Delivering Primary Care for Non-communicable Diseases: Compendium of Service Delivery Models in Low and Middle-income Countries © 2025 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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Cover Illustration: Veronica Gadea GCS, World Bank Group Design: TDL-Creative CONTENTS Acronyms 4 Introduction 5 Objective of this digest and of the compendium 7 Methodology 7 How to navigate this digest and the compendium 8 Case studies in this digest by region 9 Task-shifting to non-specialist health workers helps decentralize services and use 1 13 higher level cadres more efficiently star Friendship Bench Model for Mental Health Care in Zimbabwe 14 star Task-shifting Model for Management of Mental Health by General Practitioners 16 in Indonesia magnifyi Other notable models 18 2 Integration of NCDs and mental health care into primary health systems is essential 22 star Service with Care and Compassion Initiative (SCCI) Model in Bhutan 23 magnifyi Other notable models 25 3 Community engagement enhances outcomes and reduces barriers 28 star Heart Outcomes Prevention and Evaluation Program (HOPE 4) Model in 29 Colombia and Malaysia magnifyi Other notable models 31 4 Digital tools and telemedicine increase access to care in resource-limited settings 35 star Latin America Telemedicine Infarct Network (LATIN) in Brazil, Colombia, 37 Mexico, and Argentina 5 Multi-disease screening and integrated care improve efficiency and reach 39 star Sustainable East Africa Research in Community Health (SEARCH) Model in Kenya 40 and Uganda magnifyi Other notable models 42 6 Evidence-based, culturally adapted interventions ensure feasibility and impact 44 star PEN Fa’a Samoa: A Customized and Expanded PEN Program Model 45 magnifyi Other notable models 47 7 Strong partnerships and leadership are critical for scale-up and sustainability 48 star PRIME Model in Ethiopia, India, Nepal, South Africa, and Uganda 49 magnifyi Other notable models 52 Appendix: Compendium Case Study List 53 Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 ACRONYMS BHU Basic Health Unit CHC Community Health Campaign CHW Community Health Worker CVD Cardiovascular Disease ECG Electrocardiogram GP General Practitioner HTN Hypertension LHW Lay Health Worker LMICs Low- and Middle-income Countries MDT Multidisciplinary Teams mhGAP Mental Health Gap Action Programme (WHO) MHO Mental Health Officer NCC Nurse Care Coordinator NCD Noncommunicable Disease NPHW Non-Physician Health Worker PEN Package of Essential Noncommunicable Disease Interventions PHC Primary Health Care STEMI ST-elevation Myocardial Infarction ToC Theory of Change WHO World Health Organization 4 Acronyms Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 INTRODUCTION The global prevalence of noncommunicable prevention and control, and alleviating the burden diseases1 (NCDs) continues to escalate, leading of care at higher level facilities. New strategies and to a substantial burden of disease. NCDs account innovative solutions are needed to achieve this for 74 percent of all global deaths, causing approach and improve outcomes across the care approximately 41 million fatalities annually, with continuum, from reducing risk factors to sustainably cardiovascular diseases (CVDs), cancers, chronic managing chronic conditions at  the PHC level8. respiratory diseases, and diabetes being the main contributors.2 Low- and middle-income The Compendium Delivering Primary Care for Non-communicable Diseases: countries (LMICs) bear a disproportionate share of Service Delivery A Compendium of Service Delivery Models in Low and Middle-income Countries of this burden, experiencing around 82 percent Models in Low and of premature NCD‑related deaths.3 Middle-income Countries  compiles Yet, many health systems in low- and middle-income well‑documented, countries are inadequately prepared to deliver integrated, and effective comprehensive care for major NCDs, as primary care models to strengthen health care (PHC) services mainly focus on the NCD prevention and provision of acute and episodic care, leaving gaps management at the PHC in coverage and quality of essential services for the level. These case studies prevention, diagnosis, treatment, and long-term outline models of care management of NCDs across the care continuum.4 addressing a range of NCDs, including hypertension, diabetes, chronic respiratory conditions, cancers, While a broad range of cost-effective, equitable, CVD, and mental health conditions, which have been and evidence-based interventions to address the implemented in diverse settings across low- and growing burden of NCDs have been identified, middle-income countries. the challenge lies in effectively delivering these interventions, particularly in health systems facing significant resource constraints.5,6,7 Integrating NCD care into primary health care (PHC) services is key to expanding access to care closer to communities, supporting health promotion and facilitating NCD 1 Please note that in the context of this digest, noncommunicable diseases (NCDs) refer to conditions including hypertension, diabetes, chronic respiratory conditions, cancers, CVD, as well as to mental health conditions. 2 World Health Organization. 2023. “Noncommunicable Diseases.” Last modified September 16, 2023. https://www.who.int/ news-room/fact-sheets/detail/noncommunicable-diseases. 3 World Health Organization. 2015. “Guidance Note on the Integration of Noncommunicable Diseases into the United Nations Development Assistance Framework.” Geneva: World Health Organization. https://www.who.int/publications/i/ item/9789241508353. 4 Bitton, Asaf, Jocelyn Fifield, Hannah Ratcliffe, Ami Karlage, Hong Wang, Jeremy Veillard, Dan Schwarz et al. 2019. “Primary Healthcare System Performance in Low-Income and Middle-Income Countries: A Scoping Review of the Evidence From 2010 to 2017.” BMJ Global Health 4(Supplement 8): e001551. https://doi.org/10.1136/bmjgh-2019-001551. 5 World Health Organization. 2022. Draft Updated Appendix 3 of the WHO Global NCD Action Plan 2013– 2020. Geneva: World Health Organization. https://cdn.who.int/media/docs/default-source/ncds/mnd/2022_discussion_paper_final. pdf?s- fvrsn=78343686_7 6 Watkins, David, Jinyuan Qi, Yoshito Kawakatsu, Sarah Pickersgill, Susan Horton, and Dean Jamison. 2020. “Resource Require- ments for Essential Universal Health Coverage: A Modelling Study Based on Findings from Disease Control Priorities, 3rd Edition.” The Lancet Global Health 8(6): e829-e839. https://doi.org/10.1016/S2214-109X(20)30121-2 7 Bukhman, Gene, Ana Mocumbi, Rifat Atun, Anne Becker, Zulfiqar Bhutta, Agnes Binagwaho, Chelsea Clinton et al. 2020. “The Lancet NCDI Poverty Commission: Bridging a Gap in Universal Health Coverage for The Poorest Billion.” The Lancet 396(10256): 991-1044. https://doi.org/10.1016/S0140-6736(20)31907-3 8 Hategeka, Celestin, Prince Adu, Allissa Desloge, Robert Marten, Ruitai Shao, Maoyi Tian, Ting Wei et al. 2022. “Implemen- tation Research on Noncommunicable Disease Prevention and Control Interventions in Low- And Middle-Income Countries: A Systematic Review.” PLoS Medicine 19(7): 21004055. https://doi.org/10.1371/journal.pmed.1004055 5 Introduction Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 This digest is intended as a companion piece and entry point to the Compendium of Service Delivery Models in Low- and Middle-Income Countries. It is organized into seven sections, each highlighting a key lesson drawn from the evidence provided by the case studies compiled in the compendium and showcasing diverse examples that demonstrate how the implementation of these lessons have improved NCD care and patient outcomes. These lessons learned are: Task-shifting to non-specialist health 1 workers helps decentralize services and use higher level cadres more efficiently Integration of NCDs and mental health 2 care into primary health systems is essential 3 Community engagement enhances outcomes and reduces barriers Digital tools and telemedicine increase 4 access to care in resource-limited settings 5 Multi-disease screening and integrated care improve efficiency and reach Evidence-based, culturally adapted 6 interventions ensure feasibility and impact 7 Strong partnerships and leadership are critical for scale-up and sustainability 6 Introduction Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 OBJECTIVE OF THIS DIGEST AND OF THE COMPENDIUM The Compendium of Service Delivery Models The objective of this digest is to introduce the in Low and Middle-income Countries  is an compendium’s findings by outlining some of the implementation-oriented resource that aims to key lessons learned from the implementation of provide valuable support to countries in shifting effective PHC-based integrated care models. their focus from acute, episodic care to integrated The lessons learned are illustrated in sections 1 and coordinated, PHC-based chronic care services, to 7. The digest also aims to serve as an accessible including referral and coordination with higher levelentry point to the broader compendium: in each care for acute or complex diseases. It synthesizes section, specific components that have proved to design solutions and digital health approaches that be important features of the compendium models work in diverse ways to improve access, efficiency, have been highlighted, and examples of models effectiveness, and quality of NCD care in low- and integrating these components have been provided middle-income countries. to illustrate their application. In addition, the digest showcases eight models of care which were The compendium includes a collection of 56 case selected from the compendium for their significant studies that illustrate diverse, impactful models of impact on patient health outcomes, rigorous study care implemented in different countries. These case designs, scope and scale-up potential. studies illustrate successful approaches to NCD prevention and management, highlighting key strategies, outcomes, and lessons learned, and aim to offer valuable insights and practical examples for countries seeking to implement or adapt similar models for their own contexts to support the redesign of their PHC systems. METHODOLOGY The concept of a “model of care” can be defined A detailed explanation of the methodology as the way in which specific health services are employed in the development of the compendium delivered to a patient population at and across and the case studies is available in the Methods various levels of the health system. The models section on pages 5-13 of the compendium report . featured in the compendium specifically address NCDs (including mental health conditions) and demonstrate evidence of impact. In this context, the term “integrated” refers to coordinated health services that respond to the needs of individuals across the care continuum—spanning health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation, and palliative care—and throughout the life course. 7 Objective & Methodology Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 HOW TO NAVIGATE THIS DIGEST AND THE COMPENDIUM Each model of care in the compendium has Comprehensive lists of the case studies presented been assigned a specific number, which has in the compendium–classified by region, targeted been reflected in this digest. disease, model mechanism, use of digital health interventions, geographical setting and country The digest aims to present a broad (and non- income level are provided on pages 15-29 of the exhaustive) overview of the diverse range of compendium report. In addition, a complete list of case studies compiled in the compendium and the case studies compiled in the compendium is is structured around 7 key lessons learned. available in the Appendix for reference. Each section provides an overview of a lesson learned, and showcases one or two featured case studies which illustrate its practical application, as well as examples of other notable models which leverage similar components. This digest only aims to provide a short introduction to the service delivery models presented, and readers are invited to refer to the compendium to read the full case study describing each model of care, using the case study numbers provided. Delivering Primary Care for CLASSIFICATION LISTS Non-communicable Diseases: A Compendium of Service Delivery Models in Low and Middle-income Countries ARROW-RI Region All case studies are classified below by World Bank region, including East Asia and Pacific, Europe and Central Asia, Latin America and the Caribbean, Middle East and North Africa, South Asia, and Sub-Saharan Africa, or as multi- ARROW-RI System-integrated and Technology-enabled Model of Care (SINEMA) in China regional. Country # Model USING MOBILE HEALTH TO SUPPORT VILLAGE DOCTORS East Asia and Pacific IN IMPROVING CARE AND OUTCOMES FOR PATIENTS China  1 System-integrated and Technology-enabled Model of Care (SINEMA) in China WITH A HISTORY OF STROKE  2 Peer Leader-support Program (PLSP) Model for Diabetes Self-management in China 1 3 Chinese Older Adult Collaborations in Health (COACH) Model Geographic locale Nanhe County, Hebei Province, China Indonesia 4 Task-shifting Model for Management of Mental Health by General Practitioners in Indonesia Program setting Village clinics or township health care centers in 50 villages Malaysia 5 Cardiovascular Risk Factors Intervention Strategies (CORFIS) Model in Malaysia Target disease(s) Stroke 6 Integrated Care Pathway for Post Stroke Patients (iCaPPS©) Model in Malaysia Philippines First Line Diabetes Care (FiLDCare) Model: Enhancing Diabetes Management in the Target population Clinically stable adults (>18 years) with history of stroke 7 Northern Philippines capable of basic communication 8 EffectiveNess of LIfestyle with Diet and Physical Activity Education ProGram Among Partners/Stakeholders Nanhe County and Ren County Centers for Disease Prevention and Control, Prehypertensive and HyperTENsives (ENLIGHTEN) Model in the Philippines Nanhe County Health and Family Planning Commission Samoa 9 PEN Fa’a Samoa: A Customized and Expanded PEN Program Model Thailand 10 Chronic Diseases Clinic Model: Integrating NCDs into PHC in Thailand Background: China is an upper-middle-income country with a population of 1.4 billion.1 In 2019, China had an estimated 11 WinCare Model: A Network of Homecare Providers Using the WinCare App to Support Elderly Patients with Type 2 Diabetes and Hypertension in Thailand age-adjusted prevalence of 1.6%2 for stroke, with estimated age-adjusted years of life lost of 2,097.72 per 100,000 population from stroke. 