Addressing dual health threats: development and pilot of an integrated acute NCD and IPC training programme in Tanzania

Abstract

Background

Tanzania faces a significant gap in training healthcare workers (HCWs) to manage acute non-communicable disease (NCD) presentations while maintaining infection prevention and control (IPC). In 2021, median IPC compliance was only 50%, with some facilities as low as 24%, and 53% of COVID-19 patients in private tertiary hospitals had NCD comorbidities. In response, the Tanzania Diabetes Association, Ministry of Health, President’s Office Regional Administration and Local Government, supported by the World Diabetes Foundation, developed and piloted a 5-day integrated IPC–acute NCD training course. This study evaluates its development, implementation and early outcomes, and considers its scalability.

Methods

Using Kern’s six-step curriculum development model, we designed a curriculum (14 April to 16 April 2021) incorporating national and international guidelines. The pilot course was delivered in Dar es Salaam (19 April to 24 April 2021) to 87 HCWs from public, private and faith-based facilities. We documented course development and delivery as primary outcomes. Secondary outcomes included knowledge gains, assessed via pretest and post-test scores analysed with paired t-tests and Cohen’s d for significance and effect size. Participant feedback was summarised with descriptive statistics.

Results

Knowledge scores improved significantly from 57.19±11.50 pretraining to 67.10±9.17 post-training (mean gain 9.91±10.01, p<0.001; Cohen’s d=0.99), indicating a large effect. All professional cadres demonstrated improvement in mean knowledge scores, with no significant differences in change across groups (p=0.63). Feedback was highly positive: all participants rated the training as relevant; 93% highly rated teaching methods; 74% reported overall satisfaction. However, 74% recommended longer hands-on sessions due to limited practical resources.

Conclusions

This integrated IPC–NCD training pilot effectively addressed a critical gap during a public health emergency. It demonstrated feasibility, acceptability and preliminary effectiveness in boosting HCW knowledge. Scaling up will require strengthening practical components and improving resource availability. This model offers a replicable blueprint for addressing dual infectious and chronic disease burdens.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Healthcare workers in Tanzania demonstrated critically low infection prevention and control (IPC) compliance (24%–50%) during the early COVID-19 pandemic, while more than half of admitted patients had non-communicable disease (NCD) comorbidities. Although various standalone IPC and acute-care trainings existed, no published studies had documented an integrated, dual-focused capacity-building intervention in Tanzania or comparable low-resource settings.

WHAT THIS STUDY ADDS

• Using a recognised curriculum development framework (Kern’s model), this 5-day pilot course successfully integrated IPC and acute NCD training. The intervention was feasible, highly acceptable and resulted in a statistically significant knowledge gain (mean increase 9.91±10.01 percentage points; p<0.001; Cohen’s d=0.99), indicating a large effect. To our knowledge, it is the first documented hybrid public health–clinical training model in Tanzania, directly relevant to regional outbreaks such as Ebola, Marburg and monkeypox, which present combined infectious and chronic disease challenges.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings support scaling up simulation-enhanced, multidisciplinary IPC/NCD training through phased regional roll-out, strengthened monitoring and evaluation, and cost-effectiveness assessment. This model provides a replicable framework for bolstering frontline workforce resilience in Tanzania and other low-income and middle-income countries facing dual disease threats.

Background

Non-communicable diseases (NCDs) account for approximately 71% of deaths worldwide, with over 70% occurring in low-income and middle-income countries (LMICs), such as Tanzania.1,3 In Tanzania, as in many other countries, resources during the COVID-19 pandemic were allocated primarily to manage respiratory complications and vaccine distribution. This shift in resources led to reduced funding for NCD management, disrupting the continuum of care for patients with these conditions.^{4 5} People with NCDs, particularly hypertension, diabetes and cardiovascular diseases, are more likely to suffer from severe disease progression and even death when they are infected with COVID-19.⁶ Early data from a Tanzanian tertiary hospital revealed that 53% of COVID-19-positive patients had at least one NCD, highlighting the dual burden faced by the health system.⁷

Infection prevention and control (IPC) remains a cornerstone of safe healthcare delivery, protecting both patients and healthcare workers from healthcare-associated infections (HAIs). The WHO continues to advocate for global IPC improvements; however, LMICs such as Tanzania face persistent challenges in achieving adequate IPC standards.^{8 9} A 2015–2018 assessment of primary healthcare facilities in Tanzania revealed improvements in IPC compliance from 31% to 57%, but substantial gaps remained.¹⁰ More recently, in 2021, an evaluation of all 26 regional referral hospitals during the COVID-19 peak reported a median IPC compliance of only 50%, with wide variability between facilities (24% to 72%), highlighting ongoing deficiencies.⁸

