| 1. Prioritise NCDs for public health intervention using local data | Use local epidemiological data to build a case for public health intervention and target efforts | Completion of STEPS survey15—eg, Republic of Moldova STEPS29 30 Identification of key target populations (eg, men) Building NCD investment cases31 32 Assessment of the baseline situation of NCD burden and performance of healthcare using the NCD Global Monitoring Framework Indicators33
| Competing needs from multiple disease burdens Technical capacity to conduct and interpret epidemiological studies and in analysis/interpretation of routine data Underdeveloped health information systems
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| 2. Identify and map existing national and international resources | Deconstruct and combine the best components of multiple existing resources into a draft intervention | WHO PEN34 ESC SCORE35 HEARTS36 RESOLVE37 Brief Interventions for Tobacco38 Brief Interventions for Alcohol39
| Existence of multiple initiatives, resources and guidelines make it difficult to choose one Lack of consensus among existing resources Inappropriate content for local contexts Over-reliance on expert opinion
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| 3. Engage key stakeholders from inception to mainstreaming | Include key stakeholders throughout the entire process, including frontline primary healthcare staff and patients | Ministry of Health staff Local universities and academics Physician associations Donors and/or development partners Patients and members of the public Nurses and allied health professionals Volunteers
| Conflicts of interest Human resource capacity Allocation of working time for development Physician perception of non-physician health workers (eg, nurses) Availability of ‘expert’ patients Physician/non-physician and expert-person/lay-person power dynamics Specialist/generalist physician power dynamics
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| 4. Tailor intervention to local health system | Reconcile and adapt draft intervention with existing national clinical guidelines, availability of resources and local contextual wisdom | Access to essential medicines Access to laboratory and diagnostic tests Appropriate and aligned health financing Scope of practice of family doctors, nurses and narrow specialists
| Reluctance and/or lack of power and/or capacity to simplify existing national guidelines to be more practical Reluctance of task shifting care from specialists to primary care doctors and from doctors to nurses/non-doctors
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| 5. Generate local evidence of effectiveness | Demonstrate effectiveness locally through pragmatic, high quality, clinical trials | Pragmatic clinical trials, mixed methods evaluations,19 20 open-science resources including whoishRisk17 and CFIR13 European Health Examination Survey guidelines40
| Eagerness to change and optimism about intervention effects Lack of local (ie, national) trial methodologists, data analysts, especially for qualitative research Lack of resources/capacity for data collection, analysis and interpretation
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| 6. Ensure continuous quality improvement while before, during and after mainstreaming | If effective and acceptable, mainstreaming into the health system while balancing quality with scale | Engagement of local health leaders and academics throughout design, testing and scale-up41 Integration with medical education and continuous medical education42 Introducing quality circles and clinical audit to medical culture43
| Funding Oversight, quality assurance Punitive culture Excessive workload in primary healthcare Limited health informatics infrastructure for audit and feedback Unspecified leadership and roles
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