
==== Front
Lancet Glob Health
Lancet Glob Health
The Lancet. Global Health
2214-109X
Elsevier Ltd

S2214-109X(24)00118-9
10.1016/S2214-109X(24)00118-9
Series
Delivering non-communicable disease services through primary health care in selected south Asian countries: are health systems prepared?
Ahmed Syed Masud Prof PhD ahmed.sm@bracu.ac.bd
a*
Krishnan Anand Prof PhD b
Karim Obaida MPH a
Shafique Kashif Prof PhD c
Naher Nahitun MPH a
Srishti Sanjida Ahmed B Pharm a
Raj Aravind MSc d
Ahmed Sana FCPS c
Rawal Lal PhD e
Adams Alayne PhD d
a BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
b Centre for Community Medicine, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, New Delhi, India
c School of Public Health, Dow University of Health Sciences, Gulzar-e-Hijri, Karachi, Pakistan
d Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
e School of Health, Medical and Applied Sciences, Central Queensland University, Sydney, NSW, Australia
* Correspondence to: Prof Syed Masud Ahmed, BRAC James P Grant School of Public Health, BRAC University, Dhaka 1213, Bangladesh ahmed.sm@bracu.ac.bd
20 8 2024
10 2024
20 8 2024
12 10 e1706e1719
© 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC 4.0 license
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Summary

In the south Asian region, delivering non-communicable disease (NCD) prevention and control services through existing primary health-care (PHC) facilities is urgently required yet currently challenging. As the first point of contact with the health-care system, PHC offers an ideal window for prevention and continuity of care over the life course, yet the implementation of PHC to address NCDs is insufficient. This review considers evidence from five south Asian countries to derive policy-relevant recommendations for designing integrated PHC systems that include NCD care. Findings reveal high political commitment but poor multisectoral engagement and health systems preparedness for tackling chronic diseases at the PHC level. There is a shortage of skilled human resources, requisite infrastructure, essential NCD medicines and technologies, and dedicated financing. Although innovations supporting integrated interventions exist, such as innovations focusing on community-centric approaches, scaling up remains problematic. To deliver NCD services sustainably, governments must aim for increased financing and a redesign of PHC service.
==== Body
pmcThis is the second in a Series of five papers about primary health care in south Asia (papers 4 and 5 appear in The Lancet Regional Health Southeast Asia). All papers in the Series are available at thelancet.com/series/primary-health-care-south-asia

Introduction

Non-communicable diseases (NCDs) have emerged as the major cause of global mortality, increasing from being responsible for 61% of mortality in 2000, to 74% in 2019, and constitute a major public health challenge for the 21st century.1 The bulk of the global NCD burden is now borne by low-income and middle-income countries (LMICs) undergoing demographic transition, including countries in south Asia. Across these countries, health systems have been ill-prepared to manage the consequent double burden of communicable diseases and NCDs. This challenge was further heightened by the COVID-19 pandemic, during which disruptions of essential services hindered much needed attention to NCDs prevention and care,2 including post-pandemic priorities to incorporate health security concerns in core PHC functions and make the health system resilient to future disease outbreaks.3

NCDs prevention focuses on four common modifiable risk factors (ie, tobacco use, harmful alcohol use, unhealthy diet, and physical inactivity). Primary health care (PHC) supports first-contact, continuous, comprehensive, and coordinated person-focused care in the community. This type of care is particularly well-placed for delivering prevention services and providing opportunities for NCD “screening, early detection and management” during regular outpatient visits.4 With advancement of age individuals tend to have an increasing number of NCDs.5 In these instances, the management of this multimorbidity is best served by holistic and integrated PHC approaches, as opposed to costly specialist-based vertical care for specific NCDs. In LMICs, the focus of PHC on the provision of appropriate, equitable, and affordable health-care services is also crucial, given the increasing prevalence of NCDs among people experiencing poverty.6 Finally, PHC is the most effective and efficient way to deliver NCD services in low-resource settings, given its emphasis on task-shifting, mobilising community health workers, and engaging the community to care for their health.7 PHC is also central to achieving universal health coverage (UHC) and health-related Sustainable Development Goals as enshrined in the 2018 Astana Declaration and WHO's South-East Asia regional strategy.8, 9

Key messages

• The rising non-communicable disease (NCD) burden in south Asian countries and its disproportionate effect on disadvantaged and marginalised populations requires urgent action.

• Political commitment to multisectoral NCD action plans is widespread across the region, as is the recognition of the need for health in all policy approaches; yet, implementation is sluggish and uncertain.

• Consistent with a primary health-care approach, countries have adapted the WHO package of essential NCD interventions for national-level implementation; however, shortages in human and financial resources, poor capacity of the front-line health workers, requisite infrastructure, and interruptions in supply of essential medicines and technologies impede effective implementation.

• Given the major role of private and non-government organisations in service provision, successful coordination of NCD activities requires strengthened and centralised oversight and governance.

• South Asian countries have jump-started the use of information and communication technology and trained health-care workers to extend NCD services to rural, remote, and hard-to-reach areas.

• Creative yet feasible innovations that address NCDs at the primary health-care level and accommodate the realities of low-resource settings should be supported and scaled-up to the national level.

This review explores the evidence on how integrated PHC is implemented in selected south Asian countries and how policies and plans support it, including identification of the policy–practice gaps and challenges and opportunities for cross learning. Lessons learnt from this review will help formulate evidence-based recommendations for policy makers to re-orient and redesign PHC towards integrated and continuous care for chronic conditions.

Methods

We reviewed existing literature to extract, synthesise, and analyse knowledge on the current NCDs situation in several south Asian countries. We reviewed policies, and investigated their implementation and use of innovations related to the integration in PHC delivery infrastructure. Because of the “large, complex and heterogeneous nature of the literature” on the topic,10 we followed a systematic five-step process adapted from the Arksey and O'Malley framework (panel 1).11 Five south Asian countries—Bangladesh, India, Pakistan, Nepal, and Sri Lanka—were included in the review, comprising 98% of south Asian countries' total population. We focused on the four major NCDs: cardiovascular disease (CVD), cancer, chronic respiratory disease, and diabetes, which constitute major causes of premature death in the region (panel 1).Panel 1 The five-step process adapted from the Arksey and O'Malley framework that guided our review11

Step 1: Identifying the research question(s)

Four research questions were pursued: what is the current situation of non-communicable diseases (NCDs) in selected south Asian countries; what are current policies, strategies, and plans for managing NCDs at the primary health-care (PHC) level and related implementation challenges; what best practices or innovations exist in the region for managing NCDs at the PHC level; what are priority recommendations for re-orienting and redesigning PHC services for NCD care?

Step 2: Identifying relevant studies

Inclusion criteria set for identifying relevant studies included the following: peer-reviewed publications; grey materials on government policies, strategies, plans, and programmes for management of NCDs; materials published in English since January, 2010; and materials on diseases, such as cardiovascular disease, chronic obstructive pulmonary diseases, diabetes, and cancer. All commentaries, editorials, short communications, literature for which there was not access to the full text, materials from countries other than those selected, and materials published before January, 2010 were excluded. We used the following search engines for searching different types of materials: PubMed, SCOPUS, Google Scholar, and EBSCOHost for peer-reviewed articles; Google for grey materials; and institutional websites of Health ministries, WHO, World Bank, and NCD-programme implementing organisations for relevant documents. Key search terms were derived from review objectives (appendix p 21). The search was done from Nov 1, 2022 to Dec 1, 2022.

Step 3: Screening and selection of peer-reviewed articles

Three researchers (OK, SAS, and AR) independently searched peer-reviewed articles, including evaluation studies, case studies, literature reviews, systematic reviews, narrative reviews, and reviews. Rayyan software was used to remove duplicates and screening by title and abstract. This step was followed by a content review of the articles done independently by two researchers (OK and SAS) and, depending upon the publication's relevance, were included for analysis. A third researcher (SA) reviewed the grey literature, including government policy, strategy, and planning documents, briefs, and reports of the selected countries through Google search. Hand search was done to explore additional peer-reviewed articles and websites maintained by the health ministries of the respective countries, WHO, or any specific government-run health programme or project targeting NCDs at the PHC level. The PHC performance measurement framework by WHO was applied to review the NCD policy and national action plan for NCD control and prevention in each of the study countries.12 Any disagreements between the reviewers were resolved through discussion with the principal investigator (SMA). 33 peer-reviewed articles and nine hand-searched documents (three reports and six peer-reviewed articles) met the inclusion criteria and a total of 42 documents were finally included in this review (appendix p 1).