In response, the Tanzanian Ministry of Health (MoH), President’s Office Regional Administration and Local Government (PORALG), Tanzania Diabetes Association (TDA) and World Diabetes Foundation (WDF), with funding from the Novo Nordisk Foundation (NNF), developed a combined training programme addressing both IPC and acute management of NCD emergencies. The aim was to strengthen the capacity of healthcare workers to address acute NCD complications while adhering to essential IPC measures. The training package was developed from 14 April to 16 April 2021, and was piloted at Dar es Salaam between 19 April and 24 April 2021. By targeting healthcare workers in primary-level and secondary-level facilities, the programme employed a train-the-trainer model to empower local champions to cascade training within their districts.

To our knowledge, this was Tanzania’s first integrated course combining IPC and acute NCD management, spanning medical, trauma and mental healthcare domains. This paper documents the development and implementation of pilot training in Dar es Salaam, highlighting the lessons learnt and challenges encountered. This work is especially pertinent in the context of Tanzania, which continues to face public health threats from diseases such as Marburg virus disease, Ebola in the last 2 years and the current Monkeypox outbreak.11,14 By systematically analysing the training process and outcomes, this study aims to inform similar public health education initiatives in Tanzania and other comparable settings. Furthermore, it supports the United Nations Sustainable Development Goal (SDG) Target 3.4, which calls for reducing premature mortality from NCDs through prevention and treatment.¹⁵

Materials and methods

Study design

This narrative describes the development, piloting and early evaluation of a combined acute care and IPC training programme for NCDs in Tanzania. The training was developed over a 3-day period (14 April to 16 April 2021) and piloted at Dar es Salaam from 19 April to 24 April 2021. This study is reported following the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 Research checklist.¹⁶

Study setting and context

Tanzania is an LMIC in East Africa with a mixed healthcare system comprising public, private and faith-based facilities. Dar es Salaam, the country’s commercial capital and most populous city, was selected as the pilot region because of its diverse health facility landscape and high burden of COVID-19 cases during the pandemic.^{17 18} The healthcare system follows a pyramid structure, with increasing specialisation and complexity from lower to higher tiers.^{19 20} Most Tanzanians access healthcare at the primary and secondary levels.

Participants

The training targeted healthcare workers primarily based in primary and secondary health facilities, particularly those working in emergency units, intensive care units and medical wards. However, several participants were also recruited from the national referral hospital, the largest tertiary public health facility in Tanzania.

At the regional level, the training included the Regional Emergency Coordinator, Regional IPC Coordinator and Regional NCD Coordinator. At the district level, the targeted participants included district medical officers responsible for emergency and IPC coordination. The core trainees were clinicians and nurses working in acute care settings such as emergency and casualty departments, intensive care units (ICUs) and internal medicine wards.

The list of participants was compiled in coordination with the Regional Medical Officer’s office, which nominated individuals on the basis of their potential to both benefit from the training and to subsequently train others, in line with the train-the-trainer (ToT) model.

Implementation framework

The training was developed via Kern’s six-step model for curriculum development,²¹ which includes the following steps:

1. Problem identification and general needs assessment.

2. Targeted needs assessment.

3. Goals and objectives.

4. Educational strategies and curriculum design.

5. Implementation.

6. Evaluation and feedback.

A ToT model was employed to support sustainability and scale-up.

Step 1: problem identification and general needs assessment

A core team of two senior principal investigators from the TDA, who are grant recipients, collaborated with two members from the MoH to conduct a literature review. This review confirmed a lack of integrated training models that address both acute NCD management and IPC in Tanzania. Despite the high burden of these conditions, no competency-based short courses were available at the time. Although national data on NCD morbidity and mortality in public hospitals were limited, data from a tertiary private hospital indicated that 53% of COVID-19-positive patients (n=157) from March to July 2020 had at least one NCD.⁷ Based on these findings, stakeholders relevant to course development were identified during a subsequent think-tank meeting.

Step 2: targeted needs assessment with different stakeholders in Tanzania

On 14 April 2021, a national stakeholder meeting was convened, bringing together experts from the MoH, medical boards, professional societies and partner institutions. Participants included representatives from MoH units (case management, IPC, NCD), the Emergency Preparedness and Response Unit (EPRU), the PORALG, as well as regional and council health management teams. Additionally, professional societies such as the Emergency Medicine Association of Tanzania (EMAT), the Association of Private Health Facilities in Tanzania (APHTA), Tanzania Surgical Association (TSA), Tanzania Public Health Association (TPA), Christian Social Services Commission (CSSC) and TDA contributed. This was the team identified in step 1 to participate.

