Discussion
NCD
DISEASE, DECAY
We defined facility performance as having two inputs i) health worker clinical knowledge and ii) the facility inspection with five constituent elements of service availability and readiness.Overall, health worker knowledge was well preserved, and knowledge scores were similar across all facility levels whether by subject matter or the 3 disease case scenario questions. This indicates that over the post-trial period of 4 years, despite any decay or shortcomings in support supervision or motivation or even underutilisation of the facility; the NCD case management competence of HWs were largely sustained. Only 66% of HWs interviewed in 2020 took part in the assessment in 2016 which suggests that NCD related knowledge among new staff members was also adequate. This finding was also reinforced by a similar finding on adequate quality of care and experience which remained unchanged over this same period.Health worker knowledge is usually measured as a pre- and post-training assessment we have had the benefit of assessing it at least 4 years after the intervention. Interestingly, most studies in SSA that have assessed task shifting with nurse-led NCD management, have shown good knowledge retention in using a qualitative framework approach [Despite the decline in most of the elements of service availability and readiness over the period 2016–2020, there was no evidence of difference in overall facility performance owing to the strong performance of HWs on the clinical knowledge test. Of the five constituent elements of SAR, only the quality of records was preserved while the utilisation of NCD services and evidence of preventive activities declined most strongly. The availability of essential drugs and to a lesser extent the availability of essential equipment and consumables also declined, but less steeply. This suggests that the support obtained from functional patient clubs may have alleviated the performance decline to some extent, through the replenishment of consumables, repair or replacement of simple equipment and the direct purchase of essential medicines. However, with regards to the availability of essential medicines, the worst performing HFs only scored < 2 points out of possible 10 in 2020 (not shown), indicating that some HFs were more severely impacted by inconsistent drug supplies than others, and also had little to no patient club support.The utilisation of primary care services at public facilities usually reflects the availability of essential medicines and other consumables [The association of FPS with patient club functionality (Our findings also differ from the Nigerian study with regards to the urban health facility location, which in Uganda we speculate may be due to an intervening local administrative level at the municipality or local town council that usually distorts the district office’s direct influence. A district health officer or their team may not exercise the same direct supervisory oversight and authority over those units within a semi-autonomous local municipality as those outside because these usually report to the local municipality health officer instead. This gap often leads to poor district support in terms of consistent supervisory oversight and timely medical supplies or replenishments especially where the municipality or local authority administration is weak. Public health facilities in urban areas are often poorly utilised as urban-dwelling patients have more health care options such as services from commercial drug shops and private clinics [The weak association of FPS with HF level in the initial models where higher-level units performed up to 9-points better than HCIIs (or HCIIIs) can be partly explained by the fact that these facilities are referral clinics and have more consistent drug supplies. They also usually have stronger patient clubs.The quality of patient care and experience showed a statistically significant decline between 2016 and 2020 (The quality of patient care was strongly associated with parent district (Regarding provider or HS quality of care studies on NCDs in SSA, one study in Lesotho within HIV clinics [