Decentralizing care for hypertension and diabetes during the COVID-19 pandemic: findings from mixed-methods implementation research in Eswatini

In sub-Saharan Africa, non-communicable diseases (NCDs) are testing already-stretched health systems. In Eswatini, until 2020, care for hypertension and diabetes was only provided in tertiary health facilities. During the first phase of the COVID-19 pandemic, the Eswatini Ministry of Health expedited NCD care decentralization to primary facilities. Drawing on in-depth interviews, observations and a questionnaire-based survey, this article examines experiences of expedited NCD care decentralization. Respondents included people living with diabetes and/or hypertension (17 interviews and 248 survey respondents), nurses at primary care facilities (31 interviews) and programme managers (5 interviews). The interviews and observations indicated that the process of decentralization was initially uneven, blurred by the previous delivery of health promotion, incomplete training and the staggered nature of implementation. Reports of shortages in medicines and equipment were common and programme managers and health staff shared concerns about this undermining relationships with clients (and impacting treatment seeking). In primary facilities, NCD services were often delivered in an integrated way with consideration for co-morbidities. NCD clients expressed a strong preference for and overwhelmingly positive opinion of the decentralized services. Nonetheless, the identified challenges to delivering person-centred NCD care highlight the need to examine alternative service delivery models.