With a high proportion of the population of low and middle-income countries residing in rural settings, decentralization is necessary to provide accessible care to remote communities. Upon decentralization to district hospitals, established district NCD staff can support the establishment of basic NCD services at respective health centers through training, mentorship, and implementation. Health center staff can then directly support community health workers. This step-wise process is what we call “progressive decentralization.”
Tools for progressive decentralization
Health center training should cater to the available human resources at the facility, with ideally at least two staff trained specifically in NCD care. Content should focus on disease groups that can responsibly be addressed by the health center on a routine basis. In many cases, severe NCDs such as type 1 diabetes and rheumatic heart disease should not be treated at the health center level.
The implementation of health center level care will require close communication between district and health center teams. Below is an Implementation Process Measures (IPM) tool for the health center, produced by Inshuti Mu Buzima (IMB), Partners In Health’s sister site in Rwanda.
Community Health Workers (CHWs)
Knowledge of NCDs, especially severe NCDs like type 1 diabetes, at the community level is still quite limited in many resource-limited settings. Identifying new NCD cases and promoting lifelong adherence to NCD patients require significant community level support by local health staff, such as CHWs.
Community-based screening for diabetes and hypertension allow for identification of new cases as well as increased disease awareness. Screening events should include involvement of local community leadership and be held in a public location with high visibility. The Malawi Ministry of Health in Neno District and Abwenzi Pa Za Umoyo/Partners In Health – Malawi has implemented community-based screening across multiple disease groups, including diabetes and hypertension. APZU provides public health talks, followed by clinical screening of those attending. Multiple disease groups are included in the screening campaign to increase the efficiency of available resources. APZU’s implementation guide and clinical guidelines are included below.
Active case finding
CHWs can play a critical role in identifying potential cases and referring patients to the appropriate facility for evaluation. CHWs must be able to identify common disease presentations and follow the appropriate referral protocols. The following training tool from APZU provides critical information about NCDs to CHWs so that they are better able to identify NCD patients.
After a patient is linked to care and undergoing treatment, they may require ongoing support at home for medication and appointment adherence, psycho-social counseling, monitoring of side effects and disease complications, and sometimes drug administration. The NCD CHW Training manual describes the key responsibilities of CHW-led support of patients who have already been enrolled into care at the local health facility.
Implementation work planning of NCD CHW programs typically requires the inclusion of NCD-specific tasks into an existing framework of CHW activities. Thus, the implementation of NCD CHW activities may require a broader scope of planning and collaboration. The following Community Health Toolkit was produced by APZU and provides a wealth of resources to approaching the establishment of a robust CHW program inclusive of NCDs.
Successful establishment of multiple levels of NCD care is only as effective as the available referral pathways, which connect the levels together across a decentralized health system. Clear referral criteria, protocols, and communication are essential to execute the intended pathways. The illustration below highlights the key drivers behind strategic referral pathways.