12 VICHAI’s 7 Color Balls Model for Diabetes Care in Thailand Viet Nam 13 Communities for Healthy Viet Nam Model Model Overview: The System-integrated and Technology-enabled Model of Care (SINEMA) aimed to deliver a Europe and Central Asia primary care-based integrated mobile health intervention through village doctors to improve stroke management Moldova 14 Interprofessional Management of NCDs Model in the Republic of Moldova in rural China.3 Latin America and the Caribbean Argentina DIAbetes Primary Care, Registry, Education, and Management (DIAPREM) Model in Model Strategy: SINEMA involved village doctors at the PHC level conducting monthly follow-up visits supported by 15 Argentina the Android-based SINEMA application to collect, record, and retrieve patient information and send daily education 16 Model for the Care of Individuals with Chronic Diseases (MAPEC)-Salta in Argentina on stroke risk and prevention to patients through an automated voice messaging system. Based on the information received through the app and its clinical algorithms, village doctors assessed patient health status at the monthly Brazil 17 Matrix Support Model for Chronic Respiratory Conditions and Mental Health Disorders in Brazil follow up visits (e.g., measured blood pressure (BP), reviewed stroke symptoms, and assessed medication use) and Colombia Detection and Integrated Care for Depression and Alcohol Use in Primary Care (DIADA) provided health education with a focus on patients’ medication adherence and physical activity.3,4,5 18 Compendium Model in Colombia Costa Rica 19 Community-oriented PHC Model for NCD Care in Costa Rica Notable Features of the Model: SINEMA sought to improve care for a unique population of patients in rural China with a history of stroke by enabling village doctors to provide post-stroke management care and secondary prevention of Jamaica 20 Community Engagement Mental Health (CEMH) Model for Home Treatment of Psychosis in Jamaica stroke using a mobile health intervention.3,4,5 Mexico 21 Ambulatory Care Model Incorporating Pharmacists to Improve Adherence to Diabetes and Hypertension Medication in Mexico Model Funding: A cluster-randomized controlled trial of this model was funded by the United Kingdom Medical 22 Research Council, the Economic and Social Research Council, the Department for International Development, National Integrated Management of Diabetes in Stages (MIDE) Model in Mexico Wellcome Trust, local governments, and Duke Kunshan University.3 23 DIAbetes EMPowerment and Improvement of Care (DIABEMPIC) Model in Mexico 24 Integrated Measurement for Early Detection (MIDO) Model in Mexico Peru 25 Diabetic Retinopathy Referral Network Model in Peru St. Lucia 26 HEARTS Initiative Model for Hypertension Care in St. Lucia 15 CASE STUDIES 31 Classification list sample Case study sample 8 Introduction Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 CASE STUDIES IN THIS DIGEST BY REGION Case studies are classified below by World Bank region, including East Asia and Pacific, Europe and Central Asia, Latin America and the Caribbean, Middle East and North Africa, South Asia, and Sub- Saharan Africa, or as multi-regional. Please note that the maps below only show the models included in the digest (a full list of the models compiled in the compendium is available in the Appendix). Case study number for reference in star  # Featured case studies in digest magnifyi  # the compendium report EAST ASIA AND PACIFIC CHINA   1 • System-integrated and Technology- enabled Model of Care (SINEMA)   2 • Peer Leader-support Program (PLSP) Model for Diabetes Self-management VIET NAM PHILIPPINES   13• Communities   7 • First Line Diabetes Care (FiLDCare) for Healthy Model: Enhancing Diabetes Management Viet Nam Model   8 • HyperTENsives of Lifestyle with Diet and Physical Activity Education ProGram Among Prehypertensive and HyperTENsives (ENLIGHTEN) Model THAILAND INDONESIA star  4 • Task-shifting Model for   11• WinCare Model: A Network Management of Mental Health of Homecare Providers Using by General Practitioners the WinCare App to Support Elderly Patients with NCDS SAMOA star  9 • PEN Fa’a Samoa: MALAYSIA A Customized and Expanded PEN Program   5 • Cardiovascular Risk Model Factors Intervention Strategies (CORFIS) Model 9 Introduction Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 LATIN AMERICA AND THE CARIBBEAN JAMAICA   20• Community Engagement Mental Health (CEMH) Model for Home Treatment of Psychosis COLOMBIA   18• Detection and Integrated Care for Depression and MEXICO Alcohol Use in Primary   22• National Integrated Care (DIADA) Model Management of Diabetes in Stages (MIDE) Model   23• DIAbetes EMPowerment and Improvement of Care (DIABEMPIC) Model • Integrated Measurement for   24 Early Detection (MIDO) Model ARGENTINA   15• DIAbetes Primary Care, Registry, Education, and Management (DIAPREM) Model BRAZIL, COLOMBIA,   16• Model for the Care of MEXICO, AND ARGENTINA Individuals with Chronic Diseases (MAPEC)-Salta star  27• Latin America Telemedicine Infarct Network (LATIN) Model 10 Xxxxx Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 MIDDLE EAST AND NORTH AFRICA I. R. OF IRAN   28• Model for the Integration of Suicide Prevention into PHC SOUTH ASIA NEPAL   35• Reducing Stigma Among Healthcare ­RESHAPE) Model Providers ( BHUTAN star  29• Service with Care and Compassion Initiative (SCCI) Model PAKISTAN   36• Public-private Partnership Model for Hypertension Care   37• Integrated Model for COPD and Asthma Care in Punjab INDIA   30• mWellcare Model for Integrated Management of NCDs • Home-based Service Delivery   32 Model for NCDs in Udaipur   33• Task-shifting Model for Secondary Prevention of Stroke by Community Health Workers in Kerala   34• mPower Heart Model 11 Introduction Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 SUB-SAHARAN AFRICA KENYA AND UGANDA star  52• Sustainable East Africa Research in Community Health (SEARCH) Model NIGERIA KENYA   46• Mental Health in Primary   42• Task-shifting Model for Nurse- Care (MeHPriC) Model led Management of NCDs in Kibera   43• Medication Adherence Club (MAC) Model for Hypertension, Diabetes, and HIV in Kibera   44• Mental Health and Development Model SOUTH AFRICA MALAWI   48• Collaborative Care Model for Integrated Primary Care of   45• Integrated Chronic Care Clinic Depression Comorbid with (IC 3) Model for HIV and NCDs Chronic Conditions   49• Integrated Care Disease ZIMBABWE Management (ICDM) Model star  50• Friendship Bench Model for Mental Health Care MULTI-REGION BRAZIL, INDIA, SOUTH AFRICA, ETHIOPIA, INDIA, NEPAL, SOUTH AND THE UNITED STATES AFRICA, UGANDA   53• HealthRise Model for Hypertension star  55• Programme for Improving Mental Health and Diabetes Care (PRIME) Model COLOMBIA, MALAYSIA UGANDA, SOUTH AFRICA, SWEDEN star  54• Heart Outcomes Prevention and   56• Self-management and Reciprocal Learning Evaluation Program (HOPE 4) Mode for the Prevention and Management of Type-2 Diabetes (SMART2D) Model 12 Introduction 1 Lesson learned Task-shifting to non-specialist health workers helps decentralize services and use higher level cadres more efficiently Task-shifting–the reorganization of healthcare tasks from specialized professionals to lower cadre providers with shorter training and fewer qualifications–is an essential strategy to enable the integration of NCDs into primary care and address shortages in available human resources for health. As seen in the Task-Shifting Model for Management of Mental Health by General Practitioners in Indonesia star  4 highlighted below, general practitioners may be able to provide comparable care to higher-level specialists for some settings and conditions. Other models of task-shifting allow non-physician staff such as nurses, clinical officers, or community health workers (CHWs) to provide essential services such as disease screening, patient education, medication management, and follow-up care. As illustrated by the Friendship Bench Model for Mental Health Care in Zimbabwe star  50 , CHWs and lay health workers can play an instrumental role in bringing services closer to communities and fostering trust and continuity of care to more effectively manage chronic diseases. This approach alleviates the workload of overburdened higher-level providers while increasing access to care for underserved populations, particularly when multi- disciplinary teams are used to provide access to a comprehensive range of services. As illustrated by the Friendship Bench Model for Mental Health Care in Zimbabwe, CHWs and lay health workers can play an instrumental role in bringing services closer to communities and fostering trust and continuity of care to more effectively manage chronic disease. Overall, task-shifting is a cost-effective solution to improving access to care for NCDs and reducing health care delivery costs while maintaining quality of care. Regulatory policies, supportive supervision and investment to scale-up task-shifting will support health care systems to manage and improve access to care in the context of growing NCD prevalence and constrained resources for health. Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 Task-shifting to non-specialist health workers helps decentralize services and use 1 higher level cadres more efficiently star  50 Friendship Bench Model for Mental Health Care in Zimbabwe  herapy with lay Community-based cognitive behavioral t health workers head-sid Target Psychological disorders, particularly mood disorders including conditions depression and anxiety people-g Target Adult men and women with mental health disorders such as depression population for young people and anxiety; expanded to Youth Friendship Bench  handshak Partners / Ministry of Health and Child Welfare Zimbabwe, United States Stakeholders A  gency for International Development, World Health Organization, OPHID Trust The Friendship Bench model trains lay health workers (LHWs), typically older women known as “community grandmothers,” to provide community-based psychosocial support and counseling to people experiencing depression and anxiety. First implemented in Zimbabwe, the model has now been scaled-up to 191 primary health clinics nationally and in seven other countries: Malawi, Zanzibar (semi-autonomous province of Tanzania), Viet Nam, Kenya, and Jordan, as well as in New York City and Washington DC in the United States and London in the United Kingdom. Using a train-the-trainer approach, the LHWs are trained for eight days to equip them to provide evidence-based basic cognitive behavioral therapy, with an emphasis on problem-solving therapy, activity scheduling, and peer-led group support, and paid a basic salary for their work. They are also offered ongoing supervision sessions to expand their skills and ask for advice on difficult cases. LHWs provide services outdoors, often on benches under trees to provide a safe and non-stigmatizing environment. Clients typically meet with an LHW for three or more free sessions, with LHWs referring those needing a higher-level of care. Following one-on- one talk therapy, clients are introduced to a peer-led support groups where they are connected to other community members who have also received Friendship Bench services. These groups are designed to foster a sense of belonging, reduce stigma, and provide economic opportunities such as crocheting items to sell to the community. A combination of funding sources including government, international donors, and non-governmental organizations supports the model in Zimbabwe, with the majority of costs for program implementation, scale-up, and evaluation provided by nongovernmental sources and the remainder covered by local city health department budgets. Task-shifting to non-specialist health workers helps decentralize services 14 and use higher level cadres more efficiently Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 Task-shifting to non-specialist health workers helps decentralize services and use 1 higher level cadres more efficiently star  50 Friendship Bench Model for Mental Health Care in Zimbabwe  herapy with lay Community-based cognitive behavioral t health workers circle-q Overall The Friendship Bench model has been associated with improved findings mental health outcomes. A randomized clinical trial found that intervention participants had fewer symptoms of common mental health disorders as measured by the SSQ-14 scale (ranging from 0 (best) to 14 (worst), with a cutoff of 9 for likely common mental health disorder), with a score of 3.8 (95% CI 3.3, 4.3) compared to 8.90 (95% CI 8.3, 9.5%) in the control group. The intervention group also had a 72 percent lower risk of symptoms of depression compared to the control group (13.7% vs. 49.9%). In another analysis of programmatic data on a random sample of Friendship Bench participants followed up at six weeks, 78 percent showed a significant decrease in depression symptoms. Key lessons include the importance of engaging the community and considering cultural relevance in intervention design. Community trust and respect for the “community grandmothers” allowed them to build relationships more effectively with clients to expand mental health services. Designing the intervention with scale-up and sustainability in mind was important for longer-term success. The implementers emphasize their focus on building government technical capacity—with the government ultimately leading scale- up—and integrating the model within existing services. The Friendship Bench Model for Mental Health Care Iin Zimbabwe is also an example of an effective culturally adapted intervention, as described in Section 6.  