Standardizing non-communicable diseases surveillance: a review of variables, tools, digital platforms and a proposed integrated HMIS framework
DOI:
https://doi.org/10.18203/2394-6040.ijcmph20261823Keywords:
Noncommunicable diseases, Public health surveillance, Health information systems, Health information interoperability, Speech recognition softwareAbstract
Non-communicable diseases (NCDs) account for a significant share of preventable morbidity and mortality, yet data collection on NCDs is carried out in separate, disconnected and often inconsistent ways. This review showcases the variables, tools and digital platforms used for NCD data collection, monitoring and implementation by collecting the data elements such as behavioural risks, physical measurements, biochemical markers, clinical diagnostic and treatment variables, outcomes and system performance indicators and to classify the tools used to capture and manage them. This work also proposes a baseline NCD dataset and a unified framework for integrating survey and routine care data within a single ecosystem-wide Health Management Information System (HMIS), enabling consistent measurement, programme monitoring and actionable decision support.
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References
WHO. Noncommunicable diseases. World Health Organization. 2024. Available at: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases?. Accessed on 19 March 2026.
Joy T, Paul N, Rakesh P, Leelamoni K. High prevalence of dietary and physical activity related risk factors for non-communicable diseases among apparently healthy urban women in Kochi, Kerala, South India. Int J Community Med Public Health. 2017;4:987-1. DOI: https://doi.org/10.18203/2394-6040.ijcmph20171311
WHO. Implementation Roadmap 2023–2030 for the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2030. World Health Organization. 2022. Available at: ttps://www.who.int/publications/i/item/9789240075041. Accessed on 19 March 2026.
WHO. SDG Target 3.4: Noncommunicable diseases and mental health. World Health Organization. 2021. Available at: https://www.who.int/data/gho/data/themes/topics/sdg-target-3_4-noncommunicable-diseases-and-mental-health?. Accessed on 19 March 2026.
Quiambao A, Malekpour MR, Golestani A, Heidari-Foroozan M, Ghamari S, Abbasi-Kangevari M, et al. World health Organization’s guidance for tracking non-communicable diseases towards sustainable development goals 3.4: an initiative for facility-based monitoring. eClinicalMedicine. 2025;85: 103304. DOI: https://doi.org/10.1016/j.eclinm.2025.103304
Okop K, Delobelle P, Lambert E, Getachew H, Howe R, Kedir K, et al. Implementing and Evaluating Community Health Worker-Led Cardiovascular Disease Risk Screening Intervention in Sub-Saharan Africa Communities: A Participatory Implementation Research Protocol. Int J Environ Res Public Health. 2022;20(1):217. DOI: https://doi.org/10.3390/ijerph20010298
Njiro B, Ngowi J, Ndumwa H, Amani D, Munishi C, Mloka D, et al. Non-communicable Diseases Week: Best Practices in Addressing the NCDs Burden from Tanzania. Ann Glob Health. 2023;89(1):89. DOI: https://doi.org/10.5334/aogh.4116
WHO. WHO STEPS Instrument (Core and Expanded). World Health Organization. 2014. Available at: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/steps/instrument?. Accessed on 19 March 2026.