Step 4: Charting the data

Data were extracted from papers included in the scoping review by two independent reviewers using a data extraction template developed for the purpose (appendix p 22). The extracted data included specific details about the sample, study context, methods, and key findings relevant to the review questions.

Step 5: Collating, summarising, and reporting the results

Extracted data were synthesised using the mixed studies review method for synthesising evidence from different types of studies and presented narratively, with tables and figures where appropriate. The table included the following information: author(s), year of publication, the country where the study was done, study methodology, etc. A narrative summary was prepared for each included article that described how study results relate to the review's objectives and research questions. Findings are discussed in relation to future research needs, policy, and practice etc.

Results

The search for peer-reviewed articles yielded 1869 documents. 402 duplicates were removed, and a further 1403 articles were removed as they did not fulfil the inclusion criteria. Of the remaining 64 articles, 31 were excluded after full text evaluation because there were insufficient data, and the text of one article was not accessible. 33 articles were retained along with nine hand-searched articles for analysis (appendix p 3). These articles were published between January, 2010, and December, 2022. An overview of the articles with key findings is presented in the appendix (p 3).

Findings from this review are presented thematically, focusing on NCD burden, policies and their implementation strategies, service delivery, workforce capacity, information, technology, and supply of medicines.

NCDs' mortality and morbidity burden

Across the five countries in this review, the share of all mortality attributed to NCDs varied from 55% in Pakistan, to 82% in Sri Lanka.13 This high NCDs mortality for Sri Lanka was comparable with that of Viet Nam (80%), while Bangladesh, Nepal, Indonesia, and Myanmar had similar mortality rates of more than 70%. Among the NCDs, mortality from CVDs was the highest, with Bangladesh topping the list at more than 38% (figure). The second highest mortality rate was attributable to cancers, except in the case of Nepal, where chronic respiratory disease was the second largest contributor to mortality. The risk of premature death between the ages of 30 and 70 years from any of the four NCDs varied from 13% in Sri Lanka, to 29% in Pakistan, with Bangladesh, India, and Nepal lying in-between at around 21%.13 Sri Lanka ranked first in the prevalence of diabetes (11%), CVDs (6·4%), and COPDs (5%), plausibly possibly so because epidemiological transition began much earlier there than in the other countries included in this review.13 Sri Lanka is an outlier distinguished by high NCD mortality, low premature mortality, and a good functioning PHC system.Figure Mortality from and prevalence of NCDs in selected south Asian countries

Source: GBD 2019. https://vizhub.healthdata.org/gbd-results/. CVDs=cardiovascular diseases.

Our findings also revealed a high prevalence of the four common modifiable risk factors contributing to NCDs burden in all five countries.14 Tobacco consumption was the highest in Bangladesh (35%) and the lowest in Sri Lanka (22%), where rates of tobacco consumption in women overwhelmingly surpassed men—a complete reversal of what was observed in the other four countries. Across all countries, women were physically less active than men, with the lowest rates of physical activity (34%) reported in India.

Screening and diagnosis

Clinical examination of patients visiting PHC facilities including bedside measurements of parameters, such as blood pressure and blood glucose, can indicate the suspected presence of NCDs in high-risk individuals and justify the need for screening. Screening of high-risk cases through existing PHC infrastructure has been found to be effective and feasible in India15 and other south Asian countries, such as Bangladesh, Sri Lanka, and Nepal.16 Community-based screening can also be home-based and done by trained community health workers as shown in India,17 or delivered through PHC facilities, as done in Bangladesh. Various approaches are practised for cancer screening, such as community-based screening, clinic-based screening (eg, for breast cancer), and telephone-based follow-up (eg, for patients diagnosed with cancer).18 However, the success of screening depends upon the availability of trained human resources, supplies, and necessary logistics.19 Additional factors associated with poor attendance for facility-based screening include gender,20 cost, timing, and the responsiveness of staff engaged in the screening services.21

Socioeconomic disparities

Although our review findings did not show a consistent link between socioeconomic status and the risk for developing NCDs, across all countries the negative effects of NCDs disproportionately affected the low-income and marginalised populations.22, 23 For example, a systemic review on the prevalence of COPD and chronic bronchitis observed that low-income and non-urban residents were at an increased risk of developing these conditions due to low levels of awareness on NCDs and the absence of preventive measures, such as access to smoking cessation services.22 An inverse relationship between socioeconomic status and the prevalence of NCDs was also observed in India,23 Sri Lanka,24 and among marginalised populations of Nepal.25 In several studies, the high cost of NCD care, mainly out-of-pocket, was found to substantially affect household spending patterns, leaving little resources for food and jeopardising opportunities for long-term care and sustainable NCD management.26, 27

Policies, strategies, and plans supporting the integration of NCD care within PHC

The latest multisectoral action plans for the prevention and control of NCDs available in the public domain were reviewed to understand the policy environment in each country and results were summarised in table 1.Table 1 Multi-sectoral action plans for NCDs of the five selected south Asian countries and implementation challenges