Click here to access the compendium Task-shifting to non-specialist health workers helps decentralize services 15 and use higher level cadres more efficiently Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 Task-shifting to non-specialist health workers helps decentralize services and use 1 higher level cadres more efficiently star  4 Task-shifting Model for Management of Mental Health by General Practitioners in Indonesia Shifting care from clinical psychologists to general practitioners head-sid Target  Mental health disorders conditions people-g Target  Adults ≥ 18 years population handshak Partners / Indonesia Ministry of Health, Centre for Public Mental Health, Stakeholders Health Authorities The model aimed to shift mental health care responsibilities from clinical psychologists to general practitioners (GPs) in primary care. As part of Indonesia’s 2015 initiative to introduce the WHO Mental Health Gap Action Programme (mhGAP) to 10,000 primary care clinics, the Ministry of Health adapted the framework to improve the knowledge and skills of GPs and nurses in managing mental disorders. The MoH aligned the WHO mhGAP framework with the existing skills and abilities of primary care GPs and nurses, enabling them to effectively identify and manage a wide range of psychiatric conditions, with the discretion to refer patients to specialist care, as necessary. The mhGAP-trained GPs at Puskesmas (government-run PHC clinics) provided pharmacological and psychosocial interventions based on the mhGAP guide, with referral options for specialist care. Since 2016, the Directorate of Mental Health has organized training sessions covering all mhGAP modules, including role-playing and real-world scenarios, aiming to train all Puskesmas nationwide. Task-shifting to non-specialist health workers helps decentralize services 16 and use higher level cadres more efficiently Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 Task-shifting to non-specialist health workers helps decentralize services and use 1 higher level cadres more efficiently star  4 Task-shifting Model for Management of Mental Health by General Practitioners in Indonesia Shifting care from clinical psychologists to general practitioners circle-q Overall A 2016 partially randomized pragmatic cluster trial in Yogyakarta, findings Java, evaluated patient outcomes between two groups—those treated by GPs trained in WHO mhGAP (intervention) and those treated by clinical psychologists (standard care). To mimic real- world practices, GP treatment choices and mhGAP module use were not mandated. The study found that mental health care by GPs using mhGAP was comparable to care by clinical psychologists in reducing social and physical impairments, disability, and improving quality of life. Remission rates were high in both groups. Follow-up care was more frequent with GPs and nurses (82.4 percent) than psychologists (68.8 percent). A cost-effectiveness analysis using HoNOS scores – a set of scales measuring behavior, impairment, symptoms and social functioning – showed lower costs and better outcomes with clinical psychologists, yielding an incremental cost-effectiveness ratio of Rp 4,843 per unit improvement. These findings suggest that GPs effectively managed mental health care in primary settings and patients may have preferred them, though psychologists provided a more cost-effective long-term option, likely due to referred patients having more severe impairments.  Click here to access the compendium Task-shifting to non-specialist health workers helps decentralize services 17 and use higher level cadres more efficiently Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 Task-shifting to non-specialist health workers helps decentralize services and use 1 higher level cadres more efficiently Other notable models Task-shifting of trained providers within the formal care sector globe-am Community Engagement Mental Health (CEMH) magnifyi  20 Model for Home Treatment of Psychosis in Jamaica The Community Engagement Mental Health (CEMH) Model for Home Treatment of Psychosis in Jamaica shifts mental health care from psychiatrists to mental health officers (MHOs) and mental health nurse practitioners (MHNPs) in outpatient departments and health clinics at the primary care level. Psychiatrists serve in a more clinical supervisory and administrative role for a larger patient population, while MHOs and MHNPs monitor medications and provide acute response as part of mobile crisis teams. globe-af Task-shifting Model for Nurse-led Management magnifyi  42 of NCDs in Kibera, Kenya The Task-shifting Model for Nurse-led Management of NCDs in Kibera, Kenya shifted management of stable patients with five NCDs—hypertension, Type 2 diabetes mellitus, asthma, sickle cell disease, and epilepsy— from clinical officers to nurses within PHC settings. Nurses were trained on care guidelines to support evidence-based care and supervised by clinical officers, reducing clinical officers’ workload and improving access to care. globe-as mPower Heart Model in India magnifyi  34 The mPower Heart Model in India shifted care for patients with hypertension and diabetes from physicians to nurse care coordinators (NCC), providing NCCs with training, clinical management guidelines, and a mobile decision- support system (mDSS) tool. NCCs opportunistically screened all patients aged 30 years and older for hypertension and diabetes and input clinical parameters into the mDSS tool to generate clinical risk scoring and individualized NCD care plans for review at the same appointment by physicians or clinical officers. Task-shifting to non-specialist health workers helps decentralize services 18 and use higher level cadres more efficiently Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 Task-shifting to non-specialist health workers helps decentralize services and use 1 higher level cadres more efficiently Other notable models Task-shifting to community health workers (CHWs) and lay people globe-as Mental Health and Development Model in Kenya magnifyi  44 The Mental Health and Development Model in Kenya set up psychiatric clinics within existing primary care facilities, with nurses or primary care providers diagnosing patients and then linking them to CHWs. An existing cadre of CHWs were trained to identify mental health disorders, refer to primary care or psychiatry clinics as needed, and lead monthly support groups providing psychosocial support and income-generating activities. globe-as Task-shifting Model for Secondary Prevention of magnifyi  33 Stroke by Community Health Workers in Kerala, India The Task-shifting Model for Secondary Prevention of Stroke by Community Health Workers in Kerala, India trained CHWs in rural primary care centers to provide nursing care for stroke survivors, monitor risk factors, and offer patient education and healthy lifestyle support for prevention of second strokes or transient ischemic attacks. globe-as Home-based Service Delivery Model for NCDs in magnifyi  32 Udaipur, India The Home-based Service Delivery Model for NCDs in Udaipur, India implemented home-based screening services for hypertension, diabetes, and breast, oral, and cervical cancers by recruiting and training female CHWs to support early detection and prevention. CHWs conducted screening, referred to health care facilities as needed for further evaluation and treatment, and provided education on healthy lifestyles and symptoms of common cancers. globe-as WinCare Model: A Network of Homecare Providers Using the WinCare App to Support Elderly Patients with NCDs magnifyi  11 in Thailand The WinCare Model: A Network of Homecare Providers Using the WinCare App to Support Elderly Patients with NCDs in Thailand trained a new care of nonmedical personnel, drawn from the community but not previously serving as village health volunteers, to provide weekly home visits to patients aged 60 years and older with NCDs. Using the mobile Wincare application to capture patient data and send reminders for medications and appointments, these home care providers measure blood pressure and weight and assist with meal preparation, transportation, companionship, and respite care for family caregivers. Task-shifting to non-specialist health workers helps decentralize services 19 and use higher level cadres more efficiently Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 Task-shifting to non-specialist health workers helps decentralize services and use 1 higher level cadres more efficiently Other notable models Task-shifting across multi-disciplinary teams globe-as Integrated Chronic Care Clinic (IC3) Model for HIV magnifyi  45 and NCDs in Malawi The Integrated Chronic Care Clinic (IC3) Model for HIV and NCDs in Malawi integrated human immunodeficiency virus (HIV) care and the Chronic Care Clinic to address challenges and provide comprehensive care for patients with HIV and patients with chronic NCDs regardless of HIV status. Multidisciplinary teams and task-shifting were used to optimize the use of existing health care staff. Human resources included integrated care clerks who provided screenings and recorded patient data, pharmacists, nurses who delivered direct patient care and supported management and follow-up, physicians and clinicians who were responsible for diagnosis and treatment, and administrative and operational staff, including a clinic manager and a medical director. globe-as DIAbetes EMPowerment and Improvement of Care magnifyi  32 (DIABEMPIC) Model in Mexico The DIAbetes EMPowerment and Improvement of Care (DIABEMPIC) Model in Mexico aimed to improve clinical outcomes in individuals with Type 2 diabetes by strengthening quality of care and promoting patient empowerment, with a particular emphasis on providing multi-disciplinary case management teams and self-management education. Case management teams included an endocrinologist, a podiatrist, an ophthalmologist, a nurse trained in diabetes management, a nutritionist, a psychologist, and a social worker. A medical coordinator managed quality control and assurance for the program. globe-as First Line Diabetes Care (FiLDCare) Model: Enhancing magnifyi  7 Diabetes Management in the Northern Philippines The First Line Diabetes Care (FiLDCare) Model: Enhancing Diabetes Management in the Northern Philippines used a context-adapted chronic care model to deliver primary care and self-management education and support (SME/S) for diabetes. This model involved the creation of a chronic care team comprised of the municipal or city health officer (MHO/CHO), nurse, midwives, and barangay health workers (BHWs), accompanied by task-shifting for chronic care. The MHO/CHO continued to provide clinical consultations, while SME/S activities were shifted from the MHO/CHO or the nurse to midwives and BHWs. Task-shifting to non-specialist health workers helps decentralize services 20 and use higher level cadres more efficiently Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 Task-shifting to non-specialist health workers helps decentralize services and use 1 higher level cadres more efficiently Other notable models globe-as Collaborative Care Model for Integrated Primary Care of Depression Comorbid with Chronic Conditions in magnifyi  48 South Africa The Collaborative Care Model for Integrated Primary Care of Depression Comorbid with Chronic Conditions in South Africa was designed to improve care for chronic care patients with depression by expanding the roles and responsibilities of both nurses and lay counselors. Primary care nurse practitioners were supported to diagnose and manage depression symptoms, and referral linkages were strengthened between nurses and clinic-based lay counsellors trained in cognitive behavioral therapy techniques.  