Strengthening primary care networks and integrated screening for severe NCDs in Ghana: Early system-level results from a modular chronic care model pilot

Background: Ghana faces a rapid NCD transition, with these conditions now accounting for nearly half of all deaths. Despite progressive national policies, NCD prevention, detection, and long-term management remain fragmented across primary and secondary care levels. While the global strategy promotes integrated services at first-level referral facilities, operationalizing "bidirectional" care between community and hospital systems remains a persistent challenge in low-resource settings. 

Methods: A mixed-methods implementation study was conducted across 20 diverse districts (urban, peri-urban, and rural) under the Ghana Health Initiative. A multimodule framework aligned with PEN-Plus objectives was deployed, focusing on: Networks of Practice (NoP) to link primary and referral systems; Community-based integrated screening; Patient empowerment; And laboratory strengthening. Baseline screening reached 22,141 individuals for Hypertension (HPT) and Type 2 Diabetes (T2DM). Referral continuity was tracked for 1,119 referred patients over 12 months using routine DHIMS II data, facility registers, and stakeholder interviews. 

Results: Of 18,336 screened for HPT and 3,805 for T2DM, referral completion from primary to secondary levels was high for T2DM (96%) and co-morbid cases (84.5%), but dropped to 75.6% for HPT. Critically, the study documented a total absence (0%) of counter-referrals from district hospitals back to primary health centers, confirming a fragmented, one-way system that prevents the establishment of a true chronic care loop. These data directly informed the development of Ghana’s first integrated screening guidelines and NCD-adapted referral protocols. 

Conclusion: While initial referral occurs, the complete lack of counter-referral undermines continuity of care for severe NCDs. Embedding bidirectional referral protocols into the national NoP strategy is essential for operationalizing a sustainable, people-centered chronic care model. This modular approach offers a scalable pathway for other African health systems grappling with similar fragmentation challenges.

Caroline Mtaita is a medical doctor and public health specialist at Deutsche Gesellschaft für Internationale Zusammenarbeit GIZ) GmbH in Germany. She has extensive expertise in health interventions related to capacity building, health system strengthening, TB/HIV and sexual and reproductive, maternal and new-born health including gender issues, quality improvement and nutrition sub-Saharan Africa. Her work focuses on operationalizing integrated chronic care models, embedding implementation research into policy and bridging primary and secondary care networks to achieve equitable UHC.