	Policy or strategy	Governance and management	Political leadership	Coordination	Main activities	Challenges	
Bangladesh	Multisectoral Action Plan for Prevention and Control of NCDs 2018–25;28 MoHFW finalised and approved the MSAP in May, 2018.	National Multisectoral NCD Coordination Committee representing 21 ministries, chaired by the Minister, MoHFW. The first meeting was held in 2018; Health Minister oversees NCD programmes by holding quarterly meetings with Ministry officials.	Parliamentarians' NCD Forum advises MoHFW on NCD issues. The committee is chaired by the House Speaker and includes parliamentarians from various political parties.	NCD Control Programme in the DGHS is the coordination unit for NCD governance and responsible for implementing health sector-related activities outlined in the MSAP.	Tobacco package warnings and the ban of smoking in public places; Ministry of Health's Autism & Neuro Developmental Disease Cell collaborated with multiple ministries to create the National Strategic Plan for Autism and Neurodevelopmental Disorders in 2016.	No prioritisation of NCDs and their determinants in other sectors other than health care; poor coordination with other Ministries and within the divisions of MoHFW (eg, DGHS and DGFP); uninterrupted supplies of basic medicines and technology for NCD services at the PHC level; no referral system for uninterrupted care; insufficient regulation of public–private partnerships to ensure that service providers comply with standards; insufficient regulation of NCD services in the private sector for quality and equity; and inadequate NCD services for slum populations and street dwellers.	
India	Multi-sectoral National Action Plan (2017–22);29 MSAP was finalised and approved by the Union Government in 2018.	MoHFW formed an interministerial committee chaired by the Secretary of the MoHFW to oversee multi-sectoral efforts and resolve issues. Functional coordination committees exist for tobacco control at the state and district levels. MoHFW is assessing six states to identify how multisectoral collaboration can be improved at the state level.	In 2016, the Prime Minister launched a scheme to provide 50 million cooking gas connections to reduce household air pollution; health and finance ministers increased taxes on tobacco and sugary drinks; and population-based NCD screening is underway in one-third of districts.	Four agencies within the Health Ministry handle coordination for the country's MSAP strategic priorities; MoHFW manages multisectoral coordination; Indian Council of Medical Research oversees surveillance and monitoring; Directorate-General of Health Services strengthens the health system; and a Health Promotion Society or National Institute of Chronic Diseases is planned for health promotion strategy.	Multisectoral action and policy interventions primarily target tobacco as a substantial NCD risk factor. Actions taken in the food sector include: regulating HFSS food packaging, voluntary industry restrictions on advertising HFSS and SSBs to children, reformulating products to reduce salt and trans-fats. Government sports scheme launched for approximately 200 million children. Healthy living initiatives are part of urban rejuvenation and Smart City schemes. Ayushman Bharat Yojana aims to establish 150 000 health and wellness centres, offering screening and insurance for 500 million people.	Need for greater integration of vertical programmes to improve resource efficiency; NCDs compete with other health priorities including maternal and child health and infectious diseases; implementation of regulatory and administrative guidelines for effective public-private partnerships for health is challenging; funding for quality improvement and accountability in the public sector are insufficient; and aggressive marketing by the food, beverage, and alcohol industries.	
Nepal	Multi-sectoral Action Plan on Prevention and Control of NCD In Nepal 2021–25.30 In 2021, Nepal developed a second NCD MSAP (2021–25) that acknowledged the progress made so far in the prevention and control of NCDs and showed continued commitment to address problem of NCDs and mental health with clear terms of reference.	For effective implementation and monitoring of MSAP, a high-level committee chaired by Honourable vice-president of National Planning Commission, has been formed.	A high-level MSAP committee chaired by Chief Secretary under the Office of the Prime Minister and the Council of Ministers, has been formed. Members of this committee include secretaries of 17 relevant ministries and is responsible for the development and implementation of policies, strategies, and guidelines focused on NCDs prevention and control in Nepal.	National Planning Commission plays coordination role to facilitate the participation of multi-stakeholders and mediate resources; Health Coordination Division of MoHP Nepal monitors the implementation process of MSAPl Provincial-level coordination committees in all seven provinces focus on strengthening coordination, communication, and working together with government and non-governmental organisations, relevant stakeholders, and beneficiaries. The organisation chaired by Secretory of Provincial level health directorate. MSAP aims to form local-level coordination committees chaired by mayor, chairperson of respective metropolitan cities, or metropolitan of urban and rural municipalities.	MoHP initiated an advocacy and policy dialogue with the governments (federal, provincial, and local), policy makers, and civil societies focused on preventing and controlling NCDs in the country. Ministry of Home Affairs initiated effective implementation of WHO FCTC, actions for tax reform, and implementing protocols for illicit use of drugs and alcohol. MoHP has been implementing PEN package to expand NCDs and mental health services. Oral health is included as key element of NCDs prevention and control in the country. MoHP has been developing capacity of human resources for health essential for NCDs prevention and control in the country. MoHP leads periodic surveys of NCDs risk factors through STEPS and other surveys and establishes disease specific registries.	Poor political commitment and leadership at all levels of the governments; delays in implementing priority NCDs programmes given that Committees at all levels (federal, provincial, and local) have not been finalised; and the need to incorporate the NCD MSAP vision, mission, and programmes through structural changes in health departments at the provincial, district and local levels.	
Pakistan	Non-Communicable Diseases & Mental Health National Action Framework 2021–30.31 Ministry of National Health Services, Regulations, and Coordination developed a National Action Framework for NCDs and Mental Health to provide policy direction, which resulted in the formation of NCDs & Mentha Health Task Force and NCDs & Menal Health Technical Working Group.	Legislative actions have shifted health responsibilities from the federal level to the provincial level due to 18 constitutional amendments. Various vertical health programmes have been integrated horizontally into provincial health departments. EPHS and UHC were applied to address localised health needs and respond to the growing burden of NCDs and injuries, alongside a decrease in maternal, newborn, child health, and communicable diseases.	Provincial or area level localisation completed based on local situation, milestones. Costed NCD and mental health interventions are included in the generic and all provincial and area EPHS. Intersectoral policies have been prioritised through a consultative process with line ministries, departments, and stakeholders.	On the direction of Inter-Ministerial Health & Population Council, the Ministry is working to develop a health financing strategy to ensure enhanced generation of resources for health, pooling of funds, purchasing, and provision of services.	An approved EPHS and UHC Benefit Package informs the NCD & Mental Health Action Framework which identified five core strategic areas for interventions: governance, prevention, and reduction of risk factors, NCD health care, mental health services, and surveillance, monitoring, and research. The framework includes a set of 25 indicators to monitor progress. Costed Essential Package of Health Services and UHC benefit package finalised, designed to be implemented across the health facilities at different tiers.	Inconsistent commitment at high-level towards NCD and mental health; outdated legislation on NCD and mental health; no coherent country-wide multisectoral and intersectoral plans to address the growing burden of NCD and mental disorders; primary prevention of NCD challenged by severe resource constraints at community and PHC level; low public awareness campaigns on harmful effects of NCD and their risk factors; no implementation of laws that effect intersectoral determinants of NCD.	
Sri Lanka	National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016–20.32 Adopted in 2013, operational in Sri Lanka in 2016.	Minister of Health leads the National NCD Council for MSAP oversight. An NCD steering committee, led by the Health Secretary, manages MSAP implementation. The National NCD Council comprises 16 agencies and has convened twice since its establishment in 2017.	Health holds substantial political importance and is a key issue in elections and political party manifestos. The Health Minister leads the National NCD Council, while the Health Secretary leads the MSAP's implementation Steering Committee. Head of State's commitment has made NCDs a national priority, fostering multisectoral collaboration.	NCD unit in the Ministry of Health coordinates the National NCD Council's work. Deputy Director-General and NCD Director contribute part of their time to oversee coordination units. Insufficient staff results in work overload and delays in executing activities.	Multisectoral NCD response in the country involves relevant ministries. Sustained coordination across sectors requires dedicated staff time.	No allocated budget for NCDs hampers ministries' ability to fulfil MSAP responsibilities; frequent changes in focal points for NCDs in non-health Ministries result in a loss of institutional memory and technical consistency, requiring repeated sensitisation and capacity-building; Ministry of Trade has not introduced regulations on unhealthy food marketing and food manufacturers are delaying the implementation of standards for high fat, sugar, and salt content.	
DGFP=Directorate General Family Planning. DGHS=Directorate General Health Services. EPHS=Essential Package of Health Services. FCTC=WHO Framework Convention on Tobacco Control. HFSS=High-fat-salt-sugar. MSAPS=multi-sectoral action plans. MoHFW=Ministry of Health and Family Welfare. MoHP=Ministry of Health and Population. NCD=Non-communicable disease. SSBs=sugar-sweetened beverages. STEPS=Stepwise approach to NCD risk-factor surveillance. UHC=universal health coverage.

With the epidemiological transition occurring in south Asian countries, policy makers and practitioners are increasingly cognisant of the rising NCD burden and its implications, as reflected in their respective policy documents. Reference to the WHO package of essential NCD interventions (WHO-PEN) is also evident. Across the documents reviewed, six key directions are identified to varying degrees: re-orienting PHC for integrated NCD services, capacity-building of PHC workforce, involving all relevant sectors of government and all sections of the society to address common risk factors beyond the health sector, developing standard guidelines and protocols, instituting monitoring and surveillance, and facilitating community engagement.

Both literature and policy document review findings spotlight the importance of effective governance and management for delivering NCD services through PHC. Measures, such as engaging a broad range of stakeholders to facilitate effective communication and coordination,33, 34 a comprehensive risk reduction approach,35 monitoring of NCD-related mortality, morbidity, and risk factors,34 and monitoring and reporting of patient health records36 were emphasised as key to strengthening NCD management. Policy frameworks also emphasised improved planning to support long-term capacity-building efforts,37 defining NCD-related responsibilities at all levels,38 designated funding for NCD-related initiatives,39 and developing a separate NCD planning process to address the specific situation of urban areas. Studies from India reiterated the need for collaboration among all levels of government, civil society organisations, and other stakeholders to sustainably reach universal health coverage of NCD services.40, 41, 42 A bottom-up approach was also advocated, including establishing a home-based NCD and palliative care system and creating rehabilitation centres.40

Delivering integrated NCD services through PHC infrastructure

Historically, PHC services in south Asian countries were designed to tackle infectious diseases and acute conditions and were ill-suited for addressing chronic diseases and NCD care needs sustainably over time. However, with the onset of the NCD epidemic, efforts to initiate NCD services within PHC are apparent across the region.43 Our review identified various promising interventions for preventing and managing NCDs as a core function of PHC services in Bangladesh,33 India,44 Nepal,45 Pakistan,46 and Sri Lanka.47 The details of these interventions, including presumed factors underlying their successes and challenges to scaling up, are summarised in table 2.Table 2 A summary of success factors and challenges of some key interventions on NCDs through PHC