Click here to access the compendium Task-shifting to non-specialist health workers helps decentralize services 21 and use higher level cadres more efficiently 2 Lesson learned Integration of non-communicable diseases and mental health care into primary health systems is essential Integrating NCD and mental health services into primary care improves access, continuity of care, and outcomes for underserved populations. Research emphasizes the significance of adopting an integrated approach to PHC, actively promoting the prevention and control of NCDs in all health care settings. Lessons learned from NCD-PHC service integration underscore the importance of adapting care models to the context and leveraging existing structures. Examples of case studies on broadening primary care models through service expansion for NCD care are provided later on in this section. By integrating evidence-based interventions into PHC systems and overcoming challenges through innovative approaches, countries can effectively manage NCDs and improve outcomes for their populations. Notably, integrating mental health into care delivery for HIV/AIDS, tuberculosis (TB), and NCDs yields mutual benefits. Human resource capacity and workload must be carefully considered for success and health care workers’ roles need to be reviewed for service delivery to be patient- centered and sustainable. Digital tools can support many aspects of the NCD and mental health service integration in primary care, ranging from better care coordination, guideline-compliant case management, improved patient tracking and clinical monitoring, as well as patient education. The Service with Care and Compassion Initiative (SCCI) Model in Bhutan star  29 integrates hypertension, diabetes, and cardiovascular care into primary health units, as presented below. Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 2 Integration of NCDs and mental health care into primary health systems is essential star  29 Service with Care and Compassion Initiative (SCCI) Model in Bhutan Facility-based PHC model with community outreach adapted from WHO PEN technical package head-sid Target  All NCDs, with cardiovascular diseases, diabetes, and hypertension conditions as priority diseases people-g Target  Adults aged 18+ years, uncomplicated patients, homebound patients population handshak Partners / Bhutan Ministry of Health, Khesar Gyalpo University of Stakeholders Medical Sciences of Bhutan, district health authorities In 2009, Bhutan became one of the first countries in the world to pilot WHO’s Package of Essential Noncommunicable Disease Interventions for Primary Health Care (PEN) program by integrating the management of chronic diseases into primary care. SCCI aims to improve the geographic coverage and equitable access of NCD services. The integration of NCD services at primary level enables a people-centered approach, reducing the time and costs for patients to manage their conditions across the continuum of care. Based on the results of increased diagnoses and follow-up visits in pilots, improved NCD management, and risk factor reduction, a 5-year national scale-up to all 20 districts began in 2019. At the Basic Health Unit (BHU) level, health assistants screen, diagnose, counsel, follow-up, treat, prescribe, and dispense medication for NCDs. The Health Centre level implements systematic NCD and risk factor screening for individuals who are overweight, obese, or aged 40 years or older with linkage to appropriate care. Refills of diverse medications are available at the BHUs or via health workers’ home visits. While hospitals continue to confirm diagnoses and prescribe specialty medicines, health assistants are trained to help patients to manage their NCDs over the long term, serving as their primary health system contact for NCDs. Specialty medications are sent to BHUs for specific patients. By ensuring health worker visits to homebound patients and emphasizing this population during trainings, SCCI is disability- and elderly-inclusive. To facilitate referrals between the primary and secondary levels, the health facilities within one district are included in a group that communicates about referrals. The MoH funds the existing human resources and essential NCD medicines while the WHO financed the trainings for health workers and provided certain supplies. 23 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 2 Integration of NCDs and mental health care into primary health systems is essential star  29 Service with Care and Compassion Initiative (SCCI) Model in Bhutan Facility-based PHC model with community outreach adapted from WHO PEN technical package circle-q Overall The pilot in Paro and Bunthang districts showed increased use of findings medications for hypertension (87% to 95%) and diabetes (96% to 98%), and reduced prevalence of high blood pressure (BP) (42% to 22%) and high blood sugar (68% to 51%). The prevalence of high 10-year-CVD risk (>20% risk) declined by almost half (from 13% to 7%) over three follow-up visits. A later evaluation in 2019 suggested that NCD patients in early adopter districts better achieved treatment goals compared to nonadopter districts (44% vs. 40%) and had higher levels of BP control (56% vs. 36%) and retention in care (52% vs. 30%) while having fewer treatment gaps (65% vs. 75%). The SCCI has also been reported as motivating health professionals and supporting task-sharing and care coordination across the health system tiers. Increased interaction, including home-care visits by health assistants or village health workers, has further helped the health care professionals to gain the trust and confidence of patients and the community and increase community-based support and cooperation. More team building, mentoring, and supportive supervision activities were recorded in the early-adopter districts during the 2019 evaluation. Additionally, social media groups were used extensively by providers for team-based care. The same study found that health workers in early-adopter SCCI districts also had increased knowledge and improved record keeping. Out-of-pocket expenditure for transportation and opportunity costs for patients decreased as their long-term care visits shifted from the district hospitals to BHUs. Key lessons from SCCI implementation were that government investment in health assistants and salaries for preexisting village health workers were invaluable drivers of SCCI success, and an asset to the health system at large. The increase in NCD case detection and treatment put the medication supply system under pressure and the higher demand for drugs therefore needs to be planned for. Utilizing existing human resources and established systems and structures allowed the initiative to be scaled at relatively low cost, but health care workers needed to cope with increased workloads, emphasizing the importance of team based collaboration and coordination.  Click here to access the compendium 24 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 2 Integration of NCDs and mental health care into primary health systems is essential Other notable models Broadening primary care models through service expansion for NCD care globe-af Mental Health in Primary Care (MeHPriC) Model in Nigeria magnifyi  46 The model supports integration of mental health services into primary care and provision of screening for depression across primary care facilities, while emphasizing an evidence-based and culturally appropriate approach. Screen- positive individuals are offered psychoeducation administered by Community Health Extension Workers. Higher scoring individuals are also offered Problem Solving Therapy or antidepressants administered by a nurse or doctor, or a combination of both if improvement is lacking. Only patients with persistent or worsened symptoms are referred to the district psychiatrist. All PHC workers receive monthly face-to-face visits and ongoing mobile telephone supervision and support from the district mental health team. globe-af Integrated Chronic Care Clinic (IC3) Model for HIV and magnifyi  45 NCDs in Malawi The IC3 model integrated HIV care and the Chronic Care Clinic to address challenges and provide comprehensive care for patients with HIV and patients with chronic NCDs regardless of HIV status. The model enabled complete integration and decentralization of HIV and chronic disease care by optimizing the use of existing health care staff, decentralizing care, improving patient flow, implementing task-shifting, enhancing data management, and strengthening supply chains. The model has effectively supported integrated care for HIV, TB, hypertension, asthma, epilepsy, and diabetes, among other conditions. globe-as Integrated Model for COPD and Asthma Care in magnifyi  37 Punjab, Pakistan This model was developed to deliver integrated chronic obstructive pulmonary disease (COPD) and asthma care at primary and secondary level public health care facilities. An evaluation generated evidence and laid the foundation for the scale-up of the model beyond three pilot districts. Clinicians at the PHC facilities screen, diagnose, treat, and refer, if necessary, and provide counselling and education especially to new patients. Missed appointments are systematically tracked, and the supply chain for the required medicines and supplies is carefully managed. Inhalers and peak flow meters are distributed at no cost to patients and seen as an incentive to remain in care. The model resulted in statistically significant improvements in clinical parameters in chronic lung disease patients, quit rate among smokers, and follow-up adherence. The model has been rolled out by Punjab’s Department of Health to all 36 districts. 25 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 2 Integration of NCDs and mental health care into primary health systems is essential Other notable models Clinical decision-support tools in primary care practice globe-as System-integrated and Technology-enabled Model of magnifyi  1 Care (SINEMA) in China The SINEMA app provides follow-up visit schedules and health education information based on clinical algorithms and patient data in the app’s electronic medical record system. globe-as mWellcare Model for Integrated Management of NCDs magnifyi  30 in India The mWellCare mobile app generates tailored and guideline-based recommendations for managing hypertension, diabetes, depression, and alcohol and tobacco use. The app also registers patients, conducts initial patient evaluation, and generates recommendations. globe-as DIAbetes Primary Care, Registry, Education, magnifyi  15 and Management (DIAPREM) Model in Argentina The digital solution includes a structured patient registry to track patient progress and prompt clinicians on best clinical care practices for patients not reaching treatment targets. globe-as Detection and Integrated Care for Depression and magnifyi  18 Alcohol Use in Primary Care (DIADA) Model in Colombia The model uses a tablet-based clinical decision support system to guide diagnosis of depression and alcohol use disorder. globe-as Communities for Healthy Viet Nam Model magnifyi  13 This broad, multipronged service delivery model includes an extensive digital solutions component facing both inwards (for health service providers to increase patient tracking, management, referral, coordination and continuity of care) and outwards (for patient use to affect behavior change and facilitate disease self-management). globe-am Integrated Measurement for Early Detection (MIDO) magnifyi  24 Model in Mexico The proprietary software SI-MIDO™ is used on computer, tablet, or mobile phone to assess patient risk, provide health education and counseling, and refer patients. 26 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 2 Integration of NCDs and mental health care into primary health systems is essential Other notable models globe-as Cardiovascular Risk Factors Intervention Strategies magnifyi  5 (CORFIS) Model in Malaysia The digital solution sends reminders to both providers and patients on specific actions to take – for example, clinical visit appointments, blood sampling, and home monitoring through a secure web-based application.  Click here to access the compendium 27 Task-shifting to non-specialist health workers is effective and sustainable 3 Lesson learned Community engagement enhances outcomes and reduces barriers Community-based approaches and service delivery play a key role in facilitating the implementation of contextually relevant solutions for better health outcomes and access to care, as illustrated by the Heart Outcomes Prevention and Evaluation Program (HOPE 4) Model in Colombia and Malaysia star  54 featured in this section. In addition, effective community engagement increases awareness of NCDs, promoting and encouraging healthy behaviors to prevent the onset of NCDs and enhancing the uptake of services. For example, leveraging trusted networks, such as families, peers, and respected community members has been shown to be an effective strategy to expand screening and access to NCD and mental health care, as demonstrated in the PEN Fa’a Samoa: A Customized and Expanded PEN Program Model star  9 (see section 6 for more details or access the full case study in the Compendium) and in the Friendship Bench Model for Mental Health Care star  50 (see section 1 for more details or access the full case study in the Compendium). Community engagement is especially key to extending reach to the most vulnerable, which ensures that interventions are both equitable and sustainable, ultimately leading to better health outcomes overall. Furthermore, interventions to support patient empowerment and self- management are essential to driving behavior change and promoting treatment adherence. Empowering individuals and the community to proactively prevent and manage NCDs contributes significantly to program sustainability, fosters knowledge co-creation, and builds community capacity to respond to health issues, increasing the responsiveness of the healthcare system to people’s health needs. Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 3 outcomes and reduces barriers Community engagement enhances  star  54 Heart Outcomes Prevention and Evaluation Program (HOPE 4) Model in Colombia and Malaysia Providing community screening by non-physician health care workers, access to free antihypertensives and statins, and encouraging support from family and friends. head-sid Target  Hypertension conditions people-g Target  Adults ≥50 years population handshak Partners / Colombia (Clínica Fundación Oftalmológica de Santander), Stakeholders Malaysia (Universiti Teknologi Majlis Amanah Rakyat) HOPE 4 was a comprehensive, collaborative, and contextually appropriate model of care that aimed to decrease CVD and improve BP control. The model was developed and implemented based on an extensive barriers assessment and qualitative health-system appraisals in Colombia and Malaysia, which provided a unique health system approach tailored to the specific national context. It involved three core elements provided as a package: 1. community screening, detection, treatment, and control of CVD by non-physician health workers (NPHWs); 2. provision of locally available antihypertensive medications and statins; and 3. the active involvement of a family member or friend in the patient’s management of CVD risk to enhance medication adherence and promote healthy behaviors. NPHWs received a one-week training and were provided with a tablet for mobile health decision-support. They were responsible for the initial screening, recruitment, and follow-up visits and visited patients in their home or at a local clinic. They also recommended locally available combination antihypertensive medications and statins—under supervision by local physicians—and delivered or arranged for patients to obtain their medications based on their preference and local context. The model’s implementation was financed through partner funding, with local governments providing partial financing support for NPHWs. 29 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 3 outcomes and reduces barriers Community engagement enhances  star  54 Heart Outcomes Prevention and Evaluation Program (HOPE 4) Model in Colombia and Malaysia Providing community screening by non-physician health care workers, access to free antihypertensives and statins, and encouraging support from family and friends. magnifyi Overall A cluster-randomized controlled trial conducted in 30 urban and findings rural communities in Colombia and Malaysia to assess the impact of the HOPE 4 model of care on CVD risk showed that HOPE 4 resulted in significantly greater reductions in Framingham risk score 10-year CVD risk, total cholesterol, and LDL cholesterol compared to the control group. Additionally, change in blood pressure control status was more than twice as high in the intervention group as compared to the control group. The study concluded that this comprehensive model of care— informed by local context, led by NPHWs, and involving primary care physicians and family—substantially improved BP control and CVD risk. Overall, the strategy was found to be effective and pragmatic, with the potential to substantially reduce CVD compared with current physician-based strategies.  Click here to access the compendium 30 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 3 outcomes and reduces barriers Community engagement enhances  Other notable models Community-based service delivery with strong community engagement globe-as Home-based Service Delivery Model for NCDs in magnifyi  32 Udaipur, India The Home-based Service Delivery Model for NCDs in Udaipur, India, involved implementing home-based screening for NCDs through CHWs. globe-as Communities for Healthy Viet Nam Model magnifyi  13 The Communities for Healthy Viet Nam Model provided community-based, people-centered hypertension and diabetes management through trained CHWs equipped with supportive job aids and mentorship to offer frequent NCD screenings in convenient community locations and directly refer individuals at high risk to partnering health facilities. globe-af Mental Health and Development Model in Kenya magnifyi  44 The Mental Health and Development Model in Kenya involved a range of community-based components including community engagement meetings; mental health action groups comprised of community stakeholders; and capacity building activities including training CHWs to identify symptoms of mental health disorders, refer to primary care of psychiatric clinics, and facilitate self-help support groups, which integrated sustainable livelihood activities. globe-af Sustainable East Africa Research in Community magnifyi  52 Health (SEARCH) Model in Kenya and Uganda The Sustainable East Africa Research in Community Health (SEARCH) Model in Kenya and Uganda implemented a comprehensive and community-centered approach, including community-wide multidisease testing—HIV, TB, malaria, hypertension, diabetes—immediate treatment, integrated person-centered care, and community engagement globe-af Programme for Improving Mental Health Care (PRIME) magnifyi  55 Model in Ethiopia, India, Nepal, South Africa, and Uganda The Programme for Improving Mental Health Care (PRIME) Model in Ethiopia, India, Nepal, South Africa, and Uganda focused on the reduction of inequities and meeting the needs of vulnerable populations, with counsellors and trained health workers working within communities to provide sensitization, home- based care, case detection, and community-based activities. 31 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 3 outcomes and reduces barriers Community engagement enhances  Other notable models globe-am Community Engagement Mental Health (CEMH) Model magnifyi  20 for Home Treatment of Psychosis in Jamaica The Community Engagement Mental Health (CEMH) Model for Home Treatment of Psychosis in Jamaica is a fully integrated PHC model that provides innovative community mental health services, and focused on community-based care, social inclusion, and collaboration with patients as an alternative to hospital- based mental health care. globe-af Integrated Care Disease Management (ICDM) Model magnifyi  49 in South Africa The Integrated Care Disease Management (ICDM) Model in South Africa leverages ward-based outreach teams (WBOTs) deployed in every community ward in the country to ensure continuity of care by interacting directly with the community. WBOTs consist of nurses and CHWs who deliver a wide range of community-level interventions including health education events and mass NCD screening events. 32 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 3 outcomes and reduces barriers Community engagement enhances  Other notable models Patient empowerment and self-management support programs globe-am Model for the Care of Individuals with Chronic Diseases magnifyi  16 (MAPEC)-Salta in Argentina The Model for the Care of Individuals with Chronic Diseases (MAPEC)-Salta in Argentina emphasized a people-centered approach to health care for individuals with chronic diseases, utilizing a range of activities, digital tools and ongoing communication through WhatsApp to support self-management. globe-am National Integrated Management of Diabetes in Stages magnifyi  22 (MIDE) Model in Mexico The National Integrated Management of Diabetes in Stages (MIDE) Model in Mexico focused on patient and provider education to promote active participation by patients, their families, and social networks to enhance effective patient-physician communication and joint decision-making. globe-af Self-management and Reciprocal Learning for the Prevention and Management of Type-2 Diabetes magnifyi  56 (SMART2D) Model in Uganda, South Africa, and Sweden The Self-management and Reciprocal Learning for the Prevention and Management of Type-2 Diabetes (SMART2D) Model in Uganda, South Africa, and Sweden aimed to develop self-management strategies that were contextually appropriate by leveraging community strategies such as community mobilization, establishing a peer support program, identifying care companions, and creating community extensions linking the community and facility. globe-af Medication Adherence Club (MAC) Model for Hypertension, magnifyi  43 Diabetes, and HIV in Kibera, Kenya The Medication Adherence Club (MAC) Model for Hypertension, Diabetes, and HIV in Kibera, Kenya, aimed to alleviate the burden on health care providers by transferring the responsibility of follow-up care to peer groups. Involving patients in self-management and peer support, and integrating multiple chronic conditions allowed for comprehensive care and support for patients with diverse health needs 33 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 3 outcomes and reduces barriers Community engagement enhances  Other notable models globe-as Peer Leader-support Program (PLSP) Model for Diabetes magnifyi  2 Self-management in China The Peer Leader-support Program (PLSP) Model for Diabetes Self-management in China is a structured initiative aimed at empowering individuals with diabetes to take control of their condition through peer support. The program focuses on providing education, guidance, and encouragement to enhance self- management skills among participants. globe-as EffectiveNess of LIfestyle with Diet and Physical Activity Education ProGram Among Prehypertensive and magnifyi  8 HyperTENsives (ENLIGHTEN) Model in the Philippines The HyperTENsives of Lifestyle with Diet and Physical Activity Education ProGram Among Prehypertensive and HyperTENsives (ENLIGHTEN) Model in the Philippines highlighted the importance of personalized care and education. The focus on non-pharmacological management of hypertension and the assignment of medical residents to oversee the health of select individuals in the target community were notable features.  Click here to access the compendium 34 Task-shifting to non-specialist health workers is effective and sustainable 4 Lesson learned Digital tools and telemedicine increase access to care in resource-limited settings Digital health tools and telemedicine can play an essential role in expanding the reach and quality of care, particularly in remote and resource-limited settings. Clinical decision support systems available on mobile devices or web-based applications are a digital health tool often used to improve quality of care. These systems provide health care providers with real-time guidance and evidence-based protocols, enabling task-shifting to lower levels of care and supporting more accurate diagnoses and guideline-based treatment. The System- integrated and Technology-enabled Model of Care (SINEMA) in China magnifyi  1 provides an excellent illustration. This model used the Android- based SINEMA application to support village doctors working at the PHC level to conduct monthly follow-up visits with post-stroke patients. The SINEMA application was used to collect, record, and retrieve patient information. This information and the app’s clinical algorithms guided village doctors in their assessment of patient health status and provision of health education at each of the monthly follow up visits. Providing digital versions of regularly updated clinical practice guidelines on office computers—one component of the Model for the Care of Individuals with Chronic Diseases (MAPEC)-Salta in Argentina magnifyi  16 —is a simple strategy that eases clinician access to guideline- based care protocols. The use of Short Message Service (SMS) and/or web-based applications to improve patient adherence to treatment and follow-up appointments and provide educational information is another important digital health strategy seen across many cases in this compendium. For example, the Cardiovascular Risk Factors Intervention Strategies (CORFIS) model in Malaysia magnifyi  5 used a secure web-based application to collect patient data, coordinate care among providers, and transmit laboratory results, as well as send patients reminders about appointments, self- monitored readings, and educational materials. 4 Lesson learned Telemedicine can link primary care providers with specialized physicians, allowing remote consultations and guidance for complex cases, including the need for urgent referral, at the first point of care. The Latin America Telemedicine Infarct Network (LATIN) in Brazil, Colombia, Mexico, and Argentina star  27 described in detail below uses this strategy to improve the quality of care for patients who have experienced an ST-segment elevation myocardial infarction (STEMI), a dangerous type of heart attack in which the coronary artery is completely blocked. Electronic medical records are a key component of telemedicine initiatives that support referral linkages. The Diabetic Retinopathy Referral Network Model in Peru 25 provides another good example of a telemedicine initiative to strengthen referral from the PHC-level to specialized care. This model uses electronic medical records and telemedicine technology to enable remote assessment and monitoring of diabetic retinopathy and improved referral to specialized care, together with clinical decision support systems that support providers in diagnosis and management. The compendium categorizes the different ways in which digital technologies are being used to support health system needs (see classification list by use of digital health interventions on pages 23-25 of the compendium report). In addition, Appendix 4 in the compendium provides a comprehensive summary of the digital components of all models using digital health interventions (DHIs) to support NCD service delivery. For each case study, the model’s digital components are mapped to the relevant DHI classification, health system strengthening (HSS) objective, and system category, following the WHO Classification of Digital Health Interventions v1.0. Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 4 Digital tools and telemedicine increase access to care in resource-limited settings star  27 Latin America Telemedicine Infarct Network (LATIN) in Brazil, Colombia, Mexico, and Argentina Using a spoke and hub telemedicine model in the initial care for ST‑segment elevation myocardial infarction head-sid Target  Cardiovascular disease, acute myocardial infarction, conditions ST-segment elevation myocardial infarction people-g Target  Primarily adults population handshak Partners / Ministries of Health, the Lumen Foundation, Stakeholders International Telemedicine Systems, Medtronic The Latin America Telemedicine Infarct Network (LATIN) aims to improve the diagnosis and timely treatment of patients experiencing heart attacks in rural and underserved areas using a telemedicine platform. It provides acute myocardial infarction (AMI) management for patients by connecting small clinics and health centers with limited diagnostic capability (spokes) to higher level facilities with increased capacity (hubs) via telemedicine. These remote telemedicine diagnostic centers provide 24/7 electrocardiogram (ECG) interpretation and teleconsultation, emergency medical system activation, and overall supervision of a STEMI activation process. Hubs support an average of five spokes, generally located between five to 250 miles away. In spoke facilities, patients presenting with chest pain receive ECGs, which are then transmitted to remote diagnostic centers for analysis and diagnosis of a STEMI. Upon diagnosis of a STEMI by an expert cardiologist, the telemedicine team triages patients and refers them to the hub facility to undergo treatment, dispatching ambulances, as necessary. The LATIN model was initially piloted in Barranquilla, Colombia, in 2013, then scaled up across 77 health facilities in Colombia (11 hubs, 66 spokes) and later expanded to Argentina, Brazil, and Mexico. The LATIN network was supported by a grant from the Medtronic Foundation, and Medtronic, Inc. provided logistical support for both the pilot and the main phase of LATIN. 37 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 4 Digital tools and telemedicine increase access to care in resource-limited settings star  27 Latin America Telemedicine Infarct Network (LATIN) in Brazil, Colombia, Mexico, and Argentina Using a spoke and hub telemedicine model in the initial care for ST‑segment elevation myocardial infarction circle-q Overall One evaluation of the pilot phase of this program in Colombia and findings Brazil found that 104 telemedicine centers were established, 62,000 ECGs were remotely interpreted, 642 STEMIs were diagnosed, and 297 patients (46 percent) with STEMI were urgently reperfused. Accuracy of ECG at detecting STEMI was 98 percent, with 5.58 minutes as time to telemedicine diagnosis. A study comparing the number of patients treated before and after the implementation of the LATIN protocol reported that the door-to-balloon time post-implementation was reduced to 32 minutes from 85 minutes (p<0.05) under the previous protocol. After the scale-up phase to all four countries (Argentina, Brazil, Colombia, and Mexico), an evaluation of all sites found that LATIN spokes (n=313) screened up to 30,000 patients monthly, totaling 780,234 patients over the evaluation period. Telemedicine experts diagnosed 8,395 patients (1.1 percent) with STEMI, of which a total of 3,872 (46.1 percent) were urgently treated at 47 hubs. A total of 3,015 patients (78 percent) were reperfused with percutaneous coronary intervention at hub facilities. Time-to-telemedicine diagnosis averaged 3.5 min, down from 37 minutes. Average door-to-balloon time improved from 120 to 48 minutes during the study period, and overall STEMI mortality was 5.2 percent, which was much lower than the only comparable data from Mexico that showed approximately 28 percent mortality from AMI.  Click here to access the compendium 38 Task-shifting to non-specialist health workers is effective and sustainable 5 Lesson learned Multi-disease screening and integrated care improve efficiency and reach Screening for NCDs helps in detecting cases early before people experience symptoms or become an acute case requiring emergency care. Screening is therefore a core strategy for prevention of diabetes and hypertension, for instance. Identifying cases early through screening is a step towards enrolling cases promptly into treatment programs, thereby reducing their risk of disease progression and complications such as stroke and diabetic retionopathy. In particular, improving case finding through enhanced, decentralized screening at convenient locations can be effective at reaching a diverse cross- section of community members. Care models that integrate multidisease screening – for example, for hypertension, diabetes, HIV, and mental health – increase program efficiency and reach, and reduce missed opportunities for diagnosis and treatment. However, screening requires a clear path to confirmatory diagnosis to be effective and also rule out false positive screenings. Overall, screening activities only improve health outcomes if positive cases are linked to care. The close collaboration between the primary care level, community-based health workers and community members is therefore essential to facilitate follow-on care as well as to create screening demand in the first place. The Sustainable East Africa Research in Community Health (SEARCH) Model star  52 has championed multidisease screening at community level, systematic linkage to care, and leveraged infectious diseases infrastructure and systems, as described below. Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 5 Multi-disease screening and integrated care improve efficiency and reach star  52 Sustainable East Africa Research in Community Health (SEARCH) Model in Kenya and Uganda Improving health outcomes for chronic diseases in rural communities using a multi-disease screening and person- centered care model head-sid Target  Diabetes, HIV, hypertension conditions people-g Target  Adults with HIV infection, diabetes, and/or hypertension population handshak Partners / Ministries of Health of Uganda and Kenya; Kenya Medical Research Stakeholders Institute; Infectious Diseases Research Collaboration, Uganda; Makerere University, Kampala, Uganda; National Institutes of Health; the President’s Emergency Plan for AIDS Relief (PEPFAR); Gilead Sciences; UNAIDS; UCL; University of California San Francisco; University of Pennsylvania; Viiv Healthcare; University of California Berkeley; University College London; World Health Organization; Infectious Diseases Research Collaboration The Sustainable East Africa Research in Community Health (SEARCH) model aimed to improve health outcomes for chronic diseases in rural communities as well as to reduce HIV incidence using a multidisease, person-centered care model. The goal was to develop sustainable health care strategies that addressed the burden of chronic diseases in Kenya and Uganda. The SEARCH model had a strong focus on hypertension (HTN) due to its prevalence and disease burden which can be averted if cases get enrolled early in care. The model included community-wide multi-disease screening, HIV treatment, integrated person-centered care, and community engagement. For screening, SEARCH staff, in collaboration with the Kenyan and Ugandan Ministries of Health local staff, conducted community health campaigns (CHCs) offering universal adult screening, linkage to care, and treatment for HTN, HIV, and diabetes to which all enumerated households were invited. Each CHC participant was queried regarding history of HTN, use of HTN medications, and HTN risk factors such as alcohol use and anxiety. Participants who screened positive for HTN (elevated BP or self-reported use of HTN medication), HIV, or diabetes were referred to care at a government health center at the third or fourth tier of the Ugandan health system, or the equivalent non-dispensary health centers in the Kenyan health system. 40 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 5 Multi-disease screening and integrated care improve efficiency and reach star  52 Sustainable East Africa Research in Community Health (SEARCH) Model in Kenya and Uganda Improving health outcomes for chronic diseases in rural communities using a multi-disease screening and person- centered care model There, patients received further evaluation, counseling, and medication from clinical officers supervised by SEARCH physicians. Each CHC was sited to be within walking distance of such a health facility. Furthermore, another significant focus of the intervention was the training of health care providers to deliver care that is friendly and centered on the needs of the patients, with the aim of nurturing positive relationships between patients and providers. Trained nurses played a crucial role in conducting BP checks during the community health campaigns, overseeing the triage system, and managing patient care. Additionally, SEARCH staff members actively participated in screening, managing community health campaigns, and following up with patients. The research received support from various sources, including the Division of AIDS and the US National Institute of Allergy and Infectious Diseases, which is part of the National Institutes of Health, PEPFAR, and Gilead Sciences through HIV medicines. magnifyi Overall Ninety-one percent of community members attending community findings health campaigns received HTN screening. One analysis in ten Ugandan communities participating in the intervention arm of the SEARCH trial reported that among all positive HTN screens, 45 percent were linked to NCD care within one year. Two-thirds of patients were treated with BP-lowering medication and one-third received lifestyle counseling only. Among those who linked to HTN care, 42 percent of the intervention group and 22 percent of the control group attended at least one clinic visit per year (p<0.0001). Among adults with baseline uncontrolled HTN, 53 percent of the intervention group achieved HTN control compared to 44 percent in the control group at 3 years (RR = 1.22, 95% CI 1.12, 1.33). There was a 21% reduction in 3-year all-cause mortality in the intervention group compared to the control group. The SEARCH model to implement population-level HTN screening and treatment through an existing HIV test-and-treat program can be adapted and scaled up in other resource-limited settings.  Click here to access the compendium 41 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 5 Multi-disease screening and integrated care improve efficiency and reach Other notable models Improving case finding through enhanced, decentralized screening globe-am HealthRise Model for Hypertension and Diabetes in Brazil, magnifyi  53 India, South Africa, and the United States This model’s primary aim was to improve screening, diagnosis, and management of hypertension and diabetes in under-resourced communities. It strengthened screening in two ways: PHC centers were equipped with digital screening tools for CHWs, and it provided community-based screening services at events, in homes, and in the workplace, with tablet-based data collection. globe-as Communities for Healthy Viet Nam Model magnifyi  13 This model focuses on community-based, people-centered hypertension and diabetes management. By using partnerships between government agencies and nongovernmental organizations, it brings NCD screening to convenient, hyper-local locations such as grocery stores, coffee shops, salons, and pharmacies. Using a list provided by the local commune health center, community collaborators also conduct home visits to screen and refer those needing diagnostic confirmation and/or care. These methods help in changing individuals’ perceptions that screening is only available as a lengthy and expensive health check at a hospital. 