Sierra Leone is a West African country with a population of 7.5 million [1]. It is among the poorest countries in the world, with over 60% of its residents living below the poverty line [2]. While its fragile health care system continues to recover from two major crises—an 11-year civil war and an unprecedented Ebola virus disease (EVD) outbreak—and reduce the burden of maternal mortality, malnutrition, malaria, pneumonia, and tuberculosis, non-communicable diseases (NCDs) are becoming another major epidemic [3].

According to recent estimates, NCDs account for approximately 33% of deaths in Sierra Leone, 14% attributed to cardiovascular diseases, 3% to cancers, 2% to chronic respiratory diseases, 2% to diabetes, and 12% to other conditions [4]. Furthermore, the Global Burden of Disease study identified NCD risk factors, such as poor diet, smoking, alcohol consumption, high blood pressure, body mass index (BMI), and blood glucose levels among the top ten risk factors for death and disability in the country [3]. Although NCD prevalence data is generally poor, it is estimated that 23% of Sierra Leoneans have raised blood pressure, 8% are obese, and 5% have raised blood glucose levels [4].

In recognition of the growing NCD epidemic, the Government of Sierra Leone through the Ministry of Health and Sanitation (MoHS) developed its first National NCD Policy and Strategic Plan in 2013 [5]. However, its implementation has been limited in the face of competing priorities, scarce resources, and lack of effective care delivery models [6]. A recent study reported that the majority of patients seek NCD services in the outpatient primary health setting [7]; yet in 2017 only 35% and 25% of community health centers offered cardiovascular disease and diabetes diagnosis and management services, respectively. Furthermore, most of these facilities were private and located in urban settings, with NCD service availability being much lower (7–15%) in public health facilities in rural areas [8].

As in many low- and middle-income settings, primary and secondary health care services in Sierra Leone are structured to support patients presenting primarily with acute conditions. The provision of high quality NCD services, on the other hand, requires a comprehensive and continuous care delivery model to allow for patient registration, assessment, treatment, counselling and longitudinal follow-up [9, 10]—a model similar to that of HIV. Due to similarities in management, integrating several chronic diseases, following the model of HIV, has proven efficient and effective in other resource-limited settings [11, 12].

Affordability presents another challenge for NCD care provision. In Sierra Leone, the MoHS waives user fees under the Free Healthcare Initiative for select populations, such as pregnant and lactating women, children under the age of 5 years, and other vulnerable groups including EVD survivors [13]. NCD patients are excluded from the free health care category, and are therefore expected to incur catastrophic out-of-pocket costs, as is the case in other low-income countries [14, 15]. For example, in rural Malawi, a chronic NCD condition accounts for 22% of monthly per capita expenditures [16]. In India, urban poor spend up to 34% of their income on diabetic care [17]. A high proportion of NCD patients in low-income countries, particularly women (38%), forego taking medications because of catastrophic expenditures pushing their households into poverty [14].

In light of the NCD epidemic in Sierra Leone, Partners In Health (PIH), an international non-governmental organization, in collaboration with the MoHS, established one of the first integrated NCD clinics at Koidu Government Hospital (KGH) in Kono district in 2018. Kono is located in the eastern part of the country, bordering Guinea, with a population of approximately 506,000, 75% of which live in rural areas [1]. The district is the former epicenter of the civil war and the heart of the ‘blood diamond’ industry, both of which have had significant negative economic, environmental, and health impacts. Mining continues to contribute to land erosion, water pollution, and destruction of agriculturally productive wetlands, deepening food insecurity [18]. The EVD outbreak also significantly affected the district, further undermining public trust in the already weak health system [19].

KGH is a public district hospital jointly operated by the MoHS and PIH. It is the only referral hospital in Kono, serving over 90 primary health care facilities distributed throughout the district. The ~ 200-bed facility provides inpatient services such as surgery, deliveries, and adult and pediatric admissions. Outpatient services include HIV and TB diagnosis and treatment, antenatal care, vaccinations, mental health clinic and a general outpatient department. In addition to the patient groups supported by the Free Healthcare Initiative, KGH provides free services to patients with physical disabilities, mental health disorders and other socially or economically disadvantaged persons through the partnership with PIH. Patients enrolled in the new outpatient integrated NCD clinic also received health services free of charge.

This study is an evaluation of the initial cohort of hypertensive and diabetic patients enrolled during the first year of the clinic’s operation, conducted through a retrospective chart review. The objectives of the study were to assess patient enrollment and outcomes after 8 to 20 months of follow-up and describe the challenges and lessons learned throughout the implementation process. Despite the increasing recognition of NCD mortality and morbidity in Sierra Leone, there is no published literature on the implementation, management and outcomes of integrated NCD programs. This study aims to inform future implementations of longitudinal NCD care in Sierra Leone and in similar resource-limited settings.