Fernández-Niño JA, Ahmed S, Kibria GAA, Davlin S, Phadnis R, Cowan M, et al. A multi-country comparison between mobile phone surveys and face-to-face household surveys to estimate the prevalence of non-communicable diseases behavioural risk factors in low- and middle-income settings. BMJ Global Health. 2025;10(1):e016543. DOI: https://doi.org/10.1136/bmjgh-2024-017785
Marvi A, Sadeghi M, Aarabi M, Shabanikiya H, Kokabisaghi F, Houshmand E, et al. A scoping review of noncommunicable disease programs evaluation: bridging gaps and improving frameworks in primary healthcare. Health Science Reports. 2025;9(1):e7021. DOI: https://doi.org/10.1002/hsr2.71444
Thakur JS, Jeet G, Tripathy JP. m-STEPS: developing and implementing a smart innovative Android tool for noncommunicable disease risk factor (STEPS) survey in India. Int J Noncommun Dis. 2016;1(2):91-3. DOI: https://doi.org/10.4103/2468-8827.192018
Chandran A, Kumar SS, Hairi NN, Low WY, Mustapha FI. Non-communicable disease surveillance in Malaysia: an overview of existing systems and priorities going forward. Front Public Health. 2021;9:686533. DOI: https://doi.org/10.3389/fpubh.2021.698741
Smrithi NS, Sumit K, Zubair S. A qualitative study on users’ perspective on the functioning of the National Non-Communicable Disease portal in Dakshina Kannada district, Karnataka. BMC Health Serv Res. 2026;26:104. DOI: https://doi.org/10.1186/s12913-026-14008-0
Ma Y, Chen D, Xie J. Digital-Intelligent Precision Health Management: An Integrative Framework for Chronic Disease Prevention and Control. Biomedicines. 2026;14(1):223. DOI: https://doi.org/10.3390/biomedicines14010223
Song Y, Phadnis R, Favaloro J, Lee J, Lau CQ, Moreira M, et al. Using mobile phone data collection tool, Surveda, for noncommunicable disease surveillance in five low- and middle-income countries. Online J Public Health Inform. 2020;12(2):e13 DOI: https://doi.org/10.5210/ojphi.v12i2.10574
Madela S, James S, Sewpaul R, Madela S, Reddy P. Early detection, care and control of hypertension and diabetes in South Africa: A community-based approach. Afr J Prim Health Care Fam Med. 2020;12(1):a2160. DOI: https://doi.org/10.4102/phcfm.v12i1.2160
Ministry of Health, Brazil. Strategic Action Plan to Tackle Noncommunicable Diseases and Injuries in Brazil 2021–2030. Ministry of Health, Brazil. 2021. Available at: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/doencas-cronicas-nao-transmissiveis-dcnt. Accessed on 19 March 2026.
Ministry of Health and Family Welfare, Government of India. Operational Guidelines: National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD) (2023–2030). Ministry of Health and Family Welfare, Government of India. 2023. Available at: https://www.mohfw.gov.in/. Accessed on 19 March 2026.
World Bank. Samoa Returns to Community-Based Approach to Contain Rise of Non-Communicable Diseases. World Bank. 2021. Available at: https://www.worldbank.org/en/programs/multi-donor-trust-fund-for-integrating-externally-financed-health-programs/brief/samoa-returns-to-community-based-approach-to-contain-rise-of-ncds. Accessed on 19 March 2026.
Thodika NK, Janagam S, Kaniyampady ST, Ramaprasad A, Shetty A, Singai C. A Model of Cost and Time-Effective Disease Screening for Non-Communicable Diseases in India. Int Conf Health Inform. 2021;312-9. DOI: https://doi.org/10.5220/0010202103120319
Mallawaarachchi DSV, Wickremasinghe SC, Somatunga LC, Siriwardena VTSK, Gunawardena NS. Healthy Lifestyle Centres: a service for screening non-communicable diseases through primary health-care institutions in Sri Lanka. WHO South-East Asia J Public Health. 2016;5(2):89-95. DOI: https://doi.org/10.4103/2224-3151.206258
Qin J, Zhang Y, Fridman M, Sweeny K, Zhang L, Lin C, et al. The role of the Basic Public Health Service program in the control of hypertension in China: results from a cross-sectional health service interview survey. PLoS One. 2021;16(6):e0217185. DOI: https://doi.org/10.1371/journal.pone.0217185
WHO. Bibliographical section. Bull World Health Organ. 1951;4(1):141-8. Available at: https://www.who.int/publication. Accessed on 19 March 2026.
National Institute for Health and Care Excellence (NICE). Making Every Contact Count: How NICE resources can support local priorities. National Institute for Health and Care Excellence (NICE). 2019. Available at: https://stpsupport.nice.org.uk/mecc/index.html?. Accessed on 19 March 2026.
Loffreda G, Byström M, Berri HE, Fouad H, Hag E, Hammerich A, et al. Inequities in diabetes prevention and control in fragile, conflict-affected and vulnerable settings: a mixed-methods study from the WHO Eastern Mediterranean Region. BMJ Open. 2025;152025:e095500. DOI: https://doi.org/10.1136/bmjopen-2024-095500
National Health Mission. Community Based Assessment Checklist (CBAC) for NCDs. Ministry of Health and Family Welfare, Government of India. 2023. Available at: https://nhm.gov.in/. Accessed on 19 March 2026.