	Country	Goals	Success factor(s)	Challenges, gaps, and limitations	
NCD Corner33	Bangladesh	This initiative began in 2012 at UHCs, aimed to address NCDs through preventive services for cardiovascular diseases, diabetes, and chronic respiratory diseases (asthma and COPD), and screening for some cancers.	Recognition of the importance of early screening and diagnosis of NCDs at the PHCs might be considered as a success, reflecting the change in orientation of the policy makers. This recognition underscores the key role NCD corners can play in providing screening services for NCDs, particularly in Bangladesh where the out-of-pocket expenditure is steadily increasing with time and is quite prohibitive for the patients and their families.	Challenges encompass an insufficient number of trained personnel, insufficient equipment and laboratory facilities, inadequate logistics and drug supplies, improper recording and reporting, poor coordination and communication between NCD corners and the NCDC unit of DGHS, and no proper guidelines or standard operating procedures.	
Team-based PHC approach for NCDs 42	India (Karnatak, south India)	A package of evidence-based customised interventions for NCDs through PHC involving task-shifting (delegating responsibilities to less skilled practitioners, such as nurses and community health workers, to reduce cost and enhance efficiency) and team-based approach was tried.	Task-shifting is a key strategy implemented to address lack of enthusiasm among health-care providers, particularly doctors, in using the GoI CPHC-NCD system. Responsibilities were shifted from doctors to nurses, lab technicians, and community health workers who received appropriate training. Success factors included deployment of additional staff, motivation of the staff, and developing congenial environment within the team (cohesion) to improve team performance.	The major challenge was to re-orient the hierarchical staff arrangements within the PHC, which hampered team-spirit and team-based care. Besides, staff transfer and the time required to counsel the patients were found to be prohibitive. The programme was dependent on the availability of skilled human resources and infrastructure, which could be challenging in government health facilities.	
Lifestyle intervention by Female Community Health Volunteers45	Nepal	A lifestyle intervention led by FCHVs to reduce systolic blood pressure in patients with hypertension and address age-related increases in blood pressure in individuals who were normotensive or prehypertensive in Nepal.	The intervention involved task shifting, where FCHVs, who are part of the primary health-care system, played a key role in providing health promotion counselling and monitoring blood pressure during home visits. The intervention led to a significant reduction in systolic blood pressure, which could help reduce the risk of developing hypertension. The use of existing community health workers and low-cost tools and techniques made the intervention feasible and scalable	The study was limited to a 12-month duration, so the long-term sustainability of the intervention's effects is unknown. The study might not be applicable to men, particularly working men, who are not always available for home-based visits. The high incidence of hypertension observed after the intervention could partly be due to regression to mean. Further studies on cost-effectiveness are needed before scaling up and replication of the strategy in other settings.	
Integrated diabetes management at primary health-care facilities in Pakistan46	Pakistan	The programme or intervention involves the modification of international best practices to include a case management desk manual, a tool for lifestyle change counselling, and a training course for medical personnel.	The intervention elements were found to be simple for physicians to use and acceptable to patients. The intervention led to improved prescribing and follow-up procedures. Data collection costs were minimised by adopting a practical strategy. The intervention had a positive effect on patient glucose control, although the improvement was not statistically significant.	There were limitations, including the absence of education and occupation status information in the dataset. The use of technology for data collection, such as conducting Skype interviews, might lead to participant discomfort, which could be a challenge in the context of applied health research.	
Enhancing care outcomes by integrating CHAs47	Sri Lanka	The programme involves the selection and training of three women designated as CHAs by the Department of Community and Family Medicine. These CHAs are responsible for supporting clinics, educational initiatives, home visits, and maintaining patient records as part of a chronic illness strategy. The programme's objective is to enhance care outcomes for people with chronic illnesses by involving patients and the public.	The programme was effective in showing the value and sustainability of the approach. Most health-care providers and academics expressed satisfaction with the CHAs' performance. CHAs successfully supported the conduct of health literacy clinics, NCDs clinics, and education programmes.	CHAs faced difficulties in working with some socioeconomic groups within the community and some categories of health-care providers. Their satisfaction ratings varied among CHAs, likely influenced by factors such as individual interest in working within a specific setup. Some issues related to the retrieval of medical records were identified, including delays and incorrect identification of patients.	
CHAs=community health assistants. DGHS=Directorate General Health Services. FCHVs=Female Community Health Volunteers. NCDs=non-communicable diseases. PHC=primary health clinic. UHCs=Upazila health complexes.

In several studies from India, task-shifting was implemented to enable home-based care by trained community health workers (eg, palliative care for cancer patients48 and screening for NCDs including cancer).17 Although some of these efforts have been systems-wide, many promising innovations supporting integrated NCD service delivery have been limited to small-scale pilots (panel 2).Panel 2 Innovations to deliver integrated non-communicable disease (NCD) services through primary health care (PHC)

The review identified a few innovative NCD programmes at the PHC level:

Community radio in Bangladesh 49

The package of essential non-communicable intervention in Debhata upazila of Bangladesh included a community radio programme called Radio Nalta to educate the public on preventing and controlling NCDs. Located at Nalta village, Satkhira in the southwest of Bangladesh, Radio Nalta is one of 14 first-generation community radios in the country. Run primarily by volunteers, the radio aims to give “voices to the voiceless”, raise awareness and mobilise the local community on various issues such as health, education, human rights, climate change, and disaster preparedness. Since its initiation in 2011, the radio has offered community awareness programming including information on salt and tobacco control and information on NCD services in the locality, with support from Nalta Hospital and Community Health Foundation. Broadcasts are also promoted through school health programmes and a network of NGOs, local clubs, and other organisations. Radio Nalta has reached many people with NCD messages, thereby potentially improving health literacy and promoting behaviour change.

Module-based training for diabetes in Kerala, India 50

In an innovative experimental trial of a non-pharmacological intervention for lowering blood glucose levels of diabetic patients in south Kerala, India, a group of Junior Public Health Nurses (JPHNs) were trained to improve knowledge, attitude and practice for managing diabetes in patients attending NCD clinics in PHC settings. The one-day training module (6 h) consisted of three sessions (knowledge, attitude, and practice) relevant to management of NCDs. The contents were validated qualitatively by experts through the Delphi technique. The training followed a participatory deliberative approach in which participants learned, discussed, and practised NCD management strategies. The knowledge component (1·5 h) included slides on diabetes burden, risk factors, complications, and role of risk factors in diabetes prevention and control. The attitude-building session (2 h) involved discussion of different case scenarios in PHC settings and the best action plan to be taken. Each participant was given a chance to discuss their views and the advice they would offer in each scenario. Lastly, the practice session (2·5 h) involved hands-on training in a PHC setting. Each participant was given two patients and allotted 30 min to record the individuals' illness history, measure bedside parameters, and offer counselling on diabetic care. Participants were observed and scored by study investigators, and patient feedback was solicited. At the end of the programme, a discussion took place to better understand their participant experiences and collect patient feedback. Insights gleaned through this process were incorporated into guidance for NCD counselling. After training, JPHNs checked patients monthly for glucose homeostasis and other indicators for 6 months. Pre-intervention and post-intervention knowledge and competence assessments of the JPHNs were done using standardised questionnaires and checklists. After adjusting for baseline values, analysis revealed that individuals under the care of trained JPHNs had 1·5 times better glycaemic control than individuals under the care of a control group of untrained JPHNs. Significant improvement in the practice and skills scores of trained JPHN were also attributed to the intervention compared with the control group.

Using the 4C primary care principles to improve follow-up visits for NCDs in Nepal 51

Using the Starfield 4C principles (first-contact access, continuity, coordination of treatment, and comprehensiveness) for high quality PHC, Nepal developed an intervention for management of NCDs in the underserved district of Achham. To address workforce shortages, the intervention integrated mid-level professionals and community health workers to optimise first-contact access in facility and community respectively, and continuity and coordination of care. These services were backed up by digital technology and shared electronic health records, which ensured continuity and coordination of patient visits, and an algorithmic clinical decision support system to ensure uniform service delivery. Individual-level risk reduction and counselling strategies were used to promote comprehensive NCD prevention and control services. The intervention promoted a patient-centred approach to NCD care, focusing on empowering patients to be active regarding their health and wellness. Evaluation of the project indicated improvements in rates of follow-up including community visits, and facility-based care for patients with hypertension, cardiovascular diseases and COPDs, and low lost to follow-up, both of which are key to chronic disease management.