This meeting aligned course needs, timelines, trainer selection, content and sustainability considerations. Based on these discussions, Amana Hospital, a national COVID-19 isolation centre, was selected for a rapid field assessment to inform curriculum development.

Step 3: goals and objectives

Building on the insights from the needs assessment, the team defined the primary goal: to equip competent master trainers with the skills and knowledge necessary to cascade training to their peers. The specific objectives included:

1. Increasing awareness of COVID-19 prevention and control.

2. Creating a protective environment for frontline healthcare professionals.

3. Delivering high-quality care to patients with NCDs to minimise COVID-19 complications.

4. Expanding access to safe and quality services for COVID-19 and non-COVID-19 patients.

The facilitation team comprised national IPC and emergency care trainers alongside specialists in emergency medicine, anaesthesia, pulmonology, internal medicine, orthopaedics, psychosocial care, and monitoring and evaluation (M&E).

Step 4: educational strategies and development of a training package

Curriculum development workflow

A multidisciplinary team of emergency physicians, IPC specialists, NCD clinicians and medical education experts drafted a clinical training manual based on recommendations from steps 1 to 3. This draft manual remains under review at the Chief Medical Officer’s office for final approval and copyright clearance, thus not included in this submission. Content from the draft was aligned with national and international guidelines, including the Tanzania Standard IPC Guideline (2021), Tanzania Standard Treatment Guideline and National Essential Medicines List (STG/NEML 2021 EMAT emergency care guidelines, American Heart Association (AHA) recommendations, the WHO/International Committee of the Red Cross (ICRC) Basic Emergency Care Manual, and WHO-Integrated Management of Acute Malnutrition (IMAM) guidelines.22,26

Draft modules underwent iterative review by MoH units (case management, IPC, NCD), with revisions for local contextualisation and feasibility at primary and secondary levels. The facilitation team then developed teaching tools, including PowerPoint slides and pretest/post-test instruments (onlinesupplemental materials 1 2). All materials were piloted during the Dar es Salaam training, with participant and facilitator feedback guiding refinement of sequencing and instructional methods.

Training package composition

A final timetable and curriculum were developed (online supplemental material 3), comprising five domains:

1. IPC module: developed collaboratively with national IPC trainers from MoH and aligned with the Tanzania Standard IPC Guideline (2021). Key topics included hand hygiene, personal protective equipments (PPEs) use, screening and isolation, waste management, sharps safety and decontamination. Emphasis was on low-cost, feasible measures tailored for primary and secondary facilities. Case scenarios integrated IPC principles into acute NCD care, such as safe airway management and exposure reduction during CPR. The module was validated by national IPC coordinators prior to finalisation.

2. Medical emergency module: created by national emergency medicine trainers, emergency and internal medicine physicians, covering high-burden acute NCD presentations identified during needs assessment, that is, hypertensive emergencies, acute heart failure, asthma exacerbations, diabetic complications, fluid/electrolyte imbalances and airway obstruction. Content drew from WHO Basic Emergency Care Manual, STG/NEML (2021), AHA and EMAT guidelines, adapted for resource constraints like limited diagnostics and oxygen availability. The MoH case management and NCD units reviewed the module.

3. Surgical and trauma emergency module: developed by general surgeons and trauma specialists from Muhimbili National Hospital, focusing on head injury, spinal trauma, chest/abdominal trauma, burns and trauma in children and pregnancy—conditions with high morbidity in Tanzania. Content was informed by WHO Emergency and Essential Surgical Care, EMAT trauma protocols and WHO/ICRC Basic Emergency Care guidelines. Emphasis was on initial stabilisation and referral within the healthcare pyramid. Peer review was conducted by surgical and emergency medicine faculty from Muhimbili University of Health and Allied Science.

4. Miscellaneous module: the addressed cross-cutting competencies such as mental health and psychosocial support, ethics, professionalism and training preparation. Psychosocial health experts and social workers from regional hospitals contributed to content, prioritising support for frontline providers experiencing stress and burnout during COVID-19. Monitoring and evaluation specialists developed supervision and M&E subcomponents. All content was aligned with national training norms through MoH review.

