NCD extension: kidneys, heart failure, lungs, stroke, cancer and severe NCDs

Kidney disease is usually silent until late. In diabetes, the earliest signs are a rising blood pressure and small amounts of albumin in the urine; swelling of the legs comes very late, and the first symptoms (nausea, itching, poor appetite) are those of kidney failure. If nobody tests the urine and the blood, CKD is found only when it is too late to slow it.

Who to test

• Everyone with diabetes, once a year. HEARTS-D advises a spot urine albumin-to-creatinine ratio (ACR) or an eGFR from serum creatinine, preferably both. WHO PEN advises testing for protein in the urine every year.
• Everyone starting treatment for hypertension. The WHO hypertension guideline (2021) lists serum creatinine and a urine dipstick among the basic tests, as long as testing does not delay treatment.
• People at higher risk: long-standing or poorly controlled hypertension or diabetes, known heart disease or stroke, HIV (HIV-associated kidney disease is one cause of fluid overload in the WHO district clinician manual), and a family history of kidney disease (a reason for screening in WHO PEN).

Tests, from best to simplest

HEARTS-D ranks the ways of measuring albumin in a spot urine sample: albumin-to-creatinine ratio (best), protein-to-creatinine ratio, a dipstick read by a machine, and a dipstick read by eye. Use the best one you have; a dipstick is far better than nothing.

Making the diagnosis

One abnormal result is not a diagnosis. HEARTS-D diagnoses diabetic kidney disease when either the eGFR is under 60 mL/min/1.73 m² on at least two occasions 1 to 3 months apart, or albuminuria is present in at least two urine samples 1 to 3 months apart. The same two-test rule is a sensible habit for anyone: repeat, then label.

The eGFR is calculated from serum creatinine with an equation validated for your population (HEARTS-D names CKD-EPI where none is validated locally). Most laboratories report it; if yours does not, ask how to calculate it.

Protecting the kidneys

Prescribing safely when the kidneys are weak

• Metformin is contraindicated when the eGFR is under 30 (HEARTS-D). Between 30 and 60, follow your formulary for dose.
• NSAIDs (diclofenac, ibuprofen and others) can tip weak kidneys into acute kidney injury. The WHO report on medication safety in polypharmacy (2019) warns about the 'triple whammy': a diuretic, an ACE inhibitor or ARB, and an NSAID taken together. Use paracetamol for pain where you can.
• Sick days. The same WHO report advises checking that people know which medicines to pause if they become dehydrated (vomiting, diarrhoea). Agree the list from your national guideline and write it on the patient's card.
• Look at every medicine at every visit, including medicines bought over the counter and traditional remedies (lesson 6).

When to refer

People with end-stage kidney failure need dialysis or a transplant (HEARTS-D). Where these are not available, early palliative care and symptom relief matter (WHO PEN palliative care section).

Source: WHO HEARTS-D, 2020; WHO Guideline for the pharmacological treatment of hypertension in adults, 2021; WHO PEN, 2020; WHO Medication safety in polypharmacy, 2019; WHO IMAI District clinician manual, 2011.

In heart failure the heart cannot pump enough blood for the body's needs. Pressure builds up behind it, and fluid leaks into the lungs (breathlessness) and the tissues (swollen legs, an enlarged liver, fluid in the abdomen). It is the end point of many heart diseases, so finding the cause matters.

Recognise it

Common causes in low-resource settings

• Long-standing high blood pressure (hypertensive heart disease).
• Cardiomyopathy: including HIV-related, and peripartum cardiomyopathy, which develops in the last month of pregnancy or within six months after delivery.
• Rheumatic valve disease, especially mitral stenosis; women with mitral stenosis often decompensate in the middle of pregnancy (see the rheumatic heart disease protocol).
• Ischaemic heart disease, and in endemic areas Chagas disease.
• Kidney failure can cause the same fluid overload (lesson 1).

Source: WHO IMAI District clinician manual, 2011 (table of diagnoses presenting with acute pulmonary oedema).

What tips a stable person into failure

IMAI asks you to look for the trigger: more salt or water than usual, an infection such as pneumonia, a new irregular rhythm (atrial fibrillation), chest pain (ischaemia), very high blood pressure, or stopping medicines. Fixing the trigger is often the most important treatment.

