As global health funding continues to contract, a four-paper series being prepared for publication in The Lancet will provide the case for integration science as a tool for unlocking significant gains in health equity worldwide.

More than 50 authors from dozens of countries are writing the papers. These experts represent a range of organizations and include academics, ministry officials, and people with lived experience from across sub-Saharan Africa and South Asia.

Led by the NCDI Poverty Network’s co-chairs—Dr. Gene Bukhman of Harvard Medical School and the Center for Integration Science in Global Health Equity at Brigham and Women’s Hospital in Boston, Massachusetts, and Dr. Ana Mocumbi of Universidade Eduardo Mondlane and the National Institute of Health in Maputo, Mozambique—the series will present both the theoretical framework and real-world applications of integration science for global health equity.

A relatively new field, integration science offers a systematic approach to increasing the resources available to people worldwide across steep gradients of inequality. Integration science accomplishes this goal by aligning health workforce capabilities and clinical pathways with the needs and shared experiences of those directly affected by disease.

“We’ve been seeing countries independently moving toward integrated care delivery out of necessity, but these efforts are often fragmented and narrow,” said Dr. Bukhman, lead author of the series. “Integration science provides a data-driven methodology to make these efforts more comprehensive and effective. And, when you combine integrated delivery models with integrated social movements, you create the conditions for real progress in global health equity.”

The research captured in the series draws from a dataset of more than 5,000 patient observations in dozens of healthcare facilities across sub-Saharan Africa and South Asia. Through extensive patient shadowing and direct observation, researchers have documented the details of clinical resources, competencies, and care pathways that form the foundation for integration science applications.

The first paper will review lessons from the first five years of the NCDI Poverty Network, an initiative launched in 2020 to implement the recommendations of the Lancet Commission on Reframing Noncommunicable Diseases and Injuries for the Poorest Billion. The Network largely focuses on PEN-Plus, an integrated care delivery strategy designed for low-resource settings. To date, 29 countries have initiated PEN-Plus; of those, 16 are already implementing the model across more than a hundred clinics worldwide.

The second paper will introduce a four-step process that helps health systems move from fragmented care to integrated approaches. Through case studies, this paper will demonstrate how countries can systematically use this delivery model design to assess existing capacities, identify integration opportunities, and reconfigure care pathways for maximum efficiency.

Paper three proposes moving beyond traditional advocacy categories—including those focused on specific diseases, demographics, and health systems—toward integrated social movements based on the shared experience of illness.

The final paper will present detailed case studies to demonstrate how integration science can inform national health planning and resource allocation decisions. The authors hope the paper’s insights will help inform the broader conversation on global health allocations.

“Integration science offers a path forward for low- and lower-middle-income countries grappling with growing disease burdens and constrained resources,” said Dr. Mocumbi. “By harnessing integrated delivery models and integrated social movements, this approach can help countries achieve effective, equitable health service delivery systems that provide lifesaving care for even the poorest people in remote, rural areas.”

The Center for Integration Science, in partnership with Universidade Eduardo Mondlane in Mozambique, serves as the co-secretariat for the NCDI Poverty Network, a coalition of health, advocacy, policy, funding, and technical partners from around the world who seek to expand access to care—largely through PEN-Plus—for the world’s most vulnerable people, especially children, adolescents, and young adults whose conditions are life-threatening in the absence of treatment.

When Dr. Yvette Kisaka recently presented on Kenya’s “three-year journey” to develop and mobilize support for its PEN-Plus National Operational Plan, one clear theme emerged: the proven track record of PEN-Plus in improving care for severe, chronic noncommunicable diseases in underserved areas.

During the NCDI Poverty Network’s Advocacy Working Group meeting in February, Dr. Kisaka, the technical lead for PEN-Plus, sickle cell disease, and cardiovascular diseases at the Kenya Ministry of Health, described the country’s process in formalizing the PEN-Plus plan and engaging stakeholders. Many of the key steps she listed—involving key partners, managing expectations, balancing competing priorities, and demonstrating financial stability—would be familiar to anyone who has sought to advance a large-scale project in government or the private sector.

Yet when it ultimately came down to selling the pitch, she said, the strategy focused on showing how PEN-Plus could solve problems, especially in Kenya’s counties, where local health decisions are made.

“PEN-Plus was, and still is, positioned as a solution to existing system gaps,” she said. “When you tell local health officials that PEN-Plus provides a solution for challenges with capacity-building of the health workforce, then it makes sense to them.

“Everyone wants to be part of a good story,” she continued. “A story that provides solutions.”

An Underpinning of Research

In 2020, the Lancet Commission on Reframing Noncommunicable Diseases and Injuries for the Poorest Billion estimated that interventions like PEN-Plus—a model for integrated care and a package of clinical services for people living with severe, chronic noncommunicable diseases (NCDs), such as type 1 diabetes, sickle cell disease, and childhood heart disease—could save 1.3 million young lives in sub-Saharan Africa and South Asia by 2030.