5. Practical sessions: co-developed by emergency medicine clinicians, IPC trainers and critical care specialists, these focused on essential skills for managing acute NCDs while maintaining IPC safety, including hand hygiene, PPE use, airway assessment, oxygen therapy, bag-valve-mask ventilation, basic life support and trauma stabilisation. Skills checklists were adapted from WHO/ICRC Basic Emergency Care and national IPC guidelines, with modifications reflecting typical equipment availability at primary and secondary facilities. Stations were piloted and refined during the training.

Step 5: implementation: pilot for the Dar Es Salaam region

The finalised training package was piloted in Dar Es Salaam from 19 April to 24 April 2021. Although initially planned as a 5-day training, it was extended to 6 days to accommodate the full timetable and skills practice. To enhance understanding, both Kiswahili (the local language) and English were used throughout the workshop. Healthcare workers from public, private and faith-based organisations participated. A facilitation team comprising 13 qualified facilitators from various medical disciplines, including monitoring and evaluation experts, conducted the workshop.

At the conclusion of the training, each participant or hospital representative developed an action plan to guide the implementation of IPC and care for acute NCDs in their facilities. The action plan included the following:

1. Feedback to the district medical officer and management team regarding the training.

2. Plans to cascade training to other healthcare providers not included in the initial training.

3. Identification and procurement of IPC and acute care management equipment.

4. Improved data collection in emergency medical departments, including establishing and updating registers for capturing programme indicators.

Step 6: evaluating the effectiveness of the curriculum

Course evaluation used structured survey forms (online supplemental file 4), capturing perceptions on course duration, teaching methods, relevance of materials, logistics, venue and suggestions for improvement.

Variables and outcome measures

Primary outcome: documentation of the development and implementation process for a 5-day training course on acute NCD care and IPC during the COVID-19 pandemic. Secondary outcomes: knowledge gain measured by pretest and post-test scores; perceived relevance, satisfaction and logistics assessed via evaluation forms.

Data source

Data were collected from internal programme documentation, including stakeholder meeting minutes and attendance registers, curriculum materials and PowerPoint slides, participant rosters, participant pretest and post-test results, and participant course evaluation forms. Two investigators (GH and FN) reviewed the final data to ensure reliability and clarity in the data collected.

Data analysis

Descriptive statistics summarised Kern’s steps 2 (targeted needs assessment), 5 (knowledge gain), 6 (course evaluation) and first part of training feedback. Frequencies, percentages, means and SD were calculated. SPSS V.22.0 (International Business Machine, USA) was used. Paired t-tests compared pretest and post-test scores, with Cohen’s d quantifying effect size.

Knowledge change scores (post-test minus pretest) were computed for each participant. One-way analysis of variance (ANOVA) tested differences in knowledge change scores across professional cadres. Assumptions for parametric testing were assessed prior to analysis. Normality of knowledge change scores was evaluated using the Shapiro-Wilk test and visual inspection of Q–Q plots. Homogeneity of variances across professional cadres was assessed using Levene’s test. No significant violations of assumptions were detected (p>0.05).

Statistical significance was set at a 0.05. Qualitative feedback from open-ended responses was thematically analysed and presented.

Scaling up the training and dissemination of data

Following the successful pilot, MoH, TDA and WDF refined the training and initiated scale-up to additional regions, targeting all 26 Tanzanian regions. Training has been conducted in five (Mwanza, Mbeya, Arusha, Dodoma and Morogoro) using the revised curriculum and guided by the ToT model, with ongoing national facilitator support. Monitoring and evaluation mechanisms are in place to assess programme impact. Funding remains critical to continued expansion.

Results

Step 2: needs assessment at the COVID isolation centre: Amana Regional Referral Hospital

Between March and August 2020, Amana Regional Referral Hospital admitted 280 patients who tested positive for COVID-19. Of these, 64% (n=178) were male. The overall mortality rate was 36% (n=101), with male patients accounting for 76% (n=77) of these deaths. Comorbidities were present in 35% (n=97) of patients, with diabetes and hypertensive heart disease being the most common (table 1). A detailed monthly breakdown of admissions, deaths and associated comorbidities is provided in online supplemental file 5. Online supplemental file 6 presents a figure showing mortality rates among COVID-19 patients with versus without comorbidities during this period.

Table 1. Demographic characteristics of COVID-19-positive patients at Amana Regional Referral Hospital during the March–August 2020 period.