Pre-referral treatment at a facility that holds these medicines

• Sit upright; give oxygen to keep saturation at or above 90%.
• Furosemide 20 mg IV if the person is not already taking it; if they take it by mouth, give the same dose IV. Check the urine response after 30 minutes (IMAI).
• If the blood pressure is high: isosorbide dinitrate 5 mg under the tongue (IMAI).
• If systolic BP is under 90: do not give a diuretic; call for senior help (IMAI).
• Look for and treat the trigger (for example antibiotics for pneumonia, antimalarials if malaria is likely).

Confirming the diagnosis

Heart failure needs confirmation and a cause. IMAI lists creatinine, potassium, haemoglobin, an HIV test, a chest X-ray, an ECG and a limited echocardiogram (which a trained non-specialist can do with basic ultrasound). In the PEN-Plus model, this work-up and the start of long-term treatment happen at the first-level referral (district) hospital.

Long-term care: the health centre's job

The WHO Model List of Essential Medicines (2025) lists these medicines for heart failure: furosemide, an ACE inhibitor (enalapril) or an ARB (losartan), a beta-blocker (bisoprolol, or carvedilol or metoprolol), spironolactone, hydrochlorothiazide and digoxin. The clinician or PEN-Plus clinic chooses and adjusts them; the health centre continues them safely.

Self-care

• Salt under 5 g a day (one level teaspoon), including salt in processed food (WHO PEN).
• No tobacco; avoid harmful alcohol (WHO PEN).
• Suitable patients can be encouraged to do rehabilitation exercise at home (WHO PEN self-care).
• Weigh at home if possible, and come early if breathlessness, swelling or weight increase.
• Avoid NSAIDs bought over the counter; ask before taking any new medicine.

Your heart is weak, so water collects in your lungs and legs. These tablets help your heart and remove the extra water. Take them every day, eat less salt, and come back quickly if your breathing gets worse or your legs swell more.

Source: WHO IMAI District clinician manual, 2011; WHO Model List of Essential Medicines, 24th list, 2025; WHO PEN, 2020; Understanding the PEN-Plus approach to care, WHO Regional Office for Africa, 2025.

Asthma or COPD?

Measure peak expiratory flow (PEF), give two puffs of salbutamol and measure again after 15 minutes. An improvement of 20% or more makes asthma likely; less than 20% makes COPD more likely (WHO PEN). Where TB is common, anyone with cough for more than two weeks needs a TB test (WHO PEN; see the presumptive TB protocol).

Is the asthma controlled?

WHO PEN calls asthma controlled when all of these are true: daytime symptoms and reliever use no more than twice a week; night symptoms fewer than twice a month; no or minimal limit on daily activities; no severe attack (needing oral steroids or admission) in the last month; and PEF above 80% of predicted if you can measure it. Review control every 3 to 6 months, and sooner after any change.

The WHO PEN steps (adults)

Inhaler technique: the most common fixable problem

A metered-dose inhaler sprays a fast cloud. Without a spacer, much of it hits the back of the throat. A spacer holds the cloud so it can be breathed in. The WHO IMCI chart booklet states that no child under 5 should be given an inhaler without a spacer, and that a spacer works as well as a nebuliser if correctly used.

1. Take the cap off and shake the inhaler.
2. Fit the mouthpiece into the hole in the spacer.
3. Put the open end of the spacer in the mouth (or, for a young child, use a cup or the cut neck as a mask over mouth and nose).
4. Press the inhaler once, then breathe in and out through the spacer for three to four breaths.
5. Repeat for each puff prescribed.

Source: WHO IMCI chart booklet, 2014; WHO IMAI District clinician manual, 2011.

Making a spacer from a plastic bottle (WHO IMAI)

• Use a clean 300 to 500 mL plastic bottle, washed with detergent and rinsed well.
• Trace the shape of the inhaler mouthpiece on the base of the bottle, opposite the neck, and cut an opening the same size or slightly smaller (a heated paperclip works). Check the inhaler fits.
• Prime a new or freshly cleaned spacer with about 5 puffs before treatment (the IMCI booklet says 4 to 5). Clean it monthly.
• For a severe attack, or someone who cannot cooperate, cut the bottle at the neck and use it as a mask.

Inhaled steroids: what to tell people

• Inhalers are safe, are not habit-forming, and work better than tablets or syrup (WHO PEN).
• The steroid inhaler takes several days or weeks to work fully; keep using it when you feel well (WHO PEN).
• Thrush in the mouth and a hoarse voice are common side effects (WHO IMAI formulary). Using a spacer and rinsing the mouth after each dose are widely advised to reduce them.
• Bring your inhalers to every visit so we can watch you use them (WHO PEN).

