PEN-Plus – Integrated chronic care for severe NCDs in poor, rural areas

One of the NCDI Poverty Network's four strategic initiatives is to support development, initial implementation, and national scale-up of innovative service delivery models to effectively decentralize interventions for prevention and management of NCDIs affecting the poor.

PEN-Plus is an integrated care delivery strategy focused on alleviating the noncommunicable disease (NCD) burden among the poorest children and young adults by increasing the accessibility and quality of chronic care services for severe NCDs – such as type 1 diabetes (T1D), rheumatic heart disease (RHD) and sickle cell disease – in the rural areas of low- and lower-middle-income countries (LLMICs) where more than 90 percent of the world’s poorest people live.

In many lower-income countries, chronic care services for these severe conditions are only available at referral hospitals in major cities, making treatment both inaccessible and unaffordable for the rural poor. As a result, many poor children and young adults go without treatment for severe conditions that almost always lead to premature death if left untreated. And that is why, for example, one study found that life expectancy for children with type 1 diabetes is less than one year after diagnosis in much of sub-Saharan Africa.

PEN-Plus addresses this service gap by bringing lifesaving chronic care for severe NCDs to first-level rural hospitals for the first time. PEN-Plus trains mid-level providers such as nurses and clinical officers in the skills needed to provide integrated chronic care services for a group of severe NCDs, including diagnosis, symptom management, psychosocial support, palliative care, and referral for surgical and other specialty care when necessary.

Conditions addressed by PEN-Plus providers typically include relatively complex, less-common diseases such as type 1 diabetes, advanced rheumatic and congenital heart disease (RHD/CHD), and sickle cell disease (SCD) for which treatment had not previously been available. If scaled nationally in low- and lower-middle income countries, PEN-Plus would greatly improve access to care for people living with some of the most severe and most difficult to manage NCDs. 

PEN-Plus complements the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO PEN), which addresses less severe NCDs such as uncomplicated hypertension and type 2 diabetes at the health center level.

PEN-Plus also bridges major gaps in training, mentorship, and referral pathways for NCD services. PEN-Plus nurses with advanced NCD training provide training, supervision, and mentorship to staff who deliver WHO PEN services at health centers. This training and mentorship enables health center staff both to improve the quality of care for more common, less severe NCDs and to recognize and refer patients with severe NCDs to the PEN-Plus clinic. In turn, PEN-Plus providers receive training and mentorship from specialists at referral hospitals, refer patients for specialty services when necessary, and provide essential chronic care services following acute specialty interventions, such as anti-coagulation for RHD/CHD patients who have had valve replacement surgery.

Learn more about PEN-Plus