How well are non-communicable disease services being integrated into primary health care in Africa: A review of progress against World Health Organization's African regional targets.

OBJECTIVE: In Africa, mortality due to non-communicable diseases (NCDs) is projected to overtake the combined mortality from communicable, maternal, neonatal, and nutritional diseases by 2030. To address this growing NCD burden, primary health care (PHC) systems will require substantial re-orientation. In this study, we reviewed the progress of African countries towards integrating essential NCD services into PHC.
METHODS: A review of World Health Organization (WHO) reports was conducted for all 47 countries in the WHO African Region. To report each country's progress, we used an a priori framework developed by the WHO regional office for Africa (AFRO). Twelve indicators were used to measure countries' progress. The proportion of countries meeting each indicator was tabulated using a heat map. Correlation between country income status and attainment of each indicator was also assessed.
FINDINGS: No country met all the recommended indicators to integrate NCD services into PHC and seven countries met none of the indicators. Few countries (30%) had nationally approved guidelines for NCD management and very few reported availabilities of all essential NCD medicines (13%) and technologies (11%) in PHC facilities. There was no overall correlation between a country's GDP per capita and the aggregate of targets being met (rho = 0.23; P = .12). There was, however, a modestly negative correlation between out-of-pocket expenditure and overall country progress (rho = -0.58; P < .001).
CONCLUSION: Progress by AFRO Member States in integrating NCD care into PHC is variable across the region. Enhanced government commitment and judicious resource allocation to prioritize NCDs are needed. Particular areas of focus include increasing the uptake of simplified guidelines for NCDs; increasing workforce capacity to manage NCDs; and removing access barriers to essential medicines and basic diagnostic technologies.

Introduction

Non-communicable diseases (NCDs) were responsible for an estimated 40.5 million deaths (71% of all deaths) in 2016 [1], of which 78% occurred in low and middle-income countries (LMICs). In Africa, the age standardised disability-adjusted life-years (DALYs) due to NCDs is almost equivalent to the combined DALYs from communicable, maternal, neonatal, and nutritional (CMNN) conditions in 2017 [2], and is projected to exceed deaths due to CMNN conditions by 2030 [3, 4]. Health systems in Africa are struggling to address the growing NCD burden. Inaccessible medicines and technologies [5], high out-of-pocket (OOP) costs [6], limited integration with primary health care (PHC) [7] and low density of the health workforce are barriers to an adequate health system response to NCDs [7]. Given the limited fiscal space available to health system planners to address these issues, there is need for cost-effective and equitable programs delivered through PHC [7-10].

World leaders made commitments to address NCDs at the UN General Assembly high-level meeting in 2011 and reaffirmed their actions in 2014 and 2018. In 2016, NCDs were included in the Sustainable Development Goal target 3.4 “by 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being” [11, 12]. The World Health Organization (WHO) Global action plan for the control of NCD 2013–2020 recommended that countries strengthen their health systems and address NCDs through people-centred PHC and universal health coverage (UHC) [13]. This action reaffirmed in the third UN General Assembly high-level meeting for NCDs in 2018 [14]. These recommendations including ‘Best Buys’ (guidance on the most cost-effective interventions to invest in) [15, 16] and WHO Package of Essential Noncommunicable disease interventions (WHO PEN), (cost-effective interventions for the early detection and management of NCDs) have been successfully implemented by many countries [8, 17–19].

Despite encouraging evidence of the impact of these interventions, and high-level commitment, many countries’ policy responses to NCD control are limited. Even when polices are in place, there is variation in implementation [18-22]. Previous studies conducted to track Africa’s progress in achieving NCD targets found that more than half of the countries had not achieved the interim targets [23] and progress was slow [8, 24].

In response to this, the 67th Session of the WHO African regional committee adopted a framework for integrating essential NCD services at the PHC level [7, 23] which provides targeted guidance to Member States. Four targets have been set to be achieved by 2030: (1) adapt and use WHO PEN; (2) more than 80% of the PHC workforce should receive formal training in NCD management; (3) have the essential medicines and basic technologies needed for NCD management available at PHC facilities; and (4) have systems for collecting mortality data routinely [7].

The aims of this study were to: (1) review African regional progress towards integration of essential NCDs services at the PHC level; and (2) to examine associations between financial indicators (country-level income status and out of pocket costs) and provision of essential NCD services and NCD achievements being met.

Methods

A review of WHO documents from all 47 countries in the WHO African Region was conducted. The review procedure is detailed in the below sub-sections.

Defining indicators

Indicators of progress were derived from the four WHO African regional committee targets for integrating essential NCD services for the early detection and management of CVD, diabetes, chronic respiratory diseases and cancer in PHC. Ten of twelve indicators were derived from the four regional targets which covered: (1) use of the WHO guidance documents for NCD management within PHC services (2) PHC workforce policies, particularly the training of the non-physician healthcare workers; (3) provision of essential medicines and equipment relevant to NCD management at the PHC level and; (4) information management of NCD data. Two additional indicators, healthcare financing for NCD care and the commitment of governments to govern and manage NCD program, were included to more holistically assess progress. The targets, indicators, definitions and data sources are summarized in Table 1.

Table 1

Summary of the data extraction indicators, measurement, and data source for mapping the progress of African countries to integrate essential NCDs services, using the WHO regional committee for Africa targets, 2020.

