Understanding the role and organization of health workers delivering non-communicable disease management in primary care in low- and middle-income countries: a scoping review – BMC Primary Care

Report on Strengthening Primary Healthcare for Non-Communicable Diseases in Low- and Middle-Income Countries in Alignment with Sustainable Development Goals

Introduction: The Global NCD Challenge and Sustainable Development Goal 3

The rising burden of non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, cancer, and mental health disorders, poses a significant threat to global health and development. This challenge is a central focus of the United Nations Sustainable Development Goals (SDGs), particularly SDG 3: Good Health and Well-being. Achieving Target 3.4, which aims to reduce premature mortality from NCDs by one-third by 2030, requires robust and equitable health systems. Strengthening Primary Health Care (PHC) is recognized as the most effective strategy to deliver NCD services and advance towards Universal Health Coverage (UHC), as outlined in SDG Target 3.8. This report synthesizes evidence on the challenges and strategic interventions for integrating NCD care into PHC in Low- and Middle-Income Countries (LMICs), framing them within the SDG agenda.

Key Challenges to Achieving SDG 3 in LMICs

Several systemic barriers hinder progress towards NCD-related SDG targets in resource-limited settings. These challenges compromise health equity, a principle that underpins SDG 10 (Reduced Inequalities).

• Health System Unpreparedness: Many health systems in LMICs are ill-equipped to handle the shift from communicable to non-communicable diseases, lacking the necessary infrastructure, guidelines, and financing.
• Workforce Deficiencies: A critical shortage and inequitable distribution of trained health workers impede the delivery of quality NCD care, directly undermining the goal of UHC (SDG 3.8).
• Fragmented Service Delivery: The failure to integrate NCD services with existing primary care platforms, such as HIV or maternal health programs, leads to inefficient and siloed care that fails to address the holistic needs of patients.
• Inadequate Financing: Insufficient investment in mental health and NCD prevention and treatment remains a major obstacle, preventing the scaling of effective interventions necessary to meet SDG 3.4.

Strategic Interventions to Advance NCD Management and the SDGs

Evidence points to several innovative models of care that can strengthen PHC and accelerate progress towards the health-related SDGs.

1. Innovative Service Delivery Models

Reconfiguring how care is delivered is essential for expanding access and improving quality, directly contributing to SDG 3.

1. Task-Shifting and Task-Sharing: This strategy involves redistributing clinical tasks to less specialized health workers, such as nurses and community health workers (CHWs). It is a proven method to overcome workforce shortages and extend the reach of NCD services, including hypertension, diabetes, and mental health care, thereby making progress on UHC (SDG 3.8).
2. Multidisciplinary and Collaborative Care: Team-based approaches that bring together physicians, nurses, pharmacists, and lay counselors improve the management of complex chronic conditions and multimorbidity. This model enhances the quality of care, which is fundamental to reducing premature NCD mortality (SDG 3.4).
3. Community-Based and People-Centered Care: Engaging communities and empowering patients through education, peer support groups, and CHW-led interventions improves self-management and health outcomes. This aligns with the core principles of PHC and promotes health equity (SDG 10).

2. Workforce Capacity Building

A skilled and motivated workforce is the foundation of a resilient health system capable of achieving the SDGs.

• Training and Education: Continuous training for primary care providers in NCD management, mental health integration, and patient-centered communication is critical for improving service quality.
• Empowerment of Nurses and CHWs: Formally recognizing and expanding the roles of nurses and CHWs in NCD screening, management, and follow-up is a cost-effective strategy to strengthen PHC.
• Digital Health Integration: Utilizing mobile health (mHealth) technologies to train, support, and supervise health workers can enhance the efficiency and reach of NCD programs, especially in remote areas.

3. Health System Integration and Governance

System-level changes are required to create an enabling environment for effective NCD care.

• Decentralization of Services: Shifting NCD care from specialized hospitals to primary care facilities makes services more accessible and affordable, reducing geographic and financial barriers for vulnerable populations.
• Integration of NCD and Mental Health Services: Combining mental health care with services for chronic physical conditions like diabetes and hypertension addresses comorbidity and improves overall well-being, directly supporting the comprehensive vision of SDG 3.
• Strengthened Governance and Policy: Aligning national policies with the WHO framework for PHC and ensuring adequate financing for NCDs are essential for the sustainable implementation of effective interventions.