42 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 5 Multi-disease screening and integrated care improve efficiency and reach Other notable models Multi-disciplinary team-based care models with focus on care coordination and service integration globe-as PEN Fa’a Samoa, a Customized and Expanded PEN magnifyi  9 Program Model This model established multidisciplinary teams (MDTs) at rural district hospitals to ensure sufficient human resource capacity to manage the increased volume of NCD patients, many of whom were referred from community-based screening activities. The MDTs include a medical officer/physician, community nutritionist and assistant, data management administration officer, health inspector, nurse manager, public health nurse and midwife, and a member of the women’s health and hygiene committee. The MDTs ensure that primary care and core PHC functions can be provided, including health promotion, decentralized screening, and effective referral. (See section 6 for more details or access the full case study in the compendium) globe-as Cardiovascular Risk Factors Intervention Strategies magnifyi  5 (CORFIS) Model in Malaysia This model developed an approach of multiprofessional collaboration in the form of an allied health care team. This team consisted of a pharmacist, dietitian, and nurse educator who purposefully supported individual general practitioners in private primary care. The model targeted patients with hypertension with or without diabetes mellitus or hyperlipidemia. The allied health care team was a key component of primary care system redesign and delivered coordinated patient education, counseling, and self-monitoring guidance. Specifically, the pharmacist reviewed medications and addressed pharmaceutical care issues encountered. Dietitians provided dietary advice, while nurses offered guidance on general health care, including foot care. All these professionals collaborated closely with the GP and used a clinical information system to coordinate patient care. The allied health care team focused on individualized care, optimal medication, care continuity, and patient empowerment through home monitoring devices.  Click here to access the compendium 43 Task-shifting to non-specialist health workers is effective and sustainable 6 Lesson learned Evidence-based, culturally adapted interventions ensure feasibility and impact The case studies featured in the compendium encompass a wide range of geographies, income levels, and implementation settings, underscoring the importance of tailoring approaches to the specific contexts in which they are implemented. Indeed, tailoring interventions to specific cultural and social contexts enables NCD service delivery models to address unique barriers to care and to improve patient engagement, thereby enhancing health outcomes. For example, culturally adapted interventions are essential to overcome stigma attached to mental health conditions which, in many contexts, prevent affected persons from seeking care. Additionally, culturally relevant approaches build trust and acceptance within communities, which are critical for scaling interventions and achieving long-term sustainability, as illustrated by the PEN Fa’a Samoa: A Customized and Expanded PEN Program Model star  9 featured in this section. Furthermore, interventions to improve NCD and mental health care, including trainings for example, need to consider local constraints and cultural realities to be effective. Interventions should be tailored to available resources and integrate evidence-based design to ensure that resources are allocated efficiently. Engaging stakeholders at the local level, including healthcare professionals, communities, and people affected by NCDs and mental health conditions, is essential to design culturally appropriate models of care. Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 6 interventions ensure feasibility and impact Evidence-based, culturally adapted  star  9 PEN Fa’a Samoa: A Customized and Expanded PEN Program Model Community-based PHC model based on WHO PEN intervention, supported by multi-disciplinary teams head-sid Target  All NCDs, with a focus on diabetes, hypertension, and conditions cardiovascular diseases people-g Target  Adults, particularly high-risk adults population handshak Partners / Government of Samoa, World Health Organization, World Bank, Stakeholders New Zealand Ministry of Foreign Affairs and Trade, Australia Department of Foreign Affairs and Trade Samoa was one of the first countries to contextualize the WHO PEN protocols at the country level. The PEN Fa’a Samoa program translates to “Samoan way of life” and is a practical application of WHO PEN protocols 1 and 2 piloted as an integrated village outreach service for NCDs in 2015. One of its unique features is that it utilizes an existing, though underresourced, community structure to rapidly deploy its program: women’s health and hygiene committees or Komiti Tumama, which were trained and supported by the government to identify and refer patients with NCD risk factors within their community. The Komiti Tumama already had the community’s trust, and the local traditional governance structures approved their involvement, enabling the community actors to quickly disseminate information and screen community members. In addition, the Komiti Tumama track NCD patients in their villages, and provide follow-up visits and continued support to ensure adherence to medications or treatments, and compliance with protocols. In 2020, the program was expanded to further support the capacity of rural district hospitals through the establishment and deployment of MDTs that include a medical officer/physician, community nutritionist and assistant, data management administration officer, health inspector, nurse manager, public health nurse and midwife, and member of the Komiti Tumama stationed in rural district hospitals. The teams provide primary care and are responsible for health maintenance and disease management for the citizens in their catchment areas, carrying out core PHC functions including health promotion, screening, referral, diagnosis, and case management of NCD patients. 45 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 6 interventions ensure feasibility and impact Evidence-based, culturally adapted  star  9 PEN Fa’a Samoa: A Customized and Expanded PEN Program Model Community-based PHC model based on WHO PEN intervention, supported by multi-disciplinary teams Initially tested in two districts, by May 2023 the model had been scaled in approximately 10–12 districts, with the objective being to scale it to 37 districts by 2027. Critical to its success, the model strategy aligns with the government’s national NCD policy, and while there is a focus on NCDs in the current programming, the intention and design of the program is health systems strengthening across the board. The scale up of the model is part of the national NCD strategy and is primarily financed by the Government of Samoa, with additional support from the World Bank and the Ministries of Foreign Affairs of Australia and New Zealand. magnifyi Overall A 2018 follow-up study of the initial two districts showed high findings knowledge of the causes of hypertension (91 percent) as well as increased screening results among PEN Fa’a Samoa village residents for hypertension (70% vs. 62% for non-PEN Fa’a Samoa village residents, including 66% vs. 56% among men). During the prior 12months, more PEN Fa’a Samoa residents had their blood pressure screened three or more times (38% vs 30%), and they also had significantly better follow-up with a healthcare provider after being referred (69% vs. 50%). Additionally, a return-on-investment analysis examining the full operational and recurrent costs of the Government of Samoa’s NCD Program over the 2022–2027 period showed that every dollar invested in this project is expected to yield US$1.70 in returns. Lessons learned from this model highlight that the mobilization of the Komiti Tumama and the provision of adequate training based on context and cultural sensitivity enabled community members to overcome the cultural belief that illness is only present when a person feels ill and to educate the population about NCD risk factors and early disease. Also, donor alignment with broader government priorities as well as coordination and accountability mechanisms at the national and local levels proved critical for the success of the program.  Click here to access the compendium 46 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 6 interventions ensure feasibility and impact Evidence-based, culturally adapted  Other notable models globe-af Programme for Improving Mental Health Care (PRIME) magnifyi  55 Model in Ethiopia, India, Nepal, South Africa, and Uganda The PRIME Model in Ethiopia, India, Nepal, South Africa, and Uganda, utilized participatory “Theory of Change” workshops with extensive consultations to adapt interventions to integrate mental health care into primary care to specific country contexts. Much of the success of the PRIME model can be attributed to these workshops, which fostered community buy-in and allowed implementers to design culturally appropriate models of care. See section 7 for more details or access the full case study in the compendium. globe-af Friendship Bench Model for Mental Health Care star  50 in Zimbabwe The Friendship Bench Model in Zimbabwe is grounded in culturally sensitive therapy tailored to the local context of depression and trains lay health workers (LHWs), typically older women known as “community grandmothers,” to provide community-based psychosocial support to people experiencing depression and anxiety. See section 1 for more detail or access the full case study in the compendium. globe-as Reducing Stigma Among Healthcare Providers (RESHAPE) magnifyi  35 Model in Nepal The Reducing Stigma Among Healthcare Providers (RESHAPE) Model in Nepal aimed to address stigma as a barrier to effective mental health care in low-resource settings by adopting a holistic approach which incorporated experiential learning, the inclusion of ambassadors with lived experience, and the empowerment of primary care physicians. globe-af Mental Health in Primary Care (MeHPriC) Model in Nigeria magnifyi  46 The Mental Health in Primary Care (MeHPriC) Model in Nigeria emphasized evidence-based and culturally appropriate interventions to drive the integration of mental health services into primary care, including the wide-scale implementation of screening for depression. globe-as Heart Outcomes Prevention and Evaluation Program magnifyi  54 (HOPE 4) Model in Colombia and Malaysia The Heart Outcomes Prevention and Evaluation Program (HOPE 4) Model in Colombia and Malaysia was developed and implemented based on an extensive barriers assessment, ensuring that its health system approach was tailored to specific national contexts. See section 3 for more details or access the full case study in the compendium.  Click here to access the compendium 47 Task-shifting to non-specialist health workers is effective and sustainable 7 Lesson learned Strong partnerships and leadership are critical for scale-up and sustainability Implementing and scaling innovative models for NCD care requires strong government leadership, political will, and effective partnerships, as illustrated by the Programme for Improving Mental Health Care (PRIME) Model in Ethiopia, India, Nepal, South Africa, and Uganda star  55 featured in this section. Government leadership is essential to facilitate stakeholder alignment, ensure accountability, and allocate the necessary resources for long-term sustainability, including by securing key enablers such as the availability of essential medicines. For example, in the PEN Fa’a Samoa: A Customized and Expanded PEN Program Model star  9 , coordination and accountability mechanisms at the national and local levels, as well as donor alignment with Samoa’s national NCD strategy and priorities, proved critical for the success of the program. See section 6 for more details or access the full case study in the compendium. In addition, partnerships were fundamental to the development of many of the innovations featured in the compendium and lessons learned from implementing these models also underscore that effective collaboration between government and implementing partners must be a key consideration. Good governance, strategic partnerships, and multisectoral coordination are essential to address the complexity of NCD prevention and management. By bringing together diverse stakeholders—governments, development partners, civil society organizations, non-governmental organizations (NGOs), and private sector actors—such collaborations help align efforts, pool resources, and overcome health system challenges, enabling programs to achieve scale and long-term sustainability while delivering more equitable and cost-effective outcomes. Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 7  ritical for scale-up and sustainability Strong partnerships and leadership are c star  55 Programme for Improving Mental Health Care (PRIME) Model in Ethiopia, India, Nepal, South Africa, and Uganda A multi-country effort to generate evidence for implementing and scaling treatment programs for mental disorders in PHC settings head-sid Target  NCDs and mental health disorders including alcohol use disorder, conditions depression, psychosis, and epilepsy. people-g Target  All patients 18 years or older. population handshak Partners / Ministry of Health Ethiopia, Addis Ababa University, Ministry of Stakeholders Health India, Public Health Foundation of India, Ministry of Health Nepal, TPO Nepal, Department of Health South Africa, University of Cape Town, University of Kwazulu-Natal, Human Sciences Research Council, Ministry of Health Uganda, Makerere University/Butabiika Hospital, the World Health Organization, London School of Hygiene and Tropical Medicine. The Programme for Improving Mental Health Care (PRIME) consortium was formed to generate a high-quality evidence base for the implementation and scale up of treatment programs for mental disorders in PHC settings. The PRIME model operated from 2011 to 2019 in Ethiopia, India, Nepal, South Africa, and Uganda, and involved four components: 1. creating and applying a situational analysis tool to assess the mental health care landscape; 2. developing mental health care program plans tailored for each country using a consultative Theory of Change (ToC) methodology; 3. integrating mental health programs that are responsive to patients and stakeholders into primary and maternal health settings; and 4. evaluating and disseminating program impact. The countries where PRIME was implemented were purposively selected, in part due to their governments’ commitments to scaling up mental health care. Ministries of Health from each country were strong collaborators; all five collaborating governments had enabling policies and were committed to universal health coverage and provision of mental health services. 