Regional target	Indicator	Measurement used (including in the heat map)	Data source
Target 1: Member States adapted and are using the WHO PEN	I. Country have national guidelines/protocols/ standards for the management of four NCDs through a primary care approach approved by government	3 = Fully achieved: if document exist for all four NCDs	• 2020 WHO progress monitoring report, indicator 9 of the report https://apps.who.int/iris/bitstream/handle/10665/330805/9789240000490-eng.pdf?sequence=1&isAllowed=y
		2 = Partially achieved: if document exist for two of the four NCDs
		1 = Not achieved: no documentation available for any NCD
		0 = No data found/not known
	II. Country have adapted and are using the WHO PEN	3 = Fully achieved: if the country adapts and uses WHO PEN	• Data was obtained from the WHO regional office for Africa
			WHO 67th regional committee for Africa report https://www.afro.who.int/sites/default/files/2017-08/AFR-RC67-12%20Regional%20framework%20to%20integrate%20NCDs%20in%20PHC.pdf
		2 = Partially achieved: if the country adapts and pilots WHO PEN to develop their strategy
		1 = Not achieved: if the country did not adapt or use WHO PEN
		0 = No data found/not known
Target 2: Training of health care workers for managing NCDs at PHC level	III. Country has a strategic plan to train PHC workers on management of NCDs	3 = Yes: country has trained or plans to train PHC workers	• Country strategy was accessed from WHO’s NCDs Document Repository https://extranet.who.int/ncdccs/documents/Db
		1 = No: Data unavailable- if the country doesn’t have a strategy at all, or documents don’t indicate the PHC health worker training (this include document written in other languages)	• Specific country reports and strategic documents
Target 3: Member States have essential medicines and basic technologies for NCDs in PHC facilities	IV. National essential medicines and basic technology list for NCDs (PHC level, if available)	3 = National essential medicine and basic technologies list is available, and also country have a list for PHC	• Data was extracted from WHO National medicines list/formulation/standard treatment guideline portal https://www.who.int/selection_medicines/country_lists/en/
			• National government websites, journal articles and newspaper articles were searched
		2 = National essential medicine/basic technologies list is available
		1 = if the country didn’t have an essential medicine and basic technologies list or no list could be identified
	V. Number of essential NCD medicines reported as “generally available” in primary care facilities of the public health sector (“generally available” were described if medicine/technology were available in 50% or more of pharmacies/facilities)	• Number of essential medicines available out of 10	• 2018 WHO NCDs country profile https://www.who.int/nmh/publications/ncd-profiles-2018/en/
		The 10 essential NCD medicines include; Aspirins, Statins, Angiotensin-converting enzyme inhibitors, Thiazide diuretics, Long-acting calcium channel blockers, Beta-blockers, Insulin, Metformin, Bronchodilators, and Steroid inhalants
		For this study, data was categorized;
		3 = All the 10 NCDs medicines were available
		2 = 5–9 NCDs medicines were available
		1 = Less than 5 NCDs medicines were available
		0 = No data available
	VI. Number of essential NCD technologies reported as “generally available” in primary care facilities of the public health sector	• Number of essential technologies available out of 6	• 2018 WHO NCDs country profile https://www.who.int/nmh/publications/ncd-profiles-2018/en/
		The 6 basic technologies include; Blood pressure measurement devices, weighing scales, height measuring equipment, blood sugar and blood cholesterol measurement devices with strips, and urine strips for albumin assay
		For this study, data was categorized;
		3 = All the 6 technologies were available
		2 = 3–5 technologies were available
		1 = <3 technologies were available
		0 = No data available
	VII. Proportion of PHC centres reported to offer CVD risk stratification	• Percentage of PHC centres who offer the service	• 2018 WHO NCDs country profile https://www.who.int/nmh/publications/ncd-profiles-2018/en/
		For this study, data was categorized;
		3 = countries with > 50% facilities provide service
		2 = countries with < 25% facilities provide service
		1 = None/service not available
		0 = No data available/ don’t know
	VIII. Member State has provision of drug therapy, including glycaemic control, and counselling for eligible persons at high risk to prevent heart attacks and strokes, with emphasis on the primary care level	3 = Fully achieved: if the country reports that more than 50% of PHC facilities are offering the services	• 2020 WHO NCD progress monitoring, indicator 10 https://apps.who.int/iris/bitstream/handle/10665/330805/9789240000490-eng.pdf?sequence=1&isAllowed=y
		2 = Partially achieved: if the country reports that between 25% to 50% of PHC facilities are offering the services
		1 = Not achieved: if the country did report or don’t offer the service
		0 = No data found/ not known
Target 4: To strengthen and integrate NCD surveillance systems into health management information systems	IX. Member State has a functioning system for generating reliable cause-specific mortality data on a routine basis	3 = Fully achieved- if country meets all the criteria for reliable cause-specific mortality data (the criteria are: 70% usable; at least five years of cause-of-death data reported to the WHO in the last 10 years and recent data reported for WHO within 5 years)	• 2020 WHO NCD progress monitoring report- indicator 2 https://apps.who.int/iris/bitstream/handle/10665/330805/9789240000490-eng.pdf?sequence=1&isAllowed=y
		2 = Partially achieved- if the country does not meet all the criteria but has submitted some vital registration data to WHO
		1 = Not achieved otherwise
		0 = No data found/not known
	X. Has a STEPS survey or a comprehensive health examination survey every 5 years	3 = Fully achieved- if country answer responds “Yes” to each of the risk factors covered in the STEP survey; the country must indicate that the last survey was conducted in the past 5 years and country must also provide the needed supporting documentation	• 2020WHO progress monitoring report, indicator 3 (List of risk factors are available in the appendix 1 of the report) https://apps.who.int/iris/bitstream/handle/10665/330805/9789240000490-eng.pdf?sequence=1&isAllowed=y
		2 = Partially achieved- if the country achieved some of but not all the risk factors listed in the STEP survey, or the surveys were conducted more than 5 years ago but less than 10 years ago.
		1 = Not achieved otherwise
		0 = No data found/not know
Additional Indicators
Health care financing	XI. Out-of-pocket (OOP) expenditure as % of current health expenditure/2016	The proportion of OOP expenditure as % of Current Health Expenditure/2016	• WHO Global Health Expenditure Database http://apps.who.int/nha/database/DocumentationCentre/Index/en https://apps.who.int/iris/bitstream/handle/10665/276728/WHO-HIS-HGF-HF-WorkingPaper-18.3-eng.pdf?ua=1
		Spending categorised as:
		3 = OOP < 20%
		2 = OOP = 21–37%
		1 = OOP ≥ 38% (above the regional average)
		0 = No data available/not know
Leadership	XII. Existence of an operational Unit, branch, or department in ministry of Health with responsibility for NCDs	3 = The country has a unit or other equivalent body in the country	• WHO 2017 report from Global Health Observatory data repository https://apps.who.int/gho/data/view.main.2472 Effective date: 2018-03-13
		1 = No body available

Identification of relevant documents and scoring

For indicator data sources, we extracted information mainly from WHO reports [7, 25, 26]. The primary data sources included the WHO 2020 NCD progress monitoring report [25]; 2018 WHO NCD country profiles [26] and the report from the 67th session of WHO Regional Committee for Africa [7]. The WHO document repository for NCDs and Global Health Expenditure database were accessed for financing data [27, 28]. In addition, we worked with the WHO regional office for Africa to obtain data that were not yet publicly reported (Table 1). We did not have rigid inclusion and exclusion criteria; however, documents that did not provide a national overview were excluded.