Flare-ups

Self-management and prevention

• WHO PEN recommends self-monitoring and self-adjustment of treatment in asthma and COPD according to an action plan agreed with a health worker. Write it down: which inhaler every day, what to do when worse, when to come in.
• Stopping smoking is the most important treatment for COPD; use the 5 As (ask, advise, assess, assist, arrange) at every visit (WHO PEN).
• Reduce indoor smoke: cook outside or with a chimney, open windows and doors; reduce dust with damp cloths and by sprinkling water before sweeping (WHO PEN).
• Suitable people with COPD can be encouraged to do rehabilitation exercise (WHO PEN self-care).
• Avoid NSAIDs and beta-blockers in asthma: both can trigger attacks (WHO PEN).

Source: WHO PEN, 2020; WHO IMCI chart booklet, 2014; WHO IMAI District clinician manual, 2011; WHO Model List of Essential Medicines, 24th list, 2025.

Stroke is the second leading cause of death worldwide (WHO Package of interventions for rehabilitation, 2023). Most strokes are caused by a blocked artery; some are caused by bleeding in the brain. Most of the risk is modifiable, and high blood pressure is the biggest single factor that primary care can treat.

At first contact with a suspected stroke

• ABCDE: airway, breathing, circulation; check the level of consciousness (AVPU) and the blood glucose (WHO Basic Emergency Care).
• If the person cannot swallow safely, give nothing by mouth (no food, drink or tablets) until swallowing has been assessed. Swallowing problems are common after stroke (WHO rehabilitation package).
• Note the time the symptoms started and send it with the person.
• Do not start aspirin for a new stroke at the health centre unless your protocol says so: a stroke caused by bleeding looks the same without a brain scan.

Preventing a first stroke

• Find and treat raised blood pressure (see the hypertension protocol). Treatment to target is the single most effective step.
• Assess total cardiovascular risk and give a statin when indicated (see the CVD risk and statins protocol).
• Stop tobacco (smoked and smokeless); healthy diet with salt under 5 g a day; physical activity; avoid harmful alcohol (WHO PEN).
• Treat diabetes (see the type 2 diabetes protocol).
• Feel the pulse: a new irregular pulse may be atrial fibrillation, which can throw clots to the brain. Refer for assessment (see the rheumatic heart disease protocol for valve disease).

Preventing another stroke (secondary prevention)

Life after stroke: rehabilitation starts early and never really ends

The WHO rehabilitation package (2023) lists the problems that limit people after a stroke and the interventions that help. Many can be started or supported at primary care level, with referral for the rest.

People living with stroke need lifelong access to rehabilitation, and families provide most of the care. Carers face stress, money worries and isolation, and their own health can suffer (WHO rehabilitation package, 2023).

Your stroke happened because a blood vessel in your brain was blocked. Taking these tablets every day and keeping your blood pressure low is the best way to stop it happening again. Exercises every day will help you get stronger.

Source: WHO Package of interventions for rehabilitation, module 3, 2023; WHO Guideline for the pharmacological treatment of hypertension in adults, 2021; HEARTS technical package: evidence-based treatment protocols, 2018; WHO Basic emergency care, 2018; WHO PEN, 2020.

Cancer is curable more often when it is found early. Primary care has two jobs: recognise symptoms that could be cancer and refer quickly (early diagnosis), and offer screening where a programme exists (for example cervical screening). WHO PEN (2020) asks primary care to identify presenting features of cancer and refer to the next level for diagnosis.

Warning signs in adults (WHO PEN)

Cervical cancer: screening (WHO guideline, second edition, 2021)

• Programmes that use VIA should move to HPV testing as soon as they can, because VIA quality is hard to assure. Until then, keep screening with the test you have.
• Even screening twice in a lifetime is beneficial.
• Once a decision to treat has been made, treat as soon as possible, within six months; in pregnancy, treatment is deferred until after the birth.
• VIA and ablation are not suitable when the transformation zone cannot be seen, which is common after the menopause.
• Treatment of pre-cancer at primary level can include cryotherapy, thermal ablation or loop excision, according to national protocols (WHO PEN).

Breast cancer: early diagnosis

WHO PEN describes three groups of breast symptoms: (A) a lump or any change in the shape or consistency of the breast; (B) a lump that is growing, or fixed and hard; (C) other changes: eczema-like skin, nipple pulling in, orange-peel skin, ulceration, discharge from one nipple (especially bloody), or a lump in the armpit.