Capacity development of PHC workforce for integrated service delivery

Given the shortage of health workforce with the requisite skills to deliver NCD services at the PHC level, training is key to ensure the quality of integration. Countries emphasised different aspects of workforce capacity development and approached the issue differently depending on their context. For example, Bangladesh prioritised skill-building training following standard guidelines and tools, and ensuring access to other resources, such as NCD medicines and technologies.49, 52 Pakistan emphasised improved staff supervision, including instructions and training of doctors and allied staff to ensure universal adherence to prescription protocols.46 Nepal recommended training and awareness-building about the risk of NCDs in the community with a focus on young and older populations and individuals who are illiterate or semi-literate.53

Policy documents from India and Bangladesh have emphasised task-shifting to the non-physician health workers, such as paramedics and community health workers, with upskilling to address shortages in front-line health workers.38, 54 To ensure these individuals have the required skills, supportive supervision and continuous refresher training are advised. Medication adherence was another concern flagged for inclusion in training programmes for paramedics and community health workers in India.55

Leveraging information and communication technology (ICTs) for integrated NCD service delivery

In all five countries we reviewed, the potential of digital technologies to enhance the delivery of health-care services is recognised and embraced.33, 56 Bangladesh has organised NCD corners utilising digital technology in PHC facilities nationwide to enhance NCD management.33 In these NCD corners, a computer is provided for collecting and reporting disease-related data to higher authorities through the national health medical information system. Another programme in Bangladesh utilised digital technologies to facilitate NCD-related communication and data sharing among health-care practitioners, patients, and government officials.49

An academic community partnership in India aimed to combine technology, such as clinical decision support systems, with task-shifting tactics to address NCDs. The overall objective of this strategy was to reduce the prevalence of hypertension and diabetes in India's primary and community health-care facilities as a part of the Ayushman Bharat mission.56 Under this mission, health and wellness centres enabled regional innovations, such as NCD ticker bags, an innovation to ensure treatment adherence, follow‑up, and reduce drop‑outs.57

Increasingly, integrated care for diabetes and other diseases in Pakistan's primary care settings are employing telemedicine services, smartphone applications, and other technological tools to improve health-care access.46 Nepal is also implementing an integrated NCD intervention approach using digital tools, such as shared online electronic health records for mid-level professionals and community health workers, and electronic health records, to improve continuity and quality of services.51 During the COVID-19 pandemic, Sri Lanka successfully utilised digital technologies to manage NCDs based on existing digital infrastructure.58

Supply of essential NCD medicines and technologies

An uninterrupted supply of medications and diagnostic tools is key to the cost-effective management of NCDs at the PHC level. Several studies in the review emphasised the importance of access to continuous supplies of NCD medicines, according to the WHO essential medication list (eg, aspirin, metformin, thiazide, etc).28 The number out of ten of the essential NCD medicines that were available in PHC settings varied from as low as four in Pakistan, to as high as ten in Sri Lanka.59 Reported implications of insufficient access to necessary medicines, including NCD medicines,60 at the PHC level included out-of-pocket spending from private medicine shops, which sometimes became catastrophic with out-of-pocket health-care costs exceeding 10% of total household spending.61

Discussion

The urgency of addressing the rising NCDs burden through integrated services at the PHC level is clear and gaining momentum in south Asia. This review explored and analysed the prevailing situation to inform current efforts towards service delivery redesign that enables integration and continuity of care.62 Findings revealed promising examples of integrated interventions to control and prevent NCDs in policy and practice. However, scaling-up remains problematic due to prevailing modalities of care that sustain disease-specific approaches, workforce supply and capacity constraints, no dedicated financing, poor multisectoral coordination, and challenges in ensuring the uninterrupted supply of essential NCD medicines and technologies. These and other findings are discussed thematically, with the goal of generating recommendations supporting sustainable and PHC-enabled NCD prevention and control at the community level.

Political commitments for integrated NCD-service delivery and policy-practice gaps

The fact that all five countries included in this review prioritised providing prevention and control services for NCDs at the first level of care (ie, PHC level) is encouraging. This political commitment at high levels of policy and practice is reflected in the NCD multisectoral action plans of different countries, including adoption of package of essential non-communicable disease interventions at the PHC level (table 1).

Research from Bangladesh, Sri Lanka, and other countries has identified poor planning, inadequate infrastructure, unskilled workforce, and insufficient monitoring of targeted interventions as the major reasons behind the sluggish implementation of NCD-related policies and plans.63, 64, 65 For example, despite decades of planning and priority setting, many south Asian countries still struggle to adopt the WHO-PEN with workforce training on PEN protocols varying in scope and progress.66 Successful coordination of NCD activities across public, private, and non-governmental organisations requires centralised oversight and governance and creation of high-level committees. However, findings indicate inconsistent central-level coordination, irregular meetings, and poor follow-up on committee decisions.67

Across the five countries in this review, limitations in existing infrastructure, including national health management information systems, have impeded surveillance of NCD risk factors to understand trends, predict needs, and fine-tune interventions.66 Insufficient financing has also undermined efforts to re-orient and reorganise PHC services to integrate NCD care.43 The pluralistic nature of south Asian health systems, and their large informal and for-profit private sectors, has further complicated the management of NCDs at the community level, given their ubiquity and popularity as sources of care.68

Challenges of re-orienting and resourcing PHC to deliver integrated NCD services

Findings from this review suggest that an integrated PHC approach that targets the four modifiable risk factors for four major NCDs (four by four) is plausible, cost-effective, equitable, and likely to benefit the low-income and marginalised communities who are major users of PHC services. By simultaneously addressing infectious diseases and NCDs, integration strengthens the health system and improves resilience,69 while reducing cost and optimising resources. Consistent with experiences elsewhere (eg, Nigeria,70 Ethiopia,71 El Salvador,72 Brazil,73 and Thailand),74 re-orienting existing PHC services to include relevant NCD prevention and control services is a key and effective policy to address the NCD epidemic.43

However, adopting an integrated PHC approach requires a high level of health system readiness, especially from the supply side.75 Total health expenditure in south Asian countries is about 5% of GDP, and insufficient investments in PHC is manifested in workforce shortages, poor community awareness and knowledge,76 insufficient training for managing NCDs at the front lines,77 and weak information and surveillance systems. As a first step, existing PHC service providers need to undergo reorientation sessions to enhance their knowledge of the NCD epidemic and how to deliver NCD prevention and management services at the PHC level. Capacity development training should address both skills and attitudes to effectively “detect, screen, and diagnose NCDs” routinely within a comprehensive PHC infrastructure70 utilising universal guidelines and protocols (recommended by WHO).

The overall shortage of health workforce with appropriate skills to deliver NCD services, over and above their existing responsibilities, is a major barrier that reflects the current low priority given to financing PHC in the region.78 Besides skill-building for NCDs, there is a need for task-shifting to non-physician cadres, including paramedics, and community health workers or community health volunteers in the formal and informal sectors, supported by appropriate training and supervision.79 At the interface of community and PHC, community health workers are well placed to identify high-risk cases, initiate NCD screening, and follow up once a diagnosis is confirmed. Attention should also be given to leadership and governance, given its crucial role in driving the integration process at every level of the system and ensuring effective and sustainable implementation.

Use of ICTs for integrated NCD services at PHC levels

Our review findings indicate that south Asian countries have started to apply ICTs to help health services reach rural, remote, and hard-to-reach areas80 and organise service delivery programmes involving community health workers more effectively and efficiently.81 Depending on the stage of development of digital technology and degree of broadband internet penetration, various modalities are available (eg, mHealth services, telemedicine, electronic health records, and digital health platforms) to deliver customised services. However, many barriers must be overcome before the full potential of ICTs can be realised, including ensuring adequate infrastructure across the country, financial resources for ICT establishment and maintenance, and requisite skills to ensure sustainable implementation.82

Finally, the use of multiple platforms by different agencies needs to be resolved to address the challenges of data cross-comparability, both within and beyond the health sector. In developing the system, a full range of stakeholders should be involved, supported by high-level decision makers responsible for policy and programme.83

Uninterrupted supply of essential NCD medicines and technologies at PHC facilities

With the goal of ensuring equitable access and reducing out-of-pocket expenditures, an uninterrupted supply of affordable essential medicines and technologies is key to managing NCDs at the PHC level.84 Although a laudable and plausible goal, investments need to be made.85 For example, a nationally representative survey done in 2017–18 examining the preparedness of PHC facilities for delivering NCD services found that, in addition to human resources, essential NCD medicines and technologies “still eludes India”.86 Studies reveal a similar situation in Bangladesh87 and Nepal,88 but not Sri Lanka.89 Among the five countries reviewed, Bangladesh and India have a vibrant pharmaceutical industry that can meet more than 90% of local demand for all types of medicines (excluding cancer medication).90, 91 The country-level multisectoral action plans recognise the priority action needed to develop this sector and to improve supply chain management for the regular supply of essential NCD medicines and technologies at the PHC level. Rational use of medicines by providers, and improved demand-side awareness and knowledge on NCDs in the community, will support this goal.

