Non-communicable disease (NCD) prevention and care in humanitarian contexts has been a long-neglected issue. Healthcare systems in humanitarian settings have focused heavily on communicable diseases and immediate life-saving health needs. NCDs are a significant cause of morbidity and mortality in refugee settings, however, in many situations NCD care is not well integrated into primary healthcare services. Increased risk of poorer outcomes from COVID-19 for people living with NCDs has heightened the urgency of responding to NCDs and shone a spotlight on their relative neglect in these settings. Partnering with the United Nations Refugee Agency (UNHCR) since 2014, Primary Care International has provided clinical guidance and Training of Trainer (ToT) courses on NCDs to 649 health professionals working in primary care in refugee settings in 13 countries. Approximately 2300 healthcare workers (HCW) have been reached through cascade trainings over the last 6 years. Our experience has shown that, despite fragile health services, high staff turnover and competing clinical priorities, it is possible to improve NCD knowledge, skills and practice. ToT programmes are a feasible and practical format to deliver NCD training to mixed groups of HCW (doctors, nurses, technical officers, pharmacy technicians and community health workers). Clinical guidance must be adapted to local settings while co-creating an enabling environment for health workers is essential to deliver accessible, high-quality continuity of care for NCDs. On-going support for non-clinical systems change is equally critical for sustained impact. A shared responsibility for cascade training—and commitment from local health partners—is necessary to raise NCD awareness, influence local and national policy and to meet the UNHCR’s objective of facilitating access to integrated prevention and control of NCDs.

Background: Unpreparedness of health professionals to address non-communicable diseases (NCD) at peripheral health facilities is a critical health system challenge in Mozambique. To address this weakness and decentralize NCD care, training of the primary care workforce is needed. We describe our experience in the design and implementation of a cascade training of trainers (ToT) intervention to strengthen the prevention and control of cardiovascular disease.Methods: Between October 2018 and March 2020 a multidisciplinary global technical partnership was used to train frontline primary care health professionals from a resource-poor suburban setting in Maputo, Mozambique. Following engagement with local policy makers, clinicians, and academics, core training materials were developed, and a ToT cascade was implemented, supported by an on-site pilot clinic. Knowledge and confidence acquisition by participants and new local trainers were assessed using pre-and post-training surveys, while trainees and trainers completed further evaluation surveys at the end of the program.Results: Three ToT workshops trained 60 mixed cadre healthcare workers in assessment, diagnosis and management of hypertension, diabetes, and cardiovascular risk; of these, 11 became new local trainers. Mean pre-and post-test scores improved in all three training workshops (53% to 90%, 59% to 78%, and 58% to 74% respectively). New local trainers were highly rated by their trainees and reported increased confidence as trainers (mean Likert scale 3.0/5 pre-training to 4.8/5 post-training). Conclusion:This global health partnership delivered interprofessional training with good knowledge acquisition and increased self-reported confidence. Intensive local supervision and hands-on training empowered a new cohort of trainers to strengthen the prevention and control of cardiovascular disease and is likely to improve coordination and integration at primary care level as well as support the national scale up of NCD care delivery. 2 Harris and Juga et al.