The WHO Regional Office for Africa guide (2026) lists findings that need urgent referral at primary level: a hard or fixed lump, nipple pulling in, bloody discharge from one nipple, skin changes (orange-peel skin, rash, ulceration), and swollen lymph nodes in the armpit or neck. If imaging is not available at your facility, do not delay referral.

The clinical breast examination, step by step

1. Welcome her, explain the examination and ask consent.
2. History: symptoms, previous examinations, family history.
3. Look: shape, skin and nipples, with arms down and then raised.
4. Feel: with the pads of the fingers, every part of each breast, at three levels of pressure.
5. Feel the armpits and above the collarbones for lymph nodes.
6. Explain what you found and what happens next.

Source: WHO Regional Office for Africa, Evaluation and workup for suspected breast cancer using a primary health care approach, 2026.

The WHO Global Breast Cancer Initiative (2023) sets three targets: more than 60% of invasive cancers diagnosed at stage I or II; diagnostic evaluation, imaging, tissue sampling and pathology within 60 days of first presentation; and more than 80% of patients completing treatment. Primary care makes the first two possible.

Childhood cancer: signs every health worker should know

The WHO Global Initiative for Childhood Cancer aims for at least 60% survival for children with cancer by 2030. Its six index cancers (acute lymphoblastic leukaemia, Burkitt lymphoma, Hodgkin lymphoma, retinoblastoma, Wilms tumour and low-grade glioma) have five-year survival of 85% or more with proven treatment. Training primary care teams to recognise the signs leads to earlier diagnosis (CureAll framework, 2021).

Keeping people in the pathway

• Explain that the symptom may be cancer and that timely referral is needed; include the person's family or supporters if they wish (WHO PEN).
• Give clear written steps for the next level of care: where, when, what to bring.
• Contact people with suspected cancer at agreed intervals, or use a patient navigator, to reduce loss to follow-up (WHO PEN).
• Coordinate follow-up with the team that diagnoses and treats, and offer palliative care and pain relief at every stage.

Source: WHO PEN, 2020; WHO guideline for screening and treatment of cervical pre-cancer lesions, 2nd ed., 2021; Global Breast Cancer Initiative implementation framework, 2023; CureAll framework, 2021.

Most people who live with one long-term condition have more than one: hypertension with diabetes, HIV with hypertension, COPD with heart disease, any of these with depression. This is multimorbidity. Guidelines are almost always written for one condition at a time, so following each guideline separately can leave a person taking many medicines that interact, cost too much and are hard to remember (WHO Multimorbidity, 2016).

Why multimorbidity is risky (WHO, 2016)

• Polypharmacy, which can lead to poor adherence and adverse drug events.
• Complex treatment plans and many contacts with different services, so more chances for care to fail.
• Demanding self-management and competing priorities.
• Frailty, older age, cognitive impairment, limited health literacy, and depression or anxiety.

People with both mental and physical conditions are at the highest risk of safety incidents; depression is common in multimorbidity and often missed (WHO, 2016).

Polypharmacy

WHO describes polypharmacy as the routine use of several medicines at the same time: four or more in the Medication Without Harm challenge (2017), five or more in the WHO technical report on polypharmacy (2019). The count includes over-the-counter, prescribed and traditional medicines. Some polypharmacy is appropriate (a person after a heart attack may need four or five medicines); the problem is inappropriate polypharmacy.

The WHO Global Patient Safety Challenge, Medication Without Harm, aims to reduce severe avoidable medication-related harm by 50% in five years. It asks countries to act first on three areas: high-risk situations, polypharmacy and transitions of care.

The WHO seven-step medication review

Deprescribing is the planned tapering or stopping of medicines that are no longer needed or are doing more harm than good, under supervision (WHO, 2019). Stop one thing at a time, explain why, and review the effect.

Transitions of care

Errors happen when a person moves between hospital and home, between clinics, or between health workers. WHO Medication Without Harm calls for medication reconciliation: a formal comparison of the medicines before and after the transition. Patients can help by keeping an up-to-date list of their medicines.

• Ask people to bring every medicine they take, including tablets from the market, the pharmacy and traditional healers, to their review.
• Write one list on the patient-held card; update it at every change.
• After any hospital stay, compare the discharge list with what the person was taking before, and with what they are actually taking now.

Organising care for people with several conditions (WHO, 2016)

• A named health worker who is responsible for the person's care, and continuity with the same team.
• One integrated care plan rather than one plan per disease; one visit for several conditions where possible.
• Longer or more flexible appointments for people with many conditions.
• Screen for depression; support carers; use teach-back to check understanding.
• Shared records and a structured way to hand over (for example situation, background, assessment, recommendation).

