Implementation of WHO-PEN interventions in Eswatini: an assessment of health equity and out-of-pocket expenditure for diabetes and hypertension care

Background We rolled out the WHO Package of Essential Noncommunicable Disease (WHO-PEN) interventions at primary healthcare centres (PHCs) in Eswatini to increase care uptake for diabetes and hypertension. This study assesses the impact of WHO-PEN interventions on health equity and clients’ out-of-pocket (OOP) expenditures. Methods We conducted a cluster-randomised controlled trial with two intervention arms and one control arm among adults aged 40 years or older with diabetes, hypertension, or prediabetes. The intervention arms comprised Differentiated Service Delivery (DSD), which implemented facility- and community-based strategies to streamline care, and Community Delivery Platforms (CDP), which provided monthly outreach services; the control arm delivered the nurse-led standard of care (SoC). We assessed the cascade of care across socioeconomic groups to examine potential inequities. Out-of-pocket (OOP) expenditures were disaggregated into four categories - transport, food, consultation fees, and medication - to identify the primary cost drivers for accessing care at primary healthcare clinics. Results Access to healthcare for diabetes and hypertension was largely independent of socioeconomic status, with the exception of a difference in blood pressure measurement between the poorest and richest quintiles in the DSD arm. Participants in the DSD arm incurred lower total expenditures for a primary healthcare visit compared to those in the SoC and CDP arms, including lower transport costs. Transport was the largest component of OOP spending, and total direct expenditures per visit ranged from USD 2.65 to USD 3.96. Conclusion WHO-PEN interventions had a limited impact on health equity in Eswatini. The DSD model can potentially reduce out-of-pocket health expenses for participants, but further research is needed to address implementation challenges and to evaluate each DSD model’s distinct impact on care delivery. Trial registration US Clinical Trials Registry. NCT04183413. Trial registration date December 3, 2019. https://ichgcp.net/clinicaltrialsregistry/NCT04183413.