Total admission (n=280)	N	%
Male	178	64
Female	102	36
Total death (n=101)
Death rate	101	36
Male	77	76
Female	24	24
Comorbidities (n=280)
Present	97	35
Absent	183	65
Breakdown of comorbidities (n=97)
Diabetes	43	44.5
Hypertension	27	27.8
Chronic kidney disease	16	16.7
Pneumonia	11	11.0

Step 5: change in knowledge postimplementation

A total of 87 healthcare workers completed both pretraining and post-training assessments. Of these, 61% (n=53) were male, and the majority were nursing officers (53%, n=46). The overall mean pretraining knowledge score was 57.19±11.50, which increased to 67.10±9.17 post-training, representing a mean improvement of 9.91±10.01 percentage points. This improvement was statistically significant (p<0.001), with a large effect size (Cohen’s d=0.99).

All professional cadres showed knowledge gains (table 2). Although the magnitude of improvement varied numerically between groups, a one-way ANOVA on change scores indicated no statistically significant differences between cadres (p=0.63), indicating that knowledge change scores were similar across professional cadres.

Table 2. Demography and knowledge change for training participants.

Characteristic	N	%	Pretest mean±SD (min–max)	Post-test mean±SD (min–max)	Mean change±SD
Cadre*
Medical doctor	20	23	54.71±11.39 (29–74)	66.18±6.71 (47–74)	11.47±10.05
Assistant medical officer	6	7	61.32±8.63 (47–71)	67.88±7.57 (56–76)	6.56±2.21
Clinical officer	15	17	58.16±12.42 (41–76)	69.62±8.85 (47–79)	11.45±8.66
Nursing officer	46	53	57.42±11.67 (32–79)	66.58±10.40 (38–88)	9.16±11.00
Overall†	87	100	57.19±11.50 (29–79)	67.10±9.17 (38–88)	9.91±10.01

^*One-way ANOVA comparing change scores between cadres: p = 0.63.

^†Paired t-test for overall pre–post improvement: p< 0.001. Effect size (Cohen’s d) = 0.99.

Step 6: evaluation of the training by the pilot group

Post-training survey results showed that 74% (n=64) of participants were satisfied with the training overall, and 93% (n=81) rated the teaching methodology positively. However, 74% (n=64) expressed dissatisfaction with the time allocated for training, recommending an additional day dedicated to practical sessions (table 3).

Table 3. Evaluation of the training by the pilot group.

No	Questions	Responses (n=87)	N	%
1	Satisfaction with training logistics (preparation, payment during the training, transport to training site)	(a) Satisfactory	64	74
		(b) Unsatisfactory	23	26
2	Feedback on venue	(a) Good	4	5
		(b) Very good	22	25
		(c) Excellent	61	70
3	Feedback on food and refreshments	(a) Good	35	40
		(b) Moderate	2	2
		(c) Excellent	50	58
4	Feedback on teaching methodology	(a) Good	0	0
		(b) Very good	6	7
		(c) Excellent	81	93
5	Relevance of training materials and practical aids used	(a) Related to the subject taught	87	100
		(b) Not related to the subject taught	0	0
6	Feedback on time allocated for each session	(a) Enough	23	26
		(b) Not enough	64	74
7	Suggestions for improving future training (themes)	(a) Increase number of days for practical sessions
		(b) Use adult learning principles in explanations
		(c) More simulation/role play compared with didactic teaching

Discussion

Approximately 1 year after Tanzania confirmed its first COVID-19 case²⁷ and during the peak of the first pandemic wave, the TDA, in partnership with the MoH and the PORALG, launched the country’s first integrated training programme addressing both acute emergency care and IPC in the context of NCDs. Guided by Kern’s six-step model for curriculum development,²¹ a needs assessment revealed a critical gap: a substantial proportion of COVID-19-positive patients had comorbid NCDs. At Amana Regional Referral Hospital, a national isolation centre, 35% of patients had comorbidities, most commonly diabetes and hypertension. This figure was lower than the 67% reported by a tertiary private facility during the same period,⁷ yet both findings align with global evidence that individuals with NCDs are more vulnerable to severe COVID-19 complications and mortality.⁶

Following curriculum development, 87 healthcare workers from public, private and faith-based facilities participated in the pilot training. Pretest and post-test results showed a statistically significant knowledge gain, with mean scores increasing from 57.19±11.50 to 67.10±9.17, representing a mean improvement of 9.91±10.01 percentage points. These findings add to a growing body of evidence demonstrating that even a short, targeted training intervention can effectively enhance clinical understanding and preparedness among healthcare workers.28,32 In the context of outbreak risks and ongoing health system challenges, this approach is particularly relevant for Tanzania and other similar low-resource settings.