To detect and diagnose NCDs at the PHC level, clinical examinations are typically supplemented by essential laboratory diagnostics (eg, urine and blood samples analysis), which is poorly available in LMICs including Bangladesh and Nepal.92 For better and equitable health outcomes, including NCD outcomes, investment in essential diagnostics at PHC level should be prioritised, especially in low-resource settings of these countries.93

Social determinants of health

As noted in this review, socioeconomically disadvantaged and marginalised populations are disproportionately affected by NCDs. Those experiencing multiple and often intersecting adverse social determinants of health are at the highest risk and experience the greatest challenges in adopting healthy behaviours and accessing preventive and curative services for NCDs. Actions to address NCDs must go beyond the health sector and address factors related to social determinants of health.94 These efforts should engage education, finance, urban planning, agriculture, environment, and social protection sectors in implementing Health-in-All policies that put population health considerations at the centre of sectoral planning.

Caste and NCDs

Overlooked in this analysis was the role of caste as a social determinant affecting risk of NCDs and health inequities in access to NCD prevention and management services. Prevalent in India and Nepal, the caste system is a form of social stratification based on birth and occupation,95 which affects health and risk of disease through its effects on opportunities for education and income, and culturally defined lifestyles, access to care, social capital, and coping mechanisms. For example, in India, women belonging to scheduled castes and tribes are more likely to use tobacco or alcohol compared with other castes,96 and uncontrolled hypertension is much higher among scheduled tribes compared with scheduled castes.97 Similarly, in Nepal, a greater likelihood of hypertension, dyslipidaemia, and hyperglycaemia is found in individuals belonging to marginalised versus general, higher caste groups.98 In another study, a significant relationship between catastrophic health expenditure and caste was noted after adjustment for religion, household size, and economic status of households, especially for individuals with NCDs and seeking treatment in the private sector.99 Also, lower castes might face (compared to highest castes) increased barriers to accessing integrated care for NCDs, due to stigma, discrimination, no awareness, and financial constraints.100 These findings suggest that existence of caste has important implications for NCD burden, including participation in community-based NCD prevention and management programmes, and should be recognised in comprehensive PHC planning with the goal of promoting health equity and social justice.101

Strengths and limitations of our review

Limitations of this Series paper include its focus on allopathic medicine in a region where alternative systems exist and its assumption that the public sector is the major source of institutionalised PHC services for NCD prevention and care. Issues related to public–private partnership for prevention and control of NCDs, especially at the PHC level, is not included as this is discussed elsewhere in the Series.

This review is supported by evidence from four key databases (PubMed, SCOPUS, Google Scholar, and EBSCO Host) used to identify peer-reviewed articles, including Google to search grey materials, and a hand search of government and other relevant websites. Although this approach was successful in identifying most of the available literature, the addition of primary research eliciting the perspectives of key stakeholders involved in NCD-related policy and implementation would have enriched the analysis. Obtaining the key stakeholders' perspectives was not possible due to a shortage of time and available resources.

Conclusions

Across the south Asian region, there is wide support for NCD prevention and control through the PHC system at high levels of policy and practice. Furthermore, there is growing recognition that the social and other determinants of NCDs require multisectoral action. Integration and Health-in-All policy approaches make sense in terms of investment, efficiency, and equitable effect. However, implementation remains sluggish and uncertain. A motivated, strong, and sustained leadership is needed to generate the necessary momentum to translate many successful small-scale, fragmented, and pilot interventions into full-scale programmes on national level impact. The costs of inaction are too great to ignore.

Recommendations

Accelerated reform of PHC services towards integrated care over the life course must encompass NCDs prevention and management. To support this transition, five key policy actions are needed: sustaining political and financial commitment at high levels of policy and practice; including stewardship from the public sector to coordinate and implement the policies, strategies, and multisectoral plans on NCD in an integrated manner; reforming, re-orienting, and resourcing PHC to deliver integrated NCD services, including capacity development of health workforce at all levels, especially of front-line health workers; strengthening stewardship by the public sector for delivering integrated NCD services; expedited use of ICTs to deliver integrated NCD services to populations in rural, remote and hard-to-reach areas; and ensuring uninterrupted supply of essential NCD medicines and technologies at PHC facilities. Underpinning success across all these areas is action on the social determinants of health to reduce vulnerability and increase access to PHC such that no one is left behind.

Contributors

Declaration of interests

We declare no competing interests.

Supplementary Material

Supplementary appendix

Acknowledgments

The coordinator of this paper Series (Prof Krishna Rao, Johns Hopkins University) received funding for holding two authors' meeting in Bangkok and Colombo from WHO SEARO during initial phase of finalising the outline and contents of the Series paper and later, when the drafting of the manuscript was complete, to review and finalise the manuscript. The authors received no specific funding for conducting the study.

Conceptualisation: SMA; methods: SMA, AK, AA, and KS; data collection, analysis, and visualisation: OK, SA, SAS, NN, and AR; data interpretation: SMA, AK, AA, KS, NN, and LR; writing–original draft: SMA; writing–review and editing: SMA, AK, AA, KS, and LR.
==== Refs
References

