ComBaCaL+: Community Based Chronic Care Lesotho Plus

In line with the IC Strategy 2025-28 and the Swiss Health Foreign Policy, ComBaCaL contributes to strengthening health systems worldwide, with the aim of reducing poverty and improving preparedness for future pandemics with an evidence-based approach. In rural districts chronic care remains largely inaccessible, constrained by workforce shortages, weak supervision systems, and fragmented service delivery. Patients often travel long distances to health facilities, face medicine stockouts and receive inconsistent follow-up treatment, leading to avoidable complications and premature deaths. The first phase of the ComBaCaL project (2020-2025) generated a scientifically tested proof of concept: it demonstrated that CHW, equipped with digital tools and structured supervision, can safely and effectively diagnose and treat uncomplicated hypertension and diabetes, and therewith contribute to the prevention and care of NCDs. According to WHO NCDs killed at least 43 million people in 2021, equivalent to 75% of nonpandemic-related deaths globally. Evidence was generated through cluster-randomised trials with strong clinical outcomes. The model proved technically feasible, socially acceptable, and costeffective, offering a scalable solution for integrated chronic care in resource- limited settings. 

Building on Switzerland’s innovation potential and its search for forward-looking approaches in international cooperation (IC), SDC grants additional fund to the intervention in order to move beyond reseach and support the provided solution for real marked adoption.

ComBaCaL+ is building on the robust academic evidence provided during the research phase of the intervention and (a) supports the local authorities in Lesotho to lead on the implementation of the ComBaCaL model of care and (b) to replicate the CHW model in other similar contexts and as such prepare the ground for impact at scale.

As such, it shall lead to improved chronic disease outcomes, while advancing the rural workforce acceleration agenda through empowered CHWs and contribute to universal health coverage.

The current phase is designed to be fully implemented by the local authorities and sustainably integrated into the health system of Lesotho. It shall reach over 730,000 people across four districts (Butha-Buthe, Mokhotlong, Leribe, and Mafeteng), through 68 primary care facilities and six referral hospitals, directly benefiting an estimated 371,000 adults aged 18–64 years. 

Additionally the evidence generated has the potential to be applied in other country contexts (for example Rwanda or Senega who expressed an interest to advance digital health intervention. The pharmaceutical sector is actively involved as well.

Outcome 1: A scalable ComBaCaL+ model is endorsed by the MoH at the national level in Lesotho

Outcome 2: The digital support system is integrated into the District Health Infrastructure System (DHIS2) 

Outcome 3: The MoH in Lesotho is capacitated to sustainably scale up the implementation 

Outcome 4: Insights and learnings are disseminated globally

Risultati principali attesi:  

1. The implementation of a scalable ComBaCaL+ model at national level, codesigned with national stakeholders and in alignment with health priorities and community needs, as well as the capacitation of the MoH staff to scale up the model on their own, i.e. with regard to the CHWs.
2. The integration of a digital support system into the existing digital health infrastructure system, including content and technical functionalities of a support App and the field testing of a more sophisticated version ready for larger and lasting implementation. 
3. The global dissemination of scientific insights and learning, i.e. through the inclusion in local, national and international health policies, strategic plans, and guidelines, and by sharing results with stakeholders internationally.

Risultati fasi precedenti:  

Prior to ComBaCaL, no RCT had ever proven that CHWs could safely manage NCDs: ComBaCaL used Swiss academic excellence to generate new evidence showing that CHWs who are appropriately trained and supported by a clinical decision support app, can safely and effectively provide first-line medication to people with uncomplicated hypertension and diabetes. They may successfully treat >70% of people with hypertension and about 50% of people with diabetes, thus potentially more than half of the people who need to receive care at the health care facility. 

In terms of impact in Lesotho, ComBaCaL demonstrated and scientifically proved: more than 95% screening coverage across 103 villages achieving near-universal coverage in rural areas and reaching underserved populations. 

And with regard to scientific knowledge generated: >20 peer-reviewed publications validating feasibility, and cost-effectiveness, and strong community acceptability. Those groundbreaking results have been published in peer-reviewed journals like the Lancet Primary Health Care or Nature Medicine.

Thematic coordination with SDC’s Health and Food Section as well as sharing of results with the health network and the health specific programs in Eastern and Southern Africa, i.e. for SDC’s newly introduced evidence barometer.

Sharing of results with research focal points at the Swiss Confederation (interdepartmental) through the KoorA-RF, by feeding into the elevator approach at WHO and other UN agencies, as well as through Swiss Cooperation Offices with government stakeholders in other SDC priority countries.