Several countries that have already implemented PEN-Plus are now launching national operational plans to detail how they will use the model to expand, integrate, and decentralize care for people living with NCDs. Kenya’s launch event took place in November 2025. Zimbabwe and Zambia also launched national PEN-Plus plans last year, while Ethiopia held its launch event in January 2026.

With additional countries preparing to launch plans later this year, Dr. Kisaka’s presentation was timely. She began by detailing the burden in Kenya, where research in the early phases of PEN-Plus initiation revealed that NCDs account for about 43 percent of mortalities and 50 percent of hospital admissions. Following that foundational work, in 2023, Kenya’s Ministry of Health piloted PEN-Plus in two counties, supported by the NCDI Poverty Network and implemented by NCD Alliance Kenya.

An initial step in building the national plan, Dr. Kisaka said, involved assessing existing policies in Kenya and studying the success of more advanced PEN-Plus countries, such as Malawi.

“I have to thank the Malawi team,” she said. “Their experience helped us develop a shared vision for Kenya and identify the direction we wanted to take our plan.”

Dr. Kisaka also noted that Kenya’s plan is simultaneously the result of previous research and a platform for supporting ongoing research.

“We wanted to base our PEN-Plus National Operational Plan on evidence, data, and decision-making—but also to support evidence generation in the implementation of the plan itself,” Dr. Kisaka said.

To scale up PEN-Plus nationally, Kenya’s plan calls for implementation in at least 20 counties, including the two pilot counties, by 2031, at an estimated annual cost of US$1.85 million.

Engagement of Key Stakeholders

With the shared goals and direction defined, the planners’ next step was identifying key stakeholders, both national and local.

“In Kenya, the Ministry of Health is in charge of developing policies, regulations, and technical support,” Dr. Kisaka said. “Service delivery in the health space, though, is done at the county level. Counties are responsible for clinical service and health workforce management, along with the procurement of health products and technologies.”

Each county has an NCD coordinator, Dr. Kisaka said, and they gather collectively as an NCD Caucus—a natural group to approach for support of the PEN-Plus national plan. In addition, Kenya has an NCD intersectoral coordinating committee, whose members Dr. Kisaka also involved in the plan.

Dr. Kisaka further invited participation from Kenya’s Ministry of Education, to address child health issues in schools, and ensured that PEN-Plus efforts aligned with the country’s long-term health system reforms, including those in health financing.

“You have to be explicit about why you bring each stakeholder on board, not just so they can feel valued, but also so you’re able to manage expectations when they come to the table,” Dr. Kisaka said. “There often can be competing mandates and priorities among the stakeholders.”

Given those potential conflicts, she said, it was important to frame Kenya’s PEN-Plus National Operational Plan as a shared obligation, rather than simply a Ministry of Health initiative. That approach helped education and finance officials, for example, view the extra work not as additional burdens, but as part of a larger, collective priority.

“I recommend anchoring support in government leadership—having the Ministry of Health at the table, leading the collaboration—so engagement can be prioritized throughout the government,” she said. “That gives you some legitimate power.”

“You can’t do this alone,” she added.

Learning Across Borders

Dr. Neil Gupta, senior director of policy for the NCDI Poverty Network, expressed his gratitude to Dr. Kisaka for her insights. He also noted that several countries—including Liberia, Mozambique, Sierra Leone, Tanzania, and Uganda—have PEN-Plus national operational plans in development, and Chhattisgarh State in India is preparing a regional plan.

“This progress represents not only valuable learning experiences for us and our country partners as they rise to their challenges, but also a huge inflection point for the Network,” Dr. Gupta said. “We’re excited about how we can help our partners bring their plans to fruition over the coming years.”

Umu Barrie was on her way to a class at Njala University in southern Sierra Leone when she suddenly collapsed. Her friends rushed her to a nearby emergency department, but by the time they arrived, she had already lost consciousness.

Before that day, Barrie had been experiencing insomnia and constant fatigue. She had taken medication for malaria and then typhoid, but without any improvement.

After her collapse, she said, “I was admitted into the hospital for one week while they tried to work out what was wrong with me. They ran so many different tests to try and find the problem—HIV, hepatitis, typhoid—until finally they discovered I had type 1 diabetes.”

Barrie received insulin and stayed in the regular ward for three days of observation. She was then transported to the PEN-Plus clinic in Koidu, in the eastern part of the country. There clinicians explained type 1 diabetes management in more detail and gave her a glucometer and an insulin pen so she could monitor and treat her condition at home.

“They showed me how to use the pen and talked about the foods I should eat—or avoid—to keep my condition under control,” Barrie said. She learned to keep a record of her glucose levels for subsequent checkups and was able to take advantage of the clinic’s WhatsApp program, which facilitates support groups and allows patients to communicate directly with clinicians if they are unsure about their glucose readings at home.