1 WHO World health statistics 2022: monitoring health for the SDGs, sustainable development goals https://digitallibrary.un.org/record/4008204?ln=en&v=pdf 2022
2 Yadav UN Mistry SK Ghimire S Recognizing the roles of primary health care in addressing non-communicable diseases in low- and middle-income countries: lesson from COVID-19, implications for the future J Glob Health 11 2021 03120
3 Somanathan AS Haque TH Zhao FZ Improving primary health care to enhance pandemic preparedness https://blogs.worldbank.org/endpovertyinsouthasia/improving-primary-health-care-enhance-pandemic-preparedness May, 2023
4 Mohan V Seedat YK Pradeepa R The rising burden of diabetes and hypertension in southeast asian and african regions: need for effective strategies for prevention and control in primary health care settings Int J Hypertens 2013 2013 409083
5 Ahmed SM Hadi A Razzaque A Clustering of chronic non-communicable disease risk factors among selected Asian populations: levels and determinants Glob Health Action 2 2009 1986
6 Liu C Tang S Integrated care for chronic diseases in Asia Pacific countries https://apo.who.int/publications/i/item/integrated-care-for-chronic-diseases-in-asia-pacific-countries 2021
7 Gyawali B Khanal P Mishra SR van Teijlingen E Wolf Meyrowitsch D Building strong primary health care to tackle the growing burden of non-communicable diseases in Nepal Glob Health Action 13 2020 1788262
8 WHO Declaration of Astana: global conference on primary health care https://www.who.int/publications/i/item/WHO-HIS-SDS-2018.61 2019
9 WHO Regional Office for South-East Asia South-East Asia regional strategy for primary health care: 2022–30 https://www.who.int/publications/i/item/9789290229094 2021
10 Peters MD Godfrey CM Khalil H McInerney P Parker D Soares CB Guidance for conducting systematic scoping reviews Int J Evid-Based Healthc 13 2015 141 146 26134548
11 Arksey H O'Malley L Scoping studies: towards a methodological framework Int J Soc Res Methodol 8 2005 19 32
12 WHOUNICEF Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens https://www.who.int/publications/i/item/9789240044210 2022
13 Institute for Health Metrics and EvaluationUniversity of Washington GBD results https://vizhub.healthdata.org/gbd-results/ 2020
14 WHO World health statistics 2023: monitoring health for the SDGs, sustainable development goals https://cdn.who.int/media/docs/default-source/gho-documents/world-health-statistic-reports/2023/world-health-statistics-2023_20230519.pdf 2023
15 Newtonraj A Selvaraj K Purty AJ Feasibility and outcome of community-based screening for cardiovascular disease risk factors in a remote rural area of South India: the Chunampet rural-cardiovascular health assessment and management program Indian J Endocrinol Metab 23 2019 628 634 32042699
16 Jafar TH Gandhi M de Silva HA A community-based intervention for managing hypertension in rural South Asia N Engl J Med 382 2020 717 726 32074419
17 Basu P Mahajan M Patira N A pilot study to evaluate home-based screening for the common non-communicable diseases by a dedicated cadre of community health workers in a rural setting in India BMC Public Health 19 2019 14 30606132
18 Ether S Saif-Ur-Rahman KM A systematic rapid review on quality of care among non-communicable diseases (NCDs) service delivery in South Asia Public Health Pract 2 2021 100180
19 Rashid S Mahmood H Asma Iftikhar A Availability and readiness of primary healthcare facilities for the management of non-communicable diseases in different districts of Punjab, Pakistan Front Public Health 11 2023 1037946
20 Fernando DE Nandasena S Attendance to noncommunicable disease screening services and its associated factors among rural adults in Dimbulagala, Sri Lanka J Health Sci 7 2019 48 58
21 Karunaratna S Weerasinghe MC Ranasinghe T Improving uptake of non-communicable disease screening in Sri Lanka: eliciting people's preferences using a discrete choice experiment Health Policy Plan 37 2022 218 231 34893842
22 Jarhyan P Hutchinson A Khaw D Prabhakaran D Mohan S Prevalence of chronic obstructive pulmonary disease and chronic bronchitis in eight countries: a systematic review and meta-analysis Bull World Health Organ 100 2022 216 230 35261410
23 Sharma K Burden of noncommunicable diseases in India: setting priority for action Int J Med Sci Public Health 2 2013 7 11
24 Engelgau M Okamoto K Navaratne KV Gopalan S Prevention and control of selected chronic NCDs in Sri Lanka: policy options and action. Health, nutrition and population (HNP) discussion paper https://documents.worldbank.org/pt/publication/documents-reports/documentdetail/965981468114860720/prevention-and-control-of-selected-chronic-ncds-in-sri-lanka-policy-options-and-action 2010
25 Yadav UN Ghimire S Mistry SK Shanmuganathan S Rawal LB Harris M Prevalence of non-communicable chronic conditions, multimorbidity and its correlates among older adults in rural Nepal: a cross-sectional study BMJ Open 11 2021 e041728
26 Amarchand R Krishnan A Saraf DS Mathur P Shukla DK Nath LM Lessons for addressing noncommunicable diseases within a primary health-care system from the Ballabgarh project, India WHO South-East Asia J Public Health 4 2015 130 138 28607311
27 Islam K Huque R Saif-Ur-Rahman KM Ehtesham Kabir ANM Enayet Hussain AHM Implementation status of non-communicable disease control program at primary health care level in Bangladesh: findings from a qualitative research Public Health Pract 3 2022 100271
28 Ministry of Health and Family WelfareGovernment of Bangladesh Multi-sectoral action plan for prevention and control of non-communicable diseases 2018–2025 https://old.dghs.gov.bd/images/docs/Publicaations/NCDC_multisectoral_action_plan_2018_2025.pdf 2018
29 Ministry of Health and Family WelfareGovernment of India Multi-sectoral action plan for prevention and control of non-communicable diseases 2017–2022 https://www.mohfw.gov.in/pdf/National%20Guidelines%20for%20IPC%20in%20HCF%20-%20final%281%29.pdf 2017
30 International Cancer Control Partnership Multi-sectoral action plan for prevention and control of NCDS 2021–25 https://www.iccp-portal.org/system/files/plans/NCD%20NEPAL.pdf 2021
31 Ministry of National Health ServicesRegulations & Coordination, Pakistan Non-Communicable Diseases & Mental Health National Action Framework 2021–30 https://www.iccp-portal.org/system/files/plans/National%20Action%20Framework%20for%20Non%20Communicable%20Disease%20and%20Mental%20Health%202021-30.pdf 2021
32 Ministry of HealthNutrition and Indigenous Medicine, Sri Lanka National multisectoral action plan for the prevention and control of noncommunicable diseases 2016–20 https://www.iccp-portal.org/system/files/plans/national_ncd_action_plan_sri_lanka.pdf
33 Rawal LB Kanda K Biswas T Non-communicable disease (NCD) corners in public sector health facilities in Bangladesh: a qualitative study assessing challenges and opportunities for improving NCD services at the primary healthcare level BMJ Open 9 2019 e029562
34 Islam A Biswas T Chronic noncommunicable diseases and the healthcare system in Bangladesh: current status and way forward Chronic Dis Int 1 2014 6
35 Faruque M Barua L Banik PC Prevalence of non-communicable disease risk factors among nurses and para-health professionals working at primary healthcare level of Bangladesh: a cross-sectional study BMJ Open 11 2021 e043298
36 Panda R Mahapatra S Persai D Health system preparedness in noncommunicable diseases: Findings from two states Odisha and Kerala in India J Family Med Prim Care 7 2018 565 570 30112310
37 Pati MK Swaroop N Kar A Aggarwal P Jayanna K Van Damme W A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India Public Health Rev 41 2020 8 32435518
38 Nebhinani M Saini SK Leveraging role of non-physician health workers in prevention and control of non-communicable diseases in India: enablers and challenges J Family Med Prim Care 10 2021 595 600 34041047
39 Zafar M Malik MA Emerging challenges and health system capacity: the case of noncommunicable diseases in Pakistan; a review J Infect Dis Ther 2 2014 2332
40 Biswas S Podder D Jha SS Kathuria P Paul B Exploring challenges of access to Noncommunicable Disease (NCD) prevention, treatment and care: a qualitative study on people living with NCDs (PLWNCDs) in West Bengal, India J Educ Health Promot 11 2022 251 36325236
41 Abdussattar MI Risk factor profile for noncommunicable diseases: findings of a STEPS survey from urban settlement of Bangalore Int J Community Med Public Health 6 2019 234
42 Jayanna K Swaroop N Kar A Designing a comprehensive non-communicable diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India BMC Public Health 19 2019 409 30991978
43 Mahipala P Dorji G Tisocki K Rani M A critical review of addressing cardiovascular and other non-communicable diseases through a primary health care approach in the South-East Asia Region Cardiovasc Diagn Ther 9 2019 150 157 31143636
44 Lall D Engel N Devadasan N Horstman K Criel B Team-based primary health care for non-communicable diseases: complexities in South India Health Policy Plan 35 suppl 2 2020 ii22 ii34 33156934
45 Neupane D McLachlan CS Mishra SR Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial Lancet Glob Health 6 2018 e66 e73 29241617
46 Khan MA Walley JD Ali S Process evaluation of integrated diabetes management at primary healthcare facilities in Pakistan: a mixed-methods study BJGP Open 2 2018 X101612
47 Kumaran S Surenthirakumaran R Haq A Nithiyalingam A Gobith R Public and patients involvement in chronic illness care, a way to provide universal health coverage in poor resource setting–a case study Jaffna Med J 30 2018 8 9
48 Kar SS Subitha L Iswarya S Palliative care in India: situation assessment and future scope Indian J Cancer 52 2015 99 101 26837989
49 Zaman MM Ullah AJ Bhuiyan MR Karim MN Moniruzzaman M Rahman SM Non-communicable disease prevention and control situation in a primary health care setting of Bangladesh: design and baseline findings of an intervention J Chronic Dis 3 2016 1021
50 Rahul A Chintha S Anish TS Prajitha KC Indu PS Effectiveness of a non-pharmacological intervention to control diabetes mellitus in a primary care setting in Kerala: a cluster-randomised controlled trial Front Public Health 9 2021 747065