Participants also provided highly positive feedback on the course, with 100% affirming the content’s relevance to their clinical roles and 93% rating the teaching methodology as excellent. This high level of perceived relevance highlights the importance of aligning training content with local healthcare realities and professional needs. To our knowledge, this was Tanzania’s first initiative to integrate IPC and acute NCD care within a single training programme during a global health crisis. While standalone IPC or emergency care trainings have been implemented in Tanzania and other LMICs,28,33 this initiative was novel in combining public health and clinical content specifically tailored to NCD management during infectious outbreaks. The feedback highlights the potential for integrated training to strengthen health system capacity, particularly in resource-limited settings where healthcare workers must manage multiple, overlapping challenges.

Despite these successes, several challenges emerged. Most notably, 74% of participants reported insufficient time for practical sessions. While theoretical content was well received, the compressed schedule limited skill acquisition, particularly for oxygenation, basic life support (BLS) and emergency triage. Resource constraints, such as limited BLS manikins and oxygenation/ventilation equipment, further restricted hands-on practice. Although the trainer-to-trainee ratio (1:5) was manageable, the lack of materials constrained engagement and skill consolidation.

Contextual and political factors also shaped implementation. Training occurred during a politically complex period in Tanzania, when national COVID-19 policy fluctuated and, at times, diverged from WHO recommendations.³⁴ Early in the pandemic, Tanzania followed international guidance; however, later, policy decisions, such as halting public case reporting and limiting the enforcement of containment measures, posed challenges for pandemic response efforts. Despite this, strong local and regional government support facilitated successful implementation of the training, with MoH, PORALG and key professional associations playing an active role.

Several key lessons emerged. First, multidisciplinary involvement significantly enhances course quality. The training drew from emergency medicine, IPC, NCDs, mental health and health systems experts to ensure that the content was comprehensive and aligned with real-world needs. Second, government engagement through the ministry of health was essential for programme legitimacy, uptake and future scale-up, particularly in a politically sensitive context where institutional support could increase or decrease programme sustainability.

Strengths and limitations

A major strength of this initiative was its timely and relevant response to the COVID-19 public health emergency. The use of the verified Kern model ensured a structured and replicable approach to curriculum development. Additionally, the integration of both clinical and public health content delivered by a diverse facilitation team helped ensure relevance to frontline challenges. We acknowledge that the training demonstrated strong participant engagement, measurable knowledge gains and high perceived utility.

However, this study has several limitations. First, the sample size of 87 healthcare workers and the geographic focus on a single semiurban region of Dar es Salaam limit the generalisability of the findings to the broader Tanzanian context, where most of the population resides in rural areas. Second, resource constraints, particularly limited training equipment and inadequate venue infrastructure, such as the absence of simulation laboratories, restricted the depth and realism of practical skills training. Third, the evaluation focused only on short-term outcomes using pretest and post-test knowledge assessments and self-reported satisfaction; therefore, long-term changes in clinical practice or patient outcomes were not captured. Additionally, implementation was influenced by external political factors, which may have affected both content delivery and participant openness during the training. Finally, contextual factors such as baseline experience levels among healthcare workers may have contributed to the observed outcomes; however, the use of a pretest helped partially account for these differences.

Implications for practice and scale-up

Drawing on pilot outcomes and participant feedback, we recommend extending the training beyond 5 days to incorporate expanded simulation-based modules, particularly for oxygenation, BLS and triage, supported by investment in low-cost manikins and mobile equipment kits. Embedding adult learning techniques such as peer-led drills, case-based sessions and simulation will enhance experiential learning and retention. A structured M&E system, based on frameworks like Monitoring and Evaluation to Assess and Use Results (MEASURE) Evaluation and ExpandNet, should be established from the outset to track reach, fidelity, effectiveness and sustainability throughout scale-up.³⁵ Additionally, implementing phased scale-up, starting in representative regions and iteratively adapting to varying contexts, will allow for contextual calibration while preserving core curriculum integrity. Finally, conducting activity-based costing will guide resource allocation, demonstrate programme value to stakeholders and support policy-level investment for broader integration and sustainability.

Conclusions

This training programme was successfully developed and implemented during a critical health emergency, providing an innovative model for integrating IPC and acute NCD management. Despite logistical and contextual challenges, the initiative demonstrated feasibility, acceptability and early evidence of effectiveness. With ongoing refinement and institutional support, this approach holds strong potential for scale-up across Tanzania and other LMICs confronting dual burdens of infectious and non-communicable diseases.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.