In order to score progress, we used definitions in line with the WHO NCD progress monitoring report 2020 (2nd, 3rd, 9th and 10th indicators). That is; ‘fully achieved’ when the countries achieved all the required standards; ‘partially achieved’ when they had incomplete achievements and ‘not achieved’ where there was no evidence of progress [25]. For indicators in the WHO 2018 country profile [26] and indicators from other sources, we categorized the data in line with the 2020 WHO progress monitoring report. For healthcare financing, we used OOP expenditure as the primary indicator and classified the countries based on the WHO global health spending report [29, 30] (Table 1). We accorded a value of three points for each fully achieved indicator, two for partially achieved indicator, one for indicator that had not been achieved, and zero for which there were no data available. We generated aggregate scores for each country with a maximum score of 36 points indicating all 12 indicators were fully met.

Data were extracted and mapped against the 12 indicators (Table 1). Three researchers (AGT, WSA and CB) extracted the data and entered information into a Microsoft Excel spreadsheet. Each researcher extracted data separately and later crosschecked each other’s works to maintain the quality of the data. The research team met regularly to discuss the data extraction and management process. Furthermore, government strategic documents were reviewed qualitatively to supplement the numeric data.

Once the data extraction process was complete, a draft report was sent to the WHO Africa regional office team to provide supplementary information, focussing on those countries with limited data. This also validated the accuracy of the data extracted for other countries. The WHO Africa regional office team contacted the respective Ministry of Health/WHO focal person to verify the availability of the data. To facilitate the interpretation of findings, we also conducted targeted searches of country reports and strategic documents, with particular attention to indicators for which where country-level data were limited or missing in WHO reports.

Data analysis

Scores were tabulated and displayed using a heat map to compare each country’s achievement against various indicators. To examine correlation between financial variables and attainment of indicators, we used Gross Domestic Product per capita (GDP per capita) and OOP costs and assessed correlation with overall aggregate scores, NCD medicine scores and NCD technologies. Spearman’s rank correlation coefficient (rho) was calculated and the size of the correlation coefficient was interpreted based on the classification stated by Mukaka, where a value approaching 1 indicates high correlation, and a value less than 0.3 suggests low or negligible correlation [31]. Data analysis was done using IBM SPSS statistical software, version 25.

Ethics approval

This study used open access documents; therefore, no ethical issues involved.

Results

Characteristics of the countries

Data from all the 47 countries in the WHO African region were included. Twenty-six countries (55%) were classified as low-income countries (LICs),13 (28%)lower-middle-income countries (LMICs), 7(15%) upper-middle-income countries (UMICs) and one was classified as a high-income country (Seychelles) [32]. The estimated proportional mortality due to NCDs varied from 26% (Central African Republic) to 89% (Mauritius) of all deaths [26]. Upper-middle and HICs [Mauritius (89%), Seychelles (81%) and Algeria (76%)] had the highest proportion of NCD deaths [26]. The main findings based on the regional targets are summarised below and in Table 2.

Table 2

Heat map showing the progress of countries against the WHO regional committee for Africa target to integrate NCDs services in the PHC level, 2020.

Country Name	Indicators
	I. NCD guideline in PHC	II. WHO PEN	III. HRH trained	IV. National list of EM and technology	V. Generally available medicine/10	VI. Generally available technologies/6	VII. CVD risk stratification @PHC	VIII. Country has drug therapy @PHC	IX. Cause-specific mortality data	X. Has STEP survey	XI. Out-of-pocket expenditure	XII. Leadership
Algeria	2	1	1	2	2	3	0	1	1	2	2	3
Angola	0	1	3	3	1	2	1	2	1	2	2	3
Benin	3	3	1	2	1	1	2	2	1	2	1	3
Botswana	3	3	1	2	2	2	0	2	1	3	3	1
Burkina Faso	3	3	1	2	1	2	1	2	1	2	2	3
Burundi	2	1	1	2	1	2	1	2	1	1	2	1
Cabo Verde	1	2	1	2	3	3	3	3	2	1	2	3
Cameroon	1	1	1	2	1	2	2	2	1	1	1	3
Central African Republic	2	1	1	2	2	2	2	2	1	2	1	1
Chad	1	1	1	2	1	2	2	2	1	1	1	1
Comoros	0	1	1	1	2	2	3	2	1	2	1	1
Congo	2	1	1	2	1	2	2	2	1	1	1	1
Côte d'Ivoire	1	3	1	2	1	2	2	2	1	2	1	3
D.R Congo	2	1	1	2	1	1	1	2	1	1	2	1
Equatorial Guinea	1	1	1	1	1	1	2	2	1	1	1	1
Eritrea	1	3	3	2	1	2	2	2	1	2	1	1
Eswatini/Swaziland	1	3	3	2	3	2	2	2	1	3	3	3
Ethiopia	3	3	3	2	1	2	2	2	1	3	2	3
Gabon	1	1	1	2	1	2	2	2	1	1	2	1
Gambia	1	1	3	1	1	2	0	1	1	2	2	1
Ghana	3	2	3	2	2	2	1	0	1	2	1	1
Guinea	2	3	1	2	2	2	2	2	1	1	1	1
Guinea-Bissau	1	1	1	1	1	2	1	2	1	1	2	3
Kenya	3	1	3	2	2	2	2	2	1	3	2	3
Lesotho	3	3	3	2	2	2	0	2	1	2	3	1
Liberia	2	1	1	2	1	2	1	2	1	2	1	1
Madagascar	3	1	1	2	1	1	1	2	1	1	2	3
Malawi	3	3	3	2	2	1	1	2	1	2	3	3
Mali	1	1	1	2	2	3	0	1	1	2	2	1
Mauritania	1	1	1	2	2	1	2	2	1	1	1	1
Mauritius	2	1	1	1	3	3	1	2	3	2	1	3
Mozambique	2	1	1	2	2	2	2	2	1	2	3	3
Namibia	1	1	1	2	2	2	1	2	1	2	3	3
Niger	1	1	1	2	1	2	1	2	1	1	1	1
Nigeria	1	1	3	2	1	1	1	2	1	1	1	1
Rwanda	3	1	3	2	3	2	1	2	1	2	3	3
Sao Tome and Principe	2	1	1	1	2	2	1	2	1	2	3	3
Senegal	3	1	1	2	2	3	1	2	1	3	1	1
Seychelles	2	2	3	2	3	2	2	3	3	2	3	3
Sierra Leone	1	3	3	3	1	2	2	2	1	1	1	1
South Africa	2	1	3	3	3	2	0	1	3	2	3	3
South Sudan	1	1	1	1	1	2	1	2	1	1	0	1
Togo	2	3	1	2	2	2	2	2	1	2	1	1
U.R Tanzania	3	1	3	2	2	2	2	2	1	2	2	1
Uganda	3	2	3	2	2	2	2	2	1	3	1	3
Zambia	3	1	3	2	2	2	2	2	1	2	3	3
Zimbabwe	2	1	1	2	1	2	1	2	1	1	2	1

Target one: Adapt and use WHO guidance documents for NCD management within PHC services

Indicator I: National guidelines/protocols/standards for the management of major NCDs through a primary care approach

Among the 47 countries, 14(30%) had PHC guidelines for the management of NCDs, while 17 (36%) countries had not achieved this target (Table 3).

