Clinical outcomes of decentralised non communicable disease care in rural Eswatini using routine data

Background: Management of non-communicable diseases (NCDs) in Eswatini has traditionally been centralized in secondary and tertiary facilities, limiting access at primary healthcare clinics. This study assessed the outcomes of patients managed through a decentralized NCD care model at the primary healthcare level. Methods: We conducted a retrospective analysis of adult patients with hypertension and/or type 2 diabetes attending nine primary healthcare clinics in the Nhlangano zone from January 2020 to May 2022. Inclusion required at least six visits. Attrition, blood pressure (BP) and glycaemic control, and the effect of single-pill combination (SPC) therapy on BP were assessed. Cox proportional hazards models identified predictors of attrition, and Poisson regression analysed factors associated with BP and fasting blood glucose control. Results were reported as hazard ratios (HRs) or incidence rate ratios (IRRs) with 95% confidence intervals (CIs), with p<0.05 considered significant. Results: Of 800 patients, 588 (74%) had hypertension only, 60 (8%) had diabetes only, and 152 (19%) had both. Data completeness was limited, with 682 (85%) having baseline BP and 114 (14%) having baseline fasting glucose records. Mean systolic BP decreased from 146 mmHg to 140 mmHg by the sixth visit; fasting glucose remained unchanged. HIV-negative patients had a 44% higher chance of BP control than HIV negative. Patients on single pile combination therapy (n=151, 12%) had a 41% lower likelihood of controlling blood pressure (IRR = 0.59; 95% CI: 0.48–0.73). Kaplan-Meier analysis showed ~640(80%) remained event-free, with most attrition between months 10–20. Multivariate Cox regression found higher attrition at Mahlandle Clinic (aHR = 2.5; 95% CI: 1.4–4.3) and among HIV-negative patients (aHR = 1.7; 95% CI: 1.1–2.5), while SPC therapy was protective (aHR = 0.2; 95% CI: 0.1–0.5). Conclusions and Recommendations: Integrating NCD care into primary clinics in Eswatini is feasible, with modest BP improvements. Data gaps and poor glycaemic control highlight the need for stronger follow-up and optimized treatment strategies. Variations in attrition and the unexpected BP control pattern among SPC users warrant further investigation to enhance primary care NCD outcomes