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Background: There is limited evidence, mainly from high-income countries, that digital health interventions improve type 2 diabetes (T2DM) care. Large-scale implementation studies are lacking., Methods: A multifaceted digital health intervention comprising: (1) a self-management application ('app') for patients and lay 'family health promotors' (FHPs); and (2) clinical decision support for primary care doctors was evaluated in an open-label, parallel, cluster randomized controlled trial in 80 communities (serviced by a primary care facility for >1000 residents) in Hebei Province, China. People >40 years with T2DM and a glycated haemoglobin (HbA1c) ≥7% were recruited (∼25/community). After baseline assessment, community clusters were randomly assigned to intervention or control groups (1:1) via a web-based system, stratified by locality (rural/urban). Control arm clusters received usual care without access to the digital health application or family health promoters. The primary outcome was at the participant level defined as the proportion with ≥2 "ABC" risk factor targets achieved (HbA1c < 7.0%, blood pressure < 140/80 mmHg and LDL-cholesterol < 2.6 mmol/L) at 24 months., Findings: A total of 2072 people were recruited from the 80 community clusters (40 urban and 40 rural), with 1872 (90.3%) assessed at 24 months. In the intervention arm, patients used FHPs for support more in rural than urban communities (252 (48.6%) rural vs 92 (21.5%) urban, p < 0.0001). The mean monthly proportion of active app users was 46.4% (SD 7.8%) with no significant difference between urban and rural usage rates. The intervention was associated with improved ABC control rates (339 [35.9%] intervention vs 276 [29.9%] usual care; RR 1.20, 95% CI 1.02-1.40; p = 0.025), with significant heterogeneity by geography (rural 220 [42.6%] vs 158 [31.0%]; urban 119 [27.9%] vs 118 [28.6%]; p = 0.022 for interaction). Risk factor reductions were mainly driven by improved glycaemic control (mean HbA1C difference -0.33%, 95% CI -0.48 to -0.17; p = 0.00025 and mean fasting plasma glucose difference -0.58 mmol, 95% CI -0.89 to -0.27; p = 0.00013). There were no changes in blood pressure and LDL-cholesterol levels., Interpretation: A multifaceted digital health intervention improved T2DM risk factor control rates, particularly in rural communities where there may be stronger relationships between patients and doctors and greater family member support., Funding: National Health and Medical Research CouncilGlobal Alliance for Chronic Diseases (ID 1094712)., Competing Interests: AP received fellowship and grant support from the Australian NHMRC, UK National Institute for Health and Care Research, and Australian Medical Research Future Fund for the present manuscript. She also sits in the DSMB of an international trial on coronary artery disease screening in end-stage kidney disease patients and chairs the DSMB of a heart failure rehabilitation trial. She is the Executive Director of The George Institute for Global Health and George Institute Ventures, Non-Executive Director of George Health Enterprises, Chair of George Medicines, Director and Trustee of the Pulmonary Vascular Research Institute, and a Member of Council and Chair of the Research Committee of the Australian National Health & Medical Research Council. The other authors declare that they have no competing interests., (© 2024 The Author(s).)

