Health systems strengthening to improve detection, treatment, and control of Multiple Long-Term Conditions in South African primary health care facilities: implementing the ENHANCE trial intervention
1
Knowledge Translation Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
2
Centre for Research in Health systems, University of KwaZulu-Natal, Durban, South Africa
3
Chronic Disease Initiative for Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
4
School of Life Course & Population Sciences, King's College London, London, United Kingdom
5
Institute of Global Health, University College London, London, United Kingdom
Popul. Med. 2026;8(Supplement Supplement 1):A1798
ABSTRACT
BACKGROUND:
Multimorbidity—living with two or more chronic conditions or multiple long-term conditions (MLTCs)—is an urgent global concern, including in low- and middle-income countries, where health systems are fragmented and disease specific, contrary to the needs of integrated MLTC care (1). ENHANCE (EvideNce led co-created HeAlth systems interventioNs for MLTCs CarE) was developed to support primary health care clinics, health workers and patients to improve MLTC care. It used a type 2 hybrid, parallel-arm cluster randomised controlled trial conducted in 32 PHC clinics in KwaZulu-Natal (KZN) and Western Cape (WC) provinces of South Africa to evaluate its impact on detection, treatment and control of long-term conditions.
METHODS:
The co-created intervention interacted with the patient with MLTC at various stages in their encounter with the health system. It included an integrated clinical decision support tool (2), health literacy materials, and strengthened referral pathways plus support from community health workers (CHWs). Sub-district implementation workshops prepared the system for the intervention and shared learnings during the trial. Intervention facilitators delivered initial clinic team sessions followed by three onsite, blended clinician training sessions. CHW training comprised two sessions on treatment literacy using posters, a patient diary and lay formulary. Clinics and CHW teams received ongoing support and structured continuous quality improvement.
RESULTS:
Overall, 1102 healthcare workers received training in the ENHANCE intervention (KZN = 302, WC = 800). Trainees included CHWs and team leaders, nurses, doctors and other clinic team members such as pharmacists. A stepwise, supported implementation strategy with early systems engagement was critical for clinic preparation and training uptake. The overall completion rate for the clinical training was 93%.
CONCLUSIONS:
Standardising training through detailed manuals and online modules is feasible. However, these approaches must accommodate flexible, nuanced support to ensure uptake across trainee cadres and respectful negotiation of changes within local health systems.
Multimorbidity—living with two or more chronic conditions or multiple long-term conditions (MLTCs)—is an urgent global concern, including in low- and middle-income countries, where health systems are fragmented and disease specific, contrary to the needs of integrated MLTC care (1). ENHANCE (EvideNce led co-created HeAlth systems interventioNs for MLTCs CarE) was developed to support primary health care clinics, health workers and patients to improve MLTC care. It used a type 2 hybrid, parallel-arm cluster randomised controlled trial conducted in 32 PHC clinics in KwaZulu-Natal (KZN) and Western Cape (WC) provinces of South Africa to evaluate its impact on detection, treatment and control of long-term conditions.
METHODS:
The co-created intervention interacted with the patient with MLTC at various stages in their encounter with the health system. It included an integrated clinical decision support tool (2), health literacy materials, and strengthened referral pathways plus support from community health workers (CHWs). Sub-district implementation workshops prepared the system for the intervention and shared learnings during the trial. Intervention facilitators delivered initial clinic team sessions followed by three onsite, blended clinician training sessions. CHW training comprised two sessions on treatment literacy using posters, a patient diary and lay formulary. Clinics and CHW teams received ongoing support and structured continuous quality improvement.
RESULTS:
Overall, 1102 healthcare workers received training in the ENHANCE intervention (KZN = 302, WC = 800). Trainees included CHWs and team leaders, nurses, doctors and other clinic team members such as pharmacists. A stepwise, supported implementation strategy with early systems engagement was critical for clinic preparation and training uptake. The overall completion rate for the clinical training was 93%.
CONCLUSIONS:
Standardising training through detailed manuals and online modules is feasible. However, these approaches must accommodate flexible, nuanced support to ensure uptake across trainee cadres and respectful negotiation of changes within local health systems.
| eISSN: | 2654-1459 |
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