“As long as my glucose levels remain steady,” Barrie said, “I need to visit the clinic only once every two or three months.”

Thanks to her continued care at the PEN-Plus clinic, Barrie said, she was able to complete her studies and begin her career as a teacher.

“Receiving this treatment has encouraged me to be a role model,” she said. “I am now living my life to the full, and I want to help other people with diabetes change their lives.”

From Ghana to Zambia to Canada, peer support was a big topic for noncommunicable disease care in 2025—and the focus on mental and social wellbeing that peer support creates will continue growing in 2026.

“We’re in advanced stages of planning for more peer educators,” said Dr. Colin Pfaff, associate director of programs for the Center for Integration Science in Global Health Equity at Brigham and Women’s Hospital. The center is a co-secretariat of the NCDI Poverty Network, which supports care for people living with NCDs across sub-Saharan Africa, South and Southeast Asia, and the Caribbean.

“In each of the countries where we work, we’re preparing an integrated training for peer educators in both type 1 diabetes and sickle cell disease, to develop a cohort of peer educators with both conditions who would then have a formal role within PEN-Plus clinics, to mentor, teach, and support other warriors,” Dr. Pfaff said, using the “warrior” term that many people living with NCDs, especially young people, use to refer to themselves and each other.

PEN-Plus is a model of integrated care that focuses on training and equipping providers to bring specialized care closer to home for people in rural settings who are living with severe, chronic NCDs such as type 1 diabetes, sickle cell disease, and childhood heart disease. The patient-centered model also fosters health education and peer support for patients, who often face stigma and a lack of understanding about their disease in their communities.

Dr. Betty Bankah, a family physician and founder of the Adolescent Care Clinic at Greater Accra Regional Hospital in Ghana, said her clinic includes a casual lounge where young people with NCDs can hang out and talk with each other.

“About 80 percent of my counseling is accomplished by the warriors,” Dr. Bankah said. “What they can do in 20 minutes, talking with each other, would take me three days.”

Dr. Nana Ama Barnes, executive director of Diabetes Youth Care in Ghana, said she has a similar strategy for promoting empowerment and confidence among young people with severe NCDs. Diabetes Youth Care provides resources, education, and support for young people living with type 1 diabetes in Ghana.

“If I talk, it’s just ‘blah blah blah,’” Dr. Barnes said, making “talking” motions with her hands in a universal gesture for loquaciousness. “I just get the kids to talk to each other.”

Dr. Bankah, chair of the Diabetes Youth Care board, works closely with Dr. Barnes. In November, at the International Society for Pediatric and Adolescent Diabetes’ (ISPAD) annual conference, held in Montreal, the two stood together talking about the importance of peer support for young people, who often face significant social challenges related to the lack of community knowledge about their disease.

“It’s tough for them,” Dr. Bankah said. “My phone lines are open 24/7. We talk about how diabetes is not going to stop you.”

Diabetes has not stopped 24-year-old Emmanuella Selasi Hormenoo, secretary-general of Diabetes Youth Care and a member of the NCDI Poverty Network’s Voices for PEN-Plus advocacy team. At the World Health Summit in October, Hormenoo shared stages with global health dignitaries on two panels. She spoke about her childhood in Ghana, where her type 1 diabetes was not diagnosed until after she had fallen into a two-month coma. After four doctors had failed to treat her diabetes, Hormenoo said, a family physician saved her life, shared resources about her disease, and taught her to direct her anger into advocacy, to help other people in similar situations.

That family physician was Dr. Bankah.

Camp Camaraderie

Earlier last year, at Camp Tuli Bonse, an integrated PEN-Plus camp held in August near Lusaka, Zambia, Dr. Pfaff also witnessed the power of peer support and the strength that can come from people uplifting each other.

“What struck me, particularly, was young people sharing stories around the significant stigma that they face,” he said of the camp, which brought together nearly 60 young people living with either type 1 diabetes or sickle cell disease. “They told stories of not being able to attend school, of harmful words being spoken in the community, of misbeliefs around not being able to become pregnant or raise children, and of being excluded from job opportunities.

“We knew there was some sort of commonality in those stories, but when you sit in a group and hear those stories from individuals, told with power and emotion—it’s quite moving. There was a sense of solidarity at the camp, allowing people to find strength in one another’s shared stories.”

The NCDI Poverty Network, the Sonia Nabeta Foundation, and the Center for Infectious Disease Research in Zambia (CIDRZ) partnered to host Camp Tuli Bonse, the first disease-integrated camp for children and adolescents receiving care at PEN-Plus clinics in Zambia.