Background: Policy makers and researchers are tasked with exploring ways to strengthen primary health care (PHC) to address the growing burden of non-communicable diseases (NCDs). This study aims to use a co-design approach (i.e., meaningful involvement of research end users in study planning and design) to develop PHC interventions to improve the management of hypertension and type 2 diabetes (T2DM) in four study sites in China., Methods: The study adopted a three-step co-design approach, including (1) a two-round Delphi panel with health system and NCD professionals to identify prioritised health system challenges, (2) three co-design workshops (in each study site) with local health administrators, PHC providers, and residents with hypertension and/or T2DM, respectively, to develop interventions and identify factors influencing implementation, and (3) another round of co-design workshops with local health administrators to summarise findings and reach consensus. Qualitative synthesis was conducted to analyse results from the workshops., Findings: Thirteen experts were involved in the two-round Delphi panel, which identified three prioritised health system challenges, including limited capacities of PHC providers, suboptimal service quality and evaluation mechanisms, and unreliable health information systems. The co-design workshops involved 116 local stakeholders in 16 sessions (four in each site), and developed three groups of interventions to address the challenges: (1) empowering PHC providers through on-the-job training for capacity building; (2) empowering patient communities through health education on healthy lifestyles and NCD self-management; and (3) empowering health administrators through local health data monitoring and strengthening governance for local PHC programs. Site-specific interventions were also considered to cater for different local contexts. Several recommendations were further identified for the implementation of these interventions, emphasising the importance of local customisation, community participation, and cross-sectoral collaborations., Interpretation: By engaging multiple stakeholders in priority setting and solution generation, this study summarised several key areas for change in health workforce, service delivery, and health information. Future research should examine the effectiveness and implementation of these interventions to improve NCD management in PHC in China., Funding: This study is funded by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Diseases funding (APP1169757) and National Natural Science Foundation of China (72074065). Shangzhi Xiong is supported by University of New South Wales tuition fee scholarship., Competing Interests: DP has received salary support from an NHMRC Leadership Grant (2026765), outside the submitted work., (© 2024 The Authors.)

Fragmented care delivery is a barrier to improving health system performance worldwide. Investment in meso-level organisations is a potential strategy to improve health system integration, however, its effectiveness remains unclear. In this paper, we provide an overview of key international and Australian integrated care policies. We then describe Collaborative Commissioning - a novel health reform policy to integrate primary and hospital care sectors in New South Wales (NSW), Australia and provide a case study of a model focussed on older person's care. The policy is theorised to achieve greater integration through improved governance (local stakeholders identifying as part of one health system), service delivery (communities perceive new services as preferable to status quo ) and incentives (efficiency gains are reinvested locally with progressively higher value care achieved). If effectively implemented at scale, Collaborative Commissioning has potential to improve health system performance in Australia and will be of relevance to similar reform initiatives in other countries., Competing Interests: This work is funded by a NHMRC partnership grant (ID 1198416). This grant includes funding from the NSW Ministry of Health. The NSW Ministry of Health are co-authors on the publication., (© 2024 The Author(s).)

Background: There is increasing evidence that the COVID-19 pandemic has impacted adversely on the provision of essential health services globally. The Southeast Asia region (SEAR) has experienced extremely high rates of COVID-19 infection, with potential adverse impacts on provision of reproductive, maternal, neonatal, and child health (RMNCH) services., Methods: We conducted a systematic literature review of quantitative evidence to characterise the impact of COVID-19 on the provision of essential RMNCH services across the SEAR. Studies published between December 2019 and May 2022 were included in the study. The quality of studies was evaluated using the Joanna Briggs Institute Critical Appraisal Checklist., Findings: We reviewed 1924 studies and analysed data from 20 peer-reviewed studies and three reports documenting quantitative pre-post estimates of RMNCH service disruption because of the COVID-19 pandemic. Eleven studies were of low methodological quality, in addition to seven and five studies of moderate and high methodological qualities respectively. Six countries in the region were represented in the included studies: India (11 studies), Bangladesh (4), Nepal (3), Sri Lanka (1), Bhutan (1) and Myanmar (1). These countries demonstrated a wide reduction in antenatal care services (-1.6% to -69.6%), facility-based deliveries (-2.3% to -52.4%), child immunisation provision (-13.5% to -87.7%), emergency obstetric care (+4.0% to -76.6%), and family planning services (-4.2% to -100%)., Interpretation: There have been large COVID-19 pandemic related disruptions for a wide range of RMNCH essential health service indicators in several SEAR countries. Notably, we found a higher level of service disruption than the WHO PULSE survey estimates. If left unaddressed, such disruptions may set back hard-fought gains in RMNCH outcomes across the region. The absence of studies in five SEAR countries is a priority evidence gap that needs addressing to better inform policies for service protection., Funding: WHO Sri Lanka Country Office., Competing Interests: This work was supported by the WHO Sri Lanka Country office (payment made to institution). TG is supported by a University Postgraduate Award from the University of New South Wales. DP is supported by a NHMRC Principal Research Fellowship. TS was supported by the Queen Elizabeth II Diamond Jubilee Scholarship and was awarded T. Russell Wilkins Memorial Scholarship and Global Experience Award by McMaster University. DN was supported by the India Alliance Fellowship (IA/CPHI/16/1/502,653, salary support) and received consulting fees from Department of Data and Analytics-WHO (included guest editorship of a special issue on COVID-19 and inequality). LD received £500 on three separate occasions for delivering lectures to Kings college London (2022, 2021) and Imperial college London (2022), and is an expert member of the health economics advisory group to the UK Infected Blood Inquiry (2020–2022) [no payment was received]. Authors declare no other conflicts of interest., (© 2024 The Author(s).)