49 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 7  ritical for scale-up and sustainability Strong partnerships and leadership are c star  55 Programme for Improving Mental Health Care (PRIME) Model in Ethiopia, India, Nepal, South Africa, and Uganda A multi-country effort to generate evidence for implementing and scaling treatment programs for mental disorders in PHC settings Utilizing partnerships was one of the five guiding principles of the program and the project actively engaged with countries’ Ministries of Health who co-developed the ToC maps and designed models of care that could be feasibly integrated into existing health structures and policies. This partnership increased the likelihood of translating evidence to practice. In addition, the PRIME project worked with stakeholders at every level of the health system, including PHC providers, medical officers, health assistants, nurses, auxiliary health workers, and counsellors. Responsibility and management of program activities varied by country: implementation was led by local teams with the exception of Nepal, where PRIME project staff conducted most of the program management activities to support implementation. In Uganda and South Africa, the existing administration carried out coordination, and in Ethiopia and India, PRIME offered support to government administrators and coordinators to roll out activities. 50 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 7  ritical for scale-up and sustainability Strong partnerships and leadership are c star  55 Programme for Improving Mental Health Care (PRIME) Model in Ethiopia, India, Nepal, South Africa, and Uganda A multi-country effort to generate evidence for implementing and scaling treatment programs for mental disorders in PHC settings magnifyi Overall Across all five countries, the PRIME project demonstrated that with findings investment in training, supervision, and health system strengthening, mental health care can feasibly be integrated into primary care, and the program was eventually scaled up to 94 facilities across all countries. The model increased case detection for depression and alcohol use disorder in four of the five countries (this data is not available for Ethiopia). It was also associated with early remission and recovery for patients presenting with depression in India, with significant increases in contact coverage and initiation of treatment in Nepal, with a reduction in depression severity in South Africa, and with improvements in the clinical condition of patients in Uganda. The findings from PRIME evaluations have also been used to inform and guide national policy in Ethiopia and Nepal and guided regional health planning in India and South Africa . Lessons learned from the implementation of PRIME activities highlighted the importance of actively engaging with local stakeholders and fostering capacity building at all levels of the health system, including through the participative ToC workshops, which were instrumental in fostering collaboration and community buy-in, and enabled local teams to develop context-responsive programs, policy, and interventions in each context. Additionally, making use of “policy windows,” instances of increased political will when there is growing interest in change, was highlighted as being of the utmost importance.  Click here to access the compendium 51 Task-shifting to non-specialist health workers is effective and sustainable Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest 1 2 3 4 5 6 7 7  ritical for scale-up and sustainability Strong partnerships and leadership are c Other notable models globe-af Model for the Integration of Suicide Prevention into PHC magnifyi  28 in I. R. of Iran The model for the Integration of Suicide Prevention in the Islamic Republic of Iran, which leveraged key partnerships across government sectors, including the Ministries of Education and Agriculture, to reduce the rate of suicide. globe-as Communities for Healthy Viet Nam model magnifyi  13 The Communities for Healthy Viet Nam model, which leveraged partnerships between government agencies and NGOs to bring NCD screening to convenient, hyper-local locations such as grocery stores, coffee shops, salons, and pharmacies. globe-as Public-private Partnership Model for Hypertension Care magnifyi  36 in Urban Pakistan The Public-Private Partnership Model for Hypertension Care in Urban Pakistan that initiated a district-led public-private partnership to deliver hypertension care to patients in low resource urban settings. globe-af Mental Health and Development Model in Kenya magnifyi  44 The Mental Health and Development Model in Kenya, which leveraged small public-private partnerships in the community and targeted patient outcomes and poverty to comprehensively address the needs of people living with mental illness. This model has since expanded to 11 countries.  Click here to access the compendium 52 Task-shifting to non-specialist health workers is effective and sustainable Appendix 1 Compendium Case Study List A complete list of the case studies compiled in the compendium. Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest Document 1 2 3 4 5 6 7 CASE CO U NTRY S TU DY MODEL N C D (s) # EAST ASIA AND PACIFIC China magnifyi  1 System-integrated and Technology-enabled CVD Model of Care (SINEMA) in China magnifyi  2 Peer Leader-support Program (PLSP) Model for T2DM Diabetes Self-management in China 3 Chinese Older Adult Collaborations in Health HTN, MH (COACH) Model Indonesia star  4 Task-shifting Model for Management of Mental MH Health by General Practitioners in Indonesia Malaysia magnifyi  5 Cardiovascular Risk Factors Intervention T2DM, HTN Strategies (CORFIS) Model in Malaysia 6 Integrated Care Pathway for Post Stroke Patients CVD (iCaPPSc) Model in Malaysia Philippines magnifyi  7 First Line Diabetes Care (FiLDCare) Model: T2DM Enhancing Diabetes Management in the Northern Philippine magnifyi  8 EffectiveNess of LIfestyle with Diet and HTN Physical Activity Education ProGram Among Prehypertensive and HyperTENsives (ENLIGHTEN) Model in the Philippines Samoa star  9 PEN Fa’a Samoa: A Customized and Expanded CVD, T2DM, PEN Program Model HTN Thailand 10 Chronic Diseases Clinic Model: Integrating NCDs T2DM, HTN into PHC in Thailand magnifyi  11 WinCare Model: A Network of Homecare Providers T2DM, HTN Using the WinCare App to Support Elderly Patients with NCDs in Thailand 12 VICHAI’s 7 Color Balls Model for Diabetes Care in T2DM Thailand Viet Nam magnifyi  13 Communities for Healthy Viet Nam Model HTN, T2DM star  # Featured case studies magnifyi  # Case studies in digest # Compendium only in digest case studies 54 Appendix Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest Document 1 2 3 4 5 6 7 CASE CO U NTRY S TU DY MODEL N C D (s) # EUROPE AND CENTRAL ASIA Moldova 14 Interprofessional Management of NCDs Model in T2DM, HTN the Republic of Moldova LATIN AMERICA AND THE CARIBBEAN Argentina magnifyi  15 DIAbetes Primary Care, Registry, Education, T2DM and Management (DIAPREM) Model of Care in Argentina magnifyi  16 Model for the Care of Individuals with Chronic HTN Diseases (MAPEC)-Salta in Argentina Brazil 17 Matrix Support Model for Chronic Respiratory CRD Conditions and Mental Health Disorders in Brazil Colombia magnifyi  18 Detection and Integrated Care for Depression MH and Alcohol Use in Primary Care (DIADA) Model in Colombia Costa Rica 19 Community-oriented PHC Model for NCD Care in CVD, CRD, Costa Rica T2DM, cancer Jamaica magnifyi  20 Community Engagement Mental Health (CEMH) MH Model for Home Treatment of Psychosis in Jamaica Mexico 21 Ambulatory Care Model Incorporating T2DM, HTN Pharmacists to Improve Adherence to Diabetes and Hypertension Medication in Mexico magnifyi  22 National Integrated Management of Diabetes in T2DM Stages (MIDE) Model in Mexico magnifyi  23 DIAbetes EMPowerment and Improvement of Care T2DM (DIABEMPIC) Model in Mexico magnifyi  24 Integrated Measurement for Early Detection T2DM, HTN (MIDO) Model in Mexico Peru 25 Diabetic Retinopathy Referral Network Model in T2DM Peru star  # Featured case studies magnifyi  # Case studies in digest # Compendium only in digest case studies 55 Appendix Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest Document 1 2 3 4 5 6 7 CASE CO U NTRY S TU DY MODEL N C D (s) # St. Lucia 26 HEARTS Initiative Model for Hypertension Care in HTN St. Lucia Multi star  27 Latin America Telemedicine Infarct Network CVD country: (LATIN) Model in Brazil, Colombia, Mexico, and Brazil, Argentina Colombia, Mexico, Argentina MIDDLE EAST AND NORTH AFRICA I. R. of Iran magnifyi  28 Model for the Integration of Suicide Prevention MH into PHC in I. R. of Iran SOUTH ASIA Bhutan star  29 Service with Care and Compassion Initiative CVD, T2DM, (SCCI) Model in Bhutan HTN India magnifyi  30 mWellcare Model for Integrated Management of MH NCDs in India 31 Systematic Medical Appraisal, Referral, and MH Treatment (SMART) Mental Health Model in India magnifyi  32 Home-based Service Delivery Model for NCDs in T2DM, HTN, Udaipur, India cancer magnifyi  33 Task-shifting Model for Secondary Prevention of CVD Stroke by Community Health Workers in Kerala, India magnifyi  34 mPower Heart Model in India T2DM, HTN Nepal magnifyi  35 Reducing Stigma Among Healthcare Providers MH (RESHAPE) Model in Nepal Pakistan magnifyi  36 Public-private Partnership Model for Hypertension HTN Care in Urban Pakistan magnifyi  37 Integrated Model for COPD and Asthma Care in CRD Punjab, Pakistan star  # Featured case studies magnifyi  # Case studies in digest # Compendium only in digest case studies 56 Appendix Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest Document 1 2 3 4 5 6 7 CASE CO U NTRY S TU DY MODEL N C D (s) # Sri Lanka 38 Healthy Lifestyle Center (HLC) Model for Proactive CVD NCD Screening in Sri Lanka SUB-SAHARAN AFRICA Democratic 39 Integrated Primary Care Model for Hypertension T2DM, HTN Republic of and Diabetes Management in Conflict-affected Congo Areas of the DRC Eswatini 40 Decentralized Model of NCD Care in Eswatini T2DM, HTN Ethiopia 41 Rehabilitation Intervention for People with MH Schizophrenia in Ethiopia (RISE) Model Kenya magnifyi  42 Task-shifting Model for Nurse-led Management T2DM, HTN, of NCDs in Kibera, Kenya CRD, epilepsy, sickle cell anemia magnifyi  43 Medication Adherence Club (MAC) Model for T2DM, HTN Hypertension, Diabetes, and HIV in Kibera, Kenya magnifyi  44 Mental Health and Development Model in Kenya MH Malawi magnifyi  45 Integrated Chronic Care Clinic (IC3) Model for HIV T2DM, HTN, and NCDs in Malawi CRD Nigeria magnifyi  46 Mental Health in Primary Care (MeHPriC) Model MH in Nigeria Rwanda 47 Nurse-led Model for Integrated NCD Care in T2DM, HTN, Rural Rwanda CVD, CRD, cancer South Africa magnifyi  48 Collaborative Care Model for Integrated Primary MH Care of Depression Comorbid with Chronic Conditions in South Africa magnifyi  49 Integrated Care Disease Management (ICDM) CVD, T2DM, Model in South Africa HTN, MH Zimbabwe star  50 Friendship Bench Model for Mental Health Care MH in Zimbabwe star  # Featured case studies magnifyi  # Case studies in digest # Compendium only in digest case studies 57 Appendix Lessons Learnt chevron- chevron- Delivering Primary Care for NCDs ––  Digest Document 1 2 3 4 5 6 7 CASE CO U NTRY S TU DY MODEL N C D (s) # Multi- 51 Collaborative Shared Care to Improve Psychosis MH country: Outcomes (COSIMPO) in Nigeria and Ghana Ghana, Nigeria Multi- star  52 Sustainable East Africa Research in Community HTN country: Health (SEARCH) Model in Kenya and Uganda Kenya, Uganda MULTI-REGION Brazil, magnifyi  53 HealthRise Model for Hypertension and Diabetes T2DM, HTN India, South in Brazil, India, South Africa, and the United States Africa, and the United States Colombia, star  54 Heart Outcomes Prevention and Evaluation HTN Malaysia Program (HOPE 4) Model in Colombia and Malaysia Ethiopia, star  55 Programme for Improving Mental Health Care MH, epilepsy India, Nepal, (PRIME) Model in Ethiopia, India, Nepal, South South Africa, Africa, and Uganda Uganda Uganda, magnifyi  56 Self-management and Reciprocal Learning for the T2DM South Africa, Prevention and Management of Type-2 Diabetes Sweden (SMART2D) Model in Uganda, South Africa, and Sweden star  # Featured case studies magnifyi  # Case studies in digest # Compendium only in digest case studies 58 Appendix