Camp Tuli Bonse—which translates in Nyanja to “we are together”—was born from the idea that integrated care and support could extend beyond clinical settings, with benefits that transcend those of physical health. The camp brought together nearly 60 young people living with either type 1 diabetes or sickle cell disease, for five days of health education, empowerment, and peer support.

The Sonia Nabeta Foundation regularly hosts wellness camps and warrior education workshops in several African countries. The events are rooted in the philosophy of integrating the mind, body and spirit into type one diabetes care and management regimes.

Backed by Research

As the NCDI Poverty Network expands peer support programs in PEN-Plus clinics and camps this year, recently published research will bolster the work. A recent study facilitated by the Center for Integration Science in Global Health Equity, a co-secretariat of the NCDI Poverty Network, details positive impacts from patient-centered care that now are expanding into training programs.

Gina Ferrari, a type 1 diabetes integration advisor for the Center for Integration Science, said a one-year study of self-management education for people living with type 1 diabetes in rural Liberia—published in December in PLOS Global Public Health—convened a Patient Advisory Board, which spurred the development of a peer support group. The results have informed training sessions in both Zimbabwe and Kenya.

Dr. Pfaff said expanding peer support programs will continue to benefit PEN-Plus programs.

“I’m a real champion of the power of peers learning from one another,” Dr. Pfaff said. “We’ve seen beautiful examples of young people who are unafraid to speak boldly about their condition, to be advocates, to be champions. They are living successful lives and are inspiring examples for others. Every time we host a PEN-Plus camp, we hear children saying things like, ‘I thought I was alone. I was the only one I knew with this condition, so I felt really isolated.’

“I believe that peer support is one of the most powerful tools the Network can provide.”

 

The NCDI Poverty Network joined with the Government of Ethiopia, the Mathiwos Wondu Foundation, the World Health Organization, and other partners in a Jan. 22 ceremony to launch Ethiopia’s PEN-Plus National Operational Plan, marking another major milestone for the growth of PEN-Plus in sub-Saharan Africa.

“The PEN-Plus program is a vital strategy designed to empower primary hospitals, ensuring that they meet high standards of care for patients with severe, chronic noncommunicable diseases (NCDs),” Dr. Dereje Duguma, Ethiopia’s state minister of health, wrote in the plan’s foreword. “This program not only complements the World Health Organization’s Package of Essential NCD Interventions (PEN), but also aims to establish minimum programmatic standards across newly formed PEN-Plus clinics nationwide.”

Dignitaries at the launch ceremony included Ethiopia’s minister of health, Dr. Mekdes Daba; Dr. Duguma; Dr. Hiwot Solomon, director of disease prevention and control for the Ministry of Health; Dr. Gene Bukhman, co-chair of the NCDI Poverty Network; Wondu Bekele, chief executive director of the Mathiwos Wondu Foundation; and representatives of the World Health Organization, the World Bank, and other partners.

The Mathiwos Wondu Foundation—named for Wondu Bekele’s youngest son, who died of leukemia at the age of four—is the implementing partner for both of Ethiopia’s PEN-Plus clinics.

The national plan calls for scaling up PEN-Plus to clinics in 150 primary hospitals over five years—including, in the first year, 11 hospitals spread across the country—with a target of enrolling an estimated 82,000 patients. The total projected budget for the national plan is about US$65 million, Dr. Solomon said during the launch ceremony. Funding sources illustrate a strong example of government ownership and co-financing, Dr. Solomon added, noting that the total breaks down to about 40 percent from the Government of Ethiopia, about 32 percent from donors and partners, and about 28 percent from community-based health insurance and patient out-of-pocket costs.

The national plan also details key components of PEN-Plus implementation in Ethiopia, from staffing primary hospitals with professional care providers trained in managing severe NCDs to establishing a system-wide monitoring and evaluation framework.

“We will implement standardized treatment protocols and ensure the availability of essential medical equipment, drugs, and commodities,” Dr. Duguma wrote in the foreword. “Through robust health education and promotion, we aim to raise awareness about severe, chronic NCDs, promote early detection, and encourage adherence to treatment plans among patients and communities.”

The launch ceremony followed a similar ceremony in Kenya in November, when government officials and health leaders launched Kenya’s national operational plan as part of a conference on NCDs. Last July, Zambia commemorated its plan with an event in Lusaka, and Zimbabwe launched its plan in March. The events were part of a significant year for PEN-Plus growth across sub-Saharan Africa, and Ethiopia’s launch ceremony signals that 2026 is poised to maintain that momentum.

“We are inspired by the Government of Ethiopia’s leadership and ambition for scaling up PEN-Plus to benefit people living with severe NCDs, including type 1 diabetes and childhood-onset heart conditions,” said Dr. Neil Gupta, senior director of policy for the NCDI Poverty Network. “We’re proud to have partnered with the Ministry of Health and the Mathiwos Wondu Foundation for the past decade to make this dream a reality.”