Background: China's National Essential Public Health Service Package (NEPHSP) aims to promote health for all at the primary health care level and includes a focus on hypertension and type-2 diabetes mellitus (T2DM). However, there are limited contemporary data to quantify the care cascades of hypertension and T2DM in primary health care., Methods: This cross-sectional study involved individual level linkage of routinely collected data from the NEPHSP, health insurance claims and hospital electronic health records, from four diverse regions in China, including Xiling District (central China), Wenchuan County (western), Acheng District and Jiao District (northern). We first compared numbers of people aged ≥35 with a recorded diagnosis of hypertension and T2DM against expected numbers derived from epidemiological data. We then constructed care cascades to assess the percentages (1) enrolled in the NEPHSP, (2) adherent to the follow-up care of NEPHSP, (3) receiving medication treatment, and (4) having hypertension and/or T2DM controlled., Findings: In the four regions, the total numbers of people aged ≥35 diagnosed of hypertension and T2DM from any data source were 149,176 and 50,828, respectively. This was estimated to be 46.0% (95% confidence interval [CI]: 45.8%-46.2%) and 45.6% (95% CI: 45.3%-45.9%) of the expected totals for hypertension and T2DM, respectively. Among those diagnosed, 65.4% (95% CI: 65.1%-65.6%) with hypertension and 66.1% (95% CI: 65.7%-66.5%) with T2DM were enrolled in the NEPHSP, respectively, in which 54.8% (95% CI: 54.5%-55.2%) with hypertension and 64.7% (95% CI: 64.1%-65.2%) with T2DM were adherent to the required services. Among those enrolled, the overall treatment rates were 70.8% (95% CI: 70.6%-71.1%) for hypertension and 82.2% (95% CI: 81.8%-82.6%) for T2DM. Among those treated, a further 80.9% (95% CI: 80.6%-81.2%) with hypertension and 73.9% (95% CI: 73.3%-74.4%) with T2DM achieved control. These results varied considerably across regions, with the northern sites showing relatively higher enrolment rates while the central site had higher control rates., Interpretation: Detection and control rates for hypertension and T2DM are suboptimal in these four regions of China. Further strategies are needed to improve people's enrolment in and adherence to the NEPHSP and strengthen care delivery processes. Of note, our estimations of the diagnosis rates for each region are based on national level large epidemiological data. The interpretation of these data needs caution due to potential bias caused by regional variations., Funding: This study is funded by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Diseases funding (APP1169757), and National Natural Science Foundation of China (72074065)., Competing Interests: The authors declare no conflict of interests for this study., (© 2024 The Authors.)