Katulanda P, Thulani UB, Mettananda KCD, Warnakulasuriya DTD, Peiris TSG, Kasturiratne KTAA, et al. Validation of the World Health Organization/International Society of Hypertension (WHO/ISH) cardiovascular risk predictions in Sri Lankans. PLoS One. 2021;16(6):e0252269. DOI: https://doi.org/10.1371/journal.pone.0252267
NPS MedicineWise. Heart health check items added to the MBS. NPS MedicineWise. 2019. Available at: https://www.mohfw.gov.in/. Accessed on 19 March 2026.
WHO. WHO STEPS Surveillance Manual. World Health Organization. 2024. Available at: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/steps/manuals. Accessed on 19 March 2026.
WHO. STEPwise approach to NCD risk factor surveillance (STEPS). World Health Organization. 2024. Available at: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/steps. Accessed on 19 March 2026.
National Health Mission, Odisha. Population Based Screening of Common Non-Communicable Diseases. National Health Mission, Odisha. 2024. Available at: https://nhmodisha.gov.in/guidelines/operational-guidelines-on-prevention-screening-and-control-of-common-ncd/. Accessed on 19 March 2026.
Ministry of Health, Bhutan. Guideline for Community-Based Screening of Non-Communicable Diseases. Ministry of Health, Bhutan. 2025. Available at: https://moh.gov.bt/wp-content/uploads/2025/01/A4_NCD_Screening_Guide-2.pdf. Accessed on 19 March 2026.
Riley L, Guthold R, Cowan M, Savin S, Bhatti L, Armstrong T, et al. The World Health Organization STEPwise Approach to Noncommunicable Disease Risk-Factor Surveillance: Methods, Challenges, and Opportunities. Am J Public Health. 2016;106(1):74-8. DOI: https://doi.org/10.2105/AJPH.2015.302962
IMonitorPlus. NCD E-Registry Application Manual. iMonitorPlus. 2023. Available at: https://ncderegistry.imonitorplus.com/assets/images/NCD%20E%20Registry%20Application%20Manual.pdf. Accessed on 19 March 2026.
WHO. STEPS Part 6: Templates and Forms Overview. World Health Organization. 2010. Available at: https://cdn.who.int/media/docs/default-source/ncds/ncd-surveillance/steps/part6.pdf. Accessed on 19 March 2026.
Leal Neto O, Von Wyl V. Digital transformation of public health for noncommunicable diseases: narrative viewpoint of challenges and opportunities. JMIR Public Health Surveill. 2024;10:e49575. DOI: https://doi.org/10.2196/49575
Ministry of Health and Family Welfare. National NCD Portal for Prevention and Control. Government of India. 2023. Available at: https://ncd.nhp.gov.in/?. Accessed on 19 March 2026.
Ministério da Saúde, Brazil. e-SUS APS: Atenção Primária à Saúde Digital Platform. Ministério da Saúde, Brazil. 2025. Available at: https://sisaps.saude.gov.br/sistemas/esusaps/. Accessed on 19 March 2026.
Synapxe. SmartCMS Programme: Clinic Management Services. National HealthTech Agency, Ministry of Health, Singapore. 2026. Available at: https://www.synapxe.sg/partner-us/smartcms/. Accessed on 19 March 2026.
InSTEDD and CDC Foundation. Surveda: a platform for population-level health surveillance. Online J Public Health Inform. 2020;12(2).
Huda RK, Singh J, Agneebh, Kumar P, Kumar M, Laxmikant. Diabetes care in urban India: perceptions from primary healthcare providers. Soc Sci Humanit Open. 2025;13:101340. DOI: https://doi.org/10.1016/j.ssaho.2025.102038
Armocida B, Tolonen H, Rakovac I, Formenti B, Farrington J, Ekberg A, et al. Strengthening non-communicable diseases monitoring systems in Europe through a multistakeholder collaborative approach: a key priority for advancing data-driven policymaking. Lancet Reg Health Eur. 2026;61:101553. DOI: https://doi.org/10.1016/j.lanepe.2025.101553
WHO. WHO STEPwise approach to NCD risk factor surveillance (STEPS). World Health Organization. 2024. Available at: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/steps. Accessed on 19 March 2026.
Sarvam AI. Sarvam AI. Bengaluru: Sarvam AI. 2024. Available at: https://www.sarvam.ai/. Accessed on 19 March 2026.
OpenAI. Whisper: a general-purpose speech recognition system. San Francisco: OpenAI. 2022. Available at: https://openai.com/research/whisper. Accessed on 19 March 2026.
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