without Harm; see the NCD extension course, lesson 6).
• Rifampicin lowers the levels of sulfonylureas such as gliclazide and may increase the glucose-lowering effect of metformin; dolutegravir increases metformin levels, so consider adjusting the metformin dose when dolutegravir is started or stopped (WHO TB handbook, 2024).
• Glucose control improves the chance of TB cure and lowers the risk of recurrence; it needs close monitoring during TB treatment and sometimes insulin (WHO TB handbook, 2024).

WHO advises delivering TB and diabetes care at the same time and place, ideally based at the TB clinic at least until the early stage of TB treatment is over, to limit TB transmission (WHO TB handbook, 2024).

WHO recognises that countries differ: those with fragile, externally supported systems should build on existing (often vertical) programmes and improve NCD services without overloading them (WHO 2023, differentiated approaches).

Source: WHO Integrating the prevention and control of noncommunicable diseases in HIV/AIDS, tuberculosis, and sexual and reproductive health programmes: implementation guidance, 2023; WHO operational handbook on tuberculosis, module 6, 2024; WHO guideline for screening and treatment of cervical pre-cancer lesions, 2nd ed., 2021.

Supply failures are common: a late delivery, a broken fridge, a tender that fails, a flood or conflict. Planning for them is part of running an NCD service. The UNHCR-led inter-agency guidance on NCDs in humanitarian settings (Bausch and colleagues, 2021, and the UNHCR and IRC operational guide, 2020) and the HEARTS module on access to medicines give the principles. For the humanitarian picture, see the page on NCD continuity in emergencies.

See it coming

• Keep a stock card for every item, with a minimum level that triggers an order (HEARTS).
• Compare stock on hand with monthly use every week for insulin, strips and the core medicines.
• Report shortages early to the district, with the number of patients affected and the days of stock left.
• Record stock-out days: the HEARTS availability indicator (no stock-out in the last quarter) is your evidence for change.

When a medicine is running short

Insulin and the cold chain

• Insulin needs refrigeration; keep a temperature log (HEARTS).
• Inter-agency guidance advises coordinating the NCD cold chain with the immunisation cold chain (Bausch and colleagues, 2021).
• The WHO NCD kit (2022) includes a cold-chain module with human insulin.
• If the fridge fails, move insulin to another working fridge (for example the immunisation fridge) and report it the same day; follow the manufacturer's storage guidance and your national guidance for insulin kept out of the fridge.

Keeping people safe while supply is disrupted

• Patient-held records (a booklet or card listing diagnoses, medicines and doses) let any clinic continue treatment (Bausch and colleagues, 2021).
• Make sure every insulin user knows hypoglycaemia treatment and the danger signs of ketoacidosis, and never stops insulin.
• Keep a list of high-risk patients with contact details so that you can reach them if supplies fail or the clinic must close.
• Avoid starting treatments that cannot be continued; choose medicines that the national system can keep supplying (Bausch and colleagues, 2021).

When the crisis is bigger

In a humanitarian emergency, the WHO NCD kit (2022) is designed for 10,000 people for 3 months, with modules for medicines, the insulin cold chain, supplies and equipment, and glucometers. The Interagency Emergency Health Kit carries only a few medicines for acute NCD problems. Inter-agency guidance also suggests buffer stock and, in insecure settings, small grab-and-go kits so that care can continue if staff must move.

Source: Jacquerioz Bausch F and others, Operational considerations for the management of NCDs in humanitarian emergencies, Conflict and Health, 2021; UNHCR and IRC, Integrating NCD care in humanitarian settings: an operational guide, 2020; WHO Noncommunicable diseases kit 2022; HEARTS: access to essential medicines and technology, 2018; WHO Model List of Essential Medicines, 24th list, 2025; WHO hypertension guideline, 2021.

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