| Staff retention and engagement | Ensure detailed induction by health partners outlining NCD care objectives for all clinical staff Ensure selection criteria of ToT participants is based on ability, experience and soft training skills (eg, enthusiasm, patience, insight, confidence, communication skills, willingness to teach, leadership, capacity for reflection, ability to be constructively critical, motivation to help others and offer long term commitment)33 Ensure participants have a clear expectation of the cascade process and it is included in job descriptions Empower NCD champions to motivate staff and push for quality of care in local projects Ensure time allocated for staff mentoring, supervision, continuing professional development opportunities and consider accreditation Ensure succession planning to prepare for high staff turnover Future qualitative work needed to evaluate the barriers, challenges and facilitators to effective staff engagement in NCD care in this setting
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| Barriers to cascade training | Define cascade training and strategy from the outset Ensure ongoing protected time and supervision of participants to become confident trainers and develop soft training skills Consider extending length of ToT workshop to embed knowledge and training skills and incorporate clinical on job training where possible Provide adequate resources/budget for training equipment, travel, cost of refreshments and per diem incentives if necessary Enable logistics to encourage peer to peer learning across camp settings if appropriate Explore options for access to digital learning content to be scaled across larger numbers of healthcare workers on an ongoing basis for induction and refresher purposes
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| Lack of NCD champions and local leadership | Ensure ownership of cascade model transferred to local leadership with support to coordinate activities between organisations Create meaningful roles for trained participants as NCD champions scaling across camp and regional borders to encourage peer moderation of communities of practice Include NCDs and the ToT strategy in the mandatory induction of UNHCR PHO staff Include NCDs in any regional workshops to disseminate training information and encourage strategic planning
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| Competing clinical priorities | Prioritise funding and healthcare provision for NCDs alongside other communicable diseases in refugee settings Address implementation challenges in the context of competing priorities, such as dedicated days for NCD patient clinics and adequate staff capacity to manage clinical workload
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| Weak local health systems | Support national health system strengthening and engagement with development partners alongside WHO SARA21 to manage NCDs effectively Ensure ongoing discussions between managers and clinicians to review health system and operational issues to enable improved quality of care alongside clinical guidance
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| Availability of essential medications and equipment | |
| Lack of simple but appropriate monitoring and evaluation tools | |