Table 3

Percentage of achievement for various indicators: Mapping African countries’ progress toward integration of NCDs service at the PHC level, 2020.

Indicator	Number of country (n = 47)	Percent (%)
Availability of guidelines for the management of major NCDs at the PHC level
Fully achieved	14	30
Partially achieved	14	30
Not achieved	17	36
No available data	2	4
Country adopted and use WHO PEN
Adopted and using WHO PEN	13	28
List WHO PEN as a strategy/ pilot test WHO PEN in specific area of the country	3	6
Have not adopted WHO PEN	31	66
Training of primary healthcare workers for NCDs management
Country has trained or plans to train primary healthcare workers	17	36
No available data /document written in other language	30	64
Essential medicine LIST available nationally and at the PHC level
Essential medicine available nationally and at the PHC level	3	7
Essential medicine available at the national level only	40	85
No available data	4	8
Number of essential medicines available
<5 NCD medicines	22	48
5–9 medicines	19	40
All the 10 medicines	6	12
Number of essential NCDs technology available
<3 technologies	7	15
3–5 technologies	35	74
All the 6 technologies	5	11
Proportion of primary health care centres reported as offering CVD risk stratification
< 25% (including one country which provide in25-50% of its facilities)	21	45
> 50%	2	4
None/service not available	18	38
Don’t know (DK)/data not found	6	13
Provision of drug therapy, including glycaemic control, and counselling for eligible persons at high risk to prevent heart attacks and strokes, with emphasis on the primary care level
Fully achieved	2	4
Partially achieved	40	85
Not achieved	4	9
No data	1	2
Member State has a functioning system for generating reliable cause-specific mortality data
Fully achieved	3	6
Partially achieved	1	2
Not achieved	43	92
having STEPS survey or a comprehensive health examination survey every 5 years
Fully achieved	6	13
Partially achieved	24	51
Not achieved	17	36
Out-of-pocket expenditure as percentage of current health expenditure
≤ 20% OOP expenditure	11	23
21% - 37% OOP expenditure	15	32
≥ 38% OOP expenditure	20	43
No available data	1	2
Existence of an operational unit, branch, or department in Ministry of Health with responsibility for NCDs program
Yes	22	47
No	25	53

Indicator II: Adaptation and use of WHO Package of Essential NCDs (PEN) interventions

By December 2018, 13 (28%) countries had adapted and were using the WHO PEN (Table 3). In addition, 14 country representatives were trained on the implementation of the WHO PEN interventions [33].

Target two: Train the PHC workforce in managing NCDs

Indicator III. Strategic plan to train the PHC workforce to manage NCDs

Even though we could not access the number of health workers trained in each country, 17 (36%) countries reported that either health workers have been trained or have a national strategy that includes a plan to train PHC workers for NCDs management. For the remaining 30 countries, either their NCDs strategic plan could not be accessed or the documents did not provide information about training.

Target three: Availability of essential medicines and technologies for NCD management in PHC facilities

Indicator IV: List of essential medicines and technologies for NCDs management nationally (PHC facilities, if any)

Of the 40 (85%) countries that had essential medicines list at the national level, three (7%) countries (Angola, Sierra Leone and South Africa) had specific essential medicine lists for PHC facilities (Table 2).

Indicators V & VI: Essential NCD medicines and technologies in PHC facilities

Six countries (13%) reported having all ten recommended essential NCD-related medicines on their list, and five countries (11%) reported having the six NCD essential technologies “generally available” in their PHC facilities (Table 3). Only two countries [Cabo Verde and Mauritius—both UMICs] reported having all ten essential NCD medicines and six essential NCD technologies. Angola, Equatorial Guinea, and Gabon (UMICs), and Niger and South Sudan (both LICs) did not report availability of essential NCD medicines in PHC facilities (Tables 2 and 3).

Indicator VII: Provision of drug therapy, including glycaemic control, and counselling for people at high risk to prevent heart attacks and strokes, at PHC facilities

This indicator was fully achieved in Cabo Verde (LMIC) and Seychelles(HIC) and partially achieved in 40(80%)countries(Tables 2 and 3).

Indicator VIII: Proportion of PHC centres reported as offering cardio-vascular diseases risk stratification

Among the 47 countries, Carbo-Verde and Comoros reported having Cardiovascular Diseases (CVD) risk stratification in over 50% of its PHC facilities. In 18 (38%) countries there was no risk stratification conducted in PHC facilities (Tables 2 and 3).

Target four: Health information systems

Indicators IX & X: Functioning system for generating reliable cause-specific mortality and morbidity data using either WHO’s STEPwise approach to surveillance (STEPS) or a comprehensive health survey every 5 years

Seychelles (HIC), Mauritius (MIC) and South African(UMIC) reported fully established, reliable and routine systems to generate cause-specific NCDs mortality data. Cabo Verde reported partial achievement, and the remaining 43 (92%) countries reported no system for routine collection of NCD mortality data. In addition, six (11%) countries Botswana, Kenya, and Lesotho (MIC), and Uganda (LIC) conduct STEPS or comprehensive health surveys every five years (Tables 2 and 3).

Additional indicators

Health system financing

Indicator XI: Out-of-pocket expenditure as percentage of current health expenditure. Eleven (23%) countries (one HIC, seven MICs, and three LICs) had low (≤20%) OOP expenditure as a proportion of total health expenditure in 2016. Of these, six countries: Seychelles (HIC), Botswana, Namibia and South Africa (UMICs), and Rwanda and Mozambique (LICs) reported <10% OOP expenditure on health. Twenty (43%) countries have above the regional average of OOP spending with ≥38% [the average OOP spending for African region is 37% [30]]. Cameroon, Comoros and Equatorial Guinea (MICs) reported the highest proportions of OOP expenditure.