Fixed-dose combinations (for example two blood pressure medicines in one tablet) reduce the number of tablets and can help adherence; several are on the WHO Model List (2025). The HEARTS module on access to medicines notes that they ease supply and adherence problems.

Source: WHO Multimorbidity: technical series on safer primary care, 2016; WHO Medication Without Harm, 2017; WHO Medication safety in polypharmacy, 2019; WHO Model List of Essential Medicines, 24th list, 2025; mhGAP Intervention Guide 2.0, 2016.

Some NCDs cannot be managed by health centres alone: they need diagnosis and treatment that historically existed only at national referral hospitals. PEN-Plus is the WHO African Region strategy, adopted by all 47 Member States in 2022, to bring care for these severe NCDs to first-level referral (district) hospitals. Its four sentinel conditions are type 1 diabetes, sickle cell disease, and rheumatic and congenital heart disease (Understanding the PEN-Plus approach to care, WHO Regional Office for Africa, 2025).

Sickle cell disease

SCD is an inherited red cell disorder. It causes chronic anaemia, painful crises, acute chest syndrome, stroke, and organ damage. Children under 5 have the highest risk of death from serious bacterial infections, because the spleen stops working early. In sub-Saharan Africa, 50 to 90% of children with SCD still die before their fifth birthday, mostly because simple, cheap interventions do not reach them (WHO SCD guideline for children and adolescents, 2026).

Without newborn screening, SCD is usually diagnosed at around 6 to 12 months, when the child presents with painful swollen hands or feet (dactylitis), a serious infection, or sudden pallor with a large spleen (acute splenic sequestration).

What saves lives (WHO, 2026)

In malaria-endemic areas, malaria is an important cause of illness in people with SCD: prevent, test and treat promptly (WHO SICKLE package, module 2, 2024).

Type 1 diabetes

Type 1 diabetes is caused by destruction of the insulin-producing cells, leading to absolute insulin deficiency. It usually starts in childhood or early adulthood and more often presents with symptoms: thirst, passing a lot of urine, weight loss and tiredness (WHO HEARTS-D). Without insulin, a person with type 1 diabetes develops ketoacidosis and can die within days.

• Test the glucose in any child or young adult with thirst, frequent urination, weight loss, or unexplained vomiting and fast breathing. Plasma glucose is preferred when type 1 is suspected (HEARTS-D).
• Test the urine for ketones (WHO PEN lists ketone strips among essential tools).
• Clinical suspicion of type 1 diabetes in a newly diagnosed person is a reason for same-day referral (HEARTS-D).

Diabetic ketoacidosis (DKA)

For adults, HEARTS-D advises 0.9% sodium chloride 1000 mL IV in the first 2 hours, then 1000 mL every 4 hours until reaching hospital. Children need smaller, weight-based fluid volumes: follow your national paediatric protocol. Insulin for DKA is given in hospital.

Hypoglycaemia: every insulin user and family must know this

If the person can swallow: 15 to 20 g of glucose or sugar (for example 1 to 2 teaspoons of sugar, a sugary drink or a cup of milk), repeat if still low, then a small meal. If unconscious or unable to swallow: 20 to 50 mL of 50% glucose IV over 1 to 3 minutes (adult doses, WHO HEARTS-D and PEN). Glucagon injection is on the WHO Model List.

Living with type 1 diabetes: what the health centre does

• Keep the insulin supply going: insulin needs refrigeration, and the fridge temperature should be checked and logged (HEARTS module on access to medicines). Insulin types on the WHO Model List (2025) include human short-acting and intermediate-acting insulins and long-acting and rapid-acting analogues.
• Support self-monitoring of glucose and self-adjustment of insulin according to a plan agreed with the PEN-Plus team (WHO PEN self-care recommendations).
• Check injection sites, growth, school attendance, mood and the family's understanding at every contact.
• Never stop insulin in type 1 diabetes, even when the person is ill and not eating; seek advice the same day.
• Remember TB: people with type 1 diabetes have a higher risk of TB (one study found about four times higher; WHO TB operational handbook, module 6, 2024). Ask about cough at every visit.

Source: Understanding the PEN-Plus approach to care, WHO Regional Office for Africa, 2025; WHO consolidated guidelines on management of sickle cell disease in children and adolescents, 2026; WHO HEARTS-D, 2020; WHO PEN, 2020; WHO Model List of Essential Medicines, 24th list, 2025.

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