This study provides evidence that integrating skin NTD services with broader skin disease care within routine primary care can substantially increase service uptake at district scale. Following implementation of a district-wide intervention, recorded incidence of skin disease doubled, with the largest relative gains among children and residents of very rural communities. However, comparison of facility and community survey data revealed persistent inequities, with many individuals - particularly men, children, and those in very rural areas - not seeking care. Although patient costs were generally low once care was accessed and catastrophic expenditure was uncommon, expenditures were high prior to presentation at intervention health facilities. Together, these findings suggest that integration can expand access, but equitable and financially protective impact requires deliberate strategies to reach underserved and higher risk populations.

Our results add to emerging evidence that integrating skin disease services into primary care can improve case detection and coverage when supported by strengthened workforce capacity and information systems, and by combining active case finding and facility-or mobile-clinic based follow up [20, 38–40]. Experience from leprosy integration demonstrates that such gains are sustained only when supply chains are reliable, referral pathways functional, and case management embedded within existing primary care workflows rather than operating as parallel vertical programmes [41]. Extending this evidence, we demonstrate that comprehensive management of skin NTDs, complex wounds, and common high-burden skin conditions can be embedded within routine district primary care systems at scale – provided that health workers are trained and supported to manage both common and rare conditions, and that essential diagnostics and medicines are consistently available. The intervention sought to address gaps between NHIS coverage and practical access by improving facility-level availability of essential medicines and dressings. Although this reduced patient costs once patients presented to intervention facilities, stock gaps persisted at times, and patients incurred out-of-pocket costs when NHIS-covered commodities were unavailable. These findings highlight that integration requires not only training and decentralisation, but resilient supply systems capable of sustaining reliable access to insured services.

Consistent with previous studies in Africa [42, 43], we found a high prevalence of bacterial, and fungal skin infections and traumatic wounds - conditions frequently overlooked by interventions addressing rarer conditions such as skin NTDs and chronic ulcers. While previous integration efforts have sought to expand access to diagnosis by training frontline health workers or linking them to specialist support through teledermatology [44, 45], few have examined which populations remains excluded. Despite substantial increases in care-seeking, school-age children and males remained underrepresented amongst facility attendees relative to their overall burden of skin disease. These disparities may reflect perceptions that common skin diseases are minor, opportunity costs associated with care-seeking, and structural barriers affecting caregivers and working-age men – patterns also described in care pathways for other acute and chronic conditions in similar settings [46, 47]. While active case detection is often used for high morbidity, low prevalence conditions such as skin NTDs, it may be impractical to apply at scale for common skin conditions. Instead, integration strategies may need to leverage existing platforms – such as school-based services and community health workers – to reduce inequities in access without overextending primary care systems [48].

This study has limitations. The non-randomised design and absence of a contemporaneous control group limit causal inference. While under-reporting of skin disease prior to the intervention is unlikely given the use of facility records for NHIS reimbursement, improvements in diagnostic specificity during the intervention may have influenced condition-specific incidence trends. Missing pre-intervention hospital health records preclude assessment of potential shifts from hospital to health centres and CHPS compounds. In the cross-sectional survey, reliance on self-report prior to clinical verification and some loss to follow-up may have contributed to underestimation of true burden. We did not conduct a full cost-effectiveness analysis. However, implementation across all 17 facilities within the district’s routine health system, with minimal external support, enhances the relevance of findings for real-world scale-up, although longer follow-up is needed to assess sustainability.

Integration of health services into primary care presents a pragmatic opportunity to address interconnected burdens of ill-health, stigma and financial hardship. Sustainable care models must prioritise both common, high-burden skin problems and rare and stigmatising NTDs, while explicitly addressing inequities in access. Taken together, our findings suggest that effective integration is likely to require sustained clinical capacity through ongoing training and mentorship, decentralised service delivery through existing district health structures, and reliable availability of diagnostics and essential medicines so that insurance entitlements are met in practice. By demonstrating both the potential and the constraints of this intervention, our study offers practical evidence to guide the incorporation of comprehensive skin health services into routine primary care in ways that advance equity and universal health coverage.