Background: Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk of kidney failure and death in patients with chronic kidney disease (CKD) but are underused. We evaluated the number of patients with CKD in Australia that would be eligible for treatment and estimated the number of cardiorenal and kidney failure events that could be averted with improved uptake of SGLT2 inhibitors., Methods: This cross-sectional observational study leveraged nationally representative primary care data from 392 Australian general practices (MedicineInsight) between 1 January 2020 and 31 December 2021. We identified patients that would have met inclusion criteria of key SGLT2 inhibitor trials and applied these data to age and sex-stratified estimates of CKD prevalence for the Australian population (using national census data), estimating the number of preventable events using trial event rates. Key outcomes included cardiorenal events (CKD progression, kidney failure, or death due to cardiovascular or kidney disease) and kidney failure., Findings: In MedicineInsight, 44.2% of adults with CKD would have met CKD eligibility criteria for an SGLT2 inhibitor; baseline use was 4.1%. Applying these data to the Australian population, 230,246 patients with CKD would have been eligible for treatment with an SGLT2 inhibitor. Optimal implementation of SGLT2 inhibitors (75% uptake) could reduce cardiorenal and kidney failure events annually in Australia by 3644 (95% CI 3526-3764) and 1312 (95% CI 1242-1385), respectively., Interpretation: Improved uptake of SGLT2 inhibitors for patients with CKD in Australia has the potential to prevent large numbers of patients experiencing CKD progression or dying due to cardiovascular or kidney disease. Identifying strategies to increase the uptake of SGLT2 inhibitors is critical to realising the population-level benefits of this drug class., Funding: University of New South Wales Scientia Program and Boehringer IngelheimEli Lilly Alliance., Competing Interests: The Renal Division of The George Institute for Global Health has received sponsorship funding provided by Boehringer Ingelheim and Eli Lilly Alliance, and is supported by the University of New South Wales Scientia Program. The design, analysis, interpretation or writing of this manuscript was performed independent of all funding bodies. All study authors assumed final responsibility for all aspects of the study, including the decision to submit the manuscript for publication. BLN has received fees for travel support, advisory boards, scientific presentations and steering committee roles from AstraZeneca, Bayer, Boehringer and Ingelheim, Cambridge Healthcare Research, Janssen, and Medscape with all honoraria paid to The George Institute for Global Health. He serves as Secretariat of the SGLT2 Meta-Analysis Cardio-Renal Trialists Consortium and is a member of the Caring for Australians and New Zealanders with Kidney Impairment (CARI) living guidelines on SGLT2 inhibitors. MJ is responsible for research projects that have received unrestricted research funding from Boehringer Ingelheim and Eli Lilly Alliance. SK has received consultancy fees from Chinook and Dimerix Pharmaceuticals. This study was supported by an unrestricted research grant from Boehringer Ingelheim. SVB has served on advisory board of Bayer, AstraZeneca, GSK and Vifor Pharma; received speakers fees from Bayer, AstraZeneca, Pfizer and Vifor Pharma, and non-financial research support from Bayer with all fees paid to his institution. MJJ is supported by an NHMRC Investigator Grant; is responsible for research projects that have received funding from Amgen, Baxter, CSL, Dimerix, Eli Lilly, Gambro, and MSD; has received fees for Advisory, Steering Committee and/or Scientific Presentations from Akebia, Amgen, Astra Zeneca, Baxter, Bayer, Boehringer Ingelheim, Cesas Linx, Chinook, CSL, Janssen, Medscape, MSD, Occuryx, Roche and Vifor; with any consultancy, honoraria or travel support paid to her institution. VP has received fees for advisory boards, steering committee roles, or scientific presentations from AbbVie, Astellas, AstraZeneca, Bayer, Baxter, BMS, Boehringer Ingelheim, Dimerix, Durect, Eli Lilly, Gilead, GSK, Janssen, Merck, Mitsubishi Tanabe, Mundipharma, Novartis, Novo Nordisk, Pfizer, Pharmalink, Relypsa, Retrophin, Sanofi, Servier, Tricida, and Vitae. MW has received consultancy fees from Amgen and Freeline., (© 2023 The Author(s).)

