Table 2 Enablers, key components of each enabler, and lessons learned during programme implementation
Enabler | Key components | Lessons learned |
|---|---|---|
1. Decentralisation | Service set-up and empowerment of nurses to diagnose and manage DM and HTN | Nurse-led services fully operational in 7/9 PHC facilities and 1 hospital. Spread patient visits throughout the week to manage workload. Difficult to ensure regular access of mentoring teams to remote sites |
2. Integration | Two models emerged for NCD integration: either in general OPD or with HIV services. | What works best depends on individual circumstances of each health facility Choose the best fit rather than imposing a ‘one size fits all’ model |
3. Simplification | Context-adapted SOPs Experience-based fine-tuning of clinical treatment | Guideline development is a dynamic process requiring internal and external expertise, responding to user feedback |
4. Mentoring and task sharing | Multidisciplinary MSF mentoring teams and MoH mentees Mentoring curriculum comprising clinical and programmatic knowledge On-the-job support by mentor. Competence dashboard to monitor progress | Major limitations: Long travel distance for mentors, HR shortages limiting the availability of dedicated key staff for regular mentoring, high patient volume Requirement for ownership and leadership in health facilities |
5. Affordable medicines | Rational medication choices Free medications subsidised by MSF Advocacy to improve MoH medication supply to health facilities | Free medications improved access to care for patients Reliable MSF-supported supply allowed spacing of patient appointments ‘Pull factor’ of free medications increased programme demand |
6. Quality assured lab support | Use of pre-existing laboratory systems and equipment Introduction of POC machines for glucose and creatinine measurement External Quality Assurance system for HbA1c | Problems with transport of samples to central laboratory overcome by on-site POC machines Trained and motivated laboratory staff required to produce quality results when conventional machines are used |
7. Patient empowerment | Individual and group literacy sessions for DM and HTN | Successful implementation of DM and HTN literacy sessions |
8. Dedicated Monitoring and Evaluation | Design and implementation of patient records for DM and HTN consultations Data collection in electronic database and quarterly analysis Development of standard indicators | Simplification of patient records improved completeness and quality of data Dedicated M&E system improved resource quantification |
9. Referral system | Development of referral criteria to higher level for complex patients | On- and off-site decision support by doctors |