Table 5. Key strategies employed in response to contextual factors during adoption and initial implementation of Botswana primary health-care guidelines.

Key implementation strategies by implementation phasea	Contextual factors
Exploration
Multilevel assessment to understand sociopolitical landscape, funding, current clinical practice and strategic priorities. Used broad stakeholder inputs; review of policies, legislation, programme reports, local data analysis, and operational research	Concerns that noncommunicable diseases might reverse health gains made when combatting HIV.b Existing national noncommunicable disease programme to spearhead effortb
Assessed facility capacity and readiness to deliver quality services at primary health-care level. Used purposive sampling and local university trainees to general local data at lower cost	Constrained resources for rigorous facility and provider and/or client assessment
In-depth analysis of local data, leveraged partnerships with academic institutions	Limited research evidence interpretation and analytical expertise within the health ministry; data available from the 2014 noncommunicable disease risk factors surveyb
Preparation
Selected and adapted guidelines that fit model of care aligned with health ministry structure and strategic direction. Embedded noncommunicable diseases within primary health-care guidelines, aligning with the health ministry strategic direction and emphasizing integrated primary health-care services for individuals with multiple risk factors and morbidities	Key policy instruments did not exist before 2016; the global advocacy for UHC; the health ministry’s primary care-oriented strategic directionb
Engaged future on-the-ground adopters early on, starting with guidelines adaptation, to ensure context appropriate guidelines and facilitate ownership and sustainment	Before these guidelines, the experience and focus of health-care providers was predominantly HIV-focused, thus challenging adoption
Set up a broad technical working group and leveraged intersectoral forums to advocate for national prioritization of noncommunicable diseases and enable development of supportive policy instruments, such as a noncommunicable disease strategic plan, national essential medicines list and a national development plan	Tradition of siloed, disease and/or programme-focused approach to guidelines development
Achieved strong and streamlined stakeholder coordination to minimize fatigue and redundancy, through multiple nonlinear related processesc	The small pool of local technical experts presenting risk of meeting fatigue
Implementation
Started implementation in districts with some experience in multidisciplinary chronic disease management	Hospital-based multidisciplinary diabetes clinics established in 2012 in eight districtsb
Coupled standardized in-serve training programme with long-term mentorship to support continued change in practice	Positive and recent experience with HIV training programme, using master trainersb
Monitored standardized performance indicators,d which include process measures to signal early on delayed progress and suggest solutions to address delays	No existing routine reporting of noncommunicable diseases care; cumbersome paper-based reporting
Established public–private partnership to provide technical expertise and expediently obtain funding for initial training	Absence of global funding mechanism for noncommunicable diseases; slow government budget allocation processes
Sustainment
Included noncommunicable diseases mortality reduction priority and strategies in the next national development plan. Selected indicators included in health ministry’s key performance indcators	10th National Development Plan ending in 2016b
Developed experienced local master trainers and non-proprietary training material to allow for future trainings without need for external resources	Recent and positive experience with national HIV training programmeb
Going forward, will explore future electronic monitoring of primary health-care indicators, and regular feedback to providers, which will be critical to ensuring continued high-quality surveillance data	Existing patient-level electronic health information primarily for HIV, tuberculosis and child health

HIV: human immunodeficiency virus; UHC: universal health coverage.

^a We used a multilevel model that divides the implementation process into four phases: exploration, preparation, implementation and sustainment.²⁰

^b Enabling contextual factors.

^c Nonlinear related processes were noncommunicable disease strategy development, review of essential medicines list, development of primary care guidelines

^d We defined the indicators according to the RE-AIM framework.²⁸