Background: China launched the primary health care (PHC) system oriented National Essential Public Health Service Package (NEPHSP) in 2009, to combat health challenges including the increasing burden from hypertension and type-2 diabetes (T2DM). In this study, the PHC system was assessed to understand factors influencing the uptake of the NEPHSP for hypertension and T2DM management., Methods: A mixed-methods study was conducted in seven counties/districts from five provinces across the mainland of China. Data included a PHC facility level survey and interviews with policy makers, health administrators, PHC providers, and individuals with hypertension and/or T2DM. The facility survey used the World Health Organisation (WHO) service availability and readiness assessment questionnaire. Interviews were thematically analysed using the WHO health systems building blocks., Findings: A total of 518 facility surveys were collected with over 90% in rural settings (n = 474). Forty-eight in-depth individual interviews and 19 focus-group discussions were conducted across all sites. Triangulating the quantitative and qualitative data found that China's continuous political commitment to strengthening the PHC system led to improvements in workforce and infrastructure. Despite this, many barriers were identified, including insufficient and under-qualified PHC personnel, remaining gaps in medicines and equipment, fragmented health information systems, residents' low trust and utilization of PHC, challenges in coordinated and continuous care, and lack of cross-sectorial collaborations., Interpretation: The study findings provided recommendation for future PHC system strengthening, including improving the quality of NEPHSP delivery, facilitating resource-sharing across health facilities, establishing integrated care systems, and exploring mechanisms for better cross-sectorial engagement in health governance., Funding: The study is supported by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Disease funding (APP1169757)., Competing Interests: The authors declare no conflict of interests for this study., (© 2022 The Author(s).)

Background: COVID-19 has had a profound impact on the health systems of the 11 countries of the WHO South East Asia Region. We conducted a systematic review of studies that used quantitative and comparative approaches to assess the impact of the pandemic on the service provision of four noncommunicable diseases (NCDs) (cancer, cardiovascular disease, chronic respiratory diseases, and diabetes) in the region., Methods: A systematic search was conducted in PubMed, Embase, MedRxiv, and WHO COVID-19 databases in December 2021. The quality of studies was evaluated using the Joanna Briggs Institute Critical Appraisal Checklist and the ROBINS-I risk of bias tool. A narrative synthesis was conducted following the 'synthesis without meta-analysis' reporting guidelines., Findings: Two review authors independently screened 5,397 records with 31 studies included, 26 which were cross-sectional studies. Most studies (n=24, 77%) were conducted in India and 19 (61%) were single-site studies. Compared to a pre-pandemic period, 10/17 cancer studies found a >40% reduction in outpatient services, 9/14 cardiovascular disease found a reduction of 30% or greater in inpatient admissions and 2 studies found diagnoses and interventions for respiratory diseases reduced up to 78.9% and 83.0%, respectively. No eligible studies on the impact of COVID-19 on diabetes services were found., Interpretation: COVID-19 has substantially disrupted the provision of essential health services for NCDs in the WHO South East Asia Region, particularly cancer and cardiovascular disease. This is likely to have serious and potentially long-term downstream impacts on health and mortality of those living with or at risk of NCDs in the region., Funding: This work was supported by the WHO Sri Lanka Country Office., Competing Interests: This work was supported by the WHO Sri Lanka Country office. TG is supported by a university post graduate award from the University of New South Wales. VDRV receives a salary from the World Health Organisation South East Asia Regional Office. DP and SJ are both supported by individual investigator grants from the Australian National Health and Medical Research Council., (© 2022 Published by Elsevier Ltd.)