Leadership and governance

Indicator XII: Existence of an operational department in Ministry of Health responsible for NCDs program. The establishment of new or strengthening existing operational unit or department responsible for planning, implementation and evaluation of NCD programs is very crucial in fostering effective integration of the service at all levels. Twenty-two (47%) countries have an operational unit or department responsible to provide leadership and guidance for the implementation of NCDs activities (Table 3).

Progress scores and correlation with financial indicators

Cabo Verde, Ethiopia, Eswatini, Kenya, Malawi, Rwanda, Seychelles, South Africa, Uganda, and Zambia scored ≥25 out of a maximum of 36 points. By contrast, Chad, Democratic Republic of Congo, Equatorial Guinea, Gambia, Mauritania, Niger and South Sudan had the lowest scores with no targets fully achieved (Table 2). There was no overall correlation between countries’ GDP per capita and the aggregate score of each country’s achievement (rho = 0.23; P = .12). However, a modest negative correlation was observed between countries’ OOP expenditure and their aggregate achievement score. This showed, countries with relatively lower OOP expenditure had higher aggregate scores (rho = -0.58; P < .001) (Table 4).

Table 4

Correlation coefficient results for selected variables, African countries’ progress toward integration of NCDs service at the PHC level, 2020.

	Number of essential NCDs medicine available in the country		Number of essential NCDs technology available in the country		Aggregate score
	Spearman's rho,	p-value	Spearman's rho,	P-value	Spearman's rho,	P-value
Gross Domestic Product (GDP) per capital, 2017	0.31	0.03	0.37	0.009**	0.21	0.15
Out-of-Pocket (OOP) expenditure	-0.51	0.0001**	-0.25	0.09	-0.58	0.0001**

**Correlation is significant at p-value < 0.01 level (2-tailed)

With respect to NCD medicines and technologies, there was no correlation between GDP per capita and the availability of NCD medicines (rho = 0.31; P = .03) however, there was a positive correlation between GDP per capita and essential technologies (rho = 0.37; P = .009) (Table 4). Also, OOP expenditure displayed a moderate negative correlation with the number of essential NCD medicines available in the country. Countries with a relatively higher number of essential NCD medicines had lower OOP expenditure (r = -0.51; P < .001) (Table 4).

Discussion

We assessed progress of countries towards PHC integration of essential NCD services in the WHO African region and identified areas of relative strength and weakness in achieving the regional targets. Although no country in the region had met all the indicators assessed, some demonstrated progress. Relatively higher achievements were recorded from Cabo Verde (LMIC), Ethiopia (LIC), Eswatini (LMIC), Malawi (LIC), Rwanda (LIC), Seychelles (HIC) and South Africa (UMIC). The lowest achievement scores were observed in South Sudan (LIC), Equatorial Guinea (UMIC), and Niger (LIC). Overall there was a mixed picture with associations between financial indicators and progress against targets. Progress was not directly correlated with the income level of countries; however, for a specific indicator (access to essential NCD technologies) positive correlation was displayed with the country’s income level. For OOP expenditure there was a modest negative correlation with the country’s progress and with access to essential NCD medicines, but not with access to essential NCD technologies. The findings suggest that health system drivers to make progress in NCD targets are more complex than simply the wealth of the nation.

Variable progress was evident across all target areas. With regard to use of NCD guidelines, only 30% of countries have nationally approved NCD plans for implementation in PHC, a slight improvement from 17% in 2014 [23] and 26% from 2017 [24]. In 2017, among the 31 countries who had a national NCD strategic plan, only 17 were operational [33]. We also found few countries (47%) reported a distinct department for NCD programs. In 2017, only two-thirds (77%) of countries had one full-time professional staff member in the ministry representing a decline from previous years 83% (2010), 93% (2013) and 100% in 2015 [34].

Only 13 countries in the region have implemented WHO PEN interventions at the PHC level, indicating that activities need to be scaled-up [7]. Effective adaptation and implementation of WHO PEN guideline is a complex undertaking. Studies in Ghana and Zambia have identified critical capacity gaps in PHC facilities, particularly workforce capacity, health system infrastructure and health information systems [35, 36]. Addressing these gaps requires a multi-sectoral response with a commitment to invest in PHC. Priority areas identified in this study include: (1) the need for substantial resource commitments to strengthen and expand the workforce; (2) adequate financing and supply chains to ensure access to essential medicines and diagnostic technologies, and (3) investment in robust health information systems [35-37].

Most countries (64%) lack national plans to train PHC workers for NCD management, which is well short of achieving the target of having at least 50% of PHC workers trained in NCD management by 2020. This is exacerbated by intra-country variation with 75% of countries experiencing both shortage and mal-distribution of the workforce [7]. Task shifting to non-physician healthcare workers (typically nurses and community health workers) is a well-established strategy and valuable lessons can be learnt from successful programmes such as HIV care and maternal and child health [16, 38–40].

Similar to previous studies [41-44], many countries reported limited availability of essential NCD medicines and technologies. Only Cabo Verde and Mauritius report availability of all ten essential NCD medicines and six essential NCD technologies in their PHC facilities. Cabo Verde has achieved these targets through strong political commitment to strengthen PHC services as part of their UHC agenda [45]. The limited availability of affordable medicines and diagnostic tests is a complex challenge in sub-Saharan Africa [43]. Minimal competition among few numbers of suppliers in LMICs affects medicine supply and cost. A 2019 report showed that buyers in LMICs pay up-to 20–30 times the minimum international reference price for generic medicines [46]. Generating sufficient fiscal space to subsidise the costs of these medicines and avoid passing on the costs to end users is essential.

Despite global advocacy for strengthening health information systems, such systems remain under-developed in the region. Most countries (92%) lack sufficient systems for generating reliable NCD mortality data. With the latest 2020 WHO progress report, six countries (Botswana, Ethiopia, Eswatini, Kenya, Lesotho and Uganda) have made progress with conducting and repeating STEPS regularly. Only two countries, Ethiopia and Eswatini have made progress comparing to the 2017 progress report [24]. However, the 2018 WHO Africa Region Secretariat reports a decreasing trend of STEPS implementation in countries from 33 in 2003, to 15 in 2015 [8]. Establishing robust civil registration and vital statistics (CRVS) systems by allocating resources and training staff to generate disease specific, age and sex disaggregated data, and integrating NCD data within existing Demography Heath Survey are priorities for improving NCD surveillance [34, 47, 48]. Several WHO programmes are underway to address some of these priorities, providing technical and financial support to improve CRVS systems in Ghana, Malawi, Rwanda and Tanzania [49].

We observed countries with high OOP expenditure have lower availability of NCD medicines in the public sector. And, countries with higher GDP per capita, had slightly higher availability of NCD technologies. There were exceptions with some LIC and LMICs like Cabo Verde, Mali and Senegal reporting the availability of all essential NCD technologies. This suggests that several other factors are at play beyond resource availability such as the country’s commitment and priority setting. A study in 151 countries, suggested that NCD policy implementation is not necessarily expensive, and found that many MICs outperform HICs [50].

There are limitations to this review. The review mainly used data from the WHO reports, and we are constrained by the limitations in those reports. These reports are sourced from each country and this could bias the findings. To improve the quality of the data, WHO requested countries to provide supporting documentation pertaining to the relevant indicator/s. We found limited information to assess regional variation on progress and limited information on workforce training with only the ability to review plans for training rather than reports on actual implementation. Except for a few countries (e.g. Ethiopia and Nigeria) where the researchers had access to local networks to verify actual progress, we were not able to do that for all countries. This was mitigated by consulting with the WHO regional office and reviewing peer-reviewed journals to corroborate findings. Going forward to address these limitations we recommend: (1) independent monitoring mechanisms to assess implementation of NCDs interventions; (2) develop systems that enable reporting of NCD targets that are disaggregated by region; and (3) expand evaluation research in the field taking into consideration regional complexity.

Conclusion

This review demonstrates the need for intensified efforts to integrate essential NCD services at the PHC level in the WHO AFRO Member States. Priority areas include: (1) reorientation of PHC systems to better integrate NCD services; (2) initiatives to recruit, train, motivate and supervise PHC workers with access to simplified guidelines; (3) access to essential medicines and technologies; (4) incorporation of NCD surveillance into health information systems and availability of region-specific monitoring mechanism; (5) creating information systems that enable reporting of disaggregated NCD data by equity domains (such as; age, sex, and geography) and (6) expanding UHC initiatives to reduce OOP expenditure. Combating NCDs is a political choice which need a whole-of-government approach.

29 Jul 2020

PONE-D-20-19186

How well are non-communicable disease services being integrated into primary health care in Africa: a review of progress against World Health Organization’s African regional targets

PLOS ONE

Dear Dr. Tesema,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The authors present a timely assessment of the progress being made in integrating NCD services into primary health care in Africa. Their review highlights the key deficiencies in this integration as very few countries have met the approved targets. The variable progress across this region highlights the considerable variability found across different countries in advancing progress in this domain.

Please find my comments and the comments of the other reviewers below.   Please pay particular attention to the comments which are listed as major and provide a detailed response describing how you intend to address those issues.

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We look forward to receiving your revised manuscript.

Kind regards,

Sonak D. Pastakia

Academic Editor

PLOS ONE

Additional Editor Comments:

Methodology

Their combined research strategy of incorporating the feedback of the WHO Africa regional office is novel as it can help to validate and refine their findings with more in depth assessments from country based experts. There is a risk for bias but it seems this aspect of their methodology helped create a more comprehensive review of a difficult topic. At the same time, I do worry that some of the assessments might be biased as they are relying almost entirely on government reports of progress which would have an interest in presenting this data in a very positive light.  For example, I'm not sure that your approach for reporting availability of certain services such as medications is rigorous enough as it seems to largely be based on government-based reports rather than direct assessments of availability. Is there any way to assure the reader of the accuracy of your information and or the sources? At a minimum, this should be discussed as a limitation. (major)

One other thing which isn't entirely clear to me is how how your analysis goes beyond the WHO tracking efforts. What does the publication of this paper add to what is already presented by the WHO? It would be worthwhile to call that out specifically. (major)

If possible, I would have liked to see correlations with progress and NCD outcomes over time to potentially give positive feedback to countries that have made progress and suggestions for improvement to those who haven't. (minor)

Please also see the comments of the reviewers, especially reviewer 2, as addressing those comments will help to make this a stronger and more clear paper.

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a well researched and well written timely article. I only have minimal comments to add to this work.

Please add a definition of what the measure of mortality is that is reported at the beginning of the results section

The authors accurately point out a key limitation is the inability to verify progress vs implementation plans. The last sentence of the limitations (last paragraph in the discussion) implies that they were able to somewhat but not quite clear? Suggest you re-word for clarity. In addition, would suggest given where the study concludes, perhaps a suggestion of next steps to advance research in this field would be helpful.

The manuscript introduction and discussion sections have some minor grammar and punctuation errors rectifiable via a thorough edit e.g the first sentence of paragraph 7 of the discussion (page 10) is unclear.

Reviewer #2: I thank Editor for the opportunity to review this manuscript. I also thoroughly enjoyed reading the manuscript and commend the authors for providing incredibly interesting information and timely analyses/results regarding progress to strategically address NCD burden in Africa. I have a few minor comments that I hope the authors can address to strengthen the manuscript.

1. Overall, I was a little confused regarding which main framework was used for the analysis. It seemed that it was the Framework for Integrating Essential NCD Services at the PHC level with 4 targets. However, in the methodology and results section, it seemed that these indicators were fit into some of the WHO Health Systems Strengthening Building Blocks. When it came to the Discussion section, the authors went back to discuss their findings in the context of the 4 targets suggested by the WHO African Region Committee, without mentioning . I wasn't clear why the 12 indicators need to be "fit" into the WHO Building Blocks Framework. In my opinion, the Framework for Integrating Essential NCD Services at the PHC levels with 4 targets and 12 indicators are sufficient. If the authors are inclined to use the 6 building blocks, I think further discussion should be provided. (major)

2. The authors stated: "A review of national documents from all 47 countries in the WHO African Region was conducted. The detail review procedure is listed in the below sub-sections." I think this can be misleading because from my reading, it seemed clear that the authors analyze WHO reports primarily, not the national documents from each of these 47 countries. (please clarify, major)

3. Table 1: a few of the links led me to a website that was unrelated to the topic discussed (i.e. NCD Country Profiles) or led me to a website that could not be opened. Please double check your URLs. (major)

4. Table 2 (heat map): data were all presented as 0-3 (no data - fully achievement for the indicator). However, some of your indicators' answered are Yes/No questions (has a country trained or have plans to train PHC workers) or questions or questions answered in discrete values (# of essential medicines available out of 10). How did you translate those answers into 0-3 (major)

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30 Aug 2020

Author Response Letter: PLOS ONE [PONE-D-20-19186]

Dear Dr Pastakia,

Thank you for reviewing our manuscript on “How well are non-communicable disease services being integrated into primary health care in Africa: a review of progress against World Health Organization’s African regional targets”. We have revised the manuscript to respond to the points raised by you and the reviewers and uploaded a clean and tracked change manuscript.

Journal requirements

• Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

The manuscript is now formatted accordingly.

• Please upload copies of Figures 2 and 3, to which you refer in your text on page 8. If the figures are no longer to be included as part of the submission, please remove all reference to it within the text.

Apologies - this referred to tables 2 and 3. We have replaced the word ‘figure’ with ‘table’ in the revised version, please see page 15; line 27.

Academic Editor Comments

I. Methodology

Their combined research strategy of incorporating the feedback of the WHO Africa regional office is novel as it can help to validate and refine their findings with more in depth assessments from country-based experts. There is a risk for bias, but it seems this aspect of their methodology helped create a more comprehensive review of a difficult topic. At the same time, I do worry that some of the assessments might be biased as they are relying almost entirely on government reports of progress which would have an interest in presenting this data in a very positive light. For example, I'm not sure that your approach for reporting availability of certain services such as medications is rigorous enough as it seems to largely be based on government-based reports rather than direct assessments of availability. Is there any way to assure the reader of the accuracy of your information and or the sources? At a minimum, this should be discussed as a limitation. (major)

• We agree this review mainly relied on the WHO country’s progress reports and this may have introduced a bias. We have highlighted this as a potential limitation resulted from using these reports. We indicated this in the revised manuscript. Please see page 20; line 23-26. The implications of a positive reporting bias are that the large gaps we found could potentially be larger. As stated in the methods, we did also seek to interpret the findings drawing on empirical studies to provide greater depth to the country level findings (for example, indicator IV). However, this also comes with limitations – although internal validity may be enhanced, there is potential that external validity is compromised if the regions and populations studied are not representative at a national level.

II. One other thing which isn't entirely clear to me is how your analysis goes beyond the WHO tracking efforts. What does the publication of this paper add to what is already presented by the WHO? It would be worthwhile to call that out specifically. (major)

We believe this review adds value in three ways. First, the WHO NCDs reports are less granular, tracking all 9 NCDs voluntary global targets across multiple WHO regions to assess the overall national NCDs plan implementation progress, where health system strengthening is one of the targets. Our study had a more focussed scope reviewing African countries’ primary health care NCD implementation progress. Second, we explored associations between progress in these indicators and national health system capabilities including income status. Third, we also assessed relationships between each indicator and country level factors such as income status and out-of-pocket expenditure and found only weak associations on some parameters, suggesting that health system drivers to make progress in NCD targets are more complex than simply the wealth of the nation. We have added text regarding this on page 18; 1st paragraph of the discussion section.

III. If possible, I would have liked to see correlations with progress and NCD outcomes over time to potentially give positive feedback to countries that have made progress and suggestions for improvement to those who haven't. (minor)

The Academic editor has raised an important research gap to explore in future, looking at the correlations between country progress and NCD outcomes at different time points. Time series analyses that sought to assess impact of certain policies on NCD outcomes would help shed light on this, however causal inference will always be contested given the complex and multifaceted nature of these policies and the timing of their introduction is not always easy to ascertain.

Reviewers' comments:

Reviewer 1:

IV. Please add a definition of what the measure of mortality is that is reported at the beginning of the results section

Mortality estimates were taken from the WHO 2018 country profiles report and the measure used in the document was a proportional mortality (percentage of total death, in all ages and of both sex) for the four main NCDs. Please see page 10, line 9-10.

V. The authors accurately point out a key limitation is the inability to verify progress vs implementation plans. The last sentence of the limitations (last paragraph in the discussion) implies that they were able to somewhat but not quite clear? Suggest you re-word for clarity. In addition, would suggest given where the study concludes, perhaps a suggestion of next steps to advance research in this field would be helpful.

We have included three recommendations for next steps: (1) strengthen independent monitoring mechanisms to assess implementation of NCDs interventions; (2) expand evaluation research in the field taking into consideration regional complexity; and (3) develop systems that enable reporting of NCD targets that are disaggregated by region. Please see page 21 last paragraph of limitations section.

VI. The manuscript introduction and discussion sections have some minor grammar and punctuation errors rectifiable via a thorough edit e.g the first sentence of paragraph 7 of the discussion (page 10) is unclear.

We have clarified the idea in the revised version. Please see paragraph 7 of the discussion. Grammar and punctuation errors have been rectified throughout the paper.

Reviewer 2:

VII. Overall, I was a little confused regarding which main framework was used for the analysis. It seemed that it was the Framework for Integrating Essential NCD Services at the PHC level with 4 targets. However, in the methodology and results section, it seemed that these indicators were fit into some of the WHO Health Systems Strengthening Building Blocks. When it came to the Discussion section, the authors went back to discuss their findings in the context of the 4 targets suggested by the WHO African Region Committee, without mentioning. I wasn't clear why the 12 indicators need to be "fit" into the WHO Building Blocks Framework. In my opinion, the Framework for Integrating Essential NCD Services at the PHC levels with 4 targets and 12 indicators are sufficient. If the authors are inclined to use the 6 building blocks, I think further discussion should be provided. (major)

The main framework used was the WHO AFRO framework for Integration Essential NCDs Services at the PHC level, with its 4 targets which include PHC guidelines, workforce, medicines, and information systems. Indicators 1 – 10 fit well with 4 of the 6 WHO health systems building blocks, however, indicators 11 (out of pocket expenditure) and 12 (existence of an operational department) focus on the other two health system building blocks (financing and governance) and these are not present in the WHO AFRO framework. Given the aim of our study was to explore how NCDs are being integrated in the system we considered these two additional indicators were important to support a more holistic assessment. We agree it is a little confusing having two frameworks and so we have removed reference to the health system building blocks throughout the paper to make it clear and only referred to the WHO AFRO framework with the 4 targets and 12 indicators.

VIII. The authors stated: "A review of national documents from all 47 countries in the WHO African Region was conducted. The detail review procedure is listed in the below sub-sections." I think this can be misleading because from my reading, it seemed clear that the authors analyse WHO reports primarily, not the national documents from each of these 47 countries. (please clarify, major)

We agree this is potentially misleading and have clarified this throughout the paper to indicate that the primary data source is the WHO reports. Please also see response 2 above to the academic editor’s query related to this.

IX. Table 1: a few of the links led me to a website that was unrelated to the topic discussed (i.e. NCD Country Profiles) or led me to a website that could not be opened. Please double check your URLs. (major)

Some of the data were extracted from the 2018 WHO NCDs country profile. However, in the revised manuscript, all the links/URLs have been checked. Please see the updated Table 1.

X. Table 2 (heat map): data were all presented as 0-3 (no data - fully achievement for the indicator). However, some of your indicators answered are Yes/No questions (has a country trained or have plans to train PHC workers) or questions answered in discrete values (# of essential medicines available out of 10). How did you translate those answers into 0-3 (major)?

For most of the indicators, we used the 3-point scale to derive the heat map with a zero-value assigned if data were not available. For dichotomous value indicators, we gave a value of ‘3’ for ‘full achievement’, ‘1’ for ‘no achievement’ and ‘0’ for indicators with ‘no available data’ (see table below). Furthermore, we also present the actual numeric findings for each indicator in table 3. In the revised manuscript, we have edited Table 1 to make the measurement assumptions clearer. Please also see the method section in page 8.

Indicators (variables that measures countries’ progress) Explanation

For indicator I, II, VIII, IX, and indicator X 3= fully achieved

2= partially achieved

1= not achieved

0= No data found/not known

Indicator III 3= country has trained or plans to train PHC workers (Yes)

1= Data unavailable/country doesn’t have a strategy at all, or documents don’t indicate the PHC health worker training (this include document written in other languages) (No)

(The limitation of using this indicator is stated in page 12, line 25-28)

Indicator IV 3= national essential medicine is available, and available at PHCs (Yes at PHC)

2= national essential medicine/technology list is available (yes)

1 = if the country didn’t have an essential medicine/technology list or no list could be identified

Indicator V 3= All the 10 NCDs medicines were available

2= 5-9 NCDs medicines were available

1= < 5 NCDs medicines were available

0= No data available

Indicator VI 3= All the 6 technologies were available

2= 3-5 technologies were available

1= <3 technologies were available

0= No data available

Indicator VII 3= countries with > 50% facilities provide service

2= countries with < 25 % facilities provide service

1= None/service not available

0= No data available

Indicator XI 3= Less- if OOP < 20%

2= Medium- if the OOP = 21-37%

1= Above the average (> 38% OOP)—if OOP is > 38%

0 = No data available/not know

Indicator XII 3= The country has a unit or other equivalent body in the country

1= No body available

Also please note that since we submitted this manuscript for publication, the latest 2020 WHO NCD progress report has been released and we have updated the data from the 2017 report for indicators (indicator I, VIII, IX and indicator X). The changes in the texts and tables are made accordingly (please also see table 2 and 3). There has been little change between 2017 and 2020 WHO country reports and the main findings including the interpretation of this study remain unchanged.

Thank you again for your feedback and your time to review our paper. Please contact me if you have any further questions.

Best regards,

Azeb Gebresilassie Tesema

ORCID iD: https://orcid.org/0000-0003-0618-4499

Submitted filename: Response to Reviewers_PHC integration_31st Aug, 2020.docx

Click here for additional data file.

30 Sep 2020

PONE-D-20-19186R1

How well are non-communicable disease services being integrated into primary health care in Africa: a review of progress against World Health Organization’s African regional targets

PLOS ONE

Dear Dr. Tesema,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Thank you for your revisions.  Please see the few remaining comments as the paper is nearly ready for acceptance once those minor comments are addressed.

==============================

Please submit your revised manuscript by Nov 14 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Sonak D. Pastakia

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Thank you for your responses to the suggested revisions. The paper is considerably improved and nearly ready for publication once the few minor comments are resolved.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Thank you very much for taking the time to respond to my comments/questions. I believe the revised manuscript provided much needed clarity on areas of prior concerns, including data sources, collection, and analysis. I have very few minor comments that should be addressed prior to publication:

1. Please provide the full name of WHO PEN (WHO Package of Essential Noncommunicable disease interventions), in addition to the abbreviation, the first time you mentioned it in the manuscript (introduction).

2. Table 1 - Target 3 - URL for "Data was extracted from WHO essential medicine and health product information portal" - The page cannot be found. Please double check your URL.

3. Table 3 - Indicator "Availability of essential medicine list at national and PHC level," please change your subtext to reflect essential medicine LIST. For example, "Essential medicine LIST available nationally and at the PHC level."

Thank you!

**********

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Reviewer #1: No

Reviewer #2: No

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3 Oct 2020

Date: October 3, 2020

Author Response Letter: PLOS ONE [PONE-D-20-19186R1 and PONE-D-20-19186R2]

Dear Dr Pastakia,

Thank you for reviewing the revised manuscript on “How well are non-communicable disease services being integrated into primary health care in Africa: a review of progress against World Health Organization’s African regional targets”. We have made the revision based on the points the reviewer raised and uploaded a clean and tracked change manuscript.

Reviewer' comments

1. Please provide the full name of WHO PEN (WHO Package of Essential Noncommunicable disease interventions), in addition to the abbreviation, the first time you mentioned it in the manuscript(introduction).

• We have now included the full name of WHO PEN in the revised manuscript. Please see page 3, line 22.

2. Table 1 - Target 3 - URL for "Data was extracted from WHO essential medicine and health product information portal" - The page cannot be found. Please double check your URL.

• The correct URL has included now, where it shows the National (all countries) medicines list/formulation/standard treatment guideline portal. Please see Table 1, Target 3.

3. Table 3 - Indicator "Availability of essential medicine list at national and PHC level," please change your subtext to reflect essential medicine LIST. For example, "Essential medicine LIST available nationally and at the PHC level."

• We have made the correction in the revised manuscript. Please see Table 3.

Editor’s comment [PONE-D-20-19186R2]

1. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

• We have moved the ethics statement to the method section of the manuscript. Please see page 11, line 24.

Thank you again for your feedback and your time to review our paper. Please contact me if you have any further questions.

Best regards,

Azeb Gebresilassie Tesema

ORCID iD: https://orcid.org/0000-0003-0618-4499

Submitted filename: Response to Reviewers_PHC integration_OCt 2nd, 2020.docx

Click here for additional data file.

7 Oct 2020

How well are non-communicable disease services being integrated into primary health care in Africa: a review of progress against World Health Organization’s African regional targets

PONE-D-20-19186R2

Dear Dr. Tesema,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Sonak D. Pastakia

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for making the few remaining changes.  This final version is much improved from the original and a valuable contribution to the literature.

Reviewers' comments:

13 Oct 2020

PONE-D-20-19186R2

How well are non-communicable disease services being integrated into primary health care in Africa: a review of progress against World Health Organization’s African regional targets

Dear Dr. Tesema:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Sonak D. Pastakia

Academic Editor

PLOS ONE