Integrating NCD and Mental Health Care into Primary Health Systems through Digital Innovation

The World Bank–World Diabetes Foundation report argues that integrating noncommunicable disease and mental health services into primary health care, supported by interoperable digital tools and team-based care models, is essential to addressing the growing chronic disease burden in low- and middle-income countries. Through the Diabetes Compass case study, it shows how digitally enabled coordination between community and facility providers can improve early detection, reduce loss to follow-up, and deliver more person-centered, efficient care.

Produced by the World Bank Group in partnership with the World Diabetes Foundation and informed by evidence from institutions including the World Health Organization, the December 2025 report confronts the scale of the global noncommunicable disease and mental health crisis head-on. Noncommunicable diseases, such as diabetes, hypertension, cardiovascular disease, cancer, and chronic respiratory illness, now account for roughly 43 million deaths annually, with nearly three-quarters occurring in low- and middle-income countries. Mental health conditions frequently coexist with these diseases, amplifying both clinical complexity and health system costs. Yet many countries continue to rely on fragmented, episodic models of care that are poorly suited to chronic, lifelong conditions, placing Sustainable Development Goal 3.4 increasingly out of reach.

Why Primary Health Care Is the Front Line

The report makes a strong case that integrating NCD and mental health services into primary health care is the most cost-effective and equitable response available. Primary care is where early detection, prevention, continuity, and person-centered care can be delivered at scale, reducing the need for expensive tertiary treatment and improving long-term outcomes. Integration is also central to the World Bank’s goal of reaching 1.5 billion people with quality, affordable health services by 2030. However, the authors are candid about the barriers that persist across many LMIC health systems, including workforce shortages, limited access to diagnostics and medicines, weak referral pathways, underfunding, and poor coordination between community and facility-based services. These constraints often result in late diagnosis, high loss to follow-up, and avoidable complications.

Digital Transformation as an Enabler, Not a Shortcut

Rather than promoting technology as a quick fix, the report emphasizes that digital solutions must be designed around people’s care-seeking journeys. Understanding where individuals disengage, from screening to diagnosis to long-term treatment, is essential before deploying digital tools. When applied strategically, digital platforms can improve health literacy, support integrated screening, automate referrals, reduce administrative burdens, and strengthen clinical decision-making. Crucially, the report highlights digitally enabled team-based care, in which community health workers, clinicians, pharmacies, outreach teams, and caregivers coordinate care using shared digital tools. Interoperable systems based on standards such as HL7 FHIR allow patient information to flow seamlessly across levels of care, strengthening continuity and accountability.

Diabetes Compass and the Power of Team-Based Care

The report’s central case study is Diabetes Compass, a digital care coordination platform stewarded by the World Diabetes Foundation and implemented in Malawi, Sri Lanka, and Tanzania. Designed to address late detection, loss to follow-up, and weak NCD data systems, Diabetes Compass supports the full continuum of diabetes and hypertension care. Community health workers use mobile applications to conduct screenings during household visits, collecting basic risk data such as blood pressure and medical history. Algorithms aligned with national clinical guidelines assess risk and generate digital referrals to nearby facilities, with information transmitted in real time.

If appointments are missed, automated SMS or phone reminders are triggered, and unresolved cases prompt renewed community follow-up, creating a closed-loop referral system. Health officials in Sri Lanka report that digital screening tools have reduced reporting burdens, improved efficiency, and expanded access to hard-to-reach populations by bringing services closer to patients’ homes. Across countries, the platform was adapted to existing digital infrastructure, either by introducing new FHIR-native applications or embedding NCD modules into established health information systems to avoid duplication.

Lessons for Scaling Integrated Digital Care

A defining strength of Diabetes Compass is its emphasis on co-creation. Ministries of health, frontline workers, digital health teams, and NCD programs were involved from the outset through interviews, clinical observations, and steering committees, ensuring that solutions reflected local realities and national priorities. The report distills several broader lessons: health priorities must drive technology design; political commitment and cross-sector coordination are essential for sustainability; and open-source solutions, while avoiding licensing fees, still require long-term investment in maintenance, training, and governance. Planning for scale depends on adopting shared data standards to ensure interoperability across diseases and health system levels.

The report concludes that digitally enabled, team-based primary health care offers a practical pathway toward more resilient, patient-centered systems. When aligned with national strategies and grounded in local context, digital transformation can help countries move beyond fragmented care and respond more effectively to the rising burden of NCDs and mental health conditions.