Analysis of Sustainable Development Goals (SDGs) in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

The article, which is a comprehensive list of references, primarily focuses on health systems, non-communicable diseases (NCDs), and primary care, particularly in low- and middle-income countries (LMICs). Based on these themes, the following SDGs are addressed:

• SDG 3: Good Health and Well-being: This is the most central SDG, as the entire article revolves around strengthening primary healthcare to manage NCDs like diabetes, hypertension, cardiovascular diseases, cancer, and mental health conditions.
• SDG 10: Reduced Inequalities: The consistent focus on “low- and middle-income countries,” “sub-Saharan Africa,” “rural” settings, and “resource-poor” environments highlights an effort to address health disparities and ensure equitable access to care, which is a core component of reducing inequalities.
• SDG 17: Partnerships for the Goals: The references discuss various collaborative approaches, such as “multidisciplinary teams,” “task shifting,” “community health workers,” and integrated care models, which depend on strong partnerships between different cadres of health workers, communities, and health systems to be effective.

2. What specific targets under those SDGs can be identified based on the article’s content?

Several specific targets can be identified by analyzing the themes present in the reference titles.

1. SDG 3: Good Health and Well-being

   • Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
     
     Explanation: The article is overwhelmingly focused on this target. Numerous references mention the management, prevention, and control of NCDs such as “hypertension,” “diabetes,” “cardiovascular diseases,” and “cervical cancer.” Additionally, many sources address “mental health,” “depression,” and “anxiety disorders,” directly aligning with the promotion of mental health and well-being.
   • Target 3.8: Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
     
     Explanation: The emphasis on strengthening “primary health care” as the main platform for delivering NCD and mental health services is a fundamental strategy for achieving UHC. The article discusses improving “access to care,” “health system readiness,” and delivering services in underserved communities, all of which are key components of Target 3.8.
   • Target 3.c: Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States.
     
     Explanation: The article addresses health workforce challenges through its focus on “task shifting,” which involves training and empowering “community health workers,” “nurses,” and other non-physician health workers to deliver care. This directly relates to the development and innovative use of the health workforce to overcome shortages, a key aspect of this target.

2. SDG 10: Reduced Inequalities

   • Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.
     
     Explanation: By focusing on improving healthcare access for populations in “low- and middle-income countries,” “rural” areas, and “resource-poor settings,” the article addresses the health dimension of inequality. Ensuring that these underserved populations can access essential NCD and mental health services promotes health equity and social inclusion.

3. SDG 17: Partnerships for the Goals

   • Target 17.16: Enhance the global partnership for sustainable development, complemented by multi-stakeholder partnerships that mobilize and share knowledge, expertise, technology and financial resources…
     
     Explanation: The article itself, being a review of numerous studies, is an act of knowledge sharing. Furthermore, the references to “collaborative care,” “multidisciplinary teams,” and “integrated service delivery” highlight the importance of partnerships between different health professionals, community members, and health systems to achieve health outcomes.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

The article does not explicitly state SDG indicators, but the topics covered in the references strongly imply their use for measuring progress.

1. Indicators for SDG 3 Targets

   • Implied Indicator for Target 3.4: Indicator 3.4.1 (Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease).
     
     Explanation: The ultimate goal of the interventions for hypertension, diabetes, and cancer discussed in the article is to reduce premature death from these conditions. Therefore, the mortality rate is a key, albeit high-level, indicator of the success of these primary care programs.
   • Implied Indicator for Target 3.8: Indicator 3.8.1 (Coverage of essential health services).
     
     Explanation: The article’s focus on “screening,” “management,” and “access to care” for NCDs and mental health conditions directly relates to measuring the coverage of these essential services. The success of programs like community-based hypertension control or primary care for depression would be measured by the proportion of the target population they reach.
   • Implied Indicator for Target 3.c: Indicator 3.c.1 (Health worker density and distribution).
     
     Explanation: The extensive discussion on “task shifting,” “community health workers,” and “nurse-led” clinics is a direct response to low health worker density. The implementation and success of these strategies can be seen as a way to improve the effective health worker ratio and distribution, which this indicator measures.

4. Table of SDGs, Targets, and Indicators

Source: bmcprimcare.biomedcentral.com