Background: There is increasing evidence that the COVID-19 pandemic has impacted adversely on the provision of essential health services. The South East Asia region (SEAR) has experienced extremely high rates of COVID-19 infection, and continues to bear a significant proportion of communicable disease burden worldwide., Methods: We conducted a systematic literature review of quantitative evidence to estimate the impact of COVID-19 on the provision of essential prevention, detection, treatment, and management services for five high-burden infectious diseases across the SEAR., Findings: A total of 2338 studies were reviewed, and 12 studies were included in our analysis, covering six countries across the SEAR (Bhutan, Sri Lanka, Nepal, Myanmar, Thailand, and India) for three conditions of interest (HIV, TB, dengue fever). We identified significant disruption to TB testing (range=25% to 77.9%) and diagnoses (range=50% to 58%) in India, Nepal, and Indonesia; and similar disruptions were observed for screening, new diagnoses and commencing HIV treatment in India and Thailand. There was also drastically reduced case detection for dengue fever (range=75% to 90% disrupted) in Bhutan and Sri Lanka. No studies were identified for malaria nor hepatitis in any country, and nor for any service in the remaining six SEAR countries., Interpretation: We identified evidence of significant disruption to the prevention, diagnoses, treatment, and management of TB, HIV, and dengue fever due to the COVID-19 pandemic across multiple SEAR country settings. This has the potential to set back hard-fought gains in infectious disease control across the region. The lack of evidence for the impact of the pandemic on malaria and hepatitis services, and in the remaining six SEAR countries, is an important evidence gap that should be addressed in order to inform future policy for service protection and pandemic preparedness., Funding: This work was supported by the WHO Sri Lanka Country office., Competing Interests: This work was supported by the WHO Sri Lanka Country office. TG is supported by a University Postgraduate Award from the University of New South Wales. SJ and DP are supported by NHMRC Principal Research Fellowships., (© 2022 Published by Elsevier Ltd.)

This study aims to review China's national policies related to non-communicable disease (NCD) prevention and control at the primary health care (PHC) level since China's 2009 health system reform. Policy documents from official websites of China's State Council and 20 affiliated ministries were screened, where 151 out of 1,799 were included. Thematic content analysis was performed, and fourteen 'major policy initiatives' were identified, including the basic health insurance schemes and essential public health services. Several areas showed to have strong policy support, including service delivery, health financing, and leadership/governance. Compared with WHO recommendations, several gaps remain, including lack of emphasis on multi-sectoral collaboration, underuse of non-health-professionals, and lack of quality-oriented PHC services evaluations. Over the past decade, China continues to demonstrate its policy commitment to strengthen the PHC system for NCD prevention and control. We recommend future policies to facilitate multi-sectoral collaboration, enhance community engagement, and improve performance evaluation mechanisms., Competing Interests: The authors declare no conflict of interests for this study., (© 2022 The Authors.)

Background: Paediatric Crohn's disease (CD) has been associated with undernutrition. Accurate and accessible measures of body composition would provide data to personalise nutritional therapy. We assessed feasibility of MRI-derived measures of psoas cross-sectional area (PCSA) in paediatric CD and correlated with anthropometric and bioelectrical impedance spectroscopy (BIS) measures., Methods: MRI small bowel/pelvis images of patients with CD, aged <18 years, were retrieved. Patients with concurrent anthropometric and BIS measurements were eligible for inclusion. The PCSA at L3 was calculated by two assessors and combined. To assess reproducibility of measures we calculated the coefficient of variation (CoV). Age, height-Z-scores, weight-Z-scores and BIS measures were correlated with PCSA. Using normal paediatric data from CT-scans we derived psoas area Z-scores for our cohort., Results: 10 patients were included. Mean age at MRI scan was 14.6 years (11.7-16.3). PCSA was calculated for all MRI scans. There was high reproducibility between measurers, mean CoV 0.099. There was a significant positive correlation between PCSA and BIA-derived fat free mass, Pearson correlation coefficient (PCC) 0.831, p = 0.003. Correlation coefficients for PCSA and Height-for-age Z-score, weight-for-age -Z-score and age were PCC 0.343- p = 0.33, PCC = 0.222- p = 0.54, and PCC 0.6034- p = 0.065, respectively. The mean PCSA Z-score was -1.81, with 70% of the patients having a Z-score < -2.0., Conclusions: These data demonstrate the feasibility of deriving measures of body composition from routine MRI imagine. There was significant positive correlation between PCSA and BIS-derived lean mass. Further studies are required to confirm applicability of normal ranges prior to routine clinical implementation., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2021 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)