51 Kumar A Schwarz D Acharya B Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal BMJ Glob Health 4 2019 e001343
52 Huque R Nasreen S Ahmed F Integrating a diabetes and hypertension case management package within primary health care: a mixed methods feasibility study in Bangladesh BMC Health Serv Res 18 2018 811 30352582
53 Timalsina P Singh R Assessment of risk factors of noncommunicable diseases among semiurban population of Kavre district, Nepal J Environ Public Health 2021 2021 5584561
54 Husain MJ Haider MS Tarannum R Cost of primary care approaches for hypertension management and risk-based cardiovascular disease prevention in Bangladesh: a HEARTS costing tool application BMJ Open 12 2022 e061467
55 Yuvaraj K Gokul S Sivaranjini K Prevalence of medication adherence and its associated factors among patients with noncommunicable disease in rural Puducherry, South India– a facility-based cross-sectional study J Family Med Prim Care 8 2019 701 705 30984698
56 Jindal D Sharma H Gupta Y Improving care for hypertension and diabetes in India by addition of clinical decision support system and task shifting in the national NCD program: I-TREC model of care BMC Health Serv Res 22 2022 688 35606762
57 Gandhi PA Nangia R Thakur JS Health and Wellness Centres as a strategic choice to manage noncommunicable diseases and universal health coverage Int J Noncommun Dis 7 2022 104
58 Tennakoon TM Wijekoon WM Ranatunga PE Ratnayake RM Antonypillai C Rambukwella IW A prompt response to COVID-19 pandemic 2020: delivery of medications for care recipients of NCD clinics at national hospital Kandy, Sri Lanka. Sri Lanka J Bio-Med Inform 11 2020 28 32
59 WHO Noncommunicable diseases country profiles 2018 https://iris.who.int/handle/10665/274512 2018
60 Munday D Kanth V Khristi S Grant L Integrated management of non-communicable diseases in low-income settings: palliative care, primary care and community health synergies BMJ Support Palliat Care 9 2019 e32
61 Pati MK Bhojani U Elias MA Srinivas PN Improving access to medicines for noncommunicable diseases in rural primary care: results from a cluster randomised trial in a district in south India BMC Health Serv Res 21 2021 1 33388053
62 Roder-DeWan S Madhavan S Subramanian S Service delivery redesign is a process, not a model of care BMJ 380 2023 e071651
63 Biswas T Pervin S Tanim MIA Niessen L Islam A Islam A Bangladesh policy on prevention and control of non-communicable diseases: a policy analysis BMC Public Health 17 2017 582 28629430
64 Ranasinghe S Gunawardena N An analysis of Sri Lankan government policies for prevention and control of noncommunicable diseases and its risk factors Int J Med Sci Public Health 10 2021 1 13
65 Senanayake S Senanayake B Ranasinghe T Hewageegana NS How to strengthen primary health care services in Sri Lanka to meet the future challenges J Coll Community Physicians Sri Lanka 23 2017 43
66 WHO WHO package of essential noncommunicable (PEN) disease interventions for primary health care https://www.who.int/publications/i/item/9789240009226 2020
67 Sarker M Hossain P Ahmed ST Barua M Sutradhar I Ahmed SM A critical look at synergies and fragmentations of universal health coverage, global health security, and health promotion in delivery of frontline health care services: a case study of Bangladesh Lancet Reg Health Southeast Asia 7 2022 100087
68 Kabir A Karim MN Billah B Health system challenges and opportunities in organizing non-communicable diseases services delivery at primary healthcare level in Bangladesh: a qualitative study Front Public Health 10 2022 1015245
69 Richter P Aslam M Kostova D The case for integrating health systems to manage noncommunicable and infectious diseases in low-and middle-income countries: lessons learned from Zambia Health Secur 20 2022 286 297 35904943
70 Ajisegiri WS Abimbola S Tesema AG Odusanya OO Peiris D Joshi R The organisation of primary health care service delivery for non-communicable diseases in Nigeria: a case-study analysis PLoS Glob Public Health 2 2022 e0000566
71 Tesema AG Abimbola S Mulugeta A Health system capacity and readiness for delivery of integrated non-communicable disease services in primary health care: a qualitative analysis of the Ethiopian experience PLoS Glob Public Health 1 2021 e0000026
72 Jimenez Carrillo M León García M Vidal N Bermúdez K De Vos P Comprehensive primary health care and non-communicable diseases management: a case study of El Salvador Int J Equity Health 19 2020 50 32252764
73 Andrade MV Coelho AQ Xavier Neto M Carvalho LR Atun R Castro MC Brazil's Family Health Strategy: factors associated with programme uptake and coverage expansion over 15 years (1998–2012) Health Policy Plan 33 2018 368 380 29346551
74 Tuangratananon T Julchoo S Phaiyarom M Healthcare providers' perspectives on integrating NCDs into primary healthcare in Thailand: a mixed method study Health Res Policy Syst 19 2021 139 34838045
75 Kabir A Karim MN Islam RM Romero L Billah B Health system readiness for non-communicable diseases at the primary care level: a systematic review BMJ Open 12 2022 e060387
76 Khatiwada B Rajbhandari B Mistry SK Parsekar S Yadav UN Prevalence of and factors associated with health literacy among people with noncommunicable diseases (NCDs) in South Asian countries: a systematic review Clin Epidemiol Glob Health 3 2022 101174
77 Akinwumi AF Esimai OA Fajobi O Idowu A Esan OT Ojo TO Knowledge of primary healthcare workers regarding the prevention and control of non-communicable diseases in Osun State, Nigeria: a rural-urban comparison Afr J Prim Health Care Fam Med 13 2021 e1 e8
78 Hanson K Brikci N Erlangga D The Lancet Global Health Commission on financing primary health care: putting people at the centre Lancet Glob Health 10 2022 e715 e772 35390342
79 Dodd R Palagyi A Jan S Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region BMJ Glob Health 4 suppl 8 2019 e001487
80 WHO Leveraging telehealth for efficient delivery of primary health care in the WHO South-East Asia region https://iris.who.int/handle/10665/350199 2021
81 Mishra SR Lygidakis C Neupane D Combating non-communicable diseases: potentials and challenges for community health workers in a digital age, a narrative review of the literature Health Policy Plan 34 2019 55 66 30668690
82 Yagos WO Tabo Olok G Ovuga E Use of information and communication technology and retention of health workers in rural post-war conflict Northern Uganda: findings from a qualitative study BMC Med Inform Decis Mak 17 2017 6 28068980
83 Sumarsono S Sakkinah IS Permanasari AE Pranggono B Development of a mobile health infrastructure for noncommunicable diseases using design science research method: a case study J Ambient Intell Humaniz Comput 14 2023 12563 12574
84 Jarvis JD Woods H Bali A Oronsaye E Persaud N Selection of WHO-recommended essential medicines for non-communicable diseases on national essential medicines lists PLoS One 14 2019 e0220781
85 Castillo-Laborde C Hirmas-Adauy M Matute I Barriers and facilitators in access to diabetes, hypertension, and dyslipidemia medicines: a scoping review Public Health Rev 43 2022 1604796
86 Krishnan A Mathur P Kulothungan V Preparedness of primary and secondary health facilities in India to address major noncommunicable diseases: results of a national noncommunicable disease monitoring survey (NNMS) BMC Health Serv Res 21 2021 757 34332569
87 Islam MR Laskar SP Macer D A study on service availability and readiness assessment of noncommunicable diseases using the WHO tool for Gazipur district in Bangladesh Bangladesh J Bioeth 7 2016 1 3
88 Aryal BK Daud M Thapa A Mahotra A Ale Magar S Malla CK Assesssment of health facilities for implementation of noncommunicable disease package J Nepal Health Res Counc 16 2018 149 155 29983428
89 Dabare PR Wanigatunge CA Beneragama BH A national survey on availability, price and affordability of selected essential medicines for non communicable diseases in Sri Lanka BMC Public Health 14 2014 817 25103467
90 Faisal MA Pharmaceutical industry of Bangladesh: a multi-billion dollar industry https://www.studocu.com/row/document/north-south-university/strategic-management/pharmaceutical-industry-of-bangladesh/74103098 2019
91 Indian pharmaceutical industry: future is now https://tinyurl.com/3d5c22c6 2021
92 Yadav H Shah D Sayed S Horton S Schroeder LF Availability of essential diagnostics in ten low-income and middle-income countries: results from national health facility surveys Lancet Glob Health 9 2021 e1553 e1560 34626546
93 Fleming KA Horton S Wilson ML The Lancet Commission on diagnostics: transforming access to diagnostics Lancet 398 2021 1997 2050 34626542
94 Ndubuisi NE Noncommunicable diseases prevention in low-and middle-income countries: an overview of health in all policies (HiAP) Inquiry 58 2021 46958020927885
95 Wikipedia Contributors Caste https://en.wikipedia.org/wiki/Caste 2019
96 Behera S Sharma R Yadav K Chhabra P Das M Goel S Prevalence and predictors of risk factors for cardiovascular diseases among women aged 15-49 years across urban and rural India: findings from a nationwide survey BMC Womens Health 24 2024 77 38281909
97 Kothavale A Puri P Sangani PG Quantifying population level hypertension care cascades in India: a cross-sectional analysis of risk factors and disease linkages BMC Geriatr 22 2022 98 35114935
98 Shakya S Shrestha V Neupane D Social determinants of health and cardiometabolic risk factors in Nepal: a scoping review Nutr Metab Cardiovasc Dis 33 2023 2308 2316 37798230
99 Behera S Pradhan J Uneven economic burden of non-communicable diseases among Indian households: a comparative analysis PLoS One 16 2021 e0260628
100 Thapa R van Teijlingen E Regmi PR Heaslip V Caste exclusion and health discrimination in South Asia: a systematic review Asia Pac J Public Health 33 2021 828 838 34024157
101 Sreekumar S Understanding Dalit equity: a critical analysis of primary health care policy discourse of Kerala in the context of ‘Aardram’ mission Int J